the yorkhill - hillswick health · web viewa doctor will normally advise a stool softener or...
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Paediatrics for Primary CarePaediatrics for Primary CareHandbookEasy peasy guide Clinical care of children is often challenging, sometimes difficult, and occasionally downright unnerving. Today, perhaps more explicitly than ever before, health care staff in Primary Care and Hospital and Community Paediatric services face the demands of providing safe, effective and efficient care of ill children ‘at a distance’ while addressing the increasing expectations of their worried parents.Developments in clinical governance and the evolution of evidence-based medicine redefine our professional responsibilities which cannot be ignored, while changes in the organisation of care ,such as GP Out-of-Hours Co-operatives and the evolution of an ambulatory approach to the deliveryof hospital services for children, guarantee a shifting clinical environment such that nothing quite stays the same. As the nearest providers of secondary care for local children, the paediatric department of the Gilbert Bain Hospital, in conjunction with our Aberdeen Consultants recognise our responsibilities to support family doctors in caring for their child patients and their families..Early discussions defined areas of clinical uncertainty where GPs would welcome guidance in relation to specific clinical topics. By way of response, this is one person’s collection of clinical topic summaries originally to assist me , but which may be helpful for colleagues working in Primary Care. The individual topic summaries are not intended to be exhaustive, but to provide an easily accessed concise review of the recognition and management of common childhood conditions and to do so specifically in the context of Secondary Care provision mainly in Shetland and Aberdeen. They will not provide all the answers for every patient, but may offer some guidance for some of the children seen. I attempted, as far as possible, to produce them in a common format, but there are some inserted PDF documents which may be slower to load. This is meant to be stored on computer for ease of reference..Some topics are accompanied by a related information leaflet for parents, and for those that are not, some are available from PatientUK. Feel free to photocopy the included ones as needed.
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Hopefully you might find this useful. I would welcome written or electronic feedback to [email protected] Disclaimer; This is a personal collection of protocols some which are currently in use in Aberdeen and some in Yorkhill, but has no official status as yet in SHB.
ContentsSubject Last Revision Date………………July 2011Referral GuidanceDNA Policy (June 2002) ............................................................ April 2005New referrals and accessing consultant advice and help………April 2005Helpful phone numbers and e.mail addresses…………………….May2005Department of Child Health Gilbert Bain Hospital ……………….May 2005Child and Family Community Psychiatry Team ......................…..to followPaediatric OT and Audiology Services ..……………………………Sept 2008
RespiratoryBronchiolitis v1.0 ...................................................................... March 2005Croup v1.0 ............................................................................... March 2005 Gastrointestinal Gastroenteritis v1.0 ............................................... March 2005Constipation v1.0 ..................................................................... March 2005
Urinary Tract and GenitaliaUndescended Testes v1.0 ......................................................... March 2005Phimosis v1.0 ........................................................................... March 2005
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Inguino - scrotal swellings v1.0 ................................................. March 2005U.T.I. v1.1................................................................................. March 2005SkinAtopic Dermatitis v1.0 .............................................................March 2005Warts v1.0 ...............................................................................March 2005NewbornUmbilical Hernia v1.0 ..............................................................March 2005Tongue ties v1.0 ......................................................................March 2005Bones and JointsToe Problems v1.0 ...................................................................March 2005Flat Feet v1.0 ...........................................................................March 2005Heel Pain v1.0 .........................................................................March 2005Intoeing v1.0 ...........................................................................March 2005Leg Pains v1.0 .........................................................................March 2005Popliteal Cysts v1.0 .................................................................March 2005Knee cap Pain v1.0 ..................................................................March 2005Bowlegs and Knock-knees v1.0 ................................................March 2005Irritable Hip v1.0 .....................................................................March 2005EyesMeibomian cysts, Watering eyes and Squints v1.0 ...................March 2005Assorted protocols and CardiacMedical form for school………………………………………………..2006Paediatric Life support and emergency protocolsDiabetes…………………………………………………..2006
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ContentsSubject Next Revision Date April 2012DisclaimerNon-Attendees Policy (return)Whilst GPWSI and Consultant Medical Staff at the Gilbert Bain Hospital will endeavour to reach a satisfactory outcome, and reasonable efforts will be made to ensure this happens, it must be recognised that the parents/guardians have the ultimate responsibility for the care of children. This includes advising of name or address changes. The following provides the minimum standards required, whilst recognising that these standards may be exceeded.
Out-Patient - Return Appointment (ref: Attached Flow Chart)1.1 All case notes to be reviewed by the GPWSI/Consultant and a decision made regarding whether or not non-attendance gives cause for concern.1.2 If the child does need to attend but there is no immediate concern two further appointments will be issued. If the child subsequently fails to attend these appointments then the consultant will proceed to either 1.3 or 1.4 of this policy.1.3 If there is no need for a further follow up, a letter will be sent to the parents/guardian to inform them that the child has been removed from the list. If the parents wish their child reviewed again they will be advised in the letter to contact the GP. The GP will receive a copy of this letter.1.4.1 If the child does not attend and there is cause for concern e.g. removal of sutures, plaster of paris, continuation oftreatment, failure to thrive, a referral letter should be generated by the consultant/GPWSI and sent to the appropriate GP and health visitor and in some instances directly to the social work department.1.4.2 The health visitor will attempt to contact the family either directly . The GP will be informed of the child’s failure to attend.1.4.3 If the family is unable to be contacted a missing family alert will be generated as per the “Missing Family” policy.1.4.4 If the family is located but refuse to attend and the child is thought to be at risk, the child will be referred to the Social Work Team by the health visitors in consultation with the consultant/ GPWSI.1.4.5 All measures taken to contact the family and subsequent responses should be documented in the childs medical notes.
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In-Patients/Day Cases
If the child does not attend for the first appointment the medical secretary will endeavour to find out the reason and depending on the outcome, one further appointment will be sent.If a second appointment is not given, because the parents do not wish the child to attend, the GP will be advised and the child removed from the list.If the child is given a second appointment and does not attend, the GP to be advised that the child has been removed from the waiting list. However, if there is sequential treatment or it is known that non-attendance could cause harm to the child (examples as in Point 1.4), contact to be made with one of the Paediatric nurses , requesting they follow up the non-attendance as a matter of urgency. This would generally mean communicating with the relevant personnel in the community, but may occasionally mean visiting the child and family at home, e.g. Health Visitor or Kirstie Anderson when the family is known. Any action taken has to be communicated to the consultant/GPWSI and GP and documented in casenotes. The named person to continue to pursue until a satisfactory outcome.A letter should be sent to GP (enclosing copy for health visitor) stating outcome.
Diagnostic ImagingShould a child not attend for an appointment in the Department of Nuclear Medicine, the parents are given two weeks to make contact.If they fail to make contact the child’s consultant is advised through HISS and if an appointment is still necessary, this will require to be reordered.Should a child not attend for an ultrasound or x-ray a second appointment is sent out. If there is failure to attend on a second occasion, the child’s consultant/GPWSI is advised and if an appointment is still necessary, this will require to be re-ordered.To enable the above to function smoothly, should a member of medical staff not at consultant level run his/her own clinics, the staff in the Department of Diagnostic Imaging require to know the name of the authorising consultant.
Accident and Emergency DepartmentShould a child not attend for a return clinic appointment, this is reviewed and if there is any action to be taken, the child’s carers are
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telephoned. If urgent action is required the paediatric nurse / health visitor will be contacted by the consultant as per para 1.4. If a family wish a child to be reviewed again they will be advised to contact their GP who will discuss their case with the consultant.The Paediatric nurse will liaise either directly with the family or the relevant community personnel until a satisfactory outcome is reached. If all reasonable attempts to ensure the child is given access to the accident and emergency services have failed and the child is thought to be at risk then the paediatric nurse in consultation with the consultant should inform Social Work.Gilbert Bain Hospital Non-Attendance: Return Outpatient/Ward Attendee AppointmentsSummary of Paediatric Department Policy when dealing with non-attendance for a return appointment at the Gilbert Bain Hospital .Following any non-attendance case notes are reviewed by the consultant/ gpwsi and a clinical decision made whether to remove from the consultants list, reissue an appointment or where there is cause for concern refer to named person eg paediatric nurse.Non-Attendance for Return Appointment
C
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Does non attendence give cause for concern at this stage
Contact named Paediatric Nurse or HV until satisfactory outcome has been achieved
Reissue one further appointmentwith letter to parent
Child attends clinic?
Does non attendance give cause for concern at this stage
* If a family wish to be reviewed again , they can contact their GP who will request re-refferal.A satisfactory outcome must be achieved. If all reasonable attempts to ensure that the child has access to Paediatric services have failed then in consultation with the Consultant/GPWSI , Social Work should be informed.
Referral to the Paediatric Clinic Gilbert Bain HospitalThe GPWSI ( Dr Bowie) is acting as honorary ‘registrar’ to the Aberdeen consultants. ( Gofor).All letters to the department are reviewed by the Aberdeen consultants, Dr Osman or Dr Rogahn, and they decide who sees what. Dr Bowie is there in the department weekly usually, but can be contacted through secretary Barbara, or at the Hillswick Surgery.( 01806503277 / 316)This arrangement is useful in that the Aberdeen Consultants can ask Dr Bowie to see patients, do bloods, and get things organised for them first before they come up , speeding things up, and she can review patients that they want reviewed soonish. They also see her output which is useful from a clinical governance point of view. She has sat in with them from November 2004, after a stint in Aberdeen , for training. She also acts as their clinic ‘registrar’ when they are up .Dr Bowie is also involved in the Child Development Initiative, and has an involvement in Review meetings with Education. She will refer to other health Professionals/departments when required and issues first prescriptions to patients to avoid extra GP visits.She welcomes any feedback or queries.
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Child is removed from list. Parents and GP informed in writing *
Rolling plans for the Paediatric department include recurring Audit, both clinical , and patient experience, and the possible development/ redevelopment of shared Enuresis/ Constipation clinics. We are happy to see children admitted with constipation/asthma subsequently at the clinic.Dr Bowie has a special interest in Asthma, and all children who appear OOH repeatedly in casuality, very wheezy will be offered one appointment at her Paediatric clinic if required and desired.Remember, if you are really worried about a child, don’t wait.There is a Consultant of the Week( COW) on in Aberdeen with whom you can discuss any sick child who may need admission. The on call Paed registrars are also happy to advise.The name of the consultant of the week is available from Aberdeen switchboard .Please do not refer a child to be seen urgently by e.mail alone.Sick Children can also be admitted in an emergency to the Gilbert Bain Hospital and the medical consultants are more than happy to adviseSome useful e.mail addresses, though the author cannot comment on who is reliable at replying… [email protected];[email protected];[email protected];[email protected]; [email protected];[email protected];[email protected];[email protected];[email protected];[email protected];[email protected]; [email protected];[email protected];[email protected]; [email protected];[email protected];[email protected];[email protected]; [email protected];
[email protected]; [email protected];[email protected];[email protected];[email protected];[email protected];[email protected]; [email protected];[email protected];[email protected]; [email protected];[email protected]; [email protected];[email protected]; [email protected];[email protected]; [email protected];[email protected]; [email protected];[email protected]; [email protected];[email protected]
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ENTMr D Y Veitch Mr K A McLay Mr H A Young (Head of Service)Mr A Hussain, Mr K Ah See, Mr B Ram
Mrs Grace McGregorExt. 54168
Medical PaediatricsDr W Mike Bisset (Clinical Group Co-ordinator) (Gastroenterology) – (Bleep 2241)
Dr A Mayo (Diabetes/Endocrine)
Dr LoganathanDr W M Bisset (Gastroenterology)
Dr Derek J King (Haematology/oncology)(Bleep 2342)Dr Veronica Nefjees (bleep 3852)
Dr Rogahn
Dr Richard Brooker (Bleep 2303)Prof Peter Helms (Prof of Child Health)Dr Steve Turner (academic post – p/t RACH)
Dr Phil Booth (Neo-nates/Cardiology) (Dr John Hewitt (Dermatology))
Miss Kathryn ReidExt. 53037
Mrs Lisa WallisExt. 50125Miss Lynda McPetrie/(Mrs H Smith/on matty leave)Ext. 54715
Mrs Marcelaine JohnsonExt. 53564
Mrs Sandra NicholsonExt. 53033
Mrs Connie DurnoExt. 54587
Mrs Audrey Mitchell Ext. 59582Mrs M McLaughlan – ext 50677 - temporarily
NeurologyDr Ayaz Shah (bleep 3537)Dr Ann O’Hara (p/t at RACH, p/t at Raeden)(Bleep 3787)
Mrs Diane Honeyman Ext. 54069
Orthopaedics + OTMr T ScotlandMr P H GibsonMr T Dougall
Miss Julie Donald Ext. 54016
OpthalmologyMr W H ChurchMr Chris Scott (Head of Service)
Mrs Lynda Inglis Ext. 52677
Surgical PaediatricsMr Richard ThompsonMr Chris Driver (Head of Service)
Prof George G Youngson (Bleep 2764)
Ms Julie Murray Ext 52774Mrs Alison BrackExt. 59925Mrs Mary Gardner Ext. 52942
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Plastic SurgeryMr P S KolheMr J Holmes (Head of Service)Miss M Davies
Mrs Elsa Gordon Ext. 52698
Accident & EmergencyMr Jim Ferguson Mr John Hiscox Dr Angus Cooper (Head of Service)
Mrs Margaret Walker Ext. 52685
TherapiesDietetics – Kathleen RossPhysiotherapy – Maureen RylesSpeech & Therapy – Winnie Taylor, Head SALT, Sara Jones - RACH
Mrs Lynn Duguid Ext. 54224
Child & Family Mental HealthMs Lindsay Stewart (Head of Service)
Dr Carol Gilmour
Dr Justin Williams
Dr Jean Robinson (based in Rosehill House)
Dr Dee Rasalam (Leraning Disability)
Margaret Reid/Nicola Dalgarno (job share) Ext 50233
(Nikki Michie on Matty leave) Ext. 52234Miss Aileen CampbellExt. 59402 Mrs Marjory ReidExt. 50536 Mrs Judy Butler Ext 52706Mrs Jennie CraigExt. 59919Mrs Heather Newcombe
Social Work ReceptionMs Elaine Diack (Senior Social Worker)
Mrs Betty MacGillExt. 50139Mrs Ida Innes - Ext. 52994
Child Protection Mrs Morag MitraExt. 54705
Relief Secretaries Mrs Marion McLaughlanExt. 50677Mrs Nancy HudghtonExt. 51018
Secretary to Asst Director of Nursing (Angela Horsley)
PA to Service Manager (Gail Thomson)
Miss Kathleen McGregor/Tina Cameron Ext. 54918
Mrs Carol WalkerExt. 52043
Teaching Co-ordinator Mrs Caroline NixonExt. 53652
Community Child Health Dr Jackie Crum (Head of Service)Dr Helen Murdoch (Audiology)Dr Susan Rodger (Adoption & Fostering)Dr Liz Myerscough (Child Protection)School Doctors
School NursesClerical Assistant
Sally Davis – 51703Margaret Baxter – 51708vacant – 51707Ann Scragg – 51704Stephanie Taylor – 51706Ann Robertson – 51705Kathleen Dawson – 51709Alison Youngson – 51710Amy Fraser - 51711
Raeden Centre
G Leitch – Administrator - 72246
Elaine Gibson ext. 72257
Jacqui Thompson ext. 72257Linda Todd ext. 72255
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Pamela Booth ext. 72220Gillian Cruickshank ext. 72256
GUIDELINES FOR REFERRAL TO CHILDREN’S OCCUPATIONAL THERAPY
Rationale
These guidelines are designed to help decide if a child needs to see an Occupational Therapist following a request from a school to seek referral from a General Practitioner. They will help to ensure that we make the best use of O.T.
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resources by prioritising children who most need it at the time of their lives when it will have the most impact.
Most children and young people will have their needs met within the school system. Training and resources have been put in place by the Occupational Therapy Service to support school staff with this.
Please establish with parents that request a referral to OT what measures have been taken in school to address their child’s difficulties. Schools should have implemented and evaluated the effectiveness of the resources available to them before requesting a referral to OT.
In line with the Code of Practice (Chapter 3) relating to the ASL Act (2004) responses to requests for help and or specialist assessment should be made within the Staged Intervention process.
Specific difficulties
Children and young people who have specific difficulties with reading writing and maths, substantially below that expected for their age and ability, such that they are considered to be at Stage 2/3 within the Stages of Intervention, and where support is already being provided by an ASN teacher and/or educational psychologist.
Difficulties with coordinating movements: Developmental Coordination Disorder (DCD):
Children and young people who have specific difficulties together with poor co-ordination relating to Developmental Coordination Disorder (DCD) if the following criteria are met:
1. Marked impairment in the development of motor co-ordination2. This impairment significantly interferes with academic performance or
activities of daily living3. The co-ordination difficulties are not due to a general medical condition
(e.g. cerebral palsy or muscular dystrophy and the child is not on the Autistic Spectrum).
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4. If cognitive difficulties are present, the motor difficulties are in excess of those usually associated with it.
Sensory Difficulties
Children or young people who display difficulties in processing and responding to sensations, for example:
Avoidance of certain textures or tastes Sensitivity or abnormal responses to light or sounds High activity levels or seeking of movement i.e. rocking or spinning Poor concentration or attention to task
.NB. Children with ASD may have sensory processing difficulties and some of the behaviours, which may look sensory based, may be in fact due to ASD symptoms of rigidity or attention control etc.
Please feel free to contact me by phone or e-mail for further advice or guidance on whether a referral is appropriate.
Marc Beswick Dip COT SROTSenior Children’s Occupational Therapist
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HearingHearing impairment is the commonest sensory impairment in children. Hearing impairment can affect several different areas including development of speech, language and communication skills, educational progress, and behavioural difficulties. In children with known disabilities or developmental delay, it may be masked clinically.The commonest cause of hearing loss in children is a conductive loss due to otitis media with effusion OME with a prevalence of 20% at age 2 years and a second peak at around age 5 years of 17%.Sensorineural hearing loss is much less common. U.K. studies have shown incidence of permanent childhood bilateral sensorineural hearing loss>40dB of 1.2 children per 1,000 live births per annum, (Davis et al. (1995)), rising to 1.65 per 1,000 live births for children aged between 9-16 years. (Fortnum et al. (2001)).
Paediatric Audiology Services
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Which children should be referred?Any child about whom there is a concern regarding hearing.All children with a significant speech/ language delay or difficulty.Children with a significant difficulty in educational progress.All children with significant developmental delay or disabilityIn addition, the possibility hearing impairment should be considered in children presenting with behavioural difficulties.Who can refer?Referrals will be accepted from health or educational professionals involved in the care of the child, includingG.P., Health Visitors, Paediatricians, GPWSI , School Nurse, Speech and Language Therapist, Educational Psychologist, Psychologist
Where children should be referred?All children should be referred to the visiting ENT consultants ( may change when we get an audiologist)
How to ReferWritten referral is required. Information regarding the length of history, associated symptoms and E.N.T. examination, combined with nature of difficulties with hearing loss is very important. This is particularly true if OME is suspected, due to its fluctuating presentation.Information re development is also useful especially if you feel a child may not be able to do an age appropriate test or has complex needs as this will affect their needs in terms of audiological assessment methods. See new audiology Pathway
RespiratoryEmergency Primary Care Management of Croup
This is a guideline on the acute management of croup and is not an exhaustive text on croup. For further information consult textbooks or the published literature.Each child should be assessed and treated as an individual, using the guideline to assist decision making.
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Background Croup is an acute illness caused by viral inflammation of the upper airway, hence the hoarse voice and the cough. Children usually have inspiratory stridor due to inflammation and narrowing of the upper airway. Symptoms are usually worse at night. There is usually a short history of mild fever, runny nose and a bit of a cough. Most children have mild disease and do not even come to hospital. A tiny minority are unwell enough to need intubation. Croup is a self limiting viral illness and antibiotics are not helpful. In a previously well child the diagnosis is usually straightforward. Remember to consider other causes of upper airway obstruction.
Recognising CroupUsually caused by viral infection, Presents with:•Acute stridor•Barking seal-like cough•Hoarse voice•Low-grade fever and usually they have a runny nose….
Key Questions for differential diagnosis1. Is the child toxic or ill looking? Is there a high fever?if “yes”, suggests bacterial tracheitis. If suspected urgent admission2. Has the child been immunised with HIB/DTPVirtually excludes epiglottitis or diptheria3. Any risk of inhaled foreign body?Was the child playing with small objects or eating nuts?Was the onset sudden with no prodromal illness?4. Any possibility of allergic reaction or anaphylaxis?Bee stings, known allergens e.g. penicillin, and foods.5. Any history of exposure to physical irritants?e.g. heat or smoke in house fire
Management GuidanceAvoid distressing the child…Allow child to find position of comfort usually sitting forwards on mum’s lapDon’t examine the throat..
Recommended treatment for ALL children with CroupSingle dose of soluble prednisolone given orally, even if referring to hospital:Under 2 years - 10mg Over 2 years - 20mg
Home or Hospital?Most Croup is self limiting and will settle in 3 - 4 days. Oral steroids begin to work within 1 hour.
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If uncertain about hospital referral reassess after 1 hour.
Always refer if:• Child is under one year of age• Child has tracheal, or sternal, or subcostal indrawing at rest.• The child is toxic, or cyanosed, or dehydrated, or exhausted• Family circumstances make home care inappropriate• Uncertainty about diagnosis
What is not helpful?Antibiotics: most croup is viral, and antibiotics are of no benefit.Humidity: no evidence for benefit from steam or humidity, and risk of scalding.
If severe airway obstruction, whileawaiting ambulance or duringtransfer give 5ml of 1/1,000Adrenaline by nebuliser preferablydriven by high - flow oxygen
Croup for casuality ( Thanks to Bridget Oates)
Croup Score
Stridor none 0when agitated 1at rest 2
Subcostal and intercostal recession, tracheal tug none 0mild 1moderate 2severe 3
Air entry normal 0decreased 1markedly decreased 2
Cyanosis none 0with agitation 4at rest 5
Conscious level normal 0disorientated 5
The following management plans are for guidance only and do not replace individual assessment of each child.
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Mild to moderate croup (score 1-5)1. give single dose of oral soluble prednisolone2. hourly croup score3. observe for 4 hours – discharge if improving, admit if not
Single dose of oral soluble prednisolone:Under 2 years 10mg over 2 years 20mg
Moderate to severe croup (score 5-8)1. give single dose of oral soluble prednisolone2. give oxygen via mask if saturations <92% in air3. repeat croup score at 30 mins and 1 hour, if no improvement admit and consider
nebulised adrenaline 1ml of 1:1000 made up to 5ml with saline. Discuss with mainland centre. If improving continue to score hourly and continue as above for mild to moderate croup.
Adrenaline does not alter the course of the disease. It acts locally to reduce larangeal oedema and relieve symptoms, but the effect wears off in 30 to 60 minutes. Adrenaline may buy you some time, but it is not a cure.
Life threatening croup (score 9 or more)1. give nebulised adrenaline 1ml of 1:1000 made up to 5ml with saline and delivered
by oxygen2. give oxygen via mask if saturations <92% in air3. give single dose of oral soluble prednisolone (alternatives: nebulised budesonide
2mg or im dexamethasone 0.15mg/Kg).4. contact anaesthetist. Discuss with mainland centre. 5. reassess at 30 mins with repeat croup score, may need to repeat adrenaline
nebuliser. Continue regular assessment if improving. If not improving consider retrieval by mainland team.
Alarm bells
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‘Toxic’ child with drooling and a soft purring noise on inspiration –
think epiglottitis or bacterial tracheitis
Exhausted child – admit
Child with pre-existing narrowing of the upper airway, or Down’s
Syndrome – prone to more severe croup – admit
Under 12 months with any respiratory distress (stridor, tracheal tug,
intercostals or subcostal recession) – admit
Medication There is evidence that steroids are beneficial in relieving the symptoms of croup compared to placebo. The studies done have compared nebulised budesonide to dexamethasone oral or im with each other and with placebo. Prednisolone is commonly used but has not been trialled.
References:Stannard W, O’Callaghan C. Management of croup Paediatr.Drugs.2002 4(4):231-40Ausejo M et al The effectiveness of glucocorticoids in treating croup: meta-analysis. BMJ 1999 Sep4 319(7210):595-600
Bjornson CL et al. A randomised trial of a single dose of oral dexamethasone for mild croup. N Eng J Med. 2004 Sep23 351(13):1306-13
Cetinkaya F et al. A comparison of nebulised budesonide, and intramuscular, and oral dexamethasone for treatment of croup. Int J Pediatric Otorhinolaryngol. 2004 Apr 68(4):453-6
Geelhoed GC, Macdonald WB. Oral dexamethasone in the treatment of croup: 0.15mg/Kg versus 0.3mg/Kg versus 0.6mg/Kg.Pediatr Pulmonol. 1995 Dec 20(6):362-8
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Westley CR et al Nebulised racemic epinephrine by IPPP for the treatment of croup: a double blind study. Am J Dis Child. 1978 132:484-7
Bridget OatesRARARI Paediatric Fellow
March 2005
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BronchiolitisFacts and figures• Bronchiolitis mainly affects infants during their first winter (peak age 2-6 months).• It is a viral-induced inflammation of the bronchioles, causing symptoms and signs of airway obstruction.• Respiratory Syncytial Virus (RSV) is the principal cause (75%) although other viruses (parainfluenza, influenza, adenovirus) can cause a similar clinical picture.• Clinical severity varies from mild to severe with around 3% of infants admitted to hospital each year.• Mortality in hospitalised infants is very low(~1%) and focused on those with background high-risk clinical problems.What are the typical clinical features?After a few days of coryzal symptoms, a baby becomes unwell with fever, cough, rapid breathing and wheeze. The illness lasts around 10 days. Young infants may present with apnoea alone. Difficulty feeding and drowsiness suggest more severe disease.What are the significant examination findings?Check for signs of respiratory distress – respiratory rate (>60), heart rate, nasal flaring, and subcostal recession. Noisy breath sounds with fine crackles and/or wheeze. The liver may be displaced downwards by chest hyperinflation.Pulse oximetry (if available) can be useful– if SaO2 < 95% the infant needs Oxygen therapy. Cyanosis/pallor means severe disease.What investigations are useful?Bronchiolitis is a clinical diagnosis. None are indicated in primary care.Which children should be referred to hospital?In the bronchiolitis season, the history and examination usually make the diagnosis easy.• The pink well-perfused child not in significant respiratory distress who is feeding well can be managed at home.• Admit infants with apnoeic episodes, cyanosis, exhaustion, poor feeding or vomiting with risk of dehydration, worsening respiratory distress or if pulse oximetry shows SaO2 <95%.• Have a low threshold to refer high-risk infants – home oxygen therapy, cyanotic congenital heart disease, chronic lung disease or immune deficiency, premature or very young infants (<6 weeks). Take account of significant psychosocial factors.What treatments are helpful?• There is no proven specific treatment for bronchiolitis.• Antibiotics and steroid therapy are generally unhelpful and should be avoided.• If the infant or the family has a history of atopy, a trial of salbutamol via a nebuliser or spacer and mask is reasonable.Continue if there is a response.• Feeding smaller volumes more often may allow feeds to be better tolerated.• Advise parents when to seek help if the infant’s condition worsens.OutcomeRSV is not thought to predispose to asthma. However after bronchiolitis some children have recurrent bouts of cough and wheeze that gradually settles with increasing age.
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Asthma Easy Peasy ?…
Introduction Affecting roughly 25% Grampian Children An audit of those attending the paediatric clinic in December and
January showed 25% of attendances were to do with the management of asthma
An average GP will see one asthma death in their entire career, but its thought that 86% of those have a preventable factor one way or another..Asthma kills 50 children a year in Britain
Most common reasons for failure of asthma treatment are not using treatment, not understanding treatment and the wrong device!
And not getting help when needed.. These are also the most common causes of asthma
deaths. How do we improve the management of children’s
asthma?Goals of asthma management in childrenDiagnosis of diseaseThe right deviceAbsence of symptoms and repeated casuality visitsAbility to do normal activitiesGrowth and DevelopmentAvoidance of side effectsKnow what their treatment is …and use itEducating families (and schools) Prevention of future damage
( maybe)
General practice is uniquely placed to deal with asthma in children, due to time , the need for regular quite frequent follow ups and good relationships with parents.
Make sure that all the staff know what they are doing…and for the nurses dealing with it when to alert the GP.
Diagnosis of asthma in children
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Problems. Often the child who has been wheezy and coughing over night is well by the next day at the surgery.
Cough rather than wheeze or SOB is often the presenting symptom, and parents will often volunteer cough as a presenting symptom.However in one survey 96% of asthmatic children could be identified from the single question “ Has your child ever had attacks of wheezing”
The diagnosis can take some time (years in some!)
Peak flows under 3 are impossible and under 5 may be unreliable. They may confuse the issue,( asking the child to blow, when we want them to suck their inhalers normally) but in some its worth a try!
Children can repeatedly appear at casuality and OOH for wheeze and not be seen during the day til their next asthma check..
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So therefore….Under the age of five in a child who you
suspect of having genuine asthma, try bronchodilators and watch over a few days for improvement.
After 5 years( and worth trying in a helpful four year old!) , there are three ways to diagnose asthma based on the principal that …
Normal airways don’t get wider with a beta agonistAsthmatic airways show bronchial hyperreactivity
( BHR) in response to exercise, whereas normal airways tend to get wider ( normal airways can show BHR in response to cigarette smoke and infection)
Parents are convinced by reversibility tests, and serial peak flows (sometimes)
3 easy peasy ways to diagnose asthma in children
Reversibility Testing. Check peak flow.Best of three. Give 4 puffs of salbutamol using a spacer or breath actuated device. Recheck peak flow after 15minutes. A rise of 15% is indicative of asthma. This doesn’t work well when kids are at their best!
Serial peak flow. If reversibility is negative and history is convincing then try serial peak flows. Twice a day , best of three. For about two weeks. A variability of 15% is indicative of asthma
Exercise test them. Measure PF, best of three.Get them to run for six minutes, and then measure peak flow every five minutes for 15 minutes. A fall of 15% indicates asthma, and should then be reversible with a bronchodilator
Once Diagnosis is made
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Once diagnosis is made, the treatment is based on furthering the other goals, namely absence of symptoms, ability to do normal activities, avoidance of side effects, growth and development, the right device, knowing what their treatment is and using it,education, and ?
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prevent future damage.
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Step 1 and every further step.Aged 1-12 salbutamol PRN 2-4 puffs given by the
right device ( no place for TDS, QDS etc). That means the child should carry their own device at school.
0-1 can have salbutamol BUT may be better with Atrovent . Liquid salbutamol/orciprenaline preparations are almost NEVER used.
Step 2 and every further step.. Check beta agonist is being used and technique!!
Aged 0-12 Continue reliever and add on regular inhaled steroid by MDI and spacer 200-400ug/day ( you can add other preventer if steroids cannot be used e.g. leukotrine receptor antagonist).
Babies need mask and spacers.Goes without saying. Show mum using a teddy or the baby. They will yell and this only helps inhalation of the medicine.Roughly five breaths to one puff.
Step 3… Add on toBeta agonist PRN and regular preventer.Check inhalers are being used and technique!!!!!
Aged 0-2 Increase steroids to 400ug/day. Advice from Dr Brooker/or refer Paediatric clinic
Aged 2-5 trial of Leukotrene receptor antagonist ( inhaled steroids 200-400ug).If poor control go to step 4
Aged 5-12 keep inhaled steroids to 200-400ug and add in LABA. If poor response,continue but increase inhaled steroids to 400ug. If no response increase inhaled steroids to 400ug, and discontinue LABA, and add in Leukotrene receptor antagonist. If poor control to all of this go to …
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Step 4.Persistent poor control! Check inhalers are being used and technique!!!
Aged 2-5 . Make sure inhaled steroid is at 400ug /day and refer to clinic for follow up Dr Ismail.
Aged 5-12.Make sure inhaled steroid is at 400ug, and LABA is being used if any response. If steroids have to go above this contact Dr Brooker for advice or refer Dr Ismail.
Step 5 frequent oral steroids.. check inhalers are being used and technique!!!
Aged 5-12 make sure inhaled steroid is at 800ug , everything else has been or is being tried and refer Dr Brooker .
Don’t forget to step down if things are going well, ( slowly)
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Growth and development
Steroids of > 400 ug/day have been shown to cause growth retardation in a sizeable percentage of children, so therefore we should be measuring each child’s height yearly. Uncontrolled asthma also does the same.
Fluticasone . Be really really careful!!!! The 250ug strength can cause adrenal suppression , and has been the cause of an asthma deaths . Seretide is one to watch in these circumstances. Please go home and check which children you have on this in you practices and audit how much they are actually taking. Especially if there is any possibility that they could be using flixotide and seretide together in error
DevicesWe should see children using the devices. They need
to be taught with their parents how to use themMost of failures of treatment are caused by children
not using their devices properly or finding them impossible.
Sometimes a change of device is all that’s needed to get control
Breath actuated inhalers can be taught over the age of 5, and are easier to carry in a pocket to school. Inhale,and count to ten with fingers! A cooperative four year old may manage as well.
Find a couple you like and stick to them! My personal favourite is the autohaler. It’s the cheapest of the breath actuated devices.
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DevicesSteroid inhalers should be MDI plus spacer to avoid
thrush. Show parents how to use spacers and inhalers as well.
Remember that parents can fire an autohaler into an aerochamber if the child needs ten puffs in an emergency
Good controlIs a child who is using up one beta agonist inhaler or
less a month ,preferably a beta agonist 3 times a week or less. Its also a child who is not disturbed at night or having 3 monthly bouts of wheeze with colds.Anything more and you may need to go up a step.
Remember that when you step up steroids it can take 6 weeks to take effect, and they may relapse before the increased dose takes effect.
Remember to step down if control is excellent and there is negligible usage of beta agonists.
Every bout of wheeze is thought to possibly cause damage and therefore good control is the desirable goal
Exercise induced asthma, sometimes responds to Intal surprisingly.
Does the child and parent know what to do!
Without a written plan , probably not.( can you remember step 3 off the top of your head!)remember though we are familiar with dark blue, light
blue, green, red,orange, purple inhalers and brown ones, light and dark, patients are not.
Does the child and parent know what to do!
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Its worth asking them to repeat back what you’ve said about the asthma and the inhalers( tell them you sometimes don’t explain it well)
The child and parent must be able to demonstrate they can use the inhalers. Therefore you need plenty of placebos. And know how to use them yourself..
You need to be very very sure that they have a written plan, and can read ( my asthma death couldn’t read)
They need to know why they are doing thisSo give a written plan, again and again ( because they
get lost down the back of the sofa)I favour ‘asthma and my child’. Parents can win
a Hoover!Remember to include what to do in
emergencies…Asthma.org has a huge amount of information
for parents and children including FAQsEmergenciesKeep up to date with guidelines as they change(BTS,
BNF,SIGN) See guidelines included but ..Parents need know to give 10 puffs of a salbutamol
inhaler by spacer to have a stock of rescue soluble prednisolone 5 mgs and to know when to use it and what dose. They need to know signs of worsening asthma, and to get help quickly. Soluble prednisolone orally works in 15 minutes..as quick as I.M.
Emergencies in a nutshell
Only 2 of the brittle asthmas coming to the paediatric clinic had rescue steroid medication at home. Only one mother knew to give 10 puffs of a beta agonist.
0-2 get 10 mgs prednisolone ,
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2-5 get 20mgs and 5-12 get 30-40mgs. If a good response to
steroids they get them for 3 days. If poor response or worsening asthma they should be reassessed and referred urgently to casualty with nebulized salbutamol driven by 6 litres a minute oxygen.
Things parents ask..Drown the cat? Banish the dog?, and then bin the
inhalers? 90 % of children who are allergic to cats and dogs are also atopic and have allergies to HDM and pollen as well. They will meet other cats and dogs and can have possibly severe life threatening asthma if the inhalers have gone. Possibly early exposure to cat/dog allergens may in fact give protection. But if there is very strong cat allergy it would seem sensible not to have one.
Things parents need to know..There is evidence though that physically
getting rid of House Dust Mite when there is a known allergy is helpful
Some household chemicals also can cause bronchospasm
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Things they won’t want to hearStop Smoking, really , it does make
asthma worse .
What happens in the future..Will he/she grow out of it? 80% of children who have
‘childhood asthma’ get better apparently. 40% then relapse when they are older. There is some evidence that treating asthma well and preventing frequent relapses prevents damage
GastrointestinalGastroenteritis
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Children who show in casuality with acute asthma be offered an appointment at the paediatric clinic for review
Disclaimer: The recommendations contained in this guideline does not indicate an exclusive course of action, or serve as a standard of medical care. Variations, takingindividual circumstances into account, may be appropriate. The authors of these guidelines have made considerable efforts to ensure the information upon which they are based is accurate and up to date. The authors accept no responsibility for any inaccuracies, information perceived as misleading, or the success of any treatment regimen detailed in the guidelines.
Acute gastroenteritis is characterised by the sudden onset of diarrhoea with vomiting and fever. For most children, it is a selflimiting illness of a few days’ duration. The main risk is of dehydration and electrolyte imbalance. This risk is higher in young children. Rotavirus is the most common cause of severe diarrhoea among children, especially in those aged 6 months-2 years.In Scotland, rotavirus activity is seen mainly in the spring (April).Is it gastroenteritis?It is important to consider other diagnoses, particularly in the very young. Any child who is toxic, vomiting blood or bile or has severe abdominal pain or abdominal signs needs hospital referral. Be careful of those children with chronic illnesses, poor growth and the very young (<6 months).Evaluation• History. Assess risk of dehydration: In those < 6 months old, > 50% reduction in normal fluid intake, and/or >3 vomits and/or >5 watery stools in 24 hrs represents a significant risk.Character of stools; presence of blood or mucus.Associated symptoms (fever, malaise, etc.).Social factors: Parental competence, number of affected family members.•Assessment of dehydrationDehydration is the main clinical complication of acute gastroenteritis. Major symptoms are thirst and oliguria though the urine output can be difficult to assess in an infant with watery diarrhoea. Assess degree of dehydration on clinical signs and change in weight (if recent weight available).• Mild (<4%) there are no clinical signs.• Moderate (4-6%) - dry mucous membranes and sunken eyes.• Severe (7-9%) - altered responsiveness, cool peripheries, decreased skin turgor, impaired peripheral circulation and acidotic breathing.The “eyeball test” (i.e. just looking at the child) is usually a good indicator of illness severity. If the history from the parents suggests a more severe problem than the assessment, believe the history. Signs of dehydration may lag behind the onset of symptoms. Physical signs are unreliable in the obese infant.When should stool cultures be done?
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Routine stool cultures are unnecessary. Culture if the child has bloody stools or has recently returned from overseas travel.Consider if there is a community outbreak of infectious diarrhoea, if parents/carers work in the catering industry or if persistent loose stools (> 4 days).If the child has diarrhoea but is otherwise wellNo special drinks or treatments are needed. Feeding children normally will not make things worse and they may get better faster. Extra drinks will replace the fluid they are losing. Water flavoured with a little diluting fruit squash is probably best.• If breast-feeding, continue to feed on demand but give extra drinks of cooled boiled water between breast feeds.• If bottle-fed, continue feeding as usual with full-strength formula.Foods such as rice, potatoes, bread and cereals, lean meat, yoghurt, fruits and vegetables are best. Avoid sugary or fatty foods.Selection for hospital referralIn general, only children with clear objective evidence of significant dehydration (moderate – severe) justify referral to hospital.The others only justify referral if they are at high risk because of very young age, severe symptoms or for social reasons( or distance!)Treating mild dehydration in the in the communityMost children with mild dehydration can be treated at home with Oral Rehydration Solutions (ORS) such as Rehydrat‘ or Dioralyte‘.Traditional correction of dehydration over 24 hours or more and prolonged starvation have been abandoned. There is now a clear evidence-based approach of rapid rehydration over a 3-4 hour period giving 50 ml/kg ORS (see table below).Age Weig
ht( Kg)
4 hr ORS volume
Volume of ORS every 5 minoutes ( ml)
6 months12 months18 months2 years3 years
7.51011.512.514.5
375500575625725
810121315
The trick is to give very small amounts very frequently. Give 5-10 ml sips (or with a medicine syringe) every few minutes. As thevomiting improves, parents can increase the amount of ORS given and give it less often. Some children do not like the taste ofORS drinks but children who are dehydrated rarely refuse ORS.
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FeedingThere is now also clear evidence that early reintroduction of a normal diet will decrease the duration and severity of diarrhoea. Breast-feeding should not be discontinued. Extra fluids or ORS should be given between feeds. Start feeding after the 4-hour rehydration phase. In the formula fed, there is no evidence that regrading feeds is of any value..Normal diet should be offered to toddlers and older children. They know when they are well enough to eat. Avoid fatty or sugary foods. Give a drink of ORS for every loose stool passed.
Lactose intoleranceWhile transient lactose intolerance may occur after acute gastroenteritis it is rarely clinically significant. Average recovery time for the brush border lactase enzymes is four weeks. In infants with persistent loose stools (>5 days), a period on a lactose-free formula may be helpful and is better than continued “clear fluids”. What is unhelpful? Flat Coke/lemonade and fruit juices have NO place in the management of children with gastroenteritis. Coke/lemonade are high sugar fluids with a very low sodium content. Fruit juices such as apple juice are high in natural fruit sugar (sorbitol). Both may cause osmotic diarrhoea.MedicationsThere is NO indication for the use of anti-vomiting, anti-motility or anti-diarrhoeal agents in the treatment of childhood gastroenteritis. These therapies can worsen outcome because of side effects and do not prevent dehydration. Antibiotics are rarely indicated: Shigella dysentery; Salmonella in infants <6 monthsOutcome Parents should be given a written management plan (see linked parent advice sheet) including advice on when to seek further medical advice.
Easy Peasy Constipation and Soiling
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Child presents with history of constipation and /or soilingThe following are examples of information that is useful to obtain• History - bowel habit, onset, duration, precipitating factors, diet / fluids,milk input, abdo pain, stool withholding, urinary problems , vulvovaginitis• Examination - Weight centiles, abdo palpation, inspection of anus and perineum(avoid digital examination)
Childhood Constipation – General Advice
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AlertsDuring the examination / history were any of the followingALERTS noted?• Chronic Anal fissure• Blood without obvious cause• Weight loss• Persistent abdominal mass• Spinal abnormality• Anal abnormality (fissure, tags, malpositioned)
YESRefer on
NODiagnosis-Constipation+/- soilingFollow up in primary care or clinic,Diet exercise and toileting adviceMost appropriate evacuation path,Help from community children’s nurse
ToiletingRecommendations:- child to sit on toilet two to three times per day after meals for no longer than 5 mins.- Reward compliance and be positive when result obtained or use star chart…- parents to liaise with school regarding toilet facilitiesAvoid: - punishing for soiling, withholding- denying access to toilet
Simple Idiopathic Childhood Constipation.Normal bowel function in children ranges from three stools a day to once every two days ( Yong and Beattie 1998). Therefore, its not unreasonable to propose that
the successful treatment of constipation in children should achieve the child passing 3 stools a week without pain or soiling ( Young 1996).
3 stools/wk? Wean senna initially. When stopped wean lactulose slowly ..may take up to one year!
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DietRecommendations:- 6 – 8 cups of water based drink per day.- high fibre cereals, e.g. weetabix, shreddies, bran flakes, porridge- wholemeal bread, jacket potatoes, home made vegetable soup, baked beans- 5 pieces of fruit or veg per day- high fibre snacks, e.g. digestive biscuits, oatmeal biscuits, muesli bars, popcorn, dried fruit e.g. raisins
Reinforce general advice
No improvement? Improvement or 3 stools/wkIf no improvement at 4 weeks Continue 3 months then go to…
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Commence Lactulose<1 year 2.5 ml B.D1-5 years 5ml B.D5-10years10mlB.D>10years 15 ml B.Dup to 90mls/day
AND
SENNA 7.5mgs/5ml1 month – 2 years 0.5 ml/KG once a day2-6 years 2.5-5ml once a day> 6 years 5-10ml once a day
Commence Lactulose<1 year 2.5 ml B.D1-5 years 5ml B.D5-10years10mlB.D>10years 15 ml B.Dup to 90mls/day
Lactulose<1 year 2.5 ml B.D1-5 years 5ml B.D5-10years10mlB.D>10years 15 ml B.Dup to 90mls/day
2nd line
Sodium Picosulphate 5mgs/5ml<2 years 2.5mls 1-2X.2-5years 5ml 1-2X/day5-10yrs 10ml 1-2X/day> 10yrs 10-15ml 1-2X per day
Then go to ……
If no improvement now take advice…..Constipation disimpaction therapy
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MOVICOL-Paediatric2-6yrs one sachets a day7-11 years two sachets daily
1st lineSodium picosulphate 5mgs/mlDose as per maintenance, o.d. or b.d. for 2-3 days
2nd line hosp only
Klean PrepOrally or via NG tube20-25ml/kg/hr for 4-6 hrs ( max 4 litres over 4-6 hrs)
? IMPROVEMENT AFTER 4WEEKS
3rd linecombined oral and rectal drugslactulose and senna/sodium picosulphate as per maintenanceplus sodium citrate enema 5ml as required or phosphate enema 3-6yrs 50mls as required .>6 yrs 128mls as required
2nd lineMovicol paediatric2-4 yrs5-11 yrsDay 124Day 246Day 348Day 4610Day 5612Day 6 812Day 7812
Easy Peasy Soiling
Soiling nearly always results from constipation even though there is no history reported ( Youssef and Di Lorenzo 2001)
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Reinforce general advice
Commence lactulose followed by Senna one week later at doses Lactulose Senna<1 year 2.5 mls b.d. 2-6 yrs 2.5-5mls daily1-5 yrs 5-10ml b.d. > 6yrs 5-15 mls daily5-10 yrs 10mls B.d> 10 yrs 15mls b.d.
Has soiling resolved or improved ?
resolved
resolved
If still soiling even with some improvementContinue
medication for 3 months, no soiling and 3 good B.M.s per week
Increase doses of one or both medications
Review in four weeksAfter 3 months
gradually wean down doses. This may take up to a year before the child is off medication Still soiling
Consider 2nd or 3rd line and Refer on to clinic
Constipation in Children for parents
‘Tough Going’Constipation in children is common, and usually lasts just for a few days. A good diet and plenty to drink is often all that is needed. See a GP if constipation in a
child lasts more than a few days. Regular soiling may indicate persistent or severe constipation. A long course of laxatives may be needed for persistent or severe
constipation.
What is constipation?
Constipation in children means:
difficulty or straining when passing stools (sometimes called motions, faeces or 'poo') and/or pain when passing stools and/or
passing stools less often than normal. There is great variation in the normal frequency of passing stools. Anything from 3 times a day to once every other day is common and normal. Less often than this means that constipation is likely, but it can still be normal if the child does not strain, is
not in pain, and their stools are soft and well formed.
What causes constipation in children?
Food and drink factors are the common cause. o Not eating enough foods with fibre (the roughage part of the food that is not digested and
stays in the gut). o Not drinking enough fluid.
Stools (faeces) become harder, drier, and more difficult to pass if there is little fibre and fluid.
Holding stools in is quite common. This means the child has the feeling of needing the toilet, but resists it. You may see your child crossing their legs, sitting on the back of the heels, or doing
similar things to help resist the feeling. The stool then gets bigger, and even more difficult to pass out later. There are a number of reasons why children may 'hold on' to stools.
o A previous stool that they passed may have been a struggle or painful. So, they try and put off doing it again.
o Their anus may be sore or have a crack (anal fissure) from passing a previous large stool. It is then painful to pass further stools. So, the child may resist the urge to pass a stool.
o Dislike of unfamiliar or smelly toilets, such as at school or on holiday. The child may want to 'put things off' till they get home.
o Emotional problems may sometimes play a part.
Medical causes are uncommon. o Various conditions can cause constipation, such as an underactive thyroid, and rare bowel
disorders. Allergy to cows milk may be a factor in some children. Other symptoms are usually present, and a 'medical' cause is unlikely if the child has developed normally, and
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is otherwise well. o Some medicines can cause constipation as a side effect, for example, some cough
medicines.
What are the possible complications of constipation in children?
Most bouts of constipation in children last just a few days. Many children strain to pass a large or hard stool now and then. It is of little concern, so long as a normal pattern soon returns. See below for tips on
how to prevent and treat mild constipation.
In some cases, the constipation persists and becomes worse. The following may then develop:
Large hard stools may build up in the rectum (the last part of the gut). The rectum may enlarge (dilate).
A very large stool may develop and get stuck (impacted) in an enlarged rectum. The normal sensation of needing the toilet is reduced in an enlarged rectum. Also the 'power' of
the rectum to pass out the large stool is reduced. Softer, more liquid stools from higher up the bowel then 'bypass' around the impacted hard stool.
This leaks out and soils the pants or bed. The child has no control of this leaking, and so regular soiling may develop. Soiling due to constipation is sometimes mistaken for diarrhoea.
A child with persistent (chronic) severe constipation may also become irritable, not eat much, feel sick, have tummy pains from time to time, and may be generally out of sorts.
How can constipation in children be prevented?
A high fibre diet, and lots to drink makes stools that are bulky, but soft, and easy to pass out.
Food and fibre. Ask your practice nurse for a list of foods high in fibre if you are unsure which foods are best. Some examples include: fruit, vegetables, cereals, wholemeal bread. A change to a high fibre diet is often 'easier said then done', as many children are fussy eaters. However, any
change is better than none. Have you tried such things as giving dried apricots or raisins for snacks; jacket potatoes filled with baked beans for tea; porridge for breakfast; vegetable soups with bread. Try offering fruit with every meal. Perhaps do not allow sweets until your child has
eaten a piece of fruit.
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Drink. Encourage children to drink plenty. However, some children get into the habit of only drinking squash or fizzy drinks to quench their thirst. These may fill them up, and make them less likely to eat much food with fibre. So try and limit these kinds of drinks, and give water as the main
drink.
What is the treatment for constipation in children?
A high fibre diet and lots to drink described above is the usual first line treatment.
Laxatives are usually prescribed if the above does not work, or if the child has severe constipation. Laxatives are likely to be needed if the child has a large impacted stool with overflow
soiling (described above).
If laxatives are needed, then they are normally advised for several months. The first aim is to clear any impacted (stuck) stool. This can usually be done fairly quickly. However, if laxatives are
stopped too soon, a large stool is likely to recur again in an enlarged rectum. Regular laxatives for a few months means that:
o The child is likely go to the toilet and pass stools regularly. As they go to the toilet more often, the stools will be smaller and softer. So, the stools will be passed more easily. Any
fear of going to the toilet to pass large and hard stools will ease. o The enlarged rectum can gradually get back to normal.
o Constipation is unlikely to recur.o Remember it can take only a couple of weeks for a child
to become constipated and the same number of months to get better
There are different types of laxatives.
o Stool softeners, for example, lactulose. These make the stools soft and slippery and more easy to pass. Some children can need up to 6 teaspoons a day of this.
o Bulk forming agents, for example, fibre supplements, bran etc. These make the stools softer but bulkier, and gives the bowel more to 'work on'.
o Stimulant laxatives, for example, senna . These act on the muscle in the wall of the gut to 'squeeze' harder than usual. Some children may need up to 6 teaspoons of this.
A doctor will normally advise a stool softener or bulk forming agent at first. If one of these does not work alone, it is quite common to add in a stimulant laxative as well - but only once the stools
have been softened.
So, two different laxatives may be advised for several months. The dose is then gradually reduced and stopped. It is important to keep on with the treatment for as long as the doctor advises.
Constipation commonly recurs if treatment is stopped too soon.
Other treatments. Painkillers for a painful cracked anus (fissure) may be needed in some cases. An enema may be needed in a small number of cases if the constipation is very severe.
Some other points about constipation in children
Although you can buy laxatives at pharmacies, it is best not give them to children unless advised by your doctor. The type and dose of laxative needs to correct in each case.
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Try and get children into a regular toilet habit. After breakfast, before school or nursery, is often best. Try and allow plenty of time so they don't feel rushed.
Some kind of reward system is sometimes useful in younger children prone to 'holding on' to stools. For example, a little treat after each successful toilet trip.Or a star chart. However, try not
to make a fuss over the toilet issue. The aim is to be 'matter of fact' and relaxed about it. The more relaxed you are, the more likely your child will be relaxed.
www.childhoodconstipation.com
© EMIS and PIP 2004 Updated: April 2002 CHIQ Accredited PRODIGY Validated
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If no evidence of healing in four weeks refer Child health Department, Gilbert Bain Hospital
Nervous System
Tension Headache in Children Information to children and parentsDr. Ishaq Abu-Arafeh,Consultant Paediatrician
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Introduction:
Headache is a common complaint in children as it is in adults. In the vast majority of children the
headache is infrequent, brief and not severe enough to interfere with normal daily activities. In a
small but significant number of children the headache may become a recurrent problem that may
interfere with school education or the daily life routine.
Migraine is the most common cause of recurrent headache affecting about one in ten school age
children. Tension headache is less common than migraine and affect about 1% of schoolchildren.
Organic causes of recurrent headache are extremely rare, but usually associated with other
specific symptoms.
Most of the children are managed at home due to the small number of attacks or the mild nature
of their headaches. Other children are managed successfully by their general practitioners. Only a
small proportion of children with headache is treated by hospital paediatricians when the
diagnosis is not clear or the response to treatment is inadequate.
Tension headache in children:
Tension headache may start at any age, but it is commoner in older children than the younger
ones and affects both boys and girls equally. The problem tends to run a chronic course and
children commonly present after few months from the time of onset. In most cases no obvious
cause can be identified and all seems to have started out of the blue.
In a small number of children the initial trigger factor can be related to a school problem, family
difficulties or an illness affecting the child or a member of the family. Common types of tension
headache are:
1. Episodic tension headache: The headache is recurrent and may occur several times per
week. Each attack may last few hours and starts without warning. The pain is mild to
moderate in nature and commonly described as dull or “just sore” over the whole of the head.
During the attack the child may look tired, pale and miserable, but may continue with normal
activities. The child may complain of loss of appetite, nausea, light or noise intolerance but
there is no associated vomiting.
2. Chronic Tension-Type headache: This condition is characterised by frequent spells of daily
attacks of headache with features similar to those of episodic tension headache. Typically the
attacks occur on more than 15 days per month over several months period. Despite the
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headache the child maintains a good general health, but may miss many school days due to
the headache.
Diagnosis of tension headache:
The diagnosis is made upon fulfilling a set of clinical criteria based on the description of the
attacks given by the child and the parents. Children are often described by their parents as
worriers, anxious, sensitive, shy, perfectionists or meticulous. However, many children are
described as normal, happy and outgoing. A specific stress factor may become clear during the
interview, but often no direct association can be established.
Keeping diaries of the details of future attack may also help in establishing the diagnosis. In most
children tension headache runs a benign course, with long headache-free spells. However,
frequent relapses are also not uncommon.
In the majority of patients the typical clinical history and the physical examination can exclude
other possible causes of headache.
Occasionally, when the history is incomplete or inconsistent or if the physical examination is not
entirely normal, further investigations may be necessary including a brain scan.
Treatment:
The aims of the treatment are to relieve symptoms when they occur so as to break the cycle of
tension feeding into the headache and vice versa.
Management of acute attacks: Children should be encouraged to take a short period of rest (lying
down) or sleep to help pain relief. Painkillers should be used wisely and only as necessary to
avoid daily intake of painkillers that may aggravate the problem rather than help resolving it.
Both paracetamol and ibuprofen may be used. Stronger analgesics are not recommended. Short
courses of prophylactic treatment is occasionally needed.
Prevention of further attacks: Children should be encouraged to lead a healthy life style with regular meals, regular sleep and regular exercise and rest. Children may
identify and avoid trigger factors. With the help and support of the family, the child may be able to cope with the
headache and reduce its impact on his or her health, social life and education. COMBINED CHILD HEALTH SERVICES
DEPARTMENT OF PAEDIATRICS
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Migraine in Children Information to children and parents
Dr. Ishaq Abu-Arafeh,Consultant Paediatrician
Introduction:Headache is a common complaint in children as it is in adults. In the vast majority of children the headache is infrequent, brief and is not severe enough to interfere with normal daily activities. In a small but significant number of children the headache may become a recurrent problem that may interfere with school education or the daily life routine. Migraine is the most common cause of recurrent headache affecting about one in ten school age children. Tension headache is less common than migraine and affect about 1% of schoolchildren. Organic causes of recurrent headache are extremely rare, but usually associated with other specific symptoms. Migraine in children:Migraine may start at any age, but it is commoner in older children than the younger ones. In children under the age of 12 years boys and girls are equally affected, but over the age of 12 years, girls are more commonly affected than boys. The disease has tendency to run in families and it is not unusual to have several members of the same family affected. The natural course of the disease is variable and children may have long periods of time with few episodes of headache followed by bad spells with frequent attacks probably related to stress or excitement. Several types of migraine are recognised, but the most common types are described below:
Migraine without aura: In this type of migraine the headache starts without warning and the pain may be mild at the onset, but increases in severity over a short period of time. The pain is commonly throbbing in nature, may affect the forehead or one side of the head only. During the attack the child may look tired, pale and miserable. The child will be off his/her food, feels sick and may vomit. The child will complain of poor tolerance to light, noise or smell. The headache may last from several hours to 3 days and starts to ease off slowly. The child may find some relief from rest, sleep or after taking simple painkillers. The attacks may be triggered by stress, anxiety, excitement or some times by certain types of food.
Migraine with aura: This is similar to migraine without aura in presentation except for specific symptoms occurring just before the onset of headache called aura symptoms. The aura is commonly visual disturbances (seeing coloured dots or lines in front of the eyes) occurring few minutes to one hour before the onset of headache.
Other rare types of migraine are also recognised.
Diagnosis of migraine:The diagnosis of migraine is made on the clinical description of the attacks given by the child and the parents. Clinical criteria should be fulfilled to establish the diagnosis. The clinical history and the physical examination can exclude other possible causes of headache. Keeping diaries of the details of future attack may also help in establishing the diagnosis.
Occasionally when the history is incomplete or inconsistent or if the physical examination is not entirely normal a brain scan may be necessary to exclude other causes.
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Trigger factors of migraine:In the majority of children no obvious trigger factor can be identified, but in many children stress, anxiety, excitement, missing a meal, lack of sleep and travel are common trigger factors for migraine attacks.
Only in a small number of children, certain types of food such as cheese, chocolates and fizzy drinks may trigger attacks.
Identifying a trigger factor can sometimes be helpful in preventing further attacks of migraine, if the trigger factor can be avoided.
Treatment:The aims of the treatment are to relieve symptoms when they occur and also to prevent or reduce the number of attacks.
Management of acute attacks: Children may find relief from rest (lying down) or sleep. The sooner to take painkillers after the onset of headache the better chance of controlling the symptoms, therefore early administration of paracetamol or ibuprofen is recommended. The use of special medication such as migraleve (pink tablet) may reduce the risk of nausea and vomiting and make the painkiller more effective. Specific anti-migraine treatment such as Imigran are not yet licensed for children, but used successfully in specific cases.
Prevention of migraine attacks: Children should try to identify and avoid trigger factors if possible. Drug treatment to prevent migraine is not always successful, but worth trying in some cases.
Epilepsy In Children and Young People
Children and young people may present with similar types of seizures and in similar ways to adults with epilepsy (see separate article). However this article focuses on the forms of epilepsy
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and aspects of management which apply to children and young adults. Status epilepticus is also dealt with in a separately.
Prevalence Epilepsy is a common neurological disorder in childhood and is about twice as common in children as in adults (about 700 per 100,000 in children under the age of 16 years
compared to 330 per 100,000 in adults).Presentation Presenting features in children are similar to those in adults. However these sub-
types are commoner, or occur exclusively, in childhood:
Typical Absences (Petit Mal Seizures): Petit mal epilepsy is manifested by frequent (as many as 100 times per day or more) episodes of brief staring spells (lasting seconds at a
time). o Onset in childhood, and attacks continuing into adult life are rare.
o A typical absence attack lasts only a few seconds. The onset and termination are abrupt. The child ceases what he is doing, stares, looks a little pale, and may
flutter the eyelids. o Sometimes more extensive bodily movements occur, such as dropping the head
forwards, and there may be a few clonic movements of the arms. o The interruption of the normal stream of consciousness is very brief, and the
child may be unaware of the attacks, as indeed may be the parents for some time after onset, assuming that the child is just daydreaming.
o About one-third of all children with petit mal will have one or more tonic-clonic convulsions.
Infantile Spasms: occur in infants aged 4-8 months and consist of clusters of myoclonic spasms that occur upon awakening.
Juvenile myoclonic epilepsy occurs in the teen years. Early morning sudden myoclonic jerks, especially of the arms and shoulders. Often later develop generalised tonic-clonic
seizures. May be inherited as autosomal dominant. Benign Rolandic Epilepsy: also known as benign partial epilepsy. It occurs in children
aged 4-10 years and is more common in boys. Nocturnal seizures that are characterized by facial twitching and aphasia. Some children with benign rolandic epilepsy may also
have generalized tonic-clonic seizures. Benign childhood epilepsy with centrotemporal spikes: some older children may have
partial or generalized seizures. The inter-ictal EEG is characterized by large spike discharges over the Rolandic area of one hemispheres. Is not associated with any
structural lesion, and has an excellent prognosis.
Causes Include:
Malformations: e.g. Tuberous sclerosis and other hamartomas. Infections: Meningitis and encephalitis. Parasitic infections, particularly cysticercosis, are
common causes of epilepsy in Third World countries. Electrolyte disturbances, e.g. hypernatraemia or hyponatraemia, hypoglycaemia,
hypocalcaemia, hypomagnesaemia, toxins; trauma; metabolic defects.
Trigger factors Lack of sleep and watching television are two common triggers. It has been shown that observing the set with one eye covered prevents the occurrence of these seizures.
Differential Diagnosis Specific conditions to be considered in childhood include:
Vasovagal syncope: Loss of consciousness occurring in crowded trains, waiting at bus stops, or in school assembly, should always be presumed to be syncopal in nature unless
there is clear-cut evidence to the contrary. Night Terrors: these affect children aged between about 6 and 8 years, who suddenly
awaken from a sound sleep, wide-eyed, screaming, and inconsolable. They are amnesic for the events the following morning. They seem to occur just as often in happy children
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as in children who are not doing well at school or in the family. Fortunately they, too, pass quickly..
Breath-holding Attacks: affect younger children, aged between 1 and 2 years. A typical story is of a child who has some minor injury, or who is crossed in some way so that he becomes suddenly angry, upset, or frightened. Such attacks terminate spontaneously
without treatment. Febrile Convulsions
Munchausen's by proxy Arrhythmias
Migraine Narcolepsy .
Investigation:
EEG with photic stimulation and hyperventilation: o to support a diagnosis of epilepsy if the clinical history suggests it
o to help determine seizure type and epilepsy syndrome o to assess the risk of seizure recurrence after a first unprovoked seizure
o If an EEG is necessary, it should usually be performed only after the second epileptic seizure. It should not be used to exclude a diagnosis of epilepsy or in
the case of probable syncope (as there is a risk of false-positive result). Neuroimaging: to identify structural abnormalities that cause certain epilepsies. Not used
routinely when a diagnosis of idiopathic generalised epilepsy has been made. o MRI : is the imaging investigation of choice for people with epilepsy. It is
particularly important for children: who have developed epilepsy before the age of 2 years
who have any suggestion of a focal onset from history, examination or EEG (unless there is clear evidence of benign focal epilepsy)
in whom seizures continue in spite of first-line medication. o CT scan is an alternative to MRI: if MRI is contraindicated or unavailable
for children in whom a general anaesthetic or sedation would be required for MRI but not CT
in an acute situation, to determine whether a seizure has been caused by an acute neurological lesion or illness.
Blood tests and urine biochemistry to exclude other diagnoses and to determine an underlying cause of the epilepsy.
ECG: if the diagnosis is uncertain.
Management
Provide regular structured review by a specialist at least once a year, but probably more frequently (every 3-12 months) depending on need.
Use monotherapy whenever possible. The formulation or brand of AED should not be changed (variations in bioavailability or different pharmacokinetic profiles may increase
the potential for reduced effect or excessive side effects). Indications for monitoring AED blood levels:
o detection of non-adherence to the prescribed treatment o suspected toxicity
o adjustment of phenytoin dose o management of pharmacokinetic interactions
o specific clinical conditions (e.g. status epilepticus, organ failure or pregnancy). o Asymptomatic minor abnormalities in blood test results are not necessarily an
indication for changes in medication.
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Withdrawing treatment: When a child has been seizure-free for at least 2 years, discuss continuing or
withdrawing AED treatment with the child and their families/carers, as appropriate. The decision to withdraw medication should be taken by the child, their family and/or carers,
as appropriate, and the specialist after a full discussion of the risks and benefits of withdrawal. Withdraw gradually (over 2-3 months or longer); be aware of possible seizure recurrence. Longer for benzodiazepines (6 months or longer); be aware of drug-related
withdrawal symptoms and/or seizure recurrence. Withdraw one drug at a time.
Agree with the child with epilepsy and their family and/or carers a failsafe plan of action if seizures recur (last dose reduction reversed, medical help sought).
First line anti-epileptic drugs: o Childhood absence epilepsy: ethosuximide, lamotrigine, sodium valproate.
o Juvenile absence epilepsy: lamotrigine, sodium valproate. o Juvenile myoclonic epilepsy: lamotrigine, sodium valproate.
o Generalised tonic-clonic seizures only: carbamazepine, lamotrigine, sodium valproate, topiramate.
o Focal epilepsies: carbamazepine, lamotrigine, oxycarbazepine, sodium valproate, topiramate.
o Infantile spasms: Vigabatrin is recommended as a first-line therapy for the management of infantile spasms. Steroids are also used.
o Benign epilepsy with centrotemporal spikes: carbamazepine, lamotrigine, oxycarbazepine, sodium valproate.
o Benign epilepsy with occipital paroxysms: carbamazepine, lamotrigine, oxycarbazepine, sodium valproate.
o Severe myoclonic epilepsy of infancy: clobazam, clonazepam, sodium valproate, topiramate.
o Continuous spike wave of slow sleep: clobazam, clonazepam, ethosuximide, lamotrigine, sodium valproate, steroids.
o Lennox-Gastaut syndrome: lamotrigine, sodium valproate, topiramate. o Landau-Kleffner syndrome: lamotrigine, sodium valproate, steroids. o Myoclonic astatic epilepsy: clobazam, clonazepam, sodium valproate,
topiramate. Other interventions:
o Psychological interventions: Consider using relaxation and cognitive behaviour therapy in children with drug-resistant focal epilepsy.
o Psychological therapies should be used as adjunctive therapy, not as an alternative to pharmacological treatment.
o Vagus nerve stimulation: an adjunctive therapy to reduce the frequency of seizures in children who are refractory to AED therapy but who are not suitable
for resective surgery, including children whose epileptic disorder is dominated by partial seizures (with or without secondary generalisation) or generalised
seizures. o Ketogenic diet: Consider as an adjunctive treatment in children with drug-
resistant epilepsy.
Surgery Modern techniques for the accurate localisation of epileptic discharge and the recognition of specific seizure patterns has increased the role of surgery in the management of
drug-resistant epilepsy. Operations include temporal lobectomy, hemispherectomies and division of the corpus collosum.
Prognosis
Continuing epilepsy is more likely in those with neurological impairment or other additional medical conditions. Conditions identified by a prospective UK study included
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Lennox-Gastaut syndrome, Addison's disease, hearing loss, deaf mutism after meningitis, and congenital heart disease.
After age 16 there is a high death rate in young people with epilepsy. This emphasises the importance of maintaining supportive relationships between health care professionals
and people with epilepsy as they become independent adults In many children the seizures remit but it can have a major impact on a child's
development and affect adult life6.
References
1. NICE Epilepsy. (2004) 2. Neville BGR; Fortnightly review: Epilepsy in childhood; BMJ 1997;315:924-930 (11
October) 3. Moshe SL. ; Seizures early in life. Neurology; 2000;55(5 Suppl 1):S15-20
4. Shields WD. ; Catastrophic epilepsy in childhood. Epilepsia; 2000;41 Suppl 2:S2-6. 5. McAbee GN, Wark JE. ; A practical approach to uncomplicated seizures in children. Am
Fam Physician. 2000 Sep 1;62(5):1109-16. 6. Brorson LO, Wranne L. ; Long-term prognosis in childhood epilepsy: survival and seizure
prognosis. Epilepsia; 1987 Jul-Aug;28(4):324-30.
Internet Links
British Epilepsy Association.
Acknowledgements EMIS is grateful to Dr Colin Tidy for authoring this article. The final copy has passed peer review of the independent Mentor GP authoring team. ©EMIS 2005.
Last issued 15 Aug 2005
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Status EpilepticusGeneralised convulsive (tonic-clonic) status epilepticus is defined as a generalised convulsion lasting 30
minutes or longer, or repeated tonic-clonic convulsions occurring over a 30 minutes period without recovery of consciousness between each convulsion.
Epidemiology
Estimated incidence is between 18 and 28 cases per 100,000 population and recurs in over 13% of patients3.
Risk factors include history of epilepsy, age under 5 years or elderly, genetic predisposition, mental handicap and structural brain pathology. Potential precipitants include drug withdrawal,
intercurrent illness and metabolic disturbance (e.g. hypoglycaemia).
Presentation The diagnosis of tonic-clonic status is usually clear. Non-convulsive status (e.g. absence status or continuous partial seizures with preservation of consciousness) may be more difficult.
Management in adults
General protective measures: make the patient comfortable, ensure the head is protected, remove false teeth, release constricting neck-ware, move if in a dangerous situation (e.g. at the top of
stairs), call an ambulance to arrange urgent transfer to hospital. Secure airway (insert a Guedel or nasopharyngeal airway) and resuscitate, give oxygen if
necessary, assess cardiorespiratory function; establish intravenous access. Consider the possibility of non-epileptic status. Emergency drug therapy:
o Diazepam 10-20 mg given rectally (or intravenous diazemuls), repeated once 15 minutes later if status continues to threaten, or midazolam 10 mg given buccally.
o If seizures continue: o Lorazepam (i.v.) 0.1 mg/kg (usually a 4 mg bolus, repeated once after 10-20 minutes; rate
not critical). o Long-term maintenance: anti-epilepsy drug therapy must be given in parallel with
emergency treatment. The choice of drug depends on previous therapy, the type of epilepsy, and the clinical setting. Any pre-existing therapy should be continued at full
dose, and any recent reductions reversed. o For sustained control or if seizures continue:
o Established status Phenytoin infusion at a dose of 15-18 mg/kg and rate of 50 mg/minute, and/or Phenobarbitone 10-15 mg/kg at a rate of 100 mg/minute.
o Refractory status requires general anaesthesia. The refractory stage (general anaesthesia) is reached 60/90 minutes after the initial therapy. In some situations, general
anaesthesia should be initiated earlier and, occasionally, should be delayed. Emergency investigations: pulse oximetry, blood for blood gases, glucose, renal and liver function,
electrolytes, calcium and magnesium, full blood count, blood clotting, anti-epilepsy drug levels. 5ml of serum and 50ml of urine samples should be saved for future analysis, including toxicology,
especially if the cause of the status epilepticus is uncertain. Other therapy as required:
o Administer glucose (50 ml of 50% solution) and/or intravenous thiamine (250 mg) as high potency.
o Pabrinex if any suggestion of alcohol abuse or impaired nutrition. o Treat acidosis if severe.
Establish aetiology. Identify and treat medical complications: chest x-ray to evaluate possibility of aspiration. Other
investigations depend on the clinical circumstances and may include brain imaging, lumbar puncture.
Monitoring:
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o Regular neurological observations and measurements of pulse, blood pressure, temperature. ECG, biochemistry, blood gases, clotting, blood count, drug levels. Patients
require the full range of ITU facilities and care should be shared between anaesthetist and neurologist.
o EEG monitoring is necessary for refractory status. Consider the possibility of non-epileptic status. In refractory status epilepticus, the primary endpoint is suppression of epileptic activity on the EEG, with a secondary endpoint of burst-suppression pattern (i.e. short
intervals of up to 1 second between bursts of background rhythm).
Treating status epilepticus in children The management of a child who presents with a tonic-clonic convulsion lasting more than 5 minutes should be the same as the child who is in established status.
General measures are the same as outlined above for adults. If immediate IV access : IV lorazepam 0.1mg/kg given over 30-60 seconds.
If no IV access: diazepam 0.5mg/kg given rectally. If seizure is continuing at 10min:
o IV lorazepam 0.1mg/kg given over 30-60 seconds. o Paraldehyde 0.4 ml/kg given rectally (given with some volume of olive oil).
o Phenytoin 18 mg/kg IV over 20 minutes or, if already on phenytoin, give phenobarbitone 20 mg/kg IV over 10 minutes. (use intraosseous route if still no IV access). Also
Paraldehyde 0.4 ml/kg given rectally if not already given. o Call the on-call anaesthetist or intensive care medic.
If seizure still continues: o Rapid sequence induction of anaesthesia using thiopentone 0.4mg/kg IV.
o Transfer to intensive care unit.
Non-convulsive status epilepticus in adults and children
This is less common than tonic-clonic status epilepticus. Treatment for non-convulsive status epilepticus is less urgent than for convulsive status epilepticus. Treatment should be considered
as follows: o Maintenance or reinstatement of usual oral AED therapy
o Use of intravenous benzodiazepines under EEG control, particularly if the diagnosis is not established.
o Referral for specialist advice and/or EEG monitoring.
Prognosis
If the patient presents for the first time with status epilepticus, the chance of a structural brain lesion is greater than 50%.
Mortality and the risk of permanent brain damage are increased with duration of the attack (especially if over 1 hour). Mortality rates are up to 5-10% in adults and 3% in children.
Prevention
Good seizure control in pre-existing epilepsy.
References Used
1. Fountain N.B . Status epilepticus: risk factors and complications. Epilepsia 2000 41(2):23. 2. NICE CG20; Epilepsy. (2004)
3. Prodigy Guidance on Epilepsy. 4. SIGN No. 70 April 2003. Diagnosis and Management of Epilepsy in Adults.
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5. Sprigings D; Acute Medicine 3rd edition (2001), Blackwell Science, ISBN 0-632-05455-7
Internet and Further Reading
British Epilepsy Association.
Acknowledgements EMIS is grateful to Dr Colin Tidy for authoring this article. The final copy has passed peer review of the independent Mentor GP authoring team. ©EMIS 2005.
Last issued 11 May 2005
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Growth&Development
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Paediatric ExaminationSee Also: The Paediatric History record.
Although some of the principles of examining children are similar to adult examination there are important differences in both outline and detail. Children are not just small adults and the pattern of disease, the approach to the examination and content of the examination are quite different in children. To further complicate things the examination changes as children develop and get older. Eventually it is similar to examination in adults. The following outline aims to highlight the important differences, give some general principles and provide an outline of the examination in different age groups.General points
It is important to have established rapport with parents and child when taking the history. The approach to the examination will be determined by the age, level of development and level of understanding of the child. Inspection and observation are the most important parts of the examination. Avoid waking sleeping children. Approach the child at their level, if necessary kneel on the floor. It may be impossible to examine pyrexial, irritable children without provoking crying and they should be carefully observed before attempting closer examination. Start examining peripherally with hands and feet as this is less threatening. Make the examination fun to help with their anxiety. Make sure the child is comfortable and warm hands, stethoscope and other instruments. Wherever possible avoid unpleasant procedures (for example rectal examination). These are seldom necessary and can put children off being examined for a lifetime.
Growth and pubertal developmentGeneral points
Myelination of the nervous system at birth is incomplete. Pubertal development has important implications for growth. Assessment of puberty is important when assessing growth. Examination of children should incorporate accurate assessment of growth and pubertal development. There are three phases of growth: Infant phase:
o Rapid first year and slowing in the second year of life
o Good nutrition is important for normal growth o Metabolic hormones control growth
Childhood phase: o From second to tenth year o Pituitary hormones and growth hormone are important factors
Pubertal or adolescent phase: o From onset of puberty until adult stature reached o Sex hormones are the important factors
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Measurement Head circumference routinely in under age 2 years Length or height in older children Weight Plotting of serial measurements to establish pattern and range of growth Use appropriate growth charts Assess and plot pubertal development where indicated
Developmental assessment An awareness of normal developmental milestones should be acquired by all doctors working with children. Detailed assessment of development is complicated but useful assessments in the course of routine examinations and consultations can be achieved with experience and practice. There are large variations in normal development. Schemes to assess development centre on:
o Motor skills: gross motor and fine motor
o Special senses: vision and hearing o Communication: comprehension and expressive language
o Psychosocial aspects: social skills and behaviour Aims and purposes of paediatric examination
It is important to distinguish between: o The routine examination of well babies (to screen largely for abnormalities of growth and development). o The examination of ill babies (to establish the nature and cause and extent of any illness or injury). o The examination of children for other specific purposes such as, for example:
To establish fitness for education or certain activities. To examine for signs of sexual abuse in child protection cases.
However this is not an absolute distinction. Whether ill or well the examining doctor should have a good working knowledge of routine examination and normal findings in children at different ages. Problems with development, behaviour and growth may thus be identified opportunistically whilst examining an ill child. Doctors working with children should have a good knowledge of normal developmental milestones, as well as routine physical development and findings at different ages.
Examination Examination will be outlined in different age groups. These are not intended to be exhaustive checklists but aim to highlight important aspects of the examination in these selected age groups, particularly where there are notable differences to adult examination. The emphasis and detail of any examination will be determined by the particular aims and purposes of the examination outlined above.
Newborn babies (see also Newborn Screening) Six week old babies (see also The Six Week Review) 7 to 9 month old babies Toddlers or children under 2 years Preschool children (see also The Pre-school Check) School age children Adolescents (see also Puberty: Normal and Abnormal)
Normal valuesA distinctive feature of paediatric examination is that normal parameters change with growth and development. This is illustrated by the example of pulse, blood pressure and respiratory rate in different age groups in the table below.
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Normal ranges for pulse, blood pressure and respiratory rate in childrenNewborn and young babies
Older babies and toddlers
Preschool children
School children Adolescents
Pulse: 110- 160 beats per minuteTachycardia: over 180 beats per minute
P: 110- 160 beats per minuteT: over 160 beats per minute
P: 110 to 160 beats per minuteT: over 160 beats per minute
P: 80 to 120 beats per minuteT: over 120 beats per minute
P: 60 to 100 beats per minuteT: over 160 beats per minute
Systolic blood pressure: variable, but range 50 to 85 mmHg
SBP: 80 to 95 mmHg
SBP: 80 TO 100 mmHg
SBP: 90 to 110 mmHg
SBP: 100 to 120 mmHg
Respiratory rate: 30 to 50 breaths per minuteTachypnoea: over 60 breaths per minute
RR: 25 to 35 breaths per minuteT: over 40 breaths per minute
RR: 25 TO 30 breaths per minuteT: over 30 breaths per minute
RR: 20 to 25 breaths per minuteT: over 25 breaths per minute
RR: 15 to 20 breaths per minuteT: over 25 breaths per minute
Remember importance of cuff size for blood pressure: cuff width (2/3 of shoulder to elbow distance) and cuff length (2/3 of limb circumference)
Newborn babiesThe assessment and examination of the newborn and neonates (under 4 weeks) often requires a specific and detailed series of checks, observations and measurements supplemented with detailed history from the parents. Babies are routinely checked and examined at birth and at between 6 and 8 weeks. The objectives are generally:
To screen for congenital abnormalities (particularly those requiring intervention). About 14% of babies will have congenital abnormalities and these are often detected at the neonatal check. To answer questions from parents and discuss concerns they may have.
Preterm babies have particular characteristics best considered separately. Newborn and young babies become ill very quickly. The 'baby check' system of assessment can help health professionals and carers to quickly evaluate the seriousness of a baby's illness.1 Growth:
o There is a steep growth curve. Weight (nude) should be accurately measured and plotted: o Initial weight loss of between 5% and 10% occurs in the first week. o Subsequent weight gain over the first 5 months is approximately 0.2Kg per month. o Length needs careful measurement with a stadiometer. o Head circumference is measured with a suitable non-stretch tape at the largest point around occiput and forehead.
Development: o Social smiling is an important milestone (higher cortical function). o Babies show a startle reaction to sound
General examination: o This is performed in the light of a history of mother's health, the pregnancy and the birth. o A routine of checking systematically should cover: o It is important to assess gestation and weight:
Term- born between 37 and 42 weeks gestation Preterm- born before 37 weeks gestation Post-term-born after 42 weeks gestation
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'Small for dates' or small for gestational age if below the 10th centile (weight) for gestational age 'Large for dates' when over 90th centile for gestational age Low birth weight babies (LBW) are important to identify (associated morbidity and mortality):
LBW babies are <2.5 kg at birth (7% UK births) Very low birth weight (VLBW) are <1.5 kg (1% of UK births and mostly preterm) Extreme low birth weight (ELBW) are < 1.0 kg (less than 0.5% and nearly all preterm)
Cardiovascular examination . Early diagnosis of congenital heart disease, coarctation of the aorta and patent ductus arteriosus is important. Examination should include:
o Inspect colour looking for cyanosis. Peripheral cyanosis is common in newborns (acrocyanosis). Look for central cyanosis (tongue). o Palpate brachial and femoral pulses and the precordium. o Auscultation should detect heart sounds and murmurs. Splitting of the second sound is difficult to detect with the fast heart rate. Innocent murmurs are heard in about 20% of babies. o Appreciation of normal findings (table above)
Respiratory examination : o Observation of breathing is most important. o Signs of respiratory distress are distinct from those in older children and adults. A combination of the following may be observed:
Tachypnoea Subcostal and intercostal recession Tracheal tug Grunting Flaring of nostrils Cyanosis Apnoea and periodic breathing may be identified (preterm and neonates)
Gastrointestinal examination: o Observation:
Observe the baby feeding (distinguish normal possetting from abnormal vomiting or bile stained vomiting) Inspect nappy/ stools Look for jaundice (distinguish normal from abnormal as in neonatal jaundice)
o Palpation: Examine mouth and palate Inspect natal cleft Liver edge (1cm below costal margin is normal) Hernias should be detected Umbilical hernias are common and need no treatment Other hernias need prompt referral Hydroceles are common and need no treatment Genital anomalies should be identified and referred Brief confirmation of normal urethral and clitoral anatomy should be made (identify for example hypospadius) Ambiguous genitalia need referral Hips may be examined whilst the nappy is off (Ortolani and Barlow techniques)
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Neurological and developmental assessment: o Observation is again the most important form of examination o Inspection and palpation of the baby's head is indicated:
Fontanelle size and tone (bulging fontanelles with raised intracranial pressure) Moulding of the head is apparent in the first 24 hours (note 'chignon' after ventouse and cephalhaematomas which can take several days to resolve) Head circumference should be measured and plotted
o Eyes and hearing: Babies will fix and follow with their eyes The red reflex should be seen in each eye Squints may be normal under 8 weeks There should be a startle response to loud noises
o Reflexes: It is usually inappropriate to elicit primitive reflexes (unless asymmetry of movement or tone suspected) Observation will identify symmetrical movements
Six week old babiesThis is covered in the Six Week Review record.
Important aspects of the examination: o Ill babies can be assessed according to the baby check system1 o The examination is similar to that for newborn babies
o Progress with feeding should be discussed Growth:
o Weight, length and head circumference should be plotted
o Deviation from centiles should be discussed and followed up Development:
o Milestones should be briefly reviewed in all babies
General examination: o The parameters and methods are as for those outlined in young and newborn babies o Hips may be examined again
7 to 9 month old babies Important aspects of the examination:
o This age group are frequently seen by doctors. o From the age of about 3 months viral illnesses are very common.
o It is a period of rapid growth and development. o Routine checks are not now normally performed in this age group.
o Assessment of growth and development is usually done opportunistically. Growth:
o Growth is very rapid (with a doubling on average of birth weight by 5 months).
o Length and weight should be plotted and compared with previous readings. o It can be very difficult to obtain an accurate length in this age group.
Development: o Parents will often present with children when there are concerns over developmental progress. o It is a period of rapid developmental progress. o Developmental milestones should be reviewed opportunistically. For example:
Social smile should have appeared by 8 weeks.
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Children should be sitting unsupported by 8months. Children should be babbling by 8 months.
General examination: o Rashes are common with frequent viral infections particularly. o Doctors should be familiar with important rashes (such as the purpuric rashes of meningococcal septicaemia, idiopathic thrombocytopenic purpura and Henoch- Schönlein Purpura).
Cardiovascular examination: o Cardiac output is regulated mostly by changes in heart rate (as with newborn and younger babies). Tachycardia is an important sign which needs explanation.
Respiratory examination: o This is frequently performed in this age group. o Observation is again very important.
o It is important to distinguish wheeze from stridor. Gastrointestinal examination:
o Observation is again important. For example, with peritonitis. The child lies very still with flexed knees and shallow breaths. o Inspect anogenital area if appropriate. This is an increasingly difficult examination as children get older and requires sensitive handling. o Warm hands and reassurance are needed to palpate the abdomen of an ill child.
Neurological and developmental examination: o Formal examination is very difficult. Improvisation is often required. o Cranial nerves are examined by observation for example, of behaviour and facial movements. Cranial nerve abnormalities in this age group include:
Bell's palsy Eighth cranial nerve impairment (sensorineural deafness) Sixth cranial nerve deficit (convergent squint) with raised intracranial pressure
Toddlers Important aspects of the examination:
o Toddlers are infants who are walking (usually over 1 year) but under 2 years of age. o Again this group consults often.
o Attendance is likely to be distributed between different settings (for example hospital, primary care, clinics, walk-in centres). o It is important for there to be good communication between these different agencies. o Growth and development is rapid.
o Checks of growth and development will often have to be done opportunistically. o Genu varus is physiological in this age group.
Growth: o Growth decelerates from the end of the first year. o Head growth is rapid as the brain grows with myelination in cortical areas.
Development: o Important milestones should be identified. Briefly:
Hand dexterity improves along with visual acuity from palmar grasp to pincer grip in the first year. By the second year a tower of 6 bricks can be achieved. Speech develops from babbling to 6 or more words at 18 months and short phrases during the second year. Comprehension allows simple instructions to be followed by about a year.
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Babies progress from crawling to cruising and then walking by about a year (before 18 months).
General examination: o It is usually best to examine babies on the parent's lap and establish relaxed rapport.
o Engage in play to facilitate the examination. o It may be necessary to be quite selective and examine important or relevant systems first. o Leave more intrusive or unpleasant examinations until the end (for example throat examination).
Cardiovascular examination: o Refer to normal values.
o Identify innocent murmurs (often heard). Respiratory examination:
o Observe and identify normal rate, breathing sounds and pattern.
Gastrointestinal examination as above. Neurological and developmental examination as above.
Preschool children (age 2 to 5 years) Important aspects of the examination:
o This age group also frequently attend for medical care and advice. o Illness and increasingly, accidents will prompt attendance.
o Again rapport and confidence have to be established and maintained for easier examination. Trust can be built for future examinations. o Genu valgus is physiological in this age group.
Growth: o Growth is decelerating at this stage.
o Centile charts should be used and checked. Development:
o The most marked advances are in communication skills and use of language.
o An assessment of language skills should be briefly made in all children. General examination:
o Again most often achieved on parent's lap or standing close to parent.
o Explain and commentate on procedures as they progress. Answer questions, they are usually very inquisitive at this age.
Cardiovascular examination: o Examination is easier in this age group. o Again innocent murmurs are common.
o Heart sounds are more easily identified with slower heart rates. Respiratory examination:
o Observation is again most important.
o Peak flow measurement not reliable until about age 5 years (see Diagnosing Childhood Asthma in Primary Care)
Gastrointestinal examination: o It is often best to examine kneeling down alongside the patient. o Children may prefer palpation to be done with their hand underneath the examiners.
Hip and knee examination: o Irritable hip and other hip conditions can occur at this age and require assessment. o Normal genu varus (physiological in the toddler) and valgus (physiological in the preschool child) often require reassurance at this age.
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Neurological and developmental examination: o This increasingly approaches what is possible in adults. o Vision can be checked by shape or letter matching at 3 years of age.
o A circle will be copied by 3 years, a cross by 4 years, a square by 4.5 years and triangles by about 5 years.
School age children (from 5 to 10 plus years) Important aspects of the examination:
o This age group are examined less often by doctors. o Psychological factors begin to play more of a part in how problems present.
Growth: o Growth will be steady leading up to the pubertal growth spurt. o Concerns may begin to be expressed about growth and development in relation to puberty.
Development: o Social and behavioural aspects of development become more important.
o Other aspects of development approach those of adults. Examination:
o There are now few differences from adult examination.
Adolescents (from the onset of puberty) Important aspects of the examination:
o Adolescents attend for medical advice infrequently.
o Rapport and good communication may be difficult to establish. o Psychological factors are likely to be very important.
o Most adolescents are very self-conscious and this can impede adequate examination. o It is recommended to have a chaperone.
o Confidentiality and consent become more important issues. Growth:
o Puberty initiates a period of rapid growth. o Normal and abnormal puberty should be recognised.
Examination: o Examination is very similar to that undertaken in adults.
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Problems and Milestones
Problem / Milestone Test / Examination ReferralPhenylketonuria (PKU) Blood spot at 5 days Abnormal result direct to RACH –
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Congenital Hypothyroidism
GP informed
Congenital dislocation of the hip
Examination as neonate and 6 weeks
Breech delivery / talipes / spina bifida / family history
Screen fail or risk factors - direct to Orthopaedic Surgeon at RACH
Undescended testes Examination as neonate and 6 weeks
Screen fail referred direct to surgeon at RACH
Congenital heart disease Auscultation and feel femoral pulses as neonate and 6 weeks
Newborn: if murmur but well and femorals present, review in 1 week. If concern refer.
6 weeks: discuss with Dr Booth/Dr Kindley/SJB
Cataracts Red reflex as neonate and at 6 weeks
Urgent referral to Opthalmologist
Cleft palate Check as neonate and at 6 weeks
Refer direct to cleft palate team at RACH
Deafness Neonatal Hearing Screen
(If screen missed -distraction test at 8 months)
Referred directly – GP informed
Sitting at 9 months History and observation If concern - refer to local Paediatrician
Squint Check at 7 – 9 months Please refer any new squint directly to Opthalmologist at GBH - GP informed
Walking at 2 years History and observation If concern - refer to local Paediatrician
Language Development Speech and language check at 2 years
Refer to local Paediatrician / Speech Therapist / Dr Kindley depending on circumstances
Height Measure at 4 years If below 0.4th Centile refer to local Paediatrician
Developmental Milestones Contributed by Cynthia Dedrick, Ph.D.University of South Florida
Gross Motor Mean age Normal Range
In prone head up only 1 month 0 to 3 months
Head steady at shoulder 2 months 1 to 4 months
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In prone head up to chest 2 months 1 to 4 months
In prone head up to forearms 3 months 2 to 5 months
In prone head up with extended arms 4 months 3 to 6 months
Rolling front to back 4 months 3 to 6 months
Rolling back to front 5 months 4 to 7 months
Sitting with support 5 months 4 to 7 months
Sitting independently 6 months 5 to 9 months
Creeping on tummy 7 months 5 to 10 months
Crawling hands and knees 8 months 6 to 11 months
Pulls to a stand 9 months 6 to 12 months
Cruises 11 months 9 to 14 months
Walking 12 months 9 to 17 months
Running 15 months 13 to 20 months
Jump on two feet 24 months 17 to 34 months
Kicks Ball 24 months 18 to 30 months
Climbs stairs with alternating feet 30 months 28 to 36 months
Peddles tricycle 36 months 30 to 48 months
Fine Motor/Adaptive Mean Normal Range
Unfisted 3 months 0 to 4 months
Bats at objects 3 months 2 to 5 months
Objects to midline 4 months 3 to 6 months
Transfers objects 5 months 4 to 7 months
Raking grasp 7 months 5 to 10 months
Finger feeds 7 months 5 to 10 months
Primitive pincer 8 months 6 to 10 months
Neat pincer 9 months 7 to 10 months
Voluntary release 12 months 10 to 15 months
Helps with dressing 12 months 10 to 16 months
Spoon feeds 15 months 12 to 18 months
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Uses cup open/sippy 15 months 10 to 18 months
Imitates housework 18 months 14 to 24 months
Handedness 24 months 18 to 30 months
Helps with undressing 24 months 22 to 30 months
Undresses self 36 months 30 to 40 months
Toilet training 24 to 36 months
Social/Emotional Mean Normal Range
Social smile 5-6 weeks 1 to 3 months
Object permanence 9 months 6 to 12 months
Stranger anxiety 9 months 6 to 12 months
Affective sharing 10 months 9 to 18 months
Uses mother as secure base 12 months 9 to 18 months
Separation distress 12 months 9 to 24 months
Independence 18 months 12 to 36 months
Parallel play 24 months 12 to 30 months
Associative play 30 months 24 to 48 months
Cooperative play 36 months 24 to 48 months
Language Mean Normal Range
Cooing 3 months 1 to 4 months
Laugh 4 months 3 to 6 months
Turns to voice 4 months 3 to 6 months
Razzing 5 months 4 to 8 months
Babbling 6 months 5 to 9 months
Dada/mama non-specifically 8 months 6 to 10 months
Gesture games 9 months 7 to 12 months
Understands no, 10 months 9 to 18 months
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Mama/dada specifically 10 months 9 to 14 month
One step command with a gesture 12 months 10 to 16 months
Immature jargoning 13 months 10 to 18 months
One step command w/out a gesture 15 months 12 to 20 months
Points to body parts 18 months 12 to 24 months
Mature jargoning 18 months 16 to 24 months
Puts two words together 24 months 20 to 30 months
Pronouns inappropriately 24 months 22 to 30 months
Two step command 24 months 22 to 30 months
States first name 34 months 30 to 40 months
Pronouns appropriately 36 months 30 to 42 months
Monitoring GrowthMonitor growth and growth velocity over 6 months. Children who are "crossing the centiles" should be considered for further investigation.Check parental centiles by:
plot like-sexed parent's height on right of centile chart plot mother's height + 12.5cm on boy's chart plot father's height - 12.5cm on girl's chart
Assess bone age
Xray L wrist/hand
Investigations
FBC ESR T4 Urea Chromosomes (girls only)
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Consider referral if:
Height <3SD, no constitutional effect Clinical signs of wasting Suspicion of congenital heart disease Possible malabsorption Documented reduced growth velocity Suspicion of neglect
Head circumference Head circumference showing a progressive rise not parallel to the weight centile should be monitored more closely, with head measurements (preferably taken by the same person) and weight measurements. Progressive hydrocephalus without an associated myelomeningocoele is very rare.
Paediatric BMI Interpreting child growth centile charts Faltering Growth
Educational difficulties
When a child's school progress is poorer than the expected family norms, anxious parents will sometimes visit their GP as a first port of call end this may lead to a referral to the Consultant Community Paediatrician or to Educational Psychology.
Sometimes parents will approach the General Practitioner or Paediatrician with a diagnostic label which they have read about or seen on TV. Levels of concern about these various labels can fluctuate according to what is fashionable in the media at the time and they can include ADHD, dyspraxia and dyslexia. Often parental perceptions are accurate.
The following paragraphs describe the types of educational difficulties that sometimes lead to referral and what Community Paediatricians have to offer.
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Deteriorating School Performance This must be clearly documented by parents and school and should not be confused either with simple fluctuations or the widening gap which children sometimes experience when they have learning difficulties and the demands are becoming increasingly excessive. Deteriorating school performance may be a reflection of many things - bullying, family adversity, abuse or depressive illness. There may be an undetected medical condition such as new onset epilepsy or (rarely) a progressive degenerative neurological condition which may be associated with other regressions. The General Practitioner has a number of options in this situation.
He/she may wish to refer to the local School Nurse who can liaise appropriately with the school.
There may be a need for a psychiatric or Social Service referral Some form of statutory meeting between school, Social Services and Health. This can be facilitated by the School Health Service.
If organic factors or psychiatric illness is suspected, referral routes may either be to the Consultant Community Paediatrician, Paediatric Neurologist or Child Psychiatrist.
Dyslexia This term is applied to children who have specific learning difficulties and this may affect a number of areas (not just reading). The assessment of such children is the remit of the Educational Psychologists. Community paediatricians do not have this type of expertise. Dyspraxia We are increasingly detecting children with impairments of executive and organisational motor functioning. Sometimes it is accompanied by other difficulties such as attention deficit, tick syndromes or mild autistic spectrum. Consultant Paediatricians are happy to see such children and would carry out a full neurological examination and exclude other disorders. We may want further more detailed assessment and therapeutic advice by the Occupational Therapy/Physiotherapy Team. Schools can themselves refer directly into these service. In the past, such children were described as "clumsy".
Attention deficit hyperactivity disorder This is a controversial topic. Many children with learning difficulties also have concentration difficulties. Before making this diagnosis it is essential to ensure that them am no factors within the child e.g. anxiety/depression/adverse family situations which might be affecting
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activity and concentration levels. Poor parenting skills are relevant in a high proportion of such cases. However, it must be borne in mind that difficult overactive children can place enormous stress on parental functioning. Consultant Paediatricians sometimes assess these children, sometimes prescribe stimulant medication (Methylphenidate) and monitor aver a period of time, whilst also liaising with the school. However, Child Psychiatry may be a more appropriate referral route and some joint working can be done between Child Psychiatrists and Community paediatricians. Sometimes parents want to use the ADHD label as a panacea for other problems which they cannot easily accept,
Children with learning difficulties Children with severe learning difficulties and perhaps other handicaps are normally detected at the pre-school stage. Children with moderate or minor learning difficulties may not emerge until after they start school. Chilren with delay who come to the notice of education, preshcool, OT , Physio or SLT are usually referred on to Padiatrics and are usually assessed in the clinic first before the CDI setting. Sometimes these children are referred to Raeden in Aberdeen where assessment takes place over a week. The CDI in Shetland was set up to bring a Readen type experience to Shetland. It offers longer appointments , multidisciplinary input, multidisciplinary meetings with parents involved, and the expertise of a neurodevelopmental consultant. Referral onwards to geneticists is often undetaken where there is a suspicion of a genetics condition. Sometimes such children are referred to the Consultant Community Paediatrician or GPWSI directly by the schools or the Educational Psychologists. In children with mild or moderate learning difficulties, a specific cause is not often found and this can be disappointing to parents who are having to come to terms with the fact that their child has learning difficulties.
We are developing an ASD pathway, with fim timescales involved.
The CDI, hopefully can be integrated with the new IAF process.
In conclusion, the paediatrician has an important role in assessing some children with educational and learning difficulties. However them are limitations as to what we can offer and sometimes the problem is best dealt with by consulting the child's school (with parents permission) or facilitating more constructive dialogue between parents and school.
Home Doctors Training
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IT Links Latest Search
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Urinary TractandGenitalia
GUIDELINES FOR THE MANAGEMENT OF ACUTE URINARY TRACT INFECTION IN CHILDHOOD,
GG&C.Renal Unit
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Royal Hospital for Sick ChildrenYorkhill Division
UTI Management Version: 1 Page 1 of 13Author: Renal Clinicians Group Authorised by: Dr
J Beattie Issue Date: Jan 2011Date of Review: Jan 2012 Q-Pulse Ref: YOR-REN-
007UTI Management Version: 1 Page 2 of 13
Author: Renal Clinicians Group Authorised by: Dr J Beattie Issue Date: Jan 2011
Date of Review: Jan 2012 Q-Pulse Ref: YOR-REN-007
ContentsPage Number(s)
1. Symptoms3
2. Useful Definitions3
3. Specimen Type4
4. Criteria for Diagnosis4
5. Urine Transport5
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6. Management5
7. Acute Management7
8. Antibiotic Prophylaxis8
9. Urinary Tract Imaging9
10. Information for Parents of Children with UTI12
UTI Management Version: 1 Page 3 of 13Author: Renal Clinicians Group Authorised by: Dr
J Beattie Issue Date: Jan 2011Date of Review: Jan 2012 Q-Pulse Ref: YOR-REN-
007SYMPTOMS
Early diagnosis and prompt treatment of UTI are especially important during the first year of life. Any infant or child with a temperature of > 38o C
with no definite cause should have a urine sample examined. Other indications for
examining the urine are as follows:Unexplained vomiting or abdominal pain
Frequency of micturition, dysuria or enuresisFailure to thrive
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Prolonged jaundice in the new-bornNon specific illness
Suspected sexual abuseHaematuria or hypertension
Abdominal mass or palpable bladderUSEFUL DEFINITIONS
When considering further management of infants and children with UTI (see below), it is useful to
distinguish those symptoms which are consistent with acute pyelonephritis/upper tract infection from those consistent with lower urinary tract
infection viz.“Upper Tract” “Lower Tract”Fever Non-specific abd. Pain
Lethargy UrgencyGeneral Malaise Frequency
Vomiting WettingLoin pain Frank haematuria
Atypical UTI::
• seriously ill infant or child• poor urine flow
• abdominal or bladder mass• raised plasma creatinine
• septicaemia
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• failure to respond to treatment with suitable antibiotics within 48 hours
• infection with non E-coli organismsRecurrent UTI:
UTI Management Version: 1 Page 4 of 13Author: Renal Clinicians Group Authorised by: Dr
J Beattie Issue Date: Jan 2011Date of Review: Jan 2012 Q-Pulse Ref: YOR-REN-
007• two or more episodes of UTI with acute
pyelonephritis/upper UTI or• one episode of UTI with acute
pyelonephritis/upper UTI plus one or more episode of UTI with cystitis/lower tract UTI , or
• three or more episodes of UTI with cystitis/lower UTI.SPECIMEN TYPE
Depending on the urgency, a clean catch (CCU) or suprapubic tap
(SPA) urine in an infant or a mid stream (MSSU) urine specimen in older children should be
obtained. Only social cleanliness and dryness are required. If a bag specimen of urine is taken and
shows apositive result (see below), confirmation in
infants by SPA, CCU orless commonly by catheter specimen (CSU)
should be undertaken.
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CRITERIA FOR DIAGNOSISThe traditional criteria of a pure growth of > 105
bacterial colony forming units (CFU) per ml is based on the finding that 95% of pregnant and
non-pregnant women with a clinical diagnosis of acute pyelonephritis or acute cystitis had
bacterial colony counts of this level in a clean voided specimen. In infants and children the
probability of infection using these criteria is of the order of 80% if demonstrated on one voided
or urethral catheter specimen and 95% is demonstrated on three specimens. Lower colony
counts may be found persistently in UTI, particularly in boys but this should be an
indication for repeating the culture or obtaining a SPA. Any growth of gram negative or > 500-
1000 gram positive bacteria on a SPA sample is significant.
URINE MICROSCOPYUrine microscopy can make a useful contribution
to diagnosis,especially when urgent treatment must be
initiated without culture results. Urine microscopy should be undertaken with fresh
unspun urine, using a Neubaur counting chamber with a mirrored surface ("Crystallite", Hawksley).
The urine white cell count is calculated by counting the number of cells in two large
squares. This number, multiplied by 5 will give the c.mm. count. The high powered field method
should not be used as this method has an unacceptable variability.
Although examination of fresh urine is desirable, there can be a delay of up to 48 hours without
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significant alteration in cell count provided that the urine pH remains below 6.8.
Significant pyuria is defined as > 10 WBC per c.mm. Pyuria however, is not diagnostic of UTI, this can only be ruled out if a urine culture is
obtained prior toUTI Management Version: 1 Page 5 of 13
Author: Renal Clinicians Group Authorised by: Dr J Beattie Issue Date: Jan 2011
Date of Review: Jan 2012 Q-Pulse Ref: YOR-REN-007
treatment. In addition, the absence of pyuria, particularly in children with recurrent UTI does
not exclude significant bacteriuria.Microscopy of fresh unspun urine for the
presence of motilebacteria is also of value. This may be done at the
same time as the examination for WBC and a positive result is defined as at least 107 bacteria of the same morphology per ml (equivalent to 8
organisms per high powered field).COMBINATION DIPSTICK ANALYSIS
Combination dipstix which allow the measurement of leucocyte esterase activity and urinary nitrite in addition to standard urinalysis,are now available. However, despite encouraging
data in adult practice, the sensitivity of these combination dipstix, particularly in
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0-3 year age group is not sufficiently high for these to replace a urine culture in patients
suspected of having a UTI.In children 3 years and older combination dipstix testing can be used to inform management viz.• Both leucocyte esterase and nitrite positive.
If clinical diagnosis consistent with UTI and/or a past history of UTI send urine culture and start
antibiotic therapy (see below).• Leucocyte esterase negative and nitrite
positive.If clinical diagnosis consistent with UTI and if a
fresh urine sample was tested, send urine culture and start antibiotic therapy (see below).
• Leucocyte esterase positive and nitrite negative.
Send urine culture but only start antibiotic therapy if there is good clinical evidence of UTI as this result may indicate infection elsewhere.
Treat on the basis of the culture result.• Leucocyte esterase and nitrite negativeUTI Management Version: 1 Page 6 of 13
Author: Renal Clinicians Group Authorised by: Dr J Beattie Issue Date: Jan 2011
Date of Review: Jan 2012 Q-Pulse Ref: YOR-REN-007
No indication for urine culture or therapy. Explore other causes of illness.
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URINE TRANSPORTAccurate interpretation of microbiological culture findings on urine samples is highly dependent on
the quality of the sample and the manner in which it is transported to the laboratory. Samples are rendered useless if they are
contaminated by faecal flora at the time of collection OR if there is a delay of 4 hours or more between collection and arrival in the
laboratory.If a sterile universal container is used for the
specimen, it should be chilled immediately to 4oC (domestic fridge temperature) prior to rapid transport to the Microbiology department. If rapid transport is not possible, the universal
container should remain at 4oC prior to dispatch preferably within 24hours. The temperature of
the ward refrigerator should be checked regularly.
If boric acid is used as a preservative the correct volume of urine must be added to the container
to ensure the correct concentration of boric acid.If a dipslide urine culture technique is used,
instructions on the adequate inoculation of the plate must be followed. Following inoculation,
the dipslide should be left at room temperature prior to dispatch to the Microbiology department.
MANAGEMENTManagement is greatly helped by detailed
discussion with the parents and the older child, preferably supplemented by written information.
UTI Management Version: 1 Page 7 of 13
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Author: Renal Clinicians Group Authorised by: Dr J Beattie Issue Date: Jan 2011
Date of Review: Jan 2012 Q-Pulse Ref: YOR-REN-007
After an appropriate specimen of urine has been obtained, treatment should be started
immediately, especially in infants and children under the age of 3 years. The choice of antibiotic
should be based on a "best guess" policy until the sensitivity of the organism is available.
However, if there is no clinical response within 24-48 hours, the agent should be changed. The
following drugs are suitable for oral administration for short full dose courses.
TrimethoprimCo-amoxiclavNitrofurantoin
CefalexinAcute Management
Treatment should be provided according to the risk of serious illness as shown below. When
there is doubt about the level of risk of serious illness the child should be managed in
accordance with the higher risk level. Children with atypical UTI (see above under definitions)
should have early imaging.Children with a high risk of Urine microscopy and
cultureserious illness and/or children Treat with IV
antibiotics
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younger than 6 months withsuspicion of UTI
Acute pyelonephritis/upper UTI.Children who have bacteriuria Urine culture if not
alreadyand fever 38°C or higher. Children done.
presenting with fever lower than Treat with 7 days oral
38°C with loin pain/tenderness and antibiotics (if oral route
bacteriuria. not possible, use IV)Cystitis/lower UTI
All other infants and children with Treat with 3 days oral
symptoms of signs of UTI who antibiotics.UTI Management Version: 1 Page 8 of 13
Author: Renal Clinicians Group Authorised by: Dr J Beattie Issue Date: Jan 2011
Date of Review: Jan 2012 Q-Pulse Ref: YOR-REN-007
have bacteriuria but no systemic Review if still unwell at
symptoms or signs 24-48 hoursA third generation Cephalosporin e.g. Cefotaxime
or Ceftazidime or a combination of aminoglycoside and Co-amoxiclav would be appropriate. There is no consensus over the
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duration of intravenous therapy, however it seems reasonable to consider a minimum of
three to five days followed by 5 days oral treatment.
The resistance of community acquired urinary pathogens to Amoxycillin is too high for this drug
to be used as a first choice therapy. On completion of antibiotic therapy, the urine
should be examined to ensure the infection has been eradicated. If the child is on a prophylactic antibiotic this should not be stopped while the
urine sample is obtained.ANTIBIOTIC PROPHYLAXIS
The evidence base for the value of antibiotic prophylaxis is deficient however a prophylactic
dose of a suitable antibiotic should be considered until the initial urinary tract imaging has been completed. The drug dosage should be
adjusted to the child's age and weight and agents currently suitable for prophylaxis include:
Trimethoprim: 1-2mgs per Kg per dayNitrofurantoin: 1mg per Kg per day
Co-amoxiclav: 0-1yrs 125/31 2.5mls per day1-6yrs 125/31 5mls per day
6-12 yrs 250/62 5-10mls per dayCefalexin: 12.5mg/kg – maximum dose 125mg at
nightTo reduce the risk of dental decay, liquid
preparations of these drugs should ideally be sugar free and must not be diluted with sugar
containing diluents. In children with minor
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symptoms it is acceptable to wait for the results of the urine culture before starting therapy. If a
negative urine culture has been obtained following therapy, further follow up urine
cultures may be restricted to times during which the
UTI Management Version: 1 Page 9 of 13Author: Renal Clinicians Group Authorised by: Dr
J Beattie Issue Date: Jan 2011Date of Review: Jan 2012 Q-Pulse Ref: YOR-REN-
007child is either fevered or unwell.
The long term management of infants and children with a history of recurrent UTI, renal scarring or other imaging abnormalities e.g.
vesico ureteric reflux should be individualised.URINARY TRACT IMAGING
INITIAL STUDIESA number of urinary tract anomalies may be
detected in children of both sexes who present with UTI but recent evidence suggests a more tailored approach to urinary tract imaging is
appropriate. The following guideline is suggested as initial imaging in the light of the recently
published NICE guidelines (August 2007).0 – 6 months Urinary tract ultrasound
A 99m Tc DMSA scan and MCUG should only be arranged if there is a history of an episode of UTI
with “upper tract” symptoms (see above) or recurrent UTI. The DMSA scan should be carried
out 6 months after infection.
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MCUG should be carried out when the urine is sterile and is recommended in all boys in this age
group. MCUG should be undertaken urgently in both sexes if there is gross dilatation of the
collecting system (s) on USS and/or obstructive uropathy is suspected. In girls who have a
normal USS but abnormal DMSA, MCUG should be considered.
6 months – 3 years Urinary tract ultrasoundIf there is a history of recurrent UTI (see above
definition) or an episode of UTI with “upper tract” symptoms (see above) a 99m Tc DMSA
scan should be carried out.If an abnormality on either of these two imaging studies is found, a reflux study will depend on
the degree of continence of the child. In the pre-continent child MCUG or a direct radionuclide cystogram (see below) should be carried out.In the child who is continent and co-operative
indirect radionuclide cystography using 99m Tc DTPA or MAG3 should be used.
> 3years Urinary tract ultrasound if upper tract symptoms or recurrence (See above definition).If there is a history of recurrent UTI , a 99m Tc
DMSA scan should also be carried out. If an abnormality is detected on either of these two imaging studies then a 99M Tc DTPA or MAG3
indirect radionuclideUTI Management Version: 1 Page 10 of 13
Author: Renal Clinicians Group Authorised by: Dr J Beattie Issue Date: Jan 2011
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Date of Review: Jan 2012 Q-Pulse Ref: YOR-REN-007
cystogram should be considered.In the child who has required hospital admission, it is preferable for the urinary tract ultrasound
scan to be carried out prior to discharge if possible, particularly if there has been a delayed
response to treatment.The use of a plain abdominal x-ray is common in urinary tract imaging protocols. However, it is
recognised that in the absence of specific indications the diagnostic yield is very low
indeed. Specific indications for plain abdominal x-ray should be any patient presenting with
frank/persistent haematuria, UTI secondary to Proteus species or in a child who has an
abnormal or delayed micturition.SUBSEQUENT STUDIES
Subsequent imaging should be individualised and will depend on the age of the child, and the
presence or absence of abnormalities on initial imaging. The following suggestions may be
helpful:1. Follow up of children known to have renal
scarring isbest carried out by 99m Tc DMSA scanning rather than by ultrasound scanning. The main indication for repeating the DMSA study is the presence of recurrent or breakthrough UTI in the child known
to have risk factor(s) for the development or progression of renal scarring. In this
circumstance, ideally the DMSA should not be carried out more than once per year.
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2. Indirect radionuclide cystography should be performed if it is felt important to know if
previously demonstrated VUR has resolved. This follow up is unnecessary if the child has had no further infections and the initial 99m Tc DMSA scan is normal. It should be performed if the
child is having recurrent or breakthrough infections and if an anti-reflux procedure is being
considered.In the event of a negative indirect radionuclide
cystography and if there is sufficient clinical concern, a direct radionuclide cystogram, using
99m Tc pertechnetate could be considered. Although this is a more sensitive technique for
the evaluation of VUR, urethral catheterisation is still required.
3. Follow up of pelvic dilatation found on urinary tract ultrasound is best carried out by a
combination of urinary tract ultrasound and 99m Tc DTPA or 99m Tc MAG 3 studies.
4. The use of IVU should be tailored to the specific clinical problem, This will result in few
radiographs, a lower radiation dose and specific answers for the clinician. When a small kidney is discovered on ultrasound or isotope examination
and no VUR is found then an IVU to show the calyceal anatomy may prove helpful in
establishing the cause. In the presence of uncommon syndromes (e.g. Laurence-Moon-
Biedl) and certain diseases (dysplasia or medullary necrosis), visualisation of the calyceal
anatomy is helpful and a high quality IVU is required. Other possible indications for
UTI Management Version: 1 Page 11 of 13
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Author: Renal Clinicians Group Authorised by: Dr J Beattie Issue Date: Jan 2011
Date of Review: Jan 2012 Q-Pulse Ref: YOR-REN-007
IVU are when a complicated duplex kidney is suspected and when anatomical detail of a non dilated ureter is required, e.g. following urinary
diversion.A regular meeting is held in the renal unit involving radiologists and clinicians. This
meeting serves as a discussion forum and is open to all clinical colleagues who may have problem
cases.FOLLOW UP
Patients found to have bilateral renal scarring with or without renal functional impairment
require long term medical review. In patients with unilateral renal abnormality/scarring long term (annual), usually primary care review is only recommended in those patients in whom
there is an associated abnormality in differential function.
UTI SERVICE RHSC YORKHILLJanuary 2008
INFORMATION FOR PARENTS OF CHILDREN WITH UTI
When to suspect urinary tract infection in a child or a baby
Your child or baby may have infected urine without having the fishy smell and burning pain
on passing urine that occurs in adults with
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cystitis. In a baby or toddler you should think of urine infection if he/she is unwell and/or has a
high temperature, unless there is clearUTI Management Version: 1 Page 12 of 13
Author: Renal Clinicians Group Authorised by: Dr J Beattie Issue Date: Jan 2011
Date of Review: Jan 2012 Q-Pulse Ref: YOR-REN-007
evidence of some other explanation. You should also think of it in a baby who as repeated bouts of fever, vomiting, jaundice or poor weight gain
and, of course in any child who does have symptoms related to passing urine.
What to do if you think your child may have a urine infection
It is important to treat urinary tract infection quickly particularly in the very young child
because prolonged infection may make them quite ill and delay in treatment may damage the kidney. You should contact your doctor as soon as you suspect infection and ask for an urgent
appointment and urine culture.How to diagnose urinary tract infection
Urinary infection can only be diagnosed with certainty if a clean catch specimen is collected in a sterile container and sent without delay to the laboratory for examination. A urinary infection
cannot be demonstrated reliably on a dipstix test of the urine in children under the age of 3 years. A full result of a urine culture teakes a minimum
of 48 hours. The ideal method in babies and toddlers is the catch specimen which has been
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demonstrated to you in hospital. However if an adhesive plastic bag is used and shows a positive
result, this should be confirmed by a clean sample.
TreatmentIn babies and toddlers who are unwell and any
child with distressing symptoms, it is likely that treatment will be given before the laboratory
results are available. The most common antibiotics prescribed are Trimethoprim,
Augmentin, Nitrofurantoin and Cephradine. It may be necessary to change the antibiotic after 48 hours if your child is not obviously better. In
this case the laboratory result will probably show that the term causing the infection is not
sensitive to the antibiotic chosen and will also indicate what other antibiotics to choose. Full
treatment should be continued for 7-10 days and after that all children should continue to take a small regular dose of antibiotic until the kidneys
and bladder have been checked by scans.What to expect after treatment
It is currently recommended that that all children under the age of 3 years who have had a urinary tract infection should have at least one scan to check the kidneys and bladder are normal. This
will usually be an ultrasound scan of the kidneys (like the scan used to measure the baby during
pregnancy). Further, more detailed scans maybe necessary particularly if the ultrasound scan is abnormal. In the child who is older than 3 years of age, the need to undertake investigation with
scans is felt to be unnecessary unless the infection is severe or recurrent. When all the
tests have been completed make sure you
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understand the results and the reasons why further tests and treatment may be necessary.
What may happen in the futureBoys rarely get further infections and if they do it usually happens quite soon after the first one.
Girls however often get further infections. It does not necessarily mean that something is
wrong, but it might be an indication for further tests and perhaps long term
UTI Management Version: 1 Page 13 of 13Author: Renal Clinicians Group Authorised by: Dr
J Beattie Issue Date: Jan 2011Date of Review: Jan 2012 Q-Pulse Ref: YOR-REN-
007treatment. Long term treatment may be
necessary, particularly in the young child an in those children who have an abnormality of the
bladder of kidney. Ensure you ask enough questions and that you understand the reasons for your childs need for prolonged treatment.
General measures to reduce the risk of recurrent infection
1. Encourage regular and complete bladder emptying eg at leas twice in the morning , at least twice in the afternoon and twice before
going to bed.2. Watch out for constipation and if not
responding to diet some mild laxative treatment may be necessary.
3. Ensure regular bathing and avoid highly scented soap and bubble bath. In addition it is
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preferable to avoid shampooing the childs hair while he/she is in the bath.
4. Ensure that following a trip to the toilet the bottom is wiped clean from front to back using
soft absorbent toilet paper.5. Ensure easy access to satisfactory toilets at school.GUIDELINES FOR THE MANAGEMENT OF
ACUTE URINARY TRACT INFECTION IN CHILDHOOD
INFORMATION FOR PARENTS
URINARY TRACT INFECTIONS (UTI’s) IN CHILDREN
When to suspect urinary tract infection in a child or a baby
In a baby or toddler you should think of urine infection if he/she is unwell and/or has a high temperature with no other explanation – for example a runny nose or sore ears. Your child or baby may have infected urine without having the fishy smell and burning pain on passing urine that occurs in adults with cystitis. Children over 4 years old will usually have symptoms related to passing urine.
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What to do if you think your child may have a urine infection
It is important to treat a UTI quickly particularly in the very young child as prolonged infection may make them quite ill and delay in treatment may damage the kidney. You should contact your doctor as soon as you suspect infection and ask for an urgent appointment and urine culture.
How to diagnose urinary tract infectionUTI can only be diagnosed with certainty if a fresh urine sample is collected in a sterile container and sent without delay to the laboratory for examination. A full result should be available after 48 hours. A dipstix test of the urine can be a useful guide but is not the final test. The ideal method is the clean catch specimen, however in babies and toddlers a sterile pad in a nappy or an adhesive plastic bag is a (less accurate) alternative. A positive result from bag or pad may need to be confirmed by a clean catch sample. If getting a clean catch is proving impossible, a specimen collected in a potty washed preferably in a dishwasher or alternatively in hot water and detergent is acceptable.
TreatmentIf your child is unwell or has distressing symptoms, it is likely that treatment will be given before the laboratory results are available. It may be necessary to change the antibiotic when the result is available and full treatment should be continued for 7 days. Some children will need to continue to take a small regular dose of antibiotic until the kidneys have been checked by scans.
What to expect after treatmentAll children who have had a UTI should have an ultrasound scan to check the kidneys and bladder are normal.
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Further scans may be necessary in the young child, if the ultrasound scan is abnormal or if your child has recurrent infections. It is important you understand the results of the tests and the reasons why further tests and treatment may be necessary.
What may happen in the futureBoys rarely get further infections and if they do it usually happens quite soon after the first one. Girls however often get further infections. It does not necessarily mean that something is wrong, but it may mean further assessment is required. Longer term treatment may be necessary, particularly in the young child and in those children who have an abnormality of the bladder or kidney. Ensure you ask enough questions and that you understand the reasons for your child’s need for prolonged treatment.
General measures to reduce the risk of recurrent infection
11 Encourage regular and complete bladder emptying e.g. at least twice in the morning, at least twice in the afternoon and twice before going to bed.
11 Watch out for constipation and if not responding to diet some mild laxative treatment may be necessary.
11 Ensure regular bathing and avoid highly scented soap and bubble bath. In addition it is preferable to avoid shampooing the child’s hair while he/she is in the bath.
11 Ensure that following a trip to the toilet the bottom is wiped clean from front to back using soft absorbent toilet paper.
11 Ensure easy access to satisfactory toilets at school.11 Ensure adequate fluid intake, avoiding fizzy drinks, drinks with a
high sugar content and strong colourings or flavourings.
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Above is one view of investigations. Below is Dr Kindley’s own Investigation protocol for UTIs in children.
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Undescended TestesPhimosis and other inguinal scrotal swellings.
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Newborn
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Hip problems in children
Condition Age at presentation
Sex distribution
Pyrexia Presentation Blood tests Radiology
Perthes disease 4-10 years x4 more common in boys
No Painful limp
Hip or knee pain
Reduced ROM in hip
Normal Plain x-ray MRI
Bone scan
Developmental dysplasia of the hip
From birth x7 more common in girls
No Not painful Normal Ultrasound up to 6months
X-ray after 6 months
Septic arthritis 2-11 years More common in boys
38C+ Acute systemic illness
Painful
Will not
WCC raised
ESR raised
CRP
Plain x-ray can be normal
Ultrasound may show fluid
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walk raised MRI shows fluid
Irritable hip 2-11 years More common in boys
No or less than 37.5C
Limp +/- pain in groin thigh and knee
WCC normal
ESR normal
CRP normal or sl raised
Ultrasound may show fluid (sterile)
X-ray normal
Slipped upper femoral epiphysis
Teens x4 more common in boys, never after menarche in girls
No Painful limp, chronic, becomes acute
Normal X-ray antero-posterior + frog lateral
LimpLimp without pain
Short leg Scoliosis Dysfunctional
Limp with pain
Fracture (esp toddler) Trauma (NAI) Perthe's disease (18m to late teens) Transient synovitis (irritable hip) - refer after 48hrs ?septic arthritis Slipped upper femoral epiphysis Septic arthritis Osteitis Juvenile chronic arthritis
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Clicky hip Clicky hip is quite a common childrens' condition. In a recent survey of the Hip Screening programme, a detected incidence on neonatal screening of approximately 3% was found. The condition requires no treatment and will resolve in most cases by three months and, in nearly all cases, by a year. These children do not require to be seen in the specialist clinic unless there is some doubt that their hip is dislocatable. The cause is usually a vacuum effect as in clicking one's knuckles or due to a tendon clicking over a bony prominence on certain movements. It should only be referred if associated with other abnormal findings. Primary treatment: None. Refer when:
Limited abduction of the hip. Leg length discrepancy. Asymmetrical skin creases.
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Vision Service (Children’s Service – Shetland Islands Council)
Staged approach to interventionThe Vision Service has a staged intervention procedure that should be followed when supporting children and young people with a visual impairment. Following a referral, a Functional vision Assessment will be carried out to identify the level of need. Collaborative working with children, parents, schools, allied health professionals, the voluntary sector and the community is an integral part of vision service provision. Parental consent will be sought prior to service involvement.
STAGE 1The Vision Service may be consulted at any time on how to support a pupil with a visual impairment. Existing school staff carries out any recommendations.
The Vision Service will: Advise the school and other relevant settings about reasonable adjustments
to the environment Make recommendations for the class or subject teacher, or carer to implement Provide training for staff, parents, carers and peers if appropriate Provide resources and advise on there use if appropriate Contribute to the child’s Individual Educational Programme if appropriate Monitor annually if appropriate
STAGE 2Stage 1 applies and, in addition, The Vision Service will provide continuing, substantial and direct support for a block of time (e.g. termly, monthly) depending on the child’s level of need.
The Vision Service will also: Evaluate and monitor recommendations termly, if appropriate. Attend and contribute to review meetings and a Co-ordinated Support Plan if
required.
STAGE 3The Vision Service provides support on a full time basis.Children will have a significant visual impairment and support will be provided weekly/daily and will be continuing, substantial and direct.
Stage 1 and 2 applies and, in addition, The Vision Service will also: Support the child to access a mainstream curriculum through: forward
planning time with class teacher, co-ordination and resourcing of alternative materials and staff training to ensure an accessible curriculum is available at the same time as peers, as is required by law,
Co-ordinate, and/or deliver a special curriculum, including direct, one-to-one
input by trained staff for:
Alternative access to print (E.g. use of technology, Braille moon, speech software etc)
Mobility training
Access to skills for daily life
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Social Skills
Development of an understanding of independence
Further useful General Paediatric Information and protocols
These are leaflets provided by SHB Physiotherapy department which give similar information .
This is Dr Auchterlonie’s personal protocols which have lots of General Paediatric
useful information.
Children suspected of having a Cardiac Murmer
This pathway covers patients up to their 16th birthday who are suspected of having a cardiac problem.This pathway covers patients of any age with a known congenital cardiac problem who has not been discharged from Dr J E Burns care.
Heart murmur – no symptomsRefer to local community paediatric clinicIf murmur not present – will be dischargedIf murmur disappears during postural manipulation – May be InnocentIf the murmur persists then refer to visiting paediatricians’ clinic.If required, visiting paediatrician will request ECG/Echo to be recorded locally and sent to Dr P Booth for analysis.
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Heart murmur – symptomsI.e. murmur with - cyanotic spells, dyspnoea on feeding, failure to thrive or diastolic murmur or child < 6 months age.If visiting paediatricians’ clinic with in one week then refer as urgent.If no visiting paediatricians’ clinic then contact Dr P Booth, Consultant Paediatrician with an interest in Cardiology, RACH who is contactable at Aberdeen Maternity Hospital on 01224 552 660 or 01224 554 904.Dr Booth will either ask for tests to be recorded on Shetland and sent down to him or will ask for the patient to be sent to him.If tests are to be done on Shetland, then Dr Booth will contact Chris Brown, Physiological Measurements Officer.
Dr J E Burns annual visiting Congenital Cardiac Clinic
This clinic is for review of patients with a known congenital cardiac problem.This clinic is not for the referral of patients with a suspected or undiagnosed congenital cardiac problem.Dr JEB will decide on the patients that need reviewing.
New patients information for the congenital cardiac clinic and who have a diagnosed congenital cardiac problem, should in the first instance be passed to the Physiological Measurements Officer. Along with the referrer they will ensure that all relevant data is available to be passed to Dr J E Burns and that a copy is held in the Shetland patient notes.For patients with a known congenital cardiac problem new to Shetland copies of the catheter/surgical/echo/ecg data should be obtained from the appropriate cardiac centre.For Shetland patients the data and diagnosis information will be collected together for the Shetland notes.
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MEDICATION IN SCHOOLS FOR PUPILSREQUEST FOR SCHOOLS TO ADMINISTER
PRESCRIBED MEDICATION
FORM A
Pupil’s Details:
Pupil’s name: Date of Birth:
Address:
Home telephone number: Emergency Contact:
Name of School: Class:
Condition or illness:
Parental Request/Responsibility
Please could you give my son/daughter the Medicine, which has been prescribed by the General Practitioner/Hospital Doctor.
I will personally arrange delivery of the medicine or arrange with another adult to deliver the medicine to the school.
I will advise you immediately of any change of treatment or medication prescribed by the General Practitioner/Hospital Doctor.
Please let me know if the medication has not been given.
I accept that this is a service the school is not obliged to undertake.
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Signature: Parent/Carer Date:
Details of Medication ( to be completed by General Practitioner/Hospital Doctor)
Name of Medicine (as described on container)
Date dispensed:
Medicine prescribed by (signature)
(Printed signature/stamp)
GP/Hospital Doctor (delete as appropriate)
Directions for use:
Please refer to label on medicine container and act in accordance
Dose of medicine to be given:
Route of administration:
Times at which Medicine should be given:
Length of course (days):
Any other comments/side effects:
Self administration:
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MANAGEMENT OF DIABETIC CHILDREN IN RACH
March 2006
Version 1.3
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Handbook........................................................................................................1Contents................................................................................................................2
Gastrointestinal.........................................................2EYES..................................................................................................................................................3Contents................................................................................................................3
Subject Next Revision Date April 2012..............................................................................................3 Diagnostic Imaging...............................................................................................5Accident and Emergency Department...................................................................5
Non-Attendance for Return Appointment.............................................6YESS............................................................................................6NO................................................................................................6
YES.....................................................................................6NO......................................................................................6YES.....................................................................................6NO......................................................................................6
ENT.....................................................................................................................10Medical Paediatrics.............................................................................................10Neurology............................................................................................................10Orthopaedics + OT..............................................................................................10Opthalmology......................................................................................................10Surgical Paediatrics.............................................................................................10Plastic Surgery....................................................................................................11Accident & Emergency........................................................................................11Therapies.............................................................................................................11Child & Family Mental Health..............................................................................11Social Work Reception........................................................................................11Mrs Betty MacGill................................................................................................11Child Protection...................................................................................................11Mrs Morag Mitra..................................................................................................11Relief Secretaries................................................................................................11Mrs Marion McLaughlan......................................................................................11Secretary to Asst Director of Nursing (Angela Horsley).......................................11PA to Service Manager (Gail Thomson)..............................................................11Miss Kathleen McGregor/Tina Cameron Ext. 54918...........................................11Teaching Co-ordinator ........................................................................................11Mrs Caroline Nixon..............................................................................................11Community Child Health ....................................................................................12Raeden Centre....................................................................................................12Elaine Gibson ext. 72257...........................................................................12Rationale.............................................................................................................13Asthma Easy Peasy ?…......................................................................................26Introduction .........................................................................................................26AFFECTING ROUGHLY 25% GRAMPIAN CHILDREN....................................................................26 AN AUDIT OF THOSE ATTENDING THE PAEDIATRIC CLINIC IN DECEMBER AND JANUARY SHOWED 25% OF ATTENDANCES WERE TO DO WITH THE MANAGEMENT OF ASTHMA.............26
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AN AVERAGE GP WILL SEE ONE ASTHMA DEATH IN THEIR ENTIRE CAREER, BUT ITS THOUGHT THAT 86% OF THOSE HAVE A PREVENTABLE FACTOR ONE WAY OR ANOTHER..ASTHMA KILLS 50 CHILDREN A YEAR IN BRITAIN.................................................................................................26MOST COMMON REASONS FOR FAILURE OF ASTHMA TREATMENT ARE NOT USING TREATMENT, NOT UNDERSTANDING TREATMENT AND THE WRONG DEVICE!............................26AND NOT GETTING HELP WHEN NEEDED.. ...................................................................................26THESE ARE ALSO THE MOST COMMON CAUSES OF ASTHMA DEATHS.........................................26 HOW DO WE IMPROVE THE MANAGEMENT OF CHILDREN’S ASTHMA?.....................................26Goals of asthma management in children...........................................................26DIAGNOSIS OF DISEASE..................................................................................................................26THE RIGHT DEVICE........................................................................................................................26ABSENCE OF SYMPTOMS AND REPEATED CASUALITY VISITS......................................................26ABILITY TO DO NORMAL ACTIVITIES............................................................................................26GROWTH AND DEVELOPMENT......................................................................................................26AVOIDANCE OF SIDE EFFECTS.......................................................................................................26KNOW WHAT THEIR TREATMENT IS …AND USE IT......................................................................26EDUCATING FAMILIES (AND SCHOOLS) PREVENTION OF FUTURE DAMAGE ( MAYBE)............26GENERAL PRACTICE IS UNIQUELY PLACED TO DEAL WITH ASTHMA IN CHILDREN, DUE TO TIME , THE NEED FOR REGULAR QUITE FREQUENT FOLLOW UPS AND GOOD RELATIONSHIPS WITH PARENTS................................................................................................................................26MAKE SURE THAT ALL THE STAFF KNOW WHAT THEY ARE DOING…AND FOR THE NURSES DEALING WITH IT WHEN TO ALERT THE GP................................................................................26Diagnosis of asthma in children...........................................................................26PROBLEMS. OFTEN THE CHILD WHO HAS BEEN WHEEZY AND COUGHING OVER NIGHT IS WELL BY THE NEXT DAY AT THE SURGERY.............................................................................................27COUGH RATHER THAN WHEEZE OR SOB IS OFTEN THE PRESENTING SYMPTOM, AND PARENTS WILL OFTEN VOLUNTEER COUGH AS A PRESENTING SYMPTOM.HOWEVER IN ONE SURVEY 96% OF ASTHMATIC CHILDREN COULD BE IDENTIFIED FROM THE SINGLE QUESTION “ HAS YOUR CHILD EVER HAD ATTACKS OF WHEEZING”.......................................................................27THE DIAGNOSIS CAN TAKE SOME TIME (YEARS IN SOME!)..........................................................27PEAK FLOWS UNDER 3 ARE IMPOSSIBLE AND UNDER 5 MAY BE UNRELIABLE. THEY MAY CONFUSE THE ISSUE,( ASKING THE CHILD TO BLOW, WHEN WE WANT THEM TO SUCK THEIR INHALERS NORMALLY) BUT IN SOME ITS WORTH A TRY!............................................................27So therefore….....................................................................................................28UNDER THE AGE OF FIVE IN A CHILD WHO YOU SUSPECT OF HAVING GENUINE ASTHMA, TRY BRONCHODILATORS AND WATCH OVER A FEW DAYS FOR IMPROVEMENT.................................28AFTER 5 YEARS( AND WORTH TRYING IN A HELPFUL FOUR YEAR OLD!) , THERE ARE THREE WAYS TO DIAGNOSE ASTHMA BASED ON THE PRINCIPAL THAT ….............................................28NORMAL AIRWAYS DON’T GET WIDER WITH A BETA AGONIST...................................................28ASTHMATIC AIRWAYS SHOW BRONCHIAL HYPERREACTIVITY ( BHR) IN RESPONSE TO EXERCISE, WHEREAS NORMAL AIRWAYS TEND TO GET WIDER ( NORMAL AIRWAYS CAN SHOW BHR IN RESPONSE TO CIGARETTE SMOKE AND INFECTION)......................................................28PARENTS ARE CONVINCED BY REVERSIBILITY TESTS, AND SERIAL PEAK FLOWS (SOMETIMES).........................................................................................................................................................283 easy peasy ways to diagnose asthma in children.............................................28REVERSIBILITY TESTING. CHECK PEAK FLOW.BEST OF THREE. GIVE 4 PUFFS OF SALBUTAMOL USING A SPACER OR BREATH ACTUATED DEVICE. RECHECK PEAK FLOW AFTER 15MINUTES. A RISE OF 15% IS INDICATIVE OF ASTHMA. THIS DOESN’T WORK WELL WHEN KIDS ARE AT THEIR BEST!..............................................................................................................28
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SERIAL PEAK FLOW. IF REVERSIBILITY IS NEGATIVE AND HISTORY IS CONVINCING THEN TRY SERIAL PEAK FLOWS. TWICE A DAY , BEST OF THREE. FOR ABOUT TWO WEEKS. A VARIABILITY OF 15% IS INDICATIVE OF ASTHMA.......................................................................28EXERCISE TEST THEM. MEASURE PF, BEST OF THREE.GET THEM TO RUN FOR SIX MINUTES, AND THEN MEASURE PEAK FLOW EVERY FIVE MINUTES FOR 15 MINUTES. A FALL OF 15% INDICATES ASTHMA, AND SHOULD THEN BE REVERSIBLE WITH A BRONCHODILATOR.............29Once Diagnosis is made .....................................................................................29ONCE DIAGNOSIS IS MADE, THE TREATMENT IS BASED ON FURTHERING THE OTHER GOALS, NAMELY ABSENCE OF SYMPTOMS, ABILITY TO DO NORMAL ACTIVITIES, AVOIDANCE OF SIDE EFFECTS, GROWTH AND DEVELOPMENT, THE RIGHT DEVICE, KNOWING WHAT THEIR TREATMENT IS AND USING IT,EDUCATION, AND ?PREVENT FUTURE DAMAGE. .........................................................................................................................................................30STEP 1 AND EVERY FURTHER STEP...............................................................................................32AGED 1-12 SALBUTAMOL PRN 2-4 PUFFS GIVEN BY THE RIGHT DEVICE ( NO PLACE FOR TDS, QDS ETC). THAT MEANS THE CHILD SHOULD CARRY THEIR OWN DEVICE AT SCHOOL. 320-1 CAN HAVE SALBUTAMOL BUT MAY BE BETTER WITH ATROVENT . LIQUID SALBUTAMOL/ORCIPRENALINE PREPARATIONS ARE ALMOST NEVER USED............................32Step 2 and every further step.. Check beta agonist is being used and technique!!............................................................................................................................ 32AGED 0-12 CONTINUE RELIEVER AND ADD ON REGULAR INHALED STEROID BY MDI AND SPACER 200-400UG/DAY ( YOU CAN ADD OTHER PREVENTER IF STEROIDS CANNOT BE USED E.G. LEUKOTRINE RECEPTOR ANTAGONIST).................................................................................32BABIES NEED MASK AND SPACERS.GOES WITHOUT SAYING. SHOW MUM USING A TEDDY OR THE BABY. THEY WILL YELL AND THIS ONLY HELPS INHALATION OF THE MEDICINE.ROUGHLY FIVE BREATHS TO ONE PUFF..........................................................................................................32Step 3… Add on toBeta agonist PRN and regular preventer.Check inhalers are being used and technique!!!!!........................................................................................................32AGED 0-2 INCREASE STEROIDS TO 400UG/DAY. ADVICE FROM DR BROOKER/OR REFER PAEDIATRIC CLINIC.......................................................................................................................32AGED 2-5 TRIAL OF LEUKOTRENE RECEPTOR ANTAGONIST ( INHALED STEROIDS 200-400UG).IF POOR CONTROL GO TO STEP 4.....................................................................................32AGED 5-12 KEEP INHALED STEROIDS TO 200-400UG AND ADD IN LABA. IF POOR RESPONSE,CONTINUE BUT INCREASE INHALED STEROIDS TO 400UG. IF NO RESPONSE INCREASE INHALED STEROIDS TO 400UG, AND DISCONTINUE LABA, AND ADD IN LEUKOTRENE RECEPTOR ANTAGONIST. IF POOR CONTROL TO ALL OF THIS GO TO …...........33Step 4.Persistent poor control! Check inhalers are being used and technique!!! 33AGED 2-5 . MAKE SURE INHALED STEROID IS AT 400UG /DAY AND REFER TO CLINIC FOR FOLLOW UP DR ISMAIL. ................................................................................................................33AGED 5-12.MAKE SURE INHALED STEROID IS AT 400UG, AND LABA IS BEING USED IF ANY RESPONSE. IF STEROIDS HAVE TO GO ABOVE THIS CONTACT DR BROOKER FOR ADVICE OR REFER DR ISMAIL..........................................................................................................................33Step 5 frequent oral steroids.. check inhalers are being used and technique!!! 33AGED 5-12 MAKE SURE INHALED STEROID IS AT 800UG , EVERYTHING ELSE HAS BEEN OR IS BEING TRIED AND REFER DR BROOKER ......................................................................................33DON’T FORGET TO STEP DOWN IF THINGS ARE GOING WELL, ( SLOWLY)..........................33............................................................................................................................ 35Growth and development....................................................................................36
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STEROIDS OF > 400 UG/DAY HAVE BEEN SHOWN TO CAUSE GROWTH RETARDATION IN A SIZEABLE PERCENTAGE OF CHILDREN, SO THEREFORE WE SHOULD BE MEASURING EACH CHILD’S HEIGHT YEARLY. UNCONTROLLED ASTHMA ALSO DOES THE SAME............................36FLUTICASONE . BE REALLY REALLY CAREFUL!!!! THE 250UG STRENGTH CAN CAUSE ADRENAL SUPPRESSION , AND HAS BEEN THE CAUSE OF AN ASTHMA DEATHS . SERETIDE IS ONE TO WATCH IN THESE CIRCUMSTANCES. PLEASE GO HOME AND CHECK WHICH CHILDREN YOU HAVE ON THIS IN YOU PRACTICES AND AUDIT HOW MUCH THEY ARE ACTUALLY TAKING. ESPECIALLY IF THERE IS ANY POSSIBILITY THAT THEY COULD BE USING FLIXOTIDE AND SERETIDE TOGETHER IN ERROR....................................................................................................36Devices................................................................................................................36WE SHOULD SEE CHILDREN USING THE DEVICES. THEY NEED TO BE TAUGHT WITH THEIR PARENTS HOW TO USE THEM.........................................................................................................36MOST OF FAILURES OF TREATMENT ARE CAUSED BY CHILDREN NOT USING THEIR DEVICES PROPERLY OR FINDING THEM IMPOSSIBLE...................................................................................36SOMETIMES A CHANGE OF DEVICE IS ALL THAT’S NEEDED TO GET CONTROL.........................36BREATH ACTUATED INHALERS CAN BE TAUGHT OVER THE AGE OF 5, AND ARE EASIER TO CARRY IN A POCKET TO SCHOOL. INHALE,AND COUNT TO TEN WITH FINGERS! A COOPERATIVE FOUR YEAR OLD MAY MANAGE AS WELL.............................................................36FIND A COUPLE YOU LIKE AND STICK TO THEM! MY PERSONAL FAVOURITE IS THE AUTOHALER. IT’S THE CHEAPEST OF THE BREATH ACTUATED DEVICES...................................36Devices................................................................................................................37STEROID INHALERS SHOULD BE MDI PLUS SPACER TO AVOID THRUSH. SHOW PARENTS HOW TO USE SPACERS AND INHALERS AS WELL....................................................................................37REMEMBER THAT PARENTS CAN FIRE AN AUTOHALER INTO AN AEROCHAMBER IF THE CHILD NEEDS TEN PUFFS IN AN EMERGENCY...........................................................................................37Good control........................................................................................................37IS A CHILD WHO IS USING UP ONE BETA AGONIST INHALER OR LESS A MONTH ,PREFERABLY A BETA AGONIST 3 TIMES A WEEK OR LESS. ITS ALSO A CHILD WHO IS NOT DISTURBED AT NIGHT OR HAVING 3 MONTHLY BOUTS OF WHEEZE WITH COLDS.ANYTHING MORE AND YOU MAY NEED TO GO UP A STEP..........................................................................................................37REMEMBER THAT WHEN YOU STEP UP STEROIDS IT CAN TAKE 6 WEEKS TO TAKE EFFECT, AND THEY MAY RELAPSE BEFORE THE INCREASED DOSE TAKES EFFECT..........................................37REMEMBER TO STEP DOWN IF CONTROL IS EXCELLENT AND THERE IS NEGLIGIBLE USAGE OF BETA AGONISTS..............................................................................................................................37EVERY BOUT OF WHEEZE IS THOUGHT TO POSSIBLY CAUSE DAMAGE AND THEREFORE GOOD CONTROL IS THE DESIRABLE GOAL...............................................................................................37EXERCISE INDUCED ASTHMA, SOMETIMES RESPONDS TO INTAL SURPRISINGLY.......................37Does the child and parent know what to do!........................................................37WITHOUT A WRITTEN PLAN , PROBABLY NOT..............................................................................37( CAN YOU REMEMBER STEP 3 OFF THE TOP OF YOUR HEAD!)...................................................37REMEMBER THOUGH WE ARE FAMILIAR WITH DARK BLUE, LIGHT BLUE, GREEN, RED,ORANGE, PURPLE INHALERS AND BROWN ONES, LIGHT AND DARK, PATIENTS ARE NOT..........................37Does the child and parent know what to do!........................................................38ITS WORTH ASKING THEM TO REPEAT BACK WHAT YOU’VE SAID ABOUT THE ASTHMA AND THE INHALERS( TELL THEM YOU SOMETIMES DON’T EXPLAIN IT WELL)..................................38THE CHILD AND PARENT MUST BE ABLE TO DEMONSTRATE THEY CAN USE THE INHALERS. THEREFORE YOU NEED PLENTY OF PLACEBOS. AND KNOW HOW TO USE THEM YOURSELF... 38YOU NEED TO BE VERY VERY SURE THAT THEY HAVE A WRITTEN PLAN, AND CAN READ ( MY ASTHMA DEATH COULDN’T READ)................................................................................................38THEY NEED TO KNOW WHY THEY ARE DOING THIS.....................................................................38
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So give a written plan, again and again ( because they get lost down the back of the sofa)...............................................................................................................38I FAVOUR ‘ASTHMA AND MY CHILD’. PARENTS CAN WIN A HOOVER!.......................................38REMEMBER TO INCLUDE WHAT TO DO IN EMERGENCIES….......................................................38ASTHMA.ORG HAS A HUGE AMOUNT OF INFORMATION FOR PARENTS AND CHILDREN INCLUDING FAQS...........................................................................................................................38Emergencies........................................................................................................38KEEP UP TO DATE WITH GUIDELINES AS THEY CHANGE(BTS, BNF,SIGN) .............................38SEE GUIDELINES INCLUDED BUT ..................................................................................................38PARENTS NEED KNOW TO GIVE 10 PUFFS OF A SALBUTAMOL INHALER BY SPACER TO HAVE A STOCK OF RESCUE SOLUBLE PREDNISOLONE 5 MGS AND TO KNOW WHEN TO USE IT AND WHAT DOSE. THEY NEED TO KNOW SIGNS OF WORSENING ASTHMA, AND TO GET HELP QUICKLY. SOLUBLE PREDNISOLONE ORALLY WORKS IN 15 MINUTES..AS QUICK AS I.M.......38 ........................................................................................................................................................38Emergencies in a nutshell...................................................................................39ONLY 2 OF THE BRITTLE ASTHMAS COMING TO THE PAEDIATRIC CLINIC HAD RESCUE STEROID MEDICATION AT HOME. ONLY ONE MOTHER KNEW TO GIVE 10 PUFFS OF A BETA AGONIST..........................................................................................................................................390-2 GET 10 MGS PREDNISOLONE ,..................................................................................................39 2-5 GET 20MGS AND ................................................................................................................39 5-12 GET 30-40MGS. IF A GOOD RESPONSE TO STEROIDS THEY GET THEM FOR 3 DAYS. IF POOR RESPONSE OR WORSENING ASTHMA THEY SHOULD BE REASSESSED AND REFERRED URGENTLY TO CASUALTY WITH NEBULIZED SALBUTAMOL DRIVEN BY 6 LITRES A MINUTE OXYGEN...........................................................................................................................................39Things parents ask..............................................................................................39DROWN THE CAT? BANISH THE DOG?, AND THEN BIN THE INHALERS? 90 % OF CHILDREN WHO ARE ALLERGIC TO CATS AND DOGS ARE ALSO ATOPIC AND HAVE ALLERGIES TO HDM AND POLLEN AS WELL. THEY WILL MEET OTHER CATS AND DOGS AND CAN HAVE POSSIBLY SEVERE LIFE THREATENING ASTHMA IF THE INHALERS HAVE GONE. POSSIBLY EARLY EXPOSURE TO CAT/DOG ALLERGENS MAY IN FACT GIVE PROTECTION. BUT IF THERE IS VERY STRONG CAT ALLERGY IT WOULD SEEM SENSIBLE NOT TO HAVE ONE......................................39Things parents need to know..............................................................................39THERE IS EVIDENCE THOUGH THAT PHYSICALLY GETTING RID OF HOUSE DUST MITE WHEN THERE IS A KNOWN ALLERGY IS HELPFUL...................................................................................39SOME HOUSEHOLD CHEMICALS ALSO CAN CAUSE BRONCHOSPASM.........................................39Things they won’t want to hear............................................................................40STOP SMOKING, REALLY , IT DOES MAKE ASTHMA WORSE .......................................................40What happens in the future.................................................................................40WILL HE/SHE GROW OUT OF IT? 80% OF CHILDREN WHO HAVE ‘CHILDHOOD ASTHMA’ GET BETTER APPARENTLY. 40% THEN RELAPSE WHEN THEY ARE OLDER. THERE IS SOME EVIDENCE THAT TREATING ASTHMA WELL AND PREVENTING FREQUENT RELAPSES PREVENTS DAMAGE..........................................................................................................................................40
NO.......................................................................44 YES............................................................................44
Constipation in Children for parents....................................................................49Tension Headache in Children ...........................................................................56Information to children and parents.....................................................................56
Dr. Ishaq Abu-Arafeh,.........................................................................................................................56Migraine in Children ............................................................................................58
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Information to children and parents.....................................................................58Dr. Ishaq Abu-Arafeh,.........................................................................................................................58
Epilepsy In Children and Young People..............................................................60Status Epilepticus................................................................................................64Paediatric Examination........................................................................................68
General points......................................................................................................................................68Growth and pubertal development......................................................................................................68
General points......................................................................................................68Measurement........................................................................................................69
Developmental assessment..................................................................................................................69Normal values......................................................................................................................................70Newborn babies...................................................................................................................................70Six week old babies.............................................................................................................................727 to 9 month old babies.......................................................................................................................72Toddlers...............................................................................................................................................73Preschool children (age 2 to 5 years)..................................................................................................74School age children (from 5 to 10 plus years).....................................................................................75Adolescents (from the onset of puberty).............................................................................................75Developmental Milestones .................................................................................................................79
Monitoring Growth..............................................................................................82Deteriorating School Performance .....................................................................84Dyslexia ..............................................................................................................84Dyspraxia ............................................................................................................84Attention deficit hyperactivity disorder ..............................................................84Children with learning difficulties ......................................................................85
SYMPTOMS........................................................................................................88This is the key factor, with the urine culture to deciding who to investigate. When considering the imaging of infants and children with UTI (see below), it is useful to distinguish those symptoms which are consistent with acute pyelonephritis/upper tract from those consistent with lower urinary tract infection viz........................................................................................................................88"UPPER TRACT" "LOWER TRACT"............................................................................................88
General Malaise Wetting....................................................................................................................88Loin pain Frank Haematuria...............................................................................................................89
CRITERIA FOR DIAGNOSIS OF SIGNIFICANT UTI (= PYELONEPHRITIS) ..........................................................................................89
URINE COLLECTION ( see appendix)..........................90
.................................................................................90URINE MICROSCOPY (see appendix).................90COMBINATION DIPSTICK ANALYSIS (see appendix).........90URINE TRANSPORT............................................91
MANAGEMENT..........................................................................................91URINARY TRACT IMAGING..............................92
SUBSEQUENT STUDIES...........................................................................93COLLECTION AND EXAMINATION OF URINE:...............................................................94If < 1 year needs MCUG......................................................................................96Trimethoprim prophylaxis (2mg/kg) until investigations complete.......................96DMSA or MAG3 with indirect cystography may be useful ..................................97
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When to suspect urinary tract infection in a child or a baby...............98What to do if you think your child may have a urine infection...........98How to diagnose urinary tract infection..............................................99Treatment.............................................................................................99
What to expect after treatment...................................................99What may happen in the future.........................................................100General measures to reduce the risk of recurrent infection...............100
Hip problems in children....................................................................................114 Limp..................................................................................................................115Clicky hip ..........................................................................................................116
Vision Service (Children’s Service – Shetland Islands Council)........................128Staged approach to intervention........................................................................128STAGE 1...........................................................................................................128STAGE 2...........................................................................................................128STAGE 3...........................................................................................................128Heart murmur – no symptoms...........................................................................130Heart murmur – symptoms................................................................................130Dr J E Burns annual visiting Congenital Cardiac Clinic.....................................130THE NEWLY DIAGNOSED PATIENT...............................................................156DIAGNOSIS OF DIABETES....................................................................................................156HANDLING A NEW REFERRAL...........................................................................................156INITIAL MEDICAL MANAGEMENT...................................................................................157INITIAL NURSING MANAGEMENT....................................................................................157INSULIN......................................................................................................................................158
The First Injection.............................................................................................................................158Injection Sites....................................................................................................................................158Initial Insulin.....................................................................................................................................158Insulin Regimes.................................................................................................................................159
Twice daily insulin regime.........................................................................159Basal–bolus regime.....................................................................................160Three times daily insulin regime................................................................160
DIET.............................................................................................................................................160EDUCATION..............................................................................................................................161PREPARING FOR DISCHARGE............................................................................................162OTHER........................................................................................................................................162NEW DIABETIC FLOW CHART............................................................................................163
Twice daily insulin...................................................................163Basal–bolus regime.....................................................................................163
MANAGEMENT OF KNOWN DIABETIC CHILDREN.......................................164INSULIN REGIMES..................................................................................................................164
Twice daily injections.......................................................................................................................164An Insulin dose change of 10% is usually required to have an effect on blood sugars..........................................................................................................165 ...................................................................................................................165
Three daily injections .......................................................................................................................165Basal-Bolus regime ..........................................................................................................................165
FOOD...........................................................................................................................................166HYPOGLYCAEMIA..................................................................................................................167EXERCISE..................................................................................................................................169
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These can cause hypoglycaemia immediately and many hours after exercise....................................................................................................................169These can cause the blood glucose to go up...............................................169
BLOOD SUGAR MONITORING.............................................................................................170Equipment..........................................................................................................170Technique..........................................................................................................170
KETONE TESTING...................................................................................................................171Blood ................................................................................................................................................171Urine .................................................................................................................................................171
MANAGEMENT OF INTERCURRENT ILLNESS/ HYPERGLYCAEMIA.....................173Blood Glucose >15 mmol/l................................................................................173
MANAGEMENT OF DIABETIC KETOACIDOSIS.............................................................174Clinical Signs..................................................................175
Management .....................................................................................................................................175Confirm Diagnosis.............................................................................................175
Diabetic Ketoacidosis.................................................................................175SURGERY...................................................................................................................................176
Minor elective procedures.................................................................................................................176Medium/Major Elective procedures..................................................................................................176Elective procedures- afternoon list ...................................................................................................177Emergency surgery............................................................................................................................177
OUTPATIENT SERVICES.......................................................................................................177Medical clinics..................................................................................................................................177Nurse led clinics................................................................................................................................178Podiatry.............................................................................................................................................178Psychology........................................................................................................................................178
ROUTINE FOLLOW UP...........................................................................................................178SCI-DC.........................................................................................................................................179CGMS...........................................................................................................................................179INSULIN PUMPS.......................................................................................................................179TYPE 2 DIABETES....................................................................................................................179COMPLICATIONS....................................................................................................................180OTHER..............................................................................................................180OUT OF HOURS ADVICE AND WEEKEND ARRANGEMENTS....................................180
Newly Diagnosed Diabetics..............................................................................................................180Out Of Hours.....................................................................................................................................180
DIABETES TEAM CONTACT NUMBERS...........................................................................180REFERENCES..................................................................................................181GLOSSARY ......................................................................................................183
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THE NEWLY DIAGNOSED PATIENT
DIAGNOSIS OF DIABETESIn the majority of children and young people the diagnosis of type 1 diabetes can be made without difficulty. The assessment of a child with possible diabetes is an emergency. The child should be assessed by an experienced middle grade doctor immediately upon arrival.
Presenting symptoms are:
thirst excessive drinking (polydipsia) excessive urination (polyuria) or nocturnal enuresis weight loss lethargy and tiredness abdominal pain
The child should be tested for:
glycosuria ketonuria hyperglycemia
HANDLING A NEW REFERRAL Admit to Medical Ward directly. Unless arranged by the diabetes team, all newly
diagnosed patients are managed as in-patients. The duration of the stay is in most cases 2 to 3 days.
Inform the diabetes team as soon as the referral is taken- do not wait until the child arrives to the hospital- as this allows better planning of the input offered to the family. (DIABETES TEAM CONTACT NUMBERS p.187)
When dealing with newly diagnosed diabetics remember that families, and often children, remember the day of diagnosis (what happened, what was said) forever.
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WHO definition of diabetes:
Fasting plasma glucose >7.0 mmol/l Random or 2- hours plasma glucose > 11.1 mmol/l
INITIAL MEDICAL MANAGEMENT Exclude DKA!! This may require blood tests (U&E, Bicarbonate, pH) but there are clinical pointers to the diagnosis:
acidotic respiration, dehydration drowsiness abdominal pain/vomiting
Assess hydration and need for IVI If mild dehydration (5% or less) with high blood glucose and ketones consider a
correction dose of rapid acting insulin (MANAGEMENT OF INTERCURRENT ILLNESS/ HYPERGLYCAEMIA) and encourage oral fluids
If the child is well start insulin when next dose would be due Routine bloods: thyroid function, coeliac antibodies, islet cell antibodies (these are
non-urgent investigations and the child/family should have an explanation about the purpose of this tests prior to any blood being taken)
Initial Insulin dose 0.7 U/kg/day (0.5 U/kg/day in small children) Insulin regime depends on the age of the child
Communicating the diagnosis to child and parents: this should be done by a senior doctor or member of diabetes team; there is no need to give a full explanation but it is important to confirm the certainty of the diagnosis
INITIAL NURSING MANAGEMENTOn admission :
Notify Diabetes Team Consultant Paediatrician: Dr Amalia Mayo (Tel. 53822 – Bleep 3308) or Dr Wheldon Houlsby (Tel. 51727 – Bleep 3807) according to diabetes rota Diabetes Nurses: Isla Fairley / Edna Stewart (Tel. 52743 – Bleep 3731) Dietician: Elsie Carnegie (Tel. 52630 – Bleep 2464)
Please leave a message if you cannot speak to a member of the team directly or if out of hours.
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Definition of DKA:
hyperglycaemia (BG >11 mmol/l) and pH <7.3 or Bicarbonate < 15 mmol/l
Settle patient into ward
Record: height, weight and routine observations Test urine and/or blood for ketones (KETONE TESTING p.178) and record on
diabetic chart Test blood glucose (BLOOD SUGAR MONITORING p.177) – explain to the child
what you are going to do and why you are doing it Medical staff should tell parents/carers and child that they have diabetes and give an
outline of treatment. Parents often experience a feeling of shock and may not retain information given. It is therefore helpful if a member of the nursing staff can be present to help support the family later when they will ask more questions.
You should not give any information unless you are sure that you are giving the correct information (if in doubt it is better to give less than to cause confusion by giving wrong information).
INSULINThe prescription of Insulin is the responsibility of the medical staff. Nursing staff should be aware of the different regimes and reasons for administering insulin.As far as possible, parents/carers should be present when insulin is administered, as learning to give injections is one of the main objectives of the new diabetic admission.
The First InjectionAs the child and their family might be upset at diagnosis it is best if nursing staff do the first injection. Giving a clear explanation of why it is required and demonstration of how to give the injection.
This should include: Showing the syringe, explaining the markings on it and how to draw up the insulin to
avoid air bubbles, or Use of pen injection devices Injection technique – how to pinch skin
Injection SitesInitially it is best to use the legs as the child has often lost weight and may not have much subcutaneous tissue elsewhere. However in toddlers it may be appropriate to use buttocks, as it is often easier for a parent/carer to hold the child.
Initial Insulin
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Newly diagnosed patients will often have blood glucose readings above 10mmol/l. The body needs time to adjust to the insulin regime therefore blood glucose may run at higher levels initially.
Starting insulin depends on the time of day the child is admitted and whether there are ketones present.
If BG is >12 but ketones are negative or only trace-small, the first dose of insulin given can be at the time dictated by the next due dose on their regime, i.e. admitted 2 pm, BG 14 mmol/l, Ketones trace, then give teatime dose of insulin as first dose.
If BG >12 and ketones moderate or large, then it is necessary to give a correction dose to bring sugar down and clear ketones. This would be given as 0.1 U/kg of fast acting insulin (Novorapid). The usual regime is then commenced when the next injection would be due.
Note: The duration of action for Novorapid is 2-4 hours. If routine dose of insulin is due in less than 2 hours the combined effect could cause hypoglycaemia.
Insulin RegimesInitial Insulin Dose Calculation – 0.5-0.7 U/Kg/Day
Children under 5 years should be started on 0.5 U/kg/day
A. Children in primary school (usually aged 11 or under)
Twice daily insulin regime Novomix® 30 (biphasic insulin aspart)- 2/3 of total daily dose before breakfast Novomix® 30 (biphasic insulin aspart)- 1/3 of total daily dose before evening meal
B. Children in secondary school
The choice of regime depends on the child preference and other factors such as needle phobia but most children will be commenced on a basal-bolus regime. More dietetic input is required for this regime and they should be seen by a dietician on the ward prior to discharge.
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Basal–bolus regime Levemir® (insulin Detemir) or Lantus® (insulin Glargine) - 50% of total daily dose before evening meal Novorapid® (insulin Aspart) - 50% of total daily dose divided between 3 main meals as below:
30% before breakfast 30% before lunch 40% before evening meal
Three times daily insulin regime Novomix® 30- 2/3 of total daily dose before breakfast
Remaining insulin is further divided into 1/3 and 2/3, i.e.: Novorapid®- 1/9 of total daily dose before evening meal Insulatard®– 2/9 of total daily dose before bed
DIETChildren and young people with diabetes are often hungry after diagnosis. Encourage a good fluid intake (water or sugar free juice).
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Example: Twelve year old boy weighing 32 kgTotal daily dose of insulin 0.7x32=22.4 U, divided as: Basal-bolus regime
Novorapid 3 U before breakfast and lunch (10x0.30=3), 4 U before evening meal Glargine 12 U before evening meal (22.4x0.50=11.2)
Three daily insulin Novomix 30- 15 U before breakfast (22.4x2/3=14.9) Novorapid- 2.5 U before evening meal (22.4x1/9=2.48) Insulatard- 5 U before bed (22.4x2/9=4.97)
Don’t restrict food and snacks – the team will adjust insulin according to the child’s intake.
Food in newly diagnosed diabetes-What’s important?
1. Regular mealsThree meals and 3 snacks fairly evenly spread throughout the day. Meals and snacks should always contain a reasonable amount (dependant on age) of starchy carbohydrate. Starchy carbohydrate foods include – bread, plain breakfast cereals, potatoes, pasta, rice, pulses (eg baked beans, lentil soup or broth), milk or fruit.
2. Sugar free drinks (including water)Allow these freely. All diet coke, lemonade, Irn Bru etc are suitable. Ensure all diluting juices are sugar free. Volvic Touch of Fruit and Ribena Light are not suitable.Limit pure fruit juice to one small glass daily with a meal. Milk to drink should not be more than 1 pint daily spread throughout the day (for over 2’s the milk of choice is semi skimmed)
3. Snacks away from the wardParents may wish to take their children to the picnic box or out of the hospital for a short while. Remind them to have sugar free drinks (or milk). Suitable snacks would include a scone, pancake, toast, milk, fruit or crisps. We recommend limiting crisps to once daily.
4. Food when blood sugar is highWhen children are newly diagnosed with diabetes they are often very hungry. Even if their blood sugar is high food should not be restricted, remembering the above advice.
5. PuddingsFamilies are encouraged to use less foods that are high in sugar i.e. sweets, puddings, cakes etc. However, a small amount of sugar included as part of a meal is fine, so children can have an average portion of pudding following their main course or soup and sandwich.
6. BedtimeIt is important that the children manage to maintain their blood sugar throughout the night. Depending on the insulin regime it is important for most children that they have a bedtime snack containing a reasonable amount of carbohydrate. This is often a smaller version of their breakfast but could be a sandwich, milk and toast or a scone.
EDUCATIONThe Newly Diagnosed Checklists (available from the PDSNs) should be placed with the child kardex/ recordings and completed by the appropriate staff as education progresses. After discharge the checklists should be passed on to the PDSN so that the education process can be completed at home or on follow on visits.
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The play specialists are available in the Medical Ward to see patients as requested. Their help is particularly useful in children who are worried about staying in hospital or about injections or blood testing. Children can also be referred to the play team for education through play.
PREPARING FOR DISCHARGEThis is an example ‘discharge checklist’. The content will vary according to the patient insulin regime, injection method and blood testing equipment. The PDSN will provide an individual list for every new patient.
From Pharmacy From Diabetes Nurses/Ward Insulin Novomix® 30– vial Insulin Novorapid® – vial Insulin Insulatard® – vial (insulin prescription will vary according to regime)
GlucoGel® (formerly Hypostop) GlucaGen Hypokit® 1mg
Blood Glucose monitor Syringes 0.3ml with 8 mm needle
or Insulin Pen and needles Safe Clip Sharps Bin Ketostix®
Glucose testing strips Control solution Information pack
Following discharge all of the items above will be prescribed by the GP
OTHERSee OUT OF HOURS ADVICE AND WEEKEND ARRANGEMENTS p.187
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NEW DIABETIC FLOW CHART
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Junior Dr notified of new patientInform:
Medical Ward Admissions Diabetes Team
Patient arrives to Medical Ward: Rapid assessment by SpR Clerking by SHO Notify Diabetes Team Initial observations obtained (incl. Blood
glucose, ketones)
DKA Dehydrated with Large Ketones
Well with up to moderate ketones
DKA protocol Correction dose of insulinNovorapid 0.1U/kgEncourage oral fluids
Start routine insulin when next injection would be dueTotal daily dose (tdd):
0.7 U/kg/day 0.5 U/kg/day (under fives)
Age < 11 years (primary school)
Twice daily insulin Novomix® 30- 2/3 of tdd before
breakfast Novomix® 30- 1/3 of tdd before
evening meal
Age >11 years (secondary school)
Basal–bolus regime
Levemir® or Lantus® - 50% of tdd before evening meal
Novorapid® - 50% of tdd divided as:
30% before breakfast 30% before lunch 40% before evening meal
DKA correctedEating and drinking
Deterioration/ DKA
MANAGEMENT OF KNOWN DIABETIC CHILDREN
INSULIN REGIMESThe insulin regimen should be tailored to the individual child and family lifestyle. The discussions take place between the family and the diabetes team.The most widely used insulin regimens are:
Two daily injections - a mixture of short- and intermediate-acting insulin before both breakfast and the evening meal
Three daily injections - a mixture of short- and intermediate-acting insulin before breakfast, short-acting insulin before the evening meal and intermediate-acting insulin at bedtime
Basal-bolus injections (also termed multiple injection therapy) - short-acting insulin before the main meals and long-acting insulin analogue once or twice daily
Some considerations when changing to an intensive insulin regime are: well-motivated with good diabetes education (or willing to accept input) willing to inject insulin several times a day, including at school willing to measure blood glucose several times a day capable of adjusting the insulin doses for food and physical exercise good family support no needle-phobia.
Poor metabolic control is not per se an indication for intensified insulin treatment regimens and may even lead to poorer HbA1c values in patients who are not motivated to meet the above requirements.
Twice daily injectionsInsulin: This regime uses a biphasic insulin such as Novomix® 30 insulin, which is a mixture of 30% fast acting and 70% intermediate acting insulin and is given before breakfast and before evening meal.
Dose adjustment: Insulin adjustments are done by reverse testing looking at trends in blood sugars and NOT on a dose to dose basis nor on the immediate blood sugar result. So if there are persistent HIGH results before the EVENING MEAL then the MORNING
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insulin is increased. If persistent HIGH results are found before BREAKFAST then it is the BEDTIME insulin that has to be increased. After a change in insulin dose the dose should remain the same for 3 or 4 days before making further adjustments.
An Insulin dose change of 10% is usually required to have an effect on blood sugars.
Blood glucose testing: Minimum testing is twice daily before insulin injections. Very young children should be tested before bed (or when the parents go to bed) to ensure blood sugar is at least 8 mmol/l.
Meals: Children on twice daily pre-mixed insulin should have regular meals and snacks throughout the day and a bed time snack. The meals/snacks and insulin injections should be given at approximately the same time every day.
Three daily injections Insulin: With this regime 3 different insulins are used: Novomix® 30- biphasic insulin (30% fast acting, 70% intermediate acting) before
breakfast. Novorapid® (fast acting) with evening meal. Insulatard® (intermediate acting) before bed.
Dose adjustment: Insulin is adjusted by reverse testing as per twice daily regime, apart from the rapid acting insulin given with the evening meal which can be altered according to food intake and current blood sugar result. Adjustment to insulin at evening meal can also be made to take into account evening activities.
Blood glucose testing: Blood sugar should be tested before every insulin injection.
Meals: As per twice daily regime with some flexibility at the evening meal.
Basal-Bolus regime Insulin: In this regime children take an injection of long acting insulin analogue Glargine (Lantus®) or Detemir (Levemir®) once a day (in some cases twice daily). This injection is usually given in the evening at the same time as their evening meal insulin but in a different site. The long acting insulin should be given at the same time every day to ensure a steady background insulin supply. Fast acting insulin (Novorapid® or Humalog®) is given with meals (and snacks containing more than 10 g of CHO) based on how much
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carbohydrate they eat and the current blood sugar result. There is no need to wait before eating once the injection has been given.
Dose adjustment: Before breakfast blood sugar will guide adjustment of the long acting background insulin. It is important to get the background insulin dose right before starting to adjust the bolus doses. Adjusting bolus insulin will depend on the calculated insulin/CHO ratio for the patient. If the correct dose has been given the 2 hour post meal blood sugar will be in the normal range. If the pre meal blood sugar is above 12 mmol/l an increased dose of insulin to include a correction dose can be given.
Blood glucose testing: First thing in the morning and before meals.
Meals: There is no need to stick to a strict meal routine with this insulin regime. Insulin should be given immediately prior to eating. Snacks are not compulsory and should be taken according to natural hunger and predicted activity. Bed time snacks are recommended if blood sugar is less than 8 mmol/l before bed.
CHO/ insulin ratios: Most children with established diabetes will be injecting 1 U of insulin per 10g of CHO eaten. This can vary between children and they should let you know which ratio they are currently using. An insulin injection is required for meals as well as snacks including more than 10 g CHO.
Dose adjustment for blood sugar result: If the BG is high before a meal extra insulin can be given to correct this. Aim to correct down to 10 mmol/l. Several formulas can be used such as the Insulin Sensitivity Factor where 100 divided by total daily dose equals number of mmol/l of glucose that will be reduced by 1 U of insulin.
FOODGeneral principles:
Food should always be available for children with diabetes in the ward Insulin injections are often timed around meals
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Example: 13 years old girl on Lantus 30 U and Novorapid 1U/ 10g CHO (total daily insulin aprox. 52U). She is going to have for breakfast 60 g CHO (typical for her) and BG is 16 mmol/l.
Insulin required to cover CHO= 60/10= 6 U Insulin required to bring down BG from 16 to 10 mmol/l (i.e. by 6 mmol/l) = 100/52= 1.9mmol
reduction per 1 U insulin, so 6/1.9= 3.1U In total she should have 6+3= 9U insulin before breakfast
Depending on type of insulin, the injection needs to be given either 20-30 minutes before food (i.e. Mixtard 30 or Actrapid) or immediately before food (Novomix 30 or Novorapid)
Depending on insulin regime (p.166), some children must have regular snacks through the day
Food can be used to treat hypoglycaemia
HYPOGLYCAEMIA
There is not an exact ‘number’ definition of hypoglycaemia (low blood glucose or ‘hypo’) but often is considered as a blood glucose levels below 2.5-3 mmol/l. Generally, if blood glucose is less than 4 mmol/L there should be some action instigated, i.e. treat as per ‘hypo’, offer a snack or eat meal without delay.
The symptoms and signs of hypoglycaemia vary between individuals and change with age. They can be classified into:
Autonomic: sweating/clammy, hunger, tremor, pallor, restlessness Neuroglycopenic: weakness, headache, glazed expression, mood changes/lack of
concentration, tiredness/lethargy, visual and speech disturbances, vertigo, confusion, fits and unconsciousness
A child may display some or all of the above symptoms. Some children with hypoglycaemia unawareness might not have any symptoms. If you suspect that a child is ‘hypo’ it is essential that treatment is given as quickly as possible.First check blood glucose level if it is over 4mmol/l they are not ‘hypo’ and do not need sugary drinks or food. They maybe hungry, so offer an appropriate snack or meal if meal is due. Giving sugar when they are not hypo causes an unnecessary rise in blood glucose.
Symptomatic hypoglycaemia can be:
Mild (grade 1) - the patient is able to observe and treat the episode him/herself Moderate (grade 2) - the patient can be treated orally, but with help from someone
else Severe (grade 3) - the patient is unconscious or having fits and can not be treated
orally
The treatment of hypoglycaemia varies with the degree of severity:
Mild: If child is co-operative and aware of episode give 10-20 g of fast acting oral carbohydrate in the form of 3- 6 glucose tablets, 50ml fresh juice or lucozade, two teaspoons jam or honey. The fast acting sugar should raise the blood glucose level within 5 to 10 minutes. Only if there is no improvement after 10 minutes give more sugar. You must then follow it up with slow-acting carbohydrate to make sure the
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blood glucose level does not fall again. For example: Digestive biscuit and glass of milk, toast or sandwich, cereal, crisps, piece of fruit. Additional complex long-acting carbohydrate is not required for children and young people using continuous subcutaneous insulin infusion (insulin pump).
Moderate: If the child is unco-operative use GlucoGel® (formerly Hypostop gel). This is a fast acting sugary gel, which comes in a tube with easy twist top. The tube content is squirted into the side of the mouth and massaged into cheek. This is also followed with a snack.
Severe: Do not attempt to give anything orally. In hospital and when IV access is available give an intravenous glucose bolus (5ml/kg of 10% glucose solution over 3 minutes), followed by intravenous infusion of 5% glucose solution at 12ml/kg/h. If IV access is not immediately available give glucagon (GlucaGen Hypokit®) by injection (i.m.):
- Children < 8 years or body weight less than 25 kg: 0.5 mg (half of the emergency kit) - Children > 8 years or body weight more than 25 kg: 1 mg (the whole emergency kit)
NB: Glucagon can cause vomiting afterwards.
After severe hypoglycaemia, blood glucose should be measured after 4-5 minutes and frequently during the next hours. The blood glucose values should stay in the range of 10-15 mmol/l and after waking, the child should be offered simple carbohydrates in the form of white bread or similar. If the child is still unconscious half an hour after normalising the blood glucose level, cerebral oedema should be considered and treated accordingly.
After a severe hypoglycaemic episode the cause of the event should be sought and corrected. Hypoglycemia is the result of a mismatch between insulin, food and exercise. Points to be considered are:
Altered routine (missed or erratic meals, changes in physical activity, alterations or errors in insulin dosage or absorption)
Younger age (<6 years) Lower HbA1c Total deficiency of endogenous insulin Antecedent hypoglycemic episodes Hypoglycemic unawareness Defective glucagon and catecholamine counter-regulation (longer duration of
diabetes) Alcohol ingestion
All patients admitted with hypoglycaemic seizures should be seen by the PDSN prior to discharge (at the weekend leave a message in their maibox ext. 52734). Patients should be discussed with the consultant for consideration of CGMS (CGMS).
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EXERCISEExercise has a number of effects on blood glucose levels: Increased absorption of insulin from injection site Increased consumption of glucose without the need for extra insulin The glycogen stores in the liver are used up and have to be replenished sometimes
hours after exercise
These can cause hypoglycaemia immediately and many hours after exercise
Cells can not take up glucose if there is lack of insulin During competitive strenuous sport counteregulatory hormones are released
These can cause the blood glucose to go up
Children should not be allowed to exercise if the blood glucose is high (>15 mmol/L) AND there are ketones present as this can precipitate DKA
Prevention of hypoglycaemia during exercise:
For light or brief exercise (up to 30 min) a small intake (10 g) of rapidly absorbed carbohydrate is usually recommended prior to exercise if blood glucose is < 6 mmol/L
For intensive, strenuous or prolonged exercise Careful monitoring of BG levels Reduction of insulin should be considered For every 30 min of heavy exercise 10- 15g of carbohydrate are required (a mixture of slow and quick acting), for example 100 ml of fruit juice. Extra slowly absorbed complex carbohydrate will be necessary at bedtime. A bedtime snack containing fat and protein may help to prevent nocturnal hypoglycemia Exercise should take place in the presence of a companion familiar with the recognition and treatment of hypoglycemia
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BLOOD SUGAR MONITORINGSelf-monitoring of blood glucose (SMBG) is an essential tool in the management of childhood and adolescent diabetes:
Helps to monitor immediate and daily levels of control Detects hypoglycemia Assists in the safe management of hyperglycemia Has educational value in assessing BG responses to insulin, food and exercise
EquipmentThe following equipment is required: Blood glucose meter Test strips Finger pricking equipment
Equipment maintenance: The meter should be calibrated for every new pack of test strips and also monthly with the control solutions.
Technique Wash hands Prepare device by loading strip, ensuring that meter has been calibrated Prick finger – using the side, by the nail. Try not to use the pad of the finger as there
are more nerve endings there and it is more painful Place drop of blood on strip Wait for meter to count down and record blood glucose reading on chart.
Timing of SMBG
The number and regularity of SMBG should be individualised depending on acceptance by the young person and the type of insulin regimen. Frequent, accurate SMBG is the only method by which optimal glycaemic control can be achieved by intensified management regimens.
Suggested timing of SMBG would be:
Before insulin injections At different times in the day to assess BG response to insulin, food intake and
exercise. In this way, changes may be made in management to improve BG profiles To confirm hypoglycaemia and to monitor recovery During intercurrent illness to prevent hyperglycaemic crises In association with vigorous sport or exercise
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KETONE TESTINGKetones should be checked whenever the blood sugar is high (>15 mmol/L) or if there is concern regarding the development of ketoacidosis. They can be checked either in blood or urine.
Blood Blood ketones are measured by monitoring blood ß-hydroxybutyrate (ß-OHB). Near-patient blood ketone testing is available with the Medisense Optium or Optium Xceed meters.
This is the preferred method of monitoring ketones during an episode of DKA.
Technique: Wash your hands put a B-ketone strip into the meter and put a drop of blood on the end of the strip.
Interpretation of results:
Between 0.1 and 1.0: These are acceptable blood ketone levels. Continue to test blood glucose as usual
Between 1.1 and 3.0: This is too high. A correction dose of insulin should be administered (MANAGEMENT OF INTERCURRENT ILLNESS/ HYPERGLYCAEMIA). Blood glucose and ketones should be rechecked in 1 to 2 hours.
Over 3.0: This is too high and might indicate ketoacidosis. If blood sugar is also high a correction dose of insulin should be given or the DKA protocol initiated as appropriate.
Urine Ketone Reagent Strips are used to check for the presence of acetoacetate in the urine.
Technique:
Check the strips are not out of date or have been open for more than 6 months Remove the strip from the box and put the lid back on the box Dip the strip into fresh urine, remove strip, shake to remove excess urine At exactly 15 seconds (use a watch with seconds hand) check the strip against the
colour key on the side of the container
Interpretation:
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Small to moderate – This level is acceptable. Continue routine monitoring or as indicated.
Moderate to large – This is too high. A correction dose of fast acting insulin should be given and blood sugar and urine ketones rechecked in 1 to 2 hours.
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MANAGEMENT OF INTERCURRENT ILLNESS/ HYPERGLYCAEMIA
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Calculate the insulin correction dose =‘total daily dose’ /6
and give NOW as an extra injection of fast acting insulin (eg Novorapid)
Continue usual insulin doses at usual times. Check blood glucose 2-3 hrly
Blood Glucose <15 mmol/l Ketones: Urine: negative/ trace/ small Blood: <1.0
Blood Glucose >15 mmol/l
Check ketones: Blood (B-ketone strip), or Urine (Ketostix)
Ketones: Urine: negative/ trace/ small Blood: <1.0
Ketones: Urine: moderate/ large Blood: > 1.0
Check BG and ketones after 1 or 2 hours
Blood Glucose >15 mmol/l Ketones: Urine: moderate/ large Blood: > 1.0
MANAGEMENT OF DIABETIC KETOACIDOSIS
The management of Diabetic Ketoacidosis (DKA) includes not only the acute management but also understanding the reasons why DKA developed in the first instance. The acute management of DKA is everybody’s responsibility and the DKA protocol below should be followed. The underlying cause for the development of DKA is often straight forward and should be elucidated by good history taking. The diabetes team will usually deal with the further management such as psychology referral and increased educational input.The full and most up to date DKA guideline is available at the following link:
www.bsped.org.uk/professional/guidelines/docs/BSPEDDKAApr04.pdf
or
www.nice.org.uk/pdf/Type1diabetes(child)FULLguideline.pdf (see appendix D)
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Algorithm for the Management of Diabetic Ketoacidosis
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Clinical History- polyuria- polydipsia- weight loss- abdominal pain- weakness- vomiting- confusion
Clinical Signs- assess dehydration- deep sighing respiration (Kussmaul)- smell of ketones- lethargy, drowsiness
Biochemical Signs- ketones in urine or blood- elevated blood glucose (>11mmol/l)- acidaemia (pH<7.3)- take blood also for electrolytes, urea- perform other investigations if indicated
Confirm DiagnosisDiabetic Ketoacidosis
Call Senior Staff
ShockReduced peripheral pulse volumeReduced conscious levelComa
Dehydration > 5%Clinically acidoticVomiting
Dehydration < 5%Clinically wellTolerating fluid orally
Resuscitation- Airway + N/G tube- Breathing (100% 02)- Circulation (10ml/kg of 0.9% saline repeated until circulation restored, max 3 doses)
Intravenous therapy- calculate fluid requirements- correct over 48 hours- 0.9% saline- add KCL 20 mmol every 500 ml- insulin (Novorapid) 0.1U/kg/hour by infusion
Therapy- start with s.c insulin- give oral fluids
Observations- hourly blood glucose- neurological status at least hourly- hourly fluid input:output- electrolytes 2 hours after start of IV-therapy, then 4-hourly
No improvement
No improvement
blood glucose < 15 mmol\L
Neurological deterioration Warning signs :headache, irritability, slowing heart rate, reduced conscious level, specific signs raised intra-cranial pressure
Intravenous therapy- change to 0.45% saline + glucose 5%- continue monitoring as above- consider reducing insulin 0.05/kg/hour, but
only when pH>7.3
exclude hypoglycaemia
is it cerebral oedema ?
Re-evaluate- fluid balance + IV-therapy- if continued acidosis, may require further resuscitation fluid - check insulin dose correct- consider sepsis
Improvement- - clinically well, drinking well, tolerating food- - urine ketones may still be positive
Insulinstart subcutaneous insulin thenstop intravenous insulin 1 hour later
Management - give mannitol 1.0 g/kg- call senior staff- restrict I.V. fluids by 2/3- move to ITU- CT Scan when stabilised
SURGERYThe ISPAD consensus guideline makes recommendations regarding children and young people with type 1 diabetes who require surgery or fasting. Children and young people with type 1 diabetes who require surgery:• should be admitted to hospital for general anaesthesia• require insulin, even if they are fasting, to avoid ketoacidosis• should receive glucose infusion when fasting before an anaesthetic to prevent hypoglycaemia (unless having a minor procedure).
The Medical Team is responsible and available for advising on the management of diabetic children.As a general rule, for children on basal-bolus regimes (Basal-Bolus regime), the basal insulin is given as usual and the bolus insulin is omitted until they start eating again. Children should have IV access to manage possible hypoglycaemia.
Minor elective proceduresThe child should always be placed first on the morning list. For grommets or other very short, relatively painless procedures, at the discretion of the Consultant Anaesthetist the child can be fasted, not given morning Insulin and then given normal Insulin plus breakfast on return to the Ward at 9 to 9.30 am. A cannula is not required prior to going to theatre.
Medium/Major Elective procedures Admit to hospital the afternoon prior to surgery. The usual evening or bedtime
insulin(s) and a bedtime snack should be given. Earlier admission might be necessary if glycaemic control is poor. The child must be first on the morning list and have intravenous access in situ. For procedures where a child may not be eating or drinking later in the day an Insulin
infusion and intravenous fluids should be started. It is often most convenient to arrange this by putting in a heparinised cannula the evening before and writing up an Insulin infusion and maintenance fluids according to the instructions on the paediatric Insulin infusion sheet for the Nurses to start at 7 am.
No solid food from midnight. Clear fluids may be allowed up to 4 hours pre-operatively (this should be checked
with the anaesthetist). Omit usual morning insulin dose. Start intravenous fluid and insulin infusion at 6.00–7.00 a.m. Hourly blood glucose monitoring pre-operatively, then half-hourly during operation
and until woken from anaesthetic. Hourly blood glucose monitoring 4 hours post-operatively Aim to maintain blood glucose between 5 and 12 mmol/l.
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Continue intravenous infusion until the child or young person tolerates oral fluids and snacks (this may not be until 24–48 hours after major surgery). The infusion can then be stopped whenever the child is ready to drink and eat.
Change to usual subcutaneous insulin regimen or short-acting insulin/rapid-acting insulin analogue before the first meal is taken.
This could be at lunchtime on the day of the operation giving half the morning dose of Insulin as Novorapid or at teatime giving the normal teatime dose of Insulin or breakfast time the next morning giving the normal morning dose of Insulin.
Stop insulin infusion 60 minutes after subcutaneous insulin is given.
Elective procedures- afternoon list Whenever possible the afternoon list should be avoided unless the clinical need is such that the procedure should go ahead. For children on twice or three time a day insulin regimes:
Give one-third of the usual morning insulin dose as short-acting insulin if the operation is after midday.
Allow a light breakfast. Clear fluids may be allowed up to 4 hours preoperatively. Start intravenous fluids at midday at the latest. There is no need for IV insulin
infusion for minor procedures such as a jejunal biopsy. Then as for morning operations (see above). The child should have his usual tea time insulin and meal.
Emergency surgery• Diabetic ketoacidosis may present as ‘acute abdomen’.• Acute illness may precipitate diabetic ketoacidosis (with severe abdominal pain).• Nil by mouth.• Secure intravenous access.• Check weight, electrolytes, glucose, blood gases and ketones pre-operatively.• If ketoacidosis is present, follow protocol for diabetic ketoacidosis and delay surgery untilcirculating volume and electrolyte deficits are corrected.• If there is no ketoacidosis, start intravenous fluid and insulin infusion as for elective surgery.
OUTPATIENT SERVICES
Medical clinics RACH Clinic: Friday morning weekly from 9 am
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Fraserburgh Clinic: all day clinic alternate months Orkney Clinic: twice a year June and December one day only Shetland Clinic: twice a year April and October two days clinic Woolmanhill Young Persons Clinic: Tuesday morning, last of month
Nurse led clinics Routine review clinic: Second Thursday of the month 2-4pm – Patients whose
diabetes is well controlled and do not require to see a doctor every visit can come to this clinic and have HbA1C, height, weight checks and discuss their progress with the specialist nurse (medical advice will be available should it be required).
Diabetes education clinic: Fourth Thursday of the month 2-4pm - Education clinic for newly diagnosed patients, adolescents pre-transfer to adult service and any other educational issues. Patients/families have a 20minute slot with specialist nurse.
PodiatryA podiatrist is in attendance at the clinic on the 2nd Friday of the month but occasionally dates may changes so please check before asking a patient to attend a specific clinic.
PsychologyDr Andrew Keen is available on the last Friday of each month at the Diabetic outpatient clinic. Referral should be made through the PDSNs Isla Fairley and Edna Stewart.
ROUTINE FOLLOW UPThe following checks and discussions should take place at every routine clinic visit:
Height and weight- plot in chart HbA1c Check current insulin therapy Review of blood sugar home monitoring Review of hypoglycaemia Injection sites School issues Family issues (holidays, special dates, new situation) Other problems Has the child had an annual review in the last year?
In addition, at the time of the annual review, the following take place:
BP Urine for microalbumin (over 10 years old)
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Blood test for thyroid function and coeliac antibodies Check retinal screening in place Check Podiatrist screening done DSN review Dietetic review
SCI-DCDetails of all children are available in the SCI-DC database which is accessed from the main computers in all wards. A password is required to access the system.
CGMSSome patients might benefit from a period of Continuous Glucose Monitoring. This is available as an outpatient procedure. CGMS should only be organised after full discussion with the Consultant. A separate protocol is available for this procedure.All patients admitted with hypoglycaemic seizures should be discussed with the consultant for consideration of CGMS.
INSULIN PUMPSChildren using insulin pumps are highly competent in their use and they will guide you on their use and their insulin requirements.Never disconnect a pump for more than 30 min (for showering, etc) as there is no reserve of insulin in the body and the child might become unwell very quickly.Contact a member of the diabetes team if you are unsure about anything.
TYPE 2 DIABETESChildren with type 2 diabetes may be asymptomatic, or may have symptoms of thirst and polyuriaplus ketonuria. There is usually a family history of type 2 diabetes, and there may be evidence ofinsulin resistance (acanthosis nigricans). These children are usually overweight (=85th
centile according to the new BMI charts of Cole) or obese (=95th centile on the BMI charts). The differential diagnosis is usually between type 1 diabetes (children may have more weight loss and symptoms) or Maturity Onset Diabetes of the Young (MODY) (white UK children who are usually thin, asymptomatic, and family history of diabetes in 3 generations), or diabetes secondary to another condition (such as Prader Willi , cystic fibrosis). It cannot be stressed enough that a child should be treated as type 1 diabetes and commenced on insulin if there is any doubt about the diagnosis, or the child presents with significant symptoms, or with ketonuria. The diagnosis can always be revised at a later stage, and the child taken off insulin, if appropriate.A separate protocol on the management of children with Type 2 Diabetes is available from the diabetes team.
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COMPLICATIONS
For advise on the diagnosis and management of diabetes complications please see the Grampian Guidelines for Management of Diabetes Mellitus, Feb 2004, available in the intranet (http://193.195.78.72/nhsgrampian/files/Guidelines2004).
OTHEROUT OF HOURS ADVICE AND WEEKEND
ARRANGEMENTSNewly Diagnosed DiabeticsIf a child is admitted on Friday evening/Saturday please contact a member of the diabetic team and if available we might be able to come and see them. Contact numbers are available through the Medical Ward at RACH.Contact: Isla Fairley /Edna Stewart and Elsie Carnegie.
Out Of HoursPatients are referred to the Medical Ward RACH ext. 50380 for out of hours urgent advise- please record details of the call and advice given and pass on to Diabetes Team. If the staff member answering the call is unable to give suitable advice then the call should be passed on to middle-grade doctor on call for Medical Unit on bleep 2678.For non-urgent enquiries patients and staff are advised to leave a message on voicemail ext. 52734
DIABETES TEAM CONTACT NUMBERS
Name Role bleep phone e-mail addressDr Amalia Mayo
Consultant (RACH)
3308 Xt 53822 Xt 50125 (Sec)
Dr Wheldon Houlsby
Consultant (RACH)
3807 Xt 51727 [email protected]
Dr Willem van Ijperen
Consultant (Elgin)
Lisa Wallis Secretary Xt 50125 [email protected]
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Fax: 01224 550704
Isla Fairley PDSN 3731 Xt 52734 [email protected] Stewart PDSN 3731 Xt 52734 [email protected] Hill DSN
(Woolmanhill)Xt 55527 [email protected]
Sheena Duffus DSN (Fraserburgh)
01346 585244 [email protected]
Caroline Page DSN (Orkney) 01856 888218mobile 07884114517 page 07623978203
Kirsty Anderson
Community Paediatric Nurse (Shetland)
01595 743362 [email protected]
Elsie Carnegie Paediatric Dietitian
2464 Xt 52630 [email protected]
Shona Milne Dietitian (Fraserburgh)
Xt 56305 [email protected]
Shelly Watt/ Lynda Sime
Podiatrist Xt 55273 [email protected]
Dr Andrew Keen
Health Psychologist
Xt 52234 [email protected]
Postal address:
Diabetes ServiceDepartment of Medical PaediatricsRoyal Aberdeen Children’s HospitalWestburn Road AberdeenAB25 2ZG
REFERENCES1. ISPAD and International Diabetes Federation (European Region). Laron Z (ed).
Consensus guidelines for the management of insulin-dependent (Type 1) diabetes mellitus (IDDM) in childhood and adolescence. Tel Aviv: Freund Publishing House Ltd, 1995.
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2. The Diabetes and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. New England Journal of Medicine, 1993, 329:977-986.
3. SIGN 55 “Children and Young People” Management of Diabetes. November 2001: ISBN 1899893 82 2
4. NICE. Type 1 Diabetes (Childhood) - Full Guideline,September 2004 www.nice.org.uk/pdf/Type1diabetes(child)FULLguideline.pdf
5. Grampian Guidelines for Management of Diabetes Mellitus, Feb 2004 http://193.195.78.72/nhsgrampian/files/Guidelines2004
6. BSPED Recommended DKA Guidelines, Feb 2004 http://www.bsped.org.uk/professional/guidelines/docs/BSPEDDKAApr04.pdf
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GLOSSARY BG Blood GlucoseBMI Body Mass Index. Weight (kg) divided by square height (m2)CGMS Continuous Glucose Monitoring SystemCHO CarbohydrateDKA Diabetic KetoacidosisHbA1c A fraction of the total Haemoglobin content of the blood with glucose stuck to it.
This measurement is used to monitor diabetes controlISPAD International Society for Pediatric and Adolescent Diabetes. See ‘References’ for
their consensus documentIVI Intravenous InfusionPDSN Paediatric Diabetes Specialist NurseRACH Royal Aberdeen Children’s HospitalSCI-DC Scottish Care Information- Diabetes Collaboration. This diabetes database is used
for clinical management at the children’s servicesSMBG Self Monitoring of Blood Glucose (with a near-patient blood glucose meter)tdd Total daily dose (of insulin)WHO World Health Organisation
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