Remote assessment of children the Wessex way this month, tight foreskins, difficult airways and a journal club discussion around the likelihood of meningitis in neonatal UTI. Do leave comments below…
With thanks to Dr Ed Dallas, paediatric registrar, for putting together a succinct guide to eating disorders and the management of re-feeding syndrome.
Re-introduction of nutrition to severely malnourished individuals can precipitate refeeding syndrome which may result in cardiac failure and death.
The key biochemical abnormality is hypophosphataemia, due to total body phosphate depletion and a shift of extracellular to intracellular phosphate when the body changes from a catabolic state to anabolic.
The risk is greatest in the initial stages of refeeding (first week). The incidence increases with decreasing BMI and if weight loss is rapid.
Anorexia is a serious, potentially fatal disease—while refeeding syndrome can be fatal, the risk from malnutrition and ‘underfeeding’ is much greater.
– Assess using SCOFF questionnaire and Sit-up/Squat test.
– Consider differentials for weight loss in children (e.g. Malignancy, hormonal, illness)
– Risk Assessment according to Junior MARSIPAN guidelines: Clinical parameters, location of care, compulsory admission/treatment, legislation (e.g. Gillick competence, Mental Health Act)
See Summary below of what to look for and when to be concerned!
- Baseline bloods: Red flags: Na+ < 130mmol/L, K+ < 3mmol/L, Phosph < 0.5mmol/L often symptomatic if phosphate <1mmol/L (range 1.3-2.1mmol/L), Glucose
- ECG (look specifically for prolonged QTc)
- For children, use the percentage of 50th centile BMI, not just the BMI.*
- All vital signs, however, are to be checked against standard charts for their age. Patients can be hypotensive, bradycardic, hypothermic.
*Plot BMI on growth chart. To calculate percentage median BMI:
Percentage BMI = actual BMI (weight/height2) x 100
median BMI (50th percentile) for age & gender
Treatment & Re-feeding:
Patient should be fed in as normal a fashion as possible. If this fails, NG feeds should be considered early in the admission. Make the decision within 24 hours. Specialist paediatric dietician must be involved early.
Risk from Re-feeding Syndrome can be reduced by careful monitoring and paediatric dietician input into choice of feed composition. A diet too high in carbohydrates increases the risk of re-feeding syndrome.
Consider phosphate (and other) supplementation early. Replace and titrate according to bloods which should be taken just before the supplement is given. Stores are usually replenished after 1 week but continue for at least 2 weeks. Consider long term lower dose supplementation.
Re-feeding Bloods (U&Es, LFTs, Phosphate, Calcium, Magnesium) to be taken before re-feeding, 6 hours after starting and then daily for 2-5 days, then at 7-10 days, at least until 2 weeks. Ideally, bloods to be taken just before any supplementation are given (so levels are not falsely high).
Patients should not be ‘underfed’ for fear of refeeding syndrome: consider starting at 20 kcal/kg/day, 5-10kcal/kg/day if high risk
SCOFF questionnaire for screening Anorexia and Bulimia
Shown to have 100% sensitivity and a specificity of 89% for patients with anorexia and bulimia.
*One point for every “yes”
A score of ≥2 indicates a likely case of anorexia nervosa or bulimia
Young people with an eating disorder may deny all the above, in which case it is very important to use your clinical judgement, monitor the situation and provide follow-up.
Those who are High risk for re-feeding syndrome
- Very low percentage median body mass index
- Minimal or no nutritional intake for the past 3–4 days
- Weight loss >15% in the past 3 months
- Abnormal electrolytes prior to starting re-feeding
→ May need a more cautious approach (5–10 kcal/ kg/day starting regimen) with twice daily bloods
- Paediatric dietician for specialist advice.
- Correct dehydration – usually over 48 hours as too rapid correction can result in cardiac decompensation
- Prescribe multivitamin and mineral supplements; consider thiamine in older children. Start any multivitamins and mineral supplementations before feeding begins (NICE CG9)
- Refeeding should ideally mimic normal eating
- If the patient cannot comply with a meal plan then NG considered by 24 hours. Use a daytime bolus regimen to mimic physiological eating
- Consider starting at 20 kcal/kg/day. Aim for 0.5–1 kg/week weight gain.
- To prevent underfeeding—aim to increase by 200 kcal/day until full nutritional requirements for weight gain are achieved (this should be within 5–7 days).
- If hypophosphataemia develops, maintain rather than reduce calorie intake; consider supplementation.
- Daily Re-feeding bloods (U&Es, LFTs, phosphate, magnesium) during the ‘at-risk’ period of days 2–5 initially, and at 7– 10 days (to identify late refeeding syndrome) up to at least 2 weeks
- Restrict carbohydrate intake and increase dietary phosphate (eg, using milk). If NG feeding, avoid high calorie concentration feeds (high carbohydrate content increases the risk of re-feeding syndrome).
WHAT SHOULD I START DOING?
- Assess nutritional status based on percentage median BMI, and not BMI alone.
- Baseline clinical assessment of risk includes baseline ECG and SUSS test for weakness.
- Have a low threshold for starting NG feeding and avoid an overcautious approach to re-feeding (consider starting at 20 kcal/kg/day and increasing by 200 kcal/day until nutrition is sufficient for weight gain).
- Always consider re-feeding syndrome—monitor patient’s electrolytes (especially phosphate) before and during re-feeding, and assess the risk of re-feeding syndrome prior to starting feeding.
- Prescribe a general vitamin and mineral supplement in younger children, and consider thiamine supplements in older children (main evidence in adults).
WHAT SHOULD I STOP DOING?
- Taking an overcautious approach to re-feeding (may result in underfeeding syndrome)—patients should be receiving sufficient nutrition for weight gain within 5–7 days of re-feeding.
- For patients receiving supplemental or NG feeds, avoid calorie dense feeds, which may be too high in carbohydrates and increase the risk of re-feeding syndrome.
Useful Summary of Marsipan guidelines from BMJ:
Link to FULL Junior Marsipan Guidance from RCPSYCH (75 page PDF):
Medical Management of Anorexia Nervosa:
Managing Anorexia; BMJ Review:
Hypophospataemia in Anorexia Nervosa; BMJ review:
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 Monika Bajaj, neurodevelopmental paediatrician practising privately in east London.
ADHD is a chronic life long disorder of self-regulation with symptoms persisting in >70-80% adolescents and >50% adults.
It is real disorder with real long-term risks, just to quote a few impacts….
- Up to 30% of children may have depression and up to half of girls with ADHD may attempt self-harm
- Children with untreated ADHD are >5 times more likely to participate in fights and underachieve at school
- Adults with ADHD are 9 times more likely to end up in prison, more likely to experience financial problems and being fired from a job.
- Adults with ADHD have a higher mortality compared to those without mainly due to causes such as driving accidents, substance abuse, obesity and co-morbid problems (Dalsgaard et al. Lancet 2015, May;385(9983):2190-6)
- Organisational skills problems (time management, memory, late and unfinished homework and projects)
- Erratic work and academic performance
- Family/marital problems
- Poor sleep and other household routines
- Difficulty managing finances, impulsive shopping
- Compulsive addictions – sex, gambling, video gaming, exercise, eating
- Frequent accidents secondary to recklessness
- Speeding tickets, car and motorbike accidents
- First degree relatives with ADHD
- Low self-esteem, chronic under-achievement
ADHD is usually diagnosed after the age of 6 years to allow for the child to mature. Almost all children have times when their behaviour seems unacceptable and age inappropriate. However, when behaviours happen many times a week or daily, ADHD ought to be looked for. NICE guidance allows children to be treated after the age of 5 years and medication makes a huge and quick difference along with psychoeducation and behavioural management.
Resources: The Canadian ADHD Resource Alliance (www.caddra.ca is an excellent resource for professionals with free downloads).
US guidelines have recently changed to allow treatment of some 4 year olds with debilitating features of ADHD (https://www.healthychildren.org/English/news/Pages/Practice -Guideline-for-the-Diagnosis-Evaluation-and-Treatment-of- ADHD.aspx)
UK support group: https://www.borntobeadhd.co.uk/
With thanks to Dr Cate Luce:
Here is a systematic approach to burns using an ABCDE approach.
- 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?
- Toxic shock syndrome https://www.nhs.uk/conditions/toxic-shock-syndrome/5
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
The 2nd Paediatric and Neonatal Cardiac Emergencies Course is being run at Homerton University Hospital in London again this April. The expert faculty come from Great Ormond Street Hospital, Evelina, Homerton and Barts Health. Paediatric cardiologists, simulation trainers, neonatologists and paediatricians with expertise in cardiology and life support instructors. Do come along for a fun if somewhat intensive couple of days of defibrillation, terrifying talks on QT intervals, enlightening workshops and – acting on feedback from candidates who just couldn’t get enough last year – no less than 6 full immersion simulations. Application forms from the e-mail address on the flyer.
Flyer available to download from http://www.paediatricpearls.co.uk/wp-content/uploads/2020/01/Cardiology-Course-Flyer-April-2020.pdf . You’ll need lots of blue ink in your colour printer – sorry.