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1、Recent clinical guidelines relevant to paediatricsDr Harry BaumerConsultant PaediatricianDerriford HospitalWhy 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 interestChoosi
2、ng guidelines Rigorous evidence-based methodology Relevant to paediatricians Non-specialists perspective Important messages Likely otherwise to be overlookedGuideline review topics Sweat test for CF Post seizure management Human milk banks Arterial stroke in childhood Otitis media(UK&US compared)Par
3、apneumonic effusion/empyema CFS/ME UTIs in young children Incomplete Kawasaki disease Glucocorticoids in croup Decreased consciousness Tuberculosis2005200420032006Decreased consciousness Nottingham Paediatric A&E research group Funded by Reyes foundation Very broad scope Rigorous methodology Multipl
4、e literature searches Supported by Delphi consensus 134 recommendations,20 Grade A or B Supported by detailed algorithm Not yet pilotedDecreased consciousness:scope Children with non-traumatic coma Aged 18 years,not in neonatal unit GCS 15(not due to chronic disability)Differential diagnosis Immedia
5、te investigations Initial managementKey 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 ICPAcute metabolic illnessHypoglycaemiaHyperammonaemiaNon-
6、hyperglycaemic ketoacidosisHypoglycaemiaMain causes(excluding exogenous insulin):Severe sepsis Endogenous insulin excess Addisons disease Growth hormone deficiency Congenital adrenal hyperplasia Fatty acid oxygen defects(eg MCAD)Organic acidurias Glycogen storage disordersNon-hyperglycaemicketoacido
7、sisCauses 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 shockLP contraindicationsNICE TB Guideline Published 2006 Covers adults&children togeth
8、er Paediatric input(Dr Delane Shingadia)Broad scope:“Clinical diagnosis and management of tuberculosis,and measures for its prevention and control.”Recommendations alone 2,500 wordsCopyright 2006 BMJ Publishing Group Ltd.Marais,B J.ADC E&P(2006);91:ep1Figure 4 Chest radiograph(lateral view)of a pati
9、ent with lymph node disease.Figure 3 Chest radiograph(anteroposterior view)of a patient with lymph node disease.Recognising intrathoracic TBStandard treatment for pulmonary TB Recommendation grade:Adults(not HIV+ve)A HIV+ve adults B Children B Based on RCTs in adults6 months 2 monthsisoniazid and ri
10、fampicinpyrazinamide and ethambutolESAT-6(early secretion antigen target 6)CFP-10(culture filtrate protein 10)Not present in BCG,most environmentalnon-TB mycobacteria New rapid diagnostic techniquesfor latent TBusing interferon gamma testsTypically 3mlsblood neededDifferent testsMore specific than t
11、uberculin skin tests No gold standard for comparisonDoes negative result rule out TB?How sensitive?NICE:Mantoux firstNew tests if:Mantoux positive,orpost BCG TB meningitis“Patients with active meningeal tuberculosis should be offered a glucocorticoid at the normal dose range:Adults:equivalent to pre
12、dnisolone 20-40mg if on rifampicin,10-20mg otherwise.A Children:equivalent to prednisolone 1-2mg/kg,maximum 40mg.D(GPP)”TB meningitisBased on Cochrane review from 2000 6 RCTs of glucocorticoids mortality death or severe disability mortality in children But Small studies Poor allocation concealment P
13、ublication bias Cochrane review withdrawn Jan 2006Who 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 specia
14、lised colleagues throughout”Challenges How to provide specialist support BPSU 2004:In 55%,reporting paediatricians had 1 case Defining area for universal vaccination of all infants Monitoring of TB incidence and making appropriate changes to policy if 40/100,000 per year Making a selective policy wo
15、rk in low incidence areas Opportunistic screening and vaccination of older children Who,where and how?Key messages Effectiveness of glucocorticoids in croup Decreased consciousness Core investigations together Initial treatment of metabolic conditions,intracranial infections Contraindications to lumbar puncture Changes and challenges in TB Four drug regimen for treatment Place of new interferon gamma tests Steroids in TB meningitis?Making selective BCG effective Providing specialist support
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