Paediatric Pearls

It’s the last day of September today so I’ve just got in by the skin of my teeth…  In this month’s edition I have done a bit on BCG vaccination from the recently updated NICE guideline on TB, reminded you of where to get the new growth charts from and how to plot ex-prem babies on them and featured a somewhat depressing paper from Archives of Disease in Childhood this month on the effects of maternal obesity on the baby.  Do leave comments and questions below.

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. 

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.

Any words of wisdom on this topic very welcome here!  A slightly lax lower oesophageal sphincter is pretty normal in the under 1s but a lot of energy is expended in trying to do something about the symptoms.  The paper cited in this month’s Paediatric Pearls from the Drugs and Therapeutics bulletin is really rather depressing in its comments on both pharmacological and non-pharmacological management of reflux.  Even surgery doesn’t always work.  It is particularly common among preterm babies and much has been written about that group of patients too – with similar levels of evidence generated as with term infants.  You might want to read: Gastrooesophageal reflux disease in preterm infants: current management and diagnostic dilemmas. J L Birch, S J Newell, Arch Dis Child Fetal Neonatal Ed 2009 or Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the NASPGHAN and the ESPGHAN. J Pediatr Gastroenterol Nutr; 2009 on this topic.

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/breastfeeding.html 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.

I am teaching our local GPVTS trainees this week on faltering growth, food allergy and coeliac disease.  As usual, I have learnt more from preparing their presentation than they are going to learn in the hour it will take me to present it!  I have found a great GP training website set up by a GP in the north of the UK with similar altruistic aims to me.  Have a look at what he has to say on faltering growth at http://www.gp-training.net/training/tutorials/clinical/paediatrics/pgrowth2.htm. 

I have put together an algorithm for managing cows’ milk protein allergy and a table on various different infant formulas which you are welcome to download or comment on.

I used to work in Poole Hospital, Dorset and was pleased to find this patient information leaflet from the dieticians there on tips for families where a child is refusing to eat: http://www.poole.nhs.uk/documents/leaflets/nutrition/My%20Child%20Wont%20Eat.pdf.  It is based on the leaflet “Help, my child won’t eat” which is put together by the Paediatric Group of the British Dietetic Association but not obviously available on-line.

There has been a lot of interest in Vitamin D deficiency recently and a certain lack of consensus on what to do about it.  We certainly do see rickets in our community which we treat with oral ergocalciferol which is notoriously difficult to get hold of in community pharmacies I know.  But full blown rickets is just the tip of the iceberg.  The Department of Health produced a leaflet in January 2010 (http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_111302.pdf ) which is the nearest I can find to a national guideline dealing with the risk of Vitamin D deficiency.