Assessing the ‘Kids’ (CYP)
Baby Child Teenager Young Adult Growth & Development
Dr.Mohamed Amin,DNBE (Paediatrics), MNAMS, MRCGP, MBA Paediatric Lead (GP), Whipps Cross Hospital EUCC Linkedin Profile -http://linkedin.com/in/mohamed-amin-258b09b6 Children’s Services in Tower Hamlets
[email protected] Paediatric Hotline; : 07919598173
Paeds Rapid Access Clinic, via the hotline
Dr Julia Moody, GP Lead for Children and Young People; [email protected] Children’s Mental Health Crises
Normal Hours; CAMHS 0207 426 2375 [email protected] If not known to CAMHS will see Paediatric Liason Team 0203 594 0407
OOH; RAID (Rapid Assessment Interface and Discharge Service), under 16yr olds in Paediatric ED, over 16yr olds in Adult ED; 0203 594 3179 Duty CAMHS SpR via RLH Switchboard Topics • Assessing a Child (Look and Tell)
• Differentiating Major v/s Minor Illness
• The Crying Infant/Child
• Breathing Difficulty
• D&V
• Rash
• Limp
• Injuries
• Case Studies (30) Mohamed Amin Assessment - 3 minute toolkit https://www.spottingthesickchild.com/videos/basic-child-assessment/3-minute-toolkit/3-min-toolkit-demo/3-min-toolkit-demo/
• G eneral appearance
• A irway (Secretions, noises, FB)
• B reathing (Rate, Effort, Sats, chest)
• C irculation (colour, HR, CRT, Temp) • DEFG (BM’s) • D isability (AVPU, Pupils, tone) • E N T • T emperature • T ummy Mohamed Amin Past Medical History • Asthma
• Diabetes
• Long Term Steroids
• Oncology Patient
• Prematurity < 36/40
• Syndromic Condition
• Congenital Heart Disease
Mohamed Amin Differentiating Major from Minor illness • Activity/ Consciousness
• Feeds • Urine output History • Degree of temperature
• Airway noises
• Breathing difficulty
• Skin mottling/ Rashes Mohamed Amin Differentiating Major v/s Minor illness
• General appearance (Dull/Active, Airway noises/Drooling, Flaring nostrils, Rash/ Mottling)
• AF • Temperature Examination • Pulse
• Respiratory rate + Effort
• Cap refill
• Degree of dehydration
• Pulse oximetry (5th Vital sign) Mohamed Amin Age Dependent Values
HR RR O2 Sats Temperature
< 6Mo >160 30- 60 • Degree of temperature not related to severity of illness. NICE > 39 < 92% - 6mo- amber (3-6 mo) and > 38 Red 110-160 30-40 give O2 -1 yr (<3mo)
1-2 yrs 100-150 25-35 • Absent in serious infections or after regular paracetamol at a proper dose. 2-5 yrs 95-140 25-30 92-95% - depends • Management based on other on Resp 6-12 yrs 80-120 20-25 parameters including Age, Hx and Effort PE & identification of a focus of infection. > 12 yrs 60-100 15-20
• Adapted from NICE guideline- Traffic light system and Southampton University Hospital Guidelines Mohamed Amin !
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! Differentiating the degree of illness
Urgent attention Pre-Terminal needed
Exhaustion Difficult to rouse
Bradycardia Agitation
Silent chest Cyanosis in air
Significant apnea
Ref- Nottingham University Guidelines - Adapted from WHO and Institute of clinical systems improvement. Mohamed Amin FEVER ** Teething will not HISTORY EXAMINATION cause fever > 38.5oC History rules out most red Behaviour and flags appearance provide the best indication. ** Babies < 3 months - Well or Unwell hypothermia (<36oC) / Localising symptoms: Localising signs: temperature instability - Cough, coryza - ENT - Headache - Neck stiffness can be signs of sepsis! - Photophobia - Work of breathing - Diarrhoea - Abdominal signs - Vomiting - Skin rash ** Degree of temperature - Abdominal pain - Joint swelling does not correlate with - Joint symptoms Travel History - Malaria, Lethargy severity of illness. Dengue, Leptospira, Poor interaction Brucella, Legionella, Inconsolable Tachycardia Tachypnoea Cyanosis Poor perfusion Any Ill Contacts + Immunisation Hx Mohamed Amin REF- Adapted from RCH Melbourne Clinical Guidelines Fever - Management
• Paracetamol – what about Ibuprofen? • Fluids? • Clothing? • Tepid Sponging? • Finding a focus - Good Luck!! • Don’t forget ICE - exposure to cold air- “will develop pneumonia”! - “higher the temp- more the risk of fits”! - If a visit is requested - ‘delicate negotiation’
Mohamed Amin Fever- Referral / Home Care
• Infants less than 3 mo, Temp >38 - High Risk
• Infants 3 to 6 months of age; GP Management if:
- The child is well - A clear focus of infection identified - Follow up in 12-24 hours has been arranged - If in doubt, always discuss.
• Children older than 6 months: GP Management if:
- The child is well - A clear focus of infection identified - Follow up has been arranged (GP/111/UCC)
REF- Adapted from RCH Melbourne Clinical Guidelines Mohamed Amin Fever- No Focus?
• Infants less than 6 mo, Temp >38 OR Unwell looking / Abnormal observations - Consider Referral • Infants older than 6 months of age: - The child is well - Urine Dipstix, Travel History - Follow up in 24-48 hours. - If in doubt, always discuss with local paediatric teams.
Mohamed Amin Fever- No Focus?
• UTI - Urine MC&S remains the Gold standard (Clean-catch midstream urine & not a bag sample) • Meningitis, Early Appendicitis / Septic Arthritis • Fever in a Traveller
* CDC - https://wwwnc.cdc.gov/travel
* Fit for Travel - http://www.fitfortravel.nhs.uk/destinations.aspx
* Travel Health - http://travelhealthpro.org.uk/countries
Mohamed Amin UTI • In first decade of life, 2% boys and 8% girls will have a UTI.
• Prevalence is 7% among febrile children < 2 years.
• Present in 1 of 6 febrile neonates presenting to GP/ED.
• All febrile young infants should have of a urine culture;
• Confirmed UTI requires an USS.
Which of the following statements regarding UTIs is false? a) A cloudy urine with a bad smell is a reliable indication of a UTI. b) Asymptomatic bacteriuria not associated with long-term adverse outcomes (pyelonephritis, renal failure or hypertension), and antimicrobial treatment is not indicated. c) To diagnose a UTI, both a urine culture and a urinalysis should be obtained. d) In an appropriately collected specimen, 50,000 CFU/mL is the threshold for diagnosis.
REF- Meissner C; Common misconceptions about urinary tract infections in children; AAP; March 27, 2017 - BonadioW, Maida G; Urinary Tract Infection in Outpatient Febrile Infants Younger Than 30 Days of Mohamed Amin Age; Pediatr Infect Dis J. 2014;33(4):342-344. Urine Dipstix
• Test within 30 minutes of obtaining sample. • First morning voids are best for a positive nitrite test yield. • The best yield of Leu / Nit is in children > 2 years of age. • Children < 2 years need MC&S for confirmation/ruling out with confidence Positive leukocyte esterase Sensitivity 84% alone Specificity 77% Sensitivity 58% High positive predictive Positive nitrite alone Specificity 99% value. Positive for either leukocyte Sensitivity 92% Best for ruling out disease esterase or nitrite Positive for leukocyte Likelihood Ratio Best for ruling in disease esterase and nitrite + 28:2
REF- Mori R, et al. Diagnostic performance of urine dipstick testing in children with suspected UTI: a systematic review of relationship with age and comparison with microscopy. Acta Paediatr. 2010;99:581-584. -Whiting P, et al. Rapid tests and urine sampling techniques for the diagnosis of urinary tract infection (UTI) in children under five years: a systematic review. BMC Pediatr. 2005;5:4. Mohamed Amin -- http://bestpractice.bmj.com/best-practice/monograph/789/diagnosis/tests.html Fever in a traveller? • Typhoid: Through contaminated food and drink. Risk is higher where access to adequate sanitation and safe water is limited.
• Cholera: common during floods and after natural disasters, in areas with very poor sanitation and lack of clean drinking water. unusual for travellers to contract cholera if taking basic precautions.
• Diphtheria: spread person to person through respiratory droplets. Risk is higher if mixing with locals in poor, overcrowded living conditions.
• Hepatitis A: spread through c contaminated food and water or person to person through the faecal-oral route. Risk is higher where personal hygiene and sanitation are poor.
• Hepatitis B: through infected blood and blood products, contaminated needles and medical instruments and sexual intercourse. Risk is higher for those at occupational risk, long stays or frequent travel, children (exposed through cuts and scratches) and individuals who may need, or request, surgical procedures abroad.
• Japanese Encephalitis: spread through bite of an infected mosquito. This mosquito breeds in rice paddies and mainly bites between dusk and dawn. Risk is higher for long stay travellers to rural areas, particularly if unable to avoid mosquito bites.
• R a b i e s : saliva of an infected animal, usually through a bite, scratch or lick on broken skin. Particularly dogs and bats. Even when pre-exposure vaccine has been received, urgent medical advice should be sought after any animal or bat bite.
• Tetanus: through contamination of cuts, burns and wounds with tetanus spores found in soil worldwide. A total of 5 doses of tetanus vaccine are recommended for life in the UK. Boosters recommended in a country or situation where the correct treatment of an injury may not be readily available.
• Viral Hemorrhagic fevers - Ebola etc
REF- NHS Scotland Fit for Travel - http://www.fitfortravel.nhs.uk/destinations.aspx Mohamed Amin Fever in a traveller? Disease Incubation Clinical Manifestations Malaria 6 days- 2 yrs GI, Resp,Neurological Typhoid 3 days- 3 mo GI, Perf, Resp Hepatitis A 15- 50 days Vomiting, abdominal pain, jaundice Fever + 2 of myalgia, retro-orbital pain, arthralgia, Dengue 3-14 days headache, leucopenia, haemorrhagic.
Chikungunya 1-14 days Arthralgia, myalgia, headache, nausea, rash Headache, rigors, myalgia, vomiting, jaundice, Leptospirosis 2-26days abdominal pain, rash
Rickettsiae Days - 3 weeks Arthralgia, rash, tick eschar. Traveller’s Diarrhea Hours to 10 Campylobacter, ETEC, Shigella, Ameoeba, Giardia +/- Dysentery days Primary: weeks Tuberculosis Reactivation: yrs Lethargy, weight loss, sweats, cough, LN. Tick has fed for Erythema migrans, Later arthritis, CNS or cardiac Lyme Disease more than 48 hours. involvement.
Ref- http://www.rch.org.au/clinicalguide/guideline_index/Fever_in_the_recently_returned_traveller/ Mohamed Amin SIMPLE FEBRILE SEIZURE 6 mo-7 years Onset within 24 hours of fever
GTCS < 15 minutes Complete recovery Do not recur within the same febrile illness.
FULL RECOVERY + CHILD LOOKS WELL
FOCUS OF NO FOCUS OF INFECTION INFECTION ATYPICAL FEATURES
HOME ED +/- FU PAEDS
REF- Adapted from RCH Melbourne Clinical Guidelines Mohamed Amin The Crying Child Thorough history and a Complete physical examination
- Otitis media - Meningitis - Bronchiolitis - Eye lash in the eye - Look for bruising, feel ribs, lumps/bumps over head (NAI) Spontaneous movements of all 4 limbs (Pulled elbow, Trauma, Septic arthritis) Nappy area - Strangulated hernia, Testicular torsion, severe nappy rash Mal-rotation/ Volvulus ( green vomit, abdo distension +/- mass) Clothing thread around fingers/toes- always remove mitten and socks. Infantile colic - Diagnosis of exclusion. Just Anxious?
Mohamed Amin AOM - Clinical Approach
>12mo old, mildly unwell, Yes Analgesia Consider no antibiotics immunocompetant for first 24-48 hours
No
Analgesia Amoxycillin 15mg/kg/dose TDS No for 5 days Symptoms resolving?
Explain Natural History Give &parent Safety handoutnet Yes
Advise parents to seek medical review if ear symptoms, hearing Yes difficulty or persistent irritability Symptoms improved after 2-3 moths by 48 hours (to check for persistent effusion)
GiveGlue parent Ear pathway handout No
Review Consider alternative diagnosis Do not accept otitis media as the sole If none, switch to Amoxycillin/clavulanic acid diagnosis in a sick febrile young child 22.5mg/kg/dose BD without elimination of a more serious cause. for 5 days
Ref: http://www.rch.org.au/clinicalguide/guideline_index/Acute_otitis_media/ Mohamed Amin AOM - Management • 60% in 24 hours and 80% better < 48 hours of onset, regardless of Rx. • 14% have symptoms > 48 hours, modest benefit with early antibiotics. • If 17 children are treated early, one may have less pain and temperature at 3-5 days, but 3 or 4 will be more unwell with diarrhoea, vomiting, rashes, or thrush • Initially, antibiotics won’t help pain, Don't forget adequate analgesia.
REF- Venekamp RP, et al., Acute otitis media in children. Systematic review 301. BMJ Clinical Evidence. - http://clinicalevidence.bmj.com/x/systematic-review/0301/overview.html. 2014 September Mohamed Amin - NEL CCG’s and Barts Abx guidelines june 2015 URTI • Self-limited condition with resolution within 1-2 weeks.
• Commonly Bacterial in winter (or early spring) and viral (entero-viral in summer & autumn).
• Absence of nasal congestion and discharge.
• Group A Strep (GAS) pharyngitis clinically predicted by the presence of 3 or 4 of : pharyngeal exudate, cervical adenopathy, fever, and lack of cough.
• Other more complex clinical scoring systems are of unproven benefit.
REF- Shulman et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55:e86-e102. Mohamed Amin Strep Sore Throat - Rx
• Goals- to prevent acute rheumatic fever, reduce severity and duration of symptoms and prevent transmission.
• Oral PEN-V for 10 days. If unable to complete a 10-day oral course, a single intramuscular dose of benzylpenicillin.
• Amoxicillin may be substituted, if taste more palatable than PenV.
• No beta-lactam resistance with GAS, but in cases of ‘penicillin allergy’ a macrolide, cephalosporin, or clindamycin may be used.
• Avoid Amoxicillin with concomitant infectious mononucleosis - Severe rash
• No difference in symptom resolution between cephalosporins & Penicillins
• More adverse events with macrolides.
• GAS resistance to macrolides has been reported
REF- van Driel ML, et al. Different antibiotic treatments for group A streptococcal pharyngitis. Cochrane Database Syst Rev. 2013;(4):CD004406. Mohamed Amin “Penicillin Allergy”- BNFC
• Not Allergic to penicillin if:
- A minor rash (i.e. non-confluent, non-pruritic rash restricted to a small area of the body)
- A rash that occurs more than 72 hours after “penicillin” administration.
- “Penicillin” should not be withheld unnecessarily for serious infections; other beta-lactam antibiotics (cephalosporins) can also be used in these patients.
Ref- BNFC April 2017 Mohamed Amin Features of SOB https://www.spottingthesickchild.com/videos/symptoms/difficulty-in-breathing/key-points-in-examination/resp-exam-noisy-breathing/difficulty-in- breathing-key-points-in-examination-noisy-breathing/
• Increased respiratory rate
• Decreased respiratory rate + drowsiness = pre terminal (Look at the child, not just the monitors)
• Chest In-drawing (Youtube)
• Nasal flaring
• Tracheal Tug
• Use of accessory muscles (Neck)
• Grunting
Mohamed Amin ACUTE BREATHING DIFFICULTY (in a previously well child) PRE- ABC - RESUS TERMINAL SIGNS
RR + SPO2 < 92= O2 + ADMIT
STRIDOR
INCR WORK STERTOR OF BREATHING PATH WHEEZE — WAYS COUGH S/O serious illness or complications D/W PAEDS URTI- Home mgt + safety net
REF- http://www.nottingham.ac.uk/paediatric-guideline/breathingguideline.pdf Mohamed Amin !
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! Less obvious causes of respiratory distress
Ref- Nottingham University Guidelines - Adapted from Fleischer’s textbook of emergency medicine. Mohamed Amin STRIDOR
BARKING COUGH
PO DEXA or ? TOXIC + AGITATION / BUDESONIDE HIGH TEMPS DROOLING NEB
EPIGLOTTITIS STERTOR Bacterial Tracheitis
Airway+ PAEDS ENLARGED Airway+ Airway+ TONSILS PAEDS ENT
Ref- http://www.nottingham.ac.uk/paediatric-guideline/breathingguideline.pdf Mohamed Amin WHEEZE
Choking/ Paroxysmal cough Assess SEVERITY Manage Wheeze +CXR
AGE > 2 AGE < 2
MILD-MOD MOD - SEVERE SX SX Dry wheezy cough / Fever/ Nasal Discharge / Fine Insp crackles/ high pitched exp B2 Agonist + *LIFE* B2 Agonist + wheeze TRIAL Spacer THREATENING Spacer (Neb if on O2) Salbutamol/ Atrovent - Stop Home ABC/ RESUS / BTS Guidelines PO Steroid if not effective Bronchiolitis Safety Net +/- 4-6h O2 Sats Anticholinergic CXR- Airway+ Penumothorax PAEDS REASSESS
REF- http://www.nottingham.ac.uk/paediatric-guideline/breathingguideline.pdf Mohamed Amin Inhaler Technique
• Inhaler + Spacer & mask http://www.rch.org.au/genmed/clinical_resources/Asthma_-_using_a_puffer_with_spacer_and_mask/
• Inhaler with spacer http://www.rch.org.au/genmed/clinical_resources/Asthma_-_using_a_puffer_with_spacer/
• Turbohaler http://www.rch.org.au/genmed/clinical_resources/Asthma_-_using_a_turbuhaler/
• Accuhaler http://www.rch.org.au/genmed/clinical_resources/Asthma_-_using_a_accuhaler/
• Nasal Spray http://www.rch.org.au/genmed/clinical_resources/Asthma-_using_a_nasal_spray/
• Caring for spacer http://www.rch.org.au/genmed/clinical_resources/Asthma_-_caring_for_your_spacer/
Mohamed Amin British guideline on the management of asthma 9 • Management of acute asthma
of asthma, particularly those under two years of age. The guideline is not intended for children under one year of age unless directed by a respiratory paediatrician. The guideline should not be used to treat acute bronchiolitis
9.7.1 CLINICAL ASSESSMENT Table 14 details criteria for assessment of severity of acute asthma attacks in children. Annexes 5–8 contain algorithms summarising the recommended treatments for children presenting with acute or uncontrolled asthma in primary care (see Annex 5), the ED (see Annex 6), and hospital (see Annexes 7 and 8). Table 14: Levels of severity of acute asthma attacks in children633
Moderate asthma Able to talk in sentences
SpO2 ≥92% PEF ≥50% best or predicted BTS-2016 Heart rate ≤140/min in children aged 1–5 years ≤125/min in children >5 years Respiratory rate ≤40/min in children aged 1–5 years ≤30/min in children >5 years Acute severe asthma Can’t complete sentences in one breath or too breathless to talk or feed
SpO2 <92% PEF 33–50% best or predicted Heart rate >140/min in children aged 1–5 years >125/min in children >5 years Respiratory rate >40/min in children aged 1–5 years >30/min in children >5 years Life-threatening asthma Any one of the following in a child with severe asthma: Clinical signs Measurements
Silent chest SpO2 <92% Cyanosis PEF <33% best or predicted Poor respiratory effort Hypotension Exhaustion Confusion Mohamed Amin
| 103 COUGH
Choking/ Manage Paroxysmal Wheeze +CXR cough
TRIAL Dry wheezy Salbutamol/ cough / Fever/ Atrovent - Stop Nasal Discharge / if not effective Fine Insp crackles/ Bronchiolitis high pitched exp O2 Sats wheeze NO BLOODS/ CXR/STEROIDS
COUGH & SOB MILD-MOD + 1 of : Po Abx Fever ?Home High RR Pneumonia Grunting ICR MOD - SEVERE REASSESS Admit
REF- http://www.nottingham.ac.uk/paediatric-guideline/breathingguideline.pdf Mohamed Amin Diagnosing GE • A sudden change to loose or watery stools or onset of vomiting.
• > 6 D &/or 3V = Prone to dehydration.
Ask about:
• Recent contact with someone with D +/- V
• Recent travel abroad.
• Temperatures, Cough, Ear Discharge,
• Activity, Feeds, UO.
Mohamed Amin Dehydration - Assessment (NICE) https://www.spottingthesickchild.com/videos/symptoms/dehydration/key-points-in-examination/ signs-of-dehydration/dehydration-key-points-in-examination-signs-of-dehydration/
Mohamed Amin Increased risk of Dehydration (NICE)
• Children < 1 year (especially < 6mo)
• Ex-Pre terms and Ex-Low Birth weights
• Passed > 6 diarrhoea stools in last 24 hours
• Vomited > 3 in last 24 hours
• Not offered or not tolerating supplementary fluids
• Infants who have stopped breast feeding during the illness
• Children with signs of malnutrition
Mohamed Amin Oral Rehydration (NICE)
In children with clinical dehydration:
• Use ORS solution at 50 mls/Kg over 4 hours for fluid replacement as well as maintenance.
• Consider supplementation with their usual fluids (including milk feeds or water, but not fruit juices or fizzy drinks) if they refuse to take sufficient quantities of ORS solution and do not have red flag symptoms or signs (previous slide)
• Monitor the response to oral rehydration therapy by regular clinical assessment.
Mohamed Amin Fluid management after rehydration (NICE)
✴ Encourage breast feeding or other milk feeds
✴ Encourage fluid intake (Not juices or fizzy drinks)
✴ In children at increased risk of dehydration: (< 1 yr age, low birth weight, >6 D or > 3 V in last 24 hours) - give ORS at 5mls/kg after every loose stool
✴ Restart rehydration treatment at 50mls/kg over 4 hours if dehydration develops at anytime.
Mohamed Amin What Fluids?
• Most children don't tolerate (refuse/vomit) ORS (Dioralyte)
• Mild gastroenteritis & minimal dehydration = give dilute (½ strength) apple juice followed by the child’s own preferred fluids, results in fewer treatment failures.
REF- Freedman, et al., 2016. Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial. Jama, 315(18), pp. 1966-1974. Mohamed Amin Beware - ‘Gastroenteritis’ with fever
• Noro-virus • Otitis media • Meningitis • Pneumonia • Septicaemia • UTI
Mohamed Amin Possible indicators of other diagnoses in GE (NICE)
• Temperature of 38°C or higher (younger than 3 months) • Temperature of 39°C or higher (3 months or older) • Shortness of breath or tachypnoea • Altered conscious state • Neck stiffness
• Bulging fontanelle (in infants)1 • Non-blanching rash • Blood and/or mucus in stool • Bilious (green) vomit • Severe or localised abdominal pain • Abdominal distension or rebound tenderness.
Mohamed Amin Advise for Gastro-enteritis cases
• Most children can be safely managed at home
• Diarrhoea lasts 5–7 d and stops within 2 weeks.
• Vomiting usually lasts for 1–2 d and stops within 3 d.
• Explain how to recognise dehydration
• Prevent spread by washing hands with soap (liquid) in warm running water and careful drying.
• Towels used by infected children should not be shared.
• No school or childcare facility until 48 hours after the last episode of diarrhoea or vomiting.
• No swimming pools for 2 weeks till after the last episode of diarrhoea.
Mohamed Amin Rashes in GP • Most are non-descriptive maculo-papular rashes of viral origin.
• Most cannot be diagnosed just on their appearance.
- History - Duration - Speed of spread
- Change in general condition of the child
- Associated symptoms
* Don’t forget ICE - Many parents fear it could be a start of meningitis.
* Thorough physical examination to rule out serious causes and reassure parents.
Mohamed Amin Unwell with Systemic Symptoms
• Meningococcal Septicaemia (Different from meningitis)
• Urticaria +/- Angioedema +/- EM -> SJS (Different to Anaphylaxis)
• Staphylococcal Scalded Skin Syndrome (SSS)
• Scarlet fever
• Eczema Herpeticum
• Measles, Chicken pox, Slapped cheek,
• Hand Foot and Mouth
Source- PCDS Mohamed Amin Meningococcal Septicemia
• Fever, non-specific malaise, lethargy, vomiting, meningism, resp distress, irritability, seizures
• Maculopapular rash common early in the disease, can also be urticarial (with fever)
• Petechial rash seen in 50-60%
Mohamed Amin Impetigo • Staph Aureus or Group A Strep Pyogenes
• Classically ruptured vesicles with honey-coloured crusting.
• May be bullous.
• More common in pre-existing skin disease.
• Very contagious, rapid spread.
• Commonly starts around face/mouth.
• Rx. Topical fusidic acid or oral flucloxacillin.
• Advice re nursery/school
Mohamed Amin SSSS
• Caused by Staphylococcal exfoliative toxin
• Erythematous tender skin, progressing to desquamation after 24-48hrs
• Nikolsky sign
• 62% < 2yrs, 98% < 5yrs
• BCs usually negative in children
• Usually febrile, may rapidly progress to dehydration/ shock
• Rx. Systemic antistaphylococcal abx., emollients, may need IV fluids
Mohamed Amin Scarlet Fever • Gp A beta-haemolytic Strep • 2-4 days post-Streptococcal pharyngitis • Fever, headache, sore throat, unwell • Flushed face with circumoral pallor • Rash may extend to whole body • Rough ‘sandpaper’ skin • Desquamation after 5/7, particularly soles and palms • School age children • White strawberry tongue • Dx. Throat swab, ASO titres • Rx. Penicillin 10/7
Mohamed Amin Eczema Herpeticum
• Widespread, potentially serious viral infection of the skin.
• Can affect people with atopic eczema and other inflammatory skin conditions.
• Considered an emergency because it can spread quickly
• Aciclovir PO for mild disease and IV for widespread/ poorly responsive disease.
• Normally not contagious, but can affect people with eczema, immunosuppression and newborns.
Mohamed Amin Varicella
• Incubation 14-21 days
• Mild prodromal illness
• Rash: Face, scalp, trunk, spreads centrifugally
• Macules – papules – vesicles – pustules – crusts
• Complications: encephalitis, pneumonia, superceded Staph infection, disseminated disease in immunocompromised
• Advice to pregnant mothers
Mohamed Amin Measles
• Unwell child
• Incubation 7-14 days
• Fever, conjunctival suffusion, coryza
• Maculopapular rash starting on face and progressing to whole body
• Koplik’s spots are pathognomonic
• Complications: Otitis media, pneumonia, hepatitis, myocarditis, encephalomyelitis, SSPE
Mohamed Amin Erythema Infectiosum •Caused by infection with parvovirus B19.
• The classic presentation is a 'slapped cheek' appearance followed by a reticular, erythematous rash, predominantly on the extremities, may also cause arthritis and arthralgias.
•No specific treatment beyond symptomatic therapy and reassurance.
• People with a high RBC turnover/destruction (e.g., those with hereditary spherocytosis, sickle cell disease, thalassaemia, iron deficiency anaemia) may develop transient aplastic crisis.
Mohamed Amin Hand Foot & Mouth Disease
• Common childhood viral infection caused most often by coxsackievirus A16.
• Mild illness with low-grade fever, painful oral ulcers, and vesicles on palms of and soles.
• Resolves in 10 to 14 days, treatment supportive.
• A more severe version of the disease with serious complications is caused by enterovirus 71, occurs in South-east Asia
Mohamed Amin HSP (Vasculitis)
• Most common vasculitis of childhood.
• Rash of palpable purpura is present in all cases.
• Most cases resolve with symptomatic treatment.
• Complications can occur, with renal failure being the most common cause of death.
Mohamed Amin Clinical presentations
Tender Fever Exudate/ SYS HR Other Crusting SX BP Cellulitis +/- +/- +/- +/- -
Erysipelas + +/- +/- + +/- Well-defined border
Impetigo - +/- ++ - - May be bullous
SSSS + + ++ +/- +/-
Necrotising Low PLTS Fasciitis ++ + +/- ++ ++ Often tender beyond area of skin change
Allergic - +/- - - - Often itchy reaction May see insect bite
Adapted from : http://www.rch.org.au/clinicalguide/guideline_index/Cellulitis_and_skin_infections/ Mohamed Amin Infectivity Periods & Isolation
• Chicken pox- Few days before rash onset and 6 days after first lesions appear
• Scarlet fever - 10-21 days after rash onset (only 5 days if penicillin given)
• Slapped check disease - 14 days before rash onset. no longer infectious after rash onset.
• Measles- Prodromal sx to 4 days after rash onset
• Rubella - one week before and unto 4 days after rash
• Whooping cough - one week after exposure and 3 weeks after onset of sx ( only 7 days if abs given)
Mohamed Amin Approach to the limping child
- Measure limb length
- Check SPINE
- Check the FOOT (and shoes)
Splinter? Injury? Swollen ankle: Infection ? Arthritis
- Examine KNEE
Swelling : Infection/Arthritis/Tumour Tenderness : Injury/Infection
- Examine HIP
Septic Arthritis Dislocation /Injury Irritable hip /Septic arthritis/Perthes
Mohamed Amin The Limping child NICE- CKS Guideline : All ages- Sickle cell, malignancy •Younger than 3 years Children less than 3 years of age: ◦ Fracture or soft tissue injury (may be due to 'toddler's fracture' or child • Septic arthritis and NAI. maltreatment). ◦ Osteomyelitis or septic arthritis . • Transient synovitis is rare in this age ◦ Developmental dysplasia of the hip . group and the diagnosis should be • 3–10 years made with extreme caution after ◦ Fracture or soft tissue injury (may excluding serious causes. Urgent be due to stress fracture or child referral is advised because maltreatment). examination may be difficult and ◦ Transient synovitis . ◦ clinical signs subtle. Osteomyelitis or septic arthritis . ◦ Perthes' disease . • 10–18 years Children older than 9 years of age: ◦ Fracture or soft tissue injury (may be due to stress fracture or child • Slipped upper femoral epiphysis maltreatment). (SUFE) is more likely and needs ◦ Slipped upper femoral epiphysis . urgent investigation. ◦ Osteomyelitis or septic arthritis . ◦ Perthes' disease .
Source- http://cks.nice.org.uk/acute-childhood-limp#!scenario Mohamed Amin Injuries - History
• Suspect inflicted injury = full physical assessment
• RTA - High speed (+/- ejection), rollover, Side impact, pedestrian/cyclist, fatalities in the same collusion.
• When did the incident happen (Time)?
• Delay in presentation
• Changing story
Mohamed Amin Head Injuries
• Mechanism of Injury and consistency of the story
• When did it happen (Time)?
• LOC/ Fit / Behavioural change / ENT bleed/ Clear runny discharge from Ear or Nose / Vomiting
• Suspect inflicted injury = full physical assessment
• Safety net + Patient Information Leaflet
Mohamed Amin FRACTURES
• Mechanism of injury - Carefully listen to ‘the Story’
• Pain (no rest pain)
• Mobility/ Weight bearing
• Swelling
• Deformity
Mohamed Amin Fraser Guidelines 1. He/she has sufficient maturity and intelligence to understand the nature and implications of the proposed treatment 2. He/she cannot be persuaded to tell her parents or to allow the doctor to tell them 3. He/she is very likely to begin or continue having sexual intercourse with or without contraceptive treatment 4. His/her physical or mental health is likely to suffer unless he/she received the advice or treatment 5. The advice or treatment is in the young person’s best interests.
REF- http://www.cqc.org.uk/content/nigels-surgery-8-gillick-competency-and-fraser-guidelines Mohamed Amin Useful Resources https://www.rcn.org.uk/professional- RCN - Standards for vital sign monitoring development/publications/pub-003196 in children
NICE - Feverish illness in children <5 Yrs https://www.nice.org.uk/guidance/cg160 (2013) NICE- Diarrhoea and Vomiting caused by https://www.nice.org.uk/guidance/CG84 GE in under 5’s (2009) • NICE- When to suspect child https://www.nice.org.uk/guidance/cg89 maltreatment (2013)
• https://www.spottingthesickchild.com Spotting the sick child e-learning
http://www.nottingham.ac.uk/paediatric- Nottingham University Hospital guidelines guideline/breathingguideline.pdf
http://gp.towerhamletsccg.nhs.uk/ Antimicrobial prescribing guidance for GP%20services/Joint-guidelines/Infections/ primary care Antimicrobial%20Guidance%20Tri%20boro ugh%20CCG%20in%20collaboration%20B arts%20Health.pdf
Mohamed Amin