Week 24 - childhood conditions Flashcards
Common ailments childhood conditions
-Teething
-Threadworms
-Colic
-Head lice
-Nappy Rash
-Oral thrush
Teething
->Teething occurs when the teeth emerge through the gums
->Most children start teething around 4–12 months of age and have their full set of teeth at around 2 to 3 years old
->Signs and symptoms of teething are generally mild and usually occur about 3–5 days
before each tooth erupts
Teething -> when to refer to GP
-Fever (raised temperature above 38°C)
-Diarrhoea – there may be a change in the passage of stools at teething time -> should not cause diarrhoea
-Any infant who is systemically unwell, in severe distress or has prolonged symptoms
-Diagnostic uncertainty
Teething - treatments
First-line treatment is with self-care measures -> consider paracetamol and/or ibuprofen for symptomatic relief in infants over 3 months of age if self-care hasn’t helped
->(1st line) Paracetamol 120 mg in 5 mL sugar-free paediatric oral suspension, 100mL
->(2nd line) Ibuprofen 100 mg in 5 mL sugar-free oral suspension
^Only use if self-care methods do not help - limit to children over 3 months of age!!!
Teething - advice for patients
-Gently rub the gum with a clean finger
-Under supervision allow the child to bite on a clean, cool (not frozen) object (avoid objects that can easily be broken into hard pieces because they may be a choking risk); suitable examples include:
-A chilled teething ring or cold wet flannel (never tie the teething ring around the infant’s neck, as it is a choking hazard)
solid rings are preferred over gel or liquid filled rings, which could leak
-Chilled fruit and vegetables (e.g. banana, apple, carrot or cucumber) for children who have been weaned; sugar-free
products are preferred (avoid teething biscuits or rusks) so as not to cause tooth decay
-Cuddle, reassure and distract the child with play
-Wipe away excess saliva regularly to reduce risk of facial rash
-Cool, sugar-free drinks can help soothe gums
Dental care:
-As soon as teeth erupt, brush them using a toothbrush and fluoride toothpaste – use a tiny smear for babies, and a pea-sized amount for children
-For children under 3 years old, use a toothpaste with a fluoride level of 1000 ppm (parts per million) twice daily
-Encourage parents/carers to take their child to the dentist before the first tooth erupts, at about six months of age
Symptomatic relief:
-Teething gels that contain a local anaesthetic (e.g. Bonjela® Junior gel and Dentinox® Teething gel) are not recommended as they can cause harm if swallowed
-If teething gels are used, they are only available under the supervision of a pharmacist
-Bonjela® Junior gel is not licensed for children under the age of 5 months
-Oral gels containing salicylates must never be used in children under 16 years old because of the risk of Reye’s syndrome
-There is no good evidence that complementary treatments (e.g. herbal teething powder or homeopathic remedies) are of
benefit for teething symptoms
Threadworms
-Threadworms are small, thin, white thread-like worms about 2–13 mm long
-They do not usually cause serious problems and are
common in children -> anyone can be affected - female worms lay tiny eggs around the anus
-This causes itching which is usually worse at night
-The worms might be visible in stools or around the anus
-Adult threadworms survive for about 6 weeks and infection
is maintained by swallowing fresh eggs ->iInfection is unlikely to resolve without treatment
Possible complications:
-Lack of sleep (due to itching) with subsequent daytime irritability and difficulty concentrating
-Intestinal damage
-Bedwetting
-Excoriation and secondary infection of the perianal skin
-Disease in other sites due to worm migration (e.g. the urethra and female genito-urinary tract)
-Colitis, abscess and granuloma formation may occur within the intestines, along the perineal skin, and within the peritoneum
(extremely rare)
Threadworms -> when to refer to GP
-Individuals less than 6 months of age
-Pregnancy or breastfeeding where hygiene measures alone ineffective or not acceptable
-Frequent recurrences
-Diagnostic uncertainty
Threadworms - treatment
-Treat the person if threadworms (or eggs) have been seen
-Treatment options include:
->Hygiene measures alone (undertaken for 6 weeks)
OR
->Mebendazole and hygiene measures (undertaken for 2 weeks) - the health risks and benefits of mebendazole for children under 2 years of age should be carefully considered
-Mebendazole is given as a single dose, but as reinfection is common, a 2nd dose may be given after 2 weeks
->Treat all household members over 6 months old at the same time unless contraindicated, as asymptomatic infection is
common!!!
Threadworms - home hygiene measures
(Undertake on the first day of treatment)
-Wash sleepwear, bed linen, towels and soft toys at normal temperatures and rinse well
-Thoroughly vacuum and damp-dust all rooms, paying particular attention to the bedrooms, including vacuuming mattresses,
rinse the cloth in hot water frequently throughout dusting, then throw it away
-Disinfect kitchen and bathroom surfaces
-Avoid shaking any material that may be contaminated with eggs, such as clothing or bed sheets.
Threadworms - personal hygiene measures
->Complete for 2 weeks if combined with drug treatment or for 6 weeks if used alone
-Wear close-fitting underpants at night and change them every morning
-Use cotton gloves to help prevent night-time scratching; wash and change these, bed linen and nightwear daily for several days after treatment
-Bath or shower immediately on rising each morning, washing around the anus to remove any eggs laid by the worms during
the night
Threadworms - general hygiene measures
-Wash hands and scrub under the nails first thing in the morning, after using the toilet or changing nappies, and before eating or preparing food
-Avoid nail biting and finger sucking and keep fingernails short
-Avoid sharing towels or flannels
-Avoid scratching around the anus
-Keep toothbrushes in a closed cupboard and rinse them thoroughly before use
-Children do not need to be excluded from school or nursery
Infantile colic
Infantile colic is recurrent and prolonged periods of infant crying, fussing or irritability that occur without obvious cause, and cannot be prevented or resolved by caregivers in an infant that otherwise appears to be healthy and thriving
->It is a self-limiting condition which usually starts within the first few weeks of life, improves by 3–4 months and resolves by
5–6 months of age
Exact underlying cause is unknown but; it may be caused by:
-Abnormal gastrointestinal motility
-Inadequate amounts of lactobacilli/increased amounts of coliform bacteria in the intestinal microflora
-Psychosocial factors e.g. family tension, parental anxiety, inadequate parent-infant interaction, overstimulation of the infant, misinterpretation of crying
Symptoms include:
-Crying that often occurs in the late afternoon or evening
-Drawing knees up to abdomen or arching back when crying
-Fist clenching/going red in the face/passing flatus
Infantile colic - possible complications
-Premature cessation of breastfeeding
-Family tension and parent-infant attachment difficulties
-Increased risk of infant maltreatment
-Parental stress, fatigue, anxiety or depression.
-Loss of confidence in parenting skills
Infantile colic -> when to refer to GP
-Infants who are not thriving and/or have symptoms that are not improving or are severe
-Symptoms that haven’t improved after 4 months (an alternative underlying cause for symptoms should be considered)
-Parents/guardian feel unable to cope with the infant’s symptoms despite reassurance and advice
-Diagnostic uncertainty
Infantile colic
-There is insufficient, good quality evidence for the use of the following management strategies and so they are NOT recommended:
-Simeticone (such as Infacol®) or lactase (Colief®)
-Probiotic or herbal supplements
-Maternal diet modification if breastfeeding, or changing the infant milk formula preparation
-Manipulative strategies such as spinal manipulation or cranial osteopathy
->Therefore, for the management of infantile colic, advice, support and/or onward referral alone are recommended
Infantile colic - management strategies
-Holding, rocking or bathing the infant in a warm bath may help soothe them
- “White noise” (e.g. vacuum cleaner/hairdryer)
-Ensure an optimal winding technique is used during and after feeds
-Continue breastfeeding wherever possible
Reassurance/support to parents/guardians:
-Infantile colic is a common condition which should resolve by 6 months of age
- “Cry-sis” is a support group for families with excessively crying or sleepless children
-The “My baby is crying all the time” section on the Healthier Together website
-Parental/guardian access to appropriate support and wellbeing (e.g. friends, family, health visitor) and rest whenever
possible is very important
-Meeting other parents/carers with children of similar age to share experiences may also be beneficial
Head lice
Head lice are grey-brown parasitic insects, about the size of a sesame seed, that infest the hair and feed on blood from the scalp -> they lay eggs which hatch after 7 to 10 days - after a further 7 to 10 days, the hatched louse begins to lay eggs
-Empty yellow-white
egg-shells (nits) may be seen attached to the hair
Symptoms include:
-Itchy scalp
-Feeling something moving through the hair
Itchy scalp or the presence of eggs alone is not sufficient to diagnose active infestation; a live louse must be seen!!!
Systematic combing using a fine-toothed head lice detection comb (not a nit comb) is the best way to confirm the presence of lice -> wet combing with conditioner is more accurate than dry combing as the louse move less when wet
All household members and other close contacts should use a lice detection comb, and those with live lice should be treated on the same day to avoid reinfection
Head lice - possible complications
Complications are rare but include:
-Rash on the back of the neck and behind the ears, caused by a hypersensitivity reaction to louse faeces
-Excoriation and secondary skin infection
-Anxiety, distress, and stigma
-Loss of sleep caused by itching and missed days of school
Head lice -> when to refer to the GP
-Scalp inflammation or signs of infection
-Infestation persisting after treatment with all appropriate methods
-Under 6 months of age.
-Diagnostic uncertainty
Head lice - treatment
Treatment options depend on person/carer preference, treatment history and contra-indications
->Insecticides should only be supplied if the person is able to supply evidence of a live louse
Lice found using detection combing can be attached to sticky tape and brought to the consultation to aid diagnosis
Treatment options include:
-Wet combing with a fine-toothed head louse comb to remove the lice -> the Bug Buster® kit is the only head lice removal (and detection) method that has been evaluated in randomised controlled trials, and it is available on the NHS
-Physical insecticides are effective in 70% of cases; dimeticone lotion (Hedrin®) is poorly effective against eggs, however Hedrin® Once formulations have good ovicidal activity
-Chemical insecticides – malathion 0.5% aqueous liquid (Derbac-M®) is the only one recommended in the UK, but
resistance has been reported
Head lice - post treatment detection
Detection combing should be done after all treatments to confirm success
Treatment is successful if no living lice are found on the
scalp
Nits may be present (they can remain attached for up to 8 months) but no further treatment is necessary
Detection combing should be carried out on the days shown below:
-After wet combing - detection comb on day 17 to check for any live head lice
-After insecticide products with a single application – detection comb on day 1 and day 10
-After using products with two applications – detection comb one day after the last treatment
Head lice - treatment failure
Advise that close contacts should be assessed to identify possible sources of re-infestation and treated simultaneously
After insecticide treatment:
-Check that the treatment course was complete with correct application time, technique, and volume of product
-Repeat the same treatment or switch to a different treatment, as appropriate (if malathion has been used, consider the
possibility of resistance)
After wet combing (live louse found on Day 17):
-Confirm correct combing technique, sufficient duration of combing, and sufficient combing sessions
-Advise the person to repeat wet combing or consider using an appropriate insecticide
Nappy rash
Nappy rash is inflammation of the skin in the area of the body covered by a nappy and is primarily an irritant contact dermatitis
-Irritants such as urine, faeces, and faecal enzymes lead to skin breakdown, typically of the perineum and convex surfaces of the buttocks, with sparing of the skin folds
Features include:
-Red patches on the baby’s bottom, possibly including the whole area
-Skin that looks sore and is hot to the touch
-Spots, pimples or blisters
Although all babies can get nappy rash, it doesn’t usually develop in newborns
Most babies with mild nappy rash don’t feel sore, but if the rash is severe the baby may feel uncomfortable and be distressed
Nappy rash - possible complications
Candida (fungal) infection can occur as it thrives on the inflamed skin
This can appear as sharply marginated redness involving the skin creases and can cause an inflamed rash to look brighter or darker red
Antifungal cream can be used to treat it
Nappy rash -> when to refer to the GP
The rash presents in the following ways:
-Severe redness/soreness with or without exudate (possible bacterial infection)
-With punched out ulcers or erosions with elevated borders (possible erosive diaper dermatitis)
-With smooth, red, moist papules or nodules in the nappy area, around the perianal skin, and involving genital, suprapubic,
and buttock skin (suspected perianal pseudoverrucous)
-With asymptomatic, cherry-red, 0.5–4 cm plaques and nodules (suspected granuloma gluteal infantum - rare)
-The baby appears systemically unwell
-Diagnostic uncertainty
-Refer babies where there is suspicion of immuno -suppression, but supply appropriate treatment
Nappy rash - treatment
-Asymptomatic cases/mild erythema – thinly apply a barrier preparation at each nappy change to protect the skin, such as a soft white paraffin or a combination preparation of zinc and castor oil ointment or cream
-Inflamed rash that is causing discomfort – babies over 1 month old could be treated with hydrocortisone 1% cream (via a
PGD) applied once daily, in addition to the barrier preparation until symptoms settle; or for a maximum of 7 days (whichever comes first)
-If the rash persists and Candida infection is suspected, a clotrimazole preparation could be issued but advise avoiding the barrier preparation until the infection has settled
Nappy rash - advice for parents
Nappy rash usually clears up after about 3 days and can be prevented, following this advice:
-Make sure the baby’s nappy fits properly; if it is too tight then it can irritate the skin and if it is too loose, then the nappy will
not be able to soak up urine properly
-Change wet or dirty nappies as soon as possible after wetting or soiling
-Clean the whole nappy area gently but thoroughly, wiping from front to back; use water or fragrance-free and alcohol-free
baby wipes
-Bathe the baby daily – but avoid bathing them more than twice a day as this may dry out their skin
-Do not use soap, bubble bath, or lotions
-Dry the baby gently after washing them – avoid vigorous rubbing
-Lie the baby on a towel and leave their nappy off for as long and as often as you can to let fresh air get to their skin
-Do not use talcum powder as it contains ingredients that could irritate the baby’s skin
Oral thrush
Oral candidiasis (also known as oral thrush) is an infection caused by Candida. It can be asymptomatic although may cause discomfort if severe
Signs and symptoms include white spots or plaques in the mouth that can be wiped off, leaving behind red patches, generalised erythema and a change in taste
Babies may drool or have difficulty feeding -> it is not usually contagious
Oral thrush - risk factors
Risk factors for oral thrush (making it more common in these groups):
-Babies and the elderly
-People who wear dentures
-Immunocompromised people or people with poor health
-People who have had recent antibiotic or steroid treatment
-Diabetes mellitus
-Excessive mouthwash use
-Iron, folate or vitamin B12 deficiency
-Smokers
->Oral thrush may be the first presentation of an undiagnosed condition!!!
Oral thrush - possible complications
Chronic pain or discomfort
-Impaired speech and/or chewing
-Immunocompromised individuals may develop oesophageal candidiasis, causing painful or difficult swallowing; this can lead
to systemic candidiasis
Oral thrush -> when to refer to GP
-Babies under 4 weeks old
-Symptoms not resolved after 7 days of treatment
-Difficulty or pain on swallowing
-Pregnancy or breastfeeding – provide treatment but always refer
-Extensive, severe infection or systemically unwell
-No obvious risk factor (see: ‘About the ailment’ section).
-Possible severe immunocompromise
-Single red or red and white plaque that cannot be rubbed off (erythroplakia /erythroleukoplakia) may be pre-malignant – refer urgently to a dentist
-Treatment may be provided to individuals taking DMARDs or steroids but always refer
-Diabetes – provide treatment but always refer
-Diagnostic uncertainty
Oral thrush - treatment
-(1st line) Miconazole 20 mg/g oromucosal gel sugar free
-(2nd line) Nystatin oral suspension 100,000 units/ml
Oral thrush - advice for patients
Treatment:
-Try and ensure treatment is kept in the mouth for as long as possible – avoid swallowing immediately
-Administer after meals
-Seek medical advice if symptoms persist after 7 days.
Prevention:
-Maintain good dental and denture hygiene – dental prostheses and orthodontic appliances should be fitted and secured properly during the day (e.g. denture fixative agents), and removed at night/for at least 6 hours daily
-Clean and disinfect dentures daily
-Stop smoking – provide/ signpost to smoking cessation advice
-Ensure good inhaler technique for corticosteroids – risk of oral candidiasis can be reduced by using a spacer device with a
corticosteroid inhaler and rinsing the mouth with water (or cleaning the teeth) after using the inhaler
-Sterilise babies’ dummies and bottles
