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

2. 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

3. Care Pathways Bronchiolitis Asthma Gastroenteritis Feverish child
Head Injury
Abdominal pain

4. Primary Care Bronchiolitis
bleep 019
Consider CCN review on am to 6pm 7 days

5. Asthma ambulatory pathway
EDUCATION

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

7. Recommended CPD Pre school wheeze BMJ elearning module
intro/.html?moduleId=
Pre school wheeze review

8. 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 am to 6pm

9. 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 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

10. 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> mths, HR> years
To be read in conjunction with Feverish illness in children. NICE clinical guideline CG160

12. 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

13. 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.

14. 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 ?

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

16. Assessment - Bronchioloitis

17. Primary Care Bronchiolitis
bleep 019
Consider CCN review on am to 6pm 7 days

18. Child Asthma Pathway

19. 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

20. 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

21. Recommended CPD Pre school wheeze BMJ elearning module
intro/.html?moduleId=
Pre school wheeze review

22. Assessment
Behaviour
Talking
Heart rate
Respiratory
Oxygen saturations

23. Asthma ambulatory pathway

24. 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

25. 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

26. 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

27. 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.

28. 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

29. Assessment - Gastroenteritis
Decreased skin turgour

30. 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 am to 6pm

31. 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

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

33. Febrile Child Non Paediatric Practitioner

34. 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.

35. 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 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

36. 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> mths, HR> years
To be read in conjunction with Feverish illness in children. NICE clinical guideline CG160

37. 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

39. 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

40. Useful References
stem/uploads/attachment_data/file/224169/ Rotavirus_Q_and_As_for_healthcare_practition ers_v4_26_July_2013.pdf
dance/pdf/English
Bronchiolitis in children: diagnosis and management NICE guidelines [NG9]
Prof Bush Clinical Review :Managing wheeze in preschool children BMJ 2014; 348