The diagnosis of asthma is confirmed in children above the age of 6 years. In general boys under 12 years of age are more affected than girls of that same age group. However as children grow older, after puberty girls are more affected.
About one third of children under the age of 3 years have episodic expiratory wheeze (that is when a child wheezes during expiration). This occurs typically when a child has a viral infection. Parents can become very worried and assume that their child has asthma, but this is not always the case. More than 50% of children with episodic expiratory wheeze will grow out of this by the time they are 6 years old and the remaining will have symptoms when they are adults.
Asthma is defined as episodes of bronchus obstruction and increased sensitivity of the respiratory tract due to allergic and non-allergic agents. This can lead to a chronic infection with eosinophils in the airways.
Examples of allergic agents include
- Dogs/cats or other furry animals
- Housemites (this is one of the most important causes of allergic agents and most often causes symptoms during the fall and winter period)
- Pollen from trees, flowers and/or grass
- Seasonal changes
Examples of non-allergic agents include:
- Exercise or increased emotional state
- Viral infections
- Various odours (around the home or at work)
Protective versus non-protective factors in asthma
- Genetic factors including eczema is associated with asthma
- Social factors such as second or third hand smoke can cause asthma
- Breastfeeding can provide protection against asthma
- Chronic viral infections at young age can be protective against asthma
- Obesity has been associated with asthma
Things your GP will ask you about your child
- is there an audible wheeze
- How severe are breathing difficulties if any
- Do symptoms occur mainly at night
- Are there any episodes when the child does not have any symptoms
- What are the potential allergic or non-allergic factors
- If anyone smokes in the near vicinity of the child
- What if any are diseases that occur in the family
4 things the GP examines looks at in a child with wheeze
- Signs of respiratory distress
- Increased respiratory rate, children have higher frequency compared to adults.
- Ear-nose-throat inspections for signs of congestion or infection
- Skin inspection for signs of eczema or infection
- Growth curve, does the child grow according to his age and height
If needed, a GP can request a blood test call the Radioallergosorbent (RAST) test to detect specific antibodies (IgE) for substances that a child is allergic to. When the GP requests the test, it will dependson the child’s age.
- Less than 6 years of age in the event of a clear allergic component in the history
- Above 6 years must always be done
- RAST for allergies against food is senseless.
Another exam that can be performed is a spirometer which can be done above the age of 6 years. It is best to do this during symptoms in order to get a reliable diagnosis. This way the doctor can determine the effect of medication that is applied during the examination.
A GP will diagnose asthma in children older than 6 years when they have the following symptoms
- Shortness of breath
- Recurrence particularly in the evening
- Positive RAST, history of eczema or family history of asthma
If a GP has doubts about the diagnosis they could consider
- Pseudocroup or known as acute laryngotracheitis
- Foreign item/toy stuck in a child’s throat
- Above 12 years : dysfunctional breaths such as when hyperventilating
- Below 1 year tracheomalacia
“Asthma can either be well controlled or poorly controlled”
GP’s play a vital role in management of childhood asthma:
- Educate parents and children about asthma
- Explain causes,, what the future looks like and how to reduce recurrence of episodes
- Discuss fears and limitations associated with asthma
- Inform on the effect of daily activities such as sport, social life on asthma
- Take time to explain which (various) medication can be used
- Show how the child can inhale the medication properly with use of instructions or videos. Up to 75% of children do not use inhalation medication properly.
- Ensure that both parents and child adhere to follow-up appointments
The GP will advice on other treatment options for asthma such as
- Stop smoking management in case a family member smokes in the vicinity of the child. Even when residues are on the clothes, this can cause a child to develop asthma.
- Influenza vaccination particularly in those that are on corticosteroids
- Clean the house and air it in order to reduce the presence of dust and house mites
- Breathing exercises w
- Physical activity
- Manage obesity
The GP wi start a child on a trial basis with 2 medication
- Short-acting-beta sympathicomimetica (SABA)
- Inhalation corticosteroids (ICS)
Inhalation medication should be provided with a chamber in order to be more effective. Only when the child has shown effective inhalation technique can puffs be used. If a child needs to inhale SABA more than twice a day then the child must be started on ICS. This is important because ICS work on the inflammation component of asthma.
The reason why a GP will want to follow-up with parents and children on inhalation therapy for asthma, is because of the risk of under-treatment. There are reports of children who unfortunately pass away because they are poorly treated and many of them did not attend follow-up with their GP.
The GP will check regularly whether symptoms have improved. If symptoms have improved then your child can continue with the dosage.
Referral to a paediatrician by the GP when
- Indication for ICS in children less than 1 years
- A child is older than 1 year but needs a higher dosis of ICS than standardly allowed
- There are more than 1 episode of severe illness that required prednisolone
- There are co-morbidities that can cause severe complications
- The diagnosis is not fully determined
- If the child is acutely ill and does not respond to treatment provided by the GP
In short: Asthma in children is a diagnosis that is made after the age of 6 years. It is important to determine factors in and outside the home that could trigger an asthma attack. Children can be managed well with medication however it is important that a GP spends time with parents and children with asthma on education and proper use of inhalation medication.
Four things that a GP will do immediately if your child has an asthma attack
- Give salbutamol 100 mcg/dosis dosis-aerosol with chamber, 4 to 8 inhalation (1 inhalation per go in chamber, 5 times inhale and exhale)
- repeat the above after 15 minutes.
- If the child responds the GP can give prednison tablets or drink.
- If the child does not respond then the GP will refer the child to the paediatrician.
Support is widely available for children who suffer from asthma, ask your GP for such services. asthma is either well controlled or poorly controlled. In the latter case, it is often due to non-compliance with medication or follow-up appointments.
Unwanted hair growth in women is a problem called hirsutism. It caused by hair follicles that react to increased level of androgen hormones. If facial hair growth in women is not caused by androgen, then this condition is called hypertrichosis.
Women with hirsutism develop unwanted or excessive hair growth in places that normally occur in men. For instance they develop hair growth on the face, upper lip, chin, chest and legs. Hirsutism in itself is not a disease if it occurs in women when they have a normal menstrual cycle.
Women and men have the same number of hair follicles on the body. The only places that lack hair follicles are the soles of the hand, feet and lips. There are three types of hair follicles
- Lanugo hair; this is thin baby hair found on newborns and is shed within a few weeks to be replaced by vellus hair
- Vellus hair; this is short hair without pigment and cover most of the skin
- Terminal hair; this is long, thick pigment hair found on the head, eyebrows, armpits and pubic region.
Vellus hair can grow into terminal hair under the influence of androgen hormone. There are three stages of hair growth in men and women
- Anagen – the phase that determines the length of the hair, the longer the hair stays in this phase, the longer the hair will be
- Catagen – the phase in which the hair follicle renews itself and nothing happens – this lasts about 2 weeks
- Telogen – the phase in which the hair sheds from the skin
The skin is full of receptors and enzymes. Testosteron can be converted into androgen hormone in the skin by an enzyme called 5-alpha reductase. The androgen attaches to receptors on the vellus hair follicle to stimulate them and they then grow into terminal hairs. Women with an abnormal interaction between androgen formed in the skin and the hair receptors will develop hirsutism.
If women with hirsutism have normal menstrual cycles then this condition is not pathological and no further tests are needed. A GP could advice hair removal via laser-treatment at a skin therapy clinic. If women have hirsutism and an irregular menstrual cycle, then a GP should proceed with further tests such as determine the level of androgen hormones. A high level of androgen hormone can be caused by disease of the adrenal glands or in women with polycystic ovarium syndrome (PCOS).
The GP will want to know about the following conditions in order to determine whether it is hirsutism
- location of unwanted hair growth
- how the condition has progressed
- if this occurs in other female family members
- changes in menstruation
- use of contraception
- desires to have child(ren)
- weight loss or weight gain
- use of medication in particular anabolic steroids or danazol (used to treat endometriosis or fibrous cystics breast disease)
- use of anti-hair treatment
- the psychological consequences of excessive hair growth
- worries with regards to fertility
Next the GP will perform a physical examination and will look for presence of terminal hair growth on the breast, abdomen, back, upper legs, upper arms and face. A score from 0 (no terminal hair growth) to 4 (excessive terminal hair growth) is given based on the findings. A score of more than 8 in a light-skinned woman is classified as hirsutism.
The GP will then look at signs of
- obesity or excess fat tissue on the body
- masculine voice
- male-pattern boldness
- small breasts
- increased muscle
- enlarged clitoris
- large thyroid gland
- signs of systemic illness
A referral to a gynaecologist or endocrinologist is made when there are signs of hormonal imbalance and or changes in menstrual cycle.
There are no medication available for women who have hirsutism and normal menstrual cycle. In case of changes in menstruation and no wishes to bear children, women can opt to take an oral contraception pill. The effect is that oestrogen will stimulate testosteron binding SHBG that in turns inactivates testosteron. This in turns means that 5-alpha reductase is not able to convert the inactivated testosterone into androgen. Without androgen, vellus hair is not able to grow as terminal hair and hence reduces the presence of unwanted hair growth.
Obese women with hirsutism are encouraged to loose weight since testosteron is converted to oestradiol in fatty tissue. Oestradiol decreased follicle stimulating hormones (FSH) such that ovaries are not able to release an egg for ovulation. This causes changes in menstrual cycles.
Hirsutism is a response to hormone androgen receptors on thin hair follicles that cause them to grow into thick long hair. The presence of unwanted hair growth in the face, breast, back, upper limbs and lip can be scored 0-24 points. A score of 8 or more signals the presence of hirsutism. A GP will need to know if this occurs with a normal or abnormal menstrual cycle before he or she decides on referral to specialist care.
Cellulitis is a bacterial skin infection. Signs are acute redness of the skin, and oedema with rough borders. It usually affects lower limbs but any skin region can become infected.
The causes of cellulitis in when the skin barrier is damaged such that bacteria can cross over the skin layers and infect cells. People with pre-existent conditions such as diabetes, obesity, bite wounds or insufficient pump function of the veins are susceptible to cellulitis. Bacteria called stapylococcus aureus is the cause in 80% of cases.
The GP will differentiate between cellulitis and erysipelas. The latter is more superficial and has well marked edges or borders and usually is elevated. The GP will want to know
- How long the region of the skin has been affected
- what happened prior to developing symptoms
- Recurrence of symptoms
- Recovering from skin disease
- Presence of fever or general unwell
- If the redness spread out
- if there is pain or hypersensitivity
- Pre-existent conditions as mentioned above
A GP will check physically for the size, thickness of the cellulitis. Also comparing the skin temperature difference beween the affected skin are and normal area can be performed. Palpating for lymph nodes is an important part of the physical examination. Blood tests may be requested by the GP if cellulitis is associated with fever, chills, general unwell appearance, lymph nodes oedema or cellulitis located near the mouth or eye.
Management of cellulitis consists of
- Hygiene; keep the area clean and dry
- Pain relief; cellulitis can be very painful. Take Paracetamol 500mg, 2 tablets 4 times a day
- Bandage, elevate and immobilise the limb
- Oral antibiotics in those with no pre-existent conditions
- Flucloxacilline 500mg one tablet four times a day for 10 days
- Oral antibiotics in those with pre-existent conditions
- Amoxicilline/Clavulanic acid 625mg, one tablet 3 times a day for 7 to 10 days
- Doxycycline 200 mg one tablet once a day for 7 to 10 days
Superficial wounds also known as abrasion or graze mostly involve the epidermis layer of your skin. There are many causes of superficial wounds and the majority are caused after a fall (during sports) on the knees, elbows and hands. Children under the age of 15 years and adults above 75 years of age are those who are frequently affected by this condition.
Abrasions typically heal quickly without any complications or scars. However co-morbidities such as diabetes mellitus, obesity, or use of medication like steroids can delay wound healing. In many cases, you will not visit your GP for an abrasion wound as it heals quickly. However, most people seek advice from a GP regarding wound management.
Your GP will ask you 4 important questions
- How the wound occurred: this helps to provide information on factors such as contamination of the wound
- When the wound occurred; wounds that are older than 6 to 8 hours need to be considered as infected wounds
- If you have any co-morbidities or pre-existent conditions like immune deficiency
- Whether you have a current vaccination status for tetanus
An abrasion is recognised by your GP as small round point bleed from the dermis. Some abrasions can bleed more profusely than others depending on the location and presence of co-morbidities. Before you get to your GP for assessment you can do the following
- Clean the abrasion with running tap water, there is no need to add soap at this stage.
Once at your GP the following procedures will be done
- Clean some more; if your abrasion wound is large or contaminated the GP may give you a local anaesthetic to clean the wound as this can be painful
- Disinfect the wound with iodine which acts as an antiseptic for bacteria and fungal infection.
- Chlorhexidine can also be used and is highly effective against bacteria (gram negative and gram positive).
- Let the wound dry naturally without placing a bandage; one of the advantages of this method is that in time, the skin will produce a protective scab layer. This is a natural healing process and the scab will fall off by itself.
- Bandage abrasions that are not exposed to air and that will not be able to dry naturally as explained above.
- Occlusive bandage with an occlusive foam that protects the abrasion wound from contact with air. This provides faster healing and there is little pain or discomfort when changing the dressings
- Local antibiotics; If the wound looks infected the GP can opt to apply an antibiotic cream
- Fusidic acid (3 times a day for a week). The cream works better against staphylococcus aureus bacterial and is less effective for streptococcus bacteria.
- Systemic antibiotic; in the event of general unwell, fever, regionally enlarged lymph nodes, the GP should prescribe oral antibiotics in the form of
- flucloxacillin (500 mg 4 times daily for 10 to 14 days) or
- clarithromycin in case of penicillin allergy (500mg 2 times a day for 10 to 14 days) or
- clindamycine in case of penicillin allergy (600 mg 3 times a day for 10 to 14 days)
A referral to specialist care is very unlikely and depends on healing, scarring and general physical health
Your 3 year-old girl developed a fever in the middle of the night. She kept you and your spouse awake all night. The next morning she still feels warm and is clingy. You are worried that she is not eating and is not her usual self. You contact your GP to make an appointment for her to be seen. On the phone the practice nurse asks you a series of questions. You get upset because you want your girl to be seen by a doctor straight away. You wonder why the nurse is wasting time and not getting an urgent appointment with the GP.
What happens in a GP office when a child has fever?
In the Netherlands, the practice nurse at your GP office is the first professional you will speak to with regards to your child with fever. Her or his task is to ask a series of questions to determine one main goal: How serious is the problem?. The reason behind this process is because fever is very common in children aged between 0 and 4 years old. So much so that in the first 2 years of a child’s life, they will be sick with fever an average of 8 times. In order to avoid seeing every child with a fever which typically is caused by a virus with a naturally innocent prognosis, it is therefore important to determine any alarm symptoms. Doing so prevents potential complications to occur and allocates the doctor at the right time to treat the fever in the child. This is a system practice nurses use to inform the GP how serious the situation is and when the child should be seen.
12 signs your child’s fever is serious
During the conversation with the practice nurse, the questions asked are done so to determine the presence of alarm symptoms. There are 12 of them and these are listed below to help determine when a child with fever should be seen urgently (within 15 minutes).
- Less than 1 month old ; babies do not yet have an immune system developed enough to help them fight off infection even if a mild one.
- Looks very ill
- Behaviour is not usual
- Drowsy appearance
- Cries inconsolably
- Takes less fluids or has very few to no wet nappies
- Vomits several times an hour
- A rash that does not blanch when pressed upon
- Changes in skin color (pale, red, grey, blue lips)
- Shortness of breath and/or fast breathing with or without drooling
If your child has more than 2 alarm symptoms then a GP will need to see the child within 30 minutes.This can be at home or at the practice and depends on convenience. Should your child not have any of these alarm symptoms but is aged between 0 and 3 months then the doctor will see the child within a few hours.
Typically a GP will see your child within 24 hours if there are no alarm symptoms however, the following situation are present
- You are a worried parent who has contacted the GP practice due to the same complaint in the past 24 hours
- Uncertainty about the answers given
- Complicated communication due to language barrier
- New onset of fever after a few days without fever
What is fever and why does it occur?
You are given an appointment to come with your girl to the practice. In the waiting room, while your girl is finally asleep in your lap, you see a brochure about fever in children and read the insert:
“ Fever is when the body temperature rises above 38 degrees Celsius. It occurs as a response to an infection caused by a virus or bacteria. During this process, cells release certain enzymes called cytokines that activate the temperature regulatory organ in the brain called the hypothalamus. The response is to increase the body’s temperature in order to release more enzymes that fight off the infection. However when the temperature rises above 42 degrees Celsius, the body is not able to get rid of the excess heat and this can cause damage to vital cells in the body. This process can lead to (severe) complications…”
13 signs your GP will look for in a child with fever
You are called through into the GP’s office. You repeat the story you told the practice nurse and you highlight what a rough night you all had and do not anticipate going through it again. Your GP decides to examine your child and looks out for the following signs:
- Is the child alert or drowsy?
- Does the child seem over sensitive?
- When the child cries can the parent calm her down?
- Is the temperature measured done rectally (this must always be done in children less than 3 months old)
- Does the child have cold shivers?
- What is the colour or appearance of the skin?
- Can the child move their neck freely, or does she lie still on the bed?
- Are there any visible signs of difficulty in breathing?
- How fast is the heart rate?
- Does the abdomen feel soft or hard?
- Are there any swollen joints?
- What do the ears look like from the inside?
- Are there any swollen lymph glands in the neck or throat?
4 things to do at home when your child has fever
In many cases if there are no obvious abnormalities during physical examination, a urine test can be useful to rule out bladder infection in a child with fever without a ‘focus’. A focus is a source of where the fever originates from. In most children aged 0 to 4 this is from the ears, nose and throat region. If there are no serious complications expected, your GP will be able to send you and your child home with advice on what to do.
- It is important to realise that a child with fever will generally not have an appetite. So it is better to take time to get the child to drink fluids than to eat.
- Typically, a child will have fever for 4-6 days, sometimes even 10 days without any complications. Should the child experience pain then the GP will advise paracetamol and/or ibuprofen (dosage based on weight and age) to manage the pain in your child.
- Antibiotics will not be needed if there is no evidence of a bacterial infection.
- There is no need to measure temperature frequently during the day. You can observe the child’s behaviour and monitor any changes which will be more informative for the GP.
A child with fever is one of the most common reasons why you as a parent will contact your GP. The most important take home message is that in the vast majority of casse, if there are no alarm symptoms, the fever will resolve after 4-7 days. The guidelines are used to help determine which child needs urgent care and which can wait 24 hours for further examination. Always observe and monitor your child’s appearance or behaviour and communicate any concerns with your GP.