October 2014 holds quite a few topics: scalp ringworm, sleep and behaviour, support for victims of sexual abuse, immunotherapy for peanut allergy, link to parental asthma booklet and what to do with babies with chicken pox. Do leave comments below…
With thanks to Dr Vicky Agunloye, paediatric registrar and new Waltham Forest mum, for kicking off her parental FAQ series with a question that many GPs ring and ask me – and I always have to look it up…
Chicken pox , Varicella-Zoster Virus (VZV), is a common infection spread by droplet inhalation of the VZV from contacts with either chicken pox or shingles.
Most children have a mild disease course; however those that are immuno-compromised are at a significant risk of severe or fatal disease and need human Varicella Zoster Immunogloblin (VZIG) as soon as possible. Some neonates (<=7 days old) come into this category.
Who needs VZIG? :
- Infants whose mothers develop chickenpox (but not herpes zoster) in the period 7 days before to 7 days after delivery. VZIG can be given without antibody testing in these infants.
- An infant < 7 days of age whose contact of VZV was not the mother and mother has no positive history of VZV herself.
(Confirm patient has had significant contact, Box 1 in: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/327762/Chickenpox_immunoglobulin_Oct_2008.pdf )
Who does not need VZIG?
- Term infants > 7 days old, even if they have had significant contact
- An infant that has not had significant contact, see above.
- A term infant who is < 7 days old, whose mother has a positive protective history of VZV.
- Infants who have been exposed >10 days ago.
Whose VZV anti-bodies need checking before you can decide if VZIG is needed?
- Infants <7 days whose mothers are unsure of their VZV status (you can check mothers or infants). However do not delay more than 7 days waiting for results.
Inform mothers that up to 50% of neonates exposed to maternal VZV who get VZIG still go on to get chickenpox, most are mild cases.
If infant becomes symptomatic despite VZIG, IV acyclovir is needed.
Other useful links:
- Page 434-435: http://www.clinicalguidelines.scot.nhs.uk/Renal%20Unit%20Guidelines/Nephrotic%20syndrome%20Guideline/Varicella%20doc.pdf
Steroids vs Steroids & Antivirals for Bell ’s Palsy
by Dr Tom Waterfield
Bell’s palsy is an idiopathic facial nerve palsy first described by Sir Charles Bell in 1830. It typically presents with a sudden onset of unilateral facial palsy. It presents as a unilateral lower motor neurone weakness ie. the forehead is also involved (if the forehead is not involved, this is an upper motor neurone weakness with a different aetiology and needs prompt referral for further investigation). The prognosis in true Bell’s is typically good with up to 90% of children recovering by 3 months of age1. The mainstay of management in children is supportive (artificial tears/patching). The convention – at least in adults – is for the early (within 72 hours of onset) use of oral prednisolone at a dose of 2mg/kg (max 60-80mg) for 5 days followed by a 5 day tapering dose2. The evidence base for this comes from large randomised controlled studies in adults3,4.
Evidence for the use of steroids alone
Two large double blind randomised control studies looking at over 1300 patients demonstrated that early use of Prednisolone orally significantly improved symptoms at 3 months (p<0.001) with a NNT of around 53,4. There are no similar studies in children and it is worth considering that children typically have a better prognosis than adults. Whilst prednisolone orally would be appropriate and safe for most children there may be instances where the risks of oral steroids could be considered too great to justify their use i.e. in a poorly controlled diabetic patient (which is a group in whom Bell’s palsy is more prevalent).
Evidence for the use of combined steroids and antivirals
In the last decade there has been an ongoing debate around the use of oral antiviral agents such as Aciclovir in the management of Bell’s Palsy. It is widely believed that Bell’s Palsy is due to an underlying Herpes Simplex infection and PCR studies have demonstrated concurrent HSV infection at the facial nerve in adult patients with Bell’s Palsy5. Despite this, good quality, large scale studies looking at the efficacy of oral antiviral agents have failed to demonstrate a benefit3,4.
The current evidence base for the medical management of Bell’s palsy comes predominantly from adult data3,4. Children typically have a milder illness with a quicker recovery than adults irrespective of the treatment chosen1. UpToDate would have us believe that the mainstay of medical management is the use of oral steroids at a dose of 2mg/kg(max 60-80mg) for 5 days followed by a 5 day taper. Additional antiviral treatment appears to be unnecessary with large-scale, high quality studies not showing a benefit. Smaller, lower quality studies have suggested additional antivirals may be useful and these could be considered on a case by case basis6,7. For example in a severe case (complete paralysis) with clinical evidence of concurrent Herpes Simplex infection it may be worth considering additional antiviral medication such as oral Aciclovir.
- Peitersen E. Bell’s palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. ActaOtolaryngol Suppl. 2002.
- https://www.aan.com/Guidelines/Home/GetGuidelineContent/574 (Last accessed 19/08/2014 at 12:03)
- Sullivan FM, Swan IR, Donnan PT et al. Early treatment with prednisolone or acyclovir in Bell’s palsy. N Engl J Med. 2007;357(16):1598.
- Yeo SG, Lee YC, Park DC, Cha CI. Acyclovir and steroid versus steroid alone in the treatment of Bell’s palsy. Am J. Otolaryngol 2008;29:163–168.
- Schirm J, Mulkens PS. Bell’s palsy and herpes simplex virus. APMIS. 1997;105(11):815.
- Minnerop M, Herbst M, Fimmers R, Kaabar P et al. Bell’s palsy: combined treatment of famciclovir and prednisone is superior to prednisone alone. Neurol. 2008 Nov;255(11):1726-30.
- Lee HY, Byun JY, Park MS, Yeo SG.Steroid-antiviral treatment improves the recovery rate in patients with severe Bell’s palsy.Am J Med. 2013 Apr;126(4):336-41.
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.
April wasn’t quite long enough this year for me to get the newsletter out in time – or something like that anyway. With thanks to Stephen Flanagan of the London PHE for his input into the measles textbox and Paul Gringras for help with the sleep series again. Jess has put together another superb article for her minor injuries series and I hope you find the links to the healthy weight clinics helpful for your patients locally. Click here for the April/May 2013 newsletter.
August’s PDF only has 4 text boxes but with lots of information crammed into them and extra on the blog. A great looking PDF on poisoning in children from one of our registrars, an article on stammering from another working with a speech and language therapist and an update on BTS pneumonia guidelines just in time for the winter. Also a feature on Cardiff’s core info safeguarding work on the evidence behind different types of fractures. Do leave comments…
In October 2011 the British Thoracic Society updated its guidelines on community acquired pneumonia in children. Dr Michael Eyres looked at it in more detail for Paediatric Pearls. He was also part of our local audit team contributing to the national audit. The results showed that we, despite insisting on as few investigations as possible, are still doing too many chest x-rays, blood cultures and CRP measurements. Think – will it change management?
Here are the basics:
When to consider pneumonia
Persistent fever > 38.5°C + chest recessions + tachypnoea
• CXR should not be considered routine and is not required in children who do not need admission.
• Acute phase reactants including CRP are not useful in distinguishing viral from bacterial infection and should not
be tested routinely. Blood cultures also do not need to be routinely taken.
• Daily U&Es are required in children receiving IV fluids.
• Children with oxygen saturations <92% need hospital referral.
• Auscultation findings of absent breath sounds with dullness to percussion need hospital referral.
• Children should be reassessed if symptoms persist.
• Give parents information on managing fever, preventing dehydration and identifying deterioration.
• Children with oxygen saturations <92% need oxygen.
• NG tubes should be avoided in severe respiratory compromise and in infants.
• Chest physio is not beneficial and should not be performed in pneumonia.
• All children with a clear clinical diagnosis of pneumonia should receive antibiotics as bacterial and viral
infections cannot be reliably distinguished. However most children younger than 2 years presenting with mild symptoms of respiratory distress (this would
include the bronchiolitics) do not usually require antibiotics.
• Amoxicillin is the oral first-line for all children as it is effective, well tolerated and cheap.
• Macrolides if no response to first-line / suspected mycoplasma or chlamydia / very severe disease.
• Augmentin if pneumonia associated with influenza.
• Oral agents are effective even in severe pneumonia; IV is needed only if unable to tolerate oral or there are
signs of septicaemia, empyema or abscess.
• Children with severe pneumonia or complications should be followed up after discharge until they have recovered completely and
CXR is near normal. Follow-up CXR is not otherwise required, but may be considered in round pneumonia, collapse or if symptoms persist.
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.