Paediatrics - Holistic answers to everyday problems

Dr Jon Turner and Dr Julian Sandell consider two common scenarios that require a personalised approach

Case 1 The crying baby
A 25-year-old mother, whose husband works away from home, brings her three-month-old only child to the surgery. She is at her wits end as he is 'crying all the time'.

This is a familiar consultation that is often highly charged. It is important to recognise that crying is a way of communicating for babies. Establishing whether the baby is trying to communicate pain, hunger, cold, stress or even boredom can be difficult.

Excessive crying is defined as more than three hours per day for more than three days per week for at least three weeks.

A good and sympathetic history allows the GP to medically assess the situation as well as determine parental concerns, level of coping and support.

A full and thorough examination is essential, undressing the baby completely to try to establish an organic or non-organic cause for the symptoms. Plotting length and weight on centile charts and comparing with previous measurements should form part of this examination.

Symptomatic management typically involves supporting both parents and baby, using the primary healthcare team (for example, health visitors) and offering regular reviews.

Patient information websites can be helpful (see Resources).

Differentiating 'colic', teething, cow's milk protein allergy (CMPA) and gastro-oesopha-geal reflux disease (GORD) can be difficult but must be considered.

Teething should not cause high fever, diarrhoea, fits or vomiting and other causes must be looked for.

Symptoms of CMPA include colic and crying, constipation or diarrhoea, atopic disease (eczema/asthma), acute colitis or even occult GI blood loss.

Signs of GORD include irritability, poor weight gain, agitation, disturbed sleep, feeding phobia, arching during or after feed, respiratory symptoms such as apnoea and vomiting/possetting.

CMPA

Cow's milk protein allergy

  • Allergy to cow's milk proteins damages the small intestinal mucosa, leading to vilious atrophy.
  • Lactalbumin and lacto-globulins are important.
  • Whole protein is absorbed by the mother and excreted into breast milk. So, in CMPA, mothers should be on a diet free of cow's milk if breastfeeding.
  • Symptoms include colic and crying, constipation/diarrhoea, atopic disease and acute colitis.

Case 2 The dry, itchy infant
A 32-year-old mother of three brings her youngest, Amy, who is 18 months old. Amy has always had dry skin but it has now worsened becoming red and itchy. There is a family history of atopy. The usual emollients are not helping and mum has been seeing complementary therapists for treatment. She is asking for allergy testing.

First steps should be to establish the diagnosis. Is this really eczema? A good history and examination, as always, are important for this. Differential diagnoses include scabies, tinea infection and psoriasis.

What impact are the symptoms having both on Amy and her family? There is not necessarily a direct relationship between severity of atopic eczema and its impact on quality of life.

What has been tried? This is especially important if herbal treatment has been used as the creams may be steroid based.

Why does mum think allergy testing is required? Is there a pattern noted with certain foods?

NICE has recently produced some guidance to help with this. Initial management would include preventive treatment such as avoiding soap and bubble bath; keeping nails short and not using nylon/wool clothing.

Education of the family is very important including principles of treatment and how to use the treatments, including when and how to step up and down the treatment. The Eczema Society also has a very helpful website.

Suggested medical management includes emollients, topical steroids, oral antihistamines and treatment of infection. There is a stepped-care plan to provide uniformity of treatment.

Emollients should form the basis of atopic eczema management. The emollient should be unperfumed and used in sufficient quantities (250-500g per week) for moisturising, washing and bathing. Emollients should also be available to use at nursery, pre-school or school.

The potency of topical steroids should be tailored to the severity of the atopic eczema, which may vary according to body site.

If food allergy such as CMPA is suspected consider a six to eight week trial of extensively hydrolysed protein formula in place of cow's milk formula for bottle fed infants under six months.

It would be important to involve the paediatric dietician in the long-term follow up to ensure adequate nutrition.

  • Dr Turner is a GP principal and trainer in Bournemouth and Dr Sandell is consultant in paediatric emergency medicine in Poole
ALLERGY IN ECZEMA

Consider food allergy in:

  • children who have reacted immediately to a food
  • infants and young children with a moderate or severe uncontrolled atopic eczema, particularly with gut dysmotility or failure to thrive

Consider inhalant allergy in:

  • children with seasonal flares of atopic eczema
  • children with associated asthma and rhinitis
  • children over three years with facial atopic eczema

Consider allergic contact dermatitis in:

  • children with an exacerbation of previously controlled atopic eczema
  • children who react to topical treatments

Reassure that most children with such eczema do not need clinical testing for allergies.

Source: NICE

 

Resources

  • NICE 2007. Clinical guideline 57 Atopic eczema in children.
  • Bannon M, Carter Y. Practical Paediatric Problems in Primary Care, OUP, 2007.
  • Field D, Isaacs D, Stroobant J. Tutorials in Paediatric Differential Diagnosis 2nd edn, Elsevier Churchill Livingstone, 2005.
  • Vandenplas Y, Koletzko S, Isolauri E et al. Guidelines for diagnosis and management of cow's milk protein allergy in infants. Arch Dis Child 2007; 92: 902-8.
  • Keady S. Update on drugs for gastro-oesophageal reflux disease. Arch Dis Child Ed Pract 2007; 92: ep114-ep118.

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