Cyclical vomiting this month as the message from the front line, BESS as a learning point for those monitoring the size of an infant’s head, milia also for the babies and the perennial problem of whether or not montelukast works to control episodic wheeze. Do leave comments below:
April 2016’s offering ripe for reading over the bank holiday weekend. Last text box from the 2014 BTS asthma guideline – this time on acute management, FGM and the importance of reporting colleagues who may be involved in the practice, Group A strep infection as a complication of chicken pox and some links to some good CPD sites for you and your patients.
We also welcome Dr Kat Smith this month, paediatric registrar and education fellow at King’s College Hospital, who has kindly volunteered to write monthly articles for the newsletter. It’s nice to have a fresh pair of eyes on paediatric topics and a fresh nose to the ground so to speak. Thanks, Kat, for your help.
Do leave comments below.
September 2015: ENT feature this month – quinsy, Part 2 of the NICE guideline summary on bronchiolitis, information about a domestic violence campaign, self help books for children and a round up of topics to get you started if you are new to paediatric practice. 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.
Allergy – notes from a recent allergy update course with thanks to Dr Su Li, paediatric consultant @ Whipps Cross.
www.allergyuk.org – good factsheets on rhinitis, oral allergy syndrome etc.
www.itchysneezywheezy.co.uk is a collaborative project for patients, their parents and health professionals on all aspects of atopic illness.
RCPCH allergy care pathways for health professionals (eczema, anaphylaxis, urticaria, mastocytosis, food, drug and venom allergies etc. etc.)
www.bsaci.org (stores patient management guidelines and has recently been accredited by NICE – milk, nut and penicillin allergy guidelines all currently in progress)
How to make a diagnosis:
1. Allergy focussed clinical history
2. Allergy tests – tests look at sensitisation not clinical allergy, defines probability of allergy
Skin prick tests
Provocation tests / food challenge
IgE ranges :
|< 0.35||Grade 0|
|0.35 – 0.7||Grade 1|
|0.7 – 3.5||Grade 2|
|3.5 – 17.5||Grade 3|
|17.5 – 50||Grade 4|
|50 – 100||Grade 5|
|> 100||Grade 6|
Test equivalence :
|Skin prick||< 3 mm||3-7 mm||>7 mm|
|IgE||< 0.35||0.35 – 50||> 50|
Probability of allergy :
|< 3 mm||3-7 mm||> 7 mm|
|High clinical suspicion||Possible allergy||Probably allergy||Allergic|
|50:50||Possible allergy||Possible allergy||Probably allergy|
|Low clinical suspicion||Not allergic||Possible allergy||Possible allergy|
If ‘possible allergy’ consider food challenge.
- Your risk of anaphylaxis to peanut is 1% per year if you have a nut allergy.
- If you have had anaphylactic reaction, your risk increases to 5% per year, therefore always prescribe Adrenaline Autoinjector (EpiPen).
- The degree of positivity of a test does not change the risk of anaphylaxis.
- Your risk of having a peanut allergy is 8 times more if you have a sibling with a nut allergy – consider screening siblings.
- Common allergens associated with eczema are egg, peanut and cows milk.
- If you are allergic to egg, consider testing for the peanut and milk as they often co-exist
- Egg exclusion diets can improve eczema symptoms however there is an increased risk of anaphylaxis if you come into contact with egg whilst on an
- Consider a food challenge after 1 year as egg allergies often resolve.
Cows Milk Protein Intolerance:
- This is a non IgE mediated disease, allergy testing will be negative.
- Typical symptoms tend to be eczema or GI upset including reflux, vomiting, ‘colic’, constipation, loose stools, blood and mucous in stools.
- Management includes a 2-4 week trial of extensively hydrolysed formula (Nutramigen / Peptijunior) or amino acid formula (Nutramigen AA / Neocate).
- If breastfeeding, mothers need to go onto an exclusion diet (including soya).
- Do not use over the counter partially hydrolysed formula milks, these still contain cows milk protein.
- Refer to a dietician if on an exclusion diet.
- Consider diagnosis of FPIES (food protein intolerance enteropathy syndrome).
- Cows milk protein intolerance usually resolves around 14 months of age.
- At this age, introduce soya milk first. If well tolerated, introduce cows milk.