January 2016 newsletter continues on the theme of asthma and covers internet safety, IDA and early weight loss in breastfed babies. Do leave comments below:
August 2015: ENT feature this month – acute mastoiditis, PVL producing staph from the dermatology team, Henoch Schonlein purpura – long term management and follow up and Part 1 of the NICE guideline summary on bronchiolitis. Just in time for the RSV season….
Do leave comments below:
Dr Tom Waterfield: Wheeze And Intermittent Treatment (WAIT) trial
With winter fast approaching paediatricians, GPs and ED doctors will be bracing themselves for the inevitable surge in children presenting with wheeze. Any approach that could reduce attendances would be gratefully received and the WAIT study set out to determine if Montelukast could be used intermittently by parents to reduce unscheduled attendances with wheeze. This study published in October’s Lancet recruited 1358 children aged between 10months and 5 years over a 3 year period across 62 sites in the UK. All of the children had physician diagnosed wheeze on at least two occasions. The study set out to determine if giving Montelukast to children at the onset of cold or wheeze symptoms over a 12 month period could reduce unscheduled attendances to hospital. This double blinded, multicentre randomised control study found that intermittent Monteleukast usage did not reduce hospital attendance. The authors also performed a meta-analysis of existing studies investigating the intermittent usage of Montelukast for wheeze and again found no evidence of a benefit.
Interestingly however, the group also performed subgroup analysis based on genotyping for the arachidonate 5-lipoxygenase (ALOX5) gene promoter and found that a subgroup of childrenin the WAIT study did demonstrate a statistically significant reduction in unscheduled medical attendances for wheezing episodes.
So where does this leave us?
For this winter this study doesn’t offer any additional hope for the use of Montelukast in preventing hospital attendances but there is hope for the future. Further work to better understand how genotyping could be used to identify Montelukast responsive children could result in targeted therapy.
Dr Chin Nwokoro’s reply:
Effective treatment for preschool wheezing children remains elusive. Oral steroids do not reduce hospital admissions or length of stay (1, 2) and may cause harm. Preschool wheezers are predominantly well between attacks and chronic inhaled steroids are not justified in the absence of very frequent or clinically severe episodes. Montelukast shows promise as the only leukotriene receptor antagonist licensed in children, especially given previous work showing an increase in leukotriene axis activation during acute wheezing episodes(3). This study did not show evidence of global benefit in this age group, and the genetic subgroup effect did not in truth meet significance when the p-value for interaction is considered. The data hint at rather than firmly identify a responsive subgroup, and furthermore no link is shown between baseline leukotriene status and montelukast response(4). The success of ivacaftorin CF patients with a gating mutation is evidence that genotype-guided therapy can be transformative(5), unfortunately that evidence is lacking here. The ERS taskforce(6) suggests a role for prophylactic therapy in preschool viral wheezers with severe or frequent attacks and it is here, in the absence of steroid-modifiable pathology, where ‘preloading’ with regular (but not on this evidence intermittent) montelukast may prove of benefit.
- Oommen A, Lambert PC, Grigg J. Efficacy of a short course of parent-initiated oral prednisolone for viral wheeze in children aged 1-5 years: randomised controlled trial. Lancet. 2003;362(9394):1433-8.
- Panickar J, Lakhanpaul M, Lambert PC, Kenia P, Stephenson T, Smyth A, et al. Oral prednisolone for preschool children with acute virus-induced wheezing. N Engl J Med. 2009;360(4):329-38.
- Oommen A, Grigg J. Urinary leukotriene E4 in preschool children with acute clinical viral wheeze. Eur Respir J. 2003;21(1):149-54.
- Nwokoro C, Pandya H, Turner S, Eldridge S, Griffiths CJ, Vulliamy T, et al. Intermittent montelukast in children aged 10 months to 5 years with wheeze (WAIT trial): a multicentre, randomised, placebo-controlled trial. Lancet Respir Med. 2014;2(10):796-803.
- Ramsey BW, Davies J, McElvaney NG, Tullis E, Bell SC, Dřevínek P, et al. A CFTR potentiator in patients with cystic fibrosis and the G551D mutation. N Engl J Med. 2011;365(18):1663-72.
- Brand PL, Caudri D, Eber E, Gaillard EA, Garcia-Marcos L, Hedlin G, et al. Classification and pharmacological treatment of preschool wheezing: changes since 2008. Eur Respir J. 2014;43(4):1172-7.
I was a bit overloaded in December and couldn’t manage to get a newsletter out. The nurses in my own ED noticed but I don’t think anyone else was particularly bothered! Hope the Christmas break went well for everyone. January 2013 brings some more on speech development, a reminder of the BTS 2008 guideline on cough, another plug for vitamin supplementation and part 2 of Jess Spedding’s minor injuries series. Do leave comments below.
August’s PDF only has 4 text boxes but with lots of information crammed into them and extra on the blog. A great looking PDF on poisoning in children from one of our registrars, an article on stammering from another working with a speech and language therapist and an update on BTS pneumonia guidelines just in time for the winter. Also a feature on Cardiff’s core info safeguarding work on the evidence behind different types of fractures. Do leave comments…
In October 2011 the British Thoracic Society updated its guidelines on community acquired pneumonia in children. Dr Michael Eyres looked at it in more detail for Paediatric Pearls. He was also part of our local audit team contributing to the national audit. The results showed that we, despite insisting on as few investigations as possible, are still doing too many chest x-rays, blood cultures and CRP measurements. Think – will it change management?
Here are the basics:
When to consider pneumonia
Persistent fever > 38.5°C + chest recessions + tachypnoea
• CXR should not be considered routine and is not required in children who do not need admission.
• Acute phase reactants including CRP are not useful in distinguishing viral from bacterial infection and should not
be tested routinely. Blood cultures also do not need to be routinely taken.
• Daily U&Es are required in children receiving IV fluids.
• Children with oxygen saturations <92% need hospital referral.
• Auscultation findings of absent breath sounds with dullness to percussion need hospital referral.
• Children should be reassessed if symptoms persist.
• Give parents information on managing fever, preventing dehydration and identifying deterioration.
• Children with oxygen saturations <92% need oxygen.
• NG tubes should be avoided in severe respiratory compromise and in infants.
• Chest physio is not beneficial and should not be performed in pneumonia.
• All children with a clear clinical diagnosis of pneumonia should receive antibiotics as bacterial and viral
infections cannot be reliably distinguished. However most children younger than 2 years presenting with mild symptoms of respiratory distress (this would
include the bronchiolitics) do not usually require antibiotics.
• Amoxicillin is the oral first-line for all children as it is effective, well tolerated and cheap.
• Macrolides if no response to first-line / suspected mycoplasma or chlamydia / very severe disease.
• Augmentin if pneumonia associated with influenza.
• Oral agents are effective even in severe pneumonia; IV is needed only if unable to tolerate oral or there are
signs of septicaemia, empyema or abscess.
• Children with severe pneumonia or complications should be followed up after discharge until they have recovered completely and
CXR is near normal. Follow-up CXR is not otherwise required, but may be considered in round pneumonia, collapse or if symptoms persist.
More background to pertussis with thanks to Dr Rupa Vora
- whooping cough is caused by Bordetella pertussis, a gram negative pleomorphic bacillus. It is spread by aerosol transmission and the bacteria cause damage by attaching to the respiratory cilia
- it occurs in clusters every 2-5 years during the summer months. We currently have an outbreak with the HPA provisionally reporting 665 cases in the first quarter of 2012 (cf. 1040 cases in 2011, 421 in 2010)
- cases have dropped dramatically since pertussis vaccinations have been introduced. Acellular pertussis vaccination is given at 2 and 3 months, followed by a pre-school booster. However, protection wanes quickly and has virtually disappeared by 12 years old
- incubation period is 3-12 days and children are most infectious in the first 2-3 weeks. They are most likely to present in the second phase of illness at 3-4 weeks
- can present with coryza (1st stage which lasts a couple of weeks), paroxysms of cough, difficulty feeding and pneumonia. Younger infants (<6months) may not present with the characteristic ‘whoop’. Older children and adults often present with a persistent cough
- complications include chronic cough (“100 day cough”), hypoglycaemia, seizures, encephalopathy and intracranial haemorrhage
- any infant is vulnerable and up to 50% may need hospitalisation. Especially vulnerable are ex-prems and those with underlying cardiology, respiratory or neurological problems.
- In England and Wales, whooping cough is statutorily notifiable. The diagnosis is usually made on clinical grounds without the requirement for laboratory confirmation
- The UK Health Protection Agency advises a 7 day course of erythromycin or clarithromycin (or azithromycin for 3-5 days if under 4 weeks) to reduce spread. A pernasal swab to confirm or refute B. pertussis as the causative organism can be carried out. If the cough has been present for more than two weeks and the child is in the community, serum serology can be sent to Colindale. See table below:
Appropriate laboratory tests for a sporadic case of pertussis reported to HPA on clinical suspicion (with thanks to Dr Maria O’Callaghan):
|≤ 2 weeks cough||> 2 weeks cough|
|≤ 1 yr
|NPA/PNS for PCR (RSIL)
PNS for culture (local laboratory)
|NPA/PNS for PCR (RSIL)
PNS for culture (local laboratory)
Serum for serology (RSIL)
|≤ 1 yr
|PNS for culture (local laboratory)||Serum for serology (RSIL)|
|> 1 yr to 6 yr|
|6 to 15 yr||Serum for serology (RSIL)|
|> 15 yr|
NPA – nasopharyngeal aspirate; PNS – pernasal swab;
RSIL – Respiratory and Systemic Infections Laboratory, Colindale
Children from about 5 years old may be able to use a Peak Flow Meter to record their PEFR. As one of the parameters by which we diagnose a severe or life-threatening asthma exacerbation is the percentage drop in PEFR, it would help to know what a child’s normal PEFR is! Click here for a guide of what you might expect for height. Children don’t always conform to these norms so it is important to know what the child’s own normal PEFR is; a 20% drop in their norm suggests poor control of asthma, a 40% drop suggests a significant exacerbation.
Most families in the Emergency Department will talk about their child’s “blue” and “brown” inhaler. Can we, or they, tell which is the reliever and which the preventer?
Click here for a printable table of some common inhalers listed by colour. I have also found a very useful site put together by a pharmacist and a medical student with photos of lots of the inhalers so you can get your patient to identify which one they are on. Take a look at http://www.rch.org.au/clinicalguide/asthmadevices/
|Standard metered dose inhaler (MDI)||
|MDI and spacer||
|Dry powder device||
http://www.asthma.org.uk/health_professionals/materials_to_help_you_your_patients/index.html has a link to a comprehensive information leaflet for young people over the age of 12 who need to take control of their asthma management and understand their condition.
http://www.nice.org.uk/nicemedia/live/11400/32073/32073.pdf is the 2000 guideline on asthma management in the < 5 year olds
http://www.nice.org.uk/guidance/index.jsp?action=byID&r=true&o=11450 is the 2002 guideline for 5-15 year olds