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 (lt50 of normal in previous 24
  hours)
• Persistent vomiting (gt50 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 gt120/min
• reduced skin turgor of 2secs
• Reduced capillary refill 3secs
• dry mouth, sunken fontanelle
• Respiration
• Tachypnoea 5years gt50/min gt5years gt30/min
• Grunting and rib recession
• Others
• Marked pallor / Non-blanching rash
• Bulging fontanelle, neck stiffness
• Limping / joint swelling
• Febrile lt3months 380C
• 3months 390C

7
Feverish illness in children under 5 years
8
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

9
Eczema

• Diagnosis Itchy skin 3 or more of following
• Onset lt2years
• 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 childrenlt2 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

10
Food allergies

• 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

• 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)

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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 (lt5years) uncertainty about drug
  delivery. Needs careful assessment of inhaler
  techniques and expertise of specialist asthma
  nurse
• Young child (lt1year) 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 (gt1/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
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)

13
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 (gt30 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

14
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)
• Cows 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)

15
Diarrhoea

• Differential diagnosis
• Viral / bacterial gastroenteritris
• Non-enteral infections such as UTI, meningitis or
  pneumonia
• Cows milk protein intolerance or secondary
  lactose intolerance
• Toddlers 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 gt2 weeks
• Failure to thrive
• Failed oral rehydration because of persistent
  vomiting or increasing dehydration
• Parental anxiety / social concerns

16
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 CS, Stool CS, FBC, UEs, 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

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The crying baby

• A normal babys 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
Urinary Tract Infection

• Diagnosis
• Upper UTI (acute pyelonephritis)
• fever/loin pain or tenderness bacteriuria
• Lower UTI (cystitis)
• dysuria bacteriuria
• Investigation
• For lt3yrs Clean-catch/bag urine for CS
• 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
• lt6months
• 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 lt6months age
  (pre-existing renal tract abnormalities)

19
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 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)

20
Constipation and Soiling

• When to refer
• Passage of toothpaste-like stools (?anal
  stenosis)
• Neonatal onset of symptoms
• Cerebral palsy, spinal abnormalities,
  developmental delay

• 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

21
Obesity and Excessive weight gain

• When to refer
• lt2years, gt99.6th centile for BMI
• Exhibiting obesity-related morbidity ie sleep
  apnoea, hypertension/hyperlipidaemia, diabetes,
  orthopaedic disorders or psychological problems
• Associated physical or learning difficulties

• Diagnosis
• BMI gt98th centile Obesity
• BMI gt91st 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 lt2hrs/day or lt14hrs/week

22
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
  migraine4/month

• When to refer
• Age lt5years
• 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

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
Behavioural problems

• A significant problem in behaviour is more
  likely
• When the behaviour is frequent and chronic
• When gt1 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

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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

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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
Recognition of Non-accidental injurySafeguarding
Children and Young people a toolkit for general
practice www.rcgp.org

• Symptoms
• Any bruising to young babies
• Fracture in lt1 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

• 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

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Consultant Paediatricians with Special Interests

• Dr Awadalla, F - diabetes, metabolic disorders
• Dr Emcy, N - gastroenterology, neurodisability,
  ADHD
• Dr Khan, A - children lt1year, 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