London Speciality School of
Paediatrics
Hot Topics in
Paediatrics
Return to Acute Paediatrics
August 2014
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Aims
• To reassure you that not much has changed
• To give you some gems so you can sound
knowledgeable from the first ward round
• To update you on what’s been happening in
paediatrics as a speciality
• To signpost some resources
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Topics
• Feverish child and NICE guidance
• Head injury in children
• Optiflow
• Rotavirus Vaccine
• Haemoglobin/Codeine and Domperidone
• Frances Report
• ‘Back to facing the future’
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FEVERISH ILLNESS IN CHILDREN
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NICE Guideline “Feverish illness in children”
Provides a tool to risk assess feverish children for serious bacterial
illness, Traffic light system
An adequate ‘safety net’
a) providing the parent or carer with verbal and/or written advice on warning
symptoms
and how further care can be accessed or
b) the parent or carer is given follow up at a specific time and place or
c) ensuring direct access for the patient if further assessment is required.
Standards
1. Children presenting to Emergency Departments (EDs) with medical conditions
should have respiratory rate, oxygen saturation, pulse, blood pressure/capillary
refill, GCS/AVPU and temperature measured and recorded as part of the routine
assessment
2. Discharged children in whom no diagnosis is found and with amber features,
should be provided with an appropriate ‘safety net’
3. 90% of children with amber features and without an apparent source of infection
should not be prescribed antibiotics
4. Children with fever and without an apparent source of infection but with one or
more red features should have FBC, CRP, blood culture and urinalysis performed
5. EDs should have written advice to give to the carer/s of discharged children
6. EDs should have access to the NICE guideline Traffic Light System
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Traffic
Light
system for
identifying
risk of
serious
illness
(new 2013)
children with fever
and any of
symptoms or signs
in red colum should
be recognised as
being at high risk
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Measurement of body temperature at other sites
In infants under the age of 4 weeks:
Electronic thermometer in the axilla
In children aged 4 weeks to 5 years:
Electronic thermometer in the axilla
Chemical dot thermometer in the axilla
Infra-red tympanic thermometer
• Subjective detection of fever by parents and carers
• Reported parental perception of a fever should be
considered valid and taken seriously by healthcare
professionals
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NICE GUIDELINES FOR HEAD
INJURY
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Head Injury in Children
CT < 1hr
• NAI
• Post traumatic seizures
• GCS < 14/ GCS < 15 (under
1) on presentation to ED
• 2 hours after injury – GCS <15
• Suspected open/depressed
skull fracture/ open fontanelle
• Signs of basal skull fracture
• Focal deficit
• < 1year –bruise/ swelling/
laceration >5cm
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CT vs obs
>1 following risk factors (perform
CT in 1 hour of finding RF
• LOC > 5 minutes
• Abnormal drowsiness
• 3 or more discrete episodes of
vomiting
• Dangerous mechanism
• Amnesia > 5 minutes
Only 1 RF – observe for 4 hours
OPTIFLOW
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Optiflow
What is Optiflow?
• System required to deliver humidified high flow oxygen
therapy via a nasal cannulae
• The system comprises of a MaxVenturi and a Fisher &
Paykel MR850 humidifier
What kind of treatment does it offer?
• Humidified High Flow Nasal Cannula (HHFNC) therapy
• Increasingly utilised modality for the management of patients
with Type 1 respiratory failure
• Constitutes delivery of high inspiratory gas flow (up to 50
L/min), warmed to body temperature, pressure saturated for
optimal humidification and accurately titrated oxygen content
(32 – 100%)
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Optiflow
What are the benefits?
1. Reversal of hypoxaemia
2. Reduce work of breathing
3. Improved secretion clearance
4. Avoidance of intubation
5. Improved patient tolerance and comfort
6, Unhindered speaking/ feeding
What are the indications?
1, Patients with hypoxaemic Type I respiratory failure
2. Patients with increased work of breathing
3. Poor compliance of mask therapy where O2
requirements are > 4l/min
4. Increased secretion viscocity with an impaired ability to
clear secretions
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Optiflow
What are the contraindications?
1. Patients at risk of type II (hypercapnic Respiratory failure)
secondary to O2 delivery
2. Basal skull fractures
3. CSF leak
4. Nasal passage abnormalities or recent nasal surgery
5. Respiratory arrest/ peri-arrest
6. Platelets < 85 (or severe epistaxis)
How do you chose your flow?
2 L/kg/min up to 10Kg
Plus 0.5 L/kg/min > 10Kg
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ROTAVIRUS VACCINE
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Rotavirus Vaccine (Rotarix)
• Over 85% effective at preventing severe rotavirus gastroenteritis in
first two years of life
• Live vaccine given orally at two and three months
• Can only given if over 6 weeks and first dose before 15 weeks of age
• Course must be completed by 24 weeks of age
• Contraindications;
• Previous intussusception and GI malformation leading to
intussusception
• SCID
• Rare hereditary problems of fructose intolerance,
glucose/galactose malabsorption or sucrose- isomaltase
insufficiency
• Small risk of intussusception post first dose: MUST WARN PARENTS
• Risk of transmission through stool therefore strict hand hygiene
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Codeine / Haemoglobin and
Domperidone
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Codeine / Haemoglobin and Domperidone
Codeine Phosphate:
Statement from RCPCH 2013
Following a review of the literature and analysis of several
deaths outside hospital the advice given by the MRHA
codeine should not be used in any child with:
• A history of sleep apnoea who is undergoing tonsillectomy or
adenoidectomy
• Codeine should only be used in children over the age of
12 years.
Understanding that codeine is variably metabolised to
morphine and that some children (fast metabolisers) will
be vulnerable to unpredictable and excessive respiratory
depression
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Codeine / Haemoglobin and Domperidone
Haemoglobin:
From 2013, all haemoglobin (Hb) and mean cell haemoglobin (MCHC)
results from the haematology laboratories are now reported in g/L
This means a Hb concentration value previously expressed as 10.8 g/dl
will now be expressed as 108 g/L
Follows recommendations from The National Pathology Harmony
Committee, an initiative sponsored by the Department of Health, that
reporting units of haemoglobin (Hb) and mean cell haemoglobin
(MCHC) should be changed from g/dL to g/L
Any diagnostic or treatment algorithms that are based on haemoglobin
concentration will need to be altered to accommodate this change
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Codeine / Haemoglobin and Domperidone
Domperidone:
• Domperidone is associated with a small increased risk of serious
cardiac side effects.
• Its use is now restricted to the relief of symptoms of nausea and
vomiting
• Dosage and duration of use have been reduced.
• Now contraindicated in those with underlying cardiac conditions and
other risk factors such as hepatic failure
• In children under 12 years of age and weighing less than 35kg, the
recommended maximum dose in 24 hours is 0.75mg/kg body weight
(dose interval: 0.25mg/kg body weight up to three times a day)
• The maximum treatment duration should not exceed one week
• Patients currently receiving long-term treatment should be reassessed
at a routine appointment to advise on treatment continuation, dose
change, or cessation
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Frances Report
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Frances Report
• Enquiry into the Mid Staffordshire NHS Foundation Trust
• Enquiry of care provided between 2005- 2008
• The Inquiry Chairman, Robert Francis QC, concluded that
patients were routinely neglected by a Trust that was
preoccupied with cost cutting, targets and processes and
which lost sight of its fundamental responsibility to provide
safe care
• July 2009 the Secretary of State for Health ordered
another independent enquiry and the report was made
available in February 2013
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Frances Report
• The report was published on 6 February 2013 and
makes 290 recommendations, including:
• openness, transparency and candour throughout the
healthcare system (including a statutory duty of candour),
fundamental standards for healthcare providers
• improved support for compassionate caring and
committed nursing and stronger healthcare leadership
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Frances Report - References
Executive summary of the Francis report
http://www.midstaffspublicinquiry.com/sites/default/files/repor
t/Executive%20summary.pdf
RCPCH response to the Enquiry
http://www.rcpch.ac.uk/news/rcpch-responds-francis-inquiry
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BACK TO FACING THE FUTURE
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Back to facing the future
• Facing the Future: a
review of paediatric acute
services (April 2011)
• 10 standards for acute
paediatric services
• Back to facing the future
• commitment of the
RCPCH to audit the
standards
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Back to facing the future
Report in April 2013:
• 77% of children seen by a senior in the first 4 hours
• 88% of children seen by a senior in the first 24 hours
• Discrepancy of care in the day and evening with only 6%
of consultants being present at peak times in the weekend
• Shortfall of staff
http://www.rcpch.ac.uk/system/files/protected/page/Facing%
20the%20Future%20-%20exec%20summary.pdf
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Summary
• Not that much has changed!
• Even the papers that have had the highest impact
haven’t actually changed practice much
• Clinical experience counts more than anything
• Lots happening at an organisational level… don’t
panic
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