North of england paediatric society

NORTH OF ENGLAND PAEDIATRIC SOCIETY
The 107th Meeting of the Society was held at the Crown Hotel, Wetheral, Carlisle on Friday, 11th June 2010. The President, Dr Steve Hodges, took the Chair. The following 17 members registered their attendance. Dr K Agrawal In addition Drs Anderson, Bresnan, Onifide, Pennington and Ullman (speakers) and Prof.
Terrence Stephenson (PRCPCH) attended as guests of the society and there were 3 guests of
members also present.
Dr. Hodges welcomed members and guests to the meeting. He announced that we will need to
elect a new committee member at the November AGM to replace Dr Nyamugunduru and
suggested that nominations from the West of the region would be welcome. We would also
need to nominate a new president to serve as President elect 2010-11 and President from
2012.
Dr Ian Verber then gave a short appreciation of the life of Dr Edmund Hey (member 1977-
1995), distinguished neonatologist who had died the previous December. Members stood in
silence in his memory.
Dr Venkat Ramesh (Northern representative on RCPCH Council) then introduced Prof
Terrence Stephenson, President of RCPCH who spoke on “What the College does for its
members and for children”
Terrence told us that this was the 24th different meeting he had attended to speak to members.
He wanted to talk about the college’s achievements. The Annual Scientific meeting in
Warwick had been a great success and was the subject of an editorial in the Lancet describing
it as a model for a college meeting.
The MRCPCH exam was being extended into India and the RCPCH Master course was being
modified to make it appropriate to other centres within the EU.
The college had appointed a new Chief Executive Officer and children had been part of the
selection process.
Due to the college’s efforts the GMC now had a policy for dealing with vexatious complaints
which could be used to prevent the persecution of doctors involved in child protection work.
All members of the GMC Fitness to practice panel now had mandatory Child protection
training.
The college had published guidelines on withholding and withdrawing care, physical signs of
child sexual abuse, had published the new WHO growth charts and Medicines for Children
which now included information leaflets for parents and carers.
The college also involved itself in media campaigns where appropriate such as a ban on
smoking in cars.
There remained many challenges.
The competition rates for ST1 appointments were 1.2:1 – satisfactory but could be better.
There was a need for paediatricians to be role models for students and encourage them into
the specialty.
The RCPCH website was a mess and needed completely redesigning. The college image was
low profile and many key players did not know of our existence – we need rebranding with a
recognisable logo.
Workforce planning remains a headache. Only 50% of ST1 trainees will become general
paediatricians. EWTD with 7 doctors being the minimum to staff a department at each level
of cover will force reconfiguration of services as an economic necessity.
Revalidation will be a challenge and the college is developing new CME courses.
Terrence also felt that there should be accommodation in the college – perhaps a flat for
senior officers to encourage doctors who are not based in London to stand for senior office.
Finally he reminded us that the college could be no more than the sum of its members.
Terrence kindly agreed to answer questions from the floor which ranged from international
issues, EWTD, the examination for MRCPCH, the IPT scheme and reconfiguration of
services.
Following the Prof Stephenson’s talk, the President, Dr Steve Hodges, opened the Scientific
Session entitled “Cases I have learnt from.”
Dr Deb Lee (Whitehaven) told us “What Wilf taught me”.
Wilf was a 6 year old with a history of 3 weeks abdominal pain. He was lethargic, had a poor
appetite and lost weight. Dr Lee noted he had finger clubbing and therefore suspected some
form of inflammatory bowel disease. When all the bloods came back normal she was
reassured and Wilf was allowed home with a month’s follow up.
However 3 days alter he represented with vomiting. He had also complained of a headache
and blurred vision but his fundi were normal. He appeared completely well the following day
but when his headache recurred he had an MRI scan which showed a medulloblastoma with
spinal cord seeding. Although an operation gave him a few months good quality life he
eventually succumbed to recurrence, his terminal care largely being managed near to home in
Whitehaven with advice from Newcastle.
Dr Lee’s learning points from this case were:
 Children often describe nausea as abdominal pain so we need to be alert to a wider  If you original diagnosis is proven incorrect it’s not necessarily reassuring – you need to think again and see if there is another cause for the symptoms  Early symptoms of brain tumours can mimic common childhood conditions, can fluctuate on a daily basis and there may be no neurological abnormalities.  Good communications with the regional centre (involving video link if necessary) can save families long and possibly futile journeys.
Denise Ullman (Whitehaven) presented “Joint intensive care management in a rural
hospital”
An 11 year old boy presented with acute onset wheezing. Despite all the conventional
treatment he continued to deteriorate whilst all the while mum was pushing for discharge. He
developed hypercapnia and a silent chest, was intubated and ventilated and the retrieval team
called.
However he couldn’t be stabilised and started to develop surgical emphysema despite IV
magnesium sulphate, aminophylline and salbutamol. When the ITU retrieval team arrived
they flushed up some mucous plugs for his ET tube and changed the anaesthetic gas from
Isoflourane to halothane (which is less pulmonary irritating) and started ionotropes.
He still was extremely ill and clearly couldn’t be transported the 100 miles to PICU. He was therefore managed by the paediatric team on adult ICU at Whitehaven with telephone support from PICU in Newcastle. He improved over the next 24 hours allowing extubation and eventually discharge home. Dr Ullman’s learning points were  In extremis desperately sick children can be managed in a rural hospital with adequate  Good teamwork is essential – both within the rural hospital and between the rural  If a child is deteriorating think ahead about what is the next treatment modality and how and where can the child be best managed.  In acute severe asthma IV Magnesium Sulphate, ketamine, and halothane may all have
The third presentation was also from Whitehaven, Dr Sarah Pennington presenting a case she
had been involved with as a registrar in another unit, the title being “Joint care?”
An 11 year old girl presented with a sore throat, fever, rash, joint pains and headache.
She had a fever, lymphadenopathy and a non specific macular rash. Initially a viral infection
was suspected but her CRP was 349 and ESR 107! When a more thorough history was taken
it became apparent that the history of joint pain was much more significant than first thought
and that there was also a family history of “arthritis”.
At first she seemed to improve but on day 4 developed crushing central chest pain and shock.
The cardiologists from a tertiary centre were involved but they felt this was not a primary
cardiac problem and that transfer was not indicated.
The following day “the Mother ship” was contacted again – this time the rheumatology team.
They accepted her, decided she had septic shock, changed her antibiotics and gave her a fluid
bolus. She promptly developed pericardial and pleural effusions and ended up on cardiac
PICU where she stayed for 2-3 weeks. Although a streptococcus was isolated from her blood
culture it was thought that she had an autoimmune disease with a myocarditis.
Dr Pennington’s learning points were
 When the differential diagnosis involved both infection and auto-immune disease it can be very difficult to know when to commence steroids.  When in doubt about the diagnosis – go back to basics and retake the history  When talking to a tertiary centre about a very sick child one needs to be clear whether one is asking for advice or asking for the child to be transferred. If they don’t get the message and don’t appreciate how sick the child is then the referrer must be persistent.
Members and guests then broke for tea which was largely taken in the delightful garden at the
Crown Hotel on a lovely early summer’s day.
After re-assembling Dr Mark Anderson from Newcastle presented “Objects seen in the rear
view mirror may appear closer than they are!”
He first recounted the story of Sam, a two and a half year old boy referred form the surgeons
on a Friday afternoon with persistent vomiting. On taking a history it transpired that he had
been admitted on 5 previous occasions with vomiting, requiring IV fluids on 2 occasions but
also had 8 other episodes of vomiting at home. The surgeons had already checked base line
bloods and a barium meal and follow though which were normal. The history suggested an
intermittent metabolic defect and sure enough the serum ammonia was 210 and the next day
415. A diagnosis of Ornithine Transcarbamylase (OTC) deficiency was made.
Fast forward four years. Jacob had presented to A&E for the third time that year with
vomiting and had been referred to the rapid access clinic. Dr Anderson interviewing father
mentioned the possibility (albeit unlikely) of metabolic disease, based on his experience of looking after Sam. Although Jacob recovered rapidly with no evidence of metabolic disease his father turned up again and again with increasing amounts of print offs from the internet with about more and more rare metabolic disorders which could present with vomiting. In order to try to ally the father’s anxiety Dr Anderson felt forced to undertake unnecessary further tests on Jacob. He eventually however made the diagnosis – obsessive compulsive disorder in the father! His learning points were:  Past experience does dictate future practice – but not necessarily in the best interest of  Beware the parent who questions too much – they may have OCD.
Dr Darren Bresnan (Sunderland) then presented a case where he had been “Thrown off the
Scent”.
CS was a 6 year old girl presenting with non-bilious vomiting and upper central abdominal
pain. The next day she was tolerating fluids and seemed to be improving so was sent home.
The following day however she was back with the same symptoms. Her bloods showed a
slight neutrophilia and a CRP of 16. The next day she had developed right iliac fossa
tenderness and it appeared she had appendicitis. Hover laparoscopy showed a normal
appendix, some distended small bowel loops but no malrotation.
The following day she had developed an ileus and she was till vomiting. The surgeons were
recalled but felt the ileus was due to the laparoscopy and on the basis of the negative findings
at laparoscopy that there was no surgical problem.
The urine grew some gram negative rods and she was started on IV cefuroxime.
Despite this she continued unwell with a rising CRP (195 then 245), fever, abdominal
tenderness, ileus and abdominal distension. Despite further reassurance from the surgeons Dr
Bresnan ordered an abdominal ultrasound which showed a left sided intussusception. She was
transferred to the RVI where 10 centimetres of bowel centred round a Meckel’s diverticulum
were resected. Another example of how treacherous this condition can be
 Don’t be put off by the reassurance of colleagues if you believe the clinical findings  Laparoscopy in itself is not a cause of ileus.  If you ask the wrong question you might get the wrong answer. It wasn’t appendicitis – but that didn’t mean there wasn’t another intra-abdominal surgical problem.
Finally it was the turn of Dr Elizabeth Onifade (Northallerton) to present “Medics at Work –
Learning in Progress.”
When working in Lagos in 1990 Dr Onifade had seen an 11 year old boy recently returned
from the UK. He presented at 16:00 hours with fever, was given penicillin at 1800 hours, he
came out with a non blanching rash at 24:00 hours and 2 hours later he was dead. That was
the first case of meningococcal septicaemia she had seen and she hoped it would be the last.
However in 2007 she was working in London and a 15 month old baby presented with fever
and excessive crying. Abdominal palpation revealed faecal masses; she was given a glycerine
chip and allowed home. However the fever continued and she was readmitted with back pain
and rigors. She was found to have large tonsils and started on Augmentin. However she came
back 6 hours later with a temperature of 40.2 deg C but otherwise appeared well. She was
irritable but easily settled, her capillary refill time was normal, and shortly after admission to
the ward her observations showed a temperature of 36 degrees C, HR 148 bpm, RR 30 and
O2 saturation 100%.
Three and a half hours alter she was reviewed but only because mum was worried she hadn’t
had her bowels open. She was found to be in shock with cold peripheries and a purpuric rash.
She was resuscitated and transferred to PICU. She survived but only at the cost of lower limb amputation and an uncertain neurological outcome. Clues to the fact that she had a serious infection were  Repeated presentations with significant fever  Persistent tachycardia even when the temperature was down If there were worrying features in an apparently otherwise well child Dr Onifade’s advice was Each presentation was followed by a lively discussion form the floor and in closing the meeting at 17:50 hours Dr Hodges thanked not only the speakers for their excellent presentations but also the whole audience for their contributions to a stimulating meeting.

Source: http://nepsoc.org.uk/attachments/File/Downloads/107th_Meeting_Minutes.pdf