Paediatrics

Dr Jeremy Rajanayagam
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How to evaluate feed tolerance and when to be clinically concerned

Cindy Davenport
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Recognising the ‘red-flags’ in the history of dysmenorrhoea in a young woman

Susan Teerds
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Keeping young children and infants safe at home - injury causes more child deaths than asthma, cancer and infectious disease combined

Expert/s: Susan Teerds
Cindy Davenport
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Understanding SUDI - Sudden and Unexpected Death in Infancy

A/Prof Avi Lemberg
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Current evidence demonstrating the multiple beneficial effects of HMOs, including antimicrobial, immune modulation, prebiotic, neurodevelopment and cognition effects.

Dr Linda Calabresi
Clinical Articles iconClinical Articles

Babies with severe sleep problems are more likely to have anxiety issues as they grow up, Australian researchers say. That’s the rather depressing conclusion following the prospective Maternal Health Study, that looked at almost 1500 mother-baby pairs from 15 weeks gestation to when the child turned 10.

A/Prof Louise Hill
Clinical Articles iconClinical Articles

A miscarriage is a devastating event. Those who experience them are suddenly and unexpectedly robbed of the promise of new life and the dream of an expanded family. The emotional toll can be even greater if conception was delayed, or if fertility treatments were required to achieve a pregnancy. Many health providers have considered miscarriage as “nature’s way”, not fully acknowledging its emotional and psychological effects on those who have lost a pregnancy. Fortunately, this view is changing, and there is increasing advocacy for research into the causes, prevention and management of miscarriages. But there remains a long way to go.

Dr Linda Calabresi
Clinical Articles iconClinical Articles

It is very difficult to estimate the prevalence of fetal alcohol spectrum disorder among Australian children. This is partly due to fact that the manifestation of the disorder can be very varied and often subtle, and partly due to the fact that very few women will give a history of drinking alcohol in pregnancy. But the experts say, if we consider that at least 20% of Australians drink at risky levels and up to half of all pregnancies are unplanned, you’ve got to suspect there’s quite a large cohort of affected children out there, many of whom may be yet to be diagnosed. So … you might want to check out this resource – a Toolkit for parents, caregivers and families of children with this condition – put out by the NOFASD (National Organisation for Fetal Alcohol Spectrum Disorders).

Kate Lycett
Clinical Articles iconClinical Articles

Three simple factors can predict whether a child is likely to be overweight or obese by the time they reach adolescence: the child’s body mass index (BMI), the mother’s BMI and the mother’s education level, according to our new research. The study, published in the International Journal of Obesity, found these three factors predicted whether children of all sizes either developed weight problems or resolved them by age 14-15, with around 70% accuracy. One in four Australian adolescents is overweight or obese. This means they’re likely to be obese in adulthood, placing them at higher risk of heart disease, diabetes, Alzheimer’s and cancer. Combining these three factors may help clinicians target care to those most at risk of becoming obese in adolescence.

Dr Mihiri Silva
Clinical Articles iconClinical Articles

If you imagine a teething child, what do you see? An irritable tot with a fever, in pain, and generally unwell? Teething’s a normal developmental process that people have long associated with illness. However, the evidence says otherwise. How strong is this evidence? Is there anything you can do to help a teething child? What about teething gels and teething necklaces? Teething is when new teeth emerge through the gums, and usually starts at about six months of age. A review of 16 studies found that although teething was linked with signs and symptoms, these were usually mild involving gum irritation, irritability, and drooling. Although body temperature may be slightly raised, the review found poor evidence to suggest teething caused fever. Many symptoms linked to teething, like irritability, sleep disturbance and drooling, are difficult to measure objectively and are based on what parents report, which is subjective and may be inaccurate. And, as teething comes and goes, and its timing is relatively unpredictable, recording even measurable symptoms like temperature changes in a reproducible, reliable way is virtually impossible. So teething problems seem to be over-reported in the types of studies that rely on people remembering what happened.

What else could cause the symptoms?

Other biological triggers may in fact explain the symptoms traditionally linked to teething. Teething coincides with normal changes in children’s immunity; the mother’s antibodies are transferred to babies in pregnancy and help protect the baby in the first 6-12 months of life, but start to wane at about the same time as teething. This, together with behavioural changes as infants start to explore their surroundings, increases the chances of catching viral infections with symptoms like those reported for teething. Separation anxiety and normal changes in sleep patterns may also account for irritability and sleep disturbances, which may be mistakenly attributed to teething. As teething symptoms are generally likely to be mild and focused on the mouth, parents are warned against presuming that signs of illness in other parts of the body are due to teething. That’s because this may delay the detection of potentially serious infections that may need medical attention. It may also delay parents getting help settling their child to sleep.

How about teething gels?

The search for solutions to the perceived problem of teething may lead parents to pin their hopes on gels, toys and other products, none of which have been scientifically assessed to alleviate teething symptoms. Nevertheless, teething gels usually contain a variety of ingredients that help relieve supposed teething-related symptoms. Some, such as the recently discontinued Adelaide Women’s and Children’s Hospital Teething Gel, contain the anaesthetic lidocaine. Very little lidocaine is absorbed into the body when applied to the gums, and only minor complications like vomiting have been reported in Australia. However, accidental swallowing and applying too much can lead to poisoning, resulting in seizures, brain injury, and heart problems. The decision to discontinue the gel follows a 2014 warning issued by the US Food and Drug Administration against using teething gels with topical anaesthetics, after reports of infant and child hospitalisation and death. There have also been warnings about teething gels containing benzocaine. This is another anaesthetic applied to the gums that can lead to a dangerous and fatal blood condition called methaemoglobinaemia, which affects the blood’s ability to carry oxygen. Another common ingredient in popular teething gels is choline salicylate, an anti-inflammatory similar to aspirin. This increases the risk of liver disease and brain injury if the child eats too much. This may also carry the risk of Reye syndrome, a rare but serious condition that can lead to seizures, loss of consciousness and death. Reye syndrome has been linked to the use of aspirin in children, particularly during viral infections. A case of suspected teething gel-induced Reye syndrome in 2008 led to the products being contraindicated (warned against) in children in the UK. A number of young Australian children who used too much salicylate-containing teething gel have also reportedly been hospitalised with side-effects. But the products are still available in Australia.

How about ‘natural’ products?

Although a range of “natural” and homeopathic teething solutions are heavily marketed to parents of young children, these too have risks. A manufacturer recently recalled a range of natural teething gels after cases of reported poisoning. And US regulatory authorities found the same range contained higher than reported levels of belladonna, a poisonous plant that despite its dangers is used as a homeopathic pain killer and sedative. In searching for “natural” therapies, parents are also turning to amber teething necklaces that supposedly relieve teething symptoms. Amber is a fossilised tree resin that has historically been suggested to have anti-inflammatory properties. However, several widely reported cases of strangulation have led to warnings from both US and Australian regulatory authorities. There is currently no scientific evidence these necklaces work. The Australian Competition and Consumer Commission (ACCC) says amber and other “teething” necklaces, even when mothers wear them, are:
…colourful and playful in design, and may be confused with toys.
All toys for children aged 36 months and below, including teething toys, are strictly regulated by Australian standards. As the ACCC warns, teething necklaces are unlikely to fulfil this requirement.

What to do?

So what are the best options to relieve teething symptoms? With a lack of any good-quality evidence to recommend any specific therapy, experts suggest the best remedy is affection and attention. Rubbing a clean finger on the gum, or applying gentle, firm pressure with a cooled (but not frozen), clean washcloth or teething ring may provide some relief. Although it’s hard to know exactly how these work, they are unlikely to lead to serious problems. Teething can be a difficult time, but it will eventually pass. In the meantime, it is important that parents avoid falling prey to supposed cures that are not only unproven, but are also potentially dangerous. Mihiri Silva, Paediatric dentist, Senior Lecturer and Post-doctoral Research Fellow, Murdoch Children's Research Institute This article is republished from The Conversation under a Creative Commons license. Read the original article.
Katie Marks
Monographs iconMonographs

This article provides a framework for assessing a child’s nutrition and intake, identifying if there are problems and practical strategies to help manage these.

Expert/s: Katie Marks
Dr David Kanowski
Clinical Articles iconClinical Articles

Short or tall stature is considered to be height below or above the 3rd or 97th percentile respectively. Abnormal growth velocity, showing on serial height measurements, is also an important finding. Growth charts based on the US NHANES study are available from www.cdc.gov/growthcharts/charts.htm. Copies of growth charts, together with height velocity and puberty charts are available at the Australasian Paediatric Endocrine Group (APEG) website, https://apeg.org.au/clinical-resources-links/growth-growth-charts/. Local Australian growth charts are currently not available. The height of the parents should be considered in evaluating the child. Expected final height can be calculated from the parents’ heights as follows: For boys: Expected final height = mean parental height + 6.5cm For girls: Expected final height = mean parental height – 6.5cm Assessment of bone age (hand/wrist) is also useful. With familial short or tall stature, bone age matches chronological age. Conversely, in a child with pathological short stature, bone age is often well behind chronological age, and may continue to fall if the disease is untreated. The stage of puberty is relevant, as it will affect the likely final height. A short child who is still pre-pubertal (with unfused epiphyses) is more likely to achieve an adequate final height than one in late puberty.

Short stature

Causes to consider include:
  • Malnutrition, the commonest cause worldwide
  • Chronic disease, for example, liver/renal failure, chronic inflammatory diseases
  • Growth hormone deficiency, with/without other features of hypopituitarism
  • Other endocrinopathies, for example, hypothyroidism, (rarely) Cushing’s syndrome
  • Genetic/syndromic causes, for example, Down, Turner, Noonan, Prader-Willi syndromes
  • Depression or social deprivation should also be considered
  • Idiopathic short stature is a diagnosis of exclusion
Appropriate initial screening investigations can include liver and renal function tests, blood count, iron studies, thyroid function tests, coeliac disease screen, thyroid function tests, urinalysis (including pH) and karyotype. Other specialised tests may be needed, based on suspicion. In the lower range, IGF-1 shows considerable overlap between normal and abnormal levels, especially in the setting of poor nutrition. Small children tend to have low levels, regardless of whether growth hormone deficiency is the underlying cause. Random growth hormone levels vary widely because of pulsatile secretion and are also not a reliable test. Therefore, unless there is a clear underlying genetic or radiological diagnosis associated with clearly low IGF-1, stimulation testing is typically required to formally diagnose growth hormone deficiency and may be essential for funding of growth hormone treatment.

Tall stature

Causes include:
  • Chromosomal abnormalities, for example, Klinefelter syndrome (qv), XYY syndrome
  • Marfan syndrome
  • Homocystinuria
  • Hyperthyroidism
  • Growth hormone excess (see Acromegaly; Growth hormone; Insulin-like growth factor-1 (IGF-1))
  • Precocious puberty
  • Other syndromic causes, for example, Sotos, Beckwith-Wiedemann syndromes
  • Familial tall stature (predicted final height should match mid-parental height)
Investigation of stature is a specialised area and early discussion with a paediatric endocrinologist is indicated if there is clinical concern, for example, height below the 3rd percentile at age five, slow growth (crossing two percentile lines away from the median), significant height/ weight discrepancy (more than two centile lines), suspected/confirmed metabolic or genetic abnormality, or clinical evidence of malnutrition or marked obesity.

References

  1. Cohen P, Rogol AD, Deal CL, Saenger P, Reiter EO, Ross JL, et al. Consensus statement on the diagnosis and treatment of children with idiopathic short stature: a summary of the Growth Hormone Research Society, the Lawson Wilkins Pediatric Endocrine Society, and the European Society for Paediatric Endocrinology workshop. J Clin Endocrinol Metab. 2008 Nov; 93(11): 4210-7. DOI: [10.1210/jc.2008-0509]
  2. Nwosu BU, Lee MM. Evaluation of short and tall stature in children. Am Fam Physician. 2008 Sep 1; 78(5): 597-604. Available from: www.aafp.org/afp/2008/0901/p597.pdf.
  General Practice Pathology is a regular column each authored by an Australian expert pathologist on a topic of particular relevance and interest to practising GPs. The authors provide this editorial free of charge as part of an educational initiative developed and coordinated by Sonic Pathology.