1.  Dr Paula McQueenNew Cons in Paed Allergy  Dr Ozan HanciNew Cons in Paed Gastro  3 new cons posts To be interviewed on 5/11/15  New CDC consultantBC in preparation  Merger with ASPHSummer / autumn 2016 New Developments in Paediatrics at the Royal Surrey since 1 st April 2014

2.  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

3.  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

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

5.  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

6. Chronic Constipation in Children Dr Mark Evans Consultant Paediatrician Royal Surrey County Hospital

7.  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

8. 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

9. Unusual organic causes  Coeliac Disease  Cow’s Milk Protein Allergy  Hypothyroidism  Hypokalaemia  Hypercalcaemia  Neurological problems  Peri-anal Streptococcal Infection Chronic Constipation

10. 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

11. Recurrent Abdominal Pain Dr Mark Evans Consultant Paediatrician Royal Surrey County Hospital

12.  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

13. 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

14. 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

15. 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

16. Cow’s Milk Protein Allergy Dr Mark Evans Consultant Paediatrician Royal Surrey County Hospital

17.  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

18.  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 1 st line treatment  Amino-acid formulas should reserved for severe cases Cow’s Milk Protein Allergy

19. 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

20. 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 1 st 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

21. 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

22. GO Reflux in Children Dr Mark Evans Consultant Paediatrician Royal Surrey County Hospital

23.  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

24. 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

25. 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

26. Bronchiolitis – new NICE guidelines (June 2015) Dr Mark Evans Consultant Paediatrician Royal Surrey County Hospital

27.  1.1Assessment and diagnosis  1.2When to refer  1.3When to admit  1.4Management of bronchiolitis  1.5When to discharge  1.6Key safety info for home management Bronchiolitis – new NICE guidelines

28. 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

29.  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

30.  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)

31. Any Questions ?