Transcript 1315-1445-Richard-Brown - Children`s Health Queensland

Dr Richard Brown
General Paediatrician
Department of
Paediatrics and
Dermatology - LCCH
Taylor Medical Centre
– Woolloongabba
Referral Guidelines – Plagiocephaly
Plagiocephaly needs to be distinguished from the rare condition, craniosynostosis, which is premature fusion of one or more
cranial sutures. Craniosynostosis can occur alone or as part of a syndrome, and is treated surgically.
GP assessment and management.
Inspection and palpation of the infant’s skull from all angles looking for the following red flags for craniosynostosis:
• A bony ridge along a suture line
• A closed or triangular shaped anterior fontanelle (rather than an open, diamond shaped fontanelle)
• Unusual head appearance
• General examination for signs of possible genetic syndrome
• Check for torticollis – test passive and active neck range of motion and look for persistent head tilt to one side
• Review centile charts, in particular head growth
• Plain skull XR if craniosynostosis is considered
• If no red flags for craniosynostosis, normal developmental progress and normal head growth, manage conservatively and
review:
• Alternate sleep position on the right and left occiput
• Have a certain amount of prone “tummy time” while awake
• Vary the position for holding and carrying the infant.
There is no evidence to support the use of helmets in the majority of cases.
Plagiocephaly - When to refer
• If no red flags for craniosynostosis, normal developmental progress and normal
head growth – manage conservatively as above and review.
• If there is torticollis, persistent head tilt or tight neck muscles – consider
paediatric physiotherapy referral (private or Child Development Program)
• If abnormal head shape is associated with developmental concerns, or
deformation is severe, refer to a paediatrician or Child Development Program
• If skull XR is abnormal, refer to paediatrician or plastic reconstructive surgeon.
WHEEZE IN INFANCY & EARLY CHILDHOOD
Definition - Continuous, high pitched sound from the chest during expiration
Non-specific sign caused by turbulent air flow due to narrowing of intra-thoracic airways,
indicating expiratory air flow limitation.
Confirm expiratory sound by accurate history, video or clinical examination.
Approximately 1/3 of children have one episode of wheeze before the age of three.
WHEEZE IN INFANCY & EARLY CHILDHOOD
Differential diagnosis
Episodic wheeze with URTI or multiple triggers
Wheezing phenotype – transient intermittent wheeze of early childhood which resolves by the age of 2-3
Early onset asthma
Fixed obstruction – wheeze from birth which is constant or highly regular suggests fixed congenital airway
obstruction
Aspiration – risk factors:
• Malformation of upper respiratory / digestive tract
• Neurodevelopmental problems with impaired swallowing or airway protection
Environmental factors – cigarette smoke and daycare
AMERICAN ACADEMY OF
PAEDIATRICS
GUIDELINE – BRONCHIOLITIS
Consider risk factors for severe disease
Aged less than 12 weeks
Prematurity
Underlying cardiopulmonary disease
Immunodeficiency
Investigations
Routine chest X-ray and laboratory studies not indicated
Treatment not indicated:
Salbutamol
Antibiotics
Systemic corticosteroids
Physiotherapy
Pediatrics 2014;134:e1474-1502
BRONCHIOLITIS –
AVOID IN INFANCY:
• Antibiotics
• Steroids
• Ventolin
• Tests
ASTHMA IN CHILDREN –
LESS THAN 5 YEARS OF AGE
No current tests can diagnose asthma with certainty
Increased risk of asthma in children:
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Severe or frequent episodes, interval symptoms, eg, exercise, laughing and crying
History of eczema or positive allergy tests
First degree relative with asthma
Bronchodilator response on its own – conflicting evidence
Global initiative for Asthma (GINA)
Eur Respir J 2015; 46:622-639
FREQUENT OR PERSISTENT WHEEZE –
LESS THAN 5 YEARS OF AGE
Monitor:
Symptom Control
Inhaler technique
Adherence
Exposure – cigarette smoke, indoor / outdoor pollution, indoor
allergens
Psychological / socioeconomic problems
Eur Respir J 2015; 46:622-639
INFANTS WITH RECURRENT OR PERSISTENT WHEEZING
(American Thoracic Society Guidelines)
Investigations
All studies – low quality evidence, mainly case series
Therefore there are conditional recommendations:
• For infants less than 24 months of age
• Non-responsive to bronchodilators, inhaled corticosteroids or systemic steroids
Am.J.Resp. & Care Med 2016 194;3:356
TREATMENT OF WHEEZING IN
PRE-SCHOOL AGE
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Salbutamol for acute symptoms, if symptomatic improvement
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Seven day course of montelukast at the start of viral induced wheeze, possible benefit
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Consider trial of montelukast or inhaled corticosteroids (ICS) eg, Fluticasone – 100/200mcg / day with
more severe recurrent / persistent wheeze
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Inhaled corticosteroids - May be more beneficial in children with multiple tracheal wheeze or children with
positive asthma predictive index
• Possible adverse effects on long-term airway thickness and lung micro anatomy
• Recommend high threshold for using ICS in infancy, eg, persistent / disabling symptoms, or very severe
episodes
RECURRENT OR PERSISTENT WHEEZING
(American Thoracic Society Guidelines)
Investigations
Infants not responsive to bronchodilators, inhaled corticosteroids, systemic steroids:
Bronchoscopy – 33% abnormal - Tracheomalacia, Bronchomalacia
Vascular ring, sling, compression
Bronchoalveolar lavage: 20-30% positive bacterial culture
Empiric dietary elimination - not recommended
Consider tests for GOR - 24hr pH study + impedance monitoring
Feeding swallow study – 10-15% aspiration  feeding intervention
Am.J.Resp. & Care Med 2016 194;3:356
Excessive
Crying in
Infancy
Child:
Mother:
Father:
1st Child:
Marigold – eight weeks’ of age
Jane
William
Annabelle – aged two
Mother – Asthma, hayfever and allergic rhinitis
Second pregnancy – Annabelle aged two
At 25 weeks’ Jane’s mother – breast cancer – surgery
At 30 weeks’ William retrenched
Unexpected emergency caesarean section delivery
Slow to attach and commence breast feeding
From two weeks of age, fussing with feeds, spilling, vomiting, inconsolable crying, poor sleep pattern
From six weeks’ Jane stopped dairy products
From seven weeks’ of age Losec Syrup 10mg / day commenced
Examination normal – good weight gains
Jane sleep deprived and exhausted. Tried various settling techniques.
ISSUES
? Effect of antenatal stress on infant
? Effect of neonatal course
? Food allergy
? Gastroesophageal Reflux Disease
? Safety of long-term Losec use during infancy
? Other factors contributing
EXCESSIVE CRYING
(In An Otherwise Healthy Infant)
Infant factors
Gastroesophageal reflux
Cow’s milk allergy
Lactose intolerance
Feeding issues
Sensory issues
Maternal Factors
Anxiety/depression/stress
Responsiveness/attachment
Infant Temperament
Disorder of Regulation
Microbiome
Family / Environmental Factors
GORD – Infants at High Risk
• Neurological impairment
• Congenital oesophageal anomaly
Eg repaired tracheoesophageal fistula, hiatus hernia
• Congenital diaphragmatic hernia
• Chronic respiratory disorder, eg, cystic fibrosis, chronic neonatal lung disease
• Prematurity
• Obesity
• Family history – severe GORD, or oesophageal adenocarcinoma
National Institute for Health and Care Excellence, January 2015
GOR – American Academy for Pediatrics
Management / guidance for the Pediatrician
“No single symptom of cluster of symptoms can be reliably used to diagnose
oesophagitis or other complications of GORD in children or to predict which
patients are most likely to respond to therapy”
“GERD………….there is no single test that can rule it in or out”
Pediatrics 2013;131:5, 1684
PPI use in infants
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FDA reviewer experience
4 randomized controlled trials PPIs in infants
Symptomatic GERD (fussiness, regurgitation, gagging with feeds)
PPIs not effective
Safety concerns with long term use of PPIs
Subpopulation of infants with GER and acid induced disease,
difficult to identify
(Multi channel impedance monitoring)
J PED GASTRO and NUTRITION 2012;54:8-14
HUMAN MICROBIOME
Neonates – bacterial colonisation of gastrointestinal tract – intimately inked
• Development of the nascent immune system, gut anatomy and nervous system
• By about the age of three, GIT microbiome is starting to approach an adult-like state
• Role of gut microbiota in production of short chain fatty acids (SCFA) – important in relation to
nutrition, adipose tissue deposition, immunity and cancer
Int Med J 2014; 45:9889-898
BEWARE OF DISRUPTION OF MICROBIOTA IN EARLY INFANCY FROM ANTIBIOTICS AND PROTEIN
PUMP INHIBITORS
Respect
1. Trucks
2. The body’s normal
physiology
Infant Crying – Food Allergy
• Cow’s milk protein allergy
• Uncommon unless other GI/skin manifestations
• Consider trial elimination
• If breastfeeding – maternal dairy elimination for 2 week
• If bottle feeding – trial soy milk 2 weeks or
• Trial extensively hydrolyzed formula (Pepti Junior or Alfare)
• Re-challenge in one month
J PAEDIATRICS AND CHILD HEALTH 2009;45:481-486
Temperament – Goodness of Fit
with Parents
Sensitivity – to sound, touch, light
Activity level
Intensity – strength of reaction to change / distress
Regularity – routine
Adaptability – cope with change, intrusion into space
Persistence – with development of new skill
Soothability
Community Paediatric Review, Royal Children’s Hospital Melbourne. March 2013
Excessive Crying in Infancy
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Biological and psychological risk factors in mother and infant
interact early and can interfere with mutual regulation
Disrupted mother – infant dynamic becomes entrenched
“Complex adaptive system” vs reductionist approach
Support parents ability to respond to their individual infant’s
capacity to develop self regulation
ARCH DIS CHILD 2011;96:793
Strategies for Calming
Early infancy:
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Consider different feeding technique*
Relaxed cue based care
Physical contact
Co sleeping (share room, not bed)
Sensory stimulation
• Eye contact, reciprocal interaction
• Singing, humming, speaking softly
• White noise, warm bath
• Movement, massage
• Swaddling
* NEWBORN INFANT NURS REV. 2005;5:49-58
EXCESSIVE CRYING IN INFANCY –
REVIEW ARTICLES
Managing infants who cry excessively in the first few months of life:
P.Douglas, P.Hill.BMJ2011;243:D772
Troublesome Crying in Infancy, Arch Dis Child Educ Pract Ed,
2013:98;201
Recommend and Useful
Websites – Handout
THE MICROBIOME MELODY:
(With Apologies to the Hokey Pokey!)
You put your antibiotics in, your put your antibiotics out
You put your antibiotics in, and you shake them all about!
You worship the microbiome and turn you around
And that’s what it’s all about!
You put your PPI’s in, your put your PPI’s out
You put your PPI’s in, and you shake them all about!
You worship the microbiome and you turn around
And that’s what it’s all about!