Painless expanding facial swelling.

A previously healthy 11-year-old girl sustained a mosquito bite on her right cheek while on holiday in rural Bangladesh. A painless lump developed at the site, and over the ensuing 2 months gradually expanded. She was otherwise completely asymptomatic; there was no family history of note. On examination, there was obvious swelling affecting the right cheek and visible abnormality of the upper gum with displacement of the right upper central incisor (figure 1).

The recognition and nursing management of common oncological emergencies in children.

An oncological emergency may be the initial presentation of a cancer, a sign of cancer progression, or a complication of cancer treatment. The most frequently encountered paediatric oncological emergencies include neutropenic sepsis, hyperleukocytosis, brain tumours presenting with raised intracranial pressure, tumour lysis syndrome and superior mediastinal syndrome. These are all life-threatening conditions that require urgent recognition and management. Health professionals working in an emergency department (ED) are likely to be involved in managing these children. This article brings together the current guidance and recommendations for these specific emergencies. It also includes two case studies that demonstrate the challenges health professionals can face while managing these situations. It is important that health professionals have an acute awareness of oncological emergencies. Confidence in recognising the presentations, diagnoses and initial management are essential because these conditions may be life-threatening and time critical.

Celiac Disease Management in the United Kingdom Specialist Pediatric Gastroenterology Centers-A Service Survey.

OBJECTIVES: The 2012 European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines on celiac disease (CD) recommended a no-biopsy pathway (NBP) for symptomatic children with high immunoglobin A (IgA)-based anti-tissue transglutaminase (TGA-IgA) titers, positive anti-endomysial antibody and human leukocyte antigen (HLA)-DQ2/DQ8 status. We aimed to understand variations in practice amongst specialist pediatric gastroenterology centers (SPGIC) in the United Kingdom (UK). METHODS: A survey questionnaire was sent to all UK SPGIC (n = 29) providing endoscopy services for CD diagnosis. It was divided into four main subgroups: analyzing diagnosis of CD through adherence to the ESPGHAN (2012) guidelines, post-diagnosis care and long-term follow-up and discharge from pediatric services. RESULTS: All 29 responded. NBP was implemented in 28 of 29 centers. Five of 29 centers had already stopped HLA-DQ2/DQ8 testing for NBP diagnosis. Twenty six of 29 centers were performing endoscopy on screening-identified children (mostly asymptomatic, "at-risk" patients). Diagnosis was communicated by a doctor in 65% SPGIC (n = 19). Most centers (n = 23) waited 6-12 months post-diagnosis to start gluten-free oats. Routine vitamin D supplementation was commenced by 4 of 29 centers. All centers repeated TGA-IgA to assess normalization but at varying times post-GFD. Follow-up was with a combination of doctors/dieticians (n = 26). Eleven of 29 centers discharged their patient to primary care. CONCLUSIONS: There was excellent uptake of ESPGHAN guidelines (2012) in the UK and adherence to guidelines is generally good. Despite published evidence and pragmatic advice from the British Society of Paediatric Gastroenterology Hepatology and Nutrition and National Institute for Health and Care Excellence, significant differences remain in diagnostic and ongoing management practice and are opportunities for research and directive evidence-based follow-up guidance.

Diagnosis of celiac disease is being missed in over 80% of children particularly in those from socioeconomically deprived backgrounds.

Population-based screening studies have documented prevalence of celiac disease (CD) at 1% at age 7 years, but 90% of children remain undiagnosed. This prospective cohort study aims to examine whether observed differences in diagnosis rates of CD exist between children from different socioeconomic groups and how this has changed over a 12-year period. All children aged ≤15 years with a postcode within South West of England (SWE) diagnosed with CD during a 12-year period (1999-2010) when all diagnoses were based on endoscopic histology were included in the study. The incidence rates in socioeconomic groups were determined using the Index of Multiple Deprivation Score and Office of National Statistics population data. Four hundred fifteen children were diagnosed with CD; 65 within the City of Bristol (CoB). Diagnosis rate rose 4.2 times in SWE and 3.1 times in CoB between the first and last 4 years of the study. The rate was 1.6 times higher in the least socioeconomically deprived compared to most deprived (2.2 times in CoB), and the gap widened over the 12 years. Missed cases estimates for CoB and SWE are at least 83% and 91%, respectively.Conclusion: These findings suggest that while incidence of diagnosed CD in children has increased over a 12-year period, 83-91% remained undiagnosed. Socioeconomically deprived children are more likely to be underdiagnosed, and the gap between the least and most deprived has widened. To fully address massive underdiagnosis, further strategies including pilot studies using finger prick serological mass screening for CD in children entering primary schools are needed. What is Known: • Epidemiological studies record a 1% prevalence of celiac disease (CD), but up to 90% of children may remain undiagnosed. • Previous studies have documented an increased incidence of CD in higher socioeconomic groups, but proposed reasons remain conflicting. What is New: • Incidence of diagnosed CDhas gone up across all social classes but more so in higher socioeconomic groups and there is an increasing health/wealth gap. • This study estimates that 83-91% of children with CD are still being missed despite improved and easily available serological testing and suggest that population screening should be reconsidered.

Acute abdominal surgical presentations in children.

Surgical conditions affecting the abdomen in children can be associated with significant morbidity and mortality if they are not recognised and managed appropriately. It is therefore important that the correct diagnosis is made quickly, and the appropriate intervention is initiated in a timely manner and, if necessary, rapid transfer is made to a specialist paediatric surgical facility. This article provides an overview of the different surgical presentations encountered in children, and outlines the most important points in the history, examination and management of such cases, whether encountered in the emergency setting or in the community. Two illustrative case studies have been included to demonstrate how these emergencies may present in clinical practice.

Diagnosis and management of coeliac disease in children.

Coeliac disease (CD) is an autoimmune gluten-dependent condition with a prevalence of 1% in the population, if screened. However, approximately only a third of children with CD are diagnosed. When CD is suspected, serological screening with anti-tissue transglutaminase titres should be performed. Children with a positive result should be referred to a specialist in CD for confirmation of the diagnosis. The European Society for Paediatric Gastroenterology Hepatology and Nutrition revised their diagnostic guidance for CD in 2020 and this article discusses the current diagnostic pathways. Lifelong strict adherence to a gluten-free diet is necessary to prevent complications. Nurses and specialist paediatric dietitians have an important role in recognising and diagnosing CD early, as well as offering ongoing dietary and clinical support.

Recognition and management of neonatal sepsis.

Neonatal sepsis results from acute bacterial or viral infection occurring in the first 28 days of life. It causes significant morbidity and mortality, although the outcome can be improved by early recognition and prompt treatment by health professionals. This article describes the most common causes of sepsis, and explains why neonates are particularly vulnerable to infection. It highlights the non-specific way in which an infant with a serious infection may present, indicating the crucial features to elicit during history taking and examination, and emphasising the 'red-flag' signs and symptoms that should increase suspicion of a serious illness. The authors have adapted National Institute for Health and Care Excellence guidelines to produce an evidence-based approach to the management of an infant with suspected sepsis, and describe the roles of nurses in ensuring effective treatment and best outcomes for these babies.

Decreased level of consciousness in a child: recognition and management.

A child presenting with decreased level of conscious (dLOC) is of great concern due to the wide range of possible causes, and potential for death or serious long-term sequelae. It is therefore vital that health professionals can recognise a child with dLOC quickly, intervene appropriately and escalate for senior review as a matter of urgency. This article provides an explanation for the mechanisms of decreased consciousness, outlines the different causative pathologies, and provides a simple and logical approach to the first-line recognition and management that a health professional may apply when faced with such a patient. Illustrative case studies have been included, to demonstrate how children with dLOC may present in clinical practice.

Recognition and management of leukaemia in children.

Leukaemia is the most common cancer in children. The presenting manifestations can be wide-ranging, from a relatively well child to life-threatening complications. Symptoms can be manifested in any of the bodily systems. Undertaking a thorough clinical assessment of the child, in addition to recognising and addressing parental concerns, is vital. Furthermore, recognising that children can commonly present with musculoskeletal or abdominal symptoms increases the diagnostic yield, thereby preventing missed or late diagnoses. Childhood cancer has a huge impact on the child and their family, both at diagnosis and in the long term; providing advice and signposting families to appropriate support groups is an important aspect of their management. Nurses play a vital role in managing children with cancers, starting from raising suspicion and identifying the child with leukaemia, ensuring that high-quality care is delivered throughout their treatment, managing complications, and providing support and information to children and their families. An illustrative case study is included to highlight some of the challenges that health professionals may encounter in their clinical practice.

Benign acute childhood myositis: importance of early recognition.

Cases of children presenting with limb or joint pain are relatively common and are due mainly to benign conditions. Early diagnosis will help reduce unnecessary invasive investigations so, although a relatively rare condition, benign acute childhood myositis (BACM), which presents with acute lower limb pain and an isolated rise in creatine kinase, should be considered. BACM is characterised by an infiltration of viruses into calf muscle fibres, which may cause a subsequent inflammatory response leading to calf-muscle pain. Symptomatic and supportive management, along with explanation and reassurance, is all that is required in managing this condition. This article discusses the management of a 10-year-old boy with a classical presentation of BACM, alongside differentials and management for clinician consideration.

Evidence Supporting Serology-based Pathway for Diagnosing Celiac Disease in Asymptomatic Children From High-risk Groups.

OBJECTIVE: The European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) guidelines for diagnosing celiac disease (CD) in children were modified in 2012. They recommend that in symptomatic children with anti-tissue transglutaminase antibody (anti-tTG) titer of >10 times upper limit of normal (>10× ULN) and who have positive anti-endomysial antibody and HLA-DQ2/DQ8 haplotype, the diagnosis of CD can be based on serology. The aim of this study is to establish whether serology-based pathway of the ESPGHAN guidelines could also be reliably applied to asymptomatic children from high-risk groups. METHODS: From March 2007 to February 2017, prospective data on anti-tTG titer, age, sex, and reason for screening were collected at diagnostic endoscopy on all asymptomatic children being diagnosed as having CD. The relationship between modified Marsh-Oberhuber classification histological grading and contemporaneous anti-tTG titers was analyzed. RESULTS: A total of 157 asymptomatic children were diagnosed as having CD. Eighty-four of 157 (53.5%) had antitTG >10× ULN (normal <10 IU/mL) and 75 of 84 were from high-risk groups. All 75 had definitive histological evidence (Marsh-Oberhuber 3a-3c) of small bowel enteropathy. Fifty-three of 84 children had anti-tTG >200 IU/mL and total villous atrophy was present in 29 of 53 (55%). Main reasons for serological screening were: type-1 diabetes mellitus (n = 36) and first-degree relatives with CD (n = 24). Mean age at diagnosis was 8.8 years. Serology-based diagnosis is cost-beneficial by around £1275 per child in the United Kingdom. CONCLUSIONS: All 75 asymptomatic children from high-risk groups with anti-tTG >10× ULN had histology-proven CD. This study provides further evidence that the guidelines for diagnosing CD by the serology-based pathway should be extended to these children.

Recognition and management of febrile convulsions in children.

Febrile convulsions (FCs) are characterised by convulsions associated with fever in children aged between 6 months and 6 years. FCs are relatively common and affect 3-4% of children in western countries. This is the most common seizure disorder seen in children. The cause of febrile illness in FC is usually benign and most frequently due to acute viral infection. Convulsions secondary to an intracranial infection (e.g. meningitis, encephalitis) or from acute electrolyte imbalance should not be labelled as FCs. The diagnosis is based mainly on clinical history, and further investigations are generally unnecessary; management is largely symptomatic. Prolonged FC may need anticonvulsant medication to stop the seizure. Referral to paediatric neurologists may be considered in cases of complex or recurrent FC or in children where there is a pre-existing neurological disorder. One third of children with a first FC will develop a further FC during subsequent febrile illness; the likelihood increases in presence of other risk factors. This article outlines the presentation, management, investigations and prognosis for FC, and highlights how nurses in different clinical settings can provide education, support and counselling to help families return to normality after the event. An illustrative case study is also included to highlight the challenges faced by health professionals while managing children with this condition.

Outcomes of very high C-reactive protein levels in paediatric practice.

Siba Prosad Paul, Alifa De Aguiar, Joanna Barnden, Anna Cannon and Megan Eaton discuss the implications of high levels of the inflammatory marker, drawing on local audit.

Recognition and nursing management of reflex anoxic seizures in children.

Reflex anoxic seizures (RAS) present with a transient loss of consciousness and are triggered by an unexpected stimuli. These are paroxysmal, short-lived episodes of pronounced bradycardia or transient asystole; the episodes are self-limiting, lasting between 15 seconds and 1 minute. RAS are an important differential diagnosis of transient loss of consciousness but they are commonly misdiagnosed as epileptic events. An accurate and focused history is key to the diagnosis. They are mostly managed by performing an ECG to rule out other causes of arrhythmia, with subsequent explanation of the condition and reassurance given to parents. Nurses play an important role in eliciting the history and providing support to parents following the diagnosis. This article addresses the epidemiology and pathophysiology of RAS, with suggestions for management. An illustrative case study is included to highlight some of the challenges that health professionals working in different clinical set-ups are likely to come across while managing a child with RAS.

Nursing management of paediatric asthma in emergency departments.

Childhood asthma is a complex disease which may be resistant to treatment and varies in its clinical presentation. The number of children admitted to emergency departments (EDs) with acute exacerbation of asthma is high and many are managed solely in the department. The correct assessment of the severity of an exacerbation can be achieved through competent history taking, examination and accurate recording of observations. Nurses working in EDs should be able to recognise the clinical signs and symptoms of acute asthma, assess severity and advise on appropriate management. Nurses should have some knowledge of first-line management and how and when to help deliver these therapies. They should also be able to guide patients in discharge and follow-up care, develop a rapport with families and educate them on topics such as trigger avoidance. The assessment and management of these patients as outlined in this article is based on the British Thoracic Society/Scottish Intercollegiate Guidelines Network ( 2016 ).

Recognition and nursing management of children with non-traumatic limp.

Children with acute onset non-traumatic limp often present to emergency departments (EDs). The limp can occasionally be associated with medical emergencies such as septic arthritis and slipped upper femoral epiphysis but is often due to less severe conditions. This article discusses the common and self-limiting causes of acute onset of non-traumatic limp in children, such as transient synovitis, reactive arthritis, and benign acute childhood myositis. It also discusses more severe conditions, including septic arthritis, osteomyelitis, slipped upper femoral epiphysis, Perthes disease, malignancies and non-accidental injury. Management and prognosis of these conditions are discussed in the context of guidance from the National Institute for Health and Care Excellence. The article includes two case studies that illustrate different presentations and the challenges that nurses who manage children in EDs are likely to come across in clinical practice.