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Five-minute Practitioner: September 2007

Only got five minutes? Then just read these key points on: UTIs in children, perinatal depression, schizophrenia and opioid detoxification

Only got five minutes? Then just read these key points on: UTIs in children, perinatal depression, schizophrenia and opioid detoxification

UTIs in children

The recently published NICE guideline Urinary tract infection in children: diagnosis, treatment and long-term management builds on PRODIGY recommendations to give practical suggestions for when UTI should be suspected and on the clinical approach to take.

The guideline recommends that clinicians differentiate between pyelonephritis and lower urinary tract infections; fever 38°C or higher, or lower than this with loin pain and bacteriuria, are important indicators of pyelonephritis.

The guideline emphasises the need to consider UTI as a possible diagnosis in a child who is unwell. Non-specific signs and symptoms predominate in infants younger than three months, and all children may have fever, but specific symptoms are more frequent in older children. The new guideline endorses earlier NICE recommendations on feverish illness in children, which advise urgent referral to a paediatric specialist for any infant younger than three months with a suspected UTI.

Perinatal depression

Postnatal depression is the most common mental health problem associated with childbirth. About 10-15% of women develop a new depressive episode in pregnancy or after childbirth, which poses risks to the mother, baby and the family.

Women have considerable contact with health professionals before, during and after childbirth. GPs are encouraged to use this to identify mental health problems as early as possible in antenatal care and monitor or treat those with symptoms or risk of illness. The NICE guideline recommends that GPs should ask pregnant women two key questions about mood at the first consultation. A positive response to the third question should prompt assessment.

The puerperal depressive disorders most often encountered in primary care are non-psychotic and mild to moderate in severity. Depression is diagnosed when low mood persists and is accompanied by other symptoms that impair function.

Schizophrenia

Schizophrenia is a heterogeneous condition and commonly presents in patients aged 20-30 years, but may present in teenagers.

Patients almost always require some form of intervention to prevent harm and alleviate suffering.

In the early stages of the illness, patients may appear odd or different. They may lose interest in ordinary activities (work, studies, hobbies) and relationships, and their ability to function daily may deteriorate. Others may notice changes before the patient becomes aware of them.

Antipsychotics are effective in treating schizophrenia and 70% of patients respond with either complete or partial remission.

Patients should remain on antipsychotics for one to two years after an episode. Withdrawal should be gradual and monitoring should continue for two years after the last acute episode. Patients who have multiple relapses will require treatment for life.

Opioid detoxification

The mainstays of pharmacological treatment for opioid dependence are methadone and buprenorphine. Patients may stay on opioid substitution treatment for years before deciding to attempt detoxification.

NICE recommends that:
• The clinician should offer methadone or buprenorphine as first-line treatment. Choice of medication depends on:
– Whether the patient is receiving maintenance treatment with either drug, as detoxification should be started with the same medication
– The individual preference of the patient presenting for detoxification
• Doctors should consider lofexidine, particularly for those with mild or uncertain dependence. Patients should be warned that this necessitates the use of adjunct medications to manage withdrawal symptoms such as nausea, vomiting and shivering, which may not be completely covered by lofexidine.

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