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?
Useful resources in preparation for this year’s expected RSV bronchiolitis surge in this month’s newsletter. Also, a bit on managing young people who are “tired all the time”, height and weight issues in non face-to-face consultations and a short article asking why do we give children 10 days of foul tasting pen-V qds for tonsillitis instead of 5 days of tds amoxicillin which, it transpires, is actually cheaper? Microbiologists and others are welcome to leave comments below!
Digging deep into safeguarding again this month with thanks to Nicci Wotton, head of safeguarding at Imperial, London, UK. A reminder of useful apps for our young patients and pointers to documents that govern our safeguarding responsibilities in the UK and internationally. Do leave comments below.
Testicular torsion this month – a surgical emergency with good outcomes if operated on less than 6 hours since the pain started.
Also, links to helpful health and well being websites for young people and to good ECG CPD for psychiatrists and GPs. A bit more on ADHD and a round up of neck lumps in infants, assessment and management.
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:
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/
Using HEADSSS assessment by Dr Emma Parish
In the UK we often discuss our ageing population but sometimes fail to see the significant proportion of those in adolescence, between 12 – 19% of the total UK population in 20171.
Engaging this age group can be daunting for health professionals. HEADSSS is an interview prompt or psychosocial tool to use with young people. Still growing in the consciousness of health professionals (and in the letters making up its acronym) HEADS(SS) was first presented in publication in 19882. It has a reported yield of 1 in 3 for identifying concerns that warrant further investigation.
It follows a simple structure remembered by the acronym:
Education & Employment
Self-harm, depression & suicide
Safety (including social media/online)
The great news is that many studies have shown that self-assessment with HEADSSS tools before discussion (completed at home or in waiting rooms) yields equal, and in some cases more, information than conducting the assessment in person. Helpful for time-strapped clinicians and better utilisation of time for young people attending appointments.
Key tips for using HEADSSS
- Greet young person first, let them introduce others
- Practice discussing issues that embarrass you
- Be clear in what you mean by confidentiality relating to discussion
- See young people on their own routinely (whenever clinically appropriate)
- Use linking phrases and questions that don’t presume:
- Do you have a boyfriend/girlfriend?
- Do you have someone important in your life?
- Have you been in a relationship before? Tell me more…
For more details see the RCPCH Young People’s Health Special Interest Group (YPSIG) app – free to download here: https://app.appinstitute.com/heeadsss
Or this short HEADS-ED assessment tool: http://www.heads-ed.com/en/headsed/HEADSED_Tool_p3751.html
- Association of Young People’s Health – Key Statistics Document 2017 download here: http://www.ayph.org.uk/keydata2017/FullVersion2017.pdf
- Cohen, E, MacKenzie, R.G., Yates, G.L. (1991). HEADSS, a psychosocial risk assessment instrument: Implications for designing effective intervention programs for runaway youth. Journal of Adolescent Health 12 (7): 539-544.