High Impact Care Pathways Dr Fiona Hikmet Consultant Paediatrican Thank you Dr Hadoru for the asthma contributions

Aims Remember the high impact Care Pathways Understand the role of the children community nurses and the use of the saturation probe. GOAL – KEEP children out of hospital or REDUCE length of stay

Care Pathways Bronchiolitis Asthma Gastroenteritis Feverish child Head Injury Abdominal pain

Primary Care Bronchiolitis 01279 652556 bleep 019 Consider CCN review on 01279 692607 830am to 6pm 7 days

Asthma ambulatory pathway EDUCATION

Controversies Steriods in the under 5’s Appropriate inhaler usage Spacer Autohaler – Breath activated devices for school Accuhaler

Recommended CPD Pre school wheeze BMJ elearning module http://learning.bmj.com/learning/module- intro/.html?moduleId=10047296 Pre school wheeze review http://www.bmj.com/content/348/bmj.g15

Primary Care -Gastroenteritis < 5yrs Talk about 50mls/kg over 4 hours equates to 2 mls/kg every 10 minutes. Amber feature is dehydrated NICE say require review at 24 hours If at increased risk of dehydration or vulnerable due to clinical or social circumstance consider CCN referral on 01279 692607 830am to 6pm

Feverish Child non paediatric practitioner Do symptoms and/or signs suggest an immediately life-threatening illness? Feverish Child non paediatric practitioner No Yes Look for traffic light symptoms and signs of serious illness (see table 1) and symptoms and signs of specific diseases (see table 2 overleaf) Refer immediately to emergency medical care by the most appropriate means of transport (usually 999 ambulance) If any amber features and no red If all green features and no amber or red If any red features If further advice is required by a paediatric professional please ring the paediatric registrar on call on 01279652556 Bleep 019. Provide a safety net by using one or more of the following;   Provide parent/carer with written or verbal information on warning symptoms and accessing further healthcare Arrange specified follow up by primary care or CCN¹ Liaise with other professionals to ensure parent/carer has direct access to further assessment Send child for urgent assessment in a face-to-face setting within 2 hours Provide parents/carers with discharge advice. Follow up by arranging an appropriate health care professional. Consider referral to Children Community Nursing¹

Amber- intermediate risk Red- high risk   Green-low risk Amber- intermediate risk Red- high risk Colour .Normal colour of skin,lips and tongue .Pallor reported by parent/carer .Pale/mottled/ashen/blue Activity • Responds normally to social cues • Content/smiles • Stays awake or awakens quickly • Strong normal cry/not crying • Not responding normally to social cues • Wakes only with prolonged stimulation • Decreased activity • No smile • No response to social cues • Appears ill to a healthcare professional • Unable to rouse or if roused does not stay awake • Weak, high-pitched or continuous cry Respiratory • Nasal flaring • Tachypnoea: – RR > 50 breaths/minute age 6–12 months – RR > 40 breaths/minute age >12 months • Oxygen saturation ≤ 95% in air • Crackles • Grunting • Tachypnoea: – RR > 60 breaths/minute • Moderate or severe chest indrawing Circulation and Hydration • Normal skin and eyes • Moist mucous membranes . Reduced urine output . Tachycardia² . Poor feeding in infants . Dry mucous membranes . CRT≥ 3 seconds • Reduced skin turgor Other • None of the amber or red symptoms or signs . Age 3-6 months temperature ≥39◦C . Fever for ≥5 days . Swelling of a limb or joint . Non-weight bearing/not using an extremity . Rigors . Age 0-3 months temperature ≥38◦C . Non-blanching rash . Bulging fontanelle . Neck stiffness . Status epilepticus . Focal neurological signs . Focal seizures CRT: capillary refill time RR: respiratory rate ²Tachycardia: HR >160 <12 months, HR>150 12-24 mths, HR>140 2-5 years To be read in conjunction with Feverish illness in children. NICE clinical guideline CG160 www.nice.org.uk/CG160

Bronchiolitis Acute infection of the lower respiratory tract Epidemiology Annual epidemics Infection only confers partial immunity. Usually confined to URT over 3 years 75% of affected infants have RSV Other viruses include influenza, para-influenza, adeno, rhino and metapneumovirus

Clinical Features Starts with coryzal symptoms and associated low grade fever. After 2-3 days, the infection spreads to the lower respiratory tract causing increasing cough and shortness of breath. Apnoea may occur Associated feeding difficulties +/- vomiting Examination shows increased respiratory effort, inspiratory crackles and wheeze on auscultation. +/- signs of dehydration.

Risk Factors for severe disease Infants less than 6 weeks old. Infants with cardiac or neuromuscaular disease. Infants with lung disease e.g. chronic lung disease, premature, cystic fibrosis Immunocompromised Before day 3-5 of illness Repeated attendances Who should you worry about ?

Who needs admission /referral ? History Examination Signs of respiratory distress

Assessment - Bronchioloitis

Primary Care Bronchiolitis 01279 652556 bleep 019 Consider CCN review on 01279 692607 830am to 6pm 7 days

Child Asthma Pathway

Childhood Asthma Around 1.1 million children in the UK have asthma One in every 11 children in the UK has asthma – one of the highest rates worldwide every 18 minutes a child is admitted to hospital in the UK because of asthma Effective medicines are available, but a child’s response to treatment is unpredictable

Presentation Asthma patient present to GP with symptoms of Wheeze Cough Difficulty breathing – clinical features Chest tightness Symptoms could be Isolated or in combination Differential Diagnosis Viral induced wheeze vs multi trigger wheeze in the under 5’s Inhaled foreign body Children under 2 are more likely to have an alternative diagnosis What do you want to know in the history to distinguish these? Do CPD

Recommended CPD Pre school wheeze BMJ elearning module http://learning.bmj.com/learning/module- intro/.html?moduleId=10047296 Pre school wheeze review http://www.bmj.com/content/348/bmj.g15

Assessment Behaviour Talking Heart rate Respiratory Oxygen saturations

Asthma ambulatory pathway

Prevent severe asthma attack Has an up-to-date written asthma action plan Asthma review in a regular interval 4-6 month takes their asthma medicines regularly as prescribed

Gastroenteritis - Background Epidemiology 10% of children <5yrs present to health care yearly 28-52% of cases caused by rota virus In 2009 costs in the UK £11.5million per year July 2013 introduced and incorporated into UK vaccine schedule Duration Diahorrea lasts 5-7 days usually less than 2 weeks Vomiting 1-2 days settles within 3 days

Rota virus Diahorrea last 3-8 days July 2013 introduced in to the UK vaccination schedule. First dose before 15 weeks Second dose before 24 weeks

Clinical Features When should you question the diagnosis? History Examination The child vomiting without diahorrea always check a urine a urine dipstix is not a reliable indicator in those children who are not toilet trained NICE say older (<3yrs) therefore all children should have a urine sent off. If the child is feverish vomiting but no diahorrea or focus then particularly the younger ones should be referred as a urine microscopy should be done.

Is the diagnosis right ? Fever Shortness of breath Irritable /bulging fontanelle Neck stiffness non blanching rash Bilious vomits Severe localised abdo pain Rebound or guarding Bloody Stools Head Injury Poisoning

Assessment - Gastroenteritis Decreased skin turgour

Primary Care -Gastroenteritis < 5yrs Talk about 50mls/kg over 4 hours equates to 2 mls/kg every 10 minutes. Amber feature is dehydrated NICE say require review at 24 hours If at increased risk of dehydration or vulnerable due to clinical or social circumstance consider CCN referral on 01279 692607 830am to 6pm

Risk Factors for dehydration Less than 6 months More than 6 stools in last 24 hours Vomited > 3 times in in last 24 hours Not been offered or tolerating fluids prior to presentation Infants who have stopped breast feedings Signs of malnutrition

Investigations Urine Stool Always if vomiting without diahorrea > 7 days History of travel Suspected septicaemia Blood or mucus in the stool Child is immunocompromised

Febrile Child Non Paediatric Practitioner

NICE guidance (2013) on thermometer use Oral or rectal temperature should not be routinely recorded in children 0-5 years. Electronic thermometer under the arm(axilla) for infants <4 weeks old. Children aged 4 weeks – 5 years can have temperature recorded by: Electronic thermometer in axilla. Chemical dot thermometer in axilla. Infra-red tympanic thermometer. Forehead thermometers are unreliable.

If all green features and no amber or red If any red features Do symptoms and/or signs suggest an immediately life-threatening illness? No Yes Look for traffic light symptoms and signs of serious illness (see table 1) and symptoms and signs of specific diseases (see table 2 overleaf) Refer immediately to emergency medical care by the most appropriate means of transport (usually 999 ambulance) If any amber features and no red If all green features and no amber or red If any red features If further advice is required by a paediatric professional please ring the paediatric registrar on call on 01279652556 Bleep 019. Provide a safety net by using one or more of the following;   Provide parent/carer with written or verbal information on warning symptoms and accessing further healthcare Arrange specified follow up by primary care or CCN¹ Liaise with other professionals to ensure parent/carer has direct access to further assessment Send child for urgent assessment in a face-to-face setting within 2 hours Provide parents/carers with discharge advice. Follow up by arranging an appropriate health care professional. Consider referral to Children Community Nursing¹

Amber- intermediate risk Red- high risk   Green-low risk Amber- intermediate risk Red- high risk Colour .Normal colour of skin,lips and tongue .Pallor reported by parent/carer .Pale/mottled/ashen/blue Activity • Responds normally to social cues • Content/smiles • Stays awake or awakens quickly • Strong normal cry/not crying • Not responding normally to social cues • Wakes only with prolonged stimulation • Decreased activity • No smile • No response to social cues • Appears ill to a healthcare professional • Unable to rouse or if roused does not stay awake • Weak, high-pitched or continuous cry Respiratory • Nasal flaring • Tachypnoea: – RR > 50 breaths/minute age 6–12 months – RR > 40 breaths/minute age >12 months • Oxygen saturation ≤ 95% in air • Crackles • Grunting • Tachypnoea: – RR > 60 breaths/minute • Moderate or severe chest indrawing Circulation and Hydration • Normal skin and eyes • Moist mucous membranes . Reduced urine output . Tachycardia² . Poor feeding in infants . Dry mucous membranes . CRT≥ 3 seconds • Reduced skin turgor Other • None of the amber or red symptoms or signs . Age 3-6 months temperature ≥39◦C . Fever for ≥5 days . Swelling of a limb or joint . Non-weight bearing/not using an extremity . Rigors . Age 0-3 months temperature ≥38◦C . Non-blanching rash . Bulging fontanelle . Neck stiffness . Status epilepticus . Focal neurological signs . Focal seizures CRT: capillary refill time RR: respiratory rate ²Tachycardia: HR >160 <12 months, HR>150 12-24 mths, HR>140 2-5 years To be read in conjunction with Feverish illness in children. NICE clinical guideline CG160 www.nice.org.uk/CG160

UTI in any child less than 3 months with fever Diagnosis to be considered Symptoms and signs in conjunction with fever   Meningococcal disease Non-blanching rash, particularly with one or more of the following: • an ill-looking child • CRT ≥ 3 seconds • lesions larger than 2 mm in diameter (purpura) • neck stiffness Meningitis1 • Neck stiffness • Decreased level of consciousness • Bulging fontanelle • Convulsive status epilepticus Herpes simplex encephalitis • Focal neurological signs • Focal seizures Pneumonia • Tachypnoea, measured as: • Crackles in the chest – 0–5 months – RR > 60 breaths/minute • Nasal flaring – 6–12 months – RR > 50 breaths/minute • Chest indrawing – > 12 months – RR > 40 breaths/minute • Cyanosis • Oxygen saturation ≤ 95% Urinary tract infection (in children • Vomiting • Lethargy • Irritability aged older than 3 months)2 • Abdominal pain or tenderness • Urinary frequency or dysuria • Offensive urine or haematuria Septic arthritis/osteomyelitis • Swelling of a limb or joint • Non-weight bearing • Not using an extremity Kawasaki disease3 Fever lasting longer than 5 days and at least four of the following: • bilateral conjunctival injection • change in the peripheral extremities • change in upper respiratory tract mucous (for example, oedema, erythema or desquamation) membranes (for example, injected pharynx, • polymorphous rash dry cracked lips or strawberry tongue) • cervical lymphadenopathy CRT: capillary refill time RR: respiratory rate UTI in any child less than 3 months with fever

In Summary Bronchioloitis and gastroenteritis are common causes for medical attendances in children Remember important differential diagnosis Consider referral to the CCNs in those at risk or you think may deteriorate

Useful References https://www.gov.uk/government/uploads/sy stem/uploads/attachment_data/file/224169/ Rotavirus_Q_and_As_for_healthcare_practition ers_v4_26_July_2013.pdf http://guidance.nice.org.uk/CG160/NICEGui dance/pdf/English http://guidance.nice.org.uk/CG84 Bronchiolitis in children: diagnosis and management NICE guidelines [NG9] Prof Bush Clinical Review :Managing wheeze in preschool children BMJ 2014; 348