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Five-minute Practitioner: August 2008

Only got five minutes? Then just read these key points on: meningococcal disease, child abuse and antenatal depression

Only got five minutes? Then just read these key points on: meningococcal disease, child abuse and antenatal depression

Meningococcal disease

There are around 1,200-1,600 cases of meningococcal disease each year. The fatality rate is approximately 6%, with many of these deaths occurring in the first 24 hours of illness.

Cases can occur at any time of year, but are more common in the winter, when outbreaks of respiratory infections occur.

Most of the devastating effects of N. meningitidis infection are due to the systemic inflammatory syndrome resulting from invasion of the organism into the circulation (septicaemia), rather than the consequences of meningeal inflammation.

A new guideline from SIGN on the management of invasive meningococcal disease in children and young people provides a framework for diagnosis and referral.

The most common patterns of presentation are meningococcal septicaemia, with fever, purpura and signs of sepsis; meningitis, which is clinically indistinguishable from meningitis caused by other bacteria; and a mixed picture, with features of both meningococcal septicaemia and meningitis. Infants with meningitis may not have the classical signs of fever, headache and neck stiffness but present with non-specific symptoms.

Children deemed at high risk of invasive meningococcal disease should be referred immediately to secondary care.

The guideline recommends that parenteral antibiotics (either benzylpenicillin or cefotaxime) should be given as soon as invasive meningococcal disease is suspected.

Child abuse

General practice is the cornerstone of family healthcare for the vast majority of children. Therefore, children who are victims of abuse and neglect may already be known to the practice.

Adult survivors of abuse are four times more likely to consult their GP and much more likely to suffer pelvic pain, bladder problems, premenstrual and breast problems, gastrointestinal problems, pseudoseizures and mental health problems.

The average GP, with 2,000 patients, 400 of whom will be children or young people, might have 28 children on their list suffering physical abuse; 24 emotional abuse; 24 neglect and up to 60 sexual abuse.

It can be difficult to conduct a consultation in which the GP has suspicions about the nature of injury to a child. It is not for GPs to investigate (that is the role of social services) but to put the needs of the child first.

Phrases like ‘We need to check this in more detail than I can do here', ‘I can't yet be sure this isn't due to some other unseen cause', or ‘Further tests may help to reassure us as to the exact cause of this problem' may help to soothe some of the inherent tensions in such a consultation. Social services and the police may undertake single or joint agency investigations to establish causes and gather evidence.

The RCGP/NSPCC toolkit is a framework into which local safeguarding children policies and procedures can be integrated with information about symptoms and signs of abuse and neglect to form a training tool for practices.

Antenatal depression

A prospective cohort study has found that the children of mothers with persistent antenatal depression are more likely to have developmental delay at 18 months. The Avon study recruited 14,000 women during pregnancy in 1991-2 and has been following them up ever since. Children of mothers with persistent antenatal depression were 34% more likely to have developmental delay.

Maternal depression in pregnancy may affect the child through: poor maternal health behaviours, increased uterine artery resistance, effects on the developing fetal HPA axis and an increased risk of postnatal depression.

Young maternal age, smoking and adverse life events are also risk factors for developmental delay.

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