ADHD

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)

Red Flags:

  • 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/

 

Do you know your ABCDDE of burns management?

With thanks to Dr Cate Luce:

Here is a systematic approach to burns using an ABCDE approach.

A: Is their airway compromised?

Consider in:

  • Facial burns
  • Smoke Inhalation
  • Dyspnoea
  • Hoarseness
  • Drooling
  • 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.

https://em3.org.uk/foamed/25/10/2015/remember-remember-burns-and-blasts 2

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
  • Face/hands/feet/perineum/flexures/circumferential
  • Inhalation
  • 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.

References

  1. 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/
  2. Sillett, Remember, Remember Burns and Scalds, https://em3.org.uk/foamed/25/10/2015/remember-remember-burns-and-blasts
  3. NICE, Burns and Scalds 2019, cks.nhs.uk/burns_and_scalds.
  4. https://app.merseyburns.com/
  5. Toxic Shock Syndrome 2019, https://www.nhs.uk/conditions/toxic-shock-syndrome/
  6. Child Protection Evidence, Systemic review of burns, July 2019, https://www.rcpch.ac.uk/sites/default/files/2019-09/child_protection_evidence_-_burns.pdf

 

April 27th and 28th 2020 Homerton/GOSH cardiac emergencies course

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.

Happy Christmas and best wishes for the new decade from the Paediatric Pearls team, December 2019

A bit of a viral soup this month with articles on ‘flu vaccines, how long should children have off school when unwell, NAFLD, and dermatomyositis.  Do leave comments below.

November 2019 PDF digest

Bloody diarrhoea this month.  Inflammatory bowel disease patients are getting younger.  Also croup and acanthosis nigricans, 2 things that probably don’t go together very often.  Do leave comments below.

October 2019 PDF

Causes of chest pain in children this month (hint: it’s not the heart), causes of tachycardia, nosebleeds, Down Syndrome annual reviews, causes of erythema nodosum and a link to a fantastic document on the top 20 paediatric outpatient referrals.  Read this document from Birmingham Women and Children’s Hospital and cut your referrals by at least 50%!

September 2019 PDF digest

I’m uploading this month’s newsletter while teaching in Vietnam at the invitation of a very impressive charity, https://www.newbornsvietnam.org/.  I’m glad of the extra 6 hours of September – thanks to the time difference – to publish this on time!

Palivizumab this month; are all your eligible patients having it?  A glance at the updated BTS/SIGN guideline on asthma, a very rare case of a cardiac cause of chest pain, how to estimate a child’s weight in an emergency and a bit on haemolysis secondary to G6PD deficiency.  Do leave comments below…

August 2019 Paediatric Pearls newsletter uploaded

More on the coca-cola urine story this month, NF type I, cerebellar ataxia and restless legs syndrome.  Do leave comments below.

July 2019 PDF

July 2019:  Honing in on coca cola coloured urine this month and a closer look at armpits.  Links to suitable child safeguarding CPD on harmful sexual behaviour and a look at the ANA test.  Do leave comments below.

June 2019 newsletter

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: