Recent clinical guidelines relevant to paediatrics

Dr Harry Baumer

Consultant Paediatrician

Derriford Hospital

Why me?

• General paediatrician, Plymouth

• Previous chair RCPCH QPC

• ADC guideline reviews since 2003

• Not involved in guideline development

• Not an expert in the subjects!

• No conflict of interest

Choosing guidelines

• Rigorous evidence-based methodology

• Relevant to paediatricians

• Non-specialist’s perspective

• Important messages

• Likely otherwise to be overlooked

Guideline review topics• Sweat test for CF• Post seizure management• Human milk banks• Arterial stroke in childhood• Otitis media (UK & US compared)• Parapneumonic effusion/ empyema• CFS/ME• UTIs in young children• Incomplete Kawasaki disease• Glucocorticoids in croup• Decreased consciousness• Tuberculosis

2005

2004

2003

2006

Glucocorticoids in croup:key messages

• Based on Cochrane review (Russell et al updated 2004)• Strong RCT evidence of benefit

• 51 comparisons, 2,878 patients in placebo controlled studies• Settings: inpatient & outpatient, mild to severe

• Outcomes: croup scores, other Rx, LOS, reattendance

• ↑ by 6 hours, ↓ reattendance/readmission/LOS/ Rx

• Most studies used dexamethasone• Uncertainty about optimum dose (600 vs 150µg/kg)• 600µg/kg dexamethasone single dose orally

• most studied & recommended• = ~ 5 days prednisolone for asthma

• Nebulised budesonide an alternative, not an add on

Decreased consciousness• Nottingham Paediatric A&E research group

• Funded by Reye’s foundation

• Very broad scope

• Rigorous methodology

• Multiple literature searches

• Supported by Delphi consensus

• 134 recommendations, 20 Grade A or B

• Supported by detailed algorithm

• Not yet piloted

Decreased consciousness:scope

• Children with non-traumatic coma

• Aged <18 years, not in neonatal unit

• GCS <15 (not due to chronic disability)

• Differential diagnosis

• Immediate investigations

• Initial management

Key messages

• Core investigations undertaken together

• Acute management of metabolic conditions

• Initial management of intracranial infections

• Contraindications to lumbar puncture

• A normal CT does not exclude ↑ICP

Core investigations

4.6mls total

Acute metabolic illness

Hypoglycaemia

Hyperammonaemia

Non-hyperglycaemic ketoacidosis

Hypoglycaemia

Main causes (excluding exogenous insulin):• Severe sepsis• Endogenous insulin excess• Addison’s disease• Growth hormone deficiency• Congenital adrenal hyperplasia• Fatty acid oxygen defects (eg MCAD) • Organic acidurias• Glycogen storage disorders

Hyperammonaemia

Main causes:• Hepatic failure• Organic acidurias• Urea cycle enzyme defects• Amino acid transport defects• Reye’s syndrome

Non-hyperglycaemicketoacidosis

Causes to consider:• Organic acidopathies• Amino acidopathies (esp branch chain aminoacid disorders)• Fatty acid oxidation defects• Mitochondrial electron transport chain defects• Urea cycle enzyme defects• Circulatory shock

Intracranial infections

Consider if:• Focal neurological signs• Fluctuating consciousness for 6 hours or more• Contact with herpetic lesions• No obvious clinical signs pointing to cause

LP contraindications

NICE TB Guideline

• Published 2006

• Covers adults & children together

• Paediatric input (Dr Delane Shingadia)

• Broad scope:“Clinical diagnosis and management of tuberculosis, and measures for its prevention and control.”

• Recommendations alone >2,500 words

NICE TB Guideline

• Key points for the non-specialist:

• 4 drug regime for active respiratory TB

• New rapid diagnostic techniques

• Use of steroids in TB meningitis

• Indications for BCG

• Who should manage children with TB?

Copyright ©2006 BMJ Publishing Group Ltd.

Marais, B J. ADC E & P (2006); 91: ep1

Figure 4 Chest radiograph (lateral view) of a patient with lymph node disease.

Figure 3 Chest radiograph (anteroposterior view) of a patient with lymph node disease.

Recognising intrathoracic TB

‘Standard’ treatment for pulmonary TB

• Recommendation grade:• Adults (not HIV +ve) A• HIV +ve adults B• Children B

• Based on RCTs in adults

6 months2 months

isoniazid and rifampicin

pyrazinamide and ethambutol

ESAT-6 (early secretion antigen target 6)CFP-10 (culture filtrate protein 10)

Not present in BCG, most environmentalnon-TB mycobacteria

New rapid diagnostic techniquesfor latent TB

using interferon gamma tests

Typically 3mlsblood needed

Different tests

More specific than tuberculin skin tests

No ‘gold standard’ for comparison

Does negative result rule out TB?

How sensitive?

NICE:Mantoux firstNew tests if:

Mantoux positive, orpost BCG

TB meningitis

“Patients with active meningeal tuberculosis should be offered… a glucocorticoid at the normal dose range:

• Adults: equivalent to prednisolone 20-40mg

if on rifampicin, 10-20mg otherwise. A

• Children: equivalent to prednisolone 1-

2mg/kg, maximum 40mg. D(GPP)”

TB meningitisBased on Cochrane review from 2000• 6 RCTs of glucocorticoids• ↓ mortality• ↓ death or severe disability• ↓ mortality in children

• But…• Small studies• Poor allocation concealment• Publication bias• Cochrane review withdrawn Jan 2006

NICE TB Guideline

• Role of BCG in TB control• Drs Teo & Shingadia, ADC 2006; 91: 529-531

• New guidelines July 2005• Joint Committee on Vaccination & Immunisation

• Routine school BCG discontinued

• Vaccination of children at higher risk• Depends on local incidence of TB (≥40 per 100,000/year)

Who should manage children?

“Either a paediatrician with experience and training in the treatment of TB,

or a general paediatrician with advice

from a specialised physician.

If these arrangements are not possible,

advice should be sought from more

specialised colleagues throughout…”

Challenges…

• How to provide specialist support

• BPSU 2004: In 55%, reporting paediatricians had 1 case

• Defining ‘area’ for universal vaccination of all infants

• Monitoring of TB incidence and making appropriate

changes to policy if >40/100,000 per year

• Making a selective policy work in low incidence areas

• Opportunistic screening and vaccination of older children

• Who, where and how?

Key messages• Effectiveness of glucocorticoids in croup• Decreased consciousness

• Core investigations together

• Initial treatment of metabolic conditions, intracranial infections

• Contraindications to lumbar puncture

• Changes and challenges in TB• Four drug regimen for treatment

• Place of new interferon gamma tests

• Steroids in TB meningitis?

• Making selective BCG effective

• Providing specialist support

Acknowledgements• Glucocorticoids in croup Cochrane reviewers

• Kelly Russell• Terry Klassen• David Johnson et al

• Decreased consciousness guideline development group (Nottingham Paediatric A & E Research Group)

• Richard Bowker• Terence Stephenson• Maria Atkinson• Monica Lakhanpaul• Ian Maconochie• Harish Vyass

• NICE TB• Delane Shingadia