Presentation on theme: "Recent clinical guidelines relevant to paediatrics Dr Harry Baumer Consultant Paediatrician Derriford Hospital."— Presentation transcript:
Recent clinical guidelines relevant to paediatrics Dr Harry Baumer Consultant Paediatrician Derriford Hospital
Why me? General paediatrician, Plymouth Previous chair RCPCH QPC ADC guideline reviews since 2003 Not involved in guideline development Not an expert in the subjects! No conflict of interest
Choosing guidelines Rigorous evidence-based methodology Relevant to paediatricians Non-specialist’s perspective Important messages Likely otherwise to be overlooked
Guideline review topics Sweat test for CF Post seizure management Human milk banks Arterial stroke in childhood Otitis media (UK & US compared) Parapneumonic effusion/ empyema CFS/ME UTIs in young children Incomplete Kawasaki disease Glucocorticoids in croup Decreased consciousness Tuberculosis 2005 2004 2003 2006
Glucocorticoids in croup: key messages Based on Cochrane review (Russell et al updated 2004) Strong RCT evidence of benefit 51 comparisons, 2,878 patients in placebo controlled studies Settings: inpatient & outpatient, mild to severe Outcomes: croup scores, other R x, LOS, reattendance ↑ by 6 hours, ↓ reattendance/readmission/LOS/ R x Most studies used dexamethasone Uncertainty about optimum dose (600 vs 150µg/kg) 600µg/kg dexamethasone single dose orally most studied & recommended = ~ 5 days prednisolone for asthma Nebulised budesonide an alternative, not an add on
Decreased consciousness Nottingham Paediatric A&E research group Funded by Reye’s foundation Very broad scope Rigorous methodology Multiple literature searches Supported by Delphi consensus 134 recommendations, 20 Grade A or B Supported by detailed algorithm Not yet piloted
Decreased consciousness: scope Children with non-traumatic coma Aged <18 years, not in neonatal unit GCS <15 (not due to chronic disability) Differential diagnosis Immediate investigations Initial management
Key messages Core investigations undertaken together Acute management of metabolic conditions Initial management of intracranial infections Contraindications to lumbar puncture A normal CT does not exclude ↑ICP
NICE TB Guideline Published 2006 Covers adults & children together Paediatric input (Dr Delane Shingadia) Broad scope: “Clinical diagnosis and management of tuberculosis, and measures for its prevention and control.” Recommendations alone >2,500 words
NICE TB Guideline Key points for the non-specialist: 4 drug regime for active respiratory TB New rapid diagnostic techniques Use of steroids in TB meningitis Indications for BCG Who should manage children with TB?
‘Standard’ treatment for pulmonary TB Recommendation grade: Adults (not HIV +ve) A HIV +ve adults B Children B Based on RCTs in adults 6 months 2 months isoniazid and rifampicin pyrazinamide and ethambutol
ESAT-6 (early secretion antigen target 6) CFP-10 (culture filtrate protein 10) Not present in BCG, most environmental non-TB mycobacteria New rapid diagnostic techniques for latent TB using interferon gamma tests Typically 3mls blood needed Different tests More specific than tuberculin skin tests No ‘gold standard’ for comparison Does negative result rule out TB ? How sensitive? NICE: Mantoux first New tests if: Mantoux positive, or post BCG
TB meningitis “Patients with active meningeal tuberculosis should be offered… a glucocorticoid at the normal dose range: Adults: equivalent to prednisolone 20-40mg if on rifampicin, 10-20mg otherwise. A Children: equivalent to prednisolone 1- 2mg/kg, maximum 40mg. D(GPP) ”
TB meningitis Based on Cochrane review from 2000 6 RCTs of glucocorticoids ↓ mortality ↓ death or severe disability ↓ mortality in children But… Small studies Poor allocation concealment Publication bias Cochrane review withdrawn Jan 2006
NICE TB Guideline Role of BCG in TB control Drs Teo & Shingadia, ADC 2006; 91: 529-531 New guidelines July 2005 Joint Committee on Vaccination & Immunisation Routine school BCG discontinued Vaccination of children at higher risk Depends on local incidence of TB (≥40 per 100,000/year)
Who should manage children? “Either a paediatrician with experience and training in the treatment of TB, or a general paediatrician with advice from a specialised physician. If these arrangements are not possible, advice should be sought from more specialised colleagues throughout…”
Challenges… How to provide specialist support BPSU 2004: In 55%, reporting paediatricians had 1 case Defining ‘area’ for universal vaccination of all infants Monitoring of TB incidence and making appropriate changes to policy if >40/100,000 per year Making a selective policy work in low incidence areas Opportunistic screening and vaccination of older children Who, where and how?
Key messages Effectiveness of glucocorticoids in croup Decreased consciousness Core investigations together Initial treatment of metabolic conditions, intracranial infections Contraindications to lumbar puncture Changes and challenges in TB Four drug regimen for treatment Place of new interferon gamma tests Steroids in TB meningitis? Making selective BCG effective Providing specialist support
Acknowledgements Glucocorticoids in croup Cochrane reviewers Kelly Russell Terry Klassen David Johnson et al Decreased consciousness guideline development group (Nottingham Paediatric A & E Research Group) Richard Bowker Terence Stephenson Maria Atkinson Monica Lakhanpaul Ian Maconochie Harish Vyass NICE TB Delane Shingadia
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