Dr Paula McQueen New Cons in Paed Allergy

Dr Ozan Hanci New Cons in Paed Gastro 3 new cons posts To be interviewed on 5/11/15 New CDC consultant BC in preparation Merger with ASPHSummer / autumn 2016

New Developments in Paediatrics at the Royal Surrey since 1st April 2014

Constipation Recurrent abdominal pain Gastro-oesophageal reflux Cow’s milk protein allergy Eczema Immunisations Urinary tract infections Nocturnal enuresis

Common paediatric conditions which seldom require hospital referral

Antisocial behaviour and conduct disorders Atopic Eczema Attention Deficit Hyperactivity Disorder Autism diagnosis in children & young people Bedwetting (nocturnal enuresis) Bronchiolitis Children & young people with cancer Constipation Diabetes (types 1 & 2) in children

NICE Guidelines for Children

Diarrhoea & vomiting Drug allergy Epilepsy diagnosis & management Feverish illness Food allergy Gastro-oesophageal reflux Immunisations Looked after children Managing overweight & obesity in children

Neonatal Jaundice Preventing injuries among the under-15s Promoting physical activity for children Reducing substance misuse Social & emotional wellbeing Spasticity in children Surgical management of CSOM Urinary tract infection When to suspect child maltreatment

NICE Guidelines for Children

Chronic Constipation in Children

Dr Mark EvansConsultant Paediatrician

Royal Surrey County Hospital

Common problem in children (5-30%) Usually functional, rarely due to an organic cause Can usually be managed in General Practice NICE Guidelines available (QS62) Use oral macrogols as first line treatment May need disimpaction followed by maintenance

Rx Treat for 3 months before specialist referral Watch out for Red Flag signs needing referral

Chronic Constipation

Which children require referral for specialist advice ?

Delayed passage of meconium (> 48 hours) Symptoms starting in the first 4 weeks of life Ribbon-like stools (more likely in infants) Abdominal distension with vomiting or FTT New onset of weakness in lower limbs Disclosure suggesting Child Abuse Poor response to Rx for > than 3 months

Chronic Constipation

Unusual organic causes

Coeliac Disease Cow’s Milk Protein Allergy Hypothyroidism Hypokalaemia Hypercalcaemia Neurological problems Peri-anal Streptococcal Infection

Chronic Constipation

Investigations that can be done in General Practice

FBC & Film U&E’s TFT’s Bone profile Coeliac serology IgE and RAST to food mix Peri-anal Swab

Chronic Constipation

Recurrent Abdominal PainDr Mark Evans

Consultant PaediatricianRoyal Surrey County Hospital

Common problem in children (25%) Usually functional, rarely due to an organic

cause Can usually be managed in General Practice NICE Guidelines not yet available Reassurance is the main management May need to exclude an underlying organic

cause Watch out for Red Flag signs needing referral

Recurrent Abdominal Pain

Which children require referral for specialist advice ?

Pain associated with weight loss or chronic diarrhoea

Pain associated with significant rectal bleeding Pain associated with bile-stained vomiting Abnormal investigation results Chronic symptoms lasting for > 3 months Children who are missing a lot of school

Recurrent Abdominal Pain

Investigations that can be done in General Practice

FBC & Film ESR & CRP U&E’s, LFT’s, bone profile, amylase Coeliac serology, IgE & RAST to mixed foods MSU & Stool for m/c/s, H pylori Ag & faecal

calprotectin Plain abdominal x-ray Abdominal / pelvic ultrasound scan

Recurrent Abdominal Pain

Treatment of RAP in General Practice

Reassurance +++ (if no Red Flags) Basic investigations as discussed previously Movicol if constipation suspected or proven on AXR Pizotifen 1 – 1.5 mg OD if abdominal migraine

suspected Omeprazole 10 – 20 mg OD if acid reflux suspected CAMHS referral if psychological factors suspected Paediatric referral if symptoms > 3 months

Recurrent Abdominal Pain

Cow’s Milk Protein AllergyDr Mark Evans

Consultant PaediatricianRoyal Surrey County Hospital

Common problem in infants & children Can usually be managed in General Practice Often a self-limiting condition resolving by 4

yrs Prescribing guidelines for milks widely

available May need to exclude an alternative organic

cause Watch out for Red Flag signs needing referral

Cow’s Milk Protein Allergy

CMP Allergy affects 2 – 8 % of all babies Gastro-intestinal symptoms occur in 60 – 80

% Can also present with skin & respiratory

symptoms Sometimes presents with pr bleeding in

infants Often resolves spontaneously by 3 – 4 years

of age Hydrolysates should be used as 1st line

treatment Amino-acid formulas should reserved for

severe cases

Cow’s Milk Protein Allergy

Treatment of CMPA

Many different types of ‘special milks’ Note new prescribing guidelines on the G & W web-site Start with a hydrolysate such as Aptamil Pepti 1 or 2 Only use amino-acid based formulas if above

ineffective Do not use soya / goat’s milk / sheep’s milk, etc Coconut milk or oat milk can be used > 12 months Do not use rice milk < 4 years (contains arsenic)

Cow’s Milk Protein Allergy

Which children need referral for specialist advice ?

Babies with ‘failure-to-thrive’ (weight loss > 2 centiles) All infants on a CMP-free diet should have dietetic input Rectal bleeding in infants unresponsive to 1st line Rx Any children not responding to Rx with hydrolysates Children with CMPA as part of multiple food allergies CMP complicating Coeliac disease in older children Children requiring a CMP challenge under supervision

Cow’s Milk Protein Allergy

Useful References

Guildford & Waverley Prescribing Web-Site NICE Guidelines on Food Allergy in Children

(2011) MAP Guidelines for Rx CMPA in General

Practice (2013) Venter et al - Clinical & Transitional Allergy

2013 3:23

Cow’s Milk Protein Allergy

GO Reflux in ChildrenDr Mark Evans

Consultant PaediatricianRoyal Surrey County Hospital

Common problem in infants & children Usually functional, rarely due to an organic

cause Can usually be managed in General Practice NICE Guidelines now available (published Jan

2015) Reassurance is the main management May need to exclude an underlying organic

cause Watch out for Red Flag signs needing referral

GO Reflux in Children

Which children need referral for specialist advice ?

Projectile vomiting in the early weeks of life Bile-stained vomiting at any age Vomiting associated with significant

haematemesis Vomiting with ‘failure to thrive’ or chronic

diarrhoea Symptoms unresponsive to conventional anti-

reflux Rx Late onset or persisting beyond 12 months of

age

GO Reflux in Children

Treatment of GO Reflux in Infants

Review the feeding history and advise as appropriate Use a feed thickening agent or Infant Gaviscon 4 week trial of H2RA (ranitidine) at 2 mg / kg / tds OR 4 week trial of PPI (omeprazole) at 1-2 mg / kg / od Domperidone and erythromycin not recommended Consider using a hydrolysate in case of CMP allergy

GO Reflux in Children

Bronchiolitis – new NICE guidelines (June 2015)

Dr Mark EvansConsultant Paediatrician

Royal Surrey County Hospital

1.1 Assessment and diagnosis 1.2 When to refer 1.3 When to admit 1.4 Management of bronchiolitis 1.5 When to discharge 1.6 Key safety info for home management

Bronchiolitis – new NICE guidelines

Consider urgent referral if any of the following :-

apnoeic episodes (observed or reported) child looks seriously unwell to HC professional severe respiratory distress (respiratory rate > 60) child is centrally cyanosed O2 saturations are < 92 % breathing room air inadequate feeding or clinical dehydration secondary risk factors (prematurity, CLD, CHD)

Bronchiolitis – new NICE guidelines When to refer to hospital

Tell parents & others not to smoke in the family home

Ask parents to seek urgent help if any ‘red flag’ signs

Ensure parents can recognise red flag signs:- apnoea or cyanosis (phone 999) worsening work of breathing (rate, grunting,

recession) fluid intake < 75 % of normal or no wet nappy

for 12 hrs exhaustion (poor interaction, not waking for

feeds)

Bronchiolitis – new NICE guidelines Key safety info for managing at home

Check the Tissue Transglutaminase (TTG) antibody

If TTG ab < 10 on a gluten-containing diet - watch & wait

If TTG ab > 10 but < 200 - refer for HLA typing & biopsy

If TTG ab > 200 (and HLA DQ2 or DQ8 positive) - treat

Diagnosing Coeliac Disease – ESPGHAN criteria (2012)

Any Questions ?