Transient early wheezers (settle by 3yrs) can be differentiated from non-atopic wheezers (usually settle by 5yrs but can persist well into school age). Both precipitated by infection, neither atopic, but first related to relatively narrow airways, whereas latter show bronchial hyper-reactivity. Surprisingly, severity and frequency of symptoms does not predict persistence, whereas history of exercise induced wheeze does (Frank PI, BMJ 2008). Also associated with maternal smoking (affects lung function esp small airways; antenatal effect?), having older siblings. Exhaled nitric oxide (NO) and sputum eosinophils predict steroid sensitivity.
In wheezy infants, IgE to wheat, egg white, inhalant allergen predict later (school age) asthma.
No benefit of prednisolone in preschool wheezers, even when looking at eosinophil activity (Lancet 362;2003) however short course of steroids at onset reduces the need for additional drugs in infants admitted to hospital with acute viral wheeze, and high dose inhaled steroids may also help if given at the onset of symptoms of URTI in kids known to have episodic symptoms (but no disease modifying action on wheeze itself, whether given regularly or episodically). Leukotriene receptor antagonists show some promise (reduced rate of exacerbations by 32% and steroid use by 30%) but larger trials needed.
Nocturnal cough - ?upper airway: consider trial of Nasonex
Infrequent wheezing was associated with a relative risk of subsequent respiratory syncytial virus hospitalization of 2.98 and recurrent wheezing with a relative risk of 5.90. So while bronchiolitis can cause recurrent wheezy symptoms, underlying wheeze is a risk factor for bronchiolitis. Pediatrics Nov 1, 2006-Volume 118 Danish cohort
The evidence is: ORS is safe and effective. Seizures are less likely in the presence of hypernatraemia cf IV therapy. Rehydration and correction of acidosis is more rapid than with IV therapy. Hyper/hyponatraemia are not more or less common. Parents prefer it.
The Six Pillars Of Rehydration Therapy (for mild-moderate cases):
For IV rehydration, ESPGAN says rehydrate over 8 hours, Armon says over 12 hours.
Failure of ORS, defined as the need to rehydrate children intravenously, is infrequent (3.6%). Vomiting children rarely require intravenous treatment if small portions of ORS are gently provided. In more pronounced vomiting and in children who persistently refuse oral intakes, rehydration by nasogastric tube is safe and recommended by ESPGAN.
ORS given in the correct quantity is sufficient in itself to correct electrolyte abnormalities. It is thus unnecessary to measure electrolytes unless:
Regularly assess success of rehydration (for example, two hourly). If no improvement in clinical signs of dehydration or worsening signs, consider nasogastric tube or intravenous infusion.
Recommendations for admission:
(Kate Armon and Stephenson, Arch Dis Child 2001) - Full guideline
The point of additives in ORS is not primarily to provide electolytes and energy. Sodium loss can be significant in a secretory diarrhoea, but the real reason is to facilitate water absorption. In a diarrhoeal state, there is reduced absorption of sodium (an active process), and hence reduced absorption of water (which follows sodium). Glucose, on the other hand, can be absorbed and via a sodium-glucose cotransporter, takes sodium along in a 1:1 ratio. Similar co-transporters exist for peptides, hence food-derived ORS may be superior. Furthermore, complex carbohydrate based ORS has less osmotic effect within the bowel lumen. Hypokalaemia may contribute to the distended abdomens of sick children (atony of bowel and abdominal wall muscle).
Hypernatraemia can still be treated effectively with ORS, as it is the balance of sodium vs water that is important, rather than any excess of sodium.
The higher sodium concentrations of WHO/UNICEF ORS is a reflection of the higher incidence of sodium losing secretory diarrhoea eg cholera seen in the underdeveloped world.
Partially hydrolysed guar gum (Benefiber) is fermented in the colon, producing short chain fatty acids, which improve intestinal function in diarrhoea. Study from Dhaka ICDDR showed benefit with comminuted chicken diet. Archives of Disease in Childhood 2005;90:195-199
Probiotics appear to have a role in reducing duration of diarrhoea.
Rotavirus is responsible for a significant proportion of gastroenteritis deaths world wide. Peaks in 6-24 months, virtually all kids have been infected by 3 yrs, with a mean of 2.5 exposures by the age of 2 (Mexico, but probably the same in the North). Immunity develops so that severe disease becomes less likely with each exposure. Public has surprisingly poor awareness - GPs don't test, nosocomial cases not recognized. Vesikari clinical score. Vaccine available now. Tormentil root extract, 3 drops per year of age TDS, shortens duration of rotavirus in hospital by 2 days.
Norovirus can cause more severe, more prolonged diarrhoea. Vomit etc must be cleaned with a hypochlorite solution (detergents are not viricidal). Environmental contamination is common and due to its high resistance the virus can survive on surfaces for several weeks. Shedding continues for at least 2-3 weeks depending on age (babes worst affected) but occasionally can continue for months - exclusion is only for 48 hours after resolution of symptoms however, as PCR detection methods can pick up virus amounts much smaller than infective dose. Washing hands with alcohol was effective for removing Feline Calici Virus, a possible surrogate (Norovirus cannot be cultured so impossible to prove). J of Jap Assoc Inf Dis 80(5):496-500, 2006 PMID:17073262
Nitazoxanide for cryptosporidium, only needed in immunodeficient patients.
Bismuth subsalicylate has been shown, in frequent doses, to decrease the number of unformed stools produced by adult travelers. Controlled trials of bismuth subsalicylate in children have shown that, when administered every 4 h, it decreases the duration and frequency of diarrhea, with no measurable associated toxicity. General practice guidelines regarding gastroenteritis Tradition of not giving antibiotics is probably more to do with not having a licensed alternative after widespread resistance to Septrin developed. Azithro is convenient and treats quinolone resistant Campylobacter as found in Thailand. Ciprofloxacin is still off license, does not come in liquid form and some resistance described. Nalidixic acid is a possible alternative, more experiencee and liquid form. Studies should really look at diarrhoea related dermatitis as a negative outcome.
Chronic symptoms from acute infections increasingly recognized eg mycoplasma, Coxsackie, so beware! Note that young children are more likely to have medical explanations for their symptoms.
Many sociocultural, familial, and emotional factors determine a person's response to physical/psychological phemonena eg pain, and these will also affect the likelihood of seeking medical attention to explain and treat the problem.
In practice, a series of investigations of increasing invasiveness/cost/complexity are undertaken, usually with reducing likelihood of finding a positive result. It probably becomes more difficult to accept that symptoms do not have a purely physical explanation the longer a biological diagnosis has been considered, which in turn increases the demands for further investigations/treatments. Differential diagnoses should be considered early on and appropriate investigations undertaken without unnecessary delay. Once these have been excluded, it is important to move on to symptom management and functional rehabilitation.
The key to management is engagement. Many patients and their families feel that no-one believes them, that they are making it up or exaggerating their problems. Having a doctor who takes the time to listen, believes what they say and respects their personal opinions is the first stage to engagement. Voltaire said that medicine is about entertaining the patient while nature effects the cure! Compromise and balance are the order of the day.
Once medical explanations have been largely excluded, it is important to introduce to the patient the possibility that there may be psychological factors which contribute to the symptoms, and/or psychological techniques to help dealing with symptoms.
Where medical treatment is considered, it should be explained carefully (including licensed vs unlicensed indications, possible side effects), and consented to by patient and carers. Patients are likely to emphasize the possible benefits from treatments suggested by anecdotal reports; equally, morale can be hard hit by disappointment after frenzied anticipation. Effectiveness of treatment relates to partnership, mutually respected expertise, shared perspectives, agreed goals. An explicit plan should be made to withdraw treatment if no benefit is observed. Beware unexpected side effects of treatments eg dietary deficiencies, analgesic headache.
Pain may be best dealt with by a specialist pain team, as gabapentin, acupuncture, TENS machines etc may be offered in addition to analgesics. But pain does not determine the pace of rehabilitation: function can improve before pain.
Patients like explanations, eg visceral hypersensitivity in the case of recurrent abdominal pain. They will not appreciate obvious wild theorizing, so it is important to be explicit about what is hypothesizing cf known facts, personal experience with other patients. It may or may not be useful to explain how medicine offers incomplete understanding of many human experiences.
Chronic symptoms will inevitably have an emotional as well as social impact. Increasing emotional literacy is an important aim. Relaxation techniques may help, and possible resources in terms of friends and family should be identified. At the same time, the potential for positive as well as negative gains should be explored. Cognitive Behavioural Therapy appears to be helpful.
Occupational therapy and physiotherapy may help maintain function and offer aids to living. Beware dependency however, and maintain clear objectives of achieving good functional outcomes.
This is a group crying out for advocacy. Woe betide any who dismiss this as uninteresting medicine and them as heartsink patients and carers; you may be a heartsink doctor. (Chambers, ArchDisChild)
It is important to recognize how medicine changes, and how new explanations/diagnoses may appear. So arrange regular review, and make provision for acute crisis, even if in other ways patient is encouraged to retain responsibility and control of the condition, and the treatment.
Archives of disease in childhood 2003;88(4):281-2.
Nonepileptic seizures (pseudoseizures) are best conceptualized and referred to as stress-related seizures (Curr Op Peds 16(5); 2004).
Varies from minor discomfort to intense perineal pruritus which may prevent the girl from sleeping. On examination, the vulva and introitus are red and inflamed. Vaginal discharge usually purulent and green/brown in color. Vulvovaginitis is usually due to Haemophilus influenzae and fecal organisms. Gonococcus, gardnerella and candida rarely.
Vaginal secretions can be obtained directly from the vagina with a sterile catheter carefully inserted into the vagina (?should only be done under GA: only important if suspicion of STD). Pathogenic bacteria are isolated in 36% of cases, mostly group A beta-haemolytic streptococcus, else non-capsulate Haemophilus influenzae. Candida is rarely found - consider diabetes if present. The finding of leucocytes in vaginal secretions as an indicator for growth of pathogenic bacteria has good sensitivity but poor specificity so wait on cultures. (Archives)
Differential diagnosis: pinworm infestation, lichen sclerosis et atrophicus (LSA) and allergies (esp detergents, fabric softeners). Bloodstained: foreign body (extremely heavy, foul smelling), Botryoid sarcoma. Need EUA.
Treatment: advice on perineal hygiene, daily baths or showers and wearing of loose-fitting cotton pants. Explanation to the mother as to the cause of the condition, and reassurance that it will improve as the girl approaches puberty, is necessary. Salt baths (10 minutes in a basin of warm water with 2 tbsp salt). The use of bland emollient creams such as Sudacrem or E45 may be of benefit as a barrier. Antibacterial cream such as Sultrin may also be helpful.
Fusion of the labia is not uncommon, resulting from chronic irritation causing excoriation of the labia and adherence. cf congenital absence/agenesis of the vagina: the vulva can be easily seen, with the urethral meatus and clitoris, the hymen is seen as irregular rugae where the introitus should be. In a child with labial adhesions, the vulva is flat and no structures are seen beyond it. The adhesions usually begin at the posterior vulva and move forward until only the urinary meatus can be seen.
Oestrogen cream applied to the vulva twice daily will improve the condition by increasing the resistance of the vagina to infection, but its use must be strictly controlled. Estrogens are easily absorbed through the skin and systemic affects of local therapy are not rare. If estrogen therapy is to be used, the girl's mother must be warned of the risks of indiscriminate use. Instructions should be given to apply the cream sparingly. After 2 weeks the adhesions will usually then separate spontaneously. If necessary, subsequent courses can be given after a break of 2 weeks. Surgery to separate the adhesions is not required.
Also called vasovagal syncope, or simple faint. Classically teenagers, on standing up after a period (eg boys standing at the toilet to pass urine after hours on the sofa/floor), a prodrome of vagal symptoms viz dizziness, nausea, tunnel vision. Witnesses will report that the person went very pale. Then they collapse - there may or may not be complete loss of consciousness (and therefore there may or may not be recall of hitting the floor), and if the cerebral hypoxia is severe enough they may go on to have an immediate anoxic seizure (with jerks and incontinence). Not usually the tonic-clonic seizure seen with epilepsy, tends to be just a few seconds of stiffening, opisthotonus, and fine twitching, and an EEG if done would be flat rather than chaotic.
Differential is:
Syncope in response to loud noise, fright, or extreme emotional stress suggests that it is neurally mediated. Warning signs in the history suggesting something more sinister include:
Examination should include standing/lying BP (more than 20mmHg drop is suggestive of neurocardiogenic, but is not very sensitive). Palpate for heave, listen for murmurs, check peripheral pulses.
Tilt testing can be successfully performed in children from the age of 6 years (younger get bored!). The child rests supine for 15 minutes and is then tilted to 60 degrees head-up for a maximum of 45 minutes. During this time the blood pressure is continuously but non-invasively monitored using the Finapres system, and a three lead ECG continuously recorded. Using this protocol, approximately 50% of children with a good history for neurally mediated syncope will have a positive tilt test. The use of drugs eg isoprenaline increases the sensitivity of the test, but reduces its specificity and makes the test more unpleasant for the child.
Consider admission to hospital for continuous ambulatory ECG and EEG monitoring if syncope is occurring several times a day every day. These cases tend to have no abnormality of monitoring or BP/HR during episodes and this gives the diagnosis of psychogenic pseudosyncope.
For neurocardiogenic syncope, the main thing is reassurance.
No drug has been adequately evaluated by randomised clinical trials. Placebo effect is likely to be significant! Fludrocortisone and beta blockers (!) are the most commonly used.
Karen McLeod, Arch Dis Child 2003 PMID 12651770
Children with retropharyngeal abscess (RPA) present with limitation of neck movement, especially difficulty extending their neck to look up. They rarely present with respiratory distress or stridor. CT scan is useful to distinguish patients with RPA from those with retropharyngeal cellulitis, although even RPA can often be treated with antibiotics alone.
(Pediatrics)
ie poor vision because the brain has not had a clear image to interpret and has therefore disregarded information coming from that eye. Cause is either obstruction of vision in one eye ie cataract, ptosis; difference in reftractive error; or squint. So treat the cause first. Treating strabismus however will probably not have much benefit; timing of surgery is controversial. The earlier the problem, the more urgent the need to treat ie babies - but trials in children do not show any major benefit from treating earlier.
Then treat the amblyopia. Trial of patching vs topical atropine (given on Saturday and Sunday) found equivalent results at 6 months, although patching probably worked a bit faster, and atropine was more acceptable to parents. Patching just 1-2 hours a day does help, although patching for longer eg 6hrs probably helps more. Others argue for intensive patching for a week, which probably works more quickly. Most benefit is seen withing 12 weeks but not all. 50% will not achieve full vision, in the past ascribed to poor compliance and late treatment but this is probably unfair and some will have subtle optic nerve hypoplasia or a cerebral problem - so don't flog forever!
Alcohol and vinegar may help, esp if fungal, otherwise try antibiotic ear drops (probably quinolone most effective)
HSP. Usually preschool but any age! Boys more than girls. Vasculitis.
Features:
Complications and relapse associated with age esp over 6yr. 50% relapse, usually within 6 weeks but can be up to a year later; 50% of those will relapse more than once. Treat with NSAIDs for joint pain, strong analgesics for abdo pain. Small study from Turkey found that Ranitidine reduced symptoms.
Corticosteroids have been found to improve abdominal pain and joint pain in HSP (although no RCTs) but they do not decrease the time of the acute phase. (Review, Arch Dis Child 1999; 80:380–3.), (Szer IS, J Rheumatol 1996; 23:1661–5).
Reviewing 101 children with abdo involvement those who did not receive steroids had an average of 5 days of abdominal pain, whereas all those treated recovered within 24 to 48 hours of starting steroids
Abdominal pain is a predictor of renal involvement, so maybe that's the best reason for giving steroids... (Kidney Int 1998; 53:1755–9).
20 to 90% risk of renal disease! About 56% of those children with renal disease develop signs and symptoms of renal disease a week or more after presentation. Incidence of renal failure in HSP nephritis is 2 to 5%. NB Children who appear to recover may have significant renal disease many years later. (Lancet. 339:280282, 1992).
Corticosteroids at a dose of 1mg/kg/day for 14 days appear to substantially reduce the incidence of renal disease in children with HSP who present without evidence of renal involvement. (European Journal of Pediatrics. 151:140-144, 1992.) In the group of children who received steroids, none developed renal disease. In the group that did not receive steroids, 11.9% developed renal disease 2 to 6 weeks after acute episode. Renal disease was defined as 2 of the following:
None of the children in this study developed persistent renal insufficiency or ESRD. Other studies have been retrospective with conflicting results. There is no proven benefit of corticosteroids in the treatment of established HSP nephritis.
The major risks of corticosteroid treatment in children with HSP are masking an acute abdomen or intussuception and GI bleed.
Scottish guideline - for routine presentation, do 1 week, 1 month, 3/6/9/12 month BP and urinalysis check. Continue 6 monthly until 2 consecutive urines normal. If hypertensive or urinalysis pos, then do proper urine protein:creatinine ratio, U&Es, MC&S. Isolated haematuria is benign. As soon as urinalysis becomes normal, child can have routine follow up. Persisting proteinuria of + or more needs more frequent follow up eg 2 weekly, 2 monthly then 3 monthly with the second line investigations. Refer urgently for confirmed hypertension, nephrotic range proteinuria (P:CR over 200mg/mmol), or GFR under 60 ml/min/1.73m2. Refer for assessment if GFR 60-80, proteinuria 50-200 mg/mmol, or persistent macroscopic haematuria at 2 months, or persistent haematuria/proteinuria at 1 year.
A systematic review found no risk of long-term renal impairment in children with Henoch-Schonlein purpura with normal or minimal urinary findings without nephritic or nephrotic syndrome or renal failure (Arch Dis Child 2005;90:916–20). If urine analysis is normal at presentation, the test for 6 months after the last symptoms. If there is renal disease at presentation, then the risk for progression seems to be more associated with rising proteinuria during follow-up rather than presentation features. (Am J Kidney Dis 2006;47:993–1003)
Cough suppressants (dextromethorphan or diphenhydramine) same as placebo for easing sleep symptoms - even placebo works well! Peds2004;114:e85
Hence CXR/AXR, USS. Rx Baclofen, omeprazole (!).
Rising rate of effusion - see Respiratory.
Blood culture positive in only 2% of pneumonias, always pneumococcus. NPA for viruses but huge panel needed! 31% are mixed viruses. Under 2yrs 80% of infections are with viruses. NPA for bacteria is only useful for mycopneumonia, chlamydia and bordetella which require special cultures. Lung tap used historically, 60% sensitivity claimed.
Mycoplasma is reponsible for 10-20% of hospitalized, often with abdominal pain and vomiting. 40% are afebrile.
CXR makes up bulk of cost of being seen in A&E.
98% of pneumonias successfully treated with beta lactams despite 9% rate non-susceptible species. 18/76 of macrolide resistant pneumonias developed bacteraemia on treatment.
BMJ metanalysis compared strategy of 48hr amoxillin followed by macrolide if no benefit - no obvious benefit. In developing world evidence that oral works (PO amox vs IV benzylpenicillin. 3/7 courses as good as 5/7 courses in Pakistan
3 studies of chest physio in CAP - no benefit, if anything prolonged fever. But identifiable weaknesses in all of the trials, eg only 1 a proper RCT, 1 included all kinds of other LRTIs. The physio I talked to says only appropriate if productive cough, able to regulate breathing & improving.
Causes of morbilliform rash in highly immunized population – about 50% undiagnosed, of the rest, mostly parvo, strep A, HHV6, enterovirus. None of 195 had measles or rubella (Arch 2002;87:202).
RCT of topical chloramphenicol - Clinical cure by day 7 in 83% with placebo compared with 86% with chloramphenicol (risk difference 95% CI -4.1% to 11.8%, n=500). Identical recurrence rates (4%) within 6 weeks. Most H. influenzae, else Pneumococcus, M catarrhalis (but more staph and streps in neonates). Lancet. 2005 Jul 2-8;366(9479):37-43.
Delayed prescribing (GP study, both adults and kids) extends duration of symptoms by 0.6 days, but seems to reduce return visits.
But this study (and others probably) limited by low external validity: minority of patients agree to be randomized. Which raises the concern that those with relatively mild disease may preferentially have been enrolled. BMJ 2006;333:321-6
UK now allows pharmacies to issue chloramphenicol eyedrops OTC.
eg in infant/learning difficulty - look at teeth, tympanic membranes, eyes (glaucoma), hernias, joints/bones. Renal stones (esp anti-epileptics)? Spasticity itself in cerebral palsy can be painful. Dystonias can be seen with some anti-epileptics. Consider NAI, or social disruption.
One 30-minute application of hot air has the potential to eradicate head lice infestations. Achieves 100% egg mortality, and 80% louse mortality when operated at a comfortable temperature, slightly cooler than a standard blow-dryer. Lousebuster - Pediatrics 2006 Nov;118(5):1962-70
Benzylpenicillin and Flucloxacillin are traditionally used together, to cover Group A Strep and Staph, however Fluclox will usually cover both! No added benefit to using benzylpenicillin as well in lower limb cellulitis (adults, n=81 - Emerg Med J 2005; 22:342-346). One review suggests single agents eg nafcillin, cefazolin, ceftriaxone (NEJM 2004;350(9), 904-912).
Infection around the eye can be caused by penetration of skin organisms through a skin break, or else by spread of a sinus infection. The important clinical issue is whether the infection is post-septal as well as pre-septal, ie is there infection behind the globe of the eye which may then spread through the meninges and cause cavernous sinus thrombosis, meningitis or brain abscess. Impairment of eye movements is the biggest clue; if in doubt, do CT.
Choose antibiotic based on likely source viz trauma (staph, strep, beware MRSA) or sinusitis (moraxella, haemophilus, beware chronic eg anaerobes). Co-amoxiclav would be a good option.
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