Children &

Young People

Acute Care

Pathways

Dr Tim Fooks, GP and CYP Clinical Lead

Coastal West Sussex CCG

UK Mortality Rate

If the UK health system performed as well as that of Sweden, as many as 1500 children

might not die each year.

In the News - 2015

Sepsis is a clinical syndrome caused

by the body’s immune and

coagulation systems being switched

on by an infection.

NICE Definition of Sepsis

• 0.9/1000 children/year

• ~1/2 under 1yr

• Mortality 6-12%

• In the UK, one child a day dies of sepsis

Sepsis: Scope of the problem

• Consideration of sepsis associated with

faster onset of treatment

• Delay in antimicrobial Rx associated with

hour by hour worsening of outcome

• Only 50% of neonatal cases of meningitis

(<3m) present with fever, but do have

other features of serious illness (poor feeding, lethargy and poor overall state)

Pre-hospital Recognition of Serious Illness

• 448 children and young people ,16yr

• 103 fatal, 345 non-fatal

• Micro confirmation 373 cases

Recognition of Meningococcal Disease

• 4-6hr - non-specific symptoms

• 8hr (median time) – 72% signs of early sepsis (leg pains, cold hands and feet, abnormal skin colour)

• 24hr – most close to death

• 50% admitted after first consultation

• 19hr – median time to hospital admission

• 13-22hr – median onset of classic features (haemorrhagic rash, meningism, impaired consciousness)

Recognition of Meningococcal Disease

Early onset neonatal Late onset neonatal Infants & Young Children

Gp B Streptococcus As early onset + Strep. pneumoniae

Staphylococcus aureus Coag. Negative Staph. Neisseria meningitidis

Listeria monocytogenes (rare) Staph aureus

Gp A Strep.

Haemophilus influenzae

Bordetella pertussis

In resource poor settings, diarrhoea and pneumonia are the most common infections (and causes of death)

Sepsis in Children – clinical review BMJ 2015;350:h3017 A Plunkett, J Tong.

Typical or Important Pathogens in Sepsis in

Neonates and Young Children (out of hospital).

Child has suspected or proven infection + 2 of the following features:

Core Temperature <36°C or >38.5°C

Inappropriate tachycardia Local pathway/APLS guidance

Altered mental state eg sleepiness, irritability, lethargy, floppiness

Peripheral perfusion reduced Capillary refill time prolonged

Additional clinical notes. •BP may be maintained until late in septic process. •Decreased urinary output is common in acutely sick children. It is not a specific finding in sepsis. •A non-blanching purpuric rash is classically seen in meningococcaemia but may appear late in the disease process

Sepsis in Children – clinical review BMJ 2015;350:h3017 A Plunkett, J Tong.

When should a clinician consider sepsis or septic shock?

• Suspect sepsis if a person presents with signs or symptoms that indicate possible infection, even if they do not have a high temperature.

• Take into account that people with sepsis may have non - specific, non-localised presentations, for example feeling very unwell.

• Pay particular attention to concerns expressed by the person and their family or carers, for example, changes from usual behaviour.

• Assess people who might have sepsis with extra care if they cannot give a good history ( for example, people with English as a second language or people with communication problems ).

• Take into account that people in the groups below are at higher risk of developing sepsis :

• the very young ( under 1 year)

• the very old and frail

• Chemotherapy .... and others

NICE 2016: Identifying sepsis and people at

increased risk of sepsis

NICE 2016: Identifying sepsis – listening to patients

http://bit.ly/1TPWkJW

• In primary care and emergency departments people with

suspected sepsis are often seen by relatively inexperienced

doctors.

• Many of these people will be in low and medium risk groups

but evidence is lacking as to who can be sent home safely

and who needs intravenous or oral antibiotics.

• The consequences of getting the decision-making wrong can

be catastrophic and therefore many patients are potentially

over - investigated and admitted inappropriately.

• Current guidance is dependent on use of individual variables

informed by low quality evidence.

NICE 2016 Algorithm: Clinical Decision

taking

• Use structured set of observations.

• Consider using early warning score

• Assess temperature, heart rate, respiratory rate , systolic

blood pressure, level of consciousness and saO2 in young

people and adults with suspected sepsis .

• Assess temperature, heart rate, respiratory rate, level of

consciousness, oxygen saturation and capillary refill time in

children under 12 years with suspected sepsis.

• Measure blood pressure of children under 5 years if HR or

CRT is abnormal and facilities to measure BP, including

correct blood pressure cuff , are available.

NICE 2016 Algorithm: Assessing people for

suspected sepsis

NICE 2016 Algorithm: Managing Children under 5 yr with

suspected sepsis outside acute hospital setting

• Pre-alert secondary care ( through GP or ambulance

service) when any high risk criteria are met in a person

with suspected sepsis outside of a hospital , and transfer

them immediately.

• Ensure GPs and ambulance services have

mechanisms in place to give antibiotics in the pre -

hospital setting if transfer time is likely to be more

than 1 hour.

NICE 2016 Algorithm: Antibiotic treatment

in primary care

• Refer all people with suspected sepsis outside acute hospital settings for emergency medical care by the most appropriate means of transport (usually 999 ambulance) if :

• 1. they meet any high risk criteria ( see table 1 ) or

• 2. they are aged under 17 years , and their immunity is compromised and

• 3. they have any moderate to high risk criteria .

• Arrange review by a GP or other doctor within 1 hour when any moderate to high risk criteria in a person with suspected sepsis are identified by a non - medical practitioner outside an acute hospital

NICE 2016 Algorithm: Managing sepsis outside

of hospital 1

• Assess (by GP or other doctor) all people with suspected sepsis outside acute hospital settings with a moderate to high risk criteria for :

• definitive diagnosis of their condition

• whether they can be treated safely outside hospital .

• If a definitive diagnosis is not reached or the person cannot be treated safely outside an acute hospital setting , refer them urgently to the emergency department

• Arrange review by a GP or other doctor for a person with suspected sepsis but no high or moderate to high risk criteria if they have had their first assessment by a non - medical practitioner outside an acute hospital setting .

NICE 2016 Algorithm: Managing sepsis outside

of hospital 2

Keeping Sick

Kids Safe

Role of the Clinician

• Recognition of serious

illness

• Reassurance of parents

and carers

• Resilience promotion

Role of the GP

“The doctor is the expert in illness; the parent is the expert of the child”

• Factors affecting parents seeking help from

medical services:

• Sense of responsibility + fear of failure

• Felt or enacted criticism by professional

• Failure to be reassured:

• “Viral” explanation seen as sign of medical uncertainty

• Inconsistent approach by Clinicians

• See Re-ACT Talks: The Effect of Criticism on

Parents with Sick Children http://bit.ly/22kJsSk

Accessing Care - Parents with Sick

Children

The Goldilocks Zone

• Acknowledging the pain of the patient

• Being supportive and avoiding negative

messages.

• Give a full explanation in terms that the

patient understands

• Consistency across professions is very

important.

EurGuidelines for the management of non-specific acute LBP, 2006

Reassuring patients – lessons from pain

• Be positive and optimistic about

outcomes

• Sound confident

• Give the impression that you really know

what you’re talking about and have seen

it all before

Kessel, The Lancet 1979

Reassuring patients – Doctor behaviour?

• Simple reassurance seen as a dismissal of legitimate concerns and results in increased health-related anxiety

• Informing patients that the problem is minor and they are liekly to recover increase worry

• Psychological explanation for pain can be perceived by patients as a lack of understanding – results in more forceful assertion of their complaints

Linton et al Reassurance: help or hinder in the treatment of pain Pain 2008

Reassuring patients – Does it work?

Reassuring patients – some principles

T Pincus Effective reassurance in primary care pain patients

Acute Care

Pathways

• Fever, D&V and Bronchiolitis

• Dr Nelly Ninis, Consultant Paediatrician,

St Mary’s, Paddington.

• Expert in diagnosis of septicaemia

• Member of NICE guideline panel

• Available NOW at e-LfH

e-learning module (HEKSS)

GP Quotes

• “Personally I found them very useful

providing a clear concise and reassuring

checklist”

• “I feel much safer handling bronchiolitis

patients than I have done in the last 25

years”

30

CWS

B&H

Crawley

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Fever D&V

Bron'litis Head Injury

CWS

B&H

Crawley

Admissions with No LOS for children <5yr

2013/4

Right place, right time ....?

Fever

Acute Care Pathways

Parent Advice Sheets

- recommended by NICE

Sick Child Pathway Templates - Hx

- Dr David Gould

Sick Child Pathway Templates - RS

- Dr David Gould

Sick Child Pathway Templates - CVS

- Dr David Gould

Sick Child Pathway Templates – Exam & Misc

- Dr David Gould

NICE CG 160 Fever – key messages

A. Thermometers and the detection of fever

In children aged 4 weeks to 5 years, measure body temperature by one of the following methods:

1. electronic thermometer in the axilla

2. chemical dot thermometer in the axilla

3. infra-red tympanic thermometer. [2007]

B. Reported parental perception of a fever should be considered valid and taken seriously by healthcare professionals. [2007]

• Definition of threshold for fever

• 81% <38.0°C, (100.5°F)

• 0% between 38.0°C and 38.3°C,

• 19% >38.3°C. (101°F)

• 20% children brought to clinic for a chief complaint of fever were never truly febrile.

• 93% participants believed that high fever can cause brain damage.

• For a comfortable-appearing child with fever,

• 89% of caregivers would give antipyretics

• 86% would schedule a clinic visit.

Fever Literacy and Phobia

NICE CG 160 Fever – key messages

C. Clinical assessment of the child with fever

Assess children with feverish illness for the presence or absence of

symptoms and signs that can be used to predict the risk of serious

illness using the traffic light system [2013]

Measure and record temperature, heart rate, respiratory rate and

capillary refill time as part of the routine assessment of a child with

fever. [2007]

NICE CG 160 Fever – key messages

D. Recognise that children with tachycardia are in at least an intermediate-risk group for serious illness. Use the Advanced Paediatric Life Support (APLS)[1] criteria below to define tachycardia: [new 2013]

Age Heart rate (bpm)

<12 months >160

12–24 months >150

2–5 years >140

E. Management by remote assessment

Children with any 'red' features but who are not considered to have an immediately life-threatening illness should be urgently assessed by a healthcare professional in a face-to-face setting within 2 hours. [2007]

NICE CG 160 Fever – key messages

E. Management by the non-paediatric practitioner

If any 'amber' features are present and no diagnosis has been reached,

provide parents or carers with a 'safety net' or refer to specialist

paediatric care for further assessment. The safety net should be 1 or

more of the following:

1. providing the parent or carer with verbal and/or written

information on warning symptoms and how further healthcare can be

accessed (see section 1.7.2)

2. arranging further follow-up at a specified time and place

3. liaising with other healthcare professionals, including out-of-

hours providers, to ensure direct access for the child if further

assessment is required. [2007] 013]

NICE CG 160 Fever – key messages

F. Management by the paediatric specialist

Perform the following investigations in infants younger than 3 months with fever:

full blood count

blood culture

C-reactive protein

urine testing for urinary tract infection[2]

chest X-ray only if respiratory signs are present

stool culture, if diarrhoea is present. [2013]

NICE CG 160 Fever – key messages

G. Antipyretic interventions

• Antipyretic agents do not prevent febrile convulsions and should not be used specifically for this purpose. [2007]

• No place for tepid sponging

• Do not underdress or overwrap

H. When using paracetamol or ibuprofen in children with fever;

• continue only as long as the child appears distressed

• consider changing to the other agent if the child's distress is not alleviated

• only consider alternating these agents if the distress persists or recurs before the next dose is due. [new 2013]

• do not give both agents simultaneously

Paracetamol or Ibuprofen or Both

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Ibuprofen Paracetamol Both I+P

Reporting Odds Ratio - Acute Kidney Injury risk in <12yr Yue Z1, et al 2014

ROR

Paracetamol or Ibuprofen or both?

• Safety profiles when used alone similar but underlying health issues need to be considered

• Ibuprofen is more effective than paracetamol

• has faster onset of action & lasts longer

• relieving fever-associated discomfort,

• providing symptom relief

• improving general behaviour

• Selecting the most suitable antipyretic for the individual child may help to optimize the chance of treatment success first time, thereby limiting the need to administer further treatment

• Drugs R D. Jun 2014; 14(2): 45–55. Published online Jun 12, 2014. doi: 10.1007/s40268-014-0052-x PMCID: PMC4070461 A Practical Approach to the Treatment of Low-Risk Childhood Fever Dipak Kanabar

Paracetamol or Ibuprofen or both?

• Children under 3 months

• Varicella zoster infection • (NSAIDs linked to increased risk of severe cutaneous complications in VZV infection)

• Known aspirin sensitivity

• (2% asthmatic prone to exacerbation with ibuprofen, + another 2% have drop

in spirometry), but in those who are not NSAID sensitive, ibuprofen reduces

risk of asthma exacerbation than paracetamol)

• Pre-existing renal failure ie marked dehydration

• Multi-organ failure

• Risk of GI bleed

When to use Paracetamol

• 30mg/kg in 24 hours in divided doses

• 3-6 months: 50 mg (2.5 ml) 3 times daily.

• 6-12 months: 50 mg (2.5 ml) 3 or 4 times daily.

• 1-4 years: 100 mg (5 ml) 3 times daily.

• 4-7 years: 150 mg (7.5 ml) 3 times daily.

• 7-10 years: 200 mg (10 ml) 3 times daily.

• 10-12 years: 300 mg (15ml) 3 times daily.

Ibuprofen dose?

• Single dose 10–15 mg/kg

• 4 times daily regimen - max 60mg/kg/24hrs

• Suspension (120mg/5ml) daily dose

• No. of 5ml tspns in 24 hour period =

wt(kg) x 0.5

Paracetamol dose?

Diarrhoea &

Vomiting

Acute Care Pathways

Diagnosis

Perform stool microbiological investigations if:

• you suspect septicaemia or

• there is blood and/or mucus in the stool or

• the child is immunocompromised.

NICE CG 84 D&V – key messages

Fluid management

In children with gastroenteritis but without clinical dehydration:

• continue breastfeeding and other milk feeds

• encourage fluid intake

• discourage the drinking of fruit juices and carbonated drinks, especially in those at increased risk of dehydration (see 1.2.1.2)

• offer oral rehydration salt (ORS) solution as supplemental fluid to those at increased risk of dehydration (see 1.2.1.2).

NICE CG 84 D&V – key messages

Nutritional management

After rehydration:

• give full-strength milk straight away

• reintroduce the child's usual solid food

• avoid giving fruit juices and carbonated

drinks until the diarrhoea has stopped.

NICE CG 84 D&V – key messages

Information and advice for parents and carers

Advise parents, carers and children that[4]:

• washing hands with soap (liquid if possible) in warm running water and careful drying is the most important factor in preventing the spread of gastroenteritis

• hands should be washed after going to the toilet (children) or changing nappies (parents/carers) and before preparing, serving or eating food

• towels used by infected children should not be shared

NICE CG 84 D&V – key messages

Information and advice for parents and carers

• children should not attend any school or other childcare facility while they have diarrhoea or vomiting caused by gastroenteritis

• children should not go back to their school or other childcare facility until at least 48 hours after the last episode of diarrhoea or vomiting

• children should not swim in swimming pools for 2 weeks after the last episode of diarrhoea.

NICE CG 84 D&V – key messages

Bronchiolitis

Acute Care Pathways

Consider in an infant with

• nasal discharge

• wheezy cough

• fine inspiratory crackles and/or

• high pitched expiratory wheeze

• apnoea may be a presenting feature

SIGN 91 - Diagnosis of Bronchiolitis

Seasonality

• Prematurity (<35 weeks)

• Congenital Heart Disease

• Chronic Lung Disease of Prematurity

• Parental Smoking

• (Social Deprivation)

• Protective factor – Breast feeding

Significant Co-Morbidities

• Antivirals – not recommended

• Antibiotics – not recommended

• Beta-2 agonists – not recommended

• Anti-cholingerics – not recommended

• Nebulised ephedrine – not recommended

• Inhaled corticosteroids – not recommended

• Oral corticosteroids – not recommended

• LTRA - not recommended

• Chest physio – not recommended (unless on PICU)

• NG suction, Oxygen therapy, Ventilation – should be considered

Treatment options

Head Injury

Acute Care Pathways

Take head injuries seriously, says NICE

• 1.4 million people attend A&E in England and Wales

each year with a recent head injury. Up to 700,000 of them will be children under the age of 15.

• Head injury is the most common cause of death and disability in people up to the age of 40.

• Early detection and prompt treatment is vital to save lives and minimise risk of disability, says updated guidance from the National Institute for Health and Care Excellence (NICE).

NICE CG 16 Head Injury

PAEDIATRIC HEAD INJURIES

Dr Helen Milne

Emergency Medicine Consultant

Worthing Hospital

Head injury data 2011

Head Injury

Presentations

Total Paeds

Attendances

% Total ED

Attendances

% Paeds

ED Attendances

Worthing 2157

<16 years

16,033

<19 years

23% 10-15%

SRH 1703 ~14,930 ~25% ~11-12%

Age of patients

0

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100

150

200

250

300

350

400

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Worthing

SRH

Outcome

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discharged admitted did not wait

Worthing

SRH

Data Review

< 5 years Admissions CT Abnormal

CT

Neurosurgical

Worthing 56.5% 4.5% 0.8% 0.2% ?1 patient

SRH 55.7% 8.1% 1.5% 0.2% 1 patient

CHALICE

(22,772)

56% 6.4% 3.3% 1.2% 0.6%

Key Points

Most head injuries seen in the ED –

• Could be managed with observation at home

• Few need admitted

• Rare to need a CT scan

• Even more rare to need neurosurgery

Likelihood of brain injury increased by -

• LOC

• Mechanism of injury

• GCS

Children’s brain injuries

• Most non surgical treatment

CT scan radiation

• 100-200 chest x-rays

As soon after event as possible [1]

• Unconsciousness or lack of full consciousness, even if

the person has now recovered.

• Any clear fluid running from the ears or nose.

• Bleeding from one or both ears.

• Bruising behind one or both ears.

• Any signs of skull damage or a penetrating head injury.

• The injury was caused by a forceful blow to the head at

speed (for example, a pedestrian hit by a car, a car or

bicycle crash, a diving accident, a fall of 1 metre or

more, or a fall down more than 5 stairs).

NICE CG 176: Head Injury – when to go to hospital

As soon after event as possible [2]

• The person has had previous brain surgery.

• The person has had previous problems with

uncontrollable bleeding or a blood clotting disorder, or is

taking a drug that may cause bleeding problems (for

example, warfarin).

• The person is intoxicated by drugs or alcohol.

• There are safeguarding concerns, for example about

possible non-accidental injury or because a vulnerable

person is affected

NICE CG 176: Head Injury – when to go to hospital

If any of the following develop subsequently Problems understanding, speaking, reading or writing.

• Loss of feeling in part of the body or problems with balancing or walking.

• General weakness.

• Changes in eyesight.

• A seizure (also known as a convulsion or fit).

• Problems with memory of events before or after the injury.

• A headache that won't go away.

• Any vomiting.

• Irritability or altered behaviour such as being easily distracted, not themselves, no concentration, or no interest in things around them. This is particularly important in babies and children under 5.

NICE CG 176: Head Injury – When to go to hospital

Acute Asthma

Acute Care Pathways

National Review of Asthma Deaths Confidential Enquiry – reported 2014

• Review of all deaths from Feb 2012 to January

2013 where asthma was listed in part 1 or 2 of the

death certificate

• 3544 death certificates reviewed, 2644 excluded as

either over 75 or asthma not thought to be cause of

death

• 900 deaths included

• After data review 195 deaths thought to be from

asthma

• 80 male, 115 female

Paediatric data

• 40 (of 195) children identified – 12 cases no data returned therefore only 28

paediatric deaths reviewed

• 28 under 19 years – 10 under 10 years

– 18 aged 10 – 19 years

• 12 though to have mild / moderate asthma

• 4 had PAAP (Personal Asthma Action Plan)

• Most died before reaching hospital

• 4 known to social services

Key recommendations – all ages

• All patients prescribed more than 12 short acting reliever

inhalers in previous 12 months must be reviewed urgently

• Assessment of inhaler technique should be done at every

asthma review. This should be checked by the pharmacist

for any new device

• Use of combination inhalers is encouraged

• Monitor adherence

• Electronic surveillance of prescribing should be introduced

as a matter or urgency

• Document smoking / smoke exposure, and

• refer current smokers or carers to smoking cessation

service

Red flags

• Excessive beta agonist use

• Poor adherence to preventer treatment

• Long acting beta agonist (LABA) as

monotherapy

• Lack of PAAP

• Poor perception of worsening symptoms

Key recommendation - children

• Parents and children, and those who care for or teach them, should be educated about managing asthma.

• To include • ‘how’, ‘why’ and ‘when’ to use asthma medications,

• recognising when asthma is not controlled

• knowing when and how to seek emergency advice

• Emphasise minimising exposure to allergens and

second hand smoke, especially in young people with asthma

Personal Asthma Action Plan

Other Resources

e-LfH Learning Module

Spotting the Sick Child

Short Film for parents and carers