The prevalence of asthma and eczema among children (Fig 55.1) is increasing around the world.⁴ The notion of an ‘atopic march’ from eczema through to rhinitis has been coined,⁵ implying that early intervention may reduce the prevalence of disease in later life.

FIGURE 55.1 Incidence of different types of atopy

In our striving for cleanliness there is increasing evidence that skin sensitisation to known environmental allergens provokes immune responses that lead to eczema and, later, asthma. Immune provocation in susceptible individuals appears to trigger a cascade of events aggravated by early antibiotic exposure that may lead to medium- and long-term atopy.⁶

ECZEMA

Forty-six per cent of children with eczema have used complementary medicines by the time of presentation to a dermatologist,⁷ usually driven by their parents’ sense that standard advice has failed. Adverse effects of eczema include symptoms of itching and soreness, which cause sleeplessness. Sleep deprivation leads to tiredness, mood changes and impaired psychosocial functioning of the child and family, particularly at school and work. At the more severe end of the spectrum, embarrassment, comments, teasing and bullying may cause social isolation and may lead to depression or school avoidance. The child’s lifestyle is often limited, particularly with respect to clothing, holidays, staying with friends, owning pets, dietary exclusions, swimming or the ability to play or do sports. Restriction of normal family life, difficulties with complicated treatment regimens and increased work in caring for a child with eczema lead to parental exhaustion and feelings of hopelessness, guilt, anger and depression.⁸

Eczema usually presents by the age of 2 years, initially as an exudative vesicular rash on the face and hands, and later located at the antecubital fossae, neck, wrist and ankles. A generally dry skin is evident, together with signs of scratching and, later, lichenification.

TREATMENT

Intervention is targeted at four levels: resolving any complicating infection, relieving symptoms, reducing triggers and developing a long-term plan. Each of these must be addressed and sustained, for any intervention to be effective. A clear understanding of the triggers by both child and carers, together with a contract of engagement, will ensure likely compliance and a better outcome.

Low-grade infection is common and will retard resolution if not treated. Topical antibiotic cream may be used for localised disease, but for more widespread eczema a systemic, broad-spectrum antibiotic (flucloxacillin, erythromycin) is required.

Medical management includes:

• avoiding irritant clothing (wool etc, which abrades skin and stimulates mast cell degranulation)

• wearing cool and loose cotton garments

• avoiding overheating

• keeping scratching to a minimum (use gloves if necessary and keep fingernails short).

Chinese herbal medicine

Individualised concoctions of Chinese herbal teas have been shown to be efficacious in a small number of randomised controlled trials from one centre.⁹ In general there were about 10 plant extracts in each preparation and few side effects were noted. In other trials there was no clear benefit. However, there have been reports of hepatic and nephro-toxicity, and hypersensitivity reactions.

Other herbal medicines

Calendula, tea tree oil and chamomile have not been shown to be useful in atopic eczema, and may provoke contact dermatitis. Oatmeal baths may reduce pruritis.

Essential fatty acids

Patients with atopic dermatitis are thought to have a reduced rate of conversion from linoleic acid to gamma-linolenic acid (GLA), dihomo-gamma-linolenic acid, or arachidonic acid, compared with healthy subjects. Replacement of GLA, in the form of primrose oil or borage oil, may therefore benefit some patients. There are many randomised controlled studies assessing the effects of GLA, with most studies indicating an improved epidermal barrier on GLA application and others showing no effect, depending on the vehicle used for application.¹⁰,¹¹ Note that, in the latter study, evening primrose oil proved to have a stabilising effect on the stratum corneum barrier, but this was apparent only with the water-in-oil emulsion, not the amphiphilic emulsion for topical use. Oral evening primrose oil capsules do not, however, have a useful effect.

Other therapies

Acupuncture, homeopathy and colon cleansing are recommended by some but have no proven efficacy. Where family stressors appear to exacerbate scratching, these need to be acknowledged and addressed.

PREVENTION AND EDUCATION

Prevention and delay of symptoms are the cornerstones of appropriate management in a family setting, and pregnancy care is particularly relevant in this context.

• Prenatal cessation of smoking reduces allergy risk.

• Maternal omega-3 fatty acid supplementation may reduce the risk of food allergy and IgE-associated eczema during the first year of life in infants with a family history of allergic disease.¹²

• Some studies also suggest that babies whose mothers took probiotics during pregnancy and while breastfeeding were less likely to have eczema at up to 2 years of age ¹³ and beyond.¹⁴

• Higher maternal consumption of green and yellow vegetables, citrus fruit and beta-carotene during pregnancy may be protective against the development of eczema in offspring.¹⁵ Prolonged breastfeeding is important but has not been shown to reduce the risk of atopic eczema in the early years.¹⁶,¹⁷ Use of low-allergen milk in the first 6 months reduces the severity of eczema up to the age of 2 years in children with significant risk.

Supplementation with the probiotic Lactobacillus rhamnosus has been found to substantially reduce the cumulative prevalence of eczema, but not atopy, by 2 years in susceptible individuals with a family history of eczema when given to the mother during pregnancy and for 6 months after birth.¹⁸ Other probiotics are less effective and the choice of Lactobacillus in this context seems to be important.¹⁸

Recent recommendations delay introduction of dairy products, eggs, nuts, fish and shellfish up to 36 months ¹⁹,²⁰ in high-risk situations but not for infants with no family history. However, there is a contrary view that suggests that early antigen exposure in small amounts, in an immune tolerance exercise, might prevent disease later.²¹

High-dose steroids and immune modulation

Oral steroids and high-dose topical steroid treatment should be undertaken in consultation with a dermatologist. Topical calcineurin inhibitors (pimecrolimus 1% cream and tacrolimus ointment 0.1% and 0.03%) are potent topical immune modulators for more severe disease. They are non-steroid topical preparations that may reduce the need for potent topical steroids where poor control with standard treatment is evident.

SUMMARY

In summary, eczema is common and increasing. Dietary manipulation has little effect on outcomes except for those with more definitive family histories and where cow’s milk proteins are shown to have a causative effect in exacerbating the rash, or where a specific food sensitivity or allergy is identified. Topical treatments, both standard and CAM, are effective in improving skin barrier function and are generally safe. Fastidious attention to skin care, early treatment of emerging patches and appropriate clothing will reduce the stress of eczema in young children and will set the pattern for care later in life if the problem persists beyond childhood.

ALLERGIC RHINITIS

A diagnosis of allergic rhinitis should be considered in children who seem to have a ‘perpetual cold’, have frequent sore throats, mouth breathing, snoring, headaches, halitosis or poor concentration. Allergic rhinitis commonly occurs intercurrently with asthma, and control of allergic rhinitis may improve asthma control.

There is often a history of allergy in the child (infantile eczema) or the family.

A seasonal pattern of symptoms suggests that pollens or grasses are the allergen. Perennial rhinitis is most likely due to house dust mite or pet dander, mould or cockroaches. Food intolerance may be involved.

DIAGNOSIS

Arrange for radioallergosorbent tests (RAST) to test for specific allergens.

TREATMENT

• Avoid allergens where possible—confirm the allergen before taking action that may be inconvenient or distressing, such as removal of a household pet.

• Intranasal mometasone furorate spray continued for 3–6 months. Improvement may not be seen for 2 weeks.

• Non-sedating oral antihistamines (loratadine or cetirizine) can be used to relieve itching and sneezing or associated eye symptoms.

• Avoid topical or oral decongestant medication.

ASTHMA

(See also Ch 41, Respiratory medicine.)

Asthma is regarded as an inflammatory disorder of the airways, with oedema, hypertrophy of mucus glands, increased mucus secretion and smooth muscle constriction, resulting in recurrent episodes of cough, wheeze, chest tightness and breathlessness.

Symptoms tend to be worse at night or in the early morning, and may be triggered by exposure to allergens or changes in environmental temperature, emotional stressors or exertion. There is an inherited predisposition.

Between 100 and 150 million people around the globe suffer from asthma, and this number is rising. Worldwide, deaths from this condition have reached over 180,000 annually.²²

• Around 8% of the Swiss population suffers from asthma, as against only 2% some 25–30 years ago.

• In Germany, there are an estimated 4 million asthmatics.

• In Western Europe as a whole, asthma has doubled in 10 years, according to the UCB Institute of Allergy in Belgium.

• In the United States, the number of asthmatics has leapt by over 60% since the early 1980s, and deaths have doubled to 5000 a year.

• There are about 3 million asthmatics in Japan, of whom 7% have severe and 30% have moderate asthma.

• In Australia, one child in six under the age of 16 years is affected.

Asthma is not just a public health problem for developed countries. In developing countries, however, the incidence of the disease varies greatly.

• India has an estimated 15–20 million asthmatics.

• In the Western Pacific Region of WHO, the incidence varies from over 50% among children in the Caroline Islands to virtually zero in Papua New Guinea.

• In Brazil, Costa Rica, Panama, Peru and Uruguay, prevalence of asthma symptoms in children varies from 20% to 30%.

• In Kenya, it approaches 20%.

• In India, rough estimates indicate a prevalence of 10–15% in children aged 5–11 years.

It is important to distinguish between asthma and other causes of recurrent cough, particularly recurrent infective bronchitis. Misdiagnosis of childhood asthma leads to inappropriate treatment or overtreatment.

DIAGNOSIS

In children aged under 6 years, respiratory function tests are not practical or reliable. Diagnosis depends on careful history taking. A currently asymptomatic child is unlikely to have significant clinical signs.

In a child under the age of 12 months, wheeze is more likely to be due to respiratory syncytial virus (RSV) bronchiolitis or anatomically small airways, and a diagnosis of asthma is best withheld. Bronchodilators tend to be ineffective in this age group.

Once children are over the age of 2 years, persistent or recurrent wheeze or chronic nocturnal cough is more likely to be due to asthma.

Children aged over 6 years can have spirometry testing.

Allergy testing should be organised.

All children diagnosed with asthma will need an asthma management plan carefully developed with the child and their parents or carers, and conveyed to all carers and schools. The asthma action plan (Fig 55.2) chosen should be appropriate for the person’s age, educational status, language and culture.

FIGURE 55.2 Asthma management plan ²³

My Asthma Management Plan © Commonwealth of Australia, reproduced with permission.

Metered dose inhalers are difficult to administer to a child, so a volume spacer with a face mask is a preferable option (cannot be used in children under the age of 7 years, as coordination is inadequate). Proper use of spacers, preferably large volume, is important, although carrying one of these around is tiresome. A small-volume spacer should be used when out, and a large-volume spacer used when at home.

Management involves a strategy for preventing and relieving attacks, and for recognising deterioration in control and intervening with pre-formulated strategies.

PROPHYLAXIS

• Pregnancy—pregnant women should eat a diet rich in omega-3 fatty acids and take a supplement. It is not known definitively whether probiotics taken by pregnant women will have an effect on asthma incidence. Bottle-fed babies should be supplemented with Lactobacillus.

• Diet—encourage breastfeeding for the first 6 months. If there is a history of allergy or asthma in the family, wait until the baby is 12 months old before introducing cow’s milk and other dairy products, soy products, eggs, nut spreads (e.g. peanut butter) and fish. A formal supervised elimination diet may be indicated where food triggers are suspected.

• Ensure optimal nutrition. Encourage fresh fruit and vegetables and wholefoods.

• Eliminate food additives, colourings and preservatives.

• Medication—non-steroidal medications will be the preferred first-line preventer. These include sodium chromoglycate and nedocromil sodium (children over 2 years). They are less used in preference to Montelukast, a leukotriene antagonist (LTA), which is particularly useful in intermittent asthma associated with exercise. LTAs orally are an option in children aged over 6 years.

• If there is no clinical improvement after 4 weeks, consider using the lowest effective dose of inhaled corticosteroids.

• As in the case of topical steroids for children with eczema, many parents are naturally concerned about giving children with asthma inhaled steroids, and will need accurate information to encourage compliance with preventer medication.

• Environment—assess for environmental triggers. Eliminate exposure to tobacco smoke, pet fur and other pollutants. Keep bedrooms and bedding as dust-free as possible, preferably washable hard surfaces on the floor. Contrary to popular belief, feather doonas/duvets and pillows are preferable to synthetic varieties. Wash and thoroughly dry linen regularly. Eliminate cockroaches from the home. Avoid the use of aerosol insecticides.

• Mind–body—assess and deal with environmental stressors.

• Exercise—ensure regular exercise. Warm up slowly before vigorous activity. Use a bronchodilator before exercise, if exercise is a trigger for acute attacks.

SUPPLEMENTATION

Dietary supplementation with omega-3 fatty acids, zinc and vitamin C has been shown to significantly improve asthma control, pulmonary function tests and pulmonary inflammatory markers in children with moderately persistent bronchial asthma, either singly or in combination.²⁴ Similarly, adequate intake of vitamin D and sun exposure are important in reducing the risk of asthma.

Magnesium with supportive B-group nutrients assists smooth muscle relaxation, particularly when acutely affected by an asthma attack.

MANAGING ACUTE ASTHMA ATTACKS IN A CHILD

Beta₂ agonist inhalers (salbutamol) and a spacer device should be available to the child at all times. Assessment and initial management of a child with acute asthma are summarised in Tables 55.1 and 55.2.

TABLE 55.1 Assessment of acute asthma in children

TABLE 55.2 Initial management of children with acute asthma

Children who are acutely distressed require immediate oxygen and short-acting beta₂ agonist (SABA) before completing a full assessment.

Note that proper use of a spacer is essential: one puff into the spacer, then six breaths, then the next puff and six breaths, and so on. Do not administer six puffs into the chamber at one time.

ANAPHYLAXIS IN CHILDREN

(See also Ch 21, Allergies.)

Anaphylaxis may occur as an acute allergic response to food allergens, medication, envenomation, vaccines, food additives and others.²⁷ In some cases the causative agent is not identified.

Clinical

Presenting symptoms involve acute onset of:

• skin and/or mucosal changes (flushing, urticaria, angio-oedema, pallor, clamminess) AND

• life-threatening Airway and/or Breathing and/or Circulation problems.

Recognition of acute anaphylaxis may involve exposure to a known allergen for the patient and presence of gastrointestinal symptoms (incontinence, abdominal pain).

Common food triggers include nuts, shellfish, eggs, wheat and dairy protein. Prescribed drug reactions are common. There is often a personal history of eczema or atopy.

Investigation

Episodes of anaphylaxis need to be investigated so that identifiable triggers can be assiduously avoided. Skin prick tests for inhaled and food allergens.

Treatment

Whether in or out of hospital, help is called immediately and treatment initiated while awaiting advanced equipment and expertise. As soon as the clinical signs support the diagnosis of anaphylaxis, intramuscular adrenaline should be administered immediately while awaiting advanced equipment and expertise before an ambulance arrives.²⁸

In the event of a cardiac arrest following anaphylaxis, cardiopulmonary resuscitation should be commenced, with adrenaline given intravenously or intraosseously according to standard advanced paediatric life support guidelines. Concurrently, high-flow oxygen and intravenous access should be obtained so that rapid fluid resuscitation can be given, to restore intravascular volume.

Bronchospasm should be treated as per the emergency management of severe asthma.

For children at increased risk of anaphylaxis, formal assessment by a paediatric allergy specialist is required before providing an adrenaline auto-injector. All family members, teachers and carers need to be trained in avoidance of triggers, and in the first aid assessment and management of anaphylaxis, as they could be called upon to perform life-saving procedures.

IRON DEFICIENCY

Iron deficiency is the most common nutrient deficiency in preschoolers, despite dietary advice from a wide range of sources. The prevalence varies between 16% and 22%, and it is more common in underprivileged and ethnic minorities. It is also a useful marker for general nutrition, as other nutritional deficiencies often may coexist with iron deficiency.

It is recognised that iron deficiency is associated with a range of developmental and behavioural problems in infancy and childhood that are reversible with iron supplementation and correction of the iron deficiency. Intellectual deficits arising from iron deficiency in infancy do persist into later years, if treatment is delayed. A high degree of suspicion is useful in infancy, as anaemia is a late manifestation of iron deficiency. Risk factors include prolonged breastfeeding without supplementation, more than six breastfeeds per day after 6 months, high cow’s milk intake after 12 months and poor solid intake because of high milk intake. Primary prevention of iron deficiency in infants and toddlers can be addressed by a range of measures (Box 55.2), and screening after 12 months is reasonable, particularly in high-risk groups. While prolonged breast feeding is beneficial, without an appropriate solid intake after 6–12 months iron deficiency is much more likely, and so care is required in advising about nutritional supplementation. Some infants become more iron deficient than others, probably because of feeding practices after birth but also because of the degree of intrauterine iron accumulation in the last trimester before birth. Preterm birth and intrauterine growth restriction interrupt normal iron stores and therefore are likely to lead to frank deficiency later if not addressed earlier.

There are some medical causes of iron deficiency in children that need to be considered in differential diagnosis, particularly where response to iron supplementation is ineffective. These include:

• coeliac disease

• lead poisoning

• gastrointestinal blood loss (Meckel’s diverticulum, gastric bleeding).

SCREENING FOR HEARING LOSS

Many states in the United States have passed early hearing detection and intervention legislation. The NHS Newborn Hearing Screening Program (NHSP) offers all new parents the opportunity to have their baby’s hearing screened within the first few weeks of life. It is a core service within the NHS in England and part of the family of Antenatal and Newborn Screening Programs.

Universal Neonatal Hearing Screening (UNHS) is now well established in Australia, the United States and Europe. There are slight variations in protocols between states, but overall most use a system of automated auditory brain stem evoked responses (AABAER) using commercial screening apparatus. UNHS detects congenital sensorineural hearing loss (SNHL) and ensures that babies are enrolled in a diagnostic pathway leading to early hearing aids or cochlear implantation in a timeframe that ensures language acquisition. Cochlear implantation produces best results when intervention occurs before 6 months. It is essential that babies identified in this way are fast-tracked into hearing services and ENT consultation, and engaged in early signing to ensure meaningful communication. While babies with obvious congenital abnormalities, preterm babies and babies admitted to a neonatal intensive care units can be readily identified as being at high risk of hearing impairment, between 1 and 3 per 1000 live births of otherwise normal babies are congenitally deaf. The results of early intervention programs and cochlear implantation are gratifying ¹⁶ and allow these children to move seamlessly into normal schools, achieving normal social and educational skills.

The identification of hearing loss in an otherwise well newborn infant can be catastrophic for parents. There is a period of uncertainty as the diagnosis is confirmed by second-tier testing. Parents require support and accurate information (contact local hearing screening services; see the Resources list).

Acquired conductive hearing loss is more common. At least 50% of preschool children have one or more episodes of otitis media with effusion (OME). About 7% have more frequent episodes leading to significant hearing loss. Risk factors in children include recurrent ear infections, abnormal mucosal immunity and anatomical abnormalities leading to failure of adequate clearance of the eustachian tubes. Children at particular risk are those with Down syndrome, Turner’s syndrome, cleft palate and orofacial malformations. The administration of antibiotics for OME is seldom helpful. A combination of antibiotics and steroids is equally unhelpful in the longer term. Most guidelines recommend a period of watchfulness of at least 3 months. In general, OME resolves without significant impact. In children whose hearing is impaired, tympanostomy tubes are indicated. Care should be taken to encourage formal hearing testing. This may indicate the need for hearing aids together with specific educational strategies to assist learning at school.

Acquired sensorineural hearing loss is gaining more interest. Hearing loss due to congenital rubella is seldom seen; however, cytomegalovirus infections are much more common and may lead to progressive SNHL during the first 2 years after birth. Recently, many more children have been diagnosed with unilateral SNHL at birth and later. There is increasing evidence that in these children, hearing in both ears fluctuates over time and may lead to bilateral SNHL later. Moreover, children with unilateral SNHL are being shown to be disadvantaged and frequently have social and developmental problems that reflect unrecognised hearing impairment. Children with known unilateral SNHL must be followed carefully and encouraged to undertake regular hearing testing. Consideration of hearing aids in this group would be prudent and family support in managing these children is important. In particular, families should be encouraged to learn to sign in addition to speaking early in the child’s development, to attenuate the impact of fluctuating hearing.

The development of a robust neonatal hearing screening service broadly eliminates the utility of distraction testing during the first year of life.²⁹ The latter is usually poorly performed in less than ideal settings and has poor sensitivity. Allaying parental concerns about hearing should not be attempted by using this as a screening test.

SCREENING FOR EYE AND VISION PROBLEMS

Amblyopia is a form of cerebral visual impairment caused by abnormal vision, commonly uncorrected refractive error, during a sensitive period of development. Treatment is thought to be effective only during this sensitive period, which varies for different types of amblyopia but most commonly lasts until 7 years of age. The most common forms of amblyopia are monocular, due to squint (strabismic amblyopia), or refractive error, with a prevalence of 2–4%. Such impairment is later a bar to certain occupations, affects binocular vision and stereopsis and causes considerable disability if the normal eye suffers trauma or disease.³⁰ While definite disabilities caused by vision defects in childhood are largely unknown, more recent attention has focused on the possibility that vision problems contribute to behavioural problems or dyslexia (see below).

Intervention in children with strabismus is controversial. Treatment in those with considerably reduced acuity (6/18 and worse) can result in a mean acuity equivalent to 6/9 on the Snellen chart, whereas children with 6/9 or 6/12 show little benefit from treatment.³⁰ Children whose treatment is deferred from age 4 until age 5 years have the same acuity after treatment, but fewer need patching treatment at all. More than a third of children thought to require treatment after repeat screening do not have acuity loss.³¹ Therefore screening is important, and inspection of the eyes in preschool children is useful in detecting squint likely to lead to impairment later. A careful corneal reflection test, cover test and prism test as well as eye movement tests will delineate abnormalities. In children with a family history of squint, children with developmental delays and preterm infants are at particular risk and may need referral to a specialist optometrist or paediatric ophthalmologist.

INFANTILE COLIC

Infantile colic is a condition in which a baby cries constantly at about the same time each day (usually in the evenings) and is very difficult to settle but otherwise healthy. The baby appears to be in pain and may pull their legs up and clench their fists. There may be loud bowel sounds. It usually begins in the first weeks of life, and goes away by 4–5 months of age.³²

About one in five babies develops colic; it is more common in boys and in firstborn children. Breastfed infants have similar rates of colic as formula-fed infants. The cause is not known.

Medication is ineffective for colic and may have serious side effects, so resist the temptation to prescribe.

Exclude medical causes for symptoms, such as reflux, skin condition or urinary tract infection. Check growth to ensure adequate feeding.

Therapeutic strategies might include having the baby in a sitting position to feed and burp regularly. If the mother is breastfeeding, she can try avoiding caffeine, chocolate, dairy products, citrus fruits, broccoli, cauliflower, cabbage, nicotine and spicy foods in her diet, which may affect the breast milk. Check that formula is being prepared correctly. Elimination of cow’s milk protein is effective not only in highly selected subgroups of infants but also in primary care settings.

Acidophilus (especially bifidus species) can be given to both the breastfeeding mother and the baby (infant formula).

A warm bath and movement such as slow rocking and gentle abdominal massage may help soothe the baby. Stress management techniques for the parents can be helpful. Parents will need to harness social support from friends or family if the situation becomes difficult for them.

ENURESIS

Nocturnal enuresis can be considered normal up to the age of 5 years. It occurs in up to 20% of 5-year-olds and 10% of 10-year-olds, with a spontaneous remission rate of 14% per year. Weekly daytime wetting occurs in 5% of children, most (80%) of whom also wet the bed.³³

Primary enuresis refers to the child who has never been dry for more than a few months at a time. Important risk factors for primary nocturnal enuresis include family history, nocturnal polyuria, impaired sleep arousal and bladder dysfunction.

Secondary enuresis refers to a child who has been completely dry for more than 6 months and then starts to wet the bed again. An emotional event, urinary tract infection, diabetes mellitus, social changes or constipation may trigger this kind of bedwetting. Sexual abuse should be considered.

INVESTIGATION

• Urine microscopy and culture to exclude infection.

• A frequency/volume chart (with documentation of the time and volume of all fluid intake and urine output in 24-hour periods) can give objective information about frequency of urination and functional bladder capacity. Overnight urine production (to assess nocturnal polyuria) is measured by adding the volume of the first morning void with the overnight volume, calculated by the before-and-after weight of a nappy worn overnight by the child.

MANAGEMENT

In secondary enuresis management is to treat the underlying cause, and the enuresis tends to cease.

The initial treatment of choice for children with mono-symptomatic nocturnal enuresis is an enuresis alarm. Two types of alarm are available, to be used for a minimum of 14 consecutive dry nights to a maximum of 4 months:

• pad-and-bell alarm—the child lies on a large pad placed in the bed and any liquid triggers the alarm

• personal alarm—the alarm is clipped onto the child’s underpants or onto a continence pad placed inside the child’s underpants, and any liquid triggers the alarm.

Medication

Desmopressin:

• nasal spray 10–40 μg at night (start with 10 μg nightly and titrate up to 40 μg)

• tablet 200–400 μg at night

• available on authority prescription for children over 6 years who have failed alarm treatment or where alarm therapy is contraindicated.

Referral

Referral for specialist advice is highly recommended for treatment failure after 8–12 weeks for any form of bedwetting or daytime incontinence.

DYSLEXIA

Children whose reading is behind for their expected IQ, and who have symptoms of incoordination, poor sequencing and left-to-right confusion, are termed dyslexic. The problem affects 5–10% of children (mainly boys), who may present as depressed or develop compensatory behavioural symptoms that cause them to be labelled as lazy, ‘difficult’, defiant, ‘stupid’ or inattentive. Many more children than are diagnosed have dyslexia problems and few receive appropriate interventions in remediation. Inability to recognise the meaning of written words or to interpret unfamiliar words has physiological and anatomical correlates that can readily be identified and mapped to abnormalities in chromosome 6 and others. Recent insights have enabled the development of interventions that will attenuate symptoms and facilitate the child’s progress in a mainstream educational environment. The more recent concept of visual stress (Box 55.3) can explain a number of behaviours that are seen in children with degrees of dyslexia.

Dyslexic children identified as having high visual stress showed significantly higher percentage increases in reading rate with a coloured overlay, and reported significantly higher critical symptoms of visual stress compared to dyslexic children with low visual stress.³⁴ Thus, while phonological deficits underlie most issues for children with dyslexia, aids to visual interpretation such as coloured overlays or tinted lenses may make a significant difference in about 50%.³⁵ The other important development is in the arena of fatty acid supplementation. It is increasingly obvious that the diets of today’s children are markedly different from those of previous generations. The epidemic of obesity (see below) is serious and coincides with more attention deficit disorders and dyslexia than before. There is mounting evidence that essential fatty acid deficiency may contribute to neurodevelopmental and psychiatric problems including dyslexia, and that supplementation may have significant and long-lasting benefit.³⁶,³⁷ However, care needs to be taken in delivering essential fatty acids that are likely to be effective. A combination of 80% fish oil and 20% evening primrose oil has been used in most studies.

DEVELOPMENTAL DISORDERS AND DISABILITIES

In considering child development disorders, Hall and Elliman ³⁸ distinguished between low-prevalence high-severity conditions (cerebral palsy, learning disabilities; see Box 55.4) for which a pathological basis can be identified, and high-prevalence low-severity conditions (speech delay, clumsiness; see Box 55.5) for which a pathological basis is rarely found.

BOX 55.5 High-prevalence, low-severity conditions

• Learning difficulty

• Mild behaviour difficulties

Low-prevalence, high-severity conditions usually receive attention in current healthcare settings, but high-prevalence, low-severity conditions receive little or cursory attention and yet could lead to more complex problems later. It is essential to respond to parental or carer concerns regarding growth and development. The most useful tests in this environment are the Macarthur communicative developmental inventory (MCDI) up to age 3 years, and the parents’ evaluation of developmental status (PEDS) after 4 years.

LANGUAGE DEVELOPMENT

Language development is varied and influenced by both genes and environment. Although delayed language development is common as an isolated problem, many children have other issues including cognitive impairment (low IQ limiting language acquisition), behaviour and conduct disorders acting as comorbid conditions retarding normal language interaction. Parents, under the guidance of speech therapists, can be engaged in interventions that will improve outcome, bearing in mind that most children will eventually communicate reasonably well even after moderate delay. Often therapy involves dealing simultaneously with parenting, behavioural issues and deprivation. Care must be taken in identifying children from socially deprived environments who would benefit from early intervention services, playgroups or preschools.

BEHAVIOUR AND PSYCHOLOGICAL PROBLEMS

The point prevalence for psychological problems in childhood and adolescence is about 20%; it is worse in socially deprived areas. It has been estimated that 68% of preschool children have at least one identifiable problem, and close to one-third have three or more problems. Indeed, such problems characterise 50% of referrals to a paediatrician.³⁹

Point prevalences for a range of conditions are shown in Table 55.3.

TABLE 55.3 Point prevalence of a range of childhood conditions

Condition	Prevalence (%)
Preschool children (< 5 years)
Waking and crying	15
Overactivity	13
Difficulty settling at night	12
Refusal of food	12
Combination behavioural problems	10
Middle childhood (6–12 years)
Persistent tearful unhappy moods	12
Bedtime behavioural rituals	8
Night terrors and sleep disturbance	6
Bedwetting	5
Inattentive overactivity	5
Faecal soiling	1
Overt psychological disorder	12–25
Overt handicapping psychiatric disorder	7–14
Mild emotional behavioural problems^*	5–11
Adolescence (13–18 years)
Appreciable misery	45
Social sensitivity	30
Evident anxiety	25
Suicidal ideation	7
Complex depressive moods	10
Confirmed psychiatric disorder	2–3

* Including anxious unhappiness, difficult or antisocial behaviour, poor relationships with other children.

Source: adapted from Hall & Elliman 2006³⁸

While some of these might be considered minor or mild, they are the source of considerable misery and reflect a poor quality of existence for many parents and children in our community.³⁹ These problems interact with physical ill health and produce symptoms that span organic and psychological illness. They are characteristically persistent and polymorphous even though they may have started as discrete single problems.

Predisposing factors include:

• poor parenting skills

• inner city

• social deprivation

• boys rather than girls

• children with learning difficulties and delayed speech skills

• other problems of health and development

• adolescence

• in residential or institutional foster care

• marital discord

• mental health problems in other family members

• parental indifference

• poor parental supervision.

Single-issue presentations may reflect a more complex underlying psychopathology and should be addressed with vigour. In many instances this will divert the development of more polymorphous behavioural issues that may be difficult to address later. Established polymorphous presentations will be complex and time consuming. Intervention in single-issue presentations is often successful if other predisposing issues are recognised and addressed at the same time. The role of the general practitioner and the paediatrician in this context is to develop a holistic management strategy that involves structured encounters with locally placed services and supports.

ATTENTION DEFICIT HYPERACTIVITY DISORDER

There is rising concern that the diagnosis of attention deficit hyperactivity disorder (ADHD) in young children is increasing and that intervention using potent stimulant medication is over-used. The causes of ADHD are multifactorial.

• There is certainly a genetic component ⁴⁰ or a genetic risk factor in most individuals.

• Most children with ADHD have a demonstrable brain-based anatomical/biochemical problem.

• Environment plays a significant part in the expression of ADHD.

• Excessive television watching (screen time) increases the risk.

• Exposure to toxins and dietary deficiencies is increasingly important.

The diagnosis of ADHD is complex and reflects the difficulty of separating comorbidities that may in fact be the primary problem leading to behavioural and educational issues that need addressing. How, then, can the GP intervene and muster allied healthcare services and family support before referring to a paediatrician for consideration of more aggressive pharmacological intervention? There is no doubt that psychostimulant medication is efficacious in the short term in attenuating the symptoms of ADHD in children with uncontrollable or dangerous behaviour. In the long term, children with diagnosed ADHD, whether treated or not, have worse outcomes than those not diagnosed with ADHD. Treatment effect is short term and may allow children to function at home or at school more effectively, reducing stress on affected children and their families and improving social behaviour. However, the long-term results are not positive. The West Australian Raine study ⁴¹ found that, by age 14 years, stimulant medication did not significantly improve a child’s level of depression, self-perception or social functioning, and that these children were more likely to be performing below their age level at school by a factor of 10.5 times compared with children who had not taken stimulant medication.

Psychological support alone is helpful, and a combination of both modalities provides the best outcome. However, psychosocial support is often lacking or difficult to access, and educational supports are stretched.

INITIAL ASSESSMENT

• Ensure that symptoms cross the school, home and social environments. Confirmatory evidence that behaviours are pervasive is important. Ask parents to obtain letters of concern from teachers and other carers.

• Examine the nutrition of the household. Ask about fast foods and determine the types of meals offered. Discuss breakfast, family meals, TV and computer game culture in the household.

• Assess iron status.

• Assess magnesium status. Magnesium deficiency in children with ADHD occurs more frequently than in healthy children.⁴⁴ Supplementation has been shown to reduce hyperactivity.⁴³

• Understand the social and family interactions that describe the family. Review behavioural boundaries, expectations of parents for their children and consistency of rules.

ADHD THERAPEUTICS

• Ensure that the child is not iron deficient. Behavioural problems can be attenuated by restoring an adequate iron intake by supplementing and correcting diet.

• Consider a 1-month supervised trial of a diet eliminating gluten, casein, artificial colourings and preservatives.

• Consider fish oil (containing omega-3 and omega-6 fatty acids)⁴⁴ and multivitamin supplement.

• Limit time spent watching television and playing computer games.

• Encourage outdoor activities in a natural environment.

• Attention training techniques such as meditation help to ameliorate the symptoms.

There is some evidence that mind–body therapies can assist in modulating activity and oppositional behaviours. This requires the engagement of the family and provides a mechanism to involve them in structural change that provides both containment and restriction of escalation of adverse behaviours. Referral to family therapy, psychologists or educational interventions are beneficial where resources are available.

AUTISM AND AUTISM-SPECTRUM DISORDERS

The spectrum covers a range of neurological disorders characterised by qualitative impairments in social functioning and communication, often accompanied by repetitive and stereotypical behaviours and interests. The condition affects 1 in 150 children in a male–female ratio of 3:1. Autism-spectrum disorders (ASDs) can be diagnosed as early as 18 months, and children identified early benefit from early intervention programs that engage positive behaviours in a therapeutic alliance suppressing more negative ones. Symptoms can range from mild to severe.

• In autism the impairments in the social and communication areas are severe and sustained, and clearly present before the age of 3 years. The child is often anxious, has poor attention and motivation, responds unusually to many different stimuli, and is observed as being ‘different’ from other children. Speech is delayed, or largely absent. A strong reliance on routine is apparent, and the child can have a range of ritualistic behaviours such as toe walking, hand flapping and finger gazing. The child with autism may also be intellectually disabled.

• High-functioning autism is a loosely used term (not defined in the diagnostic criteria) to describe a child or adult who meets the criteria for a diagnosis of autism, but is not as severely affected as the more classically autistic person.

• In Asperger syndrome there is considerable social impairment, but impairment is not as severe in the language and communication area. Speech usually develops within the normal age range, but the ability to communicate effectively (known as language pragmatics) is impaired. The impairments seem more subtle in the very young child, and become more apparent as the child reaches school age. Such individuals are usually in the normal intelligence range.

• Pervasive developmental disorder—not otherwise specified (PDD-NOS) is a diagnosis given for children who present with some of the characteristics of either autism or Asperger syndrome but not severe enough for a diagnosis of either condition.

Parents often express concern about their child’s development and can identify behaviours that are worrying. These should never be dismissed and careful review may inform appropriate referral. The checklist for autism in toddlers (CHAT) (see Table 55.4) can be used to screen for likely ASD traits.

TABLE 55.4 Checklist for autism in toddlers (CHAT)

A screening test designed to be used in children from 18 months to 36 months. Darker-shaded response boxes indicate critical questions most indicative of autistic characteristics.

CHAT Section A: Questions for parents
	Yes or No
Does your child enjoy being swung, bounced on your knee, etc.?
Does your child take an interest in other children?
Does your child like climbing on things, such as chairs?
Does your child enjoy playing peek-a-boo/hide & seek?
Does your child ever pretend, for example, to make a cup of tea using a toy cup and teapot, or pretend other things (pouring juice)? [Pretend Play (PP)]
Does your child ever use his or her index finger to point, to ask for something?
Does your child ever use his or her index finger to point, to indicate interest in something? [Protodeclarative Pointing (PDP)]
Can your child play properly with small toys (e.g. cars or blocks) without just mouthing, fiddling or dropping them?
Does your child ever bring objects to you (parent), to show you something?
Shaded boxes indicate critical questions most indicative of autistic characteristics

CHAT Section B: Physician’s questions/observations
	Yes or No
Eye contact: During the appointment, has the child made eye contact with you?

Gaze monitoring (GM):

Get the child’s attention, then point across the room at an interesting object and say, ‘Oh look! There’s a (name of a toy)!’ Watch the child’s face. Does the child look across to see what you are pointing at? (To record a YES, make sure the child does not just look at your hand, but at the object you are pointing at.)

Pretend play (PP):

Get the child’s attention, then give the child a miniature toy cup and teapot and say, ‘Can you make a cup of tea?’ Does the child pretend to pour out tea and drink it? (If you can elicit an example of pretending in some other game, score a YES on this item.)

Protodeclarative pointing (PDP):

Say to the child, ‘Where’s the light?’ or ‘Show me the light’. Does the child point with their index finger at the light?

(Repeat this with, ‘Where’s the bear?’ or some other unreachable object if the child does not understand the word ‘light’. To record a YES on this item, the child must have looked up at your face at around the time of pointing.)

Block tower:

Can the child build a tower of blocks? (If so, how many?)

Overall, the more ‘NOs’ the higher the chance of autism.

In the Baron Cohen studies:

Failing all questions with shaded boxes: risk of autism 80–85%.

Passing all questions with shaded boxes: risk of autism 0%.

Sources: Baron Cohen S et al. 1992⁴⁵, 2000⁴⁶; Baird et al. 2000⁴⁷

MANAGEMENT OF AUTISM

Irrespective of the diagnosis or where it fits in the spectrum, each child diagnosed within the autism spectrum is likely to be developmentally delayed and have significant difficulties in participating in day-to-day life. Each child requires sensitive understanding, and specialist support and intervention.

What can the GP do before referral to a paediatrician?

• Refer early for assessment.

• Check chromosomes—high resolution and fragile X.

• Check iron, ferritin and transferrin saturation levels.

• Check thyroid function.

• Arrange carer’s allowance and allied health support team.

• Evaluate diet and nutritional status.

There is no medication that can alleviate the symptoms of autism.

The child and family require intensive multidisciplinary support to help with the educational and social development of children with autism. This will require coordination of services such as intensive physiotherapy, occupational therapy, speech therapy and psychological and educational interventions.

There is anecdotal evidence that some (but not all) children respond to dietary change, to varying degrees. It is a low-risk and reasonable strategy to recommend a 1-month trial of:

• a strict gluten-free, casein-free, soy-free diet

• elimination of all artificial colourings, flavourings and preservatives.

Consultation with a dietician is likely to be helpful, to ensure adequate nutrition, particularly if the child is very fussy with their food.

Multivitamin, mineral and omega-3 fatty acid supplementation may be necessary where the diet is deficient.

OBESITY

The epidemic of childhood obesity in the developed world cannot be ignored. Obesity rates for preschool children have doubled internationally, and rates for children aged 6–11 years have tripled since 1996. Overweight adolescents have a 70% chance of becoming obese adults, increasing to 80% where one or more parent is also obese or overweight. Sixty per cent of obese children have one or more additional cardiovascular risk factors (high cholesterol, triglycerides, insulin or blood pressure) identifiable at screening. Serious complications of obesity (type 2 diabetes, metabolic syndrome, fatty liver, slipped epiphyses, hypertension, polycystic ovarian syndrome etc) can be identified in many (Box 55.6).

Body mass index (BMI) is a robust predictor of continuing risk from overweight and obesity into adolescence. Children noted to be overweight at 24, 36 or 54 months are five times more likely to be obese in adolescence than children with normal BMI during infancy.⁴⁸ The formula for calculating body mass index (BMI) between 2 and 20 years is shown in Box 55.7. A useful BMI calculator with downloadable BMI curves for children can be found at the Melbourne Royal Children’s Hospital website (see Resources list). BMI categories are listed in Table 55.5.

BOX 55.7 Calculating body mass index (BMI): 2–20 years

TABLE 55.5 BMI categories

Category	BMI
Underweight	< 5th percentile for age and gender
Normal weight	≥ 5th percentile to < 85th percentile for age and gender
At risk of overweight	85th percentile to < 95th percentile for age and gender
Overweight	95th percentile for age and gender

The causes of overweight and obesity are multifactorial (genetic predisposition, overeating, sedentary lifestyle, excessive screen time, fast-food availability, poor overall nutrition, inadequate nutrition knowledge, family role-modelling, school and home environments, food marketing and advertising). The goals of preventing and reversing obesity and overweight appear straightforward—reduce energy intake while maintaining an optimal nutritional intake to support growth and development. Reduce sedentary behaviours, actively engage families, parents, carers and communities in strategies to enhance and apply knowledge and understanding of optimal nutrition during childhood.⁴⁹

Assessment and intervention begins as follows:

• evaluating the child’s growth pattern, including plotting BMI for age on an appropriate growth chart

• determining suspected cause(s) of abnormal weight gain

• assessing risk factors and comorbid conditions

• assigning proper diagnosis and excluding known medical syndromes (e.g. Prader-Willi syndrome)

• assessing motivation and readiness to change (see Table 55.6)

• educating parents in nutritional principles and parenting skills.

TABLE 55.6 Factors associated with readiness for change and engagement

Factor	Family response	Physician response
Pre-contemplation	Not interested	Deliver information about known health risks. Personalise to examination and assessment
Contemplation	Interested in the next 6 months or so	Deliver messages of health risk and identify barriers to change and engagement
Preparation	Willing to try out and plan over the next month	Assist children and family to set reasonable goals—start with one or two easy targets.
Action	Already trying to lose weight	Give positive reinforcement and set new targets
Maintenance	Successful weight management needs help in maintenance	Provide support and monitoring

NUTRITION AND INTEGRATIVE MEDICINE

Integrative medicine is most helpful in obesity management. It is clear that simple interventions for such a complex problem are unlikely to work and that patients identifying as overweight or obese need a nurturing and supportive framework to effect change. It is likely that isolated advice for a single person without involvement of the whole family is thwarted from the outset. If the entire family is ready to engage in change to a better process, there are interventions that can be tailored to each participant based on their own insights and beliefs.

• Diet:

• Recommend an anti-inflammatory diet ⁵⁰

• Polyunsaturated fatty acid supplement

• Balanced carbohydrate, protein and fat for age

• Subsitute energy-dense foods and drinks with wholefoods and water.

• Motivational interviewing:⁵¹,⁵²

• Directive counselling

• Focus on patient’s perceptions and motivations

• Seek to resolve ambivalence

• Strengthen patient’s reasons for positive behaviour change

• Trigger change aligned with patient’s own goals and values.

• Health coaching:

• Take an active role in patient’s progress

• Keep patient on track

• Individualised attention

• Follow-up phone calls, specific appointments.

• Mind–body medicine:

• Mindfulness

• Guided relaxation and imagery

• Clinical hypnosis

• Yoga

• Progressive muscle relaxation

• Biofeedback

• Cognitive behaviour therapy.

• Acupuncture.

There are adequate data to support the inclusion of these techniques in clinical practice. Their use in paediatrics and paediatric obesity is less researched but intuitively sound and promising.

EXERCISE AND PHYSICAL ACTIVITY

Physical activity is essential in long-term maintenance of weight control in children, and interventions aimed at either increasing physical activity or decreasing physical inactivity or sedentary behaviours) are useful in treating paediatric obesity.⁵³ There is definitive evidence that obesity is an inflammatory condition characterised by elevated inflammatory markers such as interleukin-6 and C-reactive protein, and that these inflammatory markers diminish with any exercise.⁵⁴

The structure of an exercise program is also important for developing an active lifestyle in treating obesity. Data from several trials incorporating moderate to intense aerobic exercise suggest that school-based exercise interventions may be a promising approach to treating childhood obesity.⁵⁵,⁵⁶ In addition, the family is important to structure and support activity, as parental activity level is a strong predictor of child activity.⁵⁷,⁵⁸ In the healthcare setting, interventions focused on increasing physical activity should be delivered in a nurturing, non-intimidating environment. Obese children respond differently physiologically and emotionally to exercise than do normal-weight children, and experience negative consequences to participation in activities considered appropriate for normal-weight children. In clinical settings, specialised exercise programs that include specific recommendations for obese children have been shown to enhance safety, efficacy and compliance during treatment. Optimal results may be achieved by combining programs to reduce sedentary behaviours with those that increase physical activity,⁵⁹ such as walking or cycling to school instead of travelling by car.

A healthcare plan for the treatment of childhood obesity should examine and modify, as necessary, the home environment as it pertains to physical activity. Some children spend more time in front of the television and playing video games than doing any other activity other than sleeping. Watching television often decreases the amount of time spent performing physical activities, and is also associated with increased food consumption either during viewing or as a result of food advertisements.⁶⁰ Children who watched 4 or more hours of television per day had significantly greater BMI than those watching less than 2 hours per day.⁶¹ Furthermore, having a television in the bedroom has been reported to be a strong predictor of being overweight, even in preschool-aged children.⁶² Note that fatness leads to inactivity, rather than inactivity leading to fatness,⁶³ but inactivity reduces fitness and increases cardiovascular inflammatory risk, whether fat or thin.

A practical approach to encouraging exercise in children has been outlined by Philpott and colleagues.⁶⁴ The easiest way to promote physical activity is to increase movement in daily life. If possible, children should walk or cycle to school, and use stairs instead of lifts. Children allowed to play outdoors usually increase their level of activity spontaneously. Increase participation in household chores from an early age. Involve children in meal preparation and clearing up, thereby reducing potential screen time while increasing responsibility and accountability. Moderate to vigorous activity for 60 minutes each day is the goal that produces the best effect, even if broken down into four 15-minute periods. Plan family activities and use the outdoors. Make practical recommendations for exercise. A written prescription will help to focus goals and stimulate discussion at subsequent visits.

Understand motivational interviewing and use tools for ensuring engagement by children and their families. Individualise the activities to suit the personality of each child—consider their like and dislikes. Consider age-appropriate interventions and recognise particular goals of older children, whether muscle building, endurance or fast exercise. Encourage dance in all its current forms and, if necessary, use interactive video games that encourage movement. There is no single ‘one-fits-all’ solution. Being aware of family dynamics and personal relationships is also important. Engage all the family together, rather than targeting individuals alone.