1.  Dr Paula McQueenAllergy  Dr Ruth Mew Allergy  Dr Ozan HanciGastroenterology  Dr Joanne BartleyOncology  Dr Rick FultonDiabetes (Locum)  Dr Archana KshirsagarDiabetes (from Sept 14) New Consultants in Paediatrics at the Royal Surrey from 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  Bedwetting (nocturnal enuresis)  Constipation  Diarrhoea & vomiting  Feverish illnesses  Food allergy NICE Guidelines for Children

4.  Immunisations  Looked-after babies & 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

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

6.  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

7. 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

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

9. 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

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

11.  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

12. 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

13. 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

14. 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

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

16.  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

17.  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

18. 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

19. 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

20. 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

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

22.  Common problem in infants & children  Usually functional, rarely due to an organic cause  Can usually be managed in General Practice  NICE Guidelines not yet available (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

23. Which children need referral for specialist advice ?  Projectile vomiting in the early weeks of life  Vomiting associated with ‘failure-to-thrive’  Vomiting associated with significant haematemesis  Symptoms unresponsive to conventional anti-reflux Rx  Symptoms persisting beyond 12 months of age GO Reflux in Children

24. Treatment of GO Reflux in Infants  Infant Gaviscon or feed thickening agent  Ranitidine at a dosage of 2 mg / kg / TDS  Domperidone at a dosage of 0.2 – 0.3 mg / kg / QDS or  Erythromycin at a dosage of 3 mg / kg QDS  Omeprazole at a dosage of 1 – 2 mg / kg OD  Consider a hydrolysate in case of CMP allergy GO Reflux in Children

25. Any Questions ?