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:
Allergy Action Plan (mild-moderate)
Allergy Action Plan (mild-moderate with asthma)
Allergy Action Plan (severe with asthma)
Coins, magnets and batteries on the menu this month as well as some more cows milk protein allergy resources. A reminder about child developmental milestones courtesy of one of our medical students and NICE on headaches. Do leave comments!
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:
Normal feeding development is as follows:
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:
The health professional must look for an organic cause of food refusal:
| Organ system | GI disorder | Mechanism |
| Mouth | Carious teeth Structural with oral dysphagia |
Pain Reluctance to swallow |
| Pharynx | Tonsils Aspiration |
Pain, obstruction Choke, gag |
| Oesophagus | Reflux oesophagitis Cows milk allergy |
Pain, burning |
| Stomach | Motility disorder | Reduced appetite, discomfort |
| Colon | Constipation | Pain, discomfort, reduced appetite |
Children with neurodevelopmental problems or autism may have additional factors affecting their feeding behaviours.
There are 5 key elements to the assessment:
Red flags to look out for include:
The history is, as always in medicine, of paramount importance and needs to be fairly detailed:
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.
The multidisciplinary approach:
Summary points:
Further resources:
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/
My Child Won’t Eat by C Gonzalez – these are both books and the links are to www.amazon.co.uk
New Toddler Taming by C Green
Click here for this month’s PDF digest! It ‘s quite hard providing a balance of information for GPs and ED juniors now that I am only doing the one newsletter. I think we’ve succeeded this month with neurodevelopmental milestones in Down’s syndrome and essential tremor aimed mainly at GPs and pulled elbow, anaphylaxis and the FEAST study aimed more towards the emergency medicine practitioners. Many thanks to my colleagues who have contributed this month. The FEAST video makes fascinating and inspiring watching for any health professional, regardless of specialty. Do leave comments, questions, suggestions!
With thanks to my colleague, Dr Su Li, for summarising this 2011 NICE guideline for Paediatric Pearls.
Anaphylaxis: assessment to confirm an anaphylactic episode and the decision to refer after emergency treatment for a suspected anaphylactic episode
December 2011
Anaphylaxis is a severe, life-threatening, generalised hypersensitivity reaction involving
There can often be skin and mucosal changes. Patients presenting with these signs and symptoms should be diagnosed as having ‘suspected anaphylaxis’.
Anaphylaxis may be an allergic response that is
This guideline does not make any drug recommendations. These can be found at http://www.resus.org.uk/pages/reaction.pdf.
Patient Centred Care
Recommendations
Research Recommendations
Do you know your valgus from your varus? Or your myclonic epilepsy from your sleep myoclonus? A link this month to new asthma patient information leaflets and some reminders of NICE’s “Do not do recommendations” in feverish children. Also the BSACI egg allergy guideline. Do leave comments on any of these topics below.
This is the first time in ages I’ve managed to get the finalised version on line in time for the end of the month! NICE on autism this month, a bit on the use of corticosteroids in croup with help from the Cochrane Library, update on secondary prevention of meningococcal disease and a pointer to our local educational psychologist service which is hoping to make stronger links with the borough’s GPs (see also below). Our feeding series continues with an article on colic from one of the junior paediatricians with lots of useful links and updates.
NICE has recently reviewed its guideline on depression in children and young people – an important diagnosis to be aware of when treating children in the ED. We have also looked at the evidence around non-sedating antihistamines and found you a “how to do it” video on pulled elbows, and indeed one on umbilical hernia repair in an adult! Umbilical hernias are common and benign, inguinal hernias may not be. Read all about it here!
The April 2011 version is now published. I have covered the recently reviewed NICE guideline on depression in children and young people. We continue with the 6 week check series with some information on umbilical hernias and granulomas. And, now that the hay fever season is upon us, we have had a look at the literature on non-sedating antihistamines.
April 2011’s editions of Paediatric Pearls are being published late because there has been a bit of pre-publication discussion about our paragraph on anti-histamines which needed checking up on! The newsletters go out to all my colleagues for checking prior to publication and occasionally Amutha and I have to go back to the drawing board for one or two of the text boxes. This month 2 of the text boxes have had to be re-done, the ones on cetirizine and umbilical hernias as the surgeon with an interest in paediatrics at Whipps had some suggested modifications for this latter one. All goes to show that this site is not just a collection of my own random thoughts….
The full abstract of the paper on cetirizine is reproduced below:
Drugs. 2004;64(5):523-61.
Cetirizine: a review of its use in allergic disorders.
Curran MP, Scott LJ, Perry CM.
Source
Adis International Limited, Auckland, New Zealand. demail@adis.co.nz
Abstract
Cetirizine is a selective, second-generation histamine H1 receptor antagonist, with a rapid onset, a long duration of activity and low potential for interaction with drugs metabolised by the hepatic cytochrome P450 system. Cetirizine was generally more effective than other H1 receptor antagonists at inhibiting histamine-induced wheal and flare responses. Cetirizine is an effective and well tolerated agent for the treatment of symptoms of seasonal allergic rhinitis (SAR), perennial allergic rhinitis (PAR) and chronic idiopathic urticaria (CIU) in adult, adolescent and paediatric patients. In adults with these allergic disorders, cetirizine was as effective as conventional dosages of ebastine (SAR, PAR, CIU), fexofenadine (SAR), loratadine (SAR, CIU) or mizolastine (SAR). This agent was significantly more effective, and with a more rapid onset of action, than loratadine in 2-day studies in environmental exposure units (SAR). In paediatric patients, cetirizine was as at least as effective as chlorphenamine (chlorpheniramine) [SAR], loratadine (SAR, PAR) and oxatomide (CIU) in the short term, and more effective than oxatomide and ketotifen (PAR) in the long term. Cetirizine was effective in reducing symptoms of allergic asthma in adults and reduced the relative risk of developing asthma in infants with atopic dermatitis sensitised to grass pollen or house dust mite allergens. It had a corticosteroid-sparing effect in infants with severe atopic dermatitis and was effective in ameliorating reactions to mosquito bites in adults. Cetirizine was well tolerated in adults, adolescents and paediatric patients with allergic disorders. In adult, adolescent and paediatric patients aged 2-11 years, the incidence of somnolence with cetirizine was dose related and was generally similar to that with other second-generation H1 receptor antagonists. Although, its sedative effect was greater than that of fexofenadine in some clinical trials and that of loratadine or fexofenadine in a postmarketing surveillance study. In infants aged 6-24 months, the tolerability profile of cetirizine was similar to that of placebo. Cetirizine did not have any adverse effects on cognitive function in adults, or cognitive function, behaviour or achievement of psychomotor milestones in paediatric patients. Cetirizine was not associated with cardiotoxicity. CONCLUSION: Cetirizine is well established in the treatment of symptoms of SAR, PAR or CIU. It demonstrated a corticosteroid-sparing effect and reduced the relative risk of developing asthma in sensitised infants with atopic dermatitis. Cetirizine was effective in the treatment of allergic cough and mosquito bites; however, its precise role in these indications has yet to be clearly established. On the basis of its favourable efficacy and tolerability profile and rapid onset of action, cetirizine provides an important option for the treatment of a wide range of allergic disorders.
