Sepsis and the “in-betweeners” this month. How to categorise the unwell children you are just not quite sure about. Also testing in malaria, the new NHSGo app and cardiac assessment prior to starting medications for ADHD. Do leave comments below:
With thanks to Geoff Ferguson, Director of the Parent Infant Centre (www.infantmentalhealth.com) for the following explanation of the Acquarone scales:
The Acquarone Detection Scales for Early Relationships are observational scales that provide a powerful tool for assessing an infant’s capacity to form relationships and a mother’s ability to respond to her infant. The scales have been developed during several decades of clinical practice by Dr Stella Acquarone, who is also the author of several books on infant development and parent infant psychotherapy and Principal of the Parent Infant Clinic. The Parent Infant Clinic is a private service but does have some subsidised places for families with limited financial resources.
There are two scales, a 25 item scale for observations of the infant and a 13 item scale for observations of the mother. In each case observations are divided into four domains: interpersonal, sensorial, motor and affect. Within each domain observers are asked to note the frequency of certain behaviours. For example, when observing ‘calling’ the observer is looking for ‘facial expressions, noises or gestures that seek to produce an affectionate response from the partner’.
A concern about the infant or the mother might be raised if a particular behaviour was never observed, perhaps showing a difficulty in relating, or was constantly observed, perhaps showing a defensive repetitiveness. The scales can be used to establish a thorough observational benchmark against which later changes can be compared.
Click here to see an example.
January 2015 newsletter is being published late with apologies. The newsletter is circulated prior to publication to be checked by my 8 paediatric consultant colleagues and any guest authors. I neglected to attach the newsletter to my initial email, a fact pointed out to me on the 31st January….. Now checked and ready to go.
Andrew Lock has put together a really helpful guide to viral exanthems with trustworthy links to proper images, Vicky Agunloye is back this month with an invaluable guide to the healthcare professional’s assessment of a crying baby (and his/her mother). Tom Waterfield has looked at the usefulness of saline nebs in bronchiolitis, there are some more “do not do” recommendations from NICE and a link to Suffolk’s guideline on managing anaphylaxis and its follow up from primary care. Do leave comments below:
More musings from Dr Waterfield this month - this time on paracetamol for immunisation discomfort. Also the 7 important features of a headache y0u must ask about, a link to a very good paediatric emergency medicine site, NICE quality standards in depression, molluscum contagiosum and more musings from me, this time on paediatric phlebotomy. Do leave comments below.
Article by Dr Hajera Sheikh, paediatric registrar
Assessment in Secondary Care
• Lifestyle Assessment
• Menstrual History
• Obstructive Sleep Apnoea: Snoring, difficulty breathing during sleep, morning headaches or fatigue
• Symptoms of co-morbidity including psychological
• Drug use (particularly glucocorticoids and atypical antipsychotics)
• Family history, particularly diabetes <40 yrs, early heart disease <60 yrs
• Height, weight, BMI
• Obesity pattern: generalised, central (greater risk of adverse cardiovascular outcomes), buffalo hump and neck (may be suggestive of Cushing syndrome)
• Blood pressure
• Pubertal assessment
• Acanthosis nigricans (indicative of insulin resistance, first seen round neck and axillae)
• Signs of endocrinopathy
• Dysmorphisms: (Look out for early onset obesity, learning difficulties, deafness, epilepsy, retinitis, dysmorphic features, hypogonadism)
• Thyroid function
• Fasting lipids (total and HDL cholesterol), triglycerides
• Liver function, including ALT
• Fasting glucose and insulin not usually done first line
Refer to Paediatric Obesity/Endocrinology or other specialist service if further investigation is required
• Genetic studies
• Thyroid studies: T3, thyroid antibodies, calcium, phosphate
• Cushing syndrome investigations
• Oral glucose test
• PCOS studies (LH, FSH, adrenal androgens, Sex Hormone Binding Globulin, prolactin, pelvic ultrasound)
• Sleep Study
Dysmorphic and monogenic syndromes associated with obesity:
Main clinical obesity associated syndromes:
• Autosomal dominant
Biemond syndrome (some cases)
• Autosomal recessive
Biemond Syndrome(some cases)
• X-linked inheritance
• Single gene lesions affecting leptin metaboilsm
Congenital leptin deficiency
Leptin receptor mutation
Prohormone convertase 1 mutation
Melanocortin 4 mutation
Clinical features suggesting obesity may be secondary to another condition or syndrome
• Severe unremitting obesity
• Disorders of the eyes
Retinal problems, especially retinitis pigmentosa
Narrow palpebral fissures
Abnormally positioned palpebral fissures
Severe squint (eg Prader-Willi)
• Skeletal abnormalities
• Sensorineural deafness (eg Alstrom syndrome: sensorineural deafness, diabetes mellitus, retinal dystrophy, obesity)
• Microcephaly and/or abnormally shaped skull
• Mental retardation
• Renal abnormalities
• Cardiac abnormalities
With many thanks to Dr Harriet Clompus, paediatric SpR with an interest in community paediatrics for summarising this core-info topic so neatly and usefully.
Emotional Neglect and Abuse
Core-info, a Cardiff university based research group, examines all areas of child abuse by systematically reviewing worldwide literature and producing recommendations based on best evidence. This is a useful resource for paediatricians, general practitioners, health visitors, nurses, social workers, educators. Find all their reviews at www.core-info.cardiff.ac.uk.
Core-info have produced a leaflet in cooperation with National Society of Prevention of Cruelty against Children (NSCPCC) following a review in 2011 of the available literature on emotional neglect and abuse in children less than 6 years old. The leaflet is available at NSCPCC resources at www.nspcc.org.uk/inform. You can also subscribe to CASPAR a news service that signposts you to latest policy, practice and research in child protection.
Definitions of emotional neglect and emotional abuse vary, but all include persistent, harmful interaction with the child by the primary care-giver.
The Core-info/NSPCC leaflet reports one in 10 children in the UK experience severe neglect in childhood. It uses the WHO definitions for emotional neglect and abuse. (World report on violence and health (2002) page 60. Edited by Krug et al)
‘Emotional neglect is the failure of a parent to provide for the emotional development of the child.’
Examples of emotional neglect include:-
- Ignoring the child’s need to interact
- Failing to express positive feelings to the child, showing no emotion in interactions with the child
- Denying the child opportunities for interacting and communicating with peers and adults.
‘Emotional abuse includes failure of a care-giver to provide an adequate and supportive environment and includes acts that have an adverse effect on the emotional health and development of a child. Such acts include restricting a child’s movements, denigration, ridicule, threats and intimidation, discrimination, rejection and other non-physical forms of hostile treatment.’
Examples of emotional abuse include:-
- Persistently telling a child they are worthless or unloved
- Bullying a child or frequently making them frightened
- Persistently ridiculing, making fun of or criticising a child.
The core-info/NSCPCC leaflet categorises behaviour/interactions to be concerned about in three different age groups (it only gives data up to 6 years and on mother (not father or other caregiver) interaction, reflecting data collection in studies reviewed). Attachment to mother is disordered and emotionally neglected children show typical pattern of initially passive and withdrawn and then hostile and disruptive behaviour and developmental delay especially in speech and language.
1) Infant (<12 months old)
- Mother-child interaction: mother insensitive and unresponsive to child’s needs. Rarely speaks to child, describes them as irritating/demanding. Failing to engage emotionally with child during feeds. Child unconcerned when mother leaves and when mother returns, child avoids her or does not go to her for comfort.
- Behaviour: Quiet and passive child. May demonstrate developmental delay within first year, particularly in speech and language (particularly if mother has had depression).
2) Toddlers (1-3 years old)
- Mother-child interaction: More obvious that mother is unresponsive or does not respond appropriately to child (called ‘lacking attunement’). Mother is often critical of child and ignores signals for help. Child is angry and avoidant of their mother.
- Emotionally neglected/abused children grow less passive and more aggressive and hostile, particularly with other children. They show more memory deficits than other children, including physically abused children.
3) Children (3 -6 years)
- Mother-child interaction: Mother offers little or no praise, rarely speaks to the child and shows less positive contact. Mother is unlikely to reach out to the child to relieve distress and the child is unlikely to go to the mother for comfort. Neglectful mothers are more likely to resort to physical punishment than other mothers.
- Emotionally neglected children show more speech and language delay than physically abused children. Girls show more language delay than boys. Their behaviour is often disruptive (rated more disruptive by parents and teachers than physically abused children or controls). They show little creativity in their play, have difficulty interpreting others emotions and have poor interactions with other children. They tend to be less likely to help others or expect help themselves.
Implications for practice:
- All practitioners (gps, paediatricians, nursery nurses and teachers, health visitors etc) need to consider emotional neglect and abuse when assessing a child’s welfare. The longer a child is left in an emotionally neglectful or emotionally abusive environment, the greater the damage. However intensive work with families to increase parental sensitivity to their child’s needs, can lead to improvements in child’s emotional development.
- Important attachment disorders are recognisable in young infants and merit referral to professionals trained in infant mental health (Waltham forest has a Parent Infant Mental Health Service (PIMHS) which accepts referrals related to disordered attachment in children under 3 years. PIMHS works with the mother and child to foster healthier attachment (the earlier in a child’s life this is done, the better the outcome). Any health care professional can refer a family to PIMHS. See paediatric pearls from May 2012 for more information:- www.paediatricpearls.co.uk/…/the-parent-infant-mental-health-service-pimhs
- In older children (>3 years) it can be difficult to know when and where to refer. Emotional neglect and abuse is by definition a persistent behaviour pattern, so cannot be diagnosed on the basis of one short consultation. Concerns about parent-child interaction witnessed in a short consultation in A+E or GP surgery may trigger a health-visitor review to gather information, prior to a possible referral to social services. Information should be sought from all those involved in the child’s care including nursery/school teachers. If concerns around behaviour witnessed in A+E or GP surgery are severe, an immediate referral to social services may be appropriate.
- Professionals should be able to recognise speech and language delay and refer appropriately. See paediatric pearls from April 2012 www.paediatricpearls.co.uk/…/stages-of-normal-speech-development/. Many of the features found in emotionally neglected and abused children may also be observed in those with Autistic Spectrum Disorder (ASD) or Attention Deficit and Hyperactivity Disorder (ADHD). If a child is showing language delay and behavioural disruption they should be referred for a formal child development assessment (either in speech and communication clinic (SACC) or child development clinic (CDC) – refer to Wood Street Child Development team in WF)
- Consider risk factors – Core-info’s systematic review did not encompass ‘risk factors’ for emotional neglect and abuse. However it states that ‘many of these children live in homes where certain risk factors are present. Namely – domestic abuse, maternal substance misuse, parental unemployment or mental health issues, an absence of a helpful supportive social network, lack of intimate emotional support and poverty’.
Lots of things to talk about this month. Reminder of what Koplik spots look like, good e-learning on human trafficking, a link to the new primary care guidelines page, night terrors v. nightmares, some good allergy websites and Jess Spedding again on scaphoid injuries. Do leave comments below.