Hot Topics in Paediatrics

1. London Speciality School of Paediatrics Hot Topics in Paediatrics Return to Acute Paediatrics August 2014

2. 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

3. Topics • Feverish child and NICE guidance • Head injury in children • Optiflow • Rotavirus Vaccine • Haemoglobin/Codeine and Domperidone • Frances Report • ‘Back to facing the future’

4. FEVERISH ILLNESS IN CHILDREN

5. 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 • 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 • Discharged children in whom no diagnosis is found and with amber features, should be provided with an appropriate ‘safety net’ • 90% of children with amber features and without an apparent source of infection should not be prescribed antibiotics • 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 • EDs should have written advice to give to the carer/s of discharged children • EDs should have access to the NICE guideline Traffic Light System

6. 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

7. 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

8. NICE GUIDELINES FOR HEAD INJURY

9. Head Injury in Children CT < 1hr CT vsobs • 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 • >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

10. OPTIFLOW

11. 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%)

12. 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

13. 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

14. ROTAVIRUS VACCINE

15. 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/galactosemalabsorption or sucrose- isomaltase insufficiency • Small risk of intussusception post first dose: MUST WARN PARENTS • Risk of transmission through stool therefore strict hand hygiene

16. Codeine / Haemoglobin and Domperidone

17. 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

18. 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

19. Codeine / Haemoglobin and Domperidone • Domperidone: • Domperidoneis 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

20. Frances Report

21. 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

22. 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

23. Frances Report - References • Executive summary of the Francis report • http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf • RCPCH response to the Enquiry • http://www.rcpch.ac.uk/news/rcpch-responds-francis-inquiry

24. BACK TO FACING THE FUTURE

25. 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

26. 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

27. 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