Paediatric cases in general practice: the limp with a normal CRP, NDIS levels, and boiled eggs

Limp-case paediatrician (name not stated)

Otter Speaker 1. Trained in the UK, came to Australia about four years ago; also trained in Nigeria. Belfast came up in the TB aside. The Otter file does not name him.

Steve, Leading Steps

Paediatrician. John Flynn about four and a half to five years, Gold Coast Private, previously Tweed. Closest full-time rooms to the New South Wales border, so he sees the southern referrals. Autism and NDIS levels.

Elisa, paediatric immunologist

Otter Speakers 21 then 6. “My name’s Elisa. I’m a paediatric immunologist.” IgE food, eczema, FPIES, antihistamines, Ryaltris. Hands older patients to Dr Sylvia (adults). Happy for GPs to email.

The four-year-old who would not stop limping

He trained in the UK, came to Australia about four years ago, did some ED time. The case is a child he saw about six years ago: a four-year-old boy, limping, no history of trauma, otherwise well. First time in front of him. What are you thinking?

The table: viral infection, BMI, trauma, transient synovitis. He pushed the natural history of post-viral limp. About two weeks after a viral illness, the child goes to bed well and wakes limping. That is one refresher. What else?

The limp list, including NAI and a splinter

History extras the room wanted: night pain that wakes them; not responding to simple analgesia. Those are flags. Then examination: vitals, well or unwell, gait, joints, swelling, range.

Hip and knee, bloods, then MRI the spine

X-ray two joints — hip and knee. Bloods: FBC, ELFT, ESR, CRP, and a blood culture if you are already taking blood, even without a fever. Rheumatoid serology if that story is in play. Looking for fluid in the joint.

All of it normal. Transient synovitis can take two or three weeks. More painkillers. This ED could bring patients back. A week later: still limping, worse, less active, not going to school, low-grade temperature, still quite well systemically.

Treatment as he told it: IV antibiotics about two weeks, then oral, four to six weeks in total. The child got better. Echo was raised for a focus of infection — unusual, but the point stands.

Bugs by age, as he listed them: infants, Staph aureus; preschool, Kingella (Otter: King General / King Day) — also a HACEK endocarditis organism; older children, strep and staph.

A GP at the table: two-year-old, perfectly well, Mum noticed a tiny lump on the spine, no fever. X-ray not conclusive. Referred to the paediatric orthopaedic surgeon the room knew (Otter: Annabel Stapler). She organised Princess Alexandra Hospital the same day, IV antibiotics, a couple of weeks — now fine. Another: complete hip dislocation after a slide, anatomy not right on bedside ultrasound at midnight, helicopter. Another: seven-year-old abdominal pain, agranulocytosis, huge spleen, marrow shut down, isolate, leukaemia.

Steve: autism, NDIS, and do not reassure on eye contact

Steve, Leading Steps. John Flynn rooms about five years, Gold Coast Private, previously Tweed. He is the full-time paediatrician closest to New South Wales, so the southern referrals land on him.

Training imagined medical paediatrics. Practice morphed into autism and ADHD. Autism has DSM-5 criteria used worldwide. “That criteria works across the whole world, except for here in Australia,” because NDIS has obscured it.

Early intervention funding to age seven without a formal label can be useful. Families then become institutionalised: therapists for free, forever. At six, the only way to keep it is an autism diagnosis. Some of those children have autism. A lot are a stretch, chasing funding. Nowhere else in the world, in his view, puts this much money in. Helpful, not sustainable. “Thriving Kids” may pull a heap of level-two children off NDIS into other therapies. Nobody has told them exactly how. He expects families to arrive saying “he’s probably more a level three, isn’t he.”

Features: do not elevate one or two. Eight-year-olds who clearly have autism — teachers saw it, therapists saw it, you feel it when they walk in — were reassured at three, four, five by a GP or a paediatrician: he made eye contact, we had a conversation, he does not have it. Autistic children can make eye contact. Some are empathetic. Some want friends. Parents then spend years thinking they are doing it wrong, without help.

Even when he is pretty sure it is not autism in a three- or four-year-old, he is careful not to cut people out. They are in the room because of huge problems — houses destroyed every night, relationships breaking. Do not make people feel good to the degree they get no help. He does not know, neurologically, why some children avoid eyes; some look down the whole time, some turn away a little as they talk. Pets can get better eye contact than people. He does not over-explain what he does not know.

Trauma written on the file is not the whole child

Thought experiment: eight-year-old boy, cannot sit still, cannot retain information, struggles with peers and transitions, hides under desks, headphones, sensory. In the care of the state from age two — neglect, addiction. Hates himself, says he would be just as happy if he were not here. What is his diagnosis?

It can be “and,” not “or.” Trauma and neurodevelopmental conditions travel together. Someone wrote “trauma” when he was little, and every subsequent person repeated PTSD as the reason he cannot relate. Take the same features in a well-supported family and you would assess ADHD and autism. Family history: Dad in jail, that whole side of the family struggled through school — genetics, ADHD and autism raging through, not only the trauma story. Those are the children who could have been helped earlier.

If you are uncertain, or there is big functional impairment, send them on. Paediatricians have longer than a GP day. They can gather reports and map the next few years. Many of these children have already seen OT, psychologist, behavioural optometrist — “relatively little evidence for most of it” — and are a long way down the track. He tries not to insist on a two-thousand-dollar psychologist report before he will diagnose. He can diagnose as well as they can. A GP in the room was furious about psychologists advertising assessments they cannot prescribe or NDIS-apply for. Steve: every paediatrician does it differently; he tries to do it himself so families do not pay twice.

Elisa: dinner, not a spreadsheet

Elisa, paediatric immunologist. Main work: IgE and real IgE. Key takeaway on introduction: there is a lot of Instagram pressure to introduce every allergen on the list. She would much rather they introduce the ones the family actually eat. Never eat fish? You do not need to give the baby fish. Never eat walnut? That is okay. We have medicalised food.

No spreadsheet. Whatever is for dinner, if it has that food, go for it. More risk in giving something once and never again — you have primed the immune system. You can be as perfect as you like in the first year and they will still eat something from a magazine. Keep it practical.

Boiled egg, floppy under two, antihistamines at night

Egg is by far the most common. If the family is anxious, boiled egg before scrambled. Everyone does scrambled first. Scrambled is considered raw from an allergy point of view: you move it around the pan, the protein does not break down, the food looks cooked and it is not. Boil six or seven minutes, white hard — mash it into anything. Safer. If they later react to scrambled, go back to boiled for a while and retry in a few months; the immune system usually sorts itself.

A little rash is fine. Babies have rashes. She does not chase the rash, the same way she does not chase every bit of eczema. Anaphylaxis under two is incredibly rare in her practice — five or six children a year — generally protein powder in a parent’s smoothie, a massive protein hit. Under two, anaphylaxis is typically floppy and lethargic, not “stopped breathing.” Most of the time they just get hives. That is the worst-case story for most families. Antihistamines at home give parents power.

She gets them to have antihistamines as soon as they start solids. Under six months, over-the-counter can be hard — script, or tell them to say they have a six-year-old. Antihistamines are used from birth; same dose; fexofenadine (Telfast) is the easiest to get, cetirizine, loratadine, whichever. You cannot overdose: eight to ten times the dose, a great sleep, nothing bad. Rarely add a second agent.

The allergy system is an excitable toddler that has never been to school. Everything new makes it overreact. Thymus, T cells learning. The only new thing in the first year is often food. Sick, or just immunised, plus a new food: it makes mistakes. Immunotherapy and egg and dairy ladders are how you teach it out of the mistake. Family history is not required. A lot of this used to sort itself because people kept feeding through a rash.

Eczema vs food anxiety: if they are really anxious that food is causing the eczema, she is more useful; if they want the skin fixed, dermatology. Severe eczema: dupilumab (Otter: Jupiter) from six months through Gold Coast Hospital. No endpoint. A good number grow out of eczema by three — some families push through, some need a biologic they will inject for the foreseeable future. Refer directly to Gold Coast if they are that bad; they get seen quickly, advice, and you skip the old cycles of oral steroid she saw in training.

RAST / IgE food panels: she hates them. Four Medicare items, labs group foods, 0.8 comes back and looks “raised” — it is square root of nothing. Mum reads it and takes everything out. Do not.

House dust mite: hot-wash sheets, soft toys off the bed or in the freezer, antihistamines at night, not first thing in the morning. Bucket-under-the-hole-in-the-roof: put the bucket out before the storm, do not mop the flood afterwards. Rotate brands if they seem to stop working — temporary tolerance. Nasal sprays: Ryaltris she likes, from the age she named in the room (Otter heard “from H” / six). Dymista comes in glass and they drop it. Nasonex: buy the adult over-the-counter pack (~$10) rather than the paediatric script (~$40) — same dose; over 13 qualifies OTC, she tells parents to say it is for the adult.

FPIES, dairy trials, and do not sign the carer form

Dairy and eczema: a large study found no link. She thinks a tiny percentage are linked. Four-week dairy-out trial with a clear endpoint. If eczema is not gone at four weeks, dairy was never it — put it back. Useful food. Instagram trials without an endpoint are not experiments.

Non-IgE through breast milk (colicky, mucusy poos, vomiting): not always dairy. Many mothers barely eat dairy. Ask what she actually eats in a day. One mother, coeliac, was rice everything — rice milk, rice pasta — rice was the trigger, dairy was fine. Oats: muesli bars, oat milk, lactation biscuits, supply-boosting oats all day. Take one food out at a time. Six weeks to reassess — not two or three days, and not an email on day two. A few good days, a few bad days, is normal. The mother is the food source; keep her nourished. Rabbit-hole elimination wrecks nutrition and you still do not know the trigger.

Three buckets as she uses them: immediate IgE; delayed through breast milk, hours to days; FPIES, usually one and a half to four hours after eating — profuse “exorcist” vomiting, some pass out floppy, then they wake as if nothing happened. Terrifying to watch. Often labelled gastro until the third exposure. Her own youngest: fish, three times, including salmon at a restaurant, before she clocked it. Management she taught the room: avoid that food six months, retry at home — you do not have to see an allergist first. She still happy to see them. Ondansetron 4 mg wafer, half (from the age she uses it; Otter heard eight weeks / “88”). You want a vomit or two to get the protein out, then ondansetron stops the fluid being dragged into the gut. Wafers absorb fast; vomiting straight after still counts.

Reassess allergies at least every five years. A GP described a 14-year-old whose parents wanted carer allowance and payment restamped from a baby anaphylaxis letter; the original allergist had died; Centrelink had stopped paying. Elisa: you are not qualified to sign it; it is not appropriate; the child can say what she eats. Sometimes extra in-home nanny-style funding exists around childcare subsidy for a handful of approved situations. Not a thousand-dollar carer payment because a toddler letter still exists.

Email her. She is better on email than the phone. Built-in gaps in the day; if she is worried she will get them. Little babies she tries to see in a week or two, whatever the waitlist quote says.

Take-home messages for clinic

1. Otherwise-well limp is not finished after normal bloods. XR hip and knee. Blood culture if you are already taking blood. Review. If it is worse, MRI including the spine. CRP can be normal. Discitis still happens.
2. Night pain, failed simple analgesia, a spinal lump in a well toddler, tiptoeing after flu: broaden. NAI is always on the list in young children. Check previous attendances. A splinter still counts.
3. Infants Staph, preschool Kingella, older strep/staph as he listed them. IV then oral, about four to six weeks, in the spinal case that got better.
4. NDIS, as Steve told it, funds level two. Almost every psychologist report is now level two. Level three on a child who just did sport should make you pause. Early-intervention money to age seven is not a diagnosis.
5. Eye contact is not a clearance. Do not reassure autism away at three because they talked to you. They are in the room because home is on fire.
6. Trauma on the file is not a stop sign for ADHD and autism assessment. Family history still counts. Send on if you are unsure or function is wrecked. He will diagnose without a $2,000 report if he can.
7. Introduce dinner, not a 14-allergen spreadsheet. Once-then-never primes. Boil the egg. A little rash is not a reason to stop the diet.
8. Anaphylaxis under two is rare in her telling, often protein powder, often floppy not breathless. Antihistamines from solids, at night for dust mite, rotate brands. Skip grouped IgE food panels.
9. Dairy-out needs a four-week endpoint for eczema; through-milk trials need six weeks and one food. Ask what Mum actually eats — rice and oats, not only cow’s milk.
10. FPIES: delayed vomiting, often called gastro. Avoid six months, retry at home, ondansetron wafers. Reassess IgE allergies at least every five years. Do not restamp a baby letter into a 14-year-old carer payment.

Dr Kotha · Gold Coast · paediatric-cases.drkotha.com