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Warts

Warts

Warts are skin growths that arise from a human papillomavirus (HPV) infection in the upper layers of the skin. 

Warts are very common especially in children, they are not dangerous but they do spread easily through contact. A miniscule defect in the skin is all that is needed for the virus to infect the skin and a wart to form.

Regardless of where they are found on the body, warts have a very typical appearance and rarely require a biopsy. Some warts grow outwards and are raised, hard, rough and have cauliflower-like appearance. Some warts grow inwards – as seen in plantar warts found on the sole of the foot. These tend to look like indentations in the foot. You may see a tiny dark spot in the middle of a wart – this is called an intracorneal haemorrhage.

Here a 5 things that your GP will want to know about your warty growth:
– The duration that you have had the wart
– The location of the wart on your body
– Pain or irritation the wart may be causing you
– Growth of the wart
– Your expectations and wishes for management

These are the most commonly used treatment options:

  1. Watch and wait: most warts will resolve on their own after 12 months.
  2. Topical Salycylic acid 40%: carefully paint this ointment onto the wart every night and cover the area with a bandaid. This treatment can take up to 12 weeks, but can be effective. It can cause skin irritation so make sure you protect the normal skin around your wart and you speak to your GP if irritation occurs.
  3. Cryotherapy: your GP can use cryotherapy to freeze the wart off. Liquid nitrogen is applied to the wart either with a cotton swab or sprayed directly onto the affected area. This treatment causes localised irritation which resolves within a few days. You may require a few sessions every 2-4 weeks depending on the size and location of the wart. 
  4. A combination of topical salicylic acid and cryotherapy.

A wart that is causing you pain and affecting your ability to do your daily activities is worth treating, so speak to your GP to find the best option for you.

Encephalitis in children

Encephalitis in children

What does the literature say about childhood encephalitis?

Recent studies show that the treatment of encephalitis in children is haphazard and improvements need to the made.  In general children with suspected encephalitis are previously healthy without any neurological conditions. Risk factors are immunosuppressed or travelled overseas. Because it is uncommon and the signs/symptoms are non-specific, initiating treatment is recommended even if there is no significant likelihood that they have the disease. 

The cause of encephalitis can be due to an infectious agent directly or indirectly by other inflammatory pathologies affecting the brain parenchyma. Herpes simplex virus type 1 is the most common cause of sporadic encephalitis.

Symptoms of encephalitis are non-specific, typically children will present with ‘flu-like’ symptoms (headache, nausea, vomiting and altered level of consciousness). Other complaints such as seizures and focal neurological signs are present. There is overlap with acute bacterial meningitis as they can have symptoms of fever, headache and neck stiffness. 

There are specific questions that must be asked by physician

  • Vaccination history
  • Travel history
  • History of a rash in child or contacts
  • Presence of cold sore or stomatitis may be caused by HSV 1

The absence of meningism should not be used to rule out encephalitis. 

Physicians should look for other symptoms such as raised blood pressure, papilloedema, abnormal pupil responses, abnormal flexion or extension to painful stimulus, altered breathing.

The failure to control the seizures is a risk factor for raised intracranial pressure, increased metabolic activity, acidosis and vasodilation

Early diagnosis is very important in order to treat the clinical syndrome and seek aetiology of the disease. Routinely it is advised to perform FBC, urea and electrolytes, liver function test, capillary glucose, blood gas, lactate, urinalysis and CSF.  

The best test to accurately determine encephalitis is autopsy or brain biopsy which is not practical. Surrogate markers include inflammatory cells in the spinal fluid or changes in brain imaging. CSF may be negative in the early stages of the disease. Neuroimaging is key in order to provide direct evidence of brain involvement from an infectious process or provide alternative diagnosis (space occupying legion, abscesses, vascular events etc). MRI is more sensitive. 

CT may misdiagnose HSV infection in the early stages of the condition whilst MRI will be able to detect other conditions (Kirkham 2012). 

Treatment is started with broad spectrum antimicrobials and antiviral medication while awaiting results of diagnostic studies.  Studies show that if therapy is commenced late, poor prognosis will ensue. So there should be a low threshold for starting acyclovir in suspected cases of encephalitis. 

However, there are also guidelines that suggests starting Aciclovir should not be commenced in children with known epilepsy with an increase in seizure and known febrile illness or acute head injury. 

Prognosis is generally poor for children with long-term neurological outcomes even despite appropriate therapy. Up to 67% of children will have long-term morbidity. 

In sum there are many unanswered questions about the ideal management and treatment of encephalitis due to lack of reporting, unknown aetiology in the majority of cases and few data on long-term outcomes.  The triage and appropriate treatment of children presenting with seizures, reduced level of consciousness or behavioural problems is complex and a controversial issue. 

References:

Thomson C, Knew R, Riodan A, Kelly D, Pollard AJ. Encephalitis in children. Archives of Disease in Childhood, 28 February 2012, Vol.97(2), p.150

Kirkham F. Guidelines for the management of encephalitis in children. Developmental Medicine & Child Neurology 2013, 55: 107–110

My child has a wheeze, is this asthma?

My child has a wheeze, is this asthma?

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 
  • Nicotine
  • Perfume 
  • 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 
  • Microbiomes 

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

  • Wheeze
  • Cough
  • 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 

  • Bronchiolitis
  • 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

  1. Indication for ICS in children less than 1 years
  2. A child is older than 1 year but needs a higher dosis of ICS than standardly allowed
  3. There are more than 1 episode of severe illness that required prednisolone
  4. There are co-morbidities that can cause severe complications
  5. The diagnosis is not fully determined
  6. 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

  1. Give salbutamol 100 mcg/dosis dosis-aerosol with chamber, 4 to 8 inhalation (1 inhalation per go in chamber, 5 times inhale and exhale)
  2. repeat the above after 15 minutes.
  3. If the child responds the GP can give prednison tablets or drink.
  4. 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.

My child has a fever, when can we see the GP?

My child has a fever, when can we see the GP?

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 
  • Convulsions

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.

ADHD in children

ADHD in children

Attention-deficit/hyperactivity disorder is a combination of various behavioural problems that is seen in children. It can occur in adult life, however it often goes unnoticed the older one gets.

The two most common signs of ADHD are

  • Lack of attention (6 of the 9 criteria)
    • inability to focus on activities or loss of interest
    • difficulty to focus on activities such as games or tasks
    • seems not to listen or pay attention when spoken to
    • unable to follow instructions or finish tasks
    • difficulty to organise tasks and activities
    • avoids tasks or activities that involve a degree of concentration
    • misplaces items that are needed to perform certain tasks
    • easily distracted by external stimulus
    • often absent-minded during daily activities
  • Hyperactivity or impulsivity (6 of 9 criteria)
    • moves around in chair or shakes feet or hands
    • stands up in situations were it is expected to remain seated
    • runs around or climbs on things where it is inappropriate
    • inability to play games in a calm manner or remain calm in games that are relaxing
    • is often doing own things and keeps on going
    • talks more than normal
    • answers questions without thinking about the meaning or consequences
    • difficulty waiting for own turn
    • pushes others away or is wants to impose own ways

Children can also have ADD where there is no sign of hyperactivity or impulsivity.

Before a GP diagnosis a child with ADHD or ADD other specialists or therapist may have already been involved in the assessment of the behaviour. The condition needs to affect and the people around him or her in both the home and school setting.

The GP will provide advice and referrals to other specialist. First instance it will be concerning behaviour management. If this has little effect the GP can consider Methylphenidate

Behaviour management consist of

  • Daily structure that is well planned with clear routines
    • time; for instance wake up, dine, sleep every day at same time
    • language; use short clear sentences when speaking
    • space; provide space for everything
  • Use pictures and visual cues to structure the day or space
  • Recognise good behaviour and applaud appropriately with treats or words of encouragement
  • Do not place unrealistic goals
  • Involve the child in finding solution
  • Provide tasks that are somewhat more challenging so they can remain focused
  • Make sure child has enough space and time to keep physically active
  • Remain patient

Prescribed medication include Methylphenidate or Dexaphetamine (both are controlled drugs and fall under opiate law)

  • Methylphenidate 5 mg one tablet twice a day (short-release dose). This can be increased to three times a day, consider the last daily dosage about 4 hours before bedtime due to side effects (difficulty falling asleep)
    • Increase daily dose by 2.5 mg to 5 mg per week to reach a maximum daily dose of 60 mg per day
    • Typical maximum daily dose depending on weight is 0.6 to 0.8 mg per kg in 2 or 3 doses.
    • In case of rebound effect and problems with compliance, consider switching to delayed-release dose Methylphenidate 18mg once a day (equivalent to 5mg three times a day)

Side effect includes difficulty sleeping, decreased appetite, headache, abdominal pains and easily agitated. Typically these side effects resolve after one or two weeks of starting medication and completely disappear once it is stopped.

At the start of treatment the GP will follow-up to assess the following

  • Effect of drug on behaviour
  • How long does the drug last for, is there rebound behaviour issues
  • Compliance with the regimen especially if child is attending high-school
  • if there are any side effects
  • presence of psychological symptoms (aggression, mood swings, suicidal thoughts, anxiety, agitation, depression or psychotic episodes)
  • If growth stops, heart rate increases or blood pressure also increases
    • GP should check blood pressure if headache occurs

The GP wil refer or deliberate with a paediatrician or paediatric psychiatrist in the event of

  • child being less than 6 years of age
  • severe disability and able to function at home or at school
  • possible pre-existing psychiatric issues
  • when treatment or therapy seems ineffective

ADHD is a complex condition that is typically seen in school-aged children. There needs to be the presence of hyperactive, impulsive and lack of paying attention to tasks or activities. It takes a multi-disciplinary approach to diagnose a child with ADHD and starting medication needs to be considered after other management options are tried. The GP will follow-up the child regularly while on oral medication to assess side-effects and rebound symptoms.