M Stephen Murphy

Recognising and diagnosing autism in children and young people: summary of NICE guidance

Autism affects children, young people, and adults and describes qualitative difference and impairments in reciprocal social interaction and communication behaviours combined with a restricted range of interests and rigid or repetitive behaviours. Autism is diagnosed when features meet the criteria defined in the ICD-10 (international classification of diseases, 10th revision)1 and the DSM-IV-TR (diagnostic and statistical manual of mental disorders, fourth edition, revised)2 for “pervasive developmental disorder” and have a considerable impact on function. Core autism behaviours are typically present in early childhood, but are not always apparent until the circumstances of the child or young person change—for example, when the child goes to nursery or primary school or moves to secondary school. Autism is also associated with several coexisting conditions including neurodevelopmental, medical, and mental health problems. Autism was once thought to be an uncommon developmental disorder, but recent studies have reported increased prevalence and the condition is now thought to occur in at least 1% of children.3 4 5 This has increased demand for diagnostic services for children and young people of all ages in the health service. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on how to recognise and diagnose autism in children and young people up to the age of 19 years.6 This summary focuses on recommendations for the non-specialist on how to recognise the condition and when to refer to a specialist autism team. NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. ### Recognition of autism

Diarrhoea and vomiting caused by gastroenteritis in children under 5 years: summary of NICE guidance

Gastroenteritis is common, with many children having more than one episode a year. The characteristic symptoms—sudden onset of diarrhoea with or without vomiting—are unpleasant and affect both the child and family or carers. Although the illness usually resolves without treatment and can be managed in the community, many children are admitted to hospital each year.1 2 In the absence of national guidance, clinical practice is thought to vary considerably across the United Kingdom, with a major effect on the use of healthcare resources.3 This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the diagnosis, assessment, and management of diarrhoea and vomiting caused by gastroenteritis in children under 5 years.4 NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, recommendations are based on the Guideline Development Group’s opinion of what constitutes good practice. Evidence levels for the recommendations are given in italics in square brackets. ### Diagnosis #### Clinical diagnosis

Management of bloody diarrhoea in children in primary care

Bloody diarrhoea is an uncommon symptom in children, and it may indicate the presence of serious disease. This review focuses on children presenting in a primary care setting. The non-specialist should be aware of the likely causes, initial management, and indications for specialist referral. The emphasis is on children in the developed world, although traveller’s diarrhoea is also considered. The epidemiology and management of this condition are different in the developing world, where infectious causes predominate. In recent years the reported incidence of inflammatory bowel disease increased greatly in the developed world and important advances have been made in its management. This diagnosis should always be considered carefully. #### Sources and selection criteria I used the Medline database to search for evidence from the literature. Randomised controlled trials, meta-analyses, and Cochrane reviews were used when relevant and available. Other sources of evidence included large case series and cohort studies. I obtained information on the incidence of specific pathogens from the UK Health Protection Agency’s Centre for Infections The likely diagnoses vary depending on age (box). At every age intestinal bacterial infections are an important cause. Inflammatory bowel disease may occur at any age but is more likely in older children (>1 year). In young infants non-specific (perhaps allergic) colitis is most likely. Other conditions are rarer but should be considered as they can be serious and even life threatening. #### Causes of bloody diarrhoea (real or apparent) in infants and children ##### Infants aged <1 year ###### Common causes ###### Less common or rare causes ##### Infants aged >1 year ###### Common causes ###### Less common or rare causes This is an important question because if it is assumed that bloody diarrhoea …

Spasticity in children and young people with non-progressive brain disorders: summary of NICE guidance

Spasticity is a form of hypertonia1 and is associated with conditions such as cerebral palsy, which affects 110 000 people in the United Kingdom.2 More than 2000 children born this year in the UK will develop spasticity, which, if unmanaged, will cause pain, affect quality of life, and may lead to complications requiring major surgery. Children and young people with spasticity need early referral to local services that will meet their individual needs and allow them access to the range of interventions that will encourage their motor development. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the management of spasticity in children and young people with non-progressive brain disorders, including those with cerebral palsy.3 NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. ### Principles of care #### Delivering care [ Both points based on the experience and opinion of the Guideline Development Group (GDG) ] #### Management programmes

Contemporary Outcomes for Ulcerative Colitis Inpatients Admitted to Pediatric Hospitals in the United Kingdom

Background:Pediatric ulcerative colitis (UC) care is variable with a lack of appropriate guidelines to guide practice until recently. Methods:UC inpatients <17 years old admitted to 23 U.K. pediatric hospitals had clinical details collected between September 2010 and 2011. Comparative data for 248 patients were available from a previous audit in 2008. Results:One hundred and seventy-six patients (98 males) of median age 13 years (interquartile range, 10–13) were analyzed; 23 were elective surgical admissions, 47 new diagnoses, and 106 needed acute medical care for established UC. Median length of stay was 6 days (interquartile range, 3–10) with no deaths. Eighty-eight of 126 patients (70%) with active disease had standard stool cultures performed (3 [2%] were positive), and 57 (45%) had Clostridium difficile toxin tested (none positive). Twenty-five of 66 (38%) emergency admissions had an abdominal x-ray on admission, and 13 of 66 patients (20%) had a Pediatric Ulcerative Colitis Activity Index score. There were 3 cases of toxic megacolon and 2 thromboses. Eighty-one of 116 patients (71%) responded to steroids. Nineteen patients who did not respond adequately to steroids received rescue therapy (7 infliximab, 11 ciclosporin, and 1 both) with overall response rate of 90%; 7 patients needed surgery acutely, 5 without previous rescue therapy. Compared with the 2008 data, stool culture rates improved significantly (86 of 121 [71%] versus 76 of 147 [52%], P = 0.001) as did heparinization rates (15 of 150 [10%] versus 5 of 215 [2%], P = 0.002) and rescue therapy usage (17 of 33 [52%] versus 10 of 38 [26%], P = 0.03). Conclusions:There were signs of improving UC care with significantly increased rates of stool culture and rescue therapy. The majority of sites, however, did not use Pediatric Ulcerative Colitis Activity Index scores.

End of life care for infants, children and young people with life limiting conditions: summary of NICE guidance

#### What you need to know Children and young people can have a wide range of life limiting conditions and may sometimes live with such conditions for many years. This guideline recommends that end of life care be managed as a long term process that begins at the time of diagnosis of a life limiting condition and entails planning for the future. Sometimes it may begin before the child’s birth. It is part of the overall care of the child or young person and runs in parallel with other active treatments for the underlying condition itself.1 Finally, it includes those aspects related to the care of the dying. This guideline was commissioned with the aim to standardise end of life care for infants, children, and young people living with a life limiting condition, and thus promote equity and consistency. Important themes are to involve children and young people and their parents or carers in decisions about their care, facilitate their care in their preferred location (most likely home), and plan for day and night care. This article summarises the most recent guidance from the recent National Institute for Health and Care Excellence (NICE) on the planning and management of end of life care in infants, children, and young people.2 For a visual summary, please …

Antibiotics for early‐onset neonatal infection: a summary of the NICE guideline 2012

Early‐onset neonatal infection (infection arising within 72 hours of birth) is an important cause of morbidity and mortality and is often caused by Streptococcus agalactiae (group B streptococcus [GBS]). Identifying and assessing risk factors for early‐onset neonatal infection before and during labour and birth is integral to clinical management. Intrapartum antibiotic prophylaxis (IAP) to prevent early‐onset neonatal infection is effective when given to women with particular risk factors, including maternal GBS colonisation. When IAP is given specifically to prevent early‐onset neonatal infection with GBS the National Institute for Health and Care Excellence (NICE) recommends using benzylpenicillin. Alternative antibiotic regimens are appropriate for women who are allergic to penicillin or where local microbiological surveillance data indicate antibiotic resistance.

New drugs: Kids come first; Con: First adults, then children

THE NEW ERA OF BIOLOGIC AGENTS It seems that we may be entering an era of profound and rapid change in the treatment of inflammatory bowel disease (IBD).1,2 Since the introduction of infliximab for the treatment of Crohn’s disease (CD) in the 1990s an ever-expanding range of biologic agents has been developing.3 Each new agent appears to offer therapeutic possibilities. In 2005 it was reported that 14 biologics had been approved by the US Food and Drug Administration (FDA), over 70 were being evaluated in clinical trials, and more than 1000 were in preclinical development.4 If newly emerging agents are thought to have therapeutic potential in IBD, should we aim to rapidly evaluate them in children with a view to incorporating them into pediatric practice? The biologics have real potential to cause harm. We currently possess a range of conventional treatments that despite their deficiencies are effective in many patients. They have the great advantage of having been in use for decades. We therefore have a wealth of information on them for risk/benefit analysis in decisions on therapy. The proper place for these new agents in pediatric IBD should emerge from carefully designed clinical trials. As a general rule, however, they should first be thoroughly evaluated in adult patients.

Faltering growth in children: summary of NICE guidance

#### What you need to know Growth in infants and preschool children is a common cause for parental and professional concern. Some weight loss is common in the early days of life, while establishing feeding, and is usually a physiological phenomenon associated with fluid shifts.1 The term “faltering growth” is used to describe a pattern of slower weight gain than expected for age and sex in infants and preschool children after these early days and is most often due to inadequate nutritional intake. Concerns about faltering growth arise in up to 5% of infants and preschool children, depending on the definition used.23 Concerns are usually raised in primary care, by parents, health visitors, or general practitioners (GPs). Current practice in assessment and management varies across the UK.4 This article summarises the recent National Institute for Health and Care Excellence (NICE) guidance on the recognition and management of infants and preschool children with faltering growth,5 focusing …