Delayed sleep phase this month and chronotherapy which sounds like quite an undertaking. Also a link to a new parent’s guide to picking up and talking about sexual abuse, links to handy recent uploads to the site, the BSACI guideline on allergic rhinitis and more banging on about vitamin D supplementation – please.
This is the first time in ages I’ve managed to get the finalised version on line in time for the end of the month! NICE on autism this month, a bit on the use of corticosteroids in croup with help from the Cochrane Library, update on secondary prevention of meningococcal disease and a pointer to our local educational psychologist service which is hoping to make stronger links with the borough’s GPs (see also below). Our feeding series continues with an article on colic from one of the junior paediatricians with lots of useful links and updates.
Well the BMJ produces 2 journals in one in August so why can’t I? All the topics featured this month are relevant for both GPs and ED doctors – for once – so you have a joint newsletter. I have covered headache this month, Vitamin D (by popular request) and we have started the “Feeding” series requested by my ED senior colleagues. It seems appropriate to have covered breastfeeding first. Do leave comments below.
My ED consultant colleagues requested that we run a series on “feeding issues” in Paediatric Pearls as it forms a part of the ED trainees curriculum and is a common subject to come up in conversation with parents in the ED. It seems appropriate to begin the series with an article on breastfeeding problems put together by our breastfeeding counsellor, Jo Naylor, and one of the current paediatric trainees, Dr Sarah Prentice. Their full article is downloadable here and I have reproduced some nuggets in this month’s Paediatric Pearls newsletter and below.
|Breastfeeding adequately?||Inadequate milk intake?|
|feeding every 2 – 5 hours for 20 – 40 minutes||infrequent feeds|
|3-4 wet nappies and changing stool by day 3||continued urates and/or meconium after day 3|
|pain free breastfeeding||painful feeds, ineffective sucking|
|weight loss < 10%||weight loss > 10%|
|baby settled between feeds||fretful, hungry baby|
Reminder: handout of local breastfeeding drop-in groups available here.
I intend to cover the following topics over the next few months (some of which have actually already been touched on in previous months): vitamin supplementation, formula milk, gastro-oesophageal reflux, starting solids, allergy, fussy eating, food refusal, dentition and use of bottles, healthy eating, obesity, eating disorders. Please do leave requests for other topics below.
Take a look at this not-definitive-but-nevertheless-sensible guideline on Vitamin D deficiency in both adults and children which Barts and the London published in January 2011: http://www.icms.qmul.ac.uk/chs/Docs/42772.pdf. Please note that it is NOT a national guideline and the authors acknowledge that more research is needed in this area and that variations in practice are common, even across London.
The Paediatric Pearls newsletters are checked every month by my consultant colleagues. We have been keen to put something together for GPs on vitamin D for a few months now but are struggling with the lack of evidence and consensus in this area. Some of the comments I have received back from my colleagues concerning this guideline include:
- A cut off of 80nmol/l is too high as the lower limit of normal. Most hospitals (including Whipps) use 50nmol/l because symptoms do not tend to be evident until that level.
- The paediatric clinical guideline currently in use at the Royal London Hospital is not quite the same as their Clinical Effectiveness Guideline in that it advocates lower doses of vitamin D therapy (than the BNFc) for a longer period of time. The advantage of this is that no monitoring of calcium levels is required.
- Liquid ergo or colecalciferol are difficult to get hold of nationally and some patients find it hard to find a community pharmacist who will supply it. There is a shortage of it at the moment and it is expensive. It would make practical sense therefore to just treat the deficient ones (<25nmol/l) rather than the asymptomatic insufficient patients (25 to 50nmol/l). This is in practice what the majority of us do, ensuring that the insufficient (and even sometimes the asymptomatic deficient group) ones get vitamin supplementation (400IU/day).
- “Symptomatic” includes general aches and pains and does not just refer to hypocalcaemic tetany or rickets.
- Healthy Start vitamins are available again now and are a better long term option than Abidec or Dalivit as they are free to young mothers and their children and to people on benefits, see http://www.healthystart.nhs.uk/. They should be available at all health centres at low cost (if the family does not qualify for healthy start vouchers) to all breastfeeding babies and then for the over ones when they have moved on to cows’ milk.
- We all agree that children with rickets and bone deformities secondary to vitamin D deficiency should be seen in secondary care as they require a greater degree of monitoring, especially their calcium levels, when first started on high doses of colecalciferol. There is also a risk of cardiomyopathy in this group.
- The Clinical Effectiveness Guideline from the Barts and the London group states that 90% of South Asian people in their region (mainly Tower Hamlets in east London) are vitamin D deficient. We don’t yet seem to have found an answer as to why there are not even more cases of rickets or hypocalcaemic tetany in that region then.
I suspect, as usual, the answer to the vitamin D conundrum is not quite as straight forward as this guideline makes out. Do leave comments below.
This is the 2011 Barts Health Vitamin D guidance, with thanks to pharmacist Nanna Christiansen for allowing me to upload it to this site. Please note that the doses here are not the same as the BNFc. There is a wide range of doses which you can prescribe for Vitamin D deficiency and insufficiency and no national agreement on what constitutes either deficiency or insufficiency.
This month I have reproduced some immunisation myths and truths from Dr Ravindran’s excellent summary published in full somewhere on this blog (use the search function if you can’t find it below). NICE’s UTI guideline has just been reviewed; did you know there was a section called “Do not do recommendations”? Worth a look as we are all guilty of doing some of what we are not supposed to. Our new list of local breastfeeding drop-in groups is out, reduced unfortunately since the cutting back of Childrens centres’ funding. The GMC have clarified parental responsibility nicely and, as a step-parent myself, I was quite pleased to see the sensible point on the end too. Lastly, it is a bit depressing to be told that it takes 3 times longer in the UK for a child with a brain tumour to be diagnosed than in the US. Do leave comments below.
May 2011 GP version available here! Can you tell the difference between septic arthritis and transient synovitis? We have a new algorithm to help you. Also a reminder about measles, information on inguinal hernias, NICE on otitis media with effusion and a link to an important discussion on the website about what one can and can not do / take while breastfeeding. Do leave comments below.
I was encouraging a mother to breastfeed the other day when she asked if I was sure that was OK with her condition. Her baby is asymptomatic on a 10 day iv course of penicillin for presumed inadequately treated maternal syphilis. I wobbled momentarily and the junior doctor and I went away to look it up. It is OK apparently as long as the mother does not have syphilitic lesions around her nipples. Take a look at http://pedclerk.bsd.uchicago.edu/page/breastfeeding which is an American teaching site and has a nice summary of when you can and can’t breastfeed. http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT is an American database of the evidence on the safety of various medicines when breastfeeding.
While doing the weekend ward round I came across this list of local breastfeeding support groups pinned up on the back of the neonatal unit door. In the August GP Paediatric Pearls we wrote about tongue tie and feeding issues. The volunteers listed here are the lactation counsellors that Mr Patel at Kings likes to assess the babies prior to referral to him for possible division of tongue tie.