Transcript The British Guidelines on asthma management

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
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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
2003
2004
2005
2006
Glucocorticoids in croup:
key messages
• Based on Cochrane review (Russell et al updated 2004)
• Strong RCT evidence of benefit
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51 comparisons, 2,878 patients in placebo controlled studies
Settings: inpatient & outpatient, mild to severe
Outcomes: croup scores, other Rx, LOS, reattendance
• ↑ by 6 hours, ↓ reattendance/readmission/LOS/ Rx
• Most studies used dexamethasone
• Uncertainty about optimum dose (600 vs 150µg/kg)
• 600µg/kg dexamethasone single dose orally
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most studied & recommended
= ~ 5 days prednisolone for asthma
Nebulised budesonide an alternative, not an add on
Decreased consciousness
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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
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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
Core investigations
4.6mls total
Acute metabolic illness
Hypoglycaemia
Hyperammonaemia
Non-hyperglycaemic ketoacidosis
Hypoglycaemia
Main causes (excluding exogenous insulin):
• Severe sepsis
• Endogenous insulin excess
• Addison’s disease
• Growth hormone deficiency
• Congenital adrenal hyperplasia
• Fatty acid oxygen defects (eg MCAD)
• Organic acidurias
• Glycogen storage disorders
Hyperammonaemia
Main causes:
• Hepatic failure
• Organic acidurias
• Urea cycle enzyme defects
• Amino acid transport defects
• Reye’s syndrome
Non-hyperglycaemic
ketoacidosis
Causes to consider:
• Organic acidopathies
• Amino acidopathies (esp branch chain aminoacid disorders)
• Fatty acid oxidation defects
• Mitochondrial electron transport chain defects
• Urea cycle enzyme defects
• Circulatory shock
Intracranial infections
Consider if:
• Focal neurological signs
• Fluctuating consciousness for 6 hours or more
• Contact with herpetic lesions
• No obvious clinical signs pointing to cause
LP contraindications
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?
Recognising intrathoracic TB
Figure 3 Chest radiograph (anteroposterior
view) of a patient with lymph node disease.
Figure 4 Chest radiograph (lateral view)
of a patient with lymph node disease.
Marais, B J. ADC E & P (2006); 91: ep1
Copyright ©2006 BMJ Publishing Group Ltd.
‘Standard’ treatment for
pulmonary TB
isoniazid and rifampicin
pyrazinamide and ethambutol
2 months
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Recommendation grade:
• Adults (not HIV +ve)
• HIV +ve adults
• Children
Based on RCTs in adults
6 months
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B
B
Typically 3mls
blood needed
ESAT-6 (early secretion antigen target 6)
CFP-10 (culture filtrate protein 10)
New rapid diagnostic techniques
for latent TB
using interferon gamma tests
Not present in BCG, most environmental
non-TB mycobacteria
More specific than tuberculin skin tests
No ‘gold standard’ for comparison
How sensitive?
Does negative result rule out TB?
Different tests
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 12mg/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…
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How to provide specialist support
• BPSU 2004: In 55%, reporting paediatricians had 1 case
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Defining ‘area’ for universal vaccination of all infants
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Monitoring of TB incidence and making appropriate
changes to policy if >40/100,000 per year
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Making a selective policy work in low incidence areas
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Opportunistic screening and vaccination of older children
• Who, where and how?
Key messages
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Effectiveness of glucocorticoids in croup
Decreased consciousness
• Core investigations together
• Initial treatment of metabolic conditions, intracranial infections
• Contraindications to lumbar puncture
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Changes and challenges in TB
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Four drug regimen for treatment
Place of new interferon gamma tests
Steroids in TB meningitis?
Making selective BCG effective
Providing specialist support
Acknowledgements
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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