August is full of cyclical vomiting, insect bites, asthma plans and NICE “do not do” recommendations. Do leave comments….
More musings from Dr Waterfield this month – this time on paracetamol for immunisation discomfort. Also the 7 important features of a headache y0u must ask about, a link to a very good paediatric emergency medicine site, NICE quality standards in depression, molluscum contagiosum and more musings from me, this time on paediatric phlebotomy. Do leave comments below.
Eczema this month, a reminder of treatment of infections and links to some useful audit tools from NICE. Next month, scabies. Another excellent website on food and nutrition in toddlers with a bit on do’s and don’ts of faddy eating and a paper on whether treating ADHD reduces crime. Do leave comments.
Article by Dr Hajera Sheikh, paediatric registrar
Assessment in Secondary Care
• Lifestyle Assessment
• Menstrual History
• Obstructive Sleep Apnoea: Snoring, difficulty breathing during sleep, morning headaches or fatigue
• Symptoms of co-morbidity including psychological
• Drug use (particularly glucocorticoids and atypical antipsychotics)
• Family history, particularly diabetes <40 yrs, early heart disease <60 yrs
• Height, weight, BMI
• Obesity pattern: generalised, central (greater risk of adverse cardiovascular outcomes), buffalo hump and neck (may be suggestive of Cushing syndrome)
• Blood pressure
• Pubertal assessment
• Acanthosis nigricans (indicative of insulin resistance, first seen round neck and axillae)
• Signs of endocrinopathy
• Dysmorphisms: (Look out for early onset obesity, learning difficulties, deafness, epilepsy, retinitis, dysmorphic features, hypogonadism)
• Thyroid function
• Fasting lipids (total and HDL cholesterol), triglycerides
• Liver function, including ALT
• Fasting glucose and insulin not usually done first line
Refer to Paediatric Obesity/Endocrinology or other specialist service if further investigation is required
• Genetic studies
• Thyroid studies: T3, thyroid antibodies, calcium, phosphate
• Cushing syndrome investigations
• Oral glucose test
• PCOS studies (LH, FSH, adrenal androgens, Sex Hormone Binding Globulin, prolactin, pelvic ultrasound)
• Sleep Study
Dysmorphic and monogenic syndromes associated with obesity:
Main clinical obesity associated syndromes:
• Autosomal dominant
Biemond syndrome (some cases)
• Autosomal recessive
Biemond Syndrome(some cases)
• X-linked inheritance
• Single gene lesions affecting leptin metaboilsm
Congenital leptin deficiency
Leptin receptor mutation
Prohormone convertase 1 mutation
Melanocortin 4 mutation
Clinical features suggesting obesity may be secondary to another condition or syndrome
• Severe unremitting obesity
• Disorders of the eyes
Retinal problems, especially retinitis pigmentosa
Narrow palpebral fissures
Abnormally positioned palpebral fissures
Severe squint (eg Prader-Willi)
• Skeletal abnormalities
• Sensorineural deafness (eg Alstrom syndrome: sensorineural deafness, diabetes mellitus, retinal dystrophy, obesity)
• Microcephaly and/or abnormally shaped skull
• Mental retardation
• Renal abnormalities
• Cardiac abnormalities
With many thanks to Dr Harriet Clompus, paediatric SpR with an interest in community paediatrics for summarising this core-info topic so neatly and usefully.
Emotional Neglect and Abuse
Core-info, a Cardiff university based research group, examines all areas of child abuse by systematically reviewing worldwide literature and producing recommendations based on best evidence. This is a useful resource for paediatricians, general practitioners, health visitors, nurses, social workers, educators. Find all their reviews at www.core-info.cardiff.ac.uk.
Core-info have produced a leaflet in cooperation with National Society of Prevention of Cruelty against Children (NSCPCC) following a review in 2011 of the available literature on emotional neglect and abuse in children less than 6 years old. The leaflet is available at NSCPCC resources at www.nspcc.org.uk/inform. You can also subscribe to CASPAR a news service that signposts you to latest policy, practice and research in child protection.
Definitions of emotional neglect and emotional abuse vary, but all include persistent, harmful interaction with the child by the primary care-giver.
The Core-info/NSPCC leaflet reports one in 10 children in the UK experience severe neglect in childhood. It uses the WHO definitions for emotional neglect and abuse. (World report on violence and health (2002) page 60. Edited by Krug et al)
‘Emotional neglect is the failure of a parent to provide for the emotional development of the child.’
Examples of emotional neglect include:-
– Ignoring the child’s need to interact
– Failing to express positive feelings to the child, showing no emotion in interactions with the child
– Denying the child opportunities for interacting and communicating with peers and adults.
‘Emotional abuse includes failure of a care-giver to provide an adequate and supportive environment and includes acts that have an adverse effect on the emotional health and development of a child. Such acts include restricting a child’s movements, denigration, ridicule, threats and intimidation, discrimination, rejection and other non-physical forms of hostile treatment.’
Examples of emotional abuse include:-
– Persistently telling a child they are worthless or unloved
– Bullying a child or frequently making them frightened
– Persistently ridiculing, making fun of or criticising a child.
The core-info/NSCPCC leaflet categorises behaviour/interactions to be concerned about in three different age groups (it only gives data up to 6 years and on mother (not father or other caregiver) interaction, reflecting data collection in studies reviewed). Attachment to mother is disordered and emotionally neglected children show typical pattern of initially passive and withdrawn and then hostile and disruptive behaviour and developmental delay especially in speech and language.
1) Infant (<12 months old)
- Mother-child interaction: mother insensitive and unresponsive to child’s needs. Rarely speaks to child, describes them as irritating/demanding. Failing to engage emotionally with child during feeds. Child unconcerned when mother leaves and when mother returns, child avoids her or does not go to her for comfort.
- Behaviour: Quiet and passive child. May demonstrate developmental delay within first year, particularly in speech and language (particularly if mother has had depression).
2) Toddlers (1-3 years old)
- Mother-child interaction: More obvious that mother is unresponsive or does not respond appropriately to child (called ‘lacking attunement’). Mother is often critical of child and ignores signals for help. Child is angry and avoidant of their mother.
- Emotionally neglected/abused children grow less passive and more aggressive and hostile, particularly with other children. They show more memory deficits than other children, including physically abused children.
3) Children (3 -6 years)
- Mother-child interaction: Mother offers little or no praise, rarely speaks to the child and shows less positive contact. Mother is unlikely to reach out to the child to relieve distress and the child is unlikely to go to the mother for comfort. Neglectful mothers are more likely to resort to physical punishment than other mothers.
- Emotionally neglected children show more speech and language delay than physically abused children. Girls show more language delay than boys. Their behaviour is often disruptive (rated more disruptive by parents and teachers than physically abused children or controls). They show little creativity in their play, have difficulty interpreting others emotions and have poor interactions with other children. They tend to be less likely to help others or expect help themselves.
Implications for practice:
– All practitioners (gps, paediatricians, nursery nurses and teachers, health visitors etc) need to consider emotional neglect and abuse when assessing a child’s welfare. The longer a child is left in an emotionally neglectful or emotionally abusive environment, the greater the damage. However intensive work with families to increase parental sensitivity to their child’s needs, can lead to improvements in child’s emotional development.
– Important attachment disorders are recognisable in young infants and merit referral to professionals trained in infant mental health (Waltham forest has a Parent Infant Mental Health Service (PIMHS) which accepts referrals related to disordered attachment in children under 3 years. PIMHS works with the mother and child to foster healthier attachment (the earlier in a child’s life this is done, the better the outcome). Any health care professional can refer a family to PIMHS. See paediatric pearls from May 2012 for more information:- www.paediatricpearls.co.uk/…/the-parent-infant-mental-health-service-pimhs
– In older children (>3 years) it can be difficult to know when and where to refer. Emotional neglect and abuse is by definition a persistent behaviour pattern, so cannot be diagnosed on the basis of one short consultation. Concerns about parent-child interaction witnessed in a short consultation in A+E or GP surgery may trigger a health-visitor review to gather information, prior to a possible referral to social services. Information should be sought from all those involved in the child’s care including nursery/school teachers. If concerns around behaviour witnessed in A+E or GP surgery are severe, an immediate referral to social services may be appropriate.
– Professionals should be able to recognise speech and language delay and refer appropriately. See paediatric pearls from April 2012 www.paediatricpearls.co.uk/…/stages-of-normal-speech-development/. Many of the features found in emotionally neglected and abused children may also be observed in those with Autistic Spectrum Disorder (ASD) or Attention Deficit and Hyperactivity Disorder (ADHD). If a child is showing language delay and behavioural disruption they should be referred for a formal child development assessment (either in speech and communication clinic (SACC) or child development clinic (CDC) – refer to Wood Street Child Development team in WF)
– Consider risk factors – Core-info’s systematic review did not encompass ‘risk factors’ for emotional neglect and abuse. However it states that ‘many of these children live in homes where certain risk factors are present. Namely – domestic abuse, maternal substance misuse, parental unemployment or mental health issues, an absence of a helpful supportive social network, lack of intimate emotional support and poverty’.
The PPIMHS teams are made up of perinatal psychiatrists, community mental health practitioners and psychotherapists/psychologists and they accept referrals from Health Visitors, GPs, midwives, Children’s Centres workers or other health professionals and self-referrals. Click here for their referral form. They may signpost elsewhere after the initial consultation if appropriate or they will offer the parent/carer and infant/child 9-12 sessions to work on the parent-infant relationship and/or psychiatric support as required.
Groups particularly at risk of having problems with bonding include families with ex-premature babies who have spent a significant amount of time on the Special Care Baby Unit, those where the baby has feeding issues or is difficult to soothe, those where breastfeeding failed to establish and those where there was a traumatic birth or difficult conception and/or pregnancy. Many of the parents on their case load have a personal history of disturbed attachments and are keen not to let history repeat itself. A recent audit showed that 41% of their mothers had some sort of mental health diagnosis which means that 59% did not. Click here for an information leaflet about their service that you might like to give to your patients.
Mums with postnatal depression or post-partum psychosis should be referred directly to PPIMHS. Parents struggling with a crying baby or fussy toddler but with no bonding issues should be referred to their health visitor. The PPIMHS team is a tier 3 (specialised) service concentrating primarily on the parent-infant relationship and perinatal mental health.
Symptoms in the baby that might suggest a bonding problem:
extreme clingy behaviours, fussy, difficult to soothe, abnormal self-soothing behaviours (eg. head-banging, hair-pulling, scratching), excessive sleep problems, extreme feeding problems, lack of verbal and non-verbal communication, stiff or floppy posture, extreme fearfulness or watchfulness, lack of interest in the world, no comfort sought from parents, avoids eye contact with parents, smiles very little.
Symptoms in the parent:
high anxiety and panic about the baby, excessive A and E or GP presentations, feeling frightened of harming the baby, lack of separation between parent and baby, baby never put down, excessive sterilising of bottles and toys, detached feelings about the baby, no pride in their development, anger about baby as if baby intends to upset the parent, feelings of failure as a parent, inability to cope.
There is some evidence around this issue and around maternal stress during pregnancy and the effect of high maternal cortisol levels on the foetus’ developing brain. I have asked the Waltham Forest PPIMHS psychologists to write a bit about that and correct anything I have written about their service!
This is the first time in ages I’ve managed to get the finalised version on line in time for the end of the month! NICE on autism this month, a bit on the use of corticosteroids in croup with help from the Cochrane Library, update on secondary prevention of meningococcal disease and a pointer to our local educational psychologist service which is hoping to make stronger links with the borough’s GPs (see also below). Our feeding series continues with an article on colic from one of the junior paediatricians with lots of useful links and updates.
Our local educational psychologists are running drop in sessions on the 3rd Wednesday of every month at their base in Leyton, E10. The current flyer which includes contact details is here and sessions will be on-going in 2012 even if not listed here. They tell me that they would be happy to run EP drop in sessions or parent workshops/training/support groups at local GP surgeries and jointly with GPs or other medical colleagues – GPs are welcome to contact them to discuss. Their Urdu speaking colleague runs sessions in a local Mosque as well.