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 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.
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%!
Local anaesthetic cream this month (why do some places not use it in the under 1’s?), a link to useful “flash card” learning in the paediatric ED from Leicester, new Movicol doses, diphtheria and the last instalment of urinalysis with bilirubin and urobilinogen. A reminder also to please discuss children with glycosuria and a high BM with a paediatrician – most children have type 1 diabetes and are at risk of DKA at diagnosis. Do leave comments below:
With thanks to Dr Kat Smith, education fellow and paediatric registrar at King’s College Hospital who answered my call last month for more writers to help me put together the monthly Paediatric Pearls newsletters.
Group A Streptococcal Infection in Chickenpox
Chickenpox in children is common and usually follows a mild and self-limiting (if somewhat itchy) course. After an incubation period of 10-21 days the first signs of illness are viral prodrome, mild pyrexia, and the classic cropping vesicular rash; the pyrexia is typically mild (38-39oC) and lasts 3-4 days.
In otherwise healthy children the most common complication of chickenpox is secondary bacterial skin infection, typically caused by scratching lesions. Whilst most of these are mild impetigo or localised cellulitis, the increased incidence of group A streptococcal (GAS) colonisation in children (around 10% are asymptomatic carriers in the throat or on skin) makes invasive GAS infection a real concern.
Secondary bacterial skin infection
This is characterised by erythema +/- tenderness around lesions. Children may be well in themselves if the infection is superficial; if they become more unwell this raises the suspicion of a more serious or invasive bacterial infection.
Serious bacterial superinfection / Invasive GAS infection
Around a third of children admitted to hospital with chickenpox have secondary skin infection, some of whom develop invasive infections such as pneumonia, osteomyelitis and septicaemia. GAS in particular can be associated with more fulminant infectious processes such as necrotising fasciitis and toxic shock syndrome (TSS); both are associated with high mortality and morbidity in children.
Features that should prompt consideration of a serious bacterial superinfection are:
- A lethargic or unwell-looking child; remember, children with chickenpox are typically uncomfortable but well.
- Spiking, high-grade pyrexia
- Pyrexia for longer than 4 days, particularly after initial improvement
- Diarrhoea or vomiting
- Soft tissue pain which seems disproportionate to other examination findings (an early sign of necrotising fasciitis)
How to prevent bacterial superinfection
Because scratching lesions is the most likely way to allow bacteria to breach the body’s normal defences, the primary aim of prevention is to limit scratching:
- Keep skin moisturised. Many parents still use calamine lotion but it is worth noting that it becomes ineffective once dry, and traditional emollients (e.g. 50:50) may be more effective.
- There is evidence that sedating antihistamines offer some benefit; chlorphenamine is licensed for this use.
- Dress children in smooth, loose, cotton clothing.
- Keep fingernails trimmed short.
- There are rare reports of NSAIDs potentially worsening skin infections in chickenpox, so ibuprofen should be used with caution. In practice, it would be unusual for a child to need ibuprofen if receiving regular paracetamol; pain or pyrexia necessitating its use in addition to paracetamol should prompt consideration of serious bacterial superinfection.
- There is no evidence to support the use of acyclovir in young, immunocompetent children with self-limiting, uncomplicated chickenpox; it does not decrease the incidence of complications.
What to do if you suspect bacterial superinfection
- Otherwise well children with evidence of few, small areas of bacterial superinfection can be managed in the community with oral antibiotics and safety-netting advice.
- Children with evidence of collection, extensive areas of bacterial superinfection, who are unwell, or have other features consistent with possible serious bacterial superinfection, need urgent referral to secondary care.
- In secondary care, unwell children with evidence of shock / sepsis need urgent resuscitation and intravenous antibiotic administration; if possible this should include clindamycin, due to its vital role in inhibiting toxin production by GAS.
- Invasive GAS infection has high mortality, and if suspected there should be a low threshold to involve senior staff, regional PICU services, and in the case of necrotising fasciitis, surgical teams (for early debridement); early use of inotropes and IVIG may also be required.
Chickenpox NICE Clinical Knowledge Summary (which I found to be the best resource by far): http://cks.nice.org.uk/chickenpox
Cohen J, Breuer J. Chickenpox treatment. Systematic review 912. BMJ Clinical Evidence.
Papadopoulos, AJ. Chickenpox. emedicineWebMD. www.emedicine.com
Re: “the increased incidence of group A streptococcal (GAS) colonisation in children (around 10% are asymptomatic carriers in the throat or on skin)”
Shaikh N, Leonard E, Martin JM. Prevalence of streptococcal pharyngitis and streptococcal carriage in children: a meta-analysis. Pediatrics. 2010 Sep;126(3):e557-64
Re. “Around a third of children admitted to hospital with chickenpox have secondary skin infection”:
Bovill B, Bannister B. Review of 26 years/ hospital admission for chickenpox in North London. Journal of Infection. 1998;36(suppl1);17-23.
Re: “necrotising fasciitis and toxic shock syndrome (TSS); both are associated with high mortality and morbidity in children.” AND “IVIG may also be required.”
Chuang YY, Huang YC, Lin TY. Toxic shock syndrome in children: epidemiology, pathogenesis, and management. Paediatr Drugs. 2005;7(1):11-25.
Re. “There is evidence that sedating antihistamines offer some benefit”
Tebruegge M, Kuruvilla M, Margarson I. Does the use of calamine or antihistamine provide symptomatic relief from pruritus in children with varicella zoster infection? Archives of Disease in Childhood. 2006:91(12);1035-1036.
Re: (continued from above) “chlorphenamine is licensed for this use.”
BNFC, available at: https://www.medicinescomplete.com/mc/bnfc/current/PHP1934-chlorphenamine-maleate.htm?q=chlorphenamine&t=search&ss=text&tot=40&p=1#_hit
Re: “if possible this should include clindamycin, due to its vital role in inhibiting toxin production by GAS.” (as well as having it drilled in to us by the microbiologists at St Thomas’):