Common Paediatric illnesses in Primary Care – when to refer?

1. Common Paediatric illnesses in Primary Care – when to refer? Southend University Hospital NHS Foundation Trust

2. Paediatric referrals • Increased by 38% over the previous year • Total Outpatient referrals per year: 15,480 • Choose and Book 750 • New referrals 3,850 • Rapid access 2400 • follow ups 8440 • Inpatient admissions: 1300 • Length of stay 1.1 days

3. 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

4. Recognition of the sick infantImportant 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

5. 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

6. 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

7. Feverish illness in children under 5 years

8. 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 Common Outpatient Referrals

9. 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 Eczema

10. 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 Food allergies

11. 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 add-on 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

12. 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) Chronic cough

13. 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 murmur-whether pathological Parental anxiety History of congenital heart disease in siblings or parents Heart murmur

14. 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) Vomiting infant

15. 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 Diarrhoea

16. 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 Chronic abdominal pain

17. 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

18. 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) Urinary Tract Infection

19. 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 short-term ie holidays or initial 3-month 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) Enuresis

20. 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 Constipation and Soiling

21. 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 obesity-related morbidity ie sleep apnoea, hypertension/hyperlipidaemia, diabetes, orthopaedic disorders or psychological problems Associated physical or learning difficulties Obesity and Excessive weight gain

22. 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 Headache

23. 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

24. 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)

25. 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 Behavioural problems

26. 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

27. 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

28. 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)

29. Signs: Delayed presentation History not consistent with injury History not consistent with development History changes Different history from carers Recurrent injuries or burns Poor interaction with carers Carers overreacting to misbehaviour Sexualised behaviour at young age Symptoms: Any bruising to young babies Fracture in <1 yr age Spiral fractures Bruising on unusual places (ie the cheeks) Small circular burns Scalds to either feet or buttocks Red lines to wrists or ankles (from ligatures) Isolated tear of upper lip fraenulum General neglect Failure to thrive without organic causes Multiple injuries of different ages Injuries to genitalia Recognition of Non-accidental injurySafeguarding Children and Young people: a toolkit for general practice: www.rcgp.org

30. 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