Common Paediatric illnesses in Primary Care – when to refer? Southend University Hospital NHS Foundation Trust Paediatric referrals • Increased by 38% over the previous year • Total Outpatient referrals per year: 15,480 – Choose and Book – New referrals – Rapid access – follow ups 750 3,850 2400 8440 • Inpatient admissions: 1300 – Length of stay 1.1 days Urgent Referrals • The acutely unwell infant • Uncertain diagnosis and you are worried! • Extreme parental anxiety • Worries about child safety or non-accidental injury; also contact social services • Low threshold for admission in: – Children with co-morbidity eg diabetes, cystic fibrosis, on immuno-suppressives/steroids – Past history of intensive care treatment eg diabetic ketoacidosis, life-threatening asthma – Young infants below 3 months Recognition of the sick infant Important considerations • Completely undress the infant (remember it is easy to miss petechiae or bruising or a hernia) • Infants are difficult to assess objectively • Illness can result in rapid deterioration over a few hours. It is therefore helpful to re-assess the child after a suitable interval • Younger the baby lower the threshold of admission • With exception of dehydration, an infant that is feeding well is unlikely to have a serious illness Recognition of the Sick Infant significant symptoms • • • • • • • • • • Reduced feeding (<50% of normal in previous 24 hours) Persistent vomiting (>50% of the previous 3 feeds) Any bile-stained vomiting Frank blood in stools Less than 4 wet nappies in 24 hours Rapid breathing – particularly if noisy and of sudden onset Inappropriate drowsiness or irritability Convulsions Persistently unusual cry History suggestive of apnoeic episodes Recognition of the Sick Infant significant signs • Activity: – Floppy – Reduced response to verbal or painful stimuli • Dehydration: – – – – tachycardia >120/min reduced skin turgor of ≥2secs Reduced capillary refill ≥3secs dry mouth, sunken fontanelle • Respiration: – Tachypnoea: ≤5years: >50/min; >5years: >30/min – Grunting and rib recession • Others: – – – – Marked pallor / Non-blanching rash Bulging fontanelle, neck stiffness Limping / joint swelling Febrile: <3months ≥380C ≥3months ≥390C Feverish illness in children under 5 years Green Low risk Amber (REFER) Intermediate risk Red (REFER) High risk Normal Pale-reported by parent/carer Pale/mottled/ashen Responds normally to social cues stays wake or awakens quickly strong normal cry/not crying Not responds normally No response Appears ill Unable to rouse or if roused does not awake Weak/highpitched/continuous cry Respiratory Normal Nasal flaring respiratory rate (RR): >50/min (6-12months) >40/min (>12months) Grunting RR >60/min Chest wall recession Hydration Normal skin, eyes and moist mucus membranes Dry mucus membrane, poor feeding (<50% intake of normal), capillary refill time(CRT)≥3secs Decreased skin turgor fever≥5days, limping/joint swelling, new lump >2cm <3months ≥380C ≥3months ≥390C Non-blanching rash, bulging fontanelle, neck stiffness, convulsions, bilious vomiting Activity Other Decreased activity No smile Common Outpatient Referrals • • • • • • • • • • Eczema Food allergies Chronic asthma Chronic cough Heart murmur Vomiting Diarrhoea Chronic abdominal pain Urinary Tract Infection Enuresis • Constipation and soiling • Obesity and excessive weight gain • Headache • Musculoskeletal problems • Behavioural disorders • Common surgical conditions • Development concerns • Non-accidental injury • Crying baby Eczema • Diagnosis: Itchy skin + 3 or more of following: – – – – Onset <2years History of asthma/rhinitis Dry skin in past 12 months Flexural dermatitis • Treatment: – Emollients and moisturisers – Hydrocortisone1% TDS on inflamed skin even on face. – Stronger steroids (eumovate, dermovate, betnovate) used only for short term (1-2 weeks), avoid in children<2 years and avoid face. – Antibiotics • Leaflet from eczema society When to Refer: (dermatologist/paediatrician) – Uncertain diagnosis – Treatment ineffective – Non-responsive eczema on the face – If child is experiencing sleep disturbance, poor school attendance or significant social or psychological problems – If eczema associated with severe and recurrent infections Food allergies • Most children with milk allergy grow out of it by 3 years • Most children with egg allergy grow out of it by 5 years • Most children with peanut allergy remain allergic (1 in 5 may resolve) • Common food allergens: milk, egg, soya, wheat, seeds, nuts (peanuts and treenuts), fish, shellfish, exotic fruits eg kiwis, avocadoes • Symptoms of tingling tongue, urticarial rash, angioedema (lip or facial swelling), vomiting, diarrhoea (mild allergic reaction) • Respiratory symptoms or cardiovascular collapse (shock) means Anaphylaxis (severe allergic reaction) When to refer: • Severe allergic reaction-anaphylaxis • History of poorly controlled asthma • Multiple food allergies • Unidentified triggers • High parental anxiety • Frequent reactions Tests: – History is often clear and no diagnostic tests are needed – Skin prick tests and RAST can be misleading, particularly in young children or those with eczema – Generally a negative result is highly reliable, but there are often false positives – Tests cannot reliably identify the severity of the allergy – Oral challenges are the only way to be sure a child has outgrown an allergy, but must be conducted in hospital if there is any risk of a severe reactioin Chronic Asthma-When to Refer: • Poor response to 800µg/day beclomethasone (or equivalent) – step 4 of BTS/SIGN guidelines and should be on other asthma treatments; concordance and drug delivery need careful assessment • Poor response to 400 µg/day beclomethasone (or equivalent) and needs addon treatments that GP is unfamiliar with • Young child (<5years); uncertainty about drug delivery. Needs careful assessment of inhaler techniques and expertise of specialist asthma nurse • Young child (<1year); often doubt about diagnosis • Features that point to another diagnosis eg finger clubbing, focal signs in chest, failure to thrive, symptoms present from birth • Recurrent admission to hospital; suggests dangerous pattern of asthma • Frequent (>1/month) use of courses of oral prednisolone • Particularly severe acute asthma, such as needing intravenous treatments or intensive care. These are high risk patients Chronic cough Defined as daily cough lasting ≥4weeks • Associated Wheeze, exacerbation with viral illness, exercise or during sleep, personal or family history of atopy – possible asthma • Barking or brassy cough – croup, tracheomalacia, habit cough • Paroxysmal (with/without wheeze) – pertussis and parapertussis • Check immunisation status, exposure to tobacco smoke and evidence of personal or family history of allergies When to Refer: • Neonatal onset of cough • Chronic moist/purulent cough • Cough started and persists after choking episode • Cough occurs during or after feeding • failure to thrive • Finger clubbing • Contact with TB • Associated abnormalities (cardiac, neurodisability, immune deficiency) Heart murmur • Central cyanosis (blue extremities and mucus membranes ie tongue) is a feature of cyanotic congenital heart disease. Cyanosis restricted to extremities (peripheral cyanosis) is normal in infancy in the absence of other symptoms or signs. • Feel for apex of heart (dextrocardia) • Feel femoral and brachial pulses (coarctation of aorta) • Innocent heart murmur is never associated with symptoms. • Innocent heart murmurs are soft, varies with posture / respiration, ejection systolic, high-pitched, grade1-2/6 and localised to praecordium; no praecordial thrill When to refer: – Associated with symptoms of central cyanosis, pale, prolonged feeding (>30 mins), short of breath or failure to thrive. – Infants below 1 year – Doubts about the murmurwhether pathological – Parental anxiety – History of congenital heart disease in siblings or parents Vomiting infant Differential Diagnosis: – Viral infections (URTI / gastroenteritis) – Gastroesophageal reflux (GOR) (worse with feeds and when lying flat; often good response to feed thickeners eg infant Gaviscon) – Pyloric stenosis (1-4 months age, weight loss) – Cow’s milk protein intolerance (often history of associated diarrhoea, atopic tendency and failure to thrive) – Surgical causes eg intussusception, malrotation (bilious vomiting) – Raised intracranial pressure (lethargy, bulging fontanelle, separated sutures) When to refer: – Bilious vomiting – Weight loss or Failure to thrive – Unable to maintain hydration – Complicated GOR associated with symptoms ie failure to thrive or crying/irritability or aspiration/apnoeic episode – Raised intracranial pressure (lethargy, bulging fontanelle, separated sutures) Diarrhoea • Differential diagnosis: – Viral / bacterial gastroenteritris – Non-enteral infections such as UTI, meningitis or pneumonia – Cow’s milk protein intolerance or secondary lactose intolerance – Toddler’s diarrhoea / IBS – Malabsorption: cystic fibrosis, coeliac disease – Inflammatory bowel disease – Surgical causes: appendicitis, intussusception – Constipation with overflow When to refer: – Blood in the stools • ≥5 stools/day in a well child • Persists beyond 7 days in a well child • Unwell child – Lethargy / persistent crying or irritability / poor feeding – Acute episode of diarrhoea lasting for >2 weeks – Failure to thrive – Failed oral rehydration because of persistent vomiting or increasing dehydration – Parental anxiety / social concerns Chronic abdominal pain • Diagnosis: – Intermittent abdominal pain on at least 3 occasions over a 3 month period – Pain interferes with normal activities • Common causes: – – – – – Functional abdominal pain IBS Abdominal migraine Constipation Mesenteric adenitis • First line investigations suggested: – Urine C&S, Stool C&S, FBC, U&Es, LFT, CRP, ESR, Coeliac screen When to refer: – Significant illness behaviour, especially time off school – Weight loss / failure to thrive – Bilious vomiting – Bleeding PR – Frequent nocturnal pains – Abnormal examination – Abnormal first line investigations The crying baby A normal baby’s cry increases from birth to a maximum at 2 months averaging 2-2.5 hours a day, with a peak between 6-12pm. Tense anxious parents have tense, anxious babies! Commonest are hunger, dirty nappy, need for company or tiredness Refer if: – – – – – – – Baby appears systemically unwell Baby is febrile without a clinical focus Baby has bilious vomiting Baby cries, with episodes of pallor Baby has hernia or swollen testes Baby is of socially isolated carers Baby appears to have limb pain or there are concerns about child abuse Urinary Tract Infection • Diagnosis: – Upper UTI (acute pyelonephritis): fever/loin pain or tenderness + bacteriuria – Lower UTI (cystitis): dysuria +bacteriuria • Investigation: – For <3yrs: Clean-catch/bag urine for C&S – For ≥3yrs: Urine dipstick leucocytes / Nitrites: • + /+ = UTI - treat • - / + = treat as UTI • + / - =treat if symptoms • - / - =No UTI • Treatment of Lower UTI: Trimethoprim or amoxycillin or cephalosporin for 3 days Always ask for Renal tract ultrasound scan (USS) before referral When to refer: – <6months – Upper UTI – Atypical UTI which includes: • Failure to respond to treatment with suitable antibiotics within 48 hours • Seriously ill • Poor urine flow • Abdominal or bladder mass • Infection with non-E coli organisms – Recurrent UTI – Abnormal renal tract USS in <6months age (pre-existing renal tract abnormalities) Enuresis • Diagnosis: – Bedwetting over 6 years of age without neurological or urological cause – Make sure there is no UTI • Treatment: – Not indicated under 6 years other than star chart to encourage / reward progress – Refer to Incontinence Nurse Specialist – Desmomelt (use for shortterm ie holidays or initial 3month trial) When to refer: – Children with daytime urinary problems – Treatment failures – Concerns over family dynamics (parents need to understand this is a developmental problem, not bad behaviour) Constipation and Soiling • Diagnosis: Either / or – infrequent (≤1/week) stools – firm/hard consistency stools – difficult/painful defaecation • Treatment: – Diet (high roughage) – Develop habit of sitting on toilet with good foot rest 20 mins after meals – Laxatives (senna liquid+/lactulose; Movicol paediatric sachets). Sometimes higher than recommended dose is necessary. Laxatives are safe – If perianal area inflamed – consider antibiotics When to refer: – Passage of toothpaste-like stools (?anal stenosis) – Neonatal onset of symptoms – Cerebral palsy, spinal abnormalities, developmental delay Obesity and Excessive weight gain • Diagnosis: – BMI >98th centile = Obesity – BMI >91st centile = overweight – Weight crosses centiles upwards, and exceeds height centile by at least 2 centiles • Treatment: – Weight maintenance is an acceptable goal – Family centred approach – Healthier diet – Increase in habitual activity to a minimum of 30 mins/day – Reduction in sedentary behaviour (eg TV/computers) to <2hrs/day or <14hrs/week When to refer: – <2years, >99.6th centile for BMI – Exhibiting obesityrelated morbidity ie sleep apnoea, hypertension/hyperlipi daemia, diabetes, orthopaedic disorders or psychological problems – Associated physical or learning difficulties Headache • Diagnosis: – Migraine/migrainous features: paroxysmal, well in between, 1-48 hours, unilateral/bilateral, frontal/temporal, banging/pulsating, worse with routine exertion, extended family history • Treatment: – Lifestyle advice – avoid cheese, dark chocolate, caffeinated drinks, orange juice – Ibuprofen/paracetamol (rescue) up to 3 days/week – Prophylaxis with pizotifen/propranolol if migraine≥4/month When to refer: – Age <5years – Acute severe headache with signs of meningeal irritation – New persistent daily headache or accelerating course – every few months, then weeks, then days – Worse lying down, bending over or coughing – Nocturnal awakening – Associated with complex symptoms/impairments eg general fatigue, social or school withdrawal, depression or behavioural disturbances – Treatment / reassurance failed Faints and Funny turns Normal paroxysmal events: – Vasovagal syncope: • Older children (-14yeras); • occurs when upright; may be triggered by pain, emotional stimuli or prolonged standing. • Associated light-headedness, nausea, blurred vision or pallor • Secondary anoxic seizures can cause stiffening or fine twitching • Recovery often rapid after lying down – Reflex anoxic seizures: • Young children (6months to 3 years) • triggered by unpleasant events eg emotional trauma or pain. • Onset is rapid and there is no preceding history of light-headedness or visual loss. • The child looks pale, loses consciousness and may have brief tonic or tonic-clonic seizure. Can be associated with incontinence and tongue biting – Blue breath-holding spells: precipitated by physical or emotional trauma. Child starts crying and holds the breath in prolonged expiration, resulting in cyanosis, limpness and loss of consciousness for a short period of time (few minutes) • Refer if: – History of collapse during exercise or swimming – Family history of sudden death – Abnormal cardiac examination or abnormal ECG (abnormal QTc) – Epileptic seizure to be likely – Associated neurological or learning difficulties Musculoskeletal problems • Common presenting symptoms are pain, limping, limb or joint swelling, limitation/paucity of movements, muscle stiffness / spasm • Refer to Orthopaedic surgeon: – History of Trauma – Febrile child with above symptoms – Night pains and always in the same place • Refer to paediatric rheumatology / physiotherapist: – for all persistent (≥2weeks) symptoms with no history of trauma – Joint swelling (≥1week) Behavioural problems • A significant problem in behaviour is more likely: – When the behaviour is frequent and chronic – When >1 problem behaviour occurs – If behaviour interferes with social and cognitive functioning • Consider referral to health visitors / child and family consultation services (CFCS) prior to hospital referral When to refer: – Less than 5 years age – Learning difficulties / developmental delay – Suspected autism – Suspected seizures – Motor coordination difficulties – Speech delay – Suspected ADHD in ≥6 years age Development Warning Signs • • • • At any age – Maternal concern – Regression in previously acquired skills At 10 weeks – Not smiling At 6 months – Persistent primitive reflexes – Persistent squint – Hand preference – Little interest in people, toys, noises At 10 - 12 months – No sitting – No double-syllable babble – No pincer grasp Developmental Warning Signs cont… • At 18 months – Not walking independently – Fewer than six words – Persistent mouthing and drooling • At 2 ½ years – No 2-3 word sentences • At 4 years – Unintelligible speech Refer to the Health visitor to do a developmental assessment and then refer to paediatrician (with interest in neurodisability) if necessary Some common surgical conditions • • • • • • • • • • • Pre-auricular skin tag: Ask for renal tract ultrasound scan (refer if abnormal). Refer to plastic surgeon for its removal. Make sure neonatal hearing screen has been done. Tongue tie: tight frenulum prevents tongue getting over lower lip and gum ridge. Refer to surgeons if difficulty with breast/bottle feeding leading to pain for the mother and poor infant weight gain Umbilical granuloma: Cauterise with silver nitrate stick (or refer). Make sure it is not a umbilical polyp (refer if unsure). Umbilical hernia: ‘Strapping’ is ineffective. Normally disappears spontaneously by 1 yr of age. Refer if: hernia persists to the age of 3-5 yrs, becomes progressively larger after 1-2yrs of age or causes symptoms Inguinal hernia: Refer Hydrocoele: disappears by 1 yr of age. Refer if persists Undescended testis: Refer if testis not descended by first birthday. Phimosis: Remember normally prepuce becomes retractable by 3 yrs of age. Refer if: prepuce not retractable by 3 yrs; history of balanoposthitis Polydactyly and syndactyly: Refer to orthopaedics or plastic surgery True talipes (the foot cannot be passively everted and dorsiflexed to the normal position): Refer to physiotherapist / orthopaedic surgery Developmental dysplasia of Hip (formerly known as congenital dislocation of hip or CDH): More common in infants born breech, family history of CDH or associated other limb or joint anomalies. Ask for: – – Before 8 months – ask for ultrasound scan of hip (if normal – discharge) ≥8 months – ask for plain Xray of Hip (if normal – discharge) Recognition of Non-accidental injury Safeguarding Children and Young people: a toolkit for general practice: www.rcgp.org Symptoms: Signs: • Any bruising to young babies • Delayed presentation • Fracture in <1 yr age • History not consistent with • Spiral fractures injury • Bruising on unusual places (ie • History not consistent with the cheeks) development • Small circular burns • History changes • Scalds to either feet or buttocks • Different history from carers • Red lines to wrists or ankles • Recurrent injuries or burns (from ligatures) • Poor interaction with carers • Isolated tear of upper lip fraenulum • Carers overreacting to misbehaviour • General neglect • Sexualised behaviour at young • Failure to thrive without organic age causes • Multiple injuries of different ages • Injuries to genitalia Consultant Paediatricians with Special Interests • Dr Awadalla, F- diabetes, metabolic disorders • Dr Emcy, N - gastroenterology, neurodisability, ADHD • Dr Khan, A - children <1year, neonatology • Dr Margarson, I - neurodisability, autism • Dr Nerminathan, V - growth/endocrinology, enuresis/encopresis • Dr Rahman, M - cardiology, neurodisability • Dr Ranasinghe, T - haematology/oncology, infectious diseases • Dr Shrivastava, A - nephrology, rheumatology, neonatology • Dr Sriskandan, S - Epilepsy, haematology/oncology Others (Associate specialists): Dr Perera, J - ADHD Dr Sen, G - Hearing impairment Dr Sutherland, V - Neurodisability