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In this episode, we explore the clinical presentation, investigation and management of this bowel-threatening condition. The classic triad is not commonly found, so be on the lookout for intussusception, an uncommon cause of belly-pain, unwellness or altered mental state in infants.

Assessing the risk of self harm or suicide in adolescents is a daunting concept for the occassional player. Last time, we discussed the HEADSS assessment tool for communicating with adolescent patients, and this is a great place to start. In this episode we explore some of the elements of a structured mental health assessment.

The challenges of being an adolescent, and of caring for adolescents! We have a good look at the HEEADSSS assessment tool, which will help you to structure your interaction with teenage patients in an open-minded and non-judgemental way.

Treating the wrong children with fluids will cause harm... as a recent NEJM paper about fluid boluses in very sick African children showed. We thought we'd get in on the discussion, before everyone goes throwing the baby out with the bathwater. In this PEMcast we try to appraise the Maitland paper in a rational, unemotional way... and almost manage!

So, a well-looking child turns up to triage and gets given a high triage priority, simply because they have a Congenital Metabolic Disorder. Do we really have to jump to it, put in an IV cannula, and call the specialist?

There are individual subtleties in managing these children with Inborn Errors of Metabolism, but a few common principles apply. This short tour of a few commoner conditions should give you a handle on this important group of patients.

Phototherapy treatment will be sufficient for the vast majority of infants with unconjugated hyperbilirubinaemia who need treatment.  When it gets more serious, we turn to higher-risk treatments like IntraVenous Immunoglobulin or exchange transfusion. What evidence do we have to guide our decisions here?

Every Special Care Nursery in the world has a bilirubin chart on the wall to guide us in terms of phototherapy limits and when to consider exchange transfusion.  Many of these are based on a study backed by the American Academy of Pediatrics from 2004.  More recently, the National Institute for Clinical Excellence in the UK have released some consensus guidelines on the treatment of neonatal jaundice.  In this podcast, we explore some of the literature relating to the care of jaundiced neonates.

Outline: Jaundice Treatment PEMcast

[CP]  intro, disclaimer

1 umol/L of bilirubin = 17.1 mg/dL

Honourable Mentions:

Maisels 2008

Hansen 2010

Exchange transfusion:

Mechanism, indications, risks, guidelines

[RR] bilitool.org quotes [AAP 2004 guidelines]

Risks of exchange transfusion: Jackson 1997

[KB] NICE CG 98 – threshold graphs in spreadsheet format

IV Ig evidence?

[RR] Alcock 2009 – Cochrane Review

[KB] Nasseri 2006 – not mentioned in Cochrane (not excluded, just ignored…probably due to language barrier, or repeat publication in 2009 without content update)

Albumin evidence?

[RR] Lack of evidence supporting use of Albumin for neonatal jaundice

Djokomuljanto 2006 – white curtains

Glacier analogy – free vs bound bilirubin (Hansen 2010)

Pharmacologic treatments on the horizon

[CP] Cuperus 2009

NICE CG 98 advises against multiple unproven therapies

Bili blanket not recommended for term babies (do not cover sufficient skin surface)

All: Summary, goodbye

Further Reading: The Papers that got away

Predicting Risk of Kernicterus: single SBR level?

(gestational age, genomic profile)

Ip 2004

Skae 2005

Ahlfors 2010

Early detection of EHBA (for early Kasai) improves outcome

Hsiao 2008 (stool colour card Taiwan)

Phototherapy: mechanism, light source, wavelength, etc

Maisels 2008

Hansen 2010

Djokomuljanto 2006 – white curtains

Breast-milk jaundice: what causes it, and is it entirely benign?

Gourley 2002

Gourley 2005

References

Maisels MJ, McDonagh AF.

Phototherapy for neonatal jaundice.

N Engl J Med. 2008 Feb 28;358(9):920-8. Review. PubMed PMID: 18305267.

Ruud Hansen TW.

Phototherapy for neonatal jaundice–therapeutic effects on more than one level?

Semin Perinatol. 2010 Jun;34(3):231-4. Review. PubMed PMID: 20494740.

American Academy of Pediatrics Subcommittee on Hyperbilirubinemia.

Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation.

Pediatrics. 2004 Jul;114(1):297-316. Erratum in: Pediatrics. 2004 Oct;114(4):1138. PubMed PMID: 15231951.

Jackson JC.

Adverse events associated with exchange transfusion in healthy and ill newborns.

Pediatrics. 1997 May;99(5):E7. PubMed PMID: 9113964.

National Institute for Health and Clinical Excellence

Clinical Guideline CG 98: Neonatal Jaundice

May 2010 http://www.nice.org.uk/CG98

Alcock GS, Liley H.

Immunoglobulin infusion for isoimmune haemolytic jaundice in neonates.

Cochrane Database Syst Rev. 2002;(3):CD003313. Review. PubMed PMID: 12137687.

Nasseri F, Mamouri GA, Babaei H.

Intravenous immunoglobulin in ABO and Rh hemolytic diseases of newborn.

Saudi Med J. 2006 Dec;27(12):1827-30. PubMed PMID: 17143357.

Djokomuljanto S, Quah BS, Surini Y, Noraida R, Ismail NZ, Hansen TW, Van Rostenberghe H.

Efficacy of phototherapy for neonatal jaundice is increased by the use of low-cost white reflecting curtains.

Arch Dis Child Fetal Neonatal Ed. 2006 Nov;91(6):F439-42. Epub 2006 Jul 28. PubMed PMID: 16877479.

Cuperus FJ, Hafkamp AM, Hulzebos CV, Verkade HJ.

Pharmacological therapies for unconjugated hyperbilirubinemia.

Curr Pharm Des. 2009;15(25):2927-38. Review. PubMed PMID: 19754369.

Ip S, Chung M, Kulig J, O’Brien R, Sege R, Glick[...]

It takes a long time and a lot of exposure to become comfortable with jaundiced newborns. Maybe we just become less cautious or less thorough over time... Most of us feel the need to slow down and consider all the possibilities, before jumping to a benign diagnosis.

Fortunately, serious injuries to the cervical spine, whether bony, ligamentous, or spinal cord injury, are uncommon in the really young... which is lucky for us, because these youngsters are also more difficult to assess, and some clinicians feel uncomfortable trying to apply the NEXUS decision instrument in the under 3 year old age group. Join us as we explore the evidence...

No-one wants to miss a broken neck... The assessment of a potential cervical spine injury in a child is a bit different when compared to adults, due to the anatomical, physiological and behavioural differences. In this PEMcast we walk through a suggested method of assessing and managing the cervical spine in children... and discuss itchy teeth.

Septic Arthritis: scary and dangerous. Transient Synovitis: bit of a limp for a few days... So how do we risk stratify children when these conditions look the same in the first couple of days? What clinical features, and what blood tests can we use to help us - without over-investigating every minor limp? We turn to the medical literature and try to sort this out - join us on our hippy mission...