Paediatrics and Child Health (United Kingdom)最新文献

Urticaria commonly occurs in childhood, affecting up to 15% of British children. It is characterized by the sudden onset of wheals, angioedema, or both. Episodes are usually acute, often triggered by viral infections or antibiotics, with approximately a third progressing to chronic or recurrent urticaria. This review focuses on chronic urticaria subtypes, diagnosis and treatment options for children. The diagnosis is usually made clinically, and a focused history is key. Detailed investigation is usually unnecessary. Chronic urticaria is divided into chronic spontaneous urticaria and the inducible urticarias. Chronic spontaneous urticaria is autoimmune in origin, in approximately 40% of older children. Cold urticaria and dermographism are the most common inducible urticarias. Isolated angioedema should prompt consideration of hereditary angioedema. The mainstay of treatment is trigger avoidance combined with non-sedating antihistamines. Higher doses of antihistamines may be required but these are usually tolerated well. We provide guidance on antihistamine updosing strategies. There is an improvement in symptoms for most children, but leukotriene receptor antagonists can provide additional improvements in some children. Tranexamic acid may provide symptomatic relief for isolated angioedema. Short courses of oral steroids may be used in acute episodes or highly symptomatic patients with chronic urticaria. Second line treatment for non-responders is primarily monoclonal anti-IgE antibody therapy but a small number of children and young people continue to have significant symptoms despite this and in these children ciclosporin may be useful. Urticaria usually resolves and almost all children and young people are disease free after 7 years.

Allergen immunotherapy, also called desensitisation, is a strategic process by which the immune system is gradually “trained” to tolerate increasing amounts of an allergen, which it previously would have reacted to. In the UK, it is estimated that approximately 20% of the population suffers with at least one allergic disease. The potential to modify the disease process is no longer out of our reach for certain allergies, with the hope of improved quality of life. Immunotherapy can be offered as a treatment for IgE mediated allergic disease such as allergic rhinoconjunctivitis, immediate type food allergies, bee and wasp anaphylaxis, and can have a synergistic effect on asthma and eczema. However, it would be incorrect to consider this treatment as a panacea, as there remain pitfalls, gaps in equity of treatment, and uncertainty with longer-term efficacy of the newer food desensitisation treatments. This review focuses on our current clinical understanding and indications for immunotherapy for children and young people, delivery and monitoring within the UK, and the future scope of immunotherapy.

FPIES (food-protein-induced enterocolitis syndrome) is a severe, non-IgE-mediated allergic reaction. Its hallmark is the onset of acute vomiting one to four hours post ingestion of a trigger food. Reactions can result in such significant hypovolaemia as to be end organ or life threatening and require prompt recognition and fluid support. FPIES is a disorder of infancy, and recent BPSU survey data suggests it is still under-recognized within the UK. Its presentation can mimic other more common conditions, such as sepsis and gastroenteritis, leading to under-recognition and diagnostic delay. Patients often end up experiencing multiple FPIES reactions before the diagnosis is reached. As it is a non-IgE-mediated condition, there is currently no diagnostic test available to confirm FPIES. Diagnosis therefore relies on awareness of the condition and accurate history taking. This article provides an overview of the epidemiology, diagnosis, and management of FPIES, and seeks to increase reader awareness and recognition of this rare but important form of food allergy.

Congenital inguinal hernias (CIH), hydrocoeles and undescended testes (UDT) are common groin conditions in neonates, infants and children that are encountered by general practitioners, paediatricians, general surgeons and paediatric surgeons. CIH, hydrocoeles and UDT share a common embryological origin. Clinical differentiation between the three conditions can be challenging, particularly as they may exist in isolation or combination in the same patient. Accurate clinical distinction is imperative as the management and outcome is different for each condition. Surgery and outcomes for these conditions is discussed.

Scrotal conditions are frequently seen in male children and can reflect a wide spectrum of underlying pathologies. Detailed history and prompt examination is essential to differentiate between those that require urgent surgical management and benign conditions that can be treated conservatively. Testicular torsion remains the most time critical event with a high risk of gonadal loss. This article provides a brief review of all aspects of diagnosis and management of such conditions, highlighting the principles of surgical management and outcome.

Infantile hypertrophic pyloric stenosis (IHPS) is one of the most commonly encountered paediatric surgical conditions. It is estimated to affect between 1 and 4 infants per 1,000 births, representing the most common cause of surgical intervention in the first 6 months of life. The exact aetiology remains unclear. It is known to be more common in males (4:1), especially those that are first-born. Abdominal examination can sometimes detect visible stomach peristalsis in the left upper quadrant and the pathognomic sign of an “olive shaped” epigastric mass may be present. In cases of diagnostic uncertainty or where a definitive mass is not felt, ultrasound is the investigation of choice for confirming IHPS, with high sensitivity and specificity. Following appropriate pre-operative optimisation and surgical correction is undertaken. The Ramstedt’s pyloromyotomy con be performed via a right upper quadrant, peri-umbilical, or laparoscopic approach. The vast majority of cases recover quickly with no concerns, with the infant almost invariably discharged soon after treatment. Perforation requiring mucosal repair and incomplete pyloromyotomy requiring re-do surgery as the specific complications.

Ankle instability is a common problem in children and adolescents. What may seem like an initial, relatively benign ankle injury for a child may lead to chronic pain, chronic instability and gradual loss of the ability to participate in certain activities. The complications of an ankle injury can include osteochondral defects, which may require urgent surgical attention and may be associated with an increased long-term risk of osteoarthritis. This article aims to provide trainees and general orthopaedic surgeons with a systematic approach to the assessment, diagnosis and management of ankle instability in the paediatric population. We explore the mechanisms of the initial injury together with factors that may increase the risk of injury to the child. Guidance on clinical examination and of the ankle joint is provided. Though short periods of immobilization and proprioceptive activities are the mainstay of treatment, there is a small subset of these patients who will benefit from further imaging and surgical intervention to prevent the chronic sequelae of ankle instability.

Abdominal pain is a common experience during childhood and frequently presents to secondary healthcare facilities. Although non-specific abdominal pain and appendicitis are the most common causes, the clinician should also be aware of the diagnosis and management of all causes of abdominal pain in children. This article provides an overview of abdominal pain in children, including history and examination, initial management, diagnostic categories, modes of investigation, and definitive treatment.

Genu valgum is a common lower limb deformity seen in children. There are multiple causes for the development of genu valgum but to be able to accurately assess the child it is important to understand the physiological development of the lower limbs. Although often asymptomatic and idiopathic, genu valgum can be associated with underlying pathology, such as rickets, previous proximal tibia fracture leading to valgus deformity, tumours and dysplasias which often require a multidisciplinary approach to management of the condition. This article will review the common causes of genu valgum in children, explain how to clinically assess the child and cover possible management options for each condition.