Category Archives: For General Practitioners

Bell’s palsy – time for a rethink re steroids for children?

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Steroids vs Steroids & Antivirals for Bell ’s Palsy

by Dr Tom Waterfield

Bell’s palsy is an idiopathic facial nerve palsy first described by Sir Charles Bell in 1830. It typically presents with a sudden onset of unilateral facial palsy. It presents as a unilateral lower motor neurone weakness ie. the forehead is also involved (if the forehead is not involved, this is an upper motor neurone weakness with a different aetiology and needs prompt referral for further investigation). The prognosis in true Bell’s is typically good with up to 90% of children recovering by 3 months of age1. The mainstay of management in children is supportive (artificial tears/patching). The convention – at least in adults – is for the early (within 72 hours of onset) use of oral prednisolone at a dose of 2mg/kg (max 60-80mg) for 5 days followed by a 5 day tapering dose2. The evidence base for this comes from large randomised controlled studies in adults3,4.

Evidence for the use of steroids alone

Two large double blind randomised control studies looking at over 1300 patients demonstrated that early use of Prednisolone orally significantly improved symptoms at 3 months (p<0.001) with a NNT of around 53,4. There are no similar studies in children and it is worth considering that children typically have a better prognosis than adults. Whilst prednisolone orally would be appropriate and safe for most children there may be instances where the risks of oral steroids could be considered too great to justify their use i.e. in a poorly controlled diabetic patient (which is a group in whom Bell’s palsy is more prevalent).

Evidence for the use of combined steroids and antivirals

In the last decade there has been an ongoing debate around the use of oral antiviral agents such as Aciclovir in the management of Bell’s Palsy. It is widely believed that Bell’s Palsy is due to an underlying Herpes Simplex infection and PCR studies have demonstrated concurrent HSV infection at the facial nerve in adult patients with Bell’s Palsy5. Despite this, good quality, large scale studies looking at the efficacy of oral antiviral agents have failed to demonstrate a benefit3,4.

Summary

The current evidence base for the medical management of Bell’s palsy comes predominantly from adult data3,4. Children typically have a milder illness with a quicker recovery than adults irrespective of the treatment chosen1. UpToDate would have us believe that the mainstay of medical management is the use of oral steroids at a dose of 2mg/kg(max 60-80mg) for 5 days followed by a 5 day taper. Additional antiviral treatment appears to be unnecessary with large-scale, high quality studies not showing a benefit. Smaller, lower quality studies have suggested additional antivirals may be useful and these could be considered on a case by case basis6,7. For example in a severe case (complete paralysis) with clinical evidence of concurrent Herpes Simplex infection it may be worth considering additional antiviral medication such as oral Aciclovir.

 

References:

  1. Peitersen E. Bell’s palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. ActaOtolaryngol Suppl. 2002.
  2. https://www.aan.com/Guidelines/Home/GetGuidelineContent/574 (Last accessed 19/08/2014 at 12:03)
  3. Sullivan FM, Swan IR, Donnan PT et al. Early treatment with prednisolone or acyclovir in Bell’s palsy. N Engl J Med. 2007;357(16):1598.
  4. Yeo SG, Lee YC, Park DC, Cha CI. Acyclovir and steroid versus steroid alone in the treatment of Bell’s palsy. Am J. Otolaryngol 2008;29:163–168.
  5. Schirm J, Mulkens PS. Bell’s palsy and herpes simplex virus. APMIS. 1997;105(11):815.
  6. Minnerop M, Herbst M, Fimmers R, Kaabar P et al. Bell’s palsy: combined treatment of famciclovir and prednisone is superior to prednisone alone. Neurol. 2008 Nov;255(11):1726-30.
  7. Lee HY, Byun JY, Park MS, Yeo SG.Steroid-antiviral treatment improves the recovery rate in patients with severe Bell’s palsy.Am J Med. 2013 Apr;126(4):336-41.

July 2014 published

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Last bit of headaches this month with guidance on management of various primary headaches, including medication overuse headache.  Also more on domperidone, psoriasis, respiratory and heart rates to worry about and a link to a new colic summary I’ve put under the Primary Care Guidelines tab.  Do leave comments below.

Sick and tired – the truth about infantile reflux

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Sick and tired – the truth about infantile reflux

By Dr Tom Waterfield

We have all had that difficult conversation regarding “reflux” when a tired parent has come to us with their “sicky child” and an unshakeable belief that their baby has gastro-oesophageal reflux disease. There is often enormous pressure to provide a solution but how do we decide which children need treatment and what treatments should we use? In view of the recent concerns regarding the use of Domperidone I have chosen to review the current evidence base for the management of this common problem.

 

The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition(NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) produced a useful guideline document in 20091. This concise 50 page document discusses the evidence base for all aspects of gastro-oesophageal reflux and some of the key points are outlined below.

 

Diagnosis

1)      Physiological Gastro-oesophageal reflux (GER) is common; around 50% of healthy infants will display symptoms of GER. These “happy spitters” will be gaining weight and healthy1.

2)      Faltering growth is unlikely to be due to GERD and alternate diagnosis such as cow’s milk protein allergy should be considered1.

Investigation

1)      The Gold-Standard investigation to make a positive diagnosis of GERD is an impedance study. This has largely replaced the pH study. In this study the changes in the electrical impedance (ie, resistance) between multiple electrodes located along an oesophageal catheter are used to measure reflux. Unlike a pH study the impedance study will also be able to detect non-acidic reflux1.

 

2)      In the majority of cases there will be no role for any other diagnostic test for GERD1

Management

1)      Reassurance

Try to avoid treating simple GER. Reassurance is often all that is required. Before starting any treatment have a frank discussion regarding the risks and benefits1.

 

2)      Positioning “Tummy Time”

There is evidence that lying prone improves GERD when compared with lying supine or semi-erect. It is however, not recommended that children sleep prone due to the associated risk of sudden infantile death (SIDS). A sensible compromise might involve allowing the child to lie prone when awake and supervised by the parent. Semi-supine positions (such as sitting in a car seat) are not recommended and may exacerbate reflux symptoms1.

 

3)      Thickened Feeds

Commercially available thickened feeds (anti-reflux feeds) are safe and relatively effective at reducing visible regurgitation1.

 

4)      Buffering agents and Alginates

There is very little evidence to support the use of alginates (e.g. Gaviscon Infant) in the treatment of GERD although their use is likely to be safe1.

 

5)      H2RAs and PPIs (Unlicensed treatments)

Antacid treatment with Histamine 2 Receptor Antagonsists (HR2As) is effective at healing proven oesophagitis in adults but there is very little data to support their use in infancy. H2RAs such as Ranitidine are relatively safe but their effectiveness is unproven and there are high rates of tachyphylaxis thereby limiting their usefulness in the long term1.

 

Proton Pump Inhibitors (PPIs) such as Lansoprazole and Omeprazole do not demonstrate tachyphylaxis and can be used for longer term acid suppression. Despite this however, randomised placebo controlled studies have failed to demonstrate a benefit of (PPIs) over placebo when treating GERD in infants1.

 

Some studies have suggested that long term acid suppression with PPIs and H2RAs can lead to increased rates of pneumonia and gastroenteritis1.

 

6)      Prokinetics (unlicensed)

ESPGHAN and NASPGHAN advise against the use of all prokinetic agents including Erythromycin and Domperidone. There is no reliable evidence to support their effectiveness at treating GERD in infants and there have been concerns raised over the potentially cardiotoxic effects of Domperidone2.

 

Summary

Reflux is very common with half of infants having some symptoms. In the majority of cases reassurance is all that is required. If symptoms are severe and persistent and an alternate diagnosis is unlikely then consider thickened feeds and “tummy time” as a first line treatment. If this is unsuccessful then consider antacids but be aware that the evidence base for these treatments is limited and they are being used off license. Prokinetics play no part in managing GERD in infants and Domperidone use may be cardiotoxic2.

 

References

1)      Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition(NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)Journal of Pediatric Gastroenterology and Nutrition. 49:498–547 # 2009

2)      Domperidone: limited benefits with significant risk for sudden cardiac death. Hondeghem LM.J CardiovascPharmacol. 2013 Mar;61(3):218-25.

 

Do baby slings cause SIDS?

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Paediatric Pearls’ “from the literature” series is written by Luton paediatric registrar, Tom Waterfield.  Always inciteful, sometimes wry and eminently readable, this month he shares with us his self-diagnosed neuroses about his new baby son’s sling:

I recently became a first time father and since then my son (Alexander) has turned my life upside down! In the space of two weeks I have morphed from a calm paediatrician into a neurotic and over anxious parent. I often ask myself “is he breathing too fast”, “is he breathing too slowly”, “what was that funny noise” and like all parents I worry about cot death (Sudden Infantile Death Syndrome – SIDS). In the UK the Back to sleep campaign has significantly reduced the risk of SIDS and most parents are now aware of the risks and how to avoid them1.

Link to Back To Sleep Article & Guidelines (www.medscape.com/viewarticle/781979_2)

Like many parents we own a baby sling and Alex loves it. I was happy with the sling until I read an article from the Telegraph on a recent high profile case of SIDS attributed to suffocation secondary to the use of a baby sling2. The case was horrific and triggered the neurotic parent in me. Had I been placing Alex at risk by using a baby sling?

The calm paediatrician in me decided that a quick literature search was required. During that search I found:

1)      In the United States the Consumer Product Safety Commission reported a total of 14 deaths attributed to baby slings spanning a period of 20 years3

  • 12 of these deaths occurred in children under 4 months of age
  • “many” of the deaths occurred in babies with additional risk factors for SIDS
  • 3 deaths occurred in 2010 following use of Infantino baby slings

 

2)      A Medline search identified three papers (all case reports/case series)4-6.

  • Two articles were only available in Spanish 5,6
  • The third was a case report of two babies (both under 4 months of age) who reportedly died from suffocation after being carried in a baby sling6

Summary

From what little literature there is available it would appear that death secondary to use of a baby sling is exceptionally rare. In most cases death has occurred in infants aged less than 4 months who have poor head control and are at risk of suffocation either by direct contact with sling fabric or with extreme neck flexion resulting in airway obstruction. If parents choose to use a sling then they should be encouraged to use them in children over 4 months of age and to be careful to ensure that manufacturer’s guidelines have been followed. Parents may choose not to use slings in children with additional risk factors for SIDS (Prematurity, low birth weight, intercurrent respiratory illness).

References

1)      Hendrie JM, Meadows-Oliver M, Expanded Back to Sleep Guidelines. PediatrNurs. 2013;39(1):40-42.

2)      http://www.telegraph.co.uk/health/10744051/Warning-over-baby-slings-after-five-week-old-suffocates.html (Last accessed 17/05/2014)

3)      http://www.cpsc.gov/en/Newsroom/News-Releases/2010/Infant-Deaths-Prompt-CPSC-Warning-About-Sling-Carriers-for-Babies/ (Last accessed 17/05/2014)

4)      Madre C, Rambaud C, Avran D et al. Infant deaths in slings.Eur J Pediatr. 2013 Dec 18.

5)      Martin-Fumadó C, Barbería E, Galtés I et al. Death by incorrect use of baby sling: multidisciplinary approach to infant injuries.AnPediatr (Barc). 2013 Apr;78(4):271-2.

6)      MaquedaCastellote E, GiliBigatà T, Sánchez Pérez S et al. Infant suffocation associated with the incorrect use of a baby sling.AnPediatr (Barc). 2012 Dec;77(6):416-7.

April 2014

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More musings from Dr Waterfield this month – this time on paracetamol for immunisation discomfort.  Also the 7 important features of a headache y0u must ask about, a link to a very good paediatric emergency medicine site, NICE quality standards in depression, molluscum contagiosum and more musings from me, this time on paediatric phlebotomy.  Do leave comments below.