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Transcript of Dr Paula McQueenAllergy Dr Ruth Mew Allergy Dr Ozan HanciGastroenterology Dr Joanne...
Dr Paula McQueen Allergy Dr Ruth Mew Allergy Dr Ozan Hanci Gastroenterology Dr Joanne Bartley Oncology Dr Rick Fulton Diabetes (Locum) Dr Archana Kshirsagar Diabetes (from Sept
14)
New Consultants in Paediatrics at the Royal Surrey from 1st April 2014
Constipation Recurrent abdominal pain Gastro-oesophageal reflux Cow’s milk protein allergy Eczema Immunisations Urinary tract infections Nocturnal enuresis
Common paediatric conditions which seldom require hospital referral
Antisocial behaviour and conduct disorders Atopic Eczema Bedwetting (nocturnal enuresis) Constipation Diarrhoea & vomiting Feverish illnesses Food allergy
NICE Guidelines for Children
Immunisations Looked-after babies & children Reducing substance misuse Social & emotional wellbeing Spasticity in children Surgical management of CSOM Urinary tract infection When to suspect child maltreatment
NICE Guidelines for Children
Chronic Constipation in Children
Dr Mark EvansConsultant Paediatrician
Royal Surrey County Hospital
Common problem in children (5-30%) Usually functional, rarely due to an organic cause Can usually be managed in General Practice NICE Guidelines available (QS62) Use oral macrogols as first line treatment May need disimpaction followed by maintenance
Rx Treat for 3 months before specialist referral Watch out for Red Flag signs needing referral
Chronic Constipation
Which children require referral for specialist advice ?
Delayed passage of meconium (> 48 hours) Symptoms starting in the first 4 weeks of life Ribbon-like stools (more likely in infants) Abdominal distension with vomiting or FTT New onset of weakness in lower limbs Disclosure suggesting Child Abuse Poor response to Rx for > than 3 months
Chronic Constipation
Unusual organic causes
Coeliac Disease Cow’s Milk Protein Allergy Hypothyroidism Hypokalaemia Hypercalcaemia Neurological problems Peri-anal Streptococcal Infection
Chronic Constipation
Investigations that can be done in General Practice
FBC & Film U&E’s TFT’s Bone profile Coeliac serology IgE and RAST to food mix Peri-anal Swab
Chronic Constipation
Recurrent Abdominal PainDr Mark Evans
Consultant PaediatricianRoyal Surrey County Hospital
Common problem in children (25%) Usually functional, rarely due to an organic
cause Can usually be managed in General Practice NICE Guidelines not yet available Reassurance is the main management May need to exclude an underlying organic
cause Watch out for Red Flag signs needing referral
Recurrent Abdominal Pain
Which children require referral for specialist advice ?
Pain associated with weight loss or chronic diarrhoea
Pain associated with significant rectal bleeding Pain associated with bile-stained vomiting Abnormal investigation results Chronic symptoms lasting for > 3 months Children who are missing a lot of school
Recurrent Abdominal Pain
Investigations that can be done in General Practice
FBC & Film ESR & CRP U&E’s, LFT’s, bone profile, amylase Coeliac serology, IgE & RAST to mixed foods MSU & Stool for m/c/s, H pylori Ag & faecal
calprotectin Plain abdominal x-ray Abdominal / pelvic ultrasound scan
Recurrent Abdominal Pain
Treatment of RAP in General Practice
Reassurance +++ (if no Red Flags) Basic investigations as discussed previously Movicol if constipation suspected or proven on AXR Pizotifen 1 – 1.5 mg OD if abdominal migraine
suspected Omeprazole 10 – 20 mg OD if acid reflux suspected CAMHS referral if psychological factors suspected Paediatric referral if symptoms > 3 months
Recurrent Abdominal Pain
Cow’s Milk Protein AllergyDr Mark Evans
Consultant PaediatricianRoyal Surrey County Hospital
Common problem in infants & children Can usually be managed in General Practice Often a self-limiting condition resolving by 4
yrs Prescribing guidelines for milks widely
available May need to exclude an alternative organic
cause Watch out for Red Flag signs needing referral
Cow’s Milk Protein Allergy
CMP Allergy affects 2 – 8 % of all babies Gastro-intestinal symptoms occur in 60 – 80
% Can also present with skin & respiratory
symptoms Sometimes presents with pr bleeding in
infants Often resolves spontaneously by 3 – 4 years
of age Hydrolysates should be used as 1st line
treatment Amino-acid formulas should reserved for
severe cases
Cow’s Milk Protein Allergy
Treatment of CMPA
Many different types of ‘special milks’ Note new prescribing guidelines on the G & W web-site Start with a hydrolysate such as Aptamil Pepti 1 or 2 Only use amino-acid based formulas if above
ineffective Do not use soya / goat’s milk / sheep’s milk, etc Coconut milk or oat milk can be used > 12 months Do not use rice milk < 4 years (contains arsenic)
Cow’s Milk Protein Allergy
Which children need referral for specialist advice ?
Babies with ‘failure-to-thrive’ (weight loss > 2 centiles) All infants on a CMP-free diet should have dietetic input Rectal bleeding in infants unresponsive to 1st line Rx Any children not responding to Rx with hydrolysates Children with CMPA as part of multiple food allergies CMP complicating Coeliac disease in older children Children requiring a CMP challenge under supervision
Cow’s Milk Protein Allergy
Useful References
Guildford & Waverley Prescribing Web-Site NICE Guidelines on Food Allergy in Children
(2011) MAP Guidelines for Rx CMPA in General
Practice (2013) Venter et al - Clinical & Transitional Allergy
2013 3:23
Cow’s Milk Protein Allergy
GO Reflux in ChildrenDr Mark Evans
Consultant PaediatricianRoyal Surrey County Hospital
Common problem in infants & children Usually functional, rarely due to an organic
cause Can usually be managed in General Practice NICE Guidelines not yet available (Jan 2015) Reassurance is the main management May need to exclude an underlying organic
cause Watch out for Red Flag signs needing referral
GO Reflux in Children
Which children need referral for specialist advice ?
Projectile vomiting in the early weeks of life Vomiting associated with ‘failure-to-thrive’ Vomiting associated with significant
haematemesis Symptoms unresponsive to conventional anti-
reflux Rx Symptoms persisting beyond 12 months of age
GO Reflux in Children
Treatment of GO Reflux in Infants
Infant Gaviscon or feed thickening agent Ranitidine at a dosage of 2 mg / kg / TDS Domperidone at a dosage of 0.2 – 0.3 mg / kg /
QDS or Erythromycin at a dosage of 3 mg / kg QDS Omeprazole at a dosage of 1 – 2 mg / kg OD Consider a hydrolysate in case of CMP allergy
GO Reflux in Children
Any Questions ?