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Wheeze

Common, General paediatrics, Respiratory

US and elsewhere use “bronchiolitis” to mean wheezing illness!  So beware definitions in studies.

Early aeroallergen sensitization predictive of ongoing symptoms and loss of lung function at school age, but does not predict response to treatment with inhaled corticosteroids (ICS)!

European Resp society task force diferentiate Episodic Viral Wheeze (EVW) from Multiple trigger wheeze (MTW) viz exercise, smoke, allergens.  Children may change categories over time.  Guides treatment.  But note that few RCTs have used this classification, and tend to conflate.

MTW is associated with more airflow obstruction, and the pathology (eosiniphilic inlfammation and remodelling) similar to asthma.  Eosiniophilic inflammation not seen in EVW.

Several clinical indices which attempt to predict future asthma – PPV generally under 50%.  Kids with EVW only have no increased risk of respiratory symptoms once they reach age 14.

No evidence that early ICS (intermittent or continuous) affects progression of disease.  [N Engl J Med 2006;354:1985-97 PMID 16687711]

Parental smoking linked to wheeze, asthma, bronchitis and nocturnal cough, with mean odds ratios all around 1.15, with independent effects of prenatal and postnatal exposures for most associations (PATY study (Pollution And The Young), n=53 879 children from 12 cross‐sectional studies).   “Not in front of the children” does not protect from effects [Jenny Pool, Cambridge – Thorax 2012;67:926]: 88% of children from families where parents only smoke outside still have detectable urine cotinine.  Nicotine levels in household dust and on surfaces is at least 3x higher in homes where parents smoke indoors, but still 5-7x higher in homes where parents smoke outside cf non-smoking houses [Tob Control 2004;13:29-37 doi:10.1136/tc.2003.003889].  Air pollution increases vulnerability to preschool wheeze, but no specific advice on individual exposure.

PREEMPT study of intermittent montelukast (1 week with onset of URTI) for EVW vs placebo reduced unscheduled consultations for asthma, days away from sc hool/nursery, parental time off work.  [Australia, Am J Respir Crit Care Med. 2007 Feb 15;175(4):323-9.] Similar findings from a US study, but not supported by much larger WAIT study, 3 way study of intermittent vs continuous montelukast vs placebo [Nwokoro, Lancet Respir Med. 2014 Oct;2(10):796-803. doi: 10.1016/S2213-2600(14)70186-9].  But “5/5 ALOX5 promoter genotype might identify a montelukast-responsive subgroup”? Discontinue when child is better, not after specified number of days!

Cochrane supports intermittent ICS for wheeze, but only due to small studies with unlicensed doses eg fluctic 750mcg BD!  No studies of combined ICS/montelukast.

No evidence for prophylactic continuous ICS, but studies looked at mild rather than severely affected children.   Could be tried if repeated hospital admission, in case interval symptoms underappreciated!  Beware growth suppression, review and wean/stop if able.

Hospital study of pred vs placebo (n=687) found no benefit!  SImilar study in primary care.  SO should not be automatic, esp when anticipated duration of admission less than 24 hours.

No evidence for treatment plans for preschool wheezers!

BMJ 2014;348:g15 Andrew Bush

Advisory labels

Allergy, General paediatrics, Immunology

Or precautionary allergy labelling.

What are Precautionary allergy labels?

These are extra bits of information sometimes provided on labels, in addition to the actual ingredients.  Phrases like “May contain…”, “Made in a factory where…”.  These precautionary allergy labels are not legally required, but manufacturers are encouraged to use them to warn their customers of a risk of accidental contamination during the production process.  The Food Standards Agency  (FSA) (2006) encourages manufacturers to be as precise as possible eg which specific nut, or else peanut or “tree nuts” rather than just “nuts” but in reality different companies do different things eg Kelloggs does not differentiate between peanut and tree nuts when they put a warning label on about nuts.

Is there a real risk or not?

Contamination of chocolate is a particular problem, particularly with nuts, and with milk in the case of dark chocolate.  In some studies, half of all the chocolate tested was contaminated.

But most foods carrying such a label will not contain any of the allergen mentioned, indeed it is sometimes hard to imagine how it possibly could!  In an Irish study looking at foods labelled marked “may contain peanut/nut”, 5% had detectable peanut or nut, which is a significant proportion but actually the peanut or nut was present at such low levels they would be unlikely to cause a reaction in the majority of allergic people.

Aren’t they just a way of avoiding legal liability?

The FSA clearly state that these labels should only be used where there is a real and unavoidable risk.  And in any case, it’s not clear it changes the company’s legal responsibilities – if there is evidence that a manufacturer has been producing food in an unsafe manner, they would be liable regardless of whether there was a warning or not.

When is a trace not a trace?

The idea of threshold is important – how much of the allergen is actually present, and is it even enough to cause a reaction?  Not everyone reacts at the same threshold, and the differences between individuals can be a factor of ten or even a hundred.

In big study of peanut challenges in kids, those who got through to last stage were 13x more likely to have anaphylaxis (related to total amount of peanut consumed, presumably). Higher thresholds found in older kids, perhaps because they would have presented earlier if they had lower threshold? [PAI 2018 vol 29:754-761]

Australia and New Zealand ask manufacturers to look at actual levels of contamination before putting a warning on their products.

In the UK and Europe, the risk associated with the processes is what matters, rather than the actual levels of contamination. It’s not clear which is actually more useful.

So what should you do about traces?

Many people tend to ignore these warnings, particularly when it is something they have eaten many times before, or when it is a big brand name, and when the wording is ambiguous rather than direct.  Yet there is no good evidence that any of these things actually makes a difference to the real risk.

What is definitely true is that people have unexpected reactions and this can be after eating things marked with these warnings, but equally after eating things without these warnings.

What is also true is that allowing yourself to eat things marked with these warnings makes life much simpler!

Some patient organizations eg Anaphylaxis Campaign recommend avoiding anything marked with precautionary allergy labels, if only because this puts the control in your hands rather than leaving you at the mercy of the manufacturers.

Doctors often recommend avoiding anything with an allergy warning, because it “seems” safer and they don’t appreciate how difficult it is in day to day life.

So I think you have to make your own choice.  If you have a nut allergy, and it’s chocolate or something else that often does contain nuts eg a muesli bar, then to me the risk seems too much.  It it’s something that wouldn’t usually contain nuts, and you’ve had it before, and you’re at home with your family, then maybe the risk is acceptable to you.  But if you are away on holiday, and you’ve forgotten to bring your allergy medicines, and your asthma is playing up, and it’s late at night, then that’s probably the worst time to take a chance.    

[https://www.food.gov.uk/business-guidance/allergen-labelling-guidance-for-food-manufacturers]

Plantar warts

Common, Dermatology, General paediatrics

2/3 resolve within 2 years.  In young children, higher spontaneous clearance.  In systematic review, only salicylic acid and aggressive cryotherapy seem to be effective.  Both are user dependent.  In RCT between the 2 and conservative management, no difference detectable after 13 weeks.  So watch and wait, unless causing a lot of pain.

Perianal warts can be transmitted vertically from mother at birth, or potentially from carers changing nappies.

Warticon cream is podophyllotoxin. Else Condyline paint.

Risk factors of allergy

Allergy, General paediatrics, Immunology

Children reported to have taken antibiotics during infancy (0-2yrs) were more likely to have asthma at 7.5yrs, with a dose response pattern.  No association between antibiotic use and atop on skin prick testing however!  Hoskin-Parr, Ped All Imm 2013;24:762 (Avon longitudinal study)

 

At 18/12 of age, babies born by SVD and whose parents suck their dummy are 2.5x less likely to have eczema than those born by LSCS whose parents do not suck their dummies.  Germany/Sweden, Peds 2013;131:e1829

 

Children born outside of US much less likely to have allergic disorder (OR 0.48), although those who have lived in US for 10+yrs have higher odds of eczema and hay fever cf those who have lived in US under 2 years.  But not clear whether children moved from developing or developed country.  Ped 2013;167:554

 

Inverse dose response effect between food diversity in infancy and asthma (OR 0.74).  26% reduction in asthma for every additional item of food added in the first year of life.  Increased risk of food allergy by age 6yr (OR0.7), but no longer statistically significant after excluding children with food allergy in the first year of life.  European cohort, JACI 2014;133:1056

Prognosis of type 1 diabetes

Endocrinology, General paediatrics,

Life expectancy now into 70s.  Rates of diabetic nephropathy have fallen over the last few decades, and progression is dramatically reduced thanks to prevention and treatment strategies.  Cancer and not CVS disease is now the main cause of death!  Survival seems to be as much about dealing with obesity, insulin resistance, hypertension and arterial disease – as you would for type 2.

Food allergy labelling

Allergy, General paediatrics, ,

The UK still currently follows the European Food Information For Consumers Regulation (FIR) that took effect from December 2014.

This applies to unpackaged food eg restaurants, takeaway’s deli’s, bakeries etc. It now also applies to food prepacked for direct sale (PPDS) such as a sandwich made on the premises of a cafe but wrapped (Natasha’s law).

Allergy advice boxes are no longer permitted, although “may contain” advisory labels are. The allergen should be emphasised in the ingredients panel through typeset eg font, style, colour.   The specific type of cereal or nut must also be stated.

The 14 allergens that must be highlighted under UK/European law are: cereals containing gluten (wheat, barley, rye etc), crustaceans (eg shrimp, prawn), molluscs (eg mussel, oyster), eggs, fish, peanuts, nuts, soybeans, milk, celery, mustard, sesame, lupin and sulphur dioxide at levels above 10mg/kg, or 10 mg/litre, expressed as SO2. Lupin and Molluscs added later.

There are some exceptions, where the food is so highly processed that they are no longer capable of triggering an adverse reaction eg fish gelatine in beer/wine, soya in vegetable oil.

If your allergy is not one of those listed, eg lentil, there is no legal duty for the manufacturer to highlight the presence of that ingredient, or for the restaurant to provide a full list of ingredients.  So you need to read the full list of ingredients carefully, and plead with the restaurant for details relevant to your allergy. In the past, some manufacturers highlighted allergens in a separate box, but this is no longer permitted.

The rules list nuts as:

  • almond,
  • hazelnut,
  • walnut,
  • cashew nut,
  • pecan nut,
  • Brazil nut,
  • pistachio nut,
  • macadamia nut or Queensland nut
  • and products made from these nuts.

Other types of nuts, and other foods which are not nuts (even though they are called nuts i.e. chestnuts, pine nuts and coconut), are not named in the rules, even though they are known to cause allergy in some people.

Note that by law, “cereals containing gluten” includes oats! Spelt and Kamut should be declared as containing wheat. Oats contain avenin, rather than gliadin, but related. Products containing oats that have not been contaminated by wheat can be declared “gluten free” by law, so effectively the law considers oats as both containing but not containing gluten…

See also Advisory labels.

(food.gov technical guidance on new labelling law)

There is no legal duty to highlight changes in recipes on packaging.  The same product with the same packaging can sometimes have different ingredients, depending on where it is produced.

The Food Standards Agency (FSA) has ordered councils to encourage restaurant owners to check their ingredients.

Note that non-EU countries will have their own rules eg US has only 10 ingredients that must be highlighted (not molluscs, mustard, celery, or lupin).

Lymphadenopathy

Clinical, Common, General paediatrics, Haem/Oncology, Infectious disease

A good proportion of healthy children will have palpable lymph nodes in the neck.  Mostly these will be under 1cm in diameter.  Acute enlargement as part of an upper respiratory tract infection is usually accompanied by tenderness, and affected nodes will reduce in size over 4-6 weeks.

Guidance from NICE and the Scottish Government provide criteria when children with lymphadenopathy should be urgently referred for suspected cancer.

These criteria include the following:

  • lymph nodes are non-tender and firm/hard
  • lymph nodes are greater than 2 cm in size
  • lymph nodes are progressively enlarging
  • other features of general ill-health, fever or weight loss
  • the axillary nodes are involved (in the absence of local infection or dermatitis)
  • the supraclavicular nodes are involved.

But caveat is “Always refer any patient with Repeat presentations (3 or more times) of any physical symptoms which do not appear to be resolving or following a normal pattern, taking into account parental and patient concern”.

No need to do bloods in the absence of any of these criteria. Not that cancer is the only concern – differential includes developmental lesions (branchial cysts etc), TB, Cat-scratch disease, non-tuberculous mycobacterial infection (esp in neck).  These are always more than 2cm and there may also be systemic features and/or overlying skin discolouration too.

Malignancies often present in the head/neck region.  Hodgkins lymphoma usually affects teenagers, Non-hodgkins tends to affect school age children, neuroblastoma tends to affect pre-school children.  B-symptoms (recurrent fever, weight loss, night sweats, pruritus, lethargy) are only seen in a minority but does suggest more advanced disease, of course.  Airway or voice changes, swallowing difficulty, Horner’s syndrome, superior vena cava syndrome may all be seen due to mass effect. Most neuroblastomas have an abdominal mass.  Nasopharyngeal carcinomas are seen so look in the nose/throat.

Do not resuscitate

Ethics, Generic

The DNR question makes parents feel that their child’s right to life, and quality of life are being questioned. Do it once, then leave it alone. Parents can agree in what circumstances it should be asked again.

Beware self fulfilling prophecies – if you are pessimistic, you may limit what they may achieve in future.

There is no such thing as false hope. Hope is today’s dream for tomorrow, it helps you keep going, putting one foot in front of the other.

Parents have needs too. Helps when professionals presume things will get better, when they acknowledge patient is beautiful, happy, loved; when they are pleased with progress, when they share good news as well as bad.

Careful with words in front of parents and siblings eg end of life pathway, dysmorphic, lethal condition.

The discipline of medicine concerns the manipulation of knowledge under uncertainty (Siddharta Mukherjee).

“When you consider that CPR would be futile for a patient dying from a terminal illness in hospital, there is no need to distress the patient with a discussion about CPR before completing the DNACPR form.”

This was considered appropriate advice until June 2014.  Patients cannot demand futile treatment and so, if the decision has been made not to resuscitate, asking the patient’s views could lead to difficulties if he/she wanted cardiopulmonary resuscitation. In addition, if handled badly, the patient may be left with the misunderstanding that a life-prolonging treatment was being withheld.

In landmark judgement re: Janet Tracey, who had terminal lung cancer, Lord Dyson said the hospital trust violated Mrs Tracey’s right to respect for her private life under Article 8 of the European Convention of Human Rights when they placed a DNR order in her notes without informing her.

“Doctors have a legal duty to consult with and inform patients if they want to place a Do Not Resuscitate (DNR) order on medical notes.  A DNR decision is one which will potentially deprive the patient of life-saving treatment, so there should be a presumption in favour of patient involvement.  There need to be convincing reasons not to involve the patient. Doctors should be wary of being too ready to exclude patients from the process on the grounds that their involvement is likely to distress them”.  June 2014

Relatives of patients should never be asked to make decisions about resuscitation status, but it is good practice to take the opportunity to inform them if a patient is known to be dying. Relatives cannot make treatment decisions unless they have legal powers to do so. Even then, they cannot demand treatment that is considered futile by medical staff. However, if a DNACPR order is written, it may offer an opportunity to inform them (and the patient if appropriate) that the patient is expected to die soon and that active care may continue but will stop short of CPR.

Carl Winspear case 2011 – High court held DNACPR wrote at 3am without consulting family was breach of human rights. Phone call would have been “practicable” albeit inconvenient. The defence that it was a clinical decision declared a “misunderstanding as to the purpose of the consultation… Input into decision making process… Dignity… Family can take on board and respond to news”

When a patient is being discharged home to die, patient and carers should be informed and in agreement with a DNACPR order as the paperwork will be kept in the house and could be discarded if not understood or wanted by the family. If at all possible, a DNACPR order should follow the patient home when death is expected. The existence and benefits of the order should be explained to the patient (if lucid and mobile) and carers, as it will most likely be seen by them and could cause distress if not known about in advance. It will only be effective if accepted by those caring for the patient, as they would be responsible for calling for emergency assistance or not in the event of death.

It should be remembered that the decision not to resuscitate is one for the medical team or the patient, but not the relatives. However, asking for a patient’s agreement with a DNACPR decision already made may cause unnecessary distress. Good, sensitive communication about end-of-life issues is important and may be prompted by a DNACPR order. The issue of time and skills needed to do this is acknowledged and the need for further clarity and discussion is apparent.

Allow Natural Death – preferable terminology?

E-patients

Generic, Patients,

See also Expert patients. E-patients – (Wikipedia) use internet on behalf of themselves or others to get information about medical  conditions.  Tom Ferguson white paper.

  1. E-patients are valuable healthcare resources, and should be recognized as such.
  2. Empowerment is trickier than you might think.  Knowledge may increase but improvements in anxiety, self efficacy, changes in behaviour do not always follow. Patients often know more than doctors realize, they often want to know about things doctors don’t have the answers to (or would avoid answering), and they often want to pass things on to other patients or give feedback to their doctors [Diana Forsythe, medical anthropologist].
  3. Patients can quickly know more about a condition than their doctor.
  4. Hazards of imperfect online health information prob exaggerated. Cf medical errors!
  5. Wherever possible, healthcare should be provided on patient’s “turf”
  6. Clinicians can no longer go it alone
  7. The most effective way of improving health care is collaboratively

In the outside world, a diagnosis (esp a rare one) can seem like a world upturning misfortune that sets you apart.  Online, it is a badge of honour that connects everyone together.

Angela Coulter – paternalism in health care – clinicians underestimate how intimidating the clinical encounter is, patients fear offending their clinician if they assert themselves or offer an agenda.  Clinicians are often unaware of the constraints that prevent patients asking questions in clinic.  Clinicians often believe patients need to be protected from the truth eg uncertainties, bad news.  Patients can often be left feeling inept, diminishing their sense of control.  Paternalistic clinicians often seen as unsympathetic or arrogant, refusing to accept ideas or suggestions.

Try:

  • What do you want to make sure we discuss today?
  • What needs to happen today to make this visit feel successful?

Patient feedback –  can sometimes lead to poor morale – positives need to be celebrated.   Confidentiality must be assured for feedback to be meaningful.