Summary
This guideline advises on the management of patients with cow's milk allergy. Cow's milk allergy presents in the first year of life with estimated population prevalence between 2% and 3%. The ...clinical manifestations of cow's milk allergy are very variable in type and severity making it the most difficult food allergy to diagnose. A careful age‐ and disease‐specific history with relevant allergy tests including detection of milk‐specific IgE (by skin prick test or serum assay), diagnostic elimination diet, and oral challenge will aid in diagnosis in most cases. Treatment is advice on cow's milk avoidance and suitable substitute milks. Cow's milk allergy often resolves. Reintroduction can be achieved by the graded exposure, either at home or supervised in hospital depending on severity, using a milk ladder. Where cow's milk allergy persists, novel treatment options may include oral tolerance induction, although most authors do not currently recommend it for routine clinical practice. Cow's milk allergy must be distinguished from primary lactose intolerance. This guideline was prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI) and is intended for clinicians in secondary and tertiary care. The recommendations are evidence based, but where evidence is lacking the panel of experts in the committee reached consensus. Grades of recommendation are shown throughout. The document encompasses epidemiology, natural history, clinical presentations, diagnosis, and treatment.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
Summary
Peanut nut and tree nut allergy are characterised by IgE mediated reactions to nut proteins. Nut allergy is a global disease. Limited epidemiological data suggest varying prevalence in ...different geographical areas. Primary nut allergy affects over 2% of children and 0.5% of adults in the UK. Infants with severe eczema and/or egg allergy have a higher risk of peanut allergy. Primary nut allergy presents most commonly in the first five years of life, often after the first known ingestion with typical rapid onset IgE‐mediated symptoms. The clinical diagnosis of primary nut allergy can be made by the combination of a typical clinical presentation and evidence of nut specifc IgE shown by a positive skin prick test (SPT) or specific IgE (sIgE) test. Pollen food syndrome is a distinct disorder, usually mild, with oral/pharyngeal symptoms, in the context of hay fever or pollen sensitisation, which can be triggered by nuts. It can usually be distinguish clinically from primary nut allergy. The magnitude of a SPT or sIgE relates to the probability of clinical allergy, but does not relate to clinical severity. SPT of ≥ 8 mm or sIgE ≥ 15 KU/L to peanut is highly predictive of clinical allergy. Cut off values are not available for tree nuts. Test results must be interpreted in the context of the clinical history. Diagnostic food challenges are usually not necessary but may be used to confirm or refute a conflicting history and test result. As nut allergy is likely to be a long‐lived disease, nut avoidance advice is the cornerstone of management. Patients should be provided with a comprehensive management plan including avoidance advice, patient specific emergency medication and an emergency treatment plan and training in administration of emergency medication. Regular re‐training is required.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
Summary
Background
Specific immunotherapy (SIT) is an effective treatment for grass and/or tree pollen‐induced severe allergic rhinoconjunctivitis. However, there are limited detailed data on the use ...of immunotherapy in children in the United Kingdom.
Objectives
We audited NHS paediatric practice against current national guidelines to evaluate patient selection, SIT modalities and adverse events (AEs).
Methods
Paediatricians offering pollen SIT were identified through the British Society of Allergy and Clinical Immunology Paediatric Allergy Group (BSACI‐PAG) and the database of SIT providers compiled for the Royal College of Physicians and Royal College of Pathologists 2010 joint working group. Standardized proformas were returned by 12 of 20 centres (60%), including 12 of 14 centres offering subcutaneous immunotherapy (SCIT) (85%).
Results
Three hundred and twenty‐three children, with mean age 11 years at initiation (69% boys), had undergone 528 SIT cycles (SCIT 31%) over 10 years. Fifty‐five percent of all patients had asthma. Among SCIT programmes 24.5% patients had perennial (± seasonal) asthma; 75.6% of asthmatics undertaking SCIT had treatments at BTS/SIGN step 2 or above. AEs occurred frequently (50.4% of all SIT cycles) but were mild. In sublingual immunotherapy (SLIT) treatment, local intraoral immediate reactions were most common (44.9% SLIT cycles), as compared with delayed reactions around the injection site in SCIT (28.3% SCIT cycles). An asthma diagnosis had no impact on the number of cycles with AEs, or the severity reported. Few cycles (2.9%) were discontinued as a result of AE(s).
Conclusions and Clinical Relevance
Pollen SIT is available across England, though small numbers of children are being treated. Current national guidelines to exclude asthmatic children in SIT programmes are not being adhered to by most specialist paediatric allergy centres. SCIT and SLIT has been well tolerated. Review of patient selection criteria is needed and may allow greater use of this therapeutic option in appropriate clinical settings.
Cite this as: G. H. S. Vance, S. Goldring, J. O. Warner, H. Cox, B. Sihra, S. Hughes, J. Gardner, J. North, G. Roberts, C. A. Proudfoot, A. Clarke, D. K. Luyt, D. Gillies and A. T. Fox, Clinical & Experimental Allergy, 2011 (41) 1313–1323.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
Objective: To describe the later health status of newborn infants who received extracorporeal membrane oxygenation (ECMO) for acute respiratory failure in the era after the UK ECMO trial. Design: ...Prospective follow up study of newborn infants who received ECMO at a single centre between January 1997 and January 2001. Setting: Departments of ECMO and Paediatric Intensive Care, University Hospitals of Leicester. Patients: All babies who received ECMO within 14 days of birth. Interventions: Neurodevelopment screening using the schedule for growing skills-II (SGS-II) assessment tool. Main outcome measures: Survival at 12 months of age by disease and functional development at follow up. Results: A total of 145 neonates received ECMO for treatment of respiratory failure. Of these, 108 (75%) were alive at 1 year of age. There were no deaths in children treated for respiratory failure secondary to meconium aspiration syndrome (73/145). Ninety three (86% of survivors) infants attended a follow up visit at 11–19 months postnatal age. Eighty two were classed as normal, seven as having “impairment”, and four as having “severe disability”. Conclusions: Most newborn infants with acute respiratory failure treated with ECMO will have a normal neurodevelopment screening assessment at 11–19 months of postnatal age. There is no evidence to suggest that changes in neonatal practice since the UK ECMO trial have led to changes in outcome of infants undergoing ECMO therapy.
Infrastructural problems force South African households to supplement their drinking water consumption from water resources of inadequate microbial quality. Microbial water quality monitoring is ...currently based on the Colilert®18 system which leads to rapidly available results. Using Escherichia coli as the indicator microorganism limits the influence of environmental sources on the reported results. The current system allows for understanding of long-term trends of microbial surface water quality and the related public health risks. However, rates of false positive for the Colilert®18-derived concentrations have been reported to range from 7.4% to 36.4%. At the same time, rates of false negative results vary from 3.5% to 12.5%; and the Colilert medium has been reported to provide for cultivation of only 56.8% of relevant strains. Identification of unknown sources of faecal contamination is not currently feasible. Based on literature review, calibration of the antibiotic-resistance spectra of Escherichia coli or the bifidobacterial tracking ratio should be investigated locally for potential implementation into the existing monitoring system. The current system could be too costly to implement in certain areas of South Africa where the modified H(2)S strip test might be used as a surrogate for the Colilert®18.
We studied the natural history of preschool respiratory symptoms in a population-based sample of children followed during the early school years. Current symptoms, ventilatory function, bronchial ...responsiveness to methacholine (BR), atopic status, and peak expiratory flow variability (PEFV) were assessed. Among those initially asymptomatic (210 subjects), 83.3% remained symptom-free, 6.7% started to wheeze, and 10% developed recurrent cough. Nearly half (46.9%) of the initial wheezing group (145 subjects) became symptom-free, 37.9% continued to wheeze, and 15.2% reported recurrent cough. Over half (56.0%) of the cough group (127 subjects) became symptom-free, 7.2% developed wheeze, and 36.8% reported continuing cough. Preschool wheezers showed the greatest BR (geometric mean 1.91 mg/ml) and the highest atopic prevalence (AP) (43.6%) when compared with the preschool asymptomatic group (BR: 3.39 mg/ml; AP: 23.8%) and the cough group (BR: 2.62 mg/ml; AP: 26.7%) (p = 0.0001 and p = 0.006 respectively). Children whose wheeze had persisted from the preschool period exhibited the poorest ventilatory function, the highest BR, a high AP, and high PEFV. The study shows that fewer than half of preschool wheezy children continued to wheeze in the early school years but those with persistent wheeze display many of the clinical characteristics consistent with a diagnosis of asthma.
OBJECTIVE--To determine the cumulative prevalences of wheeze and doctor diagnosed asthma and the point prevalences of recurrent cough and wheeze in children aged 5 years and under. ...DESIGN--Questionnaire survey of population based random sample of children registered on regional authority's child health index for immunisation; questionnaire completed by parents. SETTING--Leicestershire. SUBJECTS--1650 white children born in 1985-9 who were surveyed in 1990. MAIN OUTCOME MEASURES--Cumulative prevalences of wheeze and doctor diagnosed asthma and point prevalences of recurrent cough and wheeze by age and sex. RESULTS--There were 1422 replies (86.2%; 726 for boys, 696 for girls). Overall, 11.0% (95% confidence interval 9.4% to 12.6%) of children had formally been diagnosed as having asthma, the cumulative prevalence in boys (12.7%) being somewhat higher than in girls (9.2%) (age adjusted odds ratio 1.47, p = 0.03). As expected, the cumulative prevalence of asthma increased significantly with age (7.5% (13/173) in children under 1 year, 15.9% (61/383) in children of 4 years and over; p < 0.001). The cumulative prevalence of wheeze overall was 15.6% (13.7% to 17.5%), being higher in boys (17.6%) than in girls (13.5%) (odds ratio 1.38, p = 0.03). The overall prevalence of recurrent cough without colds was 21.8% (19.6% to 23.9%), with a non-significant excess in boys (23.1% v 20.4%). The overall prevalence of wheezing attacks during the previous 12 months was 13.0% (11.3% to 14.8%) with a non-significant excess in boys (14.5% v 11.5%). CONCLUSIONS--These findings are baseline results and emphasise the importance of studying the age group of interest rather than relying on the recall of parents of school age children.
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IntroductionAchondroplasia is the most frequent form of short-limb dwarfism. These children have hypotonia, micrognathia and mid-facial hypoplasia that predispose them to sleep-disordered breathing ...(SDB). Repeated assessments with polysomnography (PSG) are recommended to screen these children for SDB. However, as PSG is not widely available, clinicians have to rely on their clinical assessment to guide referral for further assessment.AimTo record the presenting symptoms and PSG findings in children with achondroplasia referred to our sleep service, and to ascertain whether any clinical symptoms were indicative of SDB.MethodWe performed a retrospective review on children with achondroplasia who had a PSG performed during the last eight years (2011–2018). Parents completed sleep questionnaires prior to the study on questions pertaining to children’s sleep habits, breathing in sleep, daytime symptoms and daytime breathing. Patients’ demographic data, symptomatology and PSG results were noted in structured proformas.ResultsSixteen polysomnograms were performed in children with achondroplasia during the study period; 10 (63%) of which were positive for SDB. Their mean age was 4.41±3.5 years. Discriminatory sleep symptoms present in patients with and without SDB are shown in the table below (table 1).ConclusionsThis study suggests that some symptoms may guide clinicians in their assessment of SBD in children with achondroplasia. Night-time awakening, mouth breathing, excessive sweating during sleep, excessive daytime sleepiness, tiredness and difficulty to wake up in the morning suggest SDB in these children. These symptoms were more discriminatory than the commonly reported symptoms like snoring or restless sleep. This information can help clinicians with the history-taking to identify patients needing referral for a PSG.Abstract G512(P) Table 1 Symptom SDB positive (n=10)(Percentage) SDB negative (n=6)(Percentage) Night time awakeningRestless sleepDifficulty in breathingStopping breathingSnoringMouth breathing in sleepExcessive sweatingSleeping in unusual positionExcessive day time sleepinessDay time tirednessDifficult to wake up in morningFrequent upper respiratory infectionsPersistent runny or blocked nose3040202090606070503030606016333316833333671616166767
Objective: To describe the short‐term outcome of children with meningococcal sepsis treated with extracorporeal membrane oxygenation (ECMO) in a single centre. Design: Retrospective analysis of case ...notes. Setting: The Heartlink ECMO Centre, Glenfield Hospital, Leicester. Patients: Eleven children (8 boys) out of a total caseload of 800 patients were treated for meningococcal sepsis with ECMO. Interventions: Extracorporeal membrane oxygenation. Results: All children with meningococcal sepsis treated with ECMO had a Glasgow Meningococcal Septicaemia Prognostic Score (GMSPS) >12 (positive predictive risk of death of approximately 90%). Five children had adult respiratory distress syndrome (ARDS) and six had refractory shock with multi‐organ dysfunction syndrome (MODS) at presentation for ECMO. All five children in the ARDS group survived, four of five receiving veno‐venous (VV‐) ECMO therapy. In contrast, only one of six children with refractory shock with MODS survived, all of whom required veno‐arterial (VA‐) ECMO therapy.
Conclusions: Most children with meningococcal sepsis and severe ARDS can be successfully treated with VV‐ECMO. In contrast, children with refractory shock and MODS die despite treatment with VA‐ECMO. This report does not resolve whether ECMO therapy offers any advantage over conventional therapy in treating severe meningococcal sepsis.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
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