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:
Gianotti Crosti this month, updated “Working Together” safeguarding document, epistaxis and malaria. Also links to a few other useful documents recently uploaded to the Primary Care Guidelines part of the website, with thanks to Redbridge and West Suffolk. All comments welcome.
March 2015: the first post of the new ENT feature this month – glue ear, more help with viral exanthems, important safeguarding information on the UK government’s Prevent Strategy, breastfeeding for mums and research in the paediatric ED.
Have just uploaded February 2015 newsletter – with 4.5 hours of February to go….
NICE on gastro-oesophageal reflux disease, how to recognise speech delay, more viral exanthems, resus cards and information on forthcoming allergy courses. Do leave comments below:
January 2015 newsletter is being published late with apologies. The newsletter is circulated prior to publication to be checked by my 8 paediatric consultant colleagues and any guest authors. I neglected to attach the newsletter to my initial email, a fact pointed out to me on the 31st January….. Now checked and ready to go.
Andrew Lock has put together a really helpful guide to viral exanthems with trustworthy links to proper images, Vicky Agunloye is back this month with an invaluable guide to the healthcare professional’s assessment of a crying baby (and his/her mother). Tom Waterfield has looked at the usefulness of saline nebs in bronchiolitis, there are some more “do not do” recommendations from NICE and a link to Suffolk’s guideline on managing anaphylaxis and its follow up from primary care. Do leave comments below:
December 2014 : ‘flu vaccination for children, calprotectin, paintballing bruises, eczema and some useful links to atopy downloads. Do leave comments:
WAIT study, faecal calprotectin, foreign body removal, guideline for managing cow’s milk protein allergy in primary care and some useful apps. Do leave comments….
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.
October 2014 holds quite a few topics: scalp ringworm, sleep and behaviour, support for victims of sexual abuse, immunotherapy for peanut allergy, link to parental asthma booklet and what to do with babies with chicken pox. Do leave comments below…
With thanks to Dr Vicky Agunloye, paediatric registrar and new Waltham Forest mum, for kicking off her parental FAQ series with a question that many GPs ring and ask me – and I always have to look it up…
Chicken pox , Varicella-Zoster Virus (VZV), is a common infection spread by droplet inhalation of the VZV from contacts with either chicken pox or shingles.
Most children have a mild disease course; however those that are immuno-compromised are at a significant risk of severe or fatal disease and need human Varicella Zoster Immunogloblin (VZIG) as soon as possible. Some neonates (<=7 days old) come into this category.
Who needs VZIG? :
- Infants whose mothers develop chickenpox (but not herpes zoster) in the period 7 days before to 7 days after delivery. VZIG can be given without antibody testing in these infants.
- An infant who has had significant contact with a case of varicella when < 7 days of age and whose contact of VZV was not the mother and mother has no positive history of VZV herself. In these cases, the VZIG should not be given past 7 days after the initial contact.
(Confirm patient has had significant contact, Box 1 in: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/327762/Chickenpox_immunoglobulin_Oct_2008.pdf )
Who does not need VZIG?
- Term infants > 7 days old, even if they have had significant contact
- An infant that has not had significant contact, see above.
- A term infant who is < 7 days old, whose mother has a positive protective history of VZV.
- Infants who have been exposed >10 days ago.
Whose VZV anti-bodies need checking before you can decide if VZIG is needed?
- Infants <7 days whose mothers are unsure of their VZV status (you can check mothers or infants). However do not delay more than 7 days waiting for results.
Inform mothers that up to 50% of neonates exposed to maternal VZV who get VZIG still go on to get chickenpox, most are mild cases.
If infant becomes symptomatic despite VZIG, IV acyclovir is needed.
Other useful links:
- Page 434-435: http://www.clinicalguidelines.scot.nhs.uk/Renal%20Unit%20Guidelines/Nephrotic%20syndrome%20Guideline/Varicella%20doc.pdf