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OXFORD MEDICAL PUBLICATIONS

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Oxford Specialist
Handbook of
Community
Paediatrics
Edited by

Srinivas Gada
Consultant Community Paediatrician
Oxford University
Hospitals NHS Trust
Honorary Senior
Clinical Lecturer
University of Oxford, UK

1
3
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide. Oxford is a registered trade mark of
Oxford University Press in the UK and in certain other countries
© Oxford University Press 2012
The moral rights of the author have been asserted
First Edition published in 2012
Impression: 1
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by licence or under terms agreed with the appropriate reprographics
rights organization. Enquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above
You must not circulate this work in any other form
and you must impose this same condition on any acquirer
British Library Cataloguing in Publication Data
Data available
Library of Congress Cataloging in Publication Data
Data available
ISBN 978–0–19–969695–6
Printed in Italy by
L.E.G.O. S.p.A - Lavis TN
Oxford University Press makes no representation, express or implied, that the
drug dosages in this book are correct. Readers must therefore always check
the product information and clinical procedures with the most up-to-date
published product information and data sheets provided by the manufacturers
and the most recent codes of conduct and safety regulations. The authors and
the publishers do not accept responsibility or legal liability for any errors in the
text or for the misuse or misapplication of material in this work. Except where
otherwise stated, drug dosages and recommendations are for children.
Links to third party websites are provided by Oxford in good faith and
for information only. Oxford disclaims any responsibility for the materials
contained in any third party website referenced in this work.
 v

Foreword

In 1976, Professor Donald Court’s inquiry into child health services was
published. The report identified a range of failures in the way in which
care is delivered in the UK, with poor mortality data compared to our
European counterparts. The report also identified fragmentation and
poor communication between primary and secondary care, and a lack of
paediatric competence amongst many staff looking after children. Court
made a series of radical proposals, only a few of which were implemented.
Perhaps unsurprisingly not all of the problems he identified were solved;
indeed recent data still demonstrate that our all-cause child mortality
remains unacceptably high compared to that of much of Western Europe.
However, one recommendation which was followed through was for a
group of paediatricians to work in community settings with a remit—
among other things—to look after children with disabilities and to support
a range of health promotion activities.
Contemporary child health needs and demographics within the UK
have changed considerably since Court’s time, and there is now an even
greater demand for paediatricians to be trained in social and behavioural
paediatrics, care of children with disabilities, child health promotion and
child protection. Arguably we now need even more paediatricians to work
outside of traditional hospital settings and boundaries.
Dr Gada’s book provides an excellent overview of this critically impor-
tant area of paediatrics. The book combines clear and concise notes on
the full range of community paediatric topics, along with a wealth of prag-
matic and practical information. The topics are brought alive with case
vignettes, and importantly samples reports (for example, a court report)
and letters (for example, a ‘leaving care’ letter). Complex legal and statu-
tory procedures are explained clearly and in straightforward language, and
there are numerous lists of useful resources and contacts.
This comprehensive book will provide an invaluable reference text to
health care professionals working either wholly or partly in the commu-
nity, including paediatricians, GPs, therapists, nurses, health visitors, train-
ees, medical students and indeed to the many generalists who also play a
part in the essential aspects of care outlined within these pages.

Hilary Cass
Neurodisability Consultant
Evelina Children’s Hospital
President
Royal College of Paediatrics and Child Health, UK
2012
vi

Preface

My inability to refer trainees to a single source of up-to-date information

on community paediatrics and the need for me to carry multiple folders
each filled with milestones, guidelines, diagnostic checklists, growth charts,
etc., motivated me to write this book.
Community paediatrics encompasses a wide range of subspecialities,
each covering a range of conditions managed in a variety of settings, i.e.
primary, secondary, and specialist tertiary settings. Despite this challenge
I have endeavoured to cover all aspects of the speciality into this small
pocket book.
Naturally, this book has been organized into chapters each covering a
subspeciality or an aspect of community paediatrics. You will find that the
information on a topic is in a readily accessible format with extensive use
of bullet points, tables, boxes, etc. The focus is on presenting clinically
relevant information with less emphasis on theory or background informa-
tion. Further reading and references have been intentionally limited and
all topics have been cross-referenced with other relevant aspects of the
book. Readers are encouraged to refer to BNFC for further details on
drug doses.
Hence this book is a practical guide that can quickly be referenced in the
clinic. Its practicality, portability, and well-laid out information will enable
the reader to deliver clinically effective and child/family-centred care on
the go!
This book has been written for anyone who manages children in the
community, i.e. out-of-hospital. Therefore this book can serve as an
essential companion and a first point of reference to undergraduates,
paediatric trainees, general practitioners, doctors, professionals from
allied specialities, and members of community nursing and multidiscipli-
nary teams.
I have been fortunate to be able to bring together the expertise of
contributors (who are experts in their fields) from a wide variety of dis-
ciplines. In close collaboration with them I have managed to present their
expertise into concise clear summaries on each topic. Consequently this
book encourages you to work collaboratively with other professionals
enabling you to provide holistic care to the child and family.
Community paediatrics is intriguing and I hope this book makes it more
exciting and rewarding. I would welcome your constructive suggestions
for improvement.

S. Gada
Oxford
March 2012
 vii

Dedication

To

My Family

For their numerous sacrifices, generous support,

endless encouragement, & abundant love.

&

You (the reader)

For using the information contained in this book, to make a

positive difference in the lives of children & their families, you serve.
viii

Acknowledgements

As in life, the journey of this book has seen numerous successes, some
failures, near misses, computer crashes, delays in getting responses, staff
vacancies, and relocations in the department. All of these have played
their part in its prolonged gestation! This book would not have come into
being without the support and assistance of the editorial team at OUP in
particular patience of Helen Liepman, the commissioning editor, and Tessa
Eaton, the production editor.
As a working community paediatrician much of the information that has
shaped the book was gleaned during the course of my clinical practice.
Therefore my utmost thanks go to all the children and their families who
have shared their everyday challenges, with me.
I would like to extend my sincere gratitude to all the contributors for
their hard work and for offering their invaluable time and expertise. My
special appreciation is here for their patience with numerous revisions.
Their dedication was crucial for the conclusion of this project.
My special thanks to following individuals for their assistance in reviewing/
revising the following: Michele McCoy (Public health), Dave Long (Clinical
engineering and PIMS), Fiona Ryan (Bone health), T. Girish (Gynaecological
care), Jeremy Hull (Respiratory care), Anupam Chakrapani (Inherited
metabolic diseases), Denise Challis (Development), Meg Buckingham
(Orthopaedic line diagrams), Sarah Lang (Immunisation Advisor, HPA),
Noel McCarthy (Consultant in Communicable Diseases, HPA), Nicole
Bigler (OT), Lesley Bucke (SLT), Linda Luxon (Audiology), Minoo Irani
(Chapter 4), and Neal Thurley (help with literature searches).
I am indebted to Jen Nutt (my secretary) for her seamless service.

S. Gada
2012
 ix

Contents

Contributors x
Symbols and Abbreviations xii

1 Introduction to community paediatrics 1

2 Working with child and family 15
3 Development 35
4 Neurodevelopmental disorders 61
5 Consults with allied professionals 175
6 Neurology 227
7 Vision 269
8 Audiology 295
9 Mental health 317
10 Genetics 379
11 Orthopaedics 409
12 Child abuse 439
13 Adoption, fostering, and looked-after children 479
14 Social paediatrics 501
15 Educational paediatrics 519
16 Working with partner agencies 539
17 Public Health 549
18 Support organizations and information
resources for parents and carers 579
19 Further information and reading 585

Appendix 601
Index 641
x

Contributors

Rachel Buckingham Minoo Irani

Consultant in Paediatric Consultant Community
Orthopaedics, Paediatrician,
Nuffield Orthopaedic Centre, Upton Hospital, Slough, UK
Oxford, UK
Christine Ireland
Robert Chapman Highly Specialist Speech and
Consultant Child & Adolescent Language Therapist,
Psychiatrist, Department of Community
Oxford Health NHS Foundation Paediatrics,
Trust; Oxford Children’s Hospital, UK
Honorary Senior Clinical Lecturer,
University of Oxford, UK Georgia Jackson
Consultant Community
Srinivas Gada Paediatrician,
Consultant Community Royal Berkshire Hospital,
Paediatrician, Reading, UK
Oxford Children’s Hospital;
Honorary Senior Clinical Lecturer, Sandeep Jayawant
University of Oxford, UK Consultant Paediatric Neurologist,
Honorary Senior Clinical Lecturer,
Praveen Goyal Oxford Children’s Hospital,
Consultant Community Oxford, UK
Paediatrician,
Department of Community Dominic Kelly
Paediatrics, Consultant Paediatrician,
Oxford Children’s Hospital, UK Oxford University Hospital NHS
Trust; Senior Clinical Lecturer,
David Henderson Slater University of Oxford, UK
Consultant in Neurological
Disability and Rehabilitation Usha Kini
Medicine, Consultant Clinical Geneticist,
Oxford Centre for Enablement, Oxford University Hospitals NHS
Nuffield Orthopaedic Centre, Trust;
Oxford, UK Honorary Senior Lecturer,
University of Oxford, UK
Julia Hyde
Children’s Community Sue King
Physiotherapist, Associate Specialist,
Department of Community Department of Community
Paediatrics, Paediatrics,
Oxford Children’s Hospital, UK Oxford Children’s Hospital,
Oxford, UK
 CONTRIBUTORS CONTENTS xi

Graham Mackenzie Richard Scott

Consultant in Public Health, Consultant Clinical
NHS Lothian, Edinburgh, UK Neuropsychologist,
John Radcliffe Hospital,
Chris Morris Oxford, UK
Senior Research Fellow in Child
Health, Doug Simkiss
Peninsula Medical School, Associate Clinical Professor in
University of Exeter, UK Child Health,
Division of Mental Health and
Manoj Parulekar Wellbeing,
Consultant Ophthalmic Surgeon, Warwick Medical School,
Birmingham Children’s Hospital, Coventry, UK
UK
Peter Sullivan
Anne Peake Honorary Consultant
Educational Psychologist, Paediatrician,
Educational Psychology Service, Oxford University Hospitals NHS
Oxfordshire Local Education Trust, UK
Authority,
Oxford, UK Clare Wallace
Lead Children’s Community
Clare Robertson Occupational Therapist,
Consultant Community Oxford Health NHS Foundation
Paediatrician, Department of Trust, UK
Community Paediatrics,
Oxford Children’s Hospital, UK
xii

Symbols and
Abbreviations
b cross-reference
0 warning
2 important
M website
F telephone
7 approximately
i increased
d decreased
l leading to
4 male
5 female
1* primary
2* secondary
A&E Accident and Emergency (department)
AA amino acids
AABR automated auditory brainstem response
AAC augmentative and alternative communication
AASA alpha amino adipic succinylaldehyde
ABR auditory brainstem response
ACE angiotensin converting enzyme
ACTH adrenocorticotrophic hormone
AD autosomal dominant
ADD attention deficit disorder
ADEM acute disseminated encephalomyelitis
ADHD attention-deficit hyperactivity disorder
ADI Autism Diagnostic Interview
ADL activities of daily living
ADOS-G Autism Diagnostic Observation Schedule
AED antiepileptic drugs
AFO ankle foot orthoses
AFP alphafetoprotein
AHA assisting hand assessment
AN anorexia nervosa
ANSD auditory neuropathy spectrum disorder
AOM acute otitis media
AOS apraxia of speech
AP action potential
SYMBOLS AND ABBREVIATIONS CONTENTS xiii

AP antero-posterior
APA American Psychiatric Association
APD auditory processing disorder
AR autosomal recessive
AS Asperger’s syndrome
ASD autistic spectrum disorder
ASSA adoption support service advisor
ASSR auditory steady state response
AT ataxia telangiectasia
ATRX alpha thalassaemia/mental retardation syndrome
BAAF British Association for Adoption and Fostering
BAAP British Association of Audiological Physicians
BAHA bone anchored hearing aid
BAPA British Association of Paediatricians in Audiology
BAS British Ability Scales
BC bone conduction
BCECT benign childhood epilepsy with centrotemporal spikes
BCG Bacille Calmette–Guérin
BMD bone mineral density
BN bulimia nervosa
BOR branchio-oto-renal syndrome
BP blood pressure
BP1 blind and partial sight registration form 1
BPVC benign paroxysmal vertigo of childhood
BPVS British Picture Vocabulary Scales
BSA British Society of Audiologists
BSID Bayley Scale of Infant Development
BSL British Sign Language
BTE behind-the-ear
C&YP children and young people
CaF Contact a Family (charity)
CAMHS Child and Adolescent Mental Health Service
CBC child behaviour checklist
CBT cognitive behaviour therapy
CCN children’s community nurse
CCTV closed circuit TV
CD conduct disorder
CDC child development centre
CDOP child death overview process
CDT child development team
CEA carcinoembryonic antigen
xiv CONTENTS SYMBOLS AND ABBREVIATIONS

CELF clinical evaluation of language fundamentals

CERA cortical evoked response audiometry
CFS chronic fatigue syndrome
CGH comparative genomic hybridization
CHARGE choanae, heart, anal, growth and ear anomalies
CHL conductive hearing loss
CIMT constraint-induced movement therapy
CK creatine kinase
CLD chronic lung disease
CM cochlear microphonic
CMAP compound motor action potential
CMT Charcot–Marie–Tooth
CNS central nervous system
COGMED Cogmed working memory training
CONI care of next infant
CP cerebral palsy
CPA care programme approach
CRS congenital rubella syndrome
CSA child sexual abuse
CSF cerebrospinal fluid
CSWS continuous spike wave discharge in slow sleep
CT computed tomography
CTEV congenital talipes equino varus
CVI certificate of vision impairment
CVS cardiovascular system
CXR chest X-ray
DAMP deficit in attention motor control and perception
DBT dialectic behaviour therapy
DCD developmental coordination disorder
DD developmental delay
DDH developmental dysplasia of the hip
DDK diadochokinesis
DDST Denver Development Screening Test
DEAP diagnostic evaluation of articulation and phonology
DGE delayed gastric emptying
DIDMOAD diabetes insipidus, diabetes mellitus optic atrophy deafness
DLA disability living allowance
DMD Duchenne muscular dystrophy
DNA deoxyribonucleic acid
DNA did not attend
DOB Date of Birth
 SYMBOLS AND ABBREVIATIONS CONTENTS xv

DPOAEs distortion product otoacoustic emissions

DRB deaf resource base
DRPLA dentatorubropallidoluysian atrophy
DS Down syndrome
DSH deliberate self-harm
DSM Diagnostic and Statistical Manual
DSM-IV Diagnostic and Statistical Manual Version 4
DT distraction testing
DTaP Diphtheria tetanus pertussis
DTI diffusion tensor imaging
DXA dual-energy x-ray absorptiometry
EAC external auditory canal
EAL English as an additional language
ECG electrocardiogram
ECHO echocardiogram
ECM ‘Every Child Matters’
ECU environmental control units
ED eating disorder
EDNOS eating disorder not otherwise specified
EDS Ehler–Danlos syndrome
EEG electroencephalogram
EF executive functioning
EHC eye–hand coordination
EMG electromyogram
ENT ear, nose, throat
EP educational psychology
EPO emergency protection order
EPODE Ensemble, Prévenons l’Obésité des Enfants
EPS evoked potential studies
ERG electroretinogram
ERIC education and resource for improving continence
ESR erythrocyte sedimentation rate
EUA examination under anaesthesia
EYSENIT early years special educational needs inclusion team
FASD fetal alcohol spectrum disorder
FBC full blood count
FES functional electrical stimulation
FGM female genital mutilation
FHX Family history
FII fabricated or induced illness
FISH fluorescent in situ hybridisation
xvi CONTENTS SYMBOLS AND ABBREVIATIONS

FM fine motor
FRAXTAS fragile X tremor ataxia syndrome
FTT failure to thrive
FVC forced vital capacity
GA gestational age
GABA gamma amino butyric acid
GCSE general certificate of secondary education
GDD global developmental delay
GI gastrointestinal
GM gross motor
GMDS-ER Griffiths Mental Development Scales-Extended Revised
GMFCS gross motor function classification system
GMFM gross motor function classification
GOR gastro-oesophageal reflux
GOS general ophthalmic services
GP general practitioner
GSD glycogen storage disease
GT gastrostomy tube
GUM genito-urinary medicine
HA hearing aid
HELLP haemolytic anaemia elevated liver enzymes low platelets
HEP hepatitis
HES hospital eye service
HGPRT hypoxanthine guanine phosphoribosyl transferase
HI hearing impairment
Hib Haemophilus influenzae b
HIE hypoxic ischaemic encephalopathy
HIU hearing impaired unit
HIV human immunodeficiency virus
HL hearing loss
HMSN hereditary motor sensory neuropathy
HPA health protection agency
HPV human papilloma virus
HSQ home screening questionnaire
HSV herpes simplex virus
Ht/Wt Height/weight
HV health visitor
Hx history
IADLs instrumental activities of daily living scales
ICD International Classification of Diseases
 SYMBOLS AND ABBREVIATIONS CONTENTS xvii

ICD-10 International Classification of Diseases Version 10

ICF International Classification of Functioning Disability and
Health
ICH intracranial haemorrhage
ICO interim care order
ICP intracranial pressure
ICU intensive care unit
ID intellectual disability
Id Identification
IEM inborn error of metabolism
IEP individual educational plan
Ig immunoglobulin
IMD inherited metabolic disorder
INO internuclear ophthalmoplegia
IPT interpersonal psychotherapy
IPV inactivated polio vaccine
ITE in-the-ear
IUGR intrauterine growth retardation
IVDU Intravenous drug user
IVF in vitro fertilization
JIA juvenile idiopathic arthritis
KS key stage
LA local authority
LAC looked after children
LD learning disability
LE lower extremity
LFT liver function test
LI language impairment
LRTI lower respiratory tract infection
LSCB local safeguarding childrens board
LSD lysosomal storage disease
M-ABC movement assessment battery for children
MACE mitrofanoff for antegrade colonic enema
MAP minimum auditory percept
MCAD medium chain acyl coenzyme A dehydrogenase
MCADD medium chain acyl-coenzyme A dehydrogenase deficiency
ME middle ear
ME myalgic encephalitis
MEE middle ear effusion
MELAS mitochondrial encephalopathy lactic acidosis stroke-like
episodes
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