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Community paediatrics Chapter 5: Paediatrics 187
https://t.me/med1917
Learning difficulties
GENERAL LEARNING DIFFICULTIES
Significantly sub-average IQ (<70) apparent before 18y → RF: lower
socioeconomic status
Mild (85% cases) Moderate Severe Profound
IQ <70 <50 <35 <20
Presentation At school/later Delayed speech & language (2–4y) Global developmental delay (apparent from infancy)
Functioning Only need help if problems arise
• often not recognised as LD
May need supervision
in some elements of daily
living / work
Need help with many ADLs
• often physical disability
• limited communication
Extensive/total help with ADLs
• minimal communication
Causes: 30% = unknown cause
• Genetic/chromosomal: Down’s, fragile X, PKU, neurofibromatosis, tuberous
sclerosis
• Pre-natal: hypothyroidism, fetal alcohol syndrome, pre-eclampsia, TORCH
infections
• Peri-natal: birth hypoxia, hyperbilirubinaemia, intraventricular haemorrhage
• Post-natal: brain infection/tumour, head trauma, malnutrition, neglect/abuse
SPECIFIC LEARNING DIFFICULTIES
1. Dyspraxia / developmental coordination disorder (DCD) = disorder of
motor planning/execution
Signs
• messy, slow, irregular handwriting
• difficulties with buttons/laces/clothes
• difficulties cutting up food
• messy eating/drooling – cannot coordinate chewing/swallowing
• poorly established laterality e.g. handedness
Diagnosis
• features in history + OT assessment
Management → should improve with ongoing therapy
• OT – IT/educational support
• SALT
• vision & hearing assessment = useful
2. Attention deficit hyperactivity disorder (ADHD) = overactivity in most
situations + impaired concentration
Cause: dysfunction of dopaminergic brain circuits
Diagnosis: assessed by paediatric & educational psychologists*
Features: → short-tempered & difficulty making friends
1. Inattention – concentration on work/play, distractible, don’t listen
2. Hyperactivity – fidgety, excessive movement/noise, unorganised/lose things
3. Impulsivity – interrupt others, social disinhibition, difficulty sharing/taking
turns
Comorbidities
• Poor sensory skills
• ADHD
• Depression
• Bipolar/mania
• Schizophrenia
Risk factors for ADHD: FHx, male, premature
*based on clinical assessment and questionnaire
NB Sx worse in unfamiliar environments → must
assess in >1 situation e.g. home + school
Management
59
1st-line: behavioural modification strategies – educate parents/teachers in
clear rules, consistent rewards system
2nd-line: medication – stimulants (methylphenidate/Ritalin – see over ) or
non-stimulants (atomoxetine) → no meds if age <5y
59
NICE (2018, updated 2019) Attention decit hyperactivity disorder: diagnosis and management [NG87]
need specialist community paediatrician/psychiatrist input
+ additional lifestyle factors:
diet, exercise, sleep hygiene
188 Chapter 5: Paediatrics Community paediatrics
https://t.me/med1917
Side-effects of Ritalin: need specialist paediatric psychiatrist assessment
DDx of ADHD
• Anxiety
• Personality disorders
• Autism spectrum disorder
• Hyperthyroidism
• Abdo pain, nausea, reduced appetite
• Insomnia, tics, anxiety/depression, palpitations
• Growth suppression
Requires monitoring →
AND
ENURESIS: bedwetting
Causes of nocturnal enuresis
• genetics – ²/ have affected 1st-degree
relative
• emotional stress = most common cause
• UTI
• constipation
• osmotic diuresis – diabetes mellitus
• developmental disabilities/delays
Primary nocturnal enuresis: bedwetting >2 nights/week in child old enough to
be continent (3–5y)
Investigations
• urinalysis: if recent/sudden onset or Sx of UTI/DM
VERY COMMON:
→ 10% of 5 year-olds
→ 5% of 10 year-olds
• diary of wet/dry nights
• drinking/urine volume charts
Management
60
• explanation: common problem & no conscious control
• advice: fluid intake, diet, toileting before bed, etc.
• reward systems / star charts: avoid punishments
• enuresis alarm: sounds when becomes wet (must try before desmopressin
if<7y)
• desmopressin (ADH): short-term relief e.g. sleepover
Primary daytime enuresis: lack of bladder control in day in child old enough to
be continent (3–5y)
Causes
• lack of attention to bladder sensation – developmental problem or just
preoccupied
• neuropathic bladder – associated with neuro conditions like spina bifida
• detrusor instability
• bladder neck weakness / ectopic ureter
• UTI/constipation
Management: treat underlying cause
→ star charts & alarms if no pathological cause
Investigations: r/o neuro cause
1. Examination: neuro, abdominal, rectal
2. Urinalysis – MCS
3. USS bladder
4. Urodynamic studies
Secondary enuresis: loss of previously achieved urinary continence
Causes
• emotional upset
• distraction (too busy playing)
• UTI or DM → urine dip & MCS
60
NICE (2010) Bedwetting in under 19s [CG111]
Chapter 5: Paediatrics 189
https://t.me/med1917
Child & adolescent mental health
Sleep-related problems
Difficulty settling to sleep
What: won’t go to sleep unless parent present – manifestation of separation
anxiety in toddlers
Contributing factors: separation anxiety, napping in day, no bedtime routine,
noisy environment, fear of the dark
Management: strict bedtime routine, graded lengthening of time between
leaving room and checking on child
Waking at night
What: cannot settle back to sleep without parent present – often associated with
difficulty settling to sleep
Management: treat difficulty settling to sleep first, graded lengthening approach
Nightmares
What: bad dreams that the child can recall = common
Management: REASSURE CHILD → professional input only if content indicates
morbid preoccupation e.g. death
Night terrors
What: rapid emergence from period of deep sleep causes state of high arousal &
confusion – 1.5h after settling
Features: child sitting up, eyes open, disorientated, confused, distressed,
unresponsive – no recollection in morning
Management: reassure parents, improve bedtime routine, ensure safe
environment if concurrent sleepwalking
*Eating disorders covered in Chapter 6:
Psychiatry*
suggests psychiatric disorder e.g. PTSD
Temper tantrums
→ outbursts of anger & refusal to obey parents as an ordinary response to frustration
MANAGEMENT
1. Analyse tantrums
• Antecedents – what happened minutes before?
• Behaviour – what exactly did the episode consist of?
• Consequences – what was the result? – what parent did & outcome
2. Examine child for medical/psychological factors
• e.g. global/language delay, hearing impairment, bronchodilators/
anticonvulsants
3. Interventions
• Avoid antecedents
• Distraction techniques
• Ignore until tantrum runs out
• Time-out e.g. naughty step
• Star chart to reward obedience
Aggressive behaviour
→ usually learned by copying parents, peers, siblings & persistent if not actively
managed
RISK FACTORS: tired, stressed, communication impairment
MANAGEMENT: make clear rules & stick to them → 1–2–3 approach
School refusal
→ inability to attend school due tooverwhelming anxiety
FEATURES: physical Sx of anxiety confined to weekdays/term-time
→ nausea, headache, abdo pain, hyperventilation, general illness
CAUSES
• Separation anxiety (<11y) – often provoked by life event e.g. death, moving house
• True school phobia (older kids) – anxiety provoked by an aspect of school
e.g.bullying
1. Stop doing that because…
2. If you don’t you must go to your room…
3. Go to your room
Truancy: child leaves to go to school, but never
arrives or leaves early
→ associates with other behavioural difficulties
190 Chapter 5: Paediatrics Child & adolescent mental health
https://t.me/med1917
MANAGEMENT: involve child, parents, teachers, psychologist
1.
Use HEEADSS assessment for adolescent
consultations:
Home
Education & Employment
Activities
Separation anxiety: gently promote separation from parents & graded
return to school
2. True school phobia: address underlying cause (e.g. bullying) and treat
underlying emotional disorders
Chronic fatigue syndrome (CFS)
Drugs/Drinking
Sex
Self-harm/Suicide
Safety (including Social media)
→ persistent (>3m) high levels of subjective fatigue & rapid exhaustion that limits
daily activities
CAUSES
• Viral infection: EBV, Coxsackie B → specifically known as myalgic
Symptoms of CFS
encephalomyelitis
• Psychological factors: stress, trauma, mental health disorders
• Myalgia
• Migratory arthralgia
• Headache
• Poor concentration
• Irritability
• Stomach pains
• Scalp tenderness
• Eye pain/photophobia
• Cervical lymphadenopathy
• Depression
• Genetics: more common within some families
FEATURES: often worse 24h post physical/mental exertion
MANAGEMENT
• Energy management – educate on
fluctuating energy limits
• Graded exercise therapy – slowly
tolerance
• Diet & sleep optimisation
61
: most remit spontaneously in months–years
• SSRIs if comorbid depression
• Consider analgesia if pain is a
significant symptom: following
neuropathic pain / headache
guidelines
• ± CBT
• Disturbed sleep patterns
Depression, self-harm, suicide
↳
Ix to r/o DDx:
blood glucose, urinalysis
Some differences to presentation in adults:
• Apathy/boredom & anhedonia more
obvious than low mood
• Separation anxiety reappears
• Hypochondrial ideas – complain of
chest/abdo pain & headaches
• Irritable mood / antisocial behaviour
• Decline in school performance
NB Poor sleep, lost appetites & slowed cognition = less common
MANAGEMENT62: RISK ASSESS!!!
Mild–moderate: low intensity psychotherapy (self-help) → high intensity
psychotherapy (CBT)
Severe: high intensity psychotherapy (CBT) + SSRI (fluoxetine)
Drug misuse
SIGNS
• Intoxication / medical complications
of use
• Unexplained absences from
school/home
• Mixing with known users
• High spending / stealing money
MANAGEMENT: RISK ASSESS!!!
• Interview adolescent
• Urine sample for drug screen
• Referral to drug & alcohol services
• Medical Tx of any complications
• Tx of underlying psychological
disorders e.g. depression
Psychosis
→ breakdown in perception & understanding ofreality → delusional ideas,
hallucinations, odd behaviour
CAUSES: schizophrenia, bipolar/mania, substance-induced (most common causes
in adolescents)
INVESTIGATION: urine drug screen, medication review, exclusion of
infection / metabolic disorders
MANAGEMENT: URGENT REFERRAL TO PSYCHIATRIST – antipsychotics,
psychotherapy, family education
61
NICE (2021) Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome [NG206]
62
NICE (2019) Depression in children and young people [NG134]
Safeguarding & abuse
https://t.me/med1917
Physical abuse
Chapter 5: Paediatrics 191
Suspicious features in history:
• Injury with no explanation / explanation doesn’t fit injury
• Injuries to children not yet mobile
• Time delay in seeking medical support
• Varying explanations between carers/child
• Unconcerned/aggressive/vague parents
• Previous Hx of unusual/unexplained injuries
Suspicious features on examination:
Fractures
• In non-mobile child (<18m)
• Multiple fractures but no major
trauma
• Rib & skull fractures
• ‘Bucket-handle’ fractures
Bruises
• In non-mobile child
• In shape of hand/bite/clusters
• Around neck, wrists, ankles, face
(not on bony prominence)
Burns
• In shape of instrument e.g. iron
• Glove & stocking pattern – immersion
Investigations if abuse is suspected:
→ Full skeletal X-ray
→ Bloods (r/o organic causes)
Sexual abuse
→ forcing child to take part in sexual activities ranging from non-physical
(watching porn) to rape
Suspicious signs
• Vaginal/rectal bleeding, discharge, itching
• Soiling/secondary enuresis
• Unexplained STI – note this could be transmitted from mother
• Pregnant – if <13y this is legally sexual abuse
• Depression, self-harm, aggressive, poor school performance
Investigations
• Examination requires specialist doctor
• Forensic testing may be indicated
→ often few physical signs
Estimated prevalence of abuse in children
63
<16y
Physical abuse 7.6%
Sexual abuse 7.5% (F:M = 3:1)
Emotional abuse 9.3%
DDx of physical abuse
Bruises: clotting/platelet disorder, HSP,
Mongolian blue spots
Fractures: osteogenesis imperfecta,
osteoporosis (2° to steroids)
Burns: bullous impetigo, scalded skin syndrome,
healing skin infection
Risk factors for abuse/neglect
The child
• Result of forced/commercial sex
• Not meeting parental expectations
• Disability / special needs
• Known to social care
The carer
• Mental health problems
• Alcohol/drug abuse
• Young parental age
The family/environment
• Domestic violence
• Social isolation
• Povert y / poor housing
Emotional abuse
→ persistent emotional maltreatment that adversely affects child’s emotional
development
e.g. telling them they are worthless/unloved, making fun of them, making them feel
inadequate
Suspicious signs
• Negative interactions between child & carer
• Apathetic, fearful child
• Urinary & faecal incontinence
• Faltering growth / developmental delay
• Non-attendance at school
• Substance misuse / antisocial behaviour
• Depression, self-harm
63
ONS (2020) Child abuse extent and nature, England and Wales: year ending March 2019
192 Chapter 5: Paediatrics Safeguarding & abuse
https://t.me/med1917
Neglect
→ persistent failure to meet basic physical & psychological needs which
seriously impairs health & development
e.g. inadequate food, clothing, shelter, access to medical care, education, emotional
availability/support
Suspicious signs in child
• Consistently missed medical appointments
• Needs medical/dental care, immunisations/glasses
• Seems ravenously hungry
• Dirty, poor clothing
• Faltering growth / developmental delay
Suspicious signs in carer
• Alcohol/drug abuse
• Behaves irrationally/bizarrely/depressed
• Appears indifferent to child
deliberate or non-deliberate
FII can be difficult to spot, as organic illness may
be present concurrently
Fabricated or induced illness (FII)
→ exaggeration/fabrication of, OR deliberately caused symptoms of illness
bycarer (>80% mother)
→ leads to harm of child e.g. through unnecessary investigations by healthcare
staff
Types:
1. Verbal fabrication: parents invent signs/symptoms to healthcare staff,
leading them to believe child is ill & resulting in unnecessary investigations
&treatment e.g. special diets, restricted lifestyle, unneeded medications
2. Induction of illness: parents cause illness e.g. inhalation of noxious
substances, suffocation, giving unneeded meds
Suspicious signs:
• Frequent unexplained illnesses / hospital admissions
• Symptoms only in presence of carer / not backed up by clinical findings
Managing child abuse: admit child to safety
1. Thorough history – be sensitive!
• Ask to speak to child alone if possible
• May wish to get background information from GP
2. Thorough physical examination – may want to measure height/weight/head
circumference & plot on growth chart
Clinical investigations
1. Full skeletal survey
2. Bloods (r/o organic causes of injury)
3. CT brain (if head trauma)
4. Ophthalmological exam (if subconjunctival
haemorrhage)
3. Carefully record any medical findings – in notes / photograph injuries
4. Observe & document interaction between carers and child
5. Treat injuries as necessary
6. REPORT SUSPICIONS TO SENIOR
• Assess if immediate protection from harm is needed
→ DO NOT DISCHARGE IF RISK
• Consider risk to other siblings at home
• Alert police & social services
• Follow local safeguarding policies
Emergency paediatrics
https://t.me/med1917
Chapter 5: Paediatrics 193
Assessment of the seriously ill child (ABCDE)
Airway & Breathing
• Effort – RR, WOB, accessory muscles, recessions, added sounds, resp. distress
• Efficacy – talking, air entry, SaO2 (>92%)
• Effects – skin colour, conscious level
Circulation
• Heart – rate, rhythm, pulse
• Blood pressure – hypotension = late sign
• Capillary refill (<2s)
• Peripheral temp., colour
Disability (DEFG = Don’t Ever Forget Glucose)
• Level of consciousness (AVPU)
• Pupils – size, reactivity
• Posture & tone
• Blood glucose
Exposure
• Rash, injuries, bruises
• Pain (GCS) – consider analgesia
ALERT
VOICE responsive
PAIN responsive
UNRESPONSIVE
Management of the seriously ill child
Airway & breathing
• Open & maintain airway – head tilt, chin lift, jaw thrust
• 5 initial rescue breaths if needed – ideally via mask
• 100% high flow O2 – non-rebreathe mask
• Anaesthetist involvement – if need intubation (ET tube)
Circulation
• Chest compressions if needed 100–120/min
• Obtain IV access – 2 wide-bore cannulas
• Take bloods – FBC, U&E, glucose, X-match ± cultures
• Fluid bolus – 20ml/kg 0.9% saline over 10min
• Catheterise – guide fluid resuscitation
• Consider inotropes – guide fluid resuscitation
→ Continuous monitoring & reassessment
IO access after 3 IV attempts
Shock
→ inadequate circulation to meet metabolic demands of tissues
CAUSES
→ Hypovolaemic (bleeds, burns, fever, D&V, urinary losses)
→ Fluid maldistribution (sepsis, intestinal obstruction)
→ Obstructive (cardiac tamponade, PE, tension pneumothorax)
→ Cardiogenic (RARE: myocarditis, congenital heart disease)
Normal parameters
Age RR/min HR/min SBP
(mmHg)
Neonate: <28d 50–60 120–160 50–70
Infant: <1y 30–40 110–160 70–90
Child: <5y 25–35 95–140 80–100
Child: <12y 20–25 80–120 90–110
Clinical signs of shock
Early signs
• Tachypnoea, tachycardia
• Cap refill >2s
• skin turgor, sunken eyes/fontanelle
• Mottled, pale, cold skin
• Oliguria <0.5–1ml/kg/h
Late signs
• Hypotension, bradycardia
• Metabolic acidosis
• Depressed cerebral state
SEPTIC SHOCK
Causative organisms
Neonates: GBS, Gram –ve
Children: meningococcus
Clinical features
Features of shock plus:
• Fever, lethargy, misery
• Poor feeding
± purpuric rash (meningococcal)
Management
1. Fluid resuscitation
2. IV ABX ASAP
• Ideally after cultures
3. Further support if need
MANAGEMENT
1. Fluid resuscitation = priority → 0.9% saline bolus (20ml/kg)
2. If no improvement, involve PICU
• Tracheal intubation + mechanical ventilation
• Invasive BP monitoring (arterial line)
• Inotropic support
• Correction of metabolic/biochemical/haem derangements
• Support for liver/renal failure
64
NICE (2015, updated 2020) Intravenous uid therapy in children and young people in hospital [NG29]
64
Improvement
Correction of hypovolaemia
0.9% NaCl or blood
(20ml/kg bolus)
Fig. 5.52 Fluid resuscitation.
repeat ×2
ifnecessary
No improvement
Intensive care
194 Chapter 5: Paediatrics Emergency paediatrics
https://t.me/med1917
This accounts for the requirement of
1–2mmol/kg/d of potassium
Deficit (ml) = % dehydration × body weight
(kg) × 10
Example: 42kg child is clinically dehydrated
(5%), but not shocked
Needs REPLACEMENT + MAINTENANCE
1. Maintenance = 1940ml/d (see above)
2. Deficit = 5% × weight × 10 = 5 × 42 × 10
= 2100ml/d
3. Total replacement fluid over 24h = 1940
+ 2100 = 4040ml/d
If not shocked / clinical dehydration:
Deficit replacement = 50ml/kg (5% × weight
× 10)
If shocked / severe dehydration:
Deficit replacement = 100ml/kg (10% ×
weight × 10)
Fluid therapy
65
MAINTENANCE FLUIDS: if NBM / not drinking enough
Maintenance fluids for infants & children: 0.9% saline + 5% dextrose +
10mmol KCl
Estimate blood vol.: 80ml/kg
Estimate body weight:
<9y = 2(age+4)
>9y = 3 × age
Fluid requirements over 24h Fluid requirements per hour
1st 10kg 100ml/kg 4ml/kg
2nd 10kg 50ml/kg 2ml/kg
Subsequent kg 20ml/kg 1ml/kg
Examples of calculating maintenance fluids:
18kg child: 10×100 + 8×50 = 1400ml/d
10×4 + 8×2 = 56ml/h
42kg child: 10×100 + 10×50 + 22×20 = 1940ml/d
10×4 + 10×2 + 22×1 = 82ml/h
TYPES OF FLUID
Na+ (mmol/L) Cl– (mmol/L) Additives
Plasma 135–145 100–110 K
+
, lactate, calcium,
glucose
0.9% NaCl 154 154 –
Hartmann’s 131 111 K
Plasmalyte 140 98 K
+
, lactate, calcium
+
, acetate, magnesium
5% dextrose – – 50g glucose
0.9% NaCl + 5% glucose 154 154 50g glucose
↳ use a combination of fluids for replacement/maintenance to ensure it reaches all areas of
the body
MANAGEMENT OF DEHYDRATION: if existing deficit
1. Correct deficit = % dehydration × body weight × 10
2. Maintenance fluids = see above
3. Account for ongoing losses (e.g. fever/GI)
• Gastric losses (vomiting) = saline + K
• Diarrhoeal losses = saline, K+, glucose, HCO
Degree of dehydration Clinical signs Fluid deficit Management
Mild
(sub-clinical)
Moderate
(clinical)
Severe
(shock)
Dry mucous membranes, thirst,
urine output
Tachycardia, CRT >2, turgor
Tachypnoea
Weak pulses, CRT >3, turgor
Kussmaul breathing
Hypotension, consciousness,
very tachycardic
5% of body weight
= 50ml/kg
5–10% of body weight
= 100ml/kg
>10–15% of body weight
= 150ml/kg
Beware risk of hyperchloraemia
with 0.9% NaCl
⁄ stays in vasculature
⁄ into extracellular space
→
Little enters cells = good for treating
SHOCK
Very little stays in circulation
→
Use oral route if possible!
+
weight loss = most accurate
–
measure of dehydration
3
Maintenance fluids over 24h
(oral intake / ORT if possible)
Replace fluid deficit over 4h PLUS
Maintenance fluids over 24h
(oral/NG tube if possible)
IV bolus: 20ml/kg 0.9% saline over 10min
Improvement: replace deficit + maintenance
No improvement: repeat bolus ×2 then PICU
65
NICE (2015, updated 2020) Intravenous uid therapy in children and young people in hospital [NG29]
Emergency paediatrics Chapter 5: Paediatrics 195
https://t.me/med1917
Anaphylaxis
→ life-threatening hypersensitivity reaction (IgE) with rapid onset airway &
circulation problems
ACUTE MANAGEMENT
66
1. IM adrenaline 1:1000 – repeat in 5min if no improvement
• <6m = 100–150mcg (0.1–0.15ml)
1 in 1000 = fatal
• <6y = 150mcg (0.15ml)
• 6–12y = 300mcg (0.30ml)
• >12y = 500mcg (0.50ml)
2. ABC (AND CALL FOR HELP!)
• Airway: secure airway
• Breathing: high flow O2 + SABA if wheezy
• Circulation: lie supine with legs raised + IV fluids if shock (20ml/kg
crystalloids)
3. Non-sedating antihistamines
4. Monitor – pulse oximetry, ECG, BP
LONG-TERM MANAGEMENT
• Prescribe EpiPen to keep at home/school – counsel on use
• Safety-net: allergen avoidance, signs of anaphylaxis
• Consider referral for allergy testing
Causes of anaphylaxis
• Food allergy (85%) • Drugs
• Insect stings • Latex
Symptoms of anaphylaxis
• Difficulty breathing/swallowing
• Stridor ± wheeze
• Angioedema (swollen face/tongue)
• Urticaria
• Pale, clammy
→ SHOCK may develop
DDx: asthma, panic attack, septic shock
Poisoning/overdose
→ accidental (young children), deliberate self-harm (adolescents), abuse
(bycarer)
Poison Effects Management
Alcohol
Acids/alkalis
Ethylene glycol
(antifreeze)
Paracetamol 24–48h: abdo pain, vomiting
NSAIDs Within 4h:
Iron Initial: V&D, haematemesis, melaena, gastric ulcers
Methadone
TCAs
• Hypoglycaemia
• Coma
• Respiratory failure
• Check blood alcohol levels
• Monitor blood glucose
• Ventilatory support
• Inflammation & ulceration of GI tract • Early endoscopy
• Tachycardia
• Metabolic acidosis
• FOMEPIZOLE
• Haemodialysis
• Renal failure
• Measure plasma paracetamol conc.
3–5d: liver failure
• IV N-ACETYLCYSTEINE
• Measure plasma salicylate conc.
• N&V, drowsiness, blurred vision, tinnitus
• Hyperventilation
• Acute renal failure
• Rapid BG, blood gases, Cr, FBC, ECG
• Supportive Tx: fluids, dialysis etc.
• NO ANTIDOTE
• Measure serum iron levels
Latent period
• IV DEFEROXAMINE (chelates iron)
6h later: drowsy, coma, shock, convulse, liver fails
• Drowsiness, mitosis, vomiting
• Tachypnoea/apnoea → resp. acidosis
• Tachycardia, arrhythmias
• Dry mouth, blurred vision
• Agitation, confusion, convulsions
• Respiratory depression
• Activated charcoal within 1h
• IV NALOXONE
• IV SODIUM BICARB
▶ Correct metabolic acidosis
▶ Ventilatory support
▶ Sodium bicarbonate if arrhythmias
▶ Diazepam if convulsions
66
Resuscitation Council UK (2021) Emergency treatment of anaphylaxis
196 Chapter 5: Paediatrics Emergency paediatrics
https://t.me/med1917
GENERAL MANAGEMENT OF OVERDOSE/POISONING
1. Identify agent & amount taken (ask patient/parents, Sx, blood levels)
2. Check if activated charcoal can be used to absorption
3. Investigations – FBC, renal & liver function, ECG, ABG
4. Give antidote – if available / toxicity high enough
ineffective for iron
& pesticides
5. Supportive Tx: ventilatory support, IV fluids etc.
• Apnoea
• Colour change
• Altered muscle tone
• Choking/gagging
High risk features
• <8w/o or was premature
• multiple episodes or episodes >1min
• suspect abuse
• concerning Hx/examination features
e.g. FHx cardiac death, infective Sx
DDx / underlying cause of SIDS
• Cardiac abnormalities
• Metabolic abnormalities
• Sepsis
• NAI (shaken baby)
Brief resolved unexplained events (BRUE)
→ frightening combination of symptoms: most common in <10w
POTENTIAL CAUSES
• No cause identified = 50%
• Upper airway obstruction
• Infections (URTI)
• Seizures
• Gastro-oesophageal reflux
• Cardiac arrhythmia
MANAGEMENT
67
1. Detailed Hx & examination
→ including social Hx to r/o abuse
2. Admission to hospital
→ basic investigations (FBC, U&E, LFT, glucose, lactate, blood gas, ECG)
→ usually need overnight monitoring (SaO2, RR, HR, BP)
3. Discharge if normal obs & no high risk features
→ train parents in basic life support
Further Ix to consider
• CXR – respiratory infection
• EEG – seizure
• Urinalysis (MCS) – infection
• Oesophageal pH – reflux
• Barium swallow – obstruction
• Lumbar puncture – infection
Sudden infant death syndrome (SIDS)
→ sudden, unexpected death of an infant with no identifiable cause
RISK FACTORS
The infant The parents The environment
Age: 1–6m
(peak 2–4m)
Preterm or LBW Parental smoking Overheated baby
Male
Low income, poor/overcrowded housing Co-sleeping
hot room, too many blankets
• Single, unsupported mum
Baby sleeping on tummy
• Maternal age <20y
PREVENTION
• Put infants to sleep on back & ‘feet to foot’
• Avoid heavy wrapping or hot room
• Do not co-sleep – esp. if tired/alcohol/drugs
• Sleep with baby in same room for 6m
• Do not smoke near infant
• Seek medical advice ASAP if baby becomes unwell
After sudden death of an infant
• Inform police & coroner
• Detailed Hx & examination of infant (post mortem)
• Allow parents to see baby
• Bereavement support & counselling
67
Tate C, Sunley R Brief resolved unexplained events (formerly apparent life-threatening events)
and evaluation of lower-risk infants—Archives of Disease in Childhood—Education and Practice
2018;103:95–98
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