Warts this month, steroids in Bell’s palsy, a recap of the year for the new trainees and some more edicts from NICE on what not to do. A couple of links to good CPD opportunities too. Do leave comments below.
Sick and tired – the truth about infantile reflux
By Dr Tom Waterfield
We have all had that difficult conversation regarding “reflux” when a tired parent has come to us with their “sicky child” and an unshakeable belief that their baby has gastro-oesophageal reflux disease. There is often enormous pressure to provide a solution but how do we decide which children need treatment and what treatments should we use? In view of the recent concerns regarding the use of Domperidone I have chosen to review the current evidence base for the management of this common problem.
The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition(NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) produced a useful guideline document in 20091. This concise 50 page document discusses the evidence base for all aspects of gastro-oesophageal reflux and some of the key points are outlined below.
1) Physiological Gastro-oesophageal reflux (GER) is common; around 50% of healthy infants will display symptoms of GER. These “happy spitters” will be gaining weight and healthy1.
2) Faltering growth is unlikely to be due to GERD and alternate diagnosis such as cow’s milk protein allergy should be considered1.
1) The Gold-Standard investigation to make a positive diagnosis of GERD is an impedance study. This has largely replaced the pH study. In this study the changes in the electrical impedance (ie, resistance) between multiple electrodes located along an oesophageal catheter are used to measure reflux. Unlike a pH study the impedance study will also be able to detect non-acidic reflux1.
2) In the majority of cases there will be no role for any other diagnostic test for GERD1
Try to avoid treating simple GER. Reassurance is often all that is required. Before starting any treatment have a frank discussion regarding the risks and benefits1.
2) Positioning “Tummy Time”
There is evidence that lying prone improves GERD when compared with lying supine or semi-erect. It is however, not recommended that children sleep prone due to the associated risk of sudden infantile death (SIDS). A sensible compromise might involve allowing the child to lie prone when awake and supervised by the parent. Semi-supine positions (such as sitting in a car seat) are not recommended and may exacerbate reflux symptoms1.
3) Thickened Feeds
Commercially available thickened feeds (anti-reflux feeds) are safe and relatively effective at reducing visible regurgitation1.
4) Buffering agents and Alginates
There is very little evidence to support the use of alginates (e.g. Gaviscon Infant) in the treatment of GERD although their use is likely to be safe1.
5) H2RAs and PPIs (Unlicensed treatments)
Antacid treatment with Histamine 2 Receptor Antagonsists (HR2As) is effective at healing proven oesophagitis in adults but there is very little data to support their use in infancy. H2RAs such as Ranitidine are relatively safe but their effectiveness is unproven and there are high rates of tachyphylaxis thereby limiting their usefulness in the long term1.
Proton Pump Inhibitors (PPIs) such as Lansoprazole and Omeprazole do not demonstrate tachyphylaxis and can be used for longer term acid suppression. Despite this however, randomised placebo controlled studies have failed to demonstrate a benefit of (PPIs) over placebo when treating GERD in infants1.
Some studies have suggested that long term acid suppression with PPIs and H2RAs can lead to increased rates of pneumonia and gastroenteritis1.
6) Prokinetics (unlicensed)
ESPGHAN and NASPGHAN advise against the use of all prokinetic agents including Erythromycin and Domperidone. There is no reliable evidence to support their effectiveness at treating GERD in infants and there have been concerns raised over the potentially cardiotoxic effects of Domperidone2.
Reflux is very common with half of infants having some symptoms. In the majority of cases reassurance is all that is required. If symptoms are severe and persistent and an alternate diagnosis is unlikely then consider thickened feeds and “tummy time” as a first line treatment. If this is unsuccessful then consider antacids but be aware that the evidence base for these treatments is limited and they are being used off license. Prokinetics play no part in managing GERD in infants and Domperidone use may be cardiotoxic2.
1) Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition(NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)Journal of Pediatric Gastroenterology and Nutrition. 49:498–547 # 2009
2) Domperidone: limited benefits with significant risk for sudden cardiac death. Hondeghem LM.J CardiovascPharmacol. 2013 Mar;61(3):218-25.
Lots of things to talk about this month. Reminder of what Koplik spots look like, good e-learning on human trafficking, a link to the new primary care guidelines page, night terrors v. nightmares, some good allergy websites and Jess Spedding again on scaphoid injuries. Do leave comments below.
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.
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.
Lee Noimark is a paediatric allergist at the Royal London Hospital. He and his team put these allergy action plans together. Print them out for your patients to give to nursery or school in the event of an allergic reaction. The labels are self explanatory:
Fussy eating is one of the most common things that parents present with to both primary and secondary care. My colleague, Ann Duthie, has kindly allowed me to paraphrase a recent talk she gave to the department on this subject. I hope you find the structure as sensible, helpful and reassuring as we did.
FEEDING DISORDERS IN CHILDREN encompass the behaviour of those who have difficulty consuming adequate nutrition by mouth (impaired feeding), those who eat too much and those who eat the wrong thing (pica). We have not covered here eating disorders such as anorexia or bulimia.
Common presentations include:
- Food refusal
- Self feeding inadequacy
- Excessive meal duration
- Choking, gagging, vomiting
- Inappropriate mealtime behaviours
- Food selectivity by type and texture
Normal feeding development is as follows:
- Up to 6 mths – breast/bottle fed milk
- 6-12 mths – solids introduced and increased in variety & volume. Milk intake begins to decrease.
- At 1 yr – teeth; family diet; ½ pt milk/day; change in attitude to food; active and wt gain slows
- 15 mths – hold spoon, messy feeding, use feeding cup
The child moves from a state of total dependency on parents for food to one in which he/she can exert control & independence to determine what is
eaten, when and how. Some parents struggle to adapt to this:
- Feeding cues can be missed
- Parental fear that insufficient food will be taken, child will lose weight
- Parents own food preferences
- Rejection of a food and assumption that child will never like it
- Time pressures
The health professional must look for an organic cause of food refusal:
|Organ system||GI disorder||Mechanism|
Structural with oral
Reluctance to swallow
Cows milk allergy
|Stomach||Motility disorder||Reduced appetite,
|Colon||Constipation||Pain, discomfort, reduced
Children with neurodevelopmental problems or autism may have additional factors affecting their feeding behaviours.
There are 5 key elements to the assessment:
- How is the problem manifested?
- Is the child suffering from any disease?
- Have child’s growth & development been affected?
- What is the emotional climate like during mealtimes?
- Are there any great stress factors in the family?
Red flags to look out for include:
- Swallowing difficulty with cough, choke or gag
- Vomiting/abdominal pain/arching/grimacing/eye watering
- Recurrent chest infections
- Stridor on feeding
- Snoring with sleep apnoeas
The history is, as always in medicine, of paramount importance and needs to be fairly detailed:
- Birth History
- Previous illness (inc. h/o vomiting, respiratory symptoms) & hospitalisations
- Developmental progress
- Chronology of feeding problem
– Diet since birth
- – Changes of milk formulae
– Introduction of solids
- Current diet (typical day)
- What happens at meal times?
- Family & Social history
Height and weight must be measured and plotted on an age appropriate growth chart and corrected for prematurity if less than 2 years of age. Refer children with red flags or significant faltering growth to secondary services.
- Management of the well child in primary care:
- Reduce milk intake if necessary (maximum of 500mls total in 24 hours)
- Encourage family foods
- Meal time management (see NHS Lothian’s dietetic advice)
- Aim: Improve infants comfort at meal times, relieve parental fears and improve parent-infant relationship
The multidisciplinary approach:
- Health Visitor – can assess child within home situation
- – Nutritional assessment and feeding advice
- – Calorie enrichment
- – Calorie supplementation
- – Enteral feeds (very occasionally)
- Speech & Language therapist
- – Direct assessment of feeding & advice in home situation
- – Parent-child interaction
- – Is swallow safe?
- – Toddler feeding groups (eg. Waltham Forest’s “Ooey Gooey” group at Wood Street)
- Feeding disorders in children are common
- Occur in healthy children but assessment should be made for organic causes
- – GI tract problems
- – Developmental delay
- – Autistic spectrum disorder
- Watch out for obligate milk drinkers
- Meal time management is crucial
- Involve Health Visitor
Weaning your premature baby. Free download from Leicestershire Dietetic Service 2011
Help! My child won’t eat and My child still won’t eat. British Dietetic Association. Available to buy in packs from http://www.ndr-uk.org/
New Toddler Taming by C Green