BSACI guideline for the diagnosis and management of peanut and tree nut allergy.

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.

Home-based oral immunotherapy with a baked egg protocol

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BSACI guideline for the diagnosis and management of cow's milk allergy.

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.

A national audit of pollen immunotherapy for children in the United Kingdom: patient selection and programme safety.

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.

Developmental outcome in newborn infants treated for acute respiratory failure with extracorporeal membrane oxygenation: present experience.

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.

Extracorporeal life support for children with meningococcal septicaemia.

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) > or = 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.

Short term effects of adrenaline in bronchiolitis: a randomised controlled trial.

BACKGROUND: Airway narrowing in acute bronchiolitis does not respond to inhaled bronchodilators but does to adrenaline when compared to bronchodilators. Influences of supportive care were not considered in previous treatment studies. METHODS: Short term effects of nebulised adrenaline and saline placebo were compared in infants with moderately severe acute bronchiolitis. Thirty eight infants were recruited, 19 in each treatment group. After stabilisation, infants received a single 3 ml dose of either levo-adrenaline (3 mg) or 0.9% saline placebo via Pari-BABY nebuliser driven with 6 l/min oxygen for three minutes. Changes in respiratory rate (RR), heart rate (HR), oxygen saturation (SpO(2)), Respiratory Distress Assessment Instrument (RDAI), and activity levels were assessed at 20 minutes intervals at times -20, 0, 20, 40, and 60 minutes around treatment. Respiratory virology and chest x ray were performed. RESULTS: Supportive therapy prior to study treatment resulted in significant reductions in RR (by 4.3 breaths/min) and HR (by 4.6 beats/min); there were no changes in SpO(2) or RDAI. There were no further changes in any parameter in either treatment group at any assessment time after treatment. CONCLUSION: No improvement was shown with inhaled adrenaline in acute bronchiolitis, when compared with supportive care or placebo. Improvements noted pretreatment question whether prior noted improvements were through supportive care or pharmacological interventions.

Nut allergy: symptom and severity reporting.

Nut allergy, in particular peanut allergy, is becoming more common in children. Immune sensitisation to nuts appears to be occurring earlier in life. High incidence of other allergic diseases in children with nut allergy. Onset of anaphylactic symptoms is quick but symptoms last for a short time. Necessity for hospital admission due to severity of allergic reaction is low.

Recurrent cough: natural history and significance in infancy and early childhood.

We investigated the outcome for a sample of children in whom recurrent cough was reported in the preschool years to determine 1) whether they shared the characteristics attributed to cough variant asthma, and 2) the proportion who developed classical wheezy asthma at follow-up during the early school years. A cohort of children identified as having recurrent cough in the preschool period was reassessed during the early school years. Previously identified asymptomatic preschool children who remained symptom-free provided a comparison group with respect to current respiratory symptoms, lung function, bronchial reactivity to inhaled methacholine, atopic status, peak flow variability, and recorded night cough. The response rate was modest, with 41% attending the follow-up study; information on current symptoms was available from a further 16%. Ascertainment of current symptoms showed that 70 of 125 (56.0% [95% CI 47.3-64.5%]) were symptom-free at follow-up, 46 (36.8% [28.7-45.5%]) continued to have recurrent cough in the absence of colds, and 9 (7.2% [3.6-12.8%]) reported recent attacks of wheeze. When comparing the 46 children whose recurrent cough persisted from the preschool period through to follow-up with subjects from the asymptomatic comparison group, the former had significantly more night cough (50.0% vs. 16.8%; P< 0.01), were more likely to be treated (10.9% vs. 1.7%; P=0.01), or were diagnosed (26.1% vs. 5.7%; P < 0.001) as asthmatic. They also showed greater bronchial reactivity than their asymptomatic counterparts (1.23 mg/ml vs. 3.35 mg/ml; P=0.002). Atopic status and other indices of lung function were similar between groups. We conclude that there are a group of children with long-term recurrent cough who display features consistent with a diagnosis of cough variant asthma, but at 2-4 years of follow-up, few progress to develop asthma characterized by wheeze.

Clinical presentation of chronic non-infectious rhinitis in children.

UNLABELLED: Chronic rhinitis is one of the commonest conditions affecting humans and there is evidence that its prevalence (and especially that of allergic rhinitis) is increasing. Although common, it is poorly recognised by doctors, parents and patients, particularly in children. AIMS: This study surveyed children with chronic non-infectious rhinitis to describe their presenting symptoms, differences in presentation between preschool and school-aged children and the prevalence of complications. SUBJECTS AND METHODS: We prospectively surveyed patients with a diagnosis of chronic rhinitis that was subsequently confirmed by response to therapy. Symptoms of rhinitis were assessed via an interview-conducted questionnaire. RESULTS: 567 children (357 boys), with a mean age (+/-SD) of 5.3 +/- 3.6 years, were studied over 14 months. Three hundred and fourteen were preschool children. Symptoms of a blocked or a runny nose were reported in 85% of patients, both symptoms occurring simultaneously in 59.9%. A blocked nose occurred more frequently in school-aged children, while a runny nose was commoner in preschool children. Sneeze and itch occurred less frequently in 56.1% and 33.6%, respectively. Complicating recurrent ear infections were reported in 46.9% of patients, more frequently in preschool children (P = 0.01); almost one-third (32.02%) had had grommets inserted. Learning problems, possibly secondary to somnolence as a result of poor sleep induced by sleep apnoea (snoring was reported in 58.4%), were reported in 24.1% of school-going children. CONCLUSION: As chronic rhinitis in South Africa commonly manifests with a blocked nose, patients display a high prevalence of associated complications. Doctors need to be aware of the presenting symptoms to diagnose and treat chronic non-infectious rhinitis earlier to prevent these complications.

Clinical characteristics of childhood asthmatics in Johannesburg.

OBJECTIVES: To describe the clinical features of Caucasian childhood asthmatics in Johannesburg in order to compare these with a similar population of black asthmatic children resident in Soweto. DESIGN: In a prospective study, a history was obtained by means of an investigator-administered questionnaire. MAIN OUTCOME MEASURES: Presenting asthma symptoms, precipitants of symptoms, concomitant diagnoses, individual and family background of allergy and 'delay to diagnosis' of asthma (age at symptom onset subtracted from age at diagnosis) from history and allergen sensitivity as assessed by skin-prick tests (SPTs). RESULTS: Of the 468 (297 boys) asthmatics studied, 456 (97.4%) presented with cough, 362 (77.3%) with wheeze, 286 (61.1%) with a tight chest and 277 (59.2%) with breathlessness. Cough as sole symptom occurred in 102 (21.8%) while only 8 (1.7%) wheezed and did not cough. Commonest symptom triggers were upper respiratory tract infections and activity/exercise. An individual atopic background was common-allergic rhinitis in 413 (88.2%)-as was a family history of atopy, present in 390 (83.3%). Prolonged symptomatic periods occurred in most patients before asthma was diagnosed (among children diagnosed after the age of 4 years, 50% had been symptomatic for more than 3 years). 'Delay to diagnosis' was not influenced by presenting symptoms or by previous hospitalisation for asthma. Other respiratory diagnoses of bronchitis and pneumonia were common, possibly because of misdiagnosis. Commonest allergens on SPT were corn pollen, Bermuda and 5-grass mix, and standardised mites. Aside from wheat, food allergy was uncommon. CONCLUSIONS: Cough was the commonest presenting symptom despite its still being regarded as a less classic symptom of asthma that may account for misdiagnosis and a high frequency of other respiratory diagnoses. Associated allergy, especially allergic rhinitis, occurred frequently. Many aspects of presentation in whites were similar to those in Soweto children, although the latter had a more frequent concomitant diagnosis of tuberculosis, and recognised dust and cold weather as more frequent triggers. Differences might be influenced by the care-giving situation.

Cost of therapy for allergic rhinitis.

OBJECTIVE: To describe the cost of medicines used in the treatment of allergic rhinitis in South Africa. DESIGN: MIMS was used as the reference for the list of drugs, drug formulation and size, and recommended dosage. These figures were then checked against the package insert of each agent. The cost of each agent was originally derived from the same source, but for standardisation purposes the blue book price was used. Measure of effectiveness was derived from the International Consensus Report on the Diagnosis and Management of Rhinitis. Costs per treatment periods of 10 days (course) and 30 days (month) were calculated. The 'cost' differs from the 'price' in that it takes efficacy into account. MAIN OUTCOME MEASURES: Cost of drugs used in the treatment of allergic rhinitis. RESULTS: The least costly treatments for allergic rhinitis are the intranasal corticosteroids. Sodium cromoglycate was the most costly, being nearly 20 times more expensive than the nasal steroids. Anticholinergic sprays and topical decongestants were also more costly than nasal steroids, as were the antihistamines. The older-generation antihistamine, ketotifen, was not only more costly than the four oral newer-generation agents in this class but has the added disadvantage of greater sedative side-effects. All oral antihistamines were outclassed by the topical antihistamine, levocabastine. CONCLUSIONS: This study in no way aims to recommend treatment for allergic rhinitis. However, it highlights the need to consider efficacy of a drug before unit price in the selection of treatment regimens. It is therefore a comment on practical issues in drug selection in the treatment of allergic rhinitis.

Poor discriminatory performance of the Pediatric Risk of Mortality (PRISM) score in a South African intensive care unit.

OBJECTIVE: The use of the Pediatric Risk of Mortality (PRISM) score or other scoring systems in the intensive care unit (ICU) is of great importance for evaluating the efficacy and efficiency of a particular ICU. However, the PRISM score was developed and validated in the United States and subsequently validated in Europe, but has not been evaluated in a less affluent society. In general, scoring systems should be used only in populations similar to the reference population in which the prediction model was developed. We set out to determine the applicability of the PRISM score at Baragwanath Hospital, South Africa. DESIGN: Prospective, descriptive study. SETTING: Twenty-four-bed multidisciplinary ICU. PATIENTS: We analyzed 1,528 consecutive pediatric admissions from January 1989 to June 1994. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: PRISM scores, Therapeutic Intervention Scoring System scores, demographic, and clinical data collected prospectively were entered and stored by means of a commercial software package at the time of admission of each patient. The prediction of actual mortality by PRISM scoring was evaluated by the Hosmer and Lemeshow goodness-of-fit test (chi2[8 degrees of freedom]). Receiver operating characteristic curves were constructed and compared with those curves from pediatric ICU populations in the United States and Europe. Individual receiver operating characteristic curves were constructed for surgical and nonsurgical patients, age categories, and diagnostic categories. Compared with European and American ICU populations, our patients were younger, were mostly nonsurgical emergency admissions, stayed longer in the ICU, and were more severely ill with a higher admission PRISM score and overall mortality rate. Respiratory and septic diagnoses predominated, with very few surgical cases admitted. The Hosmer and Lemeshow goodness-of-fit test showed a significant failure of the PRISM scoring system to accurately predict mortality over a wide range of expected mortality rates (chi2[8 degrees of freedom] = 465, p = 0). Similarly, receiver operating characteristic analysis indicated a poor predictive power (Az = 0.73 +/- 0.01 [SEM]), with an area under the curve significantly less than that for the PRISM reference population (p = 0). PRISM showed equally poor discriminatory function at all age groups and diagnostic categories. CONCLUSIONS: The PRISM score needs to be recalibrated or recalculated for our patient population in view of the high discrepancy and poor discriminatory function shown. Part of the inaccuracy may derive from different demographic characteristics of our ICU population and a different pattern of diseases. It appears that PRISM is not population independent.

Confirmation of the safety of central venous catheterisation in critically ill infants and children--the Baragwanath experience.

OBJECTIVE: To evaluate, in critically ill children, the safety and effectiveness of routine central venous catheterisations (CVCs) performed by residents from all disciplines. DESIGN: Prospective audit of all CVCs over a 24-month period. SETTING: Multidisciplinary intensive care unit at Baragwanath Hospital, Soweto. PATIENTS: All critically ill patients 12 years of age or younger requiring CVC. All percutaneous sites (subclavian, internal jugular and femoral) were used; these were selected by the attending doctor and not influenced by the audit. RESULTS: There were 272 catheterisation attempts, of which 241 (88.6%) were successful. Patient age and size but not disease severity influenced incidences of both catheterisation failure and minor bleeding. The latter was the commonest early complication, occurring in 63 (23.2%) successful catheterisations. There were 7 major complications-3 pneumothoraces, 2 tachyarrhythmias and 2 major bleeds, all with subclavian vein catheterisation. Catheter-related infections (CRIs) occurred in 85 (51.2%) of 166 lines and catheter-related septicaemia (CRS) in 10 (5.7%) of 175 lines where there were sufficient data for evaluation. No patient or line factor, including duration of insertion, influenced CRI or CRS. In CRI, Staphylococcus epidermidis was the commonest organism. Other common CRI isolates were Enterococcus faecalis, Klebsiella spp. and Candida albicans. Six different organisms were implicated in CRS. CONCLUSIONS: CVC is a safe procedure with a high success rate. The femoral vein is the recommended percutaneous site of choice as it carries no great risk of sepsis and does not expose the patient to the hazard of intrathoracic complications.