Burns this month – with much discussion amongst the editorial group prior to publication. There are lots of different children’s burns protocols it transpires. RCEM’s is not aligned with the London and South East Burns Network’s. The message is “use your own burns referral unit’s guideline”. The other important message about burns is watch out for NAI but, even if the burn is accidental, refer all children to their health visitor as HVs in the UK are responsible for talking to families about safety in the home.
Also, complications of Kawasaki Disease, ADHD and the updated MAP guideline (managing cows milk allergy in primary care) which emphasises that 98% of crying babies do not have CMPA. Do leave comments below.
With thanks to Dr Cate Luce:
Here is a systematic approach to burns using an ABCDE approach.
A: Is their airway compromised?
- Facial burns
- Smoke Inhalation
- Stridor, wheeze, crepitations
- Increase work of breathing
For more information: https://dontforgetthebubbles.com/picu-qa-airway-injuries-due-burns/ 1
B: Basic first aid
Adequate pain relief is essential in burns. You should use something fast-acting such as intranasal diamorphine or follow your local policy. This will allow for a better assessment of the extent of the burns and delivery of basic first aid. Don’t forget running cold water on the affected area for at least 20 minutes, which may be effective up to 3 hours after the burn. First aid steps at https://cks.nice.org.uk/burns-and-scalds.
C: Calculate the percentage of total body surface area (TBSA)
There are several methods to calculate the percentage of TBSA. The palmar aspect of a child’s hand is 1% of a child’s surface area. You can use the Lund and Browder charts.
People often overestimate the percentage of TBSA affected; remember to only include partial and full thickness burns as defined at www.cks.nhs.uk/burns_and_scalds3.
Why not make it easy for yourself and download the Mersey Burns App4, which calculates the percentage of burns for you?
Children with more than 10% of TBSA will need intravenous fluids. The app also calculates the fluid required using the Parkland Formula (3-4ml x (%TBSA) x (weight kg)). You should give half in the first 8 hours followed by the rest within the next 16hours.
D: Discussion with burns centre
- >1% TBSA in children, >3% in adults (London and South East Burns Network)
- Chemical/electrical/high pressure steam
- Serious co-morbidity
- Non accidental
D: Disabilities– what are the complications?
E: External factors
Burns can be a result of neglect or physical abuse therefore safeguarding should always be considered. All children should be referred to their Health Visitor who is responsible for talking to the family about safety in the home – even if you feel it was an accident. Use the Child Protection Companion as a guide. https://www.rcpch.ac.uk/sites/default/files/2019-09/child_protection_evidence_-_burns.pdf 6
Always check the child’s immunisation status, especially tetanus, as burns can act as a tetanus-prone wound.
- Davis, T. PICU Q+A: airway injuries due to burns, Don’t Forget the Bubbles, 2013.https://dontforgetthebubbles.com/picu-qa-airway-injuries-due-burns/
- Sillett, Remember, Remember Burns and Scalds, https://em3.org.uk/foamed/25/10/2015/remember-remember-burns-and-blasts
- NICE, Burns and Scalds 2019, cks.nhs.uk/burns_and_scalds.
- Toxic Shock Syndrome 2019, https://www.nhs.uk/conditions/toxic-shock-syndrome/
- Child Protection Evidence, Systemic review of burns, July 2019, https://www.rcpch.ac.uk/sites/default/files/2019-09/child_protection_evidence_-_burns.pdf
Possible causes of macrocephaly this month. Also the start of a new series on causes of coca-cola coloured urine and updates on safeguarding CPD requirements and the terminology of children “in care”. Do leave comments below:
April came and went a bit too fast for my Paediatric Pearls head. So I’ve produced a joint April/May newsletter for 2019. There’s a bit of safeguarding again this month with a link to a paper on what young people in care think of the language we use, a guide to enteral rehydration of children with D&V, acrodermatitis enteropathica and a reminder of what is normal on a paediatric ECG. Do leave comments below:
STIs, sexual abuse, eating disorder and haemolytic uraemic syndrome this month. Do leave comments below:
September’s newsletter reminds us of the CPD requirements for child safeguarding for all of us, warns us of the dangers of missing Kawasaki Disease, talks about PHE’s #askaboutasthma campaign and describes the differences between fever and sepsis. Do leave comments below:
August brings more returning travellers, this time with dengue fever. Also adolescent sleep problems, adverse childhood experiences (ACEs), an update on rhinitis and the neurological effects of rotavirus. Do leave comments below.
Using HEADSSS assessment by Dr Emma Parish
In the UK we often discuss our ageing population but sometimes fail to see the significant proportion of those in adolescence, between 12 – 19% of the total UK population in 20171.
Engaging this age group can be daunting for health professionals. HEADSSS is an interview prompt or psychosocial tool to use with young people. Still growing in the consciousness of health professionals (and in the letters making up its acronym) HEADS(SS) was first presented in publication in 19882. It has a reported yield of 1 in 3 for identifying concerns that warrant further investigation.
It follows a simple structure remembered by the acronym:
Education & Employment
Self-harm, depression & suicide
Safety (including social media/online)
The great news is that many studies have shown that self-assessment with HEADSSS tools before discussion (completed at home or in waiting rooms) yields equal, and in some cases more, information than conducting the assessment in person. Helpful for time-strapped clinicians and better utilisation of time for young people attending appointments.
Key tips for using HEADSSS
- Greet young person first, let them introduce others
- Practice discussing issues that embarrass you
- Be clear in what you mean by confidentiality relating to discussion
- See young people on their own routinely (whenever clinically appropriate)
- Use linking phrases and questions that don’t presume:
- Do you have a boyfriend/girlfriend?
- Do you have someone important in your life?
- Have you been in a relationship before? Tell me more…
For more details see the RCPCH Young People’s Health Special Interest Group (YPSIG) app – free to download here: https://app.appinstitute.com/heeadsss
Or this short HEADS-ED assessment tool: http://www.heads-ed.com/en/headsed/HEADSED_Tool_p3751.html
- Association of Young People’s Health – Key Statistics Document 2017 download here: http://www.ayph.org.uk/keydata2017/FullVersion2017.pdf
- Cohen, E, MacKenzie, R.G., Yates, G.L. (1991). HEADSS, a psychosocial risk assessment instrument: Implications for designing effective intervention programs for runaway youth. Journal of Adolescent Health 12 (7): 539-544.
NICE on Lyme disease this month – just in time for the weather to pick up and the tics to start biting. Also a reminder on the risk factors for SIDS, what to do in a terrorist attack, how to manage a child with a non-blanching rash and a discussion on the use of the antistreptolysin O titre. Do leave comments below:
NICE on faltering growth this month, paediatric stroke, a reminder of the new epilepsy classification and a contribution from the safeguarding team on what constitutes a “legal high”? Do leave comments below: