As the sun comes out and we all start wishing we were on holiday, we are starting to see acute presentations of seasonal and (mostly) minor conditions in children. The majority cause much upset and angst for parents but can be managed with self-care advice, safety-netting and education, and over-the-counter remedies.
Hayfever is usually worse in the UK between late March and September, especially when it’s warm, humid and windy. Symptoms of hay fever include sneezing and coughing, a runny or blocked nose, itchy, red or watery eyes, itchy throat, mouth, nose and ears. Patients with asthma may find they have a reduced peak flow or are wheezy or cough more.
Hayfever can be managed by parents and children without recourse to prescription medication in the vast majority of cases.
Most CCG areas do not routinely commission the prescription of antihistamine medication for hayfever. Notable exceptions are for people who work at heights, with heavy machinery or in aviation for whom fexofenadine is the only permitted antihistamine. Not so relevant for children.
Over the counter treatments include:
- Antihistamines to help to relieve the majority of symptoms. It is usually better to recommend non-sedating antihistamines such as cetirizine or loratadine.
- Sodium cromoglycate eye drops to treat itchy or watery eyes.
- Sodium chloride nasal irrigation sprays such as sterimar for nasal irrigation.
Steroid nasal sprays such as beclomethasone are only available on prescription for children under 18 and are contraindicated in children under 6 years old. Similarly, azelastine nasal spray is licensed from age 6 but is a prescription-only medicine for under 18s.
Grazax is a licensed medication to be used in patients with severe grass pollen allergy-resistant to treatment with all other medications. It is available in the UK only via specialist allergy clinics and most have a stepwise treatment ladder plan which includes nasal steroids, eye drops, maximum dose oral antihistamines and off-license montelukast. Kenalog injection (triamcinolone) should not be used in children (it is sometimes given privately to adults in the UK and is used more widely in Australia). As a potent parenteral steroid there is a risk of cataracts, bone thinning, and more importantly, adrenal suppression and growth suppression in children.
Polymorphic Light Eruption
PMLE is a delayed hypersensitivity reaction to UVA (and very occasionally UVB). It occurs on sun-exposed areas and can be recurrent or a “one-off” phenomenon. In children with their first presentation of facial PMLE it can easily be confused with slapped cheek/Parvovirus but is distinguished by a well-looking child with no parvo exposure and a rash in a sun-exposed distribution. Treatment is sun avoidance and/or graded exposure with sunblock which needs to have a high UVA as well as UVB rating. Topical steroids or oral antihistamines can help with itching.
Juvenile Spring Eruption
JSE causes itchy papules and blisters on the top of the ears, classically triggered by the first exposure to UV in sunlight in spring. It is often seen in children who go skiing for the first time in the UK February half term. It is commoner in boys than girls possibly because hair covering the ears provides some protection. Treatment is with topical steroids, SPF, hats and avoiding sun exposure. JSE may be a very localised version of Polymorphic Light Eruption (PMLE).
Prickly heat is an intensely itchy rash that is very irritating and “prickles”. It can occur anywhere on the body and often presents as small papules on an erythematous background. It is entirely harmless and can be treated with cool compresses, cool showers, loose clothing and antihistamines.
Children’s skin is much more sun sensitive than adults and there have been multiple public health and school-based campaigns to encourage wearing hats, staying out of the sun and wearing high factor sunscreen with UVA filters in recent years. Sunburn should be managed like any other burn recognising the advice from NICE that over 1% body surface area always needs secondary care assessment and may need burns intervention. Hydration, analgesia and good skincare are vital. There may well also be safeguarding considerations when a small child presents with significant sunburn.
Insect Bites and Stings
Insect bites are common and can be painful as well as irritating and itchy especially if a child has been bitten by a horsefly. Remember what a horsefly looks like. Their proboscis can puncture a cow or horse’s skin, i.e. can bite through leather so they really, really hurt.
The BMJ published a brilliant review article in 2020 based on the NICE guidelines for managing insect bites which explores the fact that there is little high-quality evidence base for any recommendations for managing bites but notes that flucloxacillin prescribing in the UK rises by 33% in the summer months which may be a result of overprescribing for presumed infected bites.
It is worth remembering that haematophagous insects (those that feed on blood) inject saliva into the skin – containing a variety of products, including anticoagulants, vasodilators, and digestive enzymes – to allow them to obtain their meal.
Different people will have different predispositions to bites and may have a range of inflammatory and/or allergic responses. Reactions might be immediate IgE mediated wheal and flare histaminergic reactions, or more delayed reactions characterised by pruritis, indurated papules, papular urticaria, or blistering. Reactions can vary from single, small, red reactions to multiple or large areas of erythema.
Erythema, swelling, heat, pain, and itch are typical features of any reaction and don’t necessarily indicate secondary bacterial infection.
Treatment with cold compresses, elevation and antihistamines are normally enough to settle a reaction. It is worth knowing that the median time to symptom resolution after a bite is 10 days. This can really help in the safety netting and reassurance advice you give.
Bee and wasp stings are incredibly painful, especially for small children. Reassurance, antihistamines and analgesia dosed appropriately by weight, as well as cold compresses and distraction are key. If a bite blisters it should be managed as for a blister anywhere else on the body by keeping clean and dry, only popping (with a sterile needle) if there is a risk of traumatic accidental deroofing.
There is a superb flowchart in the article summarising the NICE guidelines and this provides a pragmatic and logical approach for the majority of us.
The management of tick bites is not dissimilar to other insect bites but it is worth remembering how to remove a tick: use fine-tipped tweezers or a tick removal tool to remove a tick, grasping the tick as close to the skin as possible and pulling up firmly. If the mouth part gets stuck, try to remove it because it can cause a local infection. Do NOT squeeze the body of the tick. Antibiotics are not needed routinely however patients and parents should be advised to look out for the circular spreading rash erythema migrans, or fever. Lyme Disease is a hot topic well beyond the scope of this article.
If a child presents with erythema migrans following a tick bite NICE advise doxycycline for 21 days in children aged 9+ (though it is unlicensed in children under 12) or amoxicillin (30mg/kg if under 33kg) for 21 days in younger children.
Adders are the only poisonous snakes in the UK and adder bites result in approximately 100 presentations to the emergency department in the UK each year (Editors note: There are a lot more scary snakes around in other parts of the world. We’ll cover these in a separate post). The vast majority of reactions are localised, painful and not life-threatening. However, both immediate and delayed hypersensitivity can occur. Self-care/first aid advice involves immobilising the limb and transfer urgently to the emergency department.
All children need observation for at least 24 hours as delayed envenoming causing a systemic anaphylactoid reaction may occur.
Symptoms of delayed envenoming include nausea; retching; vomiting; abdominal colic; diarrhoea; incontinence of urine and faeces; sweating; fever; vasoconstriction; tachycardia; light-headedness; loss of consciousness; shock; angioedema of the face, lips, gums, tongue, throat, and epiglottis; urticaria; and bronchospasm. These can come on any time from immediately until 48 hours post-bite. Hypotension is a worrying early sign and children can develop an acute kidney injury and/or bleeding diatheses.
All children presenting with adder bites should have blood taken for FBC, U&E and clotting . Victims can develop an acute kidney injury and/or a bleeding diathesis. They should all have an ECG and be admitted for observation.
Specific antivenom is available but probably underused in UK clinical practice. Indications for antivenom are:
- Hypotension with or without signs of shock;
- Other signs of systemic envenoming (see above), electrocardiographic abnormalities, peripheral neutrophil leucocytosis, elevated serum creatine kinase, or metabolic acidosis;
- Local swelling that is either extensive (involving more than half the bitten limb within 48 hours of the bite) or rapidly spreading (beyond the wrist after bites on the hand or beyond the ankle after bites on the foot within about four hours of the bite).
Two ampoules of Zagreb antivenom are given (exactly the same dose for infants, children and adults) by slow intravenous injection or infusion. Adrenaline, intravenous antihistamine and hydrocortisone should be drawn up and available in case of early anaphylactoid antivenom reactions. This complicates around 10% of treatments with Zagreb antivenom. If no clinical improvement has occurred after one hour, the initial dose of two ampoules of antivenom can be repeated. Late serum sickness reactions can be treated with oral H1 blockers or corticosteroids.
If you work near the Devon or Cornish coast you may well be bored of seeing these injuries. But for those of us further away, they are worth knowing about because they often present a few days after the incident when the symptoms aren’t settling and the children have made it home.
Weaverfish live in the sand in shallow waters and classically people get stung falling of a surfboard or running into the water without the fish having enough warning to swim away. The stinger of a weaverfish is on the top of its body. When the child paddles in the warm water it enters the toe or the sole of the foot. It stings a lot at the time and first aid involves immersing the body part in water as hot as the skin can bear for at least 30 minutes. This denatures the sting. The puncture site can sting/burn or feel numb for several weeks afterwards but secondary infection or long-term injury is incredibly unusual.
Analgesia and comfortable footwear are the only real solution while they wait for it to get better.
Fortunately in the UK and Ireland, the vast majority of jellyfish stings are irritating, itchy and sore but unlikely to cause morbidity or mortality. Treatment is with over the counter antihistamines and analgesia and cold compresses. Very occasionally a child might present with an anaphylactic reaction.
New shoes and sweaty bare feet are the commonest cause of blisters and seen often in older children in summer. They should be managed symptomatically, kept clean and only popping (with a sterile needle) if there is a risk of traumatic accidental deroofing.
Beetroot Urine/Purple Poo
Late summer is when allotment keepers suddenly realise they have grown a lifetime supply of beetroot and start offloading it on their unsuspecting neighbours. Beetroot is purple because it contains betalain, an antioxidant pigment that is usually broken down in the digestive tract. In susceptive individuals, particularly if they have also eaten rhubarb, spinach or cocoa powder (two other allotment glut summer favourites, and the main ingredient in beetroot chocolate cake which is how many children get beetroot into their system!) the pigment isn’t broken down and turns their stool and/or urine purple. This can be unsettling and it is not uncommon to see children whose parents are worried they have haematuria or internal bleeding.
A logical history including what they ate the day before may well give you the answer. It is usually easy to spot that the stool is purple rather than red and that there are no signs of blood. Purple urine can be scarier, but if dip-tested will not show anything (though beware that the pigment can make the nitrite block look a funny colour on standard urine dipsticks).
Asparagusic acid is a sulphur-containing compound that seems to be found exclusively in asparagus. It is excreted in urine and can be detected around 15 minutes after eating asparagus. Luckily, not everyone can smell the compound.
It is not uncommon for anxious parents to present with a child in their first summer of introducing solids with concerns about intermittently smelly urine in a completely well child. Taking a careful history is vital – they will frequently mention the asparagus, look sheepish and apologise for wasting your time.
Warrell, D.A., 2005. Treatment of bites by adders and exotic venomous snakes. BMJ, 331(7527), pp.1244-1247
Wilcock, J., Etherington, C., Hawthorne, K. and Brown, G., 2020. Insect bites. BMJ, 370.