Lots about diarrhoea this month. Also ADHD and no need any more for an ECG prior to starting medication. Obesity in A&E; can we at least start the journey towards a more healthy future in the Emergency department?
A visual guide to the most common food allergies this month and pointers to new guidance on when to introduce allergenic foods to babies. The EATERS history is useful in ruling out allergy and there’s a good mnemonic about soap to stop us all misdiagnosing penicillin allergy. Do leave comments below:
with thanks to Dr Edward Dallas, paediatric registrar.
Constipation is <3 stools per week, often hard and large or rabbit droppings, often painful, possibly with overflow. Its prevalence is around 5-30%!
Most is idiopathic/functional, but the clinician must rule out red flag symptoms such as:
- Constipation from birth
- Delay in passing meconium <48 hours from birth, could suggest Hirschsprung’s or Cystic Fibrosis
- Abdominal distension with vomiting, could suggest obstruction
- Leg weakness or motor delay, could suggest neurological or spinal cord problem
- Ribbon stool pattern, could suggest anal stenosis (usually presents <1 yr)
- Faltering growth, could suggest coeliac disease or hypothyroidism
Remember that breast fed babies can have long periods between stooling. The introduction of cow’s milk based formulas can lead to constipation. Constipation often plays a big part in bedwetting and daytime continence issues. Examine the abdomen and spine in a child with enuresis.
The aetiology of constipation is multifactorial and includes: pain, fever, inadequate fluid intake, reduced dietary fibre intake, toilet training issues, the effects of drugs, psychosocial issues, and a family history of constipation. Primary school children who can’t quite organise themselves to empty their bowels before going to school and then won’t use the toilets at school often get bunged up quite quickly after starting school.
Management of idiopathic/functional constipation:
The management of functional constipation has 6 main components:
1– Education (demystification)
2- Fluids and diet
3- Regular toilet habit (behavioural) and exercise (re-training)
4- Disimpaction (if in doubt, disimpact!)
5- Maintenance laxatives
6- Regular follow up and support
Diet and Lifestyle advice e.g., regular toilet breaks with praise, star chart etc.
Reassurance, with sources of information & support:
- NHS: https://www.nhs.uk/conditions/baby/health/constipation-in-children/
- ERIC: https://www.eric.org.uk/what-is-constipation
- The Poo in You – Constipation and Encopresis Educational Video from Children’s Hospital Colorado
Longstanding constipation is unlikely to get better without medication. If left, it gets worse so please ensure you start the child on treatment before considering referral.
Usually start with a “Dis-impaction regime” which includes increasing doses of Paediatric Movicol, often adding Senna after a few days if the child still seems to not be passing the lumps. See https://pathways.nice.org.uk/pathways/constipation.
(A parent’s guide to dis-impaction can be found here: https://www.eric.org.uk/pdf-a-parents-guide-to-disimpaction)
If Movicol is not tolerated, try:
Bisacodyl tablets e/c 5mg (swallow whole)
OR Sodium picosulfate liquid 5mg/5mL
See NHS Lothian formulary for age-appropriate dosing at https://www.ljf.scot.nhs.uk/LothianJointFormularies/Child/1.0/1.6/Pages/default.aspx
Once dis-impacted, the child should be switched to a Maintenance regime to allow muscles and nerves to return to normal. This will take at least 6 months. Don’t stop medications too early!
Paediatric Movicol 1-4 sachets/day
If over 12 years old, use adult Movicol / cosmocol 1-2 sachets per day
Lactulose and Senna – see BNFc or the NHS Lothian formulary for suitable doses. Lactulose is bad for teeth. All laxatives can be diluted with squash, fruit juice, water or milk.
Regular follow-up and support. Aim to wean off once the child has had soft stools for at least 6 months.
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%!
April came and went a bit too fast for my Paediatric Pearls head. So I’ve produced a joint April/May newsletter for 2019. There’s a bit of safeguarding again this month with a link to a paper on what young people in care think of the language we use, a guide to enteral rehydration of children with D&V, acrodermatitis enteropathica and a reminder of what is normal on a paediatric ECG. Do leave comments below:
I got a few blank faces on a ward round recently when I was working out volumes of diarolyte for rehydrating a child with D&V. We tend to use “5mls every 5 minutes” in our Emergency Departments whatever the size of the child and however dehydrated they are and then, when they fall asleep and we want to move them out of our department for fear of 4-hour breaches, we put an iv line in, take bloods which we then have to act on and start iv fluids which we should then monitor more often than most of us do. Where is the half way point?
Have a look at http://www.paediatricpearls.co.uk/wp-content/uploads/Fluid-management-in-childhood-gastroenteritis.pdf for some help with enteral rehydration (which is safer and more efficient overall than intravenous fluids). Please let me know if you disagree with my calculations and work them all out for yourself from scratch if you happen to be dealing with a 16kg child like in the worked example…
Genetics this month and an explanation of the microarray test. Managing measles contacts in the “lessons from the front line” section, use of a smartphone app for recording palpitations and the start of a new dermatology series – skin manifestations of systemic disease. Do leave comments below.
With thanks to Dr David Gardiner, one of our current paediatric FY2 doctors at Homerton University Hospital, for updating us on HUS.
- Profuse diarrhoea that typically turns bloody after 1-3 days
- Abdominal pain (crampy)
- Fever (sometimes)
- Reduced urine output (abrupt onset) but also polyuria/normal urine output (rarer)
- Neurological complications: seizure, coma, cranial nerve palsies, confusion, hallucinations
- Classic triad – anaemia, uraemia and thrombocytopaenia
- Most common in children under the age of 5
- B/P – hypertension
- Blood film: Fragmentation and signs of haemolysis (Coombs test negative)
- Raised WCC and neutrophils, low platelets, low Hb
- Raised LDH
- Clotting screen typically normal (cf DIC)
- Raised bilirubin, low albumin
- Urea and creatinine raised
- Stool for PCR E.Coli
- Refer to secondary care urgently
- Strict input/output fluid monitoring
- Correction of anaemia
- Correction of electrolyte imbalances
- Antihypertensive therapy if required
- Furosemide to induce diuresis
- Report to PHE – can’t go back to school until 2 negative stool samples