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Introduction
Dr Michael O’Brien welcomes you to the fourth edition of our new and unique paediatrics journal
Clinical Reviews
Common orthopaedic injuries in children
Dr Niall Breslin, Cork University Hospital
Thyroid dysfunction in children with Down syndrome –
A review of important clinical features
Professor Clodagh O’Gorman, Dr Karen King and Dr Siobhan Gallagher, University of Limerick
Nutrition in children: Common problems seen by GPs
Dr Maria McDermott, PhD, clinical nutritionist, Dublin
Red flags for GPs
Management of headache in children
Dr Laura Noonan, GP, Westmeath
Sore throat - when and how to treat
Mary Llewellyn, clinical nurse specialist in general practice, Dublin
Issue 4 September 2013
www.paediatricsireland.ie
Paediatrics
IrelandJOURNAL
To register for this journal free of charge
visit www.paediatricsireland.ie
Paediatrics Ireland
Introduction
Welcome to the fourth edition of our Paediatrics Ireland Journal.
We are still getting doctors joining so the good word
must be spreading.
We now have 1,020 doctors registered who get the journal, 85% of whom are GPs. If we keep going at this rate, we could be large
enough to form a trade union! Of course this is not what the journal is about, but we will have some turbulence in the weeks and
months ahead, as our NCHD colleagues have reached a breaking point where they cannot sit idly by while further pressures are
heaped upon them.
It is a time for all doctors to support each other as each specialty relies on the other for the health system to work. It has been
proposed that “free” GP care be available to all children under the age of five. While I think this idea could be great if properly thought
out and budgeted, I fear it will cause chaos, both within GP surgeries and in paediatric emergency departments. It is well-accepted
that with “free” GP care, there will be an increase in attendance to surgeries. With this increase, there is a very real possibility that
same-day appointments may not be available to “sick” children, as all the appointments may be full. There is a very real difficulty of
these patients being triaged by the GP receptionists – who may have to ask, “How sick is each one of these children?”
We as GPs will have no other option but to recommend that if the parents are concerned then they should attend the emergency
department promptly. Having worked in A&E, I know these children’s hospitals are going to be overrun and become inefficient. I
know this, you know this, and the doctors working in children’s hospitals know this! But do the politicians and civil servants know
this? I fear they do not. How often do you complain to colleagues, wives, husbands and partners about this?
Maybe we are complaining to the wrong people? If you feel strongly about this let the ministers, junior ministers, and your local
public representative know. Your patients deserve it!
Dr Michael O’Brien, Editor
GP, Leopardstown, Dublin
The Shared Care Paediatric Network was convened by Reckitt Benckiser. All materials
were sponsored by and developed in partnership with Reckitt Benckiser Healthcare
and its agency First Medical Communications. The views expressed in the materials are
those of the Shared Care Paediatric Network and not Reckitt Benckiser.
Paediatrics Ireland is the official publication of the Shared Care
Paediatric Network. This peer-led group seeks to support and
promote an Irish-based community of paediatric learning, teaching
and collaboration.
Supporting learning and collaboration in Paediatrics
www.paediatricsireland.ie
www.paediatricsireland.ie
Summary of Product Characteristics
available at www.medicines.ie
Paediatrics Ireland CLINICAL REVIEW
Paediatric orthopaedic injury
Developmental dysplasia of the hip
Developmental dysplasia of the hip (DDH) is a varied spectrum of
disorders that may occur at birth, in infancy, or during childhood.
Problems range from a mild, simple dysplasia to a severe defect
with a dislocation, and classic DDH occurs in 0.1%-0.2% of infants.
Breech position at birth is one of the main risk factors for
developmental dysplasia, as are positive family history, being the
first-born child, and being female.
The hip is a ball and socket joint. The ball (femoral head) forms
the top part of the femur and the socket (acetabulum) forms in the
pelvic bone.
In some newborns, the socket is too shallow and the thigh bone
may slip out of the socket, either part of the way or completely.
One or both hips may be involved. The two major tests for signs of
hip instability are the Ortolani sign and the Barlow sign.
The Ortolani sign can help show hips that are dislocated when
the infant is in a resting position, while the Barlow test detects hips
that are dislocatable.
Good examination in these (and all paediatric) cases is vital. You
should look at posture and motion, with the baby in four positions:
Supine, a sitting position, a prone position, and, depending on age,
a supported standing position.
In older children, watch them when they walk or ask them to
run - running will unmask any subtle neurological signs, especially
with regard to movement in upper limbs. Hopping is also a good
way to check for problems. Mainstay of treatment in DDH is a Pavlik
harness, to be worn by the infant 24 hours a day. Ultrasound scans
should be obtained every two-to-three weeks with stress views in
the harness.
Limping
Limp is defined by a deviation from the normal gait pattern
expected for a child’s age.
Limping can be complex to manage in children, as diagnosis can
range from trivial causes such as a rock in the shoe to potentially
life- and limb-threatening causes such as septic arthritis and
malignancy.
Therefore, the possibility of serious outcomes on presentation of
limp makes accurate assessment, diagnostic evaluation, treatment,
and appropriate follow-up essential. A good history is an essential
component of evaluating a child with a limp:
•	In a toddler, history may be limited to observations by the
parent or caregiver. The caregiver should be asked where he
or she perceives the source of the patient’s pain to be, as their
perspective may allow detection of a problem not evident during
a relatively brief examination period.
•	Older children will be better able to localise a source of pain, if
present, and recount any preceding trauma. A careful history
may reveal a traumatic cause that has been forgotten or
overlooked.
Slipped capital femoral epiphysis
Slipped capital femoral epiphysis (SCFE) is the most common
adolescent hip disorder, affecting five-to-six of every 100,000
children and adolescents.
SCFE is defined as a separation of the ball of the hip joint from
the femur at the upper growing end (growth plate) of the bone.
Most patients who develop SCFE are overweight or obese, and the
majority are male.
In general, patients diagnosed with SCFE do not have significant
disability,buttheconditiondoesrequireproactivesurgicalmeasures
because if left untreated, it can develop into severe hip arthritis.
Symptoms include:
•	Difficulty walking, or walking with a limp
•	Knee or hip pain
•	Hip stiffness
•	Outward-turning leg
•	Restricted hip movements.
Examples of common knee fractures in paediatrics
Patella sleeve fractures occur between the cartilage “sleeve”
and main part of the patella and ossific nucleus. They occur most
commonly in children eight-to-12 years of age and can be quite
difficult to detect. On physical exam, watch for local tenderness
and swelling. An MRI may be needed to diagnose these fractures if
radiography does not reveal a clear diagnosis.
Meniscal tears are a common sports injury in teens. One of the
most commonly injured parts of the knee, the meniscus is a wedge-
like rubbery cushion where the major bones of the leg connect.
Initial treatment follows the basic “R.I.C.E.” formula: rest, ice,
compression and elevation, combined with nonsteroidal anti-
inflammatory drugs for pain. If the knee is stable and doesn’t lock,
this conservative treatment may be all that’s needed.
Anterior cruciate ligament (ACL) injuries commonly occur in
basketball, football, soccer, and skiing.
Most ACL tears are seen in the middle of the ligament, or the
ligament is pulled off the thigh bone. These injuries form a gap
between the torn edges, and do not heal on their own. Symptoms
include a popping sound and swelling within 6 hours of injury.
If the foot is cool and blue after a knee injury, the knee joint may
be dislocated, and blood vessels to the foot may be injured.
Finally, jumper’s knee (patellar tendonitis) can lead to pain at
the bottom and front of the kneecap, especially when pressing in
or palpating.
Jumper’s knee can be categorised as follows:
•	Grade 1: Pain only after training
•	Grade 2: Pain before and after training but pain eases once
warmed-up
•	Grade 3: Pain during training that limits performance
•	Grade 4: Pain during everyday activities.
In conclusion, a thorough history-taking and thorough
examination are the cornerstones when dealing with paediatric
patients presenting with joint pain or sports/overuse injury. When
in doubt, send the patient for ultrasound or x-ray.
References on request
Dr Niall Breslin, SpR, orthopaedics, Cork University Hospital
Dr Niall Breslin outlines common paediatric orthopaedic presentations
Paediatrics Ireland CLINICAL REVIEW
www.paediatricsireland.ie
Introduction
Thyroid dysfunction is common in children with Down syndrome.
Thyroid conditions associated with Down syndrome include
congenital hypothyroidism, autoimmune hypothyroidism,
subclinical hypothyroidism and, rarely, hyperthyroidism.
Screening for thyroid disease is particularly important in this
population as hypothyroidism may be masked by the features
of Down syndrome. The 2009 Irish guidelines for screening for
thyroid disease in children with Down syndrome recommend
routine thyroid stimulating hormone (TSH) after birth (on Guthrie
screening test), TSH and free T4 annually until age 5 years; and
TSH and free T4 every 2 years thereafter.
Discussion
Congenital hypothyroidism
The incidence of congenital hypothyroidism in children with
Down syndrome is approximately 28 times higher than found in
the general population. Studies report a prevalence of congenital
hypothyroidism in Down syndrome that ranges from 1.5%-6.1%.
Autoimmune thyroid disease
Autoimmune thyroid disease is also more prevalent in children
with Down syndrome than in the general population. The
prevalence of thyroid peroxidise (TPO) antibodies in patients with
Down syndrome has been estimated at 7.5%, 27% and 31%.
Autoimmunehypothyroidismiscommonaftereightyearsofage
in children with Down syndrome and relatively uncommon before
this age. However, there are reports of thyroid autoantibodies in
infants with Down syndrome. Those with thyroid autoantibodies
are expected to progress to overt hypothyroidism, but the
timeframe for this progression is unclear.
Subclinical hypothyroidism
Subclinical hypothyroidism is very common in children with Down
syndrome; the prevalence ranges between 25.3% and 60%.
Subclinical hypothyroidism refers to an elevated TSH level with
normal T4 and T3.
The cause of subclinical hypothyroidism in children with Down
syndrome is unknown, and commentators remain divided on its
significance.
Those who suggest treating subclinical hypothyroidism in this
population point to the safety of thyroxine treatment and to the
possible beneficial effects on the growth and development of
the child if treatment is commenced. Karlsson et al recommend
treatment of subclinical hypothyroidism in order to prevent
progression to overt hypothyroidism. Most authors who advise
treating subclinical hypothyroidism suggest doing so at TSH
>10mU/L. Prasher suggests a trial treatment of thyroxine in
symptomatic cases of subclinical hypothyroidism or those with
TPO antibodies.
Others suggest that treatment of subclinical hypothyroidism
in this population is unnecessary. In several studies transient TSH
elevation has been noted. For Gibson et al there is no clear benefit
to treating subclinical hypothyroidism as TSH elevation is often
self-limiting.
The frequency of thyroid function tests (TFTs) required to
monitor subclinical hypothyroidism is unclear. Suggestions in
the literature range from every three months to five-yearly. On
balance, internationally, authors advocate more strongly for annual
screening in children with Down syndrome, given the potential
effects on growth, puberty and intellectual development of not
treating thyroid dysfunction in childhood.
Irish guidelines for management of thyroid disease in children
with Down syndrome
The Irish guidelines for screening for thyroid disease in children
with Down syndrome recommend routine TSH after birth (on
Guthrie screening test), TSH and free T4 annually until five years
of age; and TSH and free T4 every two years thereafter.
The Irish guidelines ought to prevent children with Down
syndrome presenting with overt hypothyroidism. However, the
risk of acquiring hypothyroidism increases with age in children
with Down syndrome. Thus, there may be an argument for
future iterations of the Irish guidelines to introduce yearly thyroid
screening after 5 years of age. Other national guidelines (the
United States, Canada and Australia) suggest more frequent
thyroid screening than the Irish guidelines.
Presentation of hypothyroidism in children with Down syndrome
It may be difficult to suspect a diagnosis of hypothyroidism
in a child with Down syndrome on clinical grounds alone. The
symptoms of hypothyroidism often overlap with the features
of Down syndrome. Typical symptoms suggesting suspected
hypothyroidism include fatigue, slow movement and speech,
cold intolerance, weight gain, dry skin and hair, puffy faces,
constipation, and decreased linear growth in children. The
features of Down syndrome that overlap with hypothyroidism
include delayed development, increased body mass index
(BMI), decreased linear growth, constipation, muscle weakness,
inactivity, dry skin and fine hair. Therefore, biochemical screening
is essential in children with Down syndrome to ensure normal
thyroid function and to allow the child to maximise intellectual
and physical potential.
Conclusion
Thyroid disease is more common in children with Down syndrome
than in the general population. Regular thyroid function tests
are required to monitor these patients, particularly as clinical
diagnosis is unreliable in this population.
References on request
Dr Karen King, Dr Siobhan Gallagher and Professor Clodagh S
O’Gorman, Department of Paediatrics, University of Limerick
Thyroid dysfunction in children with
Down syndrome: A review of
important clinical features
Dr Karen King, Dr Siobhan Gallagher and Professor Clodagh S O’Gorman provide an in-depth overview of
screening for and managing thyroid disease in Down syndrome children
Paediatrics Ireland CLINICAL REVIEW
Faltering growth (which used to be referred to as ‘failure to thrive’)
is when a baby doesn’t grow at the expected rate. Babies grow
very rapidly during their first two years. Breastfed babies tend to
gain more weight during the first two months of life, compared
to formula fed babies. After two months, the trend is reversed
and formula fed babies grow at a faster rate. It’s important to
remember that most babies lose some weight after birth and
start to gain weight at around two weeks of age.
It’s essential babies receive adequate nutrition, to help them
grow and develop. This is especially important for premature
babies who need to catch up. A baby’s development, particularly
their brain development, may be affected if their growth falters.
That’s why it’s essential to recognise faltering growth as early as
possible.
Below are some guidelines and advice for recognising and
managing faltering growth, its associated complications, and
other nutritional issues.
Guidelines for basic growth assessment
•	 Weigh the child naked if under two years or in light clothing,
using regularly calibrated scales.
•	 Measure length in infants using an infant stadiometer
(measures standing or sitting height) or suitable measure mat;
in older children use a stadiometer, with the child barefoot.
•	 Measure head circumference at largest point around mid-
forehead and occipital prominence using a non-stretch tape
measure.
•	 Plot weight, height and head circumference on age-
appropriate growth chart. Correct for gestational age (until
two years) if the child was born prematurely.
•	 Refer for further investigation in following circumstances:
	 – Height and/or weight below 0.4 centile,
	 – Height and/or weight above 99.6 centile,
	 –Crossingoftwoormorecentilesbetweentwomeasurements,
	 – Weight and height differ from each other by two major
centiles.
Common nutritional problems
Growth faltering (failure to thrive)
Characteristics: There is no universally accepted definition, but
the problem involves failure to meet expected potential in growth
and other aspects of wellbeing.
Possible causes: Dietary, organic and social factors can all lead to
under nutrition.
Investigations:
•	Weight/ height measurement and history;
•	Feeding history;
•	Observation of feeding to assess for feeding difficulties,
abnormal feeding behaviour or interaction between carer and
child;
•	Biochemical/haematological/microbiological screening.
Treatment: Will depend on cause but may include:
•	Advice on feeding;
•	Increasing nutrient density of foods. Increase the nutrient
content of food by choosing more nutrient dense foods or by
adding one food to another, for example, milk and cheese to
mashed potato;
•	Reassurance and support to parents/carers;
•	Referral to specialists.
Iron deficiency anaemia
Characteristics: Often asymptomatic unless severe and then
symptoms include pallor, tiredness and poor appetite.
Diagnosis: anaemia (haemoglobin <10g/L), microcytic red cells,
low plasma ferritin (<10µg/L). Exclude other causes of anaemia.
Preventive measures include:
•	Introduction of solids by six months of age including iron-
fortified cereal and other iron containing foods;
•	Avoid whole cow’s milk before 12 months, use iron fortified
infant formula if not breast fed;
•	Encourage iron-rich foods with foods containing vitamin C to
improve absorption;
•	Iron fortified follow-on formula may be useful after one year if
‘at risk’.
Treatment: Supplemental iron (may cause nausea and
constipation), encourage healthy diet including iron-rich foods.
Vitamin D-deficient rickets
Characteristics:
•	Softened skull bones;
Clinical nutritionist Maria McDermott provides advice on dealing with common nutritional problems
in children and infants
Nutrition in children: faltering growth and other
common problems seen by GPs
Paediatrics Ireland
•	Epiphyseal swelling (especially at wrists);
•	Enlarged costochondral junction where the ribs articulate with
sternum (rickety rosary);
•	Tibial bowing (bow legs);
•	Delayed dentition.
Diagnosis:
•	Raised plasma alkaline phosphatase;
•	Low phosphate/calcium;
•	Cupping, fraying, splaying at end of long bones on x-ray.
Prevention: Vitamin D-fortified formula milk or 7.5–10µg/day
supplement in children’s vitamin drops.
Treatment:
•	25–125µg/day vitamin D until alkaline phosphatase is normal,
then 10µg/day;
•	Exposure to sunlight;
•	Good intake of calcium.
Food allergy/intolerance
Common foods implicated in food allergy/intolerance:
•	Milk;
•	Egg;
•	Nut;
•	Wheat;
•	Shellfish;
•	Soya.
Some allergies may resolve over first three years of life; others are
lifelong.
Diagnosis:
•	Skin prick test, involving the introduction of a small amount of
allergen under the skin to identify allergy;
•	Radioallergosorbent test (RAST) tests for the amount of specific
IgE antibodies in the blood to specific allergens (or antigens);
•	Food challenge test.
Treatment: Exclusion of food from diet (obvious and hidden
sources).
Complications: Nutrient deficiency and growth faltering due to
inadequate intake of food is possible. The child should be referred
to paediatric dietitian if this is suspected.
Common feeding problems and suggested solutions
Refusal of food
•	Structured family meal pattern (three meals, two-three
nutritious snacks);
•	Small portions, variety of foods, include some favourites;
•	Happy, relaxed environment;
•	Do not offer sweets or other foods as rewards;
•	Do not ‘force feed’.
Excessive milk drinking
•	Limit intake to 500–600ml/day and give after meals/with
snacks;
•	Give water between meals if thirsty;
•	Use a cup rather than bottle.
Excessive juice drinking
•	Limit to one cup/day;
•	Give plain water if thirsty and give drinks after meals;
•	Encourage milk;
•	Use a cup, not a bottle.
Refusal of milk
•	Offer in ‘fun’ cup, with coloured straw;
•	Mix milk/cheese/yoghurt into foods;
•	Try flavoured milk – warm, cold or frozen.
Refusal of fruits/vegetables
•	Include small amounts at each meal;
•	Mix grated or pureed vegetables/fruits with other foods;
•	Try raw vegetables/fruits with dips, for example, hummus or
yoghurt;
•	Make blended fruit drinks/milkshakes;
•	The family should set good example by eating/enjoying fruit
and vegetables.
References on request
Dr Maria McDermott, PhD, is a clinical nutritionist
based in Co Dublin
CLINICAL REVIEW
www.paediatricsireland.ie
If you have a paediatrics-related query or a therapeutic
area you would like covered, tell us about it and we will
address this in our future issues.
Write to us: info@paediatricsireland.ie
What would you like to see featured
in Paediatrics Ireland?
There’s more online!
Visit paediatricsireland.ie
for article references,
lists of further reading
and much more
Paediatrics Ireland RED FLAGS FOR GPs
Management of headache in children
Dr Laura Noonan provides a thorough overview of the management
of headache in children
Headache is a common reason for children and adolescents to
be brought to see the GP. Headaches may cause concern for the
parents and impact on the child’s quality of life through days lost at
school and time lost from leisure activities. In the majority of cases
a serious underlying disorder can be ruled out by the GP through
taking a comprehensive history and completing a thorough
physical examination.
The pattern of the headache needs to be identified as acute,
acute recurrent, chronic non progressive, chronic progressive or
mixed. A headache diagnosis needs to be established though the
use of the the International Headache Society (HIS) criteria, which
can aid the diagnosis of migraine, migraine with aura and tension
headache. It is important to reserve neuroimaging for those
children who have chronic progressive headache or abnormalities
on physical examination.
It is important to manage headache appropriately in children,
as for some, the impact of headache is significant. In a 2001 study
looking at the effects of headache on quality of life it was found
that headache negatively affected children’s QOL, most notably
emotional and school functioning, as adversely as other serious
chronic childhood diseases like arthritis and cancer.
Reassure, reassure, reassure
The first piece of advice to give to parents and children is to
complete a headache diary in which they record information about
their attacks. This diary needs to be continued even after diagnosis
to judge the effectiveness of treatment or identify new triggers. A
headache diary should be comprehensive and include:
•	Triggers or warning signs felt or noticed by either the parent or child
before an attack e.g. visual disturbance, pallor, confusion, vomiting,
•	Recording when the attack starts and finishes.
•	Severity of pain and the features of the headache. Parent may
observationally complete this and add the child’s own words/
behaviours/appearance. This is dependent on the child’s age. A
teenager may wish to take control of this task themselves under
parental supervision
•	Record of medication taken during each attack.
It is important for the family to try to take the control back from
the headache. This can be through headache prevention and /or
prompt management of a headache when it starts. This is vital in
order to reduce the impact the headache has on the child’s quality
of life and how the child with the headache affects the functioning
of the entire family unit. There may be jealousy from other siblings
due to increased attention the sickly sibling gets or the child may
adapt to the sick role very quickly if they feel they get the attention
they desire when they complain.
Prevention is better than cure!
For the child with headache, once triggers are identified they can
be avoided. Notably, only 20% of children with migraine are found
to have dietary triggers. These can include cheese, citrus fruits,
monosodium glutamate (MSG) (found commonly in Chinese food),
chocolate, and caffeine, both in excess and withdrawal.
Children, with the assistance of the whole family, need to be
encouraged to have a healthy lifestyle with attention to trigger
avoidance. Games consoles, cola and chocolate at 3am are not a
good combination for any child but particularly not for one with
recurrent headaches. Proper sleep hygiene is vital so that children
are getting sufficient quantities of good quality sleep to allow them
to wake refreshed.
Headache, headache go away, don’t come back another day!
Once a child complains of headache they should be offered
prompt treatment. If they haven’t eaten they should be offered
a snack and a drink and given the opportunity to lie in a darkened
room and rest. Regarding over the counter pain relief for children,
there is evidence that ibuprofen provides more effective relief from
headache than paracetemol. When a headache is present for more
than 15 days per month for at least three months, it is described as
a chronic daily headache.
A good beginning is half the work!
•	Headache management begins with a comprehensive history
and examination, followed by headache diagnosis with reference
to the International Headache Society guidelines.
•	A headache diary is a valuable tool to aid in identifying triggers
and devising a management plan.
•	Share the responsibility of headache management with the child
and their family. Give the parents and the child the tools to both
prevent the headaches and treat the headaches if they do develop.
•	Review the child after initial visit to re-examine the child and
review the contents of the headache diary.
•	Assess for red flag symptoms and refer to secondary care as
appropriate.
Red flags for GPs
Refer any headache with focal neurological signs or a rapidly
changing pattern:
•	Change in personality or behaviour
•	Crescendo pattern of headache – getting more frequent and
more severe
•	Worse when lying down (suggests raised ICP)
•	Worse on wakening/in the morning (suggests raised ICP)
•	Vomiting
•	Any neurological finding on examination (abnormal gait,
incoordination, papilloedema)
•	Any visual field defect
•	Seizures
•	Cutaneous lesions e.g. ‘café au lait’ spots
References on request
Dr Laura Noonan is a GP in Co Westmeath
*
Readers are advised that a detailed review on management of headache in children
is available by clicking the ‘journal’ tab at www.paediatricsireland.ie
Paediatrics Ireland RED FLAGS FOR GPs
Sore throat: When and how to treat
Practice nurse Mary Llewellyn uses her 20 years’ experience to review
one of the most common complaints in primary care
A sore throat is the most common ENT complaint in children in
general practice. Below are some helpful practice tips.
History taking: How long has the child had the sore throat? Is it
worsening? Is it worse on one side or the other? Can she open her
mouth normally? Has she a fever? Is she drooling? Can she swallow
normally? In babies, can they suck normally?
Red flag symptoms include unilateral soreness, severe swallowing
problems, dehydration, an immunosuppressed patient, breathing
difficulties, and behaviour changes.
Viral infections: Most sore throats are caused by a virus and are
part of an upper respiratory tract infection (URTI). Children usually
have runny eyes, runny nose and a cough, which is worse at night-
time. It usually lasts a few days; treatment is analgesia and fluids.
The biggest problem here is often that parents want an antibiotic
and it can be difficult to convince them that antibiotics are not
necessary. The other problem is that parents are often reluctant to
give sufficient analgesia and for a sufficient number of days.
Epiglottitis: Since the introduction of the Hib. vaccine into the
childhood vaccination programme, epiglottitis is thankfully rare.
If a child presents with drooling, difficulty swallowing, difficulty
breathing, fast or noisy breathing, sitting bolt upright, or chin
jutting forward – this is an acute medical emergency. Do not lie
this child down or attempt to look in the throat. That could cause a
spasm that will close the throat altogether, and cause death within
a few minutes. This is a life-threatening emergency, dial 999 or get
the child to the nearest emergency department immediately.
Childhood illness: Sore throat may be the first sign of chicken
pox or measles and mumps. Sadly our MMR vaccine uptake rate
is not enough to exclude measles or mumps from the differential
diagnosis list.
Bacterial infections: There are four criteria used to identify the
likelihood of bacterial infection being the cause of a sore throat.
1.	Has the child a high fever?
2. Are there large tonsils with exudate?
3. Is there cervical lymphadenopathy?
4. Is there an absence of cough?
The presence of all four variables gives a 40-60% likelihood of
positive bacteria. The absence of all four gives an 80% negative
likelihood of bacterial infection. Thus, the high negative predictive
value suggests these criteria can be more effectively used for ruling
out strep throat than for diagnosing it.
Laryngitis, pharyngitis, tonsillitis: Routine throat swabs are mostly
unnecessary and unhelpful. The most severe infection is caused by
Streptococcus. Symptoms include a sore throat, mild fever, swollen
lymph glands, headaches, bad breath and white patches on the
throat.
Quinsy: Physical examination shows a miserable, feverish, drooling
child with significant unilateral swelling in the area of the tonsil
bed, and a ‘hot potato’ voice. Referral to hospital for urgent
medical assessment and drainage of peritonsillar abscess (quinsy)
is necessary. It is worth remembering that quinsy is more likely to
build up on top of tonsillitis i.e. a worsening sore throat; it does not
typically develop suddenly.
Glandular fever: A child with a sore throat, general malaise (and
the malaise may have been for several weeks), posterior cervical or
generalised adenopathy and possible enlargement of the spleen
raises the suspicion of glandular fever.
Immunosuppression: Consider agranulocytosis in patients known
to be immunosuppressed because they are taking medication such
as methotrexate.
Reflux: In small children, reflux (either experienced as heartburn or
as asymptomatic silent reflux) can cause and maintain a sore throat.
Foreign bodies, injury or irritation: Occasionally, foreign bodies need
to be excluded in the case of a continuing sore throat. Referral is
often necessary. Removing a fish or chicken bone can injure the
throat. Irritation can be caused by mouth breathing, low humidity,
pollution, post nasal drip and yelling and screaming. Injury such as a
cut or puncture could be caused from falling with a pointed object
in the mouth.
Summary: Treatment depends on the cause. Viral infection
remains by far the commonest cause of sore throat. Throat pain
can be treated with a pain reliever such as the non-steroidal anti-
inflammatory agent ibuprofen (e.g. Nurofen for children) or the
mild analgesic paracetemol. These medications should be dosed
according to weight, not age. Aspirin is not recommended in
children under 18.
Full resolution is the usual outcome. However, the red-flag
awareness should alert us to the dangers of those rare incidents of
something more sinister.
Mary Llewellyn SRN, RM, RSCN
Clinical Nurse Specialist in General Practice, Co Dublin
The Shared Care Paediatric Network was convened by Reckitt Benckiser. All materials were sponsored by and developed in partnership with
Reckitt Benckiser Healthcare and its agency First Medical Communications. The views expressed in the materials are those of the Shared Care
Paediatric Network and not Reckitt Benckiser.
Paediatrics Ireland is the official publication of the Shared Care Paediatric Network.
This peer-led group seeks to support and promote an Irish-based community of
paediatric learning, teaching and collaboration.Supporting learning and collaboration in Paediatrics
www.paediatricsireland.ie
www.paediatricsireland.ie

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FMC12449_Paediatrics RB FINAL FOR PRINT

  • 1. Introduction Dr Michael O’Brien welcomes you to the fourth edition of our new and unique paediatrics journal Clinical Reviews Common orthopaedic injuries in children Dr Niall Breslin, Cork University Hospital Thyroid dysfunction in children with Down syndrome – A review of important clinical features Professor Clodagh O’Gorman, Dr Karen King and Dr Siobhan Gallagher, University of Limerick Nutrition in children: Common problems seen by GPs Dr Maria McDermott, PhD, clinical nutritionist, Dublin Red flags for GPs Management of headache in children Dr Laura Noonan, GP, Westmeath Sore throat - when and how to treat Mary Llewellyn, clinical nurse specialist in general practice, Dublin Issue 4 September 2013 www.paediatricsireland.ie Paediatrics IrelandJOURNAL To register for this journal free of charge visit www.paediatricsireland.ie
  • 2. Paediatrics Ireland Introduction Welcome to the fourth edition of our Paediatrics Ireland Journal. We are still getting doctors joining so the good word must be spreading. We now have 1,020 doctors registered who get the journal, 85% of whom are GPs. If we keep going at this rate, we could be large enough to form a trade union! Of course this is not what the journal is about, but we will have some turbulence in the weeks and months ahead, as our NCHD colleagues have reached a breaking point where they cannot sit idly by while further pressures are heaped upon them. It is a time for all doctors to support each other as each specialty relies on the other for the health system to work. It has been proposed that “free” GP care be available to all children under the age of five. While I think this idea could be great if properly thought out and budgeted, I fear it will cause chaos, both within GP surgeries and in paediatric emergency departments. It is well-accepted that with “free” GP care, there will be an increase in attendance to surgeries. With this increase, there is a very real possibility that same-day appointments may not be available to “sick” children, as all the appointments may be full. There is a very real difficulty of these patients being triaged by the GP receptionists – who may have to ask, “How sick is each one of these children?” We as GPs will have no other option but to recommend that if the parents are concerned then they should attend the emergency department promptly. Having worked in A&E, I know these children’s hospitals are going to be overrun and become inefficient. I know this, you know this, and the doctors working in children’s hospitals know this! But do the politicians and civil servants know this? I fear they do not. How often do you complain to colleagues, wives, husbands and partners about this? Maybe we are complaining to the wrong people? If you feel strongly about this let the ministers, junior ministers, and your local public representative know. Your patients deserve it! Dr Michael O’Brien, Editor GP, Leopardstown, Dublin The Shared Care Paediatric Network was convened by Reckitt Benckiser. All materials were sponsored by and developed in partnership with Reckitt Benckiser Healthcare and its agency First Medical Communications. The views expressed in the materials are those of the Shared Care Paediatric Network and not Reckitt Benckiser. Paediatrics Ireland is the official publication of the Shared Care Paediatric Network. This peer-led group seeks to support and promote an Irish-based community of paediatric learning, teaching and collaboration. Supporting learning and collaboration in Paediatrics www.paediatricsireland.ie www.paediatricsireland.ie Summary of Product Characteristics available at www.medicines.ie
  • 3. Paediatrics Ireland CLINICAL REVIEW Paediatric orthopaedic injury Developmental dysplasia of the hip Developmental dysplasia of the hip (DDH) is a varied spectrum of disorders that may occur at birth, in infancy, or during childhood. Problems range from a mild, simple dysplasia to a severe defect with a dislocation, and classic DDH occurs in 0.1%-0.2% of infants. Breech position at birth is one of the main risk factors for developmental dysplasia, as are positive family history, being the first-born child, and being female. The hip is a ball and socket joint. The ball (femoral head) forms the top part of the femur and the socket (acetabulum) forms in the pelvic bone. In some newborns, the socket is too shallow and the thigh bone may slip out of the socket, either part of the way or completely. One or both hips may be involved. The two major tests for signs of hip instability are the Ortolani sign and the Barlow sign. The Ortolani sign can help show hips that are dislocated when the infant is in a resting position, while the Barlow test detects hips that are dislocatable. Good examination in these (and all paediatric) cases is vital. You should look at posture and motion, with the baby in four positions: Supine, a sitting position, a prone position, and, depending on age, a supported standing position. In older children, watch them when they walk or ask them to run - running will unmask any subtle neurological signs, especially with regard to movement in upper limbs. Hopping is also a good way to check for problems. Mainstay of treatment in DDH is a Pavlik harness, to be worn by the infant 24 hours a day. Ultrasound scans should be obtained every two-to-three weeks with stress views in the harness. Limping Limp is defined by a deviation from the normal gait pattern expected for a child’s age. Limping can be complex to manage in children, as diagnosis can range from trivial causes such as a rock in the shoe to potentially life- and limb-threatening causes such as septic arthritis and malignancy. Therefore, the possibility of serious outcomes on presentation of limp makes accurate assessment, diagnostic evaluation, treatment, and appropriate follow-up essential. A good history is an essential component of evaluating a child with a limp: • In a toddler, history may be limited to observations by the parent or caregiver. The caregiver should be asked where he or she perceives the source of the patient’s pain to be, as their perspective may allow detection of a problem not evident during a relatively brief examination period. • Older children will be better able to localise a source of pain, if present, and recount any preceding trauma. A careful history may reveal a traumatic cause that has been forgotten or overlooked. Slipped capital femoral epiphysis Slipped capital femoral epiphysis (SCFE) is the most common adolescent hip disorder, affecting five-to-six of every 100,000 children and adolescents. SCFE is defined as a separation of the ball of the hip joint from the femur at the upper growing end (growth plate) of the bone. Most patients who develop SCFE are overweight or obese, and the majority are male. In general, patients diagnosed with SCFE do not have significant disability,buttheconditiondoesrequireproactivesurgicalmeasures because if left untreated, it can develop into severe hip arthritis. Symptoms include: • Difficulty walking, or walking with a limp • Knee or hip pain • Hip stiffness • Outward-turning leg • Restricted hip movements. Examples of common knee fractures in paediatrics Patella sleeve fractures occur between the cartilage “sleeve” and main part of the patella and ossific nucleus. They occur most commonly in children eight-to-12 years of age and can be quite difficult to detect. On physical exam, watch for local tenderness and swelling. An MRI may be needed to diagnose these fractures if radiography does not reveal a clear diagnosis. Meniscal tears are a common sports injury in teens. One of the most commonly injured parts of the knee, the meniscus is a wedge- like rubbery cushion where the major bones of the leg connect. Initial treatment follows the basic “R.I.C.E.” formula: rest, ice, compression and elevation, combined with nonsteroidal anti- inflammatory drugs for pain. If the knee is stable and doesn’t lock, this conservative treatment may be all that’s needed. Anterior cruciate ligament (ACL) injuries commonly occur in basketball, football, soccer, and skiing. Most ACL tears are seen in the middle of the ligament, or the ligament is pulled off the thigh bone. These injuries form a gap between the torn edges, and do not heal on their own. Symptoms include a popping sound and swelling within 6 hours of injury. If the foot is cool and blue after a knee injury, the knee joint may be dislocated, and blood vessels to the foot may be injured. Finally, jumper’s knee (patellar tendonitis) can lead to pain at the bottom and front of the kneecap, especially when pressing in or palpating. Jumper’s knee can be categorised as follows: • Grade 1: Pain only after training • Grade 2: Pain before and after training but pain eases once warmed-up • Grade 3: Pain during training that limits performance • Grade 4: Pain during everyday activities. In conclusion, a thorough history-taking and thorough examination are the cornerstones when dealing with paediatric patients presenting with joint pain or sports/overuse injury. When in doubt, send the patient for ultrasound or x-ray. References on request Dr Niall Breslin, SpR, orthopaedics, Cork University Hospital Dr Niall Breslin outlines common paediatric orthopaedic presentations
  • 4. Paediatrics Ireland CLINICAL REVIEW www.paediatricsireland.ie Introduction Thyroid dysfunction is common in children with Down syndrome. Thyroid conditions associated with Down syndrome include congenital hypothyroidism, autoimmune hypothyroidism, subclinical hypothyroidism and, rarely, hyperthyroidism. Screening for thyroid disease is particularly important in this population as hypothyroidism may be masked by the features of Down syndrome. The 2009 Irish guidelines for screening for thyroid disease in children with Down syndrome recommend routine thyroid stimulating hormone (TSH) after birth (on Guthrie screening test), TSH and free T4 annually until age 5 years; and TSH and free T4 every 2 years thereafter. Discussion Congenital hypothyroidism The incidence of congenital hypothyroidism in children with Down syndrome is approximately 28 times higher than found in the general population. Studies report a prevalence of congenital hypothyroidism in Down syndrome that ranges from 1.5%-6.1%. Autoimmune thyroid disease Autoimmune thyroid disease is also more prevalent in children with Down syndrome than in the general population. The prevalence of thyroid peroxidise (TPO) antibodies in patients with Down syndrome has been estimated at 7.5%, 27% and 31%. Autoimmunehypothyroidismiscommonaftereightyearsofage in children with Down syndrome and relatively uncommon before this age. However, there are reports of thyroid autoantibodies in infants with Down syndrome. Those with thyroid autoantibodies are expected to progress to overt hypothyroidism, but the timeframe for this progression is unclear. Subclinical hypothyroidism Subclinical hypothyroidism is very common in children with Down syndrome; the prevalence ranges between 25.3% and 60%. Subclinical hypothyroidism refers to an elevated TSH level with normal T4 and T3. The cause of subclinical hypothyroidism in children with Down syndrome is unknown, and commentators remain divided on its significance. Those who suggest treating subclinical hypothyroidism in this population point to the safety of thyroxine treatment and to the possible beneficial effects on the growth and development of the child if treatment is commenced. Karlsson et al recommend treatment of subclinical hypothyroidism in order to prevent progression to overt hypothyroidism. Most authors who advise treating subclinical hypothyroidism suggest doing so at TSH >10mU/L. Prasher suggests a trial treatment of thyroxine in symptomatic cases of subclinical hypothyroidism or those with TPO antibodies. Others suggest that treatment of subclinical hypothyroidism in this population is unnecessary. In several studies transient TSH elevation has been noted. For Gibson et al there is no clear benefit to treating subclinical hypothyroidism as TSH elevation is often self-limiting. The frequency of thyroid function tests (TFTs) required to monitor subclinical hypothyroidism is unclear. Suggestions in the literature range from every three months to five-yearly. On balance, internationally, authors advocate more strongly for annual screening in children with Down syndrome, given the potential effects on growth, puberty and intellectual development of not treating thyroid dysfunction in childhood. Irish guidelines for management of thyroid disease in children with Down syndrome The Irish guidelines for screening for thyroid disease in children with Down syndrome recommend routine TSH after birth (on Guthrie screening test), TSH and free T4 annually until five years of age; and TSH and free T4 every two years thereafter. The Irish guidelines ought to prevent children with Down syndrome presenting with overt hypothyroidism. However, the risk of acquiring hypothyroidism increases with age in children with Down syndrome. Thus, there may be an argument for future iterations of the Irish guidelines to introduce yearly thyroid screening after 5 years of age. Other national guidelines (the United States, Canada and Australia) suggest more frequent thyroid screening than the Irish guidelines. Presentation of hypothyroidism in children with Down syndrome It may be difficult to suspect a diagnosis of hypothyroidism in a child with Down syndrome on clinical grounds alone. The symptoms of hypothyroidism often overlap with the features of Down syndrome. Typical symptoms suggesting suspected hypothyroidism include fatigue, slow movement and speech, cold intolerance, weight gain, dry skin and hair, puffy faces, constipation, and decreased linear growth in children. The features of Down syndrome that overlap with hypothyroidism include delayed development, increased body mass index (BMI), decreased linear growth, constipation, muscle weakness, inactivity, dry skin and fine hair. Therefore, biochemical screening is essential in children with Down syndrome to ensure normal thyroid function and to allow the child to maximise intellectual and physical potential. Conclusion Thyroid disease is more common in children with Down syndrome than in the general population. Regular thyroid function tests are required to monitor these patients, particularly as clinical diagnosis is unreliable in this population. References on request Dr Karen King, Dr Siobhan Gallagher and Professor Clodagh S O’Gorman, Department of Paediatrics, University of Limerick Thyroid dysfunction in children with Down syndrome: A review of important clinical features Dr Karen King, Dr Siobhan Gallagher and Professor Clodagh S O’Gorman provide an in-depth overview of screening for and managing thyroid disease in Down syndrome children
  • 5. Paediatrics Ireland CLINICAL REVIEW Faltering growth (which used to be referred to as ‘failure to thrive’) is when a baby doesn’t grow at the expected rate. Babies grow very rapidly during their first two years. Breastfed babies tend to gain more weight during the first two months of life, compared to formula fed babies. After two months, the trend is reversed and formula fed babies grow at a faster rate. It’s important to remember that most babies lose some weight after birth and start to gain weight at around two weeks of age. It’s essential babies receive adequate nutrition, to help them grow and develop. This is especially important for premature babies who need to catch up. A baby’s development, particularly their brain development, may be affected if their growth falters. That’s why it’s essential to recognise faltering growth as early as possible. Below are some guidelines and advice for recognising and managing faltering growth, its associated complications, and other nutritional issues. Guidelines for basic growth assessment • Weigh the child naked if under two years or in light clothing, using regularly calibrated scales. • Measure length in infants using an infant stadiometer (measures standing or sitting height) or suitable measure mat; in older children use a stadiometer, with the child barefoot. • Measure head circumference at largest point around mid- forehead and occipital prominence using a non-stretch tape measure. • Plot weight, height and head circumference on age- appropriate growth chart. Correct for gestational age (until two years) if the child was born prematurely. • Refer for further investigation in following circumstances: – Height and/or weight below 0.4 centile, – Height and/or weight above 99.6 centile, –Crossingoftwoormorecentilesbetweentwomeasurements, – Weight and height differ from each other by two major centiles. Common nutritional problems Growth faltering (failure to thrive) Characteristics: There is no universally accepted definition, but the problem involves failure to meet expected potential in growth and other aspects of wellbeing. Possible causes: Dietary, organic and social factors can all lead to under nutrition. Investigations: • Weight/ height measurement and history; • Feeding history; • Observation of feeding to assess for feeding difficulties, abnormal feeding behaviour or interaction between carer and child; • Biochemical/haematological/microbiological screening. Treatment: Will depend on cause but may include: • Advice on feeding; • Increasing nutrient density of foods. Increase the nutrient content of food by choosing more nutrient dense foods or by adding one food to another, for example, milk and cheese to mashed potato; • Reassurance and support to parents/carers; • Referral to specialists. Iron deficiency anaemia Characteristics: Often asymptomatic unless severe and then symptoms include pallor, tiredness and poor appetite. Diagnosis: anaemia (haemoglobin <10g/L), microcytic red cells, low plasma ferritin (<10µg/L). Exclude other causes of anaemia. Preventive measures include: • Introduction of solids by six months of age including iron- fortified cereal and other iron containing foods; • Avoid whole cow’s milk before 12 months, use iron fortified infant formula if not breast fed; • Encourage iron-rich foods with foods containing vitamin C to improve absorption; • Iron fortified follow-on formula may be useful after one year if ‘at risk’. Treatment: Supplemental iron (may cause nausea and constipation), encourage healthy diet including iron-rich foods. Vitamin D-deficient rickets Characteristics: • Softened skull bones; Clinical nutritionist Maria McDermott provides advice on dealing with common nutritional problems in children and infants Nutrition in children: faltering growth and other common problems seen by GPs
  • 6. Paediatrics Ireland • Epiphyseal swelling (especially at wrists); • Enlarged costochondral junction where the ribs articulate with sternum (rickety rosary); • Tibial bowing (bow legs); • Delayed dentition. Diagnosis: • Raised plasma alkaline phosphatase; • Low phosphate/calcium; • Cupping, fraying, splaying at end of long bones on x-ray. Prevention: Vitamin D-fortified formula milk or 7.5–10µg/day supplement in children’s vitamin drops. Treatment: • 25–125µg/day vitamin D until alkaline phosphatase is normal, then 10µg/day; • Exposure to sunlight; • Good intake of calcium. Food allergy/intolerance Common foods implicated in food allergy/intolerance: • Milk; • Egg; • Nut; • Wheat; • Shellfish; • Soya. Some allergies may resolve over first three years of life; others are lifelong. Diagnosis: • Skin prick test, involving the introduction of a small amount of allergen under the skin to identify allergy; • Radioallergosorbent test (RAST) tests for the amount of specific IgE antibodies in the blood to specific allergens (or antigens); • Food challenge test. Treatment: Exclusion of food from diet (obvious and hidden sources). Complications: Nutrient deficiency and growth faltering due to inadequate intake of food is possible. The child should be referred to paediatric dietitian if this is suspected. Common feeding problems and suggested solutions Refusal of food • Structured family meal pattern (three meals, two-three nutritious snacks); • Small portions, variety of foods, include some favourites; • Happy, relaxed environment; • Do not offer sweets or other foods as rewards; • Do not ‘force feed’. Excessive milk drinking • Limit intake to 500–600ml/day and give after meals/with snacks; • Give water between meals if thirsty; • Use a cup rather than bottle. Excessive juice drinking • Limit to one cup/day; • Give plain water if thirsty and give drinks after meals; • Encourage milk; • Use a cup, not a bottle. Refusal of milk • Offer in ‘fun’ cup, with coloured straw; • Mix milk/cheese/yoghurt into foods; • Try flavoured milk – warm, cold or frozen. Refusal of fruits/vegetables • Include small amounts at each meal; • Mix grated or pureed vegetables/fruits with other foods; • Try raw vegetables/fruits with dips, for example, hummus or yoghurt; • Make blended fruit drinks/milkshakes; • The family should set good example by eating/enjoying fruit and vegetables. References on request Dr Maria McDermott, PhD, is a clinical nutritionist based in Co Dublin CLINICAL REVIEW www.paediatricsireland.ie If you have a paediatrics-related query or a therapeutic area you would like covered, tell us about it and we will address this in our future issues. Write to us: info@paediatricsireland.ie What would you like to see featured in Paediatrics Ireland? There’s more online! Visit paediatricsireland.ie for article references, lists of further reading and much more
  • 7. Paediatrics Ireland RED FLAGS FOR GPs Management of headache in children Dr Laura Noonan provides a thorough overview of the management of headache in children Headache is a common reason for children and adolescents to be brought to see the GP. Headaches may cause concern for the parents and impact on the child’s quality of life through days lost at school and time lost from leisure activities. In the majority of cases a serious underlying disorder can be ruled out by the GP through taking a comprehensive history and completing a thorough physical examination. The pattern of the headache needs to be identified as acute, acute recurrent, chronic non progressive, chronic progressive or mixed. A headache diagnosis needs to be established though the use of the the International Headache Society (HIS) criteria, which can aid the diagnosis of migraine, migraine with aura and tension headache. It is important to reserve neuroimaging for those children who have chronic progressive headache or abnormalities on physical examination. It is important to manage headache appropriately in children, as for some, the impact of headache is significant. In a 2001 study looking at the effects of headache on quality of life it was found that headache negatively affected children’s QOL, most notably emotional and school functioning, as adversely as other serious chronic childhood diseases like arthritis and cancer. Reassure, reassure, reassure The first piece of advice to give to parents and children is to complete a headache diary in which they record information about their attacks. This diary needs to be continued even after diagnosis to judge the effectiveness of treatment or identify new triggers. A headache diary should be comprehensive and include: • Triggers or warning signs felt or noticed by either the parent or child before an attack e.g. visual disturbance, pallor, confusion, vomiting, • Recording when the attack starts and finishes. • Severity of pain and the features of the headache. Parent may observationally complete this and add the child’s own words/ behaviours/appearance. This is dependent on the child’s age. A teenager may wish to take control of this task themselves under parental supervision • Record of medication taken during each attack. It is important for the family to try to take the control back from the headache. This can be through headache prevention and /or prompt management of a headache when it starts. This is vital in order to reduce the impact the headache has on the child’s quality of life and how the child with the headache affects the functioning of the entire family unit. There may be jealousy from other siblings due to increased attention the sickly sibling gets or the child may adapt to the sick role very quickly if they feel they get the attention they desire when they complain. Prevention is better than cure! For the child with headache, once triggers are identified they can be avoided. Notably, only 20% of children with migraine are found to have dietary triggers. These can include cheese, citrus fruits, monosodium glutamate (MSG) (found commonly in Chinese food), chocolate, and caffeine, both in excess and withdrawal. Children, with the assistance of the whole family, need to be encouraged to have a healthy lifestyle with attention to trigger avoidance. Games consoles, cola and chocolate at 3am are not a good combination for any child but particularly not for one with recurrent headaches. Proper sleep hygiene is vital so that children are getting sufficient quantities of good quality sleep to allow them to wake refreshed. Headache, headache go away, don’t come back another day! Once a child complains of headache they should be offered prompt treatment. If they haven’t eaten they should be offered a snack and a drink and given the opportunity to lie in a darkened room and rest. Regarding over the counter pain relief for children, there is evidence that ibuprofen provides more effective relief from headache than paracetemol. When a headache is present for more than 15 days per month for at least three months, it is described as a chronic daily headache. A good beginning is half the work! • Headache management begins with a comprehensive history and examination, followed by headache diagnosis with reference to the International Headache Society guidelines. • A headache diary is a valuable tool to aid in identifying triggers and devising a management plan. • Share the responsibility of headache management with the child and their family. Give the parents and the child the tools to both prevent the headaches and treat the headaches if they do develop. • Review the child after initial visit to re-examine the child and review the contents of the headache diary. • Assess for red flag symptoms and refer to secondary care as appropriate. Red flags for GPs Refer any headache with focal neurological signs or a rapidly changing pattern: • Change in personality or behaviour • Crescendo pattern of headache – getting more frequent and more severe • Worse when lying down (suggests raised ICP) • Worse on wakening/in the morning (suggests raised ICP) • Vomiting • Any neurological finding on examination (abnormal gait, incoordination, papilloedema) • Any visual field defect • Seizures • Cutaneous lesions e.g. ‘café au lait’ spots References on request Dr Laura Noonan is a GP in Co Westmeath * Readers are advised that a detailed review on management of headache in children is available by clicking the ‘journal’ tab at www.paediatricsireland.ie
  • 8. Paediatrics Ireland RED FLAGS FOR GPs Sore throat: When and how to treat Practice nurse Mary Llewellyn uses her 20 years’ experience to review one of the most common complaints in primary care A sore throat is the most common ENT complaint in children in general practice. Below are some helpful practice tips. History taking: How long has the child had the sore throat? Is it worsening? Is it worse on one side or the other? Can she open her mouth normally? Has she a fever? Is she drooling? Can she swallow normally? In babies, can they suck normally? Red flag symptoms include unilateral soreness, severe swallowing problems, dehydration, an immunosuppressed patient, breathing difficulties, and behaviour changes. Viral infections: Most sore throats are caused by a virus and are part of an upper respiratory tract infection (URTI). Children usually have runny eyes, runny nose and a cough, which is worse at night- time. It usually lasts a few days; treatment is analgesia and fluids. The biggest problem here is often that parents want an antibiotic and it can be difficult to convince them that antibiotics are not necessary. The other problem is that parents are often reluctant to give sufficient analgesia and for a sufficient number of days. Epiglottitis: Since the introduction of the Hib. vaccine into the childhood vaccination programme, epiglottitis is thankfully rare. If a child presents with drooling, difficulty swallowing, difficulty breathing, fast or noisy breathing, sitting bolt upright, or chin jutting forward – this is an acute medical emergency. Do not lie this child down or attempt to look in the throat. That could cause a spasm that will close the throat altogether, and cause death within a few minutes. This is a life-threatening emergency, dial 999 or get the child to the nearest emergency department immediately. Childhood illness: Sore throat may be the first sign of chicken pox or measles and mumps. Sadly our MMR vaccine uptake rate is not enough to exclude measles or mumps from the differential diagnosis list. Bacterial infections: There are four criteria used to identify the likelihood of bacterial infection being the cause of a sore throat. 1. Has the child a high fever? 2. Are there large tonsils with exudate? 3. Is there cervical lymphadenopathy? 4. Is there an absence of cough? The presence of all four variables gives a 40-60% likelihood of positive bacteria. The absence of all four gives an 80% negative likelihood of bacterial infection. Thus, the high negative predictive value suggests these criteria can be more effectively used for ruling out strep throat than for diagnosing it. Laryngitis, pharyngitis, tonsillitis: Routine throat swabs are mostly unnecessary and unhelpful. The most severe infection is caused by Streptococcus. Symptoms include a sore throat, mild fever, swollen lymph glands, headaches, bad breath and white patches on the throat. Quinsy: Physical examination shows a miserable, feverish, drooling child with significant unilateral swelling in the area of the tonsil bed, and a ‘hot potato’ voice. Referral to hospital for urgent medical assessment and drainage of peritonsillar abscess (quinsy) is necessary. It is worth remembering that quinsy is more likely to build up on top of tonsillitis i.e. a worsening sore throat; it does not typically develop suddenly. Glandular fever: A child with a sore throat, general malaise (and the malaise may have been for several weeks), posterior cervical or generalised adenopathy and possible enlargement of the spleen raises the suspicion of glandular fever. Immunosuppression: Consider agranulocytosis in patients known to be immunosuppressed because they are taking medication such as methotrexate. Reflux: In small children, reflux (either experienced as heartburn or as asymptomatic silent reflux) can cause and maintain a sore throat. Foreign bodies, injury or irritation: Occasionally, foreign bodies need to be excluded in the case of a continuing sore throat. Referral is often necessary. Removing a fish or chicken bone can injure the throat. Irritation can be caused by mouth breathing, low humidity, pollution, post nasal drip and yelling and screaming. Injury such as a cut or puncture could be caused from falling with a pointed object in the mouth. Summary: Treatment depends on the cause. Viral infection remains by far the commonest cause of sore throat. Throat pain can be treated with a pain reliever such as the non-steroidal anti- inflammatory agent ibuprofen (e.g. Nurofen for children) or the mild analgesic paracetemol. These medications should be dosed according to weight, not age. Aspirin is not recommended in children under 18. Full resolution is the usual outcome. However, the red-flag awareness should alert us to the dangers of those rare incidents of something more sinister. Mary Llewellyn SRN, RM, RSCN Clinical Nurse Specialist in General Practice, Co Dublin The Shared Care Paediatric Network was convened by Reckitt Benckiser. All materials were sponsored by and developed in partnership with Reckitt Benckiser Healthcare and its agency First Medical Communications. The views expressed in the materials are those of the Shared Care Paediatric Network and not Reckitt Benckiser. Paediatrics Ireland is the official publication of the Shared Care Paediatric Network. This peer-led group seeks to support and promote an Irish-based community of paediatric learning, teaching and collaboration.Supporting learning and collaboration in Paediatrics www.paediatricsireland.ie www.paediatricsireland.ie