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Bronchiolitis treatment

General paediatrics, Respiratory

NICE guidance updated 2021.

Essentially supportive.  Oxygen, feeding, respiratory support if necessary.  Beware secondary bacterial infection, lobar collapse, pneumothorax, concomitant UTI.

Hypertonic saline

Not recommended by NICE. Cochrane 2010, patients treated with nebulized 3% saline had a significantly shorter mean length of hospital stay compared to those treated with nebulized 0.9% saline (MD -1.16 days, 95% CI -1.55 to -0.77, P < 0.00001).   No significant adverse events related to 3% saline inhalation were reported.  Not recommended for emergency departments as 2 doses didn’t seem to affect clinical scores.

But subsequent studies less impressive.  SABRE trial randomized 317 infants to 3% hypertonic saline nebulised every 6 h from admission compared with nothing (ie, standard care). No difference between the two arms of the study in time to discharge [Legg and Cunningham, Arch Dis Child 2015;100:1104-1105].

But AAP guidelines recommend nebulized hypertonic saline for infants hospitalized with bronchiolitis, with the expectation of reducing bronchiolitis scores and length of stay when it is expected to last more than 72 hours. Some think potentially an advantage for hypertonic saline in reducing admission rates from the emergency department [DOI: 10.5863/1551-6776-21.1.7]

High Flow

Franklin study of early high flow oxygen use – babies were randomized as soon as they needed oxygen.  Not generally what happens, of course.

  • Outcome was “escalation of care” ie signs requiring further intervention eg tachycardia, hypoxia. Intervention was high flow, of course.  Rate was 23%, but nearly a third of these did not meet the prespecified criteria (so doctor just decided they “needed” high flow anyway).
  • In sites without PICU, 28% of standard therapy group required escalation of care.  This is way in excess of the rate we would report in our unit.
  • No differences in length of stay or duration of O2 therapy.
  • Of 167 who “failed” on standard care, 61% responded to high flow.
  • No age effect.

So it seems to me that if you have facility to do high flow, you will find that at least a quarter of your oxygen dependent bronchiolitis babies “need” it.  I’m not sure this is a useful or meaningful study.  Babies may be more comfortable on high flow, and you may prevent the odd ICU admission, which is definitely worth considering. [N Engl J Med 2018 Mar 22;378(12):1121-1131.]

BIDS study

A study to see if safe to discharge babies with less than normal saturations.  RCT of 308 infants, no need to admit if sats >92% AND >50% feed requirements.

For those needing admission, start oxygen only if <90%, and only discharge once sats >90% continuously over 4hr period including sleep, and taking >75% feeds! Exclude babies with risk factors (<3/12, ex-prem, CLD etc– should have sats >92%)

Compared with standard pulse oximeter parameters (treat <94%), no difference in adverse events eg high dependency, readmission.  Excluded prems, recent oxygen therapy, CF or other chronic lung disease, immune deficit. [Edinburgh, Steve Cunningham, Lancet 2015; 386: 1041–48]

Study in emergency departments (n=213) found that babies discharged with artificially raised saturations (+3%) actually were less likely to be readmitted than babies with true oxygen saturations, suggesting that it’s a poor predictor (probably true for other respiratory conditions, too).

Combined bronchodilator and steroids

One study found better outcomes with neb adrenaline and systemic steroids but subgroup analysis and not adequately powered.

Immunotherapy

Allergy, General paediatrics, Immunology, , ,

First described in the literature in 1908! For egg. Noon and Freeman described grass immunotherapy in 1911. First double-blind trial was by William Frankland in 1954 for subcutaneous grass immunotherapy for seasonal asthma.

Should always be done with extreme caution, if at all, if asthma.  Available for wasp/bee stings, grass and tree pollen.  Lots of evidence for food allergies, especially in younger children eg peanut immunotherapy.  House dust mite sublingual now approved by NICE for resistant allergic rhinitis.

Some evidence that immunotherapy for rhinitis also prevents asthma, which fits with “one airway” hypothesis.

Immunotherapy should be initiated and monitored in a specialist centre experienced in immunotherapy.

Text message reminders doubles adherence – even non-personalised.

Immunomodulation with omalizumab appears to improve success rates of immunotherapy. Treatment with dupilumab (anti-IL4/13) reduces specific IgE levels in people with atopic dermatitis (clinical effect unknown just now).

Grass/pollen allergy

EAACI indications for rhinoconjunctivitis immunotherapy includes:

  • mild rhinitis for reasons of asthma control.
  • Moderate-severe symptoms.

Bad asthma and poor compliance are contraindications. Bad asthma was an exclusion criterium for most of the studies, so no evidence of safety.  Poor evidence for under 5yrs (for HDM).

Polysensitization common, US tend to to treat all, Europe tends to pick 1 or 2 most useful, at intervals. 17 fatalities to date with immunotherapy. 1 per million injections (risk with sublingual much less, even though used for higher risk patients). Large local reactions common but don’t predict further reactions. Risk of systemic reaction only increased if recurrent. Consider predosing with antihistamine, else reduce dose.

Sublingual immunotherapy (SLIT) in children aged 4 to 12  years with grass pollen-allergic rhinitis/rhinoconjunctivitis significantly  reduced symptoms and medication use, well tolerated, and no serious treatment-related  events were reported. [Journal of Allergy & Clinical Immunology.  130(4):886-93.e5, 2012 Oct.]

In metanalysis by Dhami S et al, overall standardized mean difference (SMD) of -0.53 (95% CI -0.63, -0.42) in symptoms scores, roughly equal numbers of SCIT and SLIT studies, roughly equivalent scores.  When looking just at children, benefit seems less (SMD -0.25 (95% CI -0.46, -0.05)).  Continuous treatment probably slightly better than pre/co-season treatment.  Manufacturers suggest “disease modifying effect” of treatment beyond first year, which has theoretical rationale.  Four studies of long term outcome, demonstrates continuing benefit if treatment continued beyond first year [Allergy 2017]. 

Grazax (grass) can be safely administered by general practitioners (£80 per month, licensed from 5yrs up): tablet needs to be kept under tongue for at least 1 minute, first dose should be monitored by doctor for 20 minutes.  Don’t eat or drink for 5 minutes.

Give antihistamines for local effects. Oral blistering occurs!  Isolated cases of eosinophilic oesophagitis but impossible to link of course.

Contains fish gelatine but no reported problems in those with fish allergy.  Severe asthma contraindication (in children, defined as <80% predicted FEV1 on treatment).

Aim to start 4 months before season starts, although still some benefit if started 2-3 months before.  If no benefit in first season, no point continuing (according to Grazax own SPC).

Symptom relief begins only in the second season of therapy?  BNFc says continue only for 3 yrs.  Not approved by SMC for Scotland, because no great evidence for benefit after first year – would need individual patient treatment request.  Rosie says children wouldn’t tolerate daily doses for months and years.

Pollinex subcut, given into middle third of upperarm.  2 versions: Trees, and 13 grasses incl rye. 3 injections at 7-14 day intervals each year (£450 each), before season starts.  Maintenance kit of 4 vials also available, presumably if additional benefit thought possible.  Manufacturer recommends using for 3 successive years. Asthma and beta blocker treatment are relative contraindications.  Age 6+, not in SMC at all. [Metanalysis, Chest 2008; 133:589, Journal of Allergy & Clinical Immunology. 115(4):676-84, 2005 Apr.]

Some evidence for short course – in multicentre study of adults (not UK) with grass mix SPT positive rhinitis, 8 subcutaneous injections of placebo or Lolium perenne (LPP) were administered in 4 visits (2 jabs each visit, 30 mins apart, different arms) over 3 weeks between January and April. Combined symptom and medication score (CSMS) measured over the peak pollen season was reduced 15.5% (P = .041) during the peak period and −17.9% (P = .029) over the entire pollen season. Also lower rhinoconjunctivitis QOL global score (P = .005) compared with placebo group.

Asthma

Dhami metanalysis immunotherapy for asthma in kids – symptoms improved, less medication, esp HDM, grass, cat/dog. Not just severe asthma! But no prolonged benefit.

1 study of adults with poor control, HDM. Reduces time to first exacerbation.

Mite allergy prevention study n=111 HDM treatment effective. 2002 PAT study reduced asthma at 10yr follow up after grass/pollen treatment.

[Gillian Vance, Newcastle]

Eczema

House dust mite immunotherapy with SLIT (3 doses per week) shown to have some benefit in RCT from Brazil (66 children and adults) using SCORAD eczema severity questionnaire. Placebo group showed 35% improvement over 18 months, SLIT group showed 55%. No difference in Dermatology Life Quality index, pruritus score or any of the various other measures used!

Swimming and asthma

General paediatrics, Respiratory, ,

For competitive swimmers, note FINA doping control rules (based on the World Anti-Doping Agency regulations). Most asthma medications are on the Prohibited List including inhaled steroids and inhaled Beta2 agonists.

Therefore, elite athletes with asthma must apply for special permission to use these medications, known as the “Therapeutic Use Exemption” (TUE) program.  If competing at FINA events, then you apply directly to the FINA Doping Control Review Board to have their applications considered. Lower level athletes should apply to their national anti-doping body.

Epilepsy

General paediatrics, Neurology

Historically, people with epilepsy were “considered to have unique powers, even hailed as geniuses, regarded as having a sacred disease and leading sacred lives”.&nbsp;&nbsp;But then demonisation, persecution, social rejection. “Epileptic personality” described by psychiatry in 20th century. [Sacred lives, Ian Bone]

Self control is central to our self image and the manner in which we and society believe we should behave. Epilepsy jeopardises this. Patients often conceal. Guilt, loss of confidence and low mood common after seizures.

Definition: At least 2 unprovoked (or reflex) seizures, occurring more than 24hrs apart; else one unprovoked (or reflex) seizure and probability of further seizures similar to that seen in those who have had 2 unprovoked seizures (ie at least 60%); or recognized epilepsy syndrome.  Also part of the definition is that epilepsy is considered “resolved” if age dependent syndrome and past applicable age, or else those who have been seizure free for 10 years and off medication for 5 years. (ILAE 2014)

Note that “seizure” does not have any real medical meaning!  Transient signs/symptoms due to excessive or synchronous neuronal activity in brain (ILAE 2017) – but implies you can tell whether caused by abnormal brain activity, which can be hard!

First assessment:

  • NICE standard is that patient is seen within 2 weeks by a specialist! NICE guideline just says seen by doctor with training and expertise in epilepsy.
  • First assessment should include description of event, age/timing of event, frequency of events.
  • Physical examination of neurology, cardiac, mental state and development.
  • Presence/absence of developmental, learning or schooling problems.

Investigations

EEG

Despite increasing sophistication, interpreting EEG remains an inexact science! Irregular background activity overlaps with detectable abnormality. Plus, only really picks up activity at surface of brain, and can miss simple partial seizures (but not tonic-clonic generalised). Review in 2000 did not find much evidence base. Requires dialogue between referrer and neurophysiologist. Diagnosis remains principally clinical – eg more than 1 tonic-clonic seizure, or multiple absences! Incidence of epileptiform activity in asymptomatic individuals appears to be about 1%, of which a few percent will develop epilepsy over the subsequent years. Abnormal activity is certainly more likely if structural abnormality, but still many will be and remain asymptomatic.<

50% of children with epilepsy have normal EEGs – so not a particularly useful test! Not only that, but in studies, at least 20% of “epileptics” were ultimately given a non-epileptic diagnosis! So request EEG with caution; should be used for confirming clinical opinion, or to guide treatment, not where symptoms are vague. Hence a firm diagnosis of epilepsy and then decisions about treatment may take some time; difficult for families to understand, but it is quite safe to be cautious esp considering the implications of a mistaken diagnosis.

If EEG is negative, then proceed to a sleep EEG (where child is woken by parents at 3am, kept awake then brought to department and allowed to fall asleep during monitoring). This has 80% sensitivity. Failing that, Medilog or Video with continous monitoring. This is good for distinguishing non-epileptic tonic-clonic seizures, but does not rule out co-existing epilepsy.

Good for:

  • status in PICU patients, or non-convulsive status
  • where children too young to describe their symptoms
  • absences – typical absence epilepsy have 3Hz spike and wave with hyperventilation. Highly specific, although absences can be seen in complex partial seizures, which would also be obvious on EEG.
  • indicating underlying brain disease (abnormal background)
  • specific syndromes
  • cognitive impairments that may be seizure related

Beware – an EEG finding of partial epilepsy may not have a surgical lesion! Must be used in conjunction with MRI. A generalized epilepsy may have multiple foci, so if you are unlucky to capture just one you will be misled. Similarly, if secondary generalization occurs rapidly, its partial nature may be missed.

Not usually useful to do after multiple seizures, unless type or frequency changes significantly, in which case a new syndrome/prognosis may have developed.</p>

<p><em>”The brain is subject to maturation; there are multiple protecting and triggering factors, often unpredictable. Seizures may be rare and easy to treat for months and years, but may become more frequent and difficult to control later on. But in many children a precise syndromic diagnosis can be made, and a good final prognosis can be expected in most cases.”</em></p>

Other investigations

All children with recurrent seizures should have an ECG with calculated QTc. &nbsp;Children under 2 with epilepsy or with recurrent focal seizures (other than CECTS) should have an elective MRI brain scan. &nbsp;In most other cases the course is predictable. A normal MRI does not rule out a small dysplastic lesion, equally the finding of a lesion does not mean that it is the cause of the epilepsy. However, at least you can exclude a tumour or malformation.</p>

Focal/partial often have acquired or congenital lesions, often specific precipitating factors eg sleep, startle!</p>

Differential

Management

<p>Consider:</p>

  • Drug treatment (see below) – and risk with prenatal exposure
  • Education – written, peer support
  • Specialist epilepsy nurse review
  • Emergency medication, if appropriate

First aid advice

  • <li><a href=”http://scottishpaeds.org.uk/2017/01/31/living-with-epilepsy/”>Safety advice</a></li>

<li>When/how to access health services</li>

</ul>

</div>

Treatment

Should not be started after first tonic-clonic generalized seizure. Try not to start before EEG done as may mask features.

Refer to tertiary if –

  • child fails to respond to two AEDs appropriate to the epilepsy in adequate dosages over a period of 6 months (SIGN), or 3 over 12 months (NICE)
  • children less than 2 years with epilepsy as defined

SPEN network has pathways for first seizure, new diagnosis, continuing seizures.

See also Living with Epilepsy

Caldicott 2

Ethics

Dame Fiona Caldicott’s review of original 1997
information governance recommendations – response to perceived
reluctance to share info appropriately.

Appropriate sharing should be the rule, not the exception.  Given need for informed consent, concludes that patients should be better informed as to how their
information is used.  Needs system for recording consent applicable
across all NHS and care systems.  Sharing info with a private
organisation or local authority should be equally straightforward, if
data protection principles are applied.

Confidentiality

Ethics, ,

For information to be confidential in law it must:

  • not be common knowledge among lots of people, for example, the
    content of a discussion between a patient and a health professional;
  • and be useful and not irrelevant or trivial

Explicit consent is not required for the following purposes:

  • Where patient information is used for the routine clinical care of that patient – for example between health professionals and intra NHS multidisciplinary teams
  • Where patient information is used for administration and management purposes, for example, waiting list management.
  • Child protection purposes (see below)

Most patients understand that their information must be shared within
the healthcare team. However, patients do not expect this to be shared
with others who will not be involved in their care.

Aggregated and management information is used to plan and monitor
progress of the organisation in its delivery of services. This is
generally outside the scope of the Data Protection Act 1998 on the
basis that a living individual could not be identified from such data.

Anonymized/coded information would normally fall outside the scope of
the Data Protection Act 1998, but care must be taken with all coded
and anonymised information as it may still be possible to identify
individuals, e.g. with rare diseases, drug treatments or statistical
analyses within a small population.

For other uses, it is your responsibility to make sure that patients
are aware of the wider uses of their information and to get their
permission.  It is your responsibility to make sure that you provide
versions in any community languages or meet other accessibility
requirements.

You should:

* make clear to patients when information is or may be disclosed
(shared) to others involved in their health care;

* make sure that patients are aware of the choices that are available
to them on how their information may be disclosed and used;

* check with patients to make sure that they have no concerns or
questions about how their information will be disclosed and may be
used;

* answer any questions personally or direct patients to others who can
answer their questions; and

* respect the rights of patients and help them to access their health
records if they have asked to do this.

Intra NHS Information Sharing NHS Scotland policy

3rd party info eg family history or info coming from an identifiable
family member – may itself be confidential, even if in patient’s
record, so 3rd parties should be told if their identity might be
revealed, and given opportunity to decline.

Beware use of automated reports for insurance etc, where only minimum
necessary info is appropriate, and would be wrong to disclose more
than that.

Option to opt out of data analysis emphasized – not clear how this
would be done.

Training seen as tick box rather than education.

£100 000 fine for Aberdeen city council for a home worker accidentally uploading files regarding vulnerable children to an online file store.  A fine has never been issued for formal sharing of information.  “Blagging” is also an issue, where a 3rd party obtains information by ostensibly acting as a healthcare professional or family member.
Guidance from 2003 still applies – obtain confirmation of identity (or
phone number etc) from second source.  If breach occurs, individual
should be informed.

See also Data Protection for Caldicott principles etc.

Child Protection

Scottish Government’s Sharing Information about Children at Risk: A Guide to Good Practice (2003) states:-

“If there is reasonable concern that a child may be at risk of harm this will always override a professional or agency requirement to keep information confidential. All professionals and service providers have a responsibility to act to make sure that a child whose safety or welfare may be at risk is protected from harm.”

The National Guidance for Child Protection in Scotland (2014) states:

‟Harm‟ means the ill treatment or the impairment of the health or development of the child, including, for example, impairment suffered as a result of seeing or hearing the ill treatment of another. In this context, ‟development‟ can mean physical, intellectual, emotional, social or behavioural development and ‟health‟ can mean physical or mental health.”

Recent advice has also been received from the Scottish Government, having consulted with the Information Commissioner’s Office, regarding the impact of GDPR and the Data Protection Act 2018 in this area.  The Information Commissioner’s Officer has confirmed:

“It is important that those whose work brings them into contact with children and young people continue to share child protection concerns in the same way as they did previously. Child protection matters at the significant harm level equate to sharing/processing being necessary to protect the vital interests of the child where reliance on consent may be prejudicial to that purpose. The same lawful purposes are provided for in Articles 6:1(b) and 9:2(c) of the GDPR for personal and special category data so nothing has changed at that level”.

It is important to be open and transparent and make people aware that we will share information when we suspect a child or young person is at risk of harm. It is also important to record any decision to share or not to share information and reasons for doing so.

Relevant Acts/Policies

* Human Rights Act 1998

* Freedom of Information (Scotland) Act 2002

* NHSS Code of Practice on Protecting Patient Confidentiality.

* NHSS Information Governance standards 2005

Note that Scotland leads patient data protection with Fairwarning software.

VZV encephalitis

General paediatrics, Infectious disease, Neurology

VZV encephalitis presentation not different from usual, viz  fever, headache, altered consciousness, etc. But can be subacute onset.

The more common neuro manifestation of VZV in young children is post-infectious cerebellitis  – usually mild and self limiting, child not unwell but risk of secondary
hydrocephalus in more severe cases.

There is also a well recognized association in childhood  between VZV infection and stroke, usually presents after the rash has cleared – typically 3 months [London study, Miravet & Danchaivijitr 2007).  Post-VZV thromboembolism also seen rarely eg lower limb DVT.

Encephalitis can present early, even before rash (which may
not be very obvious either).  PCR for VZV DNA in the CSF is positive in around a third of patients; VZV specific IgG seen in 90% in CSF. Compare  levels to serum as a way
of confirming CNS involvement.

Usually (not for cerebellitis), steroids given eg 60-80 mg of prednisolone daily for 3 to 5 days) is given (Gilden & Kleinschmidt-DeMasters  2000) esp where MRI evidence of vasculitis.
[encephalitis article, source?]

Chickenpox (Varicella Zoster virus)

General paediatrics, Infectious disease

A systemic viral illness characterised by widespread vesicles. Like other herpesviruses, it retains the ability to lie dormant in ganglions after initial infection, possibly reactivating in the future as Herpes Zoster (= shingles).

Clinical

Congenital varicella

Congenital, Infectious disease, Neonatology,

If a pregnant woman is infected during the first trimester (risk extends to 20th week), a fetus has a 1% chance of developing widespread scarring, hypoplastic limbs, cataracts and brain lesions (congenital varicella). Affected infants have a poor neurodevelopmental outlook.

Risk of neonatal VZV (severe, disseminated disease in newborn) if chickenpox is contracted by the mother 4 days before birth, to 2 days after  (risk 20%).  Before that, good chance that maternal immune response will protect baby, after that the dose of infection transmitted to the baby via the umbilical cord is likely to be small (although will still be exposed to droplets).

See Maternal for advice on varicella exposure in pregnancy and in neonates.