Multivitamins & Children

This is a common question I get asked as a GP. We know that growing children have nutritional needs. The Department of Health recommends that children between six months to five years are given daily vitamin supplements.

If your child eats a balanced diet then they may not need supplements however. A daily healthy diet consists of protein such as lean meat or fish, pulses or eggs and five portions of fruits/vegetables. Seek advice from your health visitor, GP or pharmacist. They may advise that in those with chronic diseases like asthma or a restrictive diet eg veganism, supplements be given. For fussy eaters just remember that supplements are not the answer and should not be used to justify a poor diet. Focus on improving eating habits rather than relying on multivitamins.

Vitamin toxicity can occur so be careful about giving more than one supplement such as cod liver oil and a multivitamin tablet – as cod liver oil has vitamin A. Treat vitamins as medicines, keep out of children’s reach and do not exceed the recommended dose.

A Word About Vitamin D…

Vitamin D is important to regulate the body’s calcium which is needed for healthy bones, teeth and muscles. The body creates vitamin D from direct sunlight, which occurs in sufficient amounts from March to September. Some foods have vitamin D such as oily fish, red meat and egg yolks. However, for the winter months a supplement maybe needed.

The Department of Health recommends that:

  • Children aged 1-4 years old should be given a daily supplement containing 10mcg of vitamin D
  • For children over the age of 5 (during autumn and winter) should consider taking a daily supplement containing 10mcg of vitamin D.

The Department of Health recommends that you take a daily supplement containing 10mcg of vitamin D throughout the year if you:

  • are not often outdoors – for example, if you’re frail or housebound
  • usually wear clothes that cover up most of your skin when outdoors eg religious clothing
  • if you’re from a minority ethnic group with dark skin, such as African, African-Caribbean or south Asian

High levels of Vitamin D can affect heart and kidneys. Children aged 1-10 years shouldn’t have more than 50mcg a day. Infants under 12 months shouldn’t have more than 25mcg a day.

More information on vitamin D:

https://www.rnoh.nhs.uk/our-services/children-adolescents/vitamin-d-children

Food Allergies Among Young Children

This is the first in a series of medical articles. Food allergies amongst young children are becoming more commonplace. Allergy specialist Consultant Dr Adam Fox has passed on his expertise on the area to mum2sons.

What is a food allergy?

Once a medical curiosity, now almost every classroom in the US, UK and Australia has a child who must avoid milk, egg or nuts. Food allergies occur when your immune system becomes confused – instead of ignoring harmless food proteins, it triggers a reaction that leads to the release of a chemical called histamine. It is this that causes the classic allergy symptoms of hives or swelling. If the reaction becomes severe, it is called anaphylaxis and this type of reaction may be life-threatening.

Scientists are still puzzled as to why there has been such a rapid increase in allergies. The most popular explanation is the ‘hygiene hypothesis’, which suggests the increasing cleanliness of the modern world is leaving our immune systems under-stimulated. With too few bacteria and viruses to fight, our body’s defences start to direct inappropriate responses to harmless things such as pollen or foods.

How will I know if my child has a food allergy?

Food allergies are far more common among children in families where other members suffer from an allergy. Babies who suffer from eczema are particularly at risk of food allergies. The more severe the eczema, and the earlier in life it began, the more likely there is to be a food allergy. Some food allergies are quite easy to spot – as soon as the food is eaten (often for the first or second time) an itchy rash develops, usually around the mouth. There may also be swelling of the face, runny nose and itchiness, as well as vomiting. With severe reactions, there may be difficulty breathing and, if this occurs, you should call an ambulance immediately.

Sometimes, food allergies can be more subtle and difficult to detect, especially if they are delayed allergies. These tend to be more of a problem in infancy. Delayed allergic involve parts of the immune system that take much longer to respond. The end result means it’s difficult to pinpoint a particular food as the problem and sufferers may continue to eat or drink the food allergen. Delayed allergies in infants may cause chronic symptoms such as eczema, reflux, colic, poor growth, diarrhoea or even constipation. The symptoms only get better when the food is removed from the diet. However, these symptoms commonly occur during childhood and an allergic reaction is only one possible explanation – and not the only one. Trying to work out whether the problem is a food allergy can be very difficult and requires the help of an experienced doctor.

What should I do if I suspect an allergy?

If you think your child has had an immediate reaction, it is best to avoid the food until you have seen a doctor. If you suspect something in your child’s diet is causing more delayed symptoms – such as eczema or reflux – it can be helpful to keep a food diary until you see the doctor.

What can my doctor do for me?

Diagnosing food allergies relies on keeping a careful medical history, examination and special allergy tests. With immediate allergies, testing can be done by a blood test or by a ‘skin-prick’ test, when food extracts are placed on the skin of the arm.

Unfortunately, things are less easy with delayed allergies because there are not any reliable and straightforward tests. However, careful exclusion diets – with the suspected food completely taken out of the diet – may be recommended with the assistance of an experienced dietician.​

Looking after a child with a food allergy

The best treatment for a food allergy is to completely avoid the problem food. Being diagnosed with a food allergy has a massive impact on the whole family. A simple supermarket trip has been shown to be almost 40% longer when shopping for a food-allergic child.

Parents also need to be able to recognise reactions and know exactly how to deal with them when they occur. This usually involves carrying antihistamines everywhere the child goes and, for those children at risk of anaphylaxis, adrenaline injections as well.​

Future

Many food allergies, such as egg and milk, are outgrown during childhood, while allergies to peanuts, nuts, fish and shellfish tend not to go away. Children with food allergies also have a high chance of other allergic problems, such as asthma, eczema and hayfever. It is essential children with food allergies continue to be seen by their doctors as they grow up.

Unfortunately, there appears to be no cure for food allergies at present, although exciting research does promise real progress over the next five to 10 years, not only in our understanding of how to prevent allergies in the first place, but in helping those who already have them.

Dr Adam Fox

Consultant Paediatric Allergist

Adam read Medicine and Neuroscience at Cambridge University before completing his clinical training at University College London. Having completed specialist training in Paediatric Allergy in 2006, he spent 9 years as clinical lead of Allergy at Guy’s & St Thomas’ Hospitals, London. This included the founding of a new Paediatric Allergy service at the Evelina Children’s Hospital, which he developed with his colleagues, Gideon Lack and George du Toit, into Europe’s largest specialist allergy service.

Adam chaired the UK Department of Health National Care Pathway for Food Allergy in Childhood and was a member and later Chair of the National Institute of Healthcare and Clinical Excellence (NICE) clinical guideline development group for food allergy in children.

He is also senior author of the Milk Allergy in Primary Care guideline, which has been widely adopted across the world. Adam was awarded ‘Paediatric Allergist of the Year’ from Allergy UK in 2007. His work on food allergy received the Raymond Horton-Smith prize from Cambridge University for best post-doctoral thesis in 2012 and he was included in The Times ‘Britain’s 100 Best Children’s Doctors’ (2012) as well as the Tatler Doctors List (Top 250 UK consultants).

Adam received the William Frankland Award for Outstanding Contribution to Allergy by the British Society of Allergy & Clinical Immunology in 2015 and was awarded a National Clinical Excellence Award by the Department of Health in 2016.

“https://www.allergylondon.com”

Managing Fever in Children

A fever is defined a high temperature and generally, in children a temperature of over 37.5C (99.5F) is classified as a fever. Dr Seraj Anwer discuses one of the most common presentations for a GP.

.It is a worrying time for most parents when their child has a fever but most of these cases often clear up by themselves without treatment. A digital thermometer is the best way to take your child’s tmperature. Always use the thermometer in the armpit with children under five

Most common causes of Fever

  • Upper Respiratory Tract Infections
  • Flu or flu like illnesses
  • Ear Infections
  • Viral infection with rashes – including chickenpox, roseola, etc.
  • Tonsillitis
  • Urinary Tract Infections (UTIs)
  • After Vaccinations

When to seek urgent medical advice?

Contact your GP or NHS 111 urgently if your child:

  • is under three months old and has a temperature of 38C (101F) or above
  • is between three and six months old and has a temperature of 39C (102F) or above

You should also seek medical attention if your child has other signs of being unwell, such as persistent vomiting, refusal to feed, floppiness or drowsiness. If your child seems well in themselves, playing and attentive – it is less likely they are seriously ill. However it is best to speak to your GP if you are not sure.

Treating a fever

If your child has a fever, it’s important to keep them well hydrated by giving them plenty of cool water to drink. Babies should be given plenty of liquids, such as breast milk or formula. Even if your child is not thirsty, try to get them to drink little and often. If the environment is warm, you could help your child cool down by covering them with a light sheet or opening a window. Sponging is no longer recommended.

Medication

Children’s Paracetamol (Calpol) or Ibuprofen (Neurofen) work as antipyretics, which help to reduce fever, as well as helping pain. It can take up to an hour to work. You cannot give them both at the same time but if one does not work, you may want to try the other later. For example, paracetamol is given at 9am, if your child is still distressed at 11am then can give ibuprofen. If at 3pm there is no improvement, then you give paracetamol again.

Antipyretics are not always necessary. If your child is not distressed there is no need to use them to reduce a fever.

More serious illnesses

Occasionally a fever can be associated with more serious signs and symptoms, such as:

  • short of breath
  • vomiting
  • rash
  • fits/seizures

Possible serious bacterial illnesses include meningitis and pneumonia but these are relatively rare.

Dr Seraj Anwer

(Reference www.nhs.uk)

Dr Seraj Anwer qualified from Himalayan University, India in 2000; he went on to do Surgical Training in Wales for 5 years. He completed his General Practice Training in Hertfordshire and acquired his MRCGP from Royal College of London in 2007. He has been a partner at Lincoln House Surgery, Hemel Hempstead since 2011. His qualifications include MB BS, MRCGP.

Dr Anwer has specialist interests in minor surgery, joint injections & child health. He is also Mental Health Clinical Lead for HVCCG in Dacorum. He is the Dementia and IT Lead at the practice. His hobbies include football, photography, a love for gadgets and spending time with his two sons.

“www.serajanwer.com”

Quick guide to infections
school exclusion
  • Athlete’s foot – none
  • Chickenpox- until all vesicles have crusted over
  • Cold sores (Herpes simplex)- none​
  • Conjunctivitis -none
  • Diarrhoea and/or vomiting – 48 hours from last episode
  • Flu – until recovered
  • German measles (rubella)- four days from onset of rash
  • Glandular fever -none
  • Hand, foot and mouth – none
  • Head lice – none
  • Impetigo- until lesions are crusted (or 48 hours after starting antibiotics)
  • Measles- four days from onset of rash
  • Molluscum contagiosum – none
  • Mumps – exclude child for five days after onset of swelling
  • Ringworm- exclusion not necessary
  • Scabies – can return after first treatment
  • Scarlet fever – can return 24 hours after starting antibiotics
  • Threadworms – none​​
  • Tonsillitis – none
  • Warts and verrucae – none (verrucas should be covered in swimming pools and gyms)
  • Whooping cough – 5 days from starting antibiotic treatment (or 21 days from onset if no treatment
photo-1453733190371-0a9bedd82893

“www.gov.uk for more information”

african male doctor examining baby boy
Asthma

Managing asthma attacks

“Asthma attacks (also known as exacerbations) should be managed by treating the acute symptoms with drugs; and also by establishing why the person had an attack; and whether any preventable risk factors can be addressed to regain control. In my opinion, and the findings of the NRAD, not enough effort is put into the last two aspects of treatment of asthma attacks. In this item, I discuss the drugs and will address the other issues in a later blog.”

  • High doses of reliever medication (short acting bronchodilators, salbutamol – usually delivered via a nebuliser or the blue inhalers using a spacer device.)
  • Oxygen (Ideally used to drive a nebuliser at flow rates over 6L/min)
  • Corticosteroids (prednisolone, cortisone) – lifesaving drugs during attacks which help to clear up the inflammation that occurs before and during attacks.

The issue I’d like to focus on here relates to the duration of corticosteroid treatment after the immediate treatment of the attack. Given that no one knows how long an asthma attack lasts, how long then should corticosteroids be prescribed for asthma attacks?

The problem being that a proportion of people have another attack soon after being treated for one. One of the explanations for this is that the first attack wasn’t treated until completely resolved (i.e. symptoms have cleared up, no need for receiver inhaler and peak expiratory flow back to normal). In particular, because the oral corticosteroid tablets were not continued for long enough.

It seems logical that emergency short courses of corticosteroid treatment should be continued until the attack is over; ie until the person is symptom free. Yet health care professionals tend to prescribe fixed doses of corticosteroids for specific periods of time; typically people are sent home after emergency treatment for an asthma attack, with 3, 5 or 7 days of medication, irrespective of the severity or duration of the attack or response to treatment.

The BTS/SIGN guideline is very clear about the duration of treatment – i.e. that it should be continued until recovery. Also this guideline states that a review should be done within two working days – ie before the person runs out of corticosteroid tablets.

So what do people with asthma and health professionals need to do in order to try to reduce the number of preventable asthma attacks?

In my opinion, three things:

  • People treated for asthma attacks should see their doctor (or asthma nurse) before they run out of corticosteroid (cortisone) tablets so they can be advised whether their attack has resolved, whether to continue or stop these tablets and so that the health professional can identify what went wrong/what led to the attack and optimise the treatment.
  • Provide a peak flow meter and symptom diary chart when sending someone home after treatment. This could help patients, their carers and health care professionals determine whether the attack has resolved based on the readings as well as symptoms. These readings can help decide when the attack is over and when to discontinue corticosteroids.
  • The health care professional should do a detailed asthma review after the attack to determine what went wrong and to optimise treatment based on the assessment.

This blog is not intended as medical advice for individual people with asthma. Always consult your own doctor for advice, but please do feel free to use this blog as a basis for discussion.

Dr Levy has written numerous publications regarding asthma, here are two of his books.