Search

A child presenting with decreased level of conscious (dLOC) is of great concern due to the wide range of possible causes, and potential for death or serious long-term sequelae. It is therefore vital that health professionals can recognise a child with dLOC quickly, intervene appropriately and escalate for senior review as a matter of urgency. This article provides an explanation for the mechanisms of decreased consciousness, outlines the different causative pathologies, and provides a simple and logical approach to the first-line recognition and management that a health professional may apply when faced with such a patient. Illustrative case studies have been included, to demonstrate how children with dLOC may present in clinical practice

Systemic lupus erythematosus (SLE) is an autoimmune multisystem disease. Childhood-onset SLE is extremely rare and comprises only 10% to 20% of all cases. In this case report, we present a 9-year-old boy from northeastern India who presented with fever, cough, vague abdominal pain, lethargy and swelling of face and legs. Initial impression was one of sepsis with central nervous system (CNS) involvement and was treated accordingly. Detailed clinical examination with subsequent laboratory and imaging studies clinched the diagnosis of SLE. The patient showed rapid resolution of symptoms with immunoglobulins, cyclophosphamide and steroid therapy. A brief discussion on childhood neuropsychiatric lupus syndrome and SLE with CNS infections is included here.

Leukaemia is the most common cancer in children. The presenting manifestations can be wide-ranging, from a relatively well child to life-threatening complications. Symptoms can be manifested in any of the bodily systems. Undertaking a thorough clinical assessment of the child, in addition to recognising and addressing parental concerns, is vital. Furthermore, recognising that children can commonly present with musculoskeletal or abdominal symptoms increases the diagnostic yield, thereby preventing missed or late diagnoses. Childhood cancer has a huge impact on the child and their family, both at diagnosis and in the long term; providing advice and signposting families to appropriate support groups is an important aspect of their management. Nurses play a vital role in managing children with cancers, starting from raising suspicion and identifying the child with leukaemia, ensuring that high-quality care is delivered throughout their treatment, managing complications, and providing support and information to children and their families. An illustrative case study is included to highlight some of the challenges that health professionals may encounter in their clinical practice.

Coeliac disease (CD) is an immune-mediated systemic disorder caused by the ingestion of gluten. In children, it may present with intestinal or extra-intestinal manifestations such as diarrhoea, weight loss, iron deficiency anaemia or faltering growth. Diagnosis is confirmed by small bowel biopsies showing histological changes consistent with enteropathy. In 2012, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition revised the CD guidelines and suggested that, in a selective group of symptomatic children, CD can be diagnosed without the need for small-bowel biopsies. Management of CD is through strict adherence to a life-long gluten-free diet (GFD). CD is of great public health significance as its prevalence in developing countries has been found to be similar to that in developed countries. Early recognition and treatment improves prognosis. Patients and families require long term support to enable effective adherence to a GFD lifestyle. This alone can be challenging, but through support of health professionals and dietitians, can improve patient outcomes. In resource-limited settings medical professionals need to be creative in formulating cheaper and locally sourced gluten free options in close cooperation with the dietitians thereby ensuring availability of gluten free food items at affordable prices. In this paper, we gave an overview of the subject followed by authors’ view to emphasize the need for improved awareness in resource-limited settings.

In 2012, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) revised diagnostic guidance for paediatric coeliac disease (CD).1 It recommended a no-biopsy pathway (NBP) for symptomatic children if so-called ‘triple test’ criteria are satisfied1: The British Society of Paediatric Gastroenterology, Hepatology and Nutrition adopted the guidelines in 2013. ESPGHAN suggested that CD can only be diagnosed by paediatric gastroenterologists or consultant paediatricians with special interest (SPIN) in gastroenterology.1 Many secondary care centres (SCC) in the UK have no SPIN consultant, therefore CD diagnosis is often made by (non-SPIN) general paediatricians. The NBP was implemented in Southwest England (SWE) in May 2013.2 An electronic register is maintained in …

Feverish illness is one of the leading causes for a child to be seen by healthcare professionals, and is a major cause for hospital admissions. In 2007, the National Institute for Health and Care Excellence (NICE) published the original guidance on feverish illness in children (CG47). This was developed to aid healthcare professionals in their decision-making process while managing children aged

Rationale and key points Measuring and monitoring growth in infants and young children under two years old is an important part of their clinical assessment in hospital and the community. This article outlines the procedure for measuring growth in infants and children under two years old, and discusses the main factors to consider when undertaking this assessment. » The procedures and some of the data used to monitor the growth of infants and children under two years old differs from those used in older children. » Obtaining growth information for an infant or child involves measuring and recording their length, weight and head circumference. The process of obtaining this information is not necessarily straightforward and errors may occur while measuring and plotting or interpreting data. » Correct use of growth measuring equipment and growth charts is essential to obtain accurate results. Nurses should be able to plot weight, length and head circumference data for infants and children under two years old, and to correctly interpret this data to identify malnutrition and faltering growth. Reflective activity 'How to' articles can help you update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of: 1. How you think this article will change your practice when you assess growth in infants and children under two years old. 2. What practical experience you require to consolidate your learning, having read this article. 3. Any learning needs that you have identified that would increase your clinical effectiveness and professional development.

Foreign body ingestion and foreign body aspiration commonly affect children. The most vulnerable age is between six months and four years, when children tend to explore new objects with their mouths. Many of these events remain asymptomatic, with the swallowed object passing through the gastrointestinal tract without causing harm. However, the frequency of serious complications as a result of the ingestion of hazardous objects has increased in recent years, in particular button batteries and magnets. To increase the likelihood of identifying foreign body ingestion and aspiration, healthcare professionals should maintain a high index of suspicion, be aware of the variation in presentations and include it as a differential diagnosis in children presenting with non-specific symptoms, such as fever, cough, drooling, dysphagia and abdominal pain. Management of most foreign body ingestions is conservative, using a 'watch-and-wait' approach. Children should be triaged as an emergency if they have signs or symptoms of airway obstruction or a history that indicates dangerous foreign body ingestion. Early recognition and management leads to improved outcomes for patients. Nurses have a vital role in providing education and practical advice to parents, which reduces the occurrence of these events. Stronger legislation is required to ensure manufacturers emphasise the potential dangers of certain products and design child-safe devices.

Diabetes mellitus is a common condition in children, characterised by chronic hyperglycaemia resulting from an absolute insulin deficiency. It can present in various ways, and hospital admission may result from complications related to previously diagnosed diabetes, or from a new diagnosis. To raise awareness of the condition, Diabetes UK has launched the 4Ts campaign, which highlights the four most common symptoms of diabetes. This article discusses the different clinical presentations, diagnosis and management of children with diabetes, and includes two case studies to illustrate some of the challenges faced by emergency department nurses.

Irritable bowel syndrome (IBS) is the most common cause of non-organic recurrent abdominal pain in children. IBS is a clinical diagnosis, which is based on the Rome IV criteria for functional gastrointestinal disorders in children, as well as the patient's history. The diagnosis of IBS is established following the exclusion of organic causes of recurrent abdominal pain. Staggered investigations should be avoided because they might increase the child's and family's anxiety in the absence of an organic diagnosis. In most cases, providing a positive diagnosis of IBS and explaining the current understanding of the functional pathophysiology of the condition and management strategies gives reassurance to the child and their family. Management is based on dietary, pharmacological and biopsychosocial interventions. IBS can be a debilitating condition, with effects on activities of daily living, education and social interactions. Nurses working in various clinical settings will encounter children with IBS and have an important role in the management of children with this condition.

Brain tumours comprise over one quarter of all childhood cancers in the UK and are the most common cause of cancer-related deaths in children. The presentation of brain tumours can vary substantially in children. The presenting symptoms are often similar to less serious conditions, and are often managed as such initially. Therefore, it can be difficult to diagnose brain tumours in children. An early diagnosis is usually associated with more effective treatment and improved health outcomes. The diagnostic interval between first presentation to a health professional and diagnosis for brain tumours in children has been shown to be three times longer in the UK than in other developed countries. As a result, the HeadSmart campaign launched a symptom card in 2011 to increase awareness of brain tumours in children among the general population and healthcare professionals, with the aim of reducing the diagnostic interval to 5 weeks. Nurses have an essential role in early recognition of brain tumours in children, and in providing care and support to the child and their family following a diagnosis.

Head injury is the most common cause of injury-related death and permanent disability in children. Minor head trauma is common in childhood and does not require any medical treatment. Although deficits can occur even after mild to moderate head injury, they are markedly greater and become clinically evident following severe head injury. It is important that emergency department clinicians are aware of the signs and symptoms that indicate severe traumatic brain injury and triage for urgent intervention in those children who present with these signs and symptoms. Clinicians also need to know when children can be sent home with reassurance and information, and when they require admission or transfer to a neurosurgical unit. This article examines the literature on head injuries in children, describes assessment, management and treatment, and provides a simple management algorithm.

Children with a petechial rash commonly present to emergency departments. The rash can be associated with serious illnesses, such as invasive meningococcal disease (IMD), but is usually associated with less severe conditions. This article discusses the common and important causes of petechial rash, including IMD, viral illnesses, trauma, Henoch-Schonlein purpura and idiopathic thrombocytopenic purpura. It also analyses the National Institute for Health and Care Excellence (NICE) ( 2014 ) pathway for management of petechial rash in children and examines treatment of the various causes. The article includes two relevant case studies and discusses the role of emergency nurses.

Children with red swollen eyes frequently present to emergency departments. Some patients will have orbital cellulitis, a condition that requires immediate diagnosis and treatment. Orbital cellulitis can be confused with the less severe, but more frequently encountered, periorbital cellulitis, which requires less aggressive management. Delayed recognition of the signs and symptoms of orbital cellulitis can lead to serious complications such as blindness, meningitis and cerebral abscess. This article describes the clinical features, epidemiology and outcomes of the condition, and discusses management and treatment. It also includes a case study.

Enteroviral meningitis in infants and children commonly leads to hospital admission. Diagnosing viral meningitis can be difficult clinically. We examined the usefulness of enteroviral polymerase chain reaction (PCR) testing using cerebrospinal fluid (CSF) samples on clinical practice by comparing positive enteroviral CSF PCR cases (n = 39/136) to negative controls using both clinical outcomes and laboratory parameters. A positive result correlated with a reduced admission to high dependency unit, reduced the duration of antibiotics and a shorter length of stay (P .05). Adjusted CSF white cell count 5/μL correlated with positive PCR (P .05) but would have missed 32% of cases of enteroviral meningitis. Following these findings, an algorithm for the management of suspected viral meningitis has been introduced.

Febrile convulsions (FCs) are characterised by convulsions associated with fever in children aged between 6 months and 6 years. FCs are relatively common and affect 3–4% of children in western countries. This is the most common seizure disorder seen in children. The cause of febrile illness in FC is usually benign and most frequently due to acute viral infection. Convulsions secondary to an intracranial infection (e.g. meningitis, encephalitis) or from acute electrolyte imbalance should not be labelled as FCs. The diagnosis is based mainly on clinical history, and further investigations are generally unnecessary; management is largely symptomatic. Prolonged FC may need anticonvulsant medication to stop the seizure. Referral to paediatric neurologists may be considered in cases of complex or recurrent FC or in children where there is a pre-existing neurological disorder. One third of children with a first FC will develop a further FC during subsequent febrile illness; the likelihood increases in presence of other risk factors. This article outlines the presentation, management, investigations and prognosis for FC, and highlights how nurses in different clinical settings can provide education, support and counselling to help families return to normality after the event. An illustrative case study is also included to highlight the challenges faced by health professionals while managing children with this condition.

A newborn male infant was admitted to the neonatal unit with suspected early onset neonatal sepsis for monitoring and intravenous antibiotics. Despite his initial normal clinical and laboratory parameters, cerebrospinal fluid cultures done on day 4 of life confirmed Streptococcus oralis meningitis. His mother became unwell shortly after labour, and grew Streptococcus oralis in her blood cultures. Both were successfully treated with antibiotics and made a full recovery. Streptococcus oralis has been associated with meningitis in patients receiving spinal anaesthesia or following dental work, but is an uncommon cause of neonatal meningitis and maternal sepsis. We describe the first case in the literature where a mother-baby pair developed invasive non-pyogenic streptococcal disease with the same organism. There is a need for robust guidelines on antibiotic therapy in these cases.

Coeliac disease is an autoimmune condition caused by the ingestion of gluten-containing foods and affects about 1% of children and young people in the UK. Classic symptoms include diarrhoea, bloating, weight loss and abdominal pain. However, extra-intestinal manifestations, such as iron deficiency anaemia, faltering growth, delayed puberty and mouth ulcers, are increasingly being recognised. Some children have an increased risk of developing coeliac disease, such as a strong family history, certain genetic conditions and type 1 diabetes, therefore there is a need for increased awareness and early diagnosis before symptoms occur. If coeliac disease is suspected, a child should have serological screening with anti-tissue transglutaminase titres. Diagnosis is traditionally confirmed by a small bowel biopsy while the child remains on a 'normal' diet that does not exclude gluten. More recently, for a selective group of children, modification of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition guidelines has enabled non-biopsy (serological) diagnosis of coeliac disease. Children's nurses have an important role in recognising and diagnosing coeliac disease earlier as well as offering ongoing dietary support. Enabling children to maintain a gluten-free diet is essential for general wellbeing and preventing long-term complications.

Coeliac disease is an immune-mediated systemic disorder caused by ingestion of gluten. The condition presents classically with gastrointestinal signs including diarrhoea, bloating, weight loss and abdominal pain, but presentations can include extra-intestinal symptoms such as iron-deficiency anaemia, faltering growth, delayed puberty and mouth ulcers. Some children are at higher risk of developing coeliac disease, for example those with a strong family history, certain genetic disorders and other autoimmune conditions. If coeliac disease is suspected, serological screening with anti-tissue transglutaminase titres should be performed and the diagnosis may be confirmed by small bowel biopsy while the child remains on a normal (gluten-containing) diet. Modified European guidelines recommend that symptomatic children with anti-tissue transglutaminase titres more than ten times the upper limit of normal, and positive human leucocyte antigen (HLA)-DQ2 or HLA-DQ8 status, do not require small bowel biopsy for diagnosis of coeliac disease. Management of the disease involves strict adherence to a lifelong gluten-free diet, which should lead to resolution of symptoms and prevention of long-term complications. Healthcare professionals should be aware of the varied presentations of coeliac disease to ensure timely screening and early initiation of a gluten-free diet.

Apart from causing the majority of episodes of gastroenteritis in children, rotaviruses can also cause systemic illnesses such as encephalitis, hepatitis, and acute haemorrhagic edema. Infectious rotavirus particles have been demonstrated in the blood and CSF and more associations are to be expected. This case series present a new association of encephalopathic state and vasculitic rash in 3 children who were found to have rotavirus on stool testing. Rotavirus can mimic serious bacterial infections including meningococcaemia and meningitis and any child presenting with vasculitic rash, encephalopathy and gastroenteritis should have a stool sample examined for rotavirus. Awareness of this association will help paediatricians provide a definitive diagnosis for some children presenting with signs of meningococcal sepsis who test positive for rotavirus.

The causes of febrile convulsions are usually benign. Such convulsions are common in children and their long-term consequences are rare. However, other causes of seizures, such as intracranial infections, must be excluded before diagnosis, especially in infants and younger children. Diagnosis is based mainly on history taking, and further investigations into the condition are not generally needed in fully immunised children presenting with simple febrile convulsions. Treatment involves symptom control and treating the cause of the fever. Nevertheless, febrile convulsions in children can be distressing for parents, who should be supported and kept informed by experienced emergency department (ED) nurses. This article discusses the aetiology, clinical presentation, diagnosis and management of children with febrile convulsion, and best practice for care in EDs. It also includes a reflective case study to highlight the challenges faced by healthcare professionals who manage children who present with febrile convulsion.

Commentary on: Mukhopadhyay S, Taylor JA, Von Kohorn I, et al . Variation in sepsis evaluation across a national network of nurseries. Pediatr 2017;139:e20162845. Neonatal sepsis is a leading cause of morbidity and mortality. However, there are substantial differences in the practice of risk assessment of neonates with suspected EOS. Attempts have been made to streamline the management pathways in the USA, UK and elsewhere through publication of the national guidelines.1 2 A rational approach is needed to …

Siba Prosad Paul, Alifa De Aguiar, Joanna Barnden, Anna Cannon and Megan Eaton discuss the implications of high levels of the inflammatory marker, drawing on local audit

Accidental hanging is rare in childhood but is often fatal. Window blind cords pose a particular and unique risk to young children in the UK, accounting for one to two deaths annually. These accidents are frequently associated with non-adherence to the safety instructions provided by the manufacturers. Early discovery of the child and initiation of effective cardiopulmonary resuscitation at the site of the incident are likely to improve the outcome. Prolonged suspension, children who are pulseless at first contact by the emergency paramedic responder, and patients with prolonged periods of remaining in asystole before return of spontaneous circulation after starting cardiopulmonary resuscitation are unlikely to have intact neurological survival. Management in the hospital includes early airway protection by intubation, maintenance of normal oxygen saturation, normothermia, active control of clinical and sub-clinical seizures, and strict electrolyte and glucose regulation. Child safeguarding concerns should be considered when children have asphyxial injuries, and other signs of child physical abuse should be actively looked for. There is a need for stronger legislation in the UK to prevent some of these accidents, especially those relating to window blind cords.

To document the frequency at diagnosis and evolution over time of inflammatory bowel disease-unclassified in children. Analysis of case records (2004–2011) of patients diagnosed with inflammatory bowel disease-unclassified following uppergastrointestinal endoscopy, ileocolonoscopy and small bowel imaging. Any subsequent diagnostic reclassification by 2016 was recorded. 344 children diagnosed as inflammatory bowel disease: 58% Crohn’s disease, 34.5% ulcerative colitis, and 7.5% (n=26) inflammatory bowel disease-unclassified. 25/26 inflammatory bowel disease-unclassified patients were followed for 4.5–11.5 years. 17 of these patients needed endoscopic reevaluation leading to changed diagnosis in ten (Crohn’s disease 7, ulcerative colitis 3). 7.5% (25/344) of inflammatory bowel disease children had inflammatory bowel disease-unclassified at diagnosis; 10 (40%) evolved into Crohn’s disease or ulcerative colitis.

The European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) guidelines for diagnosing celiac disease (CD) in children were modified in 2012. They recommend that in symptomatic children with anti-tissue transglutaminase antibody (anti-tTG) titer of10 times upper limit of normal (10× ULN) and who have positive anti-endomysial antibody and HLA-DQ2/DQ8 haplotype, the diagnosis of CD can be based on serology. The aim of this study is to establish whether serology-based pathway of the ESPGHAN guidelines could also be reliably applied to asymptomatic children from high-risk groups.From March 2007 to February 2017, prospective data on anti-tTG titer, age, sex, and reason for screening were collected at diagnostic endoscopy on all asymptomatic children being diagnosed as having CD. The relationship between modified Marsh-Oberhuber classification histological grading and contemporaneous anti-tTG titers was analyzed.A total of 157 asymptomatic children were diagnosed as having CD. Eighty-four of 157 (53.5%) had antitTG10× ULN (normal10 IU/mL) and 75 of 84 were from high-risk groups. All 75 had definitive histological evidence (Marsh-Oberhuber 3a-3c) of small bowel enteropathy. Fifty-three of 84 children had anti-tTG200 IU/mL and total villous atrophy was present in 29 of 53 (55%). Main reasons for serological screening were: type-1 diabetes mellitus (n = 36) and first-degree relatives with CD (n = 24). Mean age at diagnosis was 8.8 years. Serology-based diagnosis is cost-beneficial by around £1275 per child in the United Kingdom.All 75 asymptomatic children from high-risk groups with anti-tTG10× ULN had histology-proven CD. This study provides further evidence that the guidelines for diagnosing CD by the serology-based pathway should be extended to these children.

Eating disorders form a group of mental health conditions characterised by abnormal eating habits and are associated with high mortality rates. This article provides nurses working in various settings with evidence-based strategies to identify, manage and refer children and young people with eating disorders. It explores what eating disorders are, and their association with physical and psychiatric co-morbidities. Eating disorders have a significant effect on children and young people's health and development, and nurses have a vital role in managing them. This article presents a case study that illustrates some of the challenges nurses may experience when managing children and young people with eating disorders.