Paediatric Pearls

Most children who are dehydrated presenting to UK emergency departments can be rehydrated orally. 

• Give 50ml/kg ORS solution over 4hrs, plus ORS solution for maintenance, often and in small amounts (even by syringe or spoon)
• Continue breast feeding
• Consider supplementing with usual fluids (but not fruit juices or carbonated drinks) if a child without red flag symptoms or signs (see http://www.nice.org.uk/CG84) refuses to take sufficient ORS solution.  Don’t give solids.
• Consider giving ORS solution via ng tube if child is unable to take it or continues to vomit (esp. with red flag symptoms/signs)
• Monitor carefully

This is a worked example for a 3 year old child weighing 14kgs who has been assessed as about 5% dehydrated.

Maintenance = 100mls/kg for first 10kgs and 50mls/kg for next 10 kgs = 1000mls + 200mls = 1200mls over 24 hours

Replacement = 5 x 14 x 10 = 700mls over the first 4 hours (extra to maintenance needs)

Therefore the child needs 225mls per hour for the first 4 hours (1200/24 + 700/4), followed by 50mls (1200/24) per hour.

The 225 mls is best given as 18 mls every 5 minutes or 56mls every 15 minutes if vomiting seems to have stopped or if using nasogastric tube.

They should have 5mls/kg = 70mls extra diarolyte (ORS) with each diarrhoeal stool or vomit.

Give parents written information to go home with so they understand that diarrhoea may continue for a few days but this does not matter as long as they are able to get enough fluid in the top end.  The NICE guideline parent information is at http://guidance.nice.org.uk/CG84/PublicInfo/pdf/English.

Managing Fever in Children with thanks to Dr Ranjev Kainth

Fever, both in primary and secondary care is a frequent presentation. Often, it is a sign of an illness and in the first instance, it is important to establish the most likely underlying causative factor. Once this has been determined, focus often turns to the management of the fever.  Two recent articles in Archives highlight the varying practice amongst clinicians both in primary and secondary care.

In accordance with NICE guidelines¹, the authors^2-3 suggest anti-pyretics should not be used for the sole purpose of controlling fever.  Agents such as paracetamol and ibuprofen are often administered to promote comfort in the child when there is  fever.  In such situations, children may be prescribed single or dual therapy.

In a systematic review, E.Purssell³ examines the evidence for combined anti-pyretic therapy with either paracetamol or ibuprofen alone. He concluded that ‘only marginal benefit was shown for the combined treatment compared with each drug individually which, taken alongside the risk of overdose and further increasing the fear of fever, suggests there is little to recommend this practice’.

With the real risk of parents being unable to accurately measure medication⁴, it is important clear guidance is given on when and what type of drug therapy is appropriate in clinical situations.

References:

1. NICE Guideline: Feverish Illness in Children:  Quick reference guideline http://guidance.nice.org.uk/CG47/QuickRefGuide/pdf/English
2. McLyntyre, J. Management of fever in Children. Arch Dis Child Dec 2011 V 96;12 P.1173
3. Purssell, E. Systematic review of studies comparing combined treatment with paracetamol and ibuprofen, with either drug alone. Arch Dis Child Dec 2011 V 96;12 P.1175
4. Beckett, V.L. et al. Accurately administering oral medication to children isn’t child’s play. Arch Dis Child 2011;96:A7 doi:10.1136/adc.2011.212563.14  

Children from about 5 years old may be able to use a Peak Flow Meter to record their PEFR. As one of the parameters by which we diagnose a severe or life-threatening asthma exacerbation is the percentage drop in PEFR, it would help to know what a child’s normal PEFR is! Click here for a guide of what you might expect for height. Children don’t always conform to these norms so it is important to know what the child’s own normal PEFR is; a 20% drop in their norm suggests poor control of asthma, a 40% drop suggests a significant exacerbation.

The ED version of May 2011′s “Pearls” is available here!  NICE on otitis media with effusion, inguinal hernias, measles, the child with a limp and the significance of a high anion gap.  Do leave comments below.

You know when you are not quite sure what the name is of the rash that a child has but you know it is not an acute emergency? I often wish I had done Latin “A” level and could come up with something credible sounding on the spur of the moment. I sent yet another “viral exanthem” child to my dermatology colleagues yesterday because I hesitated for a second too long over a possible diagnosis and lost the confidence of the parent. So today I have been educating myself. Take a look at www.dermnetnz.org for some fantastic images and information on more types of enteroviruses than you could possibly imagine existed.  The site also has some self-directed learning modules on it.

There’s another site worth looking at, aimed at non-health professionals but with some quite useful photos on.  Have a look at http://www.skinsite.com/index_dermatology_diseases.htm.

This month’s emergency department version of Paediatric Pearls has information on dehydration from the NICE guideline on gastroenteritis in the under 5s, a bit on seizures and the evidence behind our reluctance to let you request chest x-rays for children.  I’ve featured the NICE guideline on antibiotics for respiratory illness in primary care too as they are also relevant for the children we see in EUCC and the Emergency Department.  I hope you find it helpful; I think the average length of time for each infection is useful information to be able to hand on to parents.  Download December’s Paediatric Pearls here.

With thanks to Amutha for this article….

As winter approaches, most of us are very well aware that the bronchiolitis season is in full swing. Bronchiolitis is a lower respiratory tract infection – in the under 1s predominantly – that can cause fever, dry cough, nasal discharge and bilateral fine inspiratory creps ± wheeze.  Most cases of bronchiolitis occur from November to March, when the viruses that can cause bronchiolitis are more common. It is also possible to get bronchiolitis more than once during the same winter season (1).

Treatment is largely supportive and many infants are managed at home if they are feeding adequately and do not have significant respiratory difficulty.  Patients at high risk are ex-premature babies, those with congenital cardiac or respiratory diseases, immunodeficiency and babies < 3months of age (2).  When seeing a child, we should focus our history and examination on risk factors, signs of dehydration and respiratory distress.  This podcast provides an example of respiratory distress:

 http://empem.org/2010/09/bronchiolitis-part-1-of-2/comment-page-1/#comment-294

 3% of children will present with severe illness and require admission (2).  Map of Medicine (http://healthguides.mapofmedicine.com/choices/map/bronchiolitis1.html)  defines “severe” as those with:

• poor feeding – less than half normal intake
• lethargy
• history of apnoea
• respiratory rate above 70breaths/minute
• presence of nasal flare and/or grunting
• severe chest wall recession
• cyanosis
• marked use of accessory muscles
• marked intercostal and subcostal recession
• oxygen saturation (SaO₂) 94% or less

 There have been no therapies that have been consistently effective enough to change the current supportive management of bronchiolitis. The majority of trials show that bronchodilators do not provide benefit and their routine use is not recommended (3). 

 1.http://www.nhs.uk/conditions/Bronchiolitis/Pages/Introduction.aspx

 2. Scottish Intercollegiate Guidelines Network (SIGN). Bronchiolitis in children. A national clinical guideline. Edinburgh: SIGN; 2006. http://www.sign.ac.uk/pdf/sign91.pdf

3. Petruzella FD, Gorelick MH. Current therapies in bronchiolitis. Pediatr Emerg Care 2010 Apr;26(4):302-7