28 research outputs found
Gastro-oesophageal reflux disease in paediatric patients
No abstract available.http://www.pntonline.co.za/index.php/PN
Should the routine approach to diarrhoea management be modified in an area of high prevalence of paediatric HIV infection?
BACKGROUND: Unthinking application of the routine diarrhoea management protocol in patients presenting with diarrhoea could risk possible co-morbidities such as HIV infection being ignored in an environment with a high prevalence of HIV infection. Furthermore, a patterned response to testing for HIV infection only those children in whom it is suspected on clinical grounds will lead to missed opportunities for HIV care.
AIMS AND METHODS: This was a retrospective review of patients admitted to Kalafong and Steve Biko referral hospitals to identify the impact of a high prevalence of HIV infection in the community on the routine management of diarrhoea.
RESULTS: A total of 176 patients were included. HIV tests were performed on 99 patients, and HIV infection was therefore not considered as a co-diagnosis in 78 of 176 (44.3%) of patients with diarrhoea.
On admission, the group of children tested for HIV infection were similar to the other groups (not tested for HIV or HIV negative) in age, but showed differences in respect of duration of diarrhoea and preceding events prior to referral. More children tested for HIV infection also had clinical wasting, generalised lymphadenopathy or hepatomegaly compared with untested children (p<0.005). However, there were no differences in the proportion of tested children with prior antibiotics before referral, presence of co-morbid pneumonia or urinary infection.
Patients with diarrhoea were more likely to be tested for HIV if they were severely malnourished or clinically wasted, if they had hyponatraemia or hypokalaemia, and if they had hepatomegaly or lymphadenopathy. The presence of shock or severe dehydration on admission, or of co-morbid pneumonia, did not differentiate between those who were tested for HIV and those who were not.
There were statistically significant differences between those tested for HIV and those not tested in respect of outcome. Among the children tested for HIV, 24.2% of survivors had a prolonged hospital stay (more than 10 days), compared with 1.4% among those not tested (p<0.005). While more children in the group tested for HIV died in hospital (6.1% v. 2.6%), this did not reach statistical significance (p=0.466).
CONCLUSION: In this study, HIV testing was found to be predominantly based on clinical grounds at the time of admission. Because of considerable clinical overlap between diarrhoea patients with and without HIV infection, HIV co-infection cannot be reliably predicted on clinical features alone and must be actively excluded.
Effective ART is now available. All patients with diarrhoea must therefore be offered HIV testing to provide earlier access to appropriate management.http://www.sajch.org.za/index.php/SAJC
Prevalence of coeliac disease in children and adolescents with type 1 diabetes mellitus in a tertiary hospital in South Africa
Background. International literature has shown the prevalence of coeliac disease (CD) in children and adolescents with diabetes to range
from 1 - 10%. Prevalence rates in African countries are limited or unknown.
Objective. The objective was to describe the prevalence of CD in all children and adolescents with type 1 diabetes mellitus presenting to
the paediatric and adult diabetic clinic at Steve Biko Academic Hospital, Pretoria, South Africa.
Method. A retrospective review of the files of all children and adolescents in the paediatric and adult diabetic clinic with type 1
diabetes mellitus between August 2016 and June 2019 was conducted. Children requiring screening and/or intestinal biopsies were also
prospectively included during this period. The setting of this study was Steve Biko Academic Hospital, a tertiary referral centre, in Pretoria,
South Africa. Coeliac screening included anti-deaminated gliadin antibodies and anti-tissue transglutaminase antibodies (both IgA and
IgG). All biopsies were obtained by a paediatric gastroenterologist or an experienced paediatric surgeon.
Results. A total of 184 files were screened; 132 met inclusion criteria but only 108 patients in total had coeliac screening. Positive antibody
screening for CD was found in 11 out of 108 patients (10.2%). Nine of the 11 serology-positive patients had biopsies performed. Out of the
nine biopsies, two (22.2%) were positive for CD based on the Marsh-Oberhuber classification.
Conclusion. This study found a prevalence of serology-positive CD in our local population of South African children with type 1 diabetes
mellitus of 10.2%, while the prevalence of biopsy-confirmed CD was found to be 1.9%.http://www.sajch.org.za/http://www.sajch.org.za/index.php/SAJCHInternal MedicinePaediatrics and Child Healt
South African food allergy consensus document 2014
The prevalence of food allergy is increasing worldwide and is an important cause of anaphylaxis. There are no local South African food allergy guidelines. This document was devised by the Allergy Society of South Africa (ALLSA), the South African Gastroenterology Society (SAGES) and the Association for Dietetics in South Africa (ADSA). Subjects may have reactions to more than one food, and different types and severity of reactions to different foods may coexist in one individual. A detailed history directed at identifying the type and severity of possible reactions is essential for every food allergen under consideration. Skin-prick tests and specific immunoglobulin E (IgE) (ImmunoCAP) tests prove IgE sensitisation rather than clinical reactivity. The magnitude of sensitisation combined with the history may be sufficient to ascribe causality, but where this is not possible an incremental oral food challenge may be required to assess tolerance or clinical allergy. For milder non-IgE-mediated conditions a diagnostic elimination diet may be followed with food re-introduction at home to assess causality. The primary therapy for food allergy is strict avoidance of the offending food/s, taking into account nutritional status and provision of alternative sources of nutrients. Acute management of severe reactions requires prompt intramuscular administration of adrenaline 0.01 mg/kg and basic resuscitation. Adjunctive therapy includes antihistamines, bronchodilators and corticosteroids. Subjects with food allergy require risk assessment and those at increased risk for future severe reactions require the implementation of risk-reduction strategies, including education of the patient, families and all caregivers (including teachers), the provision of a written emergency action plan, a MedicAlert necklace or bracelet and injectable adrenaline (preferably via auto-injector) where necessary.http://www.samj.org.zaam2016Paediatrics and Child Healt
Epidemiology of IgE-mediated food allergy
Despite the large number of foods that may cause immunoglobulin E (IgE)-mediated reactions, most prevalence studies have focused on
the most common allergenic foods, i.e. cow’s milk, hen’s egg, peanut, tree nut, wheat, soya, fish and shellfish.
Food allergy peaks during the first two years of life, and then diminishes towards late childhood as tolerance to several foods develops.
Based on meta-analyses and large population-based studies, the true prevalence of food allergy varies from 1% to >10%, depending on the
geographical area and age of the patient.
The prevalence of food allergy in South Africa (SA) is currently being studied. The prevalence of IgE-mediated food allergy in SA
children with moderate-to-severe atopic dermatitis is 40%; however, this represents a high-risk population for food allergy. Preliminary data
from the South African Food Sensitisation and Food Allergy (SAFFA) study, which is investigating food allergy in an unselected cohort of
1 - 3-year olds, show a prevalence of 11.6% sensitisation to common foods. Food allergy was most common to egg (1.4%) and peanut (1.1%).
Food allergy appears to be the most common trigger of anaphylactic reactions in the community, especially in children, in whom food is
responsible for ≥85% of such reactions. In adults, shellfish and nut, and in children, peanut, tree nut, milk and egg, are the most common
triggers of food-induced anaphylaxis.http://www.samj.org.zahb201
Exclusion diets and challenges in the diagnosis of food allergy
Instituting an exclusion diet for 2 - 6 weeks, and following it up with a planned and intentional re-introduction of the diet, is important for
the diagnosis of a food allergy when a cause-and-effect relationship between ingestion of food and symptoms is unclear.
Food may be re-introduced after (short-term) exclusion diets for mild-to-moderate non-immunoglobulin E (IgE)-mediated conditions in
a safe clinical environment or cautiously at home. However, patients who have had an IgE-mediated immediate reaction to food, a previous
severe non-IgE-mediated reaction or a long period of food exclusion should not have a home challenge, but rather a formal incremental
food challenge protocol in a controlled setting.
An incremental oral food challenge (OFC) test is the gold standard to diagnose clinical food allergy or demonstrate tolerance. It consists
of gradual feeding of the suspected food under close observation. It should be done by trained practitioners in centres that have experience
in performing the procedure in an appropriate setting.
An OFC must be performed in a setting where resuscitation equipment is available in the event of a severe anaphylactic reaction. OFCs are
terminated when a reaction becomes apparent. Standardised and pre-set criteria are available on when to discontinue challenges. Patients who
tolerate the full dose ‘pass’ the challenge and are advised to eat a full portion of the food at least twice a week to maintain tolerance. Those who
have reactions have ‘failed’ the challenge, should avoid the food, receive education and implement risk-reduction strategies where appropriate.
Patients should be observed for a minimum of 2 hours following a negative challenge and for 4 hours after a positive one.http://www.samj.org.zahb201
Vaccination in food allergic patients
Important potential food allergens in vaccines include egg and gelatin. Rare cases of reactions to yeast, lactose and casein have been reported.
It is strongly recommended that when vaccines are being administered resuscitation equipment must be available to manage potential
anaphylactic reactions, and that all patients receiving a vaccine are observed for a sufficient period.
Children who are allergic to egg may safely receive the measles-mumps-rubella (MMR) vaccine; it may also be given routinely in primary
healthcare settings. People with egg allergy may receive influenza vaccination routinely; however, some authorities still perform prior skinprick
testing and give two-stage dosing. The purified chick embryo cell culture rabies vaccine contains egg protein, and therefore the human
diploid cell and purified verocell rabies vaccines are preferred in cases of egg allergy.
Yellow fever vaccine has the greatest likelihood of containing amounts of egg protein sufficient to cause an allergic reaction in allergic
individuals. This vaccine should not be routinely administered in egg allergic patients and referral to an allergy specialist is recommended,
as vaccination might be possible after careful evaluation, skin-testing and graded challenge or desensitisation.http://www.samj.org.zahb201
Novel therapies in the management of food allergy : oral immunotherapy and anti-IgE
The process of oral immunotherapy (OIT) consists of a series of dose escalations with the immediate goal of inducing desensitisation and
ultimately achieving a state of tolerance.
Owing to the limitations of OIT, including side-effects and lack of proven efficacy in long-term tolerance induction, it is not yet
recommended in routine clinical practice and should be restricted to the research setting.
Studies using anti-immunoglobulin E (IgE) antibody in food allergy management are limited, but show promising results. The possible
applications are for increasing the sensitivity threshold to certain foods such as peanut, and also for use in combination with OIT to enhance
safety and rapidity of the OIT process; however, anti-IgE is not yet licensed for use in food allergy.http://www.samj.org.zahb201
Severe food allergy and anaphylaxis : treatment, risk assessment and risk reduction
An anaphylactic reaction may be fatal if not recognised and managed appropriately with rapid treatment. Key steps in the management of
anaphylaxis include eliminating additional exposure to the allergen, basic life-support measures and prompt intramuscular administration
of adrenaline 0.01 mg/kg (maximum 0.5 mL). Adjunctive measures include nebulised bronchodilators for lower-airway obstruction,
nebulised adrenaline for stridor, antihistamines and corticosteroids. Patients with an anaphylactic reaction should be admitted to a medical
facility so that possible biphasic reactions may be observed and risk-reduction strategies initiated or reviewed after recovery from the acute
episode.
Factors associated with increased risk of severe reactions include co-existing asthma (and poor asthma control), previous severe
reactions, delayed administration of adrenaline, adolescents and young adults, reaction to trace amounts of foods, use of non-selective
β-blockers and patients who live far from medical care.
Risk-reduction measures include providing education with regard to food allergy and a written emergency treatment plan on allergen
avoidance, early symptom recognition and appropriate emergency treatment. Risk assessment allows stratification with provision of
injectable adrenaline (preferably via an auto-injector) if necessary. Patients with ambulatory adrenaline should be provided with written
instructions regarding the indications for and method of administration of this drug and trained in its administration. Patients and their
caregivers should be instructed about how to avoid foods to which the former are allergic and provided with alternatives. Permission must
be given to inform all relevant caregivers of the diagnosis of food allergy. The patient must always wear a MedicAlert necklace or bracelet
and be encouraged to join an appropriate patient support organisation.http://www.samj.org.zahb201