Raised intracranial pressure on the front line this month, menorrhagia in adolescents, psychological first aid and some normal reference values for children from Royal College of Paediatrics and Child Health.
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With thanks to Dr Isabel Wilson, paediatric registrar with experience of working with refugees and internally displaced people in southern Europe.
Public Health England has developed a course on PFA in Covid-19. Almost 100,000 people have already signed up to learn how to give practical and emotional support to individuals traumatised by their experience of lockdown or Covid-19 itself. Sign up at https://www.futurelearn.com/courses/psychological-first-aid-covid-19
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.
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Safeguarding issue again this month. Round up of CPD resources and a reminder of how much demonstrable child safeguarding CPD health professionals have to do per 3 year cycle. Also some support groups for your patients and a quiz on social media sites – in case you thought you were ahead of the game…
From left to right: Dubsmash (high risk of bullying), Snapchat (overall safety rating – average), Smule (official age rating 13+), We chat (high risk sexual and bullying), Twitch (“it’s hard to censor because it’s live”), YouTube (“people write mean things in the comments on videos”). Follow the links to read about each site’s safety profile and find out what kind of thing your own children and your young patients are using the individual sites for.
Social media sites are here to stay and preventing children having access to them is not likely to be a successful parental pastime. https://www.net-aware.org.uk/ is an O2 and NSPCC project which looks at the safety of social media sites and gives parents tips on how to protect their children while they are using them.
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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!
*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
→ May need a more cautious approach (5–10 kcal/ kg/day starting regimen) with twice daily bloods
WHAT SHOULD I START DOING?
WHAT SHOULD I STOP DOING?
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: