PAEDIATRICS:

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PAEDIATRICS Last minute on a Friday
afternoon Wednesday, 20th May 2009, 16.00 Dr Tim
Lee Consultant in Paediatric Medicine, Honorary
Senior Lecturer, Co-organiser MSc in Child
Health Leeds Teaching Hospitals NHS Trust and the
University of Leeds
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Declaration of interests

• I have received fees from the following for
  giving talksMerck Sharp Dohme
  GlaxoSmithKline AstraZeneca Forest Laboratories
• I have received support to attend conferences
  from the followingMerck Sharp Dohme
  GlaxoSmithKline

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What we will cover
139-178

• Annabelles skin
• Billies tummy ache
• Charlies fever
• Declans delay
• Ewans roll off sofa

• Eczema food allergy
• Chronic abdominal pain
• Pre-school fever
• Delay in walking/talking
• Safeguarding children

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Annabelle
139-144

• Mother attends with 7 month old Annabelle
• Baby has significant atopic eczema
• Mother upset - despite avoiding nuts,
  breastfeeding, and weaning with soya formula
  still following the family tradition

5
Breastfeeding prevents atopic disease

• True
• False

6
Pregnancy allergen avoidance reduces the chance
of atopic disease

• True
• False

7
Food allergy is correlated with atopic disease

• True
• False

8
Feeding with soya formula decreases atopy

• True
• False

9
Paternal atopy is as important as maternal atopy
in offsprings risk of atopy

• True
• False

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Annabelle
139-144

• Breastfeeding prevents atopic disease
• Pregnancy allergen avoidance reduces the chance
  of atopic disease
• Food allergy is correlated with atopic disease
• Feeding with soya formula decreases atopy
• Paternal atopy is as important as maternal atopy
  in offsprings risk of atopy

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Cochrane Review
139-144

• Maternal dietary antigen avoidance during
  pregnancy or lactation, or both, for preventing
  or treating atopic disease in the child
  MS Kramer, R Kakuma

Trials of mothers' avoidance of milk, eggs, and
other potentially "antigenic" foods during
pregnancy or breastfeeding, or both, provide
inadequate evidence about whether such avoidance
helps prevent atopic eczema or asthma in the
child.
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So, for Annabelle
139-144

• Soya milk formulas are not hypoallergenic
• Switch from Soya to a extensively hydrolysed
  formula (eg Pepti-Junior Nutramigen)
• If poor response paediatric referral

Soya milk formulas should generally be avoided,
esplt 6mo
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Food allergy
139-144

• Is it real?
• Who needs a referral?
• Who should get an EpiPen?

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Presentations of food allergy
139-144
Immediate onset IgE mediated
Late onset
X
Eczema/atopic dermatitis
Food protein induced enterocolitis
Allergic dysmotility
Food protein enteropathy
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Who needs referral
139-144

• Have a food allergy suspected and
• Severe eczema
• Severe asthma
• Failing to thrive
• Multiple food allergies
• Anaphylaxis, or severe allergic reaction
• Breastfeeding with rectal bleeding

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Who should get an Epipen?
139-144

• Those at HIGH risk of death/anaphylaxis
• Asthma food allergy
• Previous anaphylaxis
• Idiopathic anaphylaxis
• (Small quantity reactors)
• (Teenagers)
• (Peanut allergy)

Epipens are over-prescribed and should only be as
part of a properly documented management plan
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Billie
147-152

• 11 yr old girl
• Tummy ache on and off for last 4 months
• Can last 3 or 4 days
• Feels too unwell to attend school when occurs
• Mother gets frequent migraine

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Billie What features would make you worry?
147-152

• Significant vomiting
• Pallor/Anaemia
• Weight loss
• Growth deceleration
• Abdominal mass
• Recurrent temperatures
• Rectal bleeding
• Nocturnal or weekend pain
• Significant chronic diarrhoea
• Family history of inflammatory bowel disease
• Stigmata Mouth ulcers, digital clubbing

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Chronic Abdominal Pain
147-152

• Common 10 of school age children
• Commonest cause is Functional

• History and examination should usually be enough
  to differentiate between non-organic causes and
  the more serious organic causes that need
  referral
• If no worrying features then Ix such as urine
  bloods or USS not useful

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So, for Billie
147-152

• No worrying features in history, examination,
  height or weight
• Seems school related
• Acknowledge that the discomfort exists but
  reassure no worrying cause
• Explore possible factors, encourage school
  attendance

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Charlies fever
153-160

• 2 year old boy
• Hot and miserable since yesterday
• Temp 38.8
• No focus on examination
• No rash
• Cap refill normal

Q What would you do?
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Pre-school fever NICE?

• Children gt3mo and lt3 years with fever and no
  focus should always have a urine culture checked
  (dipstick may help determine focus)
• Treat lower UTI with 3 days oral antibiotics, if
  suspect pyelonephritis refer secondary care
• If settles rapidly no need for Ix or prophylaxis
  if gt6mo

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When should I refer febrile children?
Red high risk
153-160

• Temp gt38º if lt3mo gt39º if 3-6mo gt40º if gt6mo
• Pale/mottled/ashen/blue
• Unresponsive and looks sick to you
• Cry weak or high pitched or continuous
• Grunting RRgt60 mod/severe recession
• Reduced skin turgor
• Non blanching rash, bulging fontanelle
• Limping/swollen joint
• Fever gt 4 days

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So, for Charlie
153-160

• Urine dipstick leuc ve, nitrite ve
• Culture sent, later confirmed E. coli UTI
• Settled quickly on 3 days oral trimethoprim

Managed in primary care, no USS, prophylaxis, or
follow-up needed for first uncomplicated UTI gt6mo
age
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Declans delay
161-170

• Seen at 2 year developmental review
• Walking since 11mo
• Drinking from cup at 13mo
• Scribbling with a pencil from 18mo
• 5 intelligible words at 2 yr

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Developmental delay
161-170

• Parents may not always be aware
• May be only presenting feature of significant
  pathology
• Speech delay common (6 at 3 yrs)
• Consider hearing problems social autism
• CHAT questionnaire poor sensitivity (lt50)

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Five key items on CHAT
163-164

• Ask parent1) Does child ever PRETEND, eg make
  cup of tea using toys?2) Does child ever point,
  to indicate INTEREST in something?
• Health practitioner observation3) Get childs
  attention, then point across room at interesting
  object, say Oh look! Theres a (name of toy)!
  Does child look across to see what you are
  pointing at? (INTEREST)4) Get childs attention,
  give child toy cup and teapot, say Can you make
  a cup of tea? Does child PRETEND to make tea?
  5) Say to child Wheres the light?, or Show
  me the light. Does child POINT with index finger
  at light and look up at your face around the time
  of pointing?

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So, for Declan
161-170

• Perform CHAT questionnaire
• Ask about any nursery, parental reading to Declan
• Examine, especially for glue ear
• Check hearing screen
• Advise daily reading
• SALT if not improved in 3 months

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Ewan
171-178

• Brought to your surgery 6pm on a Friday
• Rolled off sofa
• Mum noticed bruise and came straight down
• Does not appear unwell
• As the familys GP you are aware that mum was
  the victim of domestic violence in the past

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Ewan What would you do?
171-178

• Take and carefully record history
• Examine carefully
• If you think the injuries may be
  non-accidental- discuss with colleagues- phone
  social services- phone paediatrics
• Document concerns
• Other children at risk?

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Mother becomes upset and says she is taking Ewan
home. You should

• Prevent them leaving the surgery and call the
  police
• Advise her that it would be best to cooperate
• Allow them to leave but discuss immediately with
  social services emergency duty team
• Ask one of your staff to follow them at a
  discreet distance until a decision is made

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Background
171-178
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Practical advice
171-178

• This child has the highest mortality risk of all
  todays cases
• Discuss the problem with mum but dont
  interrogate her or child
• Try make referrals whilst they are still at
  surgery
• Inform Social Services emergency duty team by
  phone immediately and in writing within 48 hours
• Any concerns of child sexual abuse needs
  specialist examination which may be urgent

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Key messages Paediatric Update

• Food allergy Epipens overprescribed
• Serious causes of chronic abdominal pain can
  usually be excluded by history and examination
• Children gt3mo and lt3 years with fever and no
  focus should always have a urine culture
• Speech delay consider hearing social autism
• Everyone has a responsibility to safeguard
  children social services are key co-ordinators
  of the response

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And finally

• Go home
• Enjoy your work life but enjoy your home life
  more