Immune

Question 1

what immunisations is baby given at 8 weeks?

Answer 1

this is the 1st set of immunisations, unless given BCG vaccine at birth if deemed at risk of TB, or Hep B if baby born to Hep B infected mother
5 in 1 vaccine: diphtheria,tetanus, pertussis, polio, haemophilus influenzae type B (Hib)
pneumococcal (13 serotypes)
meningococcal group B (MenB)
rotavirus gastroenteritis

Question 2

what immunisations follow the those given at 8 weeks

Answer 2

next set at 12 weeks:
diphtheria, tetanus, pertussis, polio and Hib
meningococcal group C (MenC)-discontinued from 01/07/16
rotavirus

Question 3

what immunisations is baby given at 4 months (16 weeks)?

Answer 3

diphtheria, tetanus, pertussis, polio and Hib
MenB
pneumococcal

Question 4

what immunisations follow those given at 16 weeks?

Answer 4

next at 1 year:
Hib and Men C (given as a single jab)
MenB
pneumococcal
MMR-measles, mumps and rubella

Question 5

when is influenza vaccine given to children?

Answer 5

now given each year to children aged between 2 and 7.

Question 6

what immunisations are given at 3 years 4 months old?

Answer 6

diphtheria, tetanus, pertussis and polio (4 in 1 booster)

MMR

Question 7

when is the HPV vaccine given?

Answer 7

girls aged 12 to 13 years
2 injections given 6-12mnths apart
protects against cervical Ca caused by HPV types 16 and 18, and genital warts caused by types 6 and 11.

Question 8

immunisations at 14 years old?

Answer 8

diphtheria, tetanus and polio (3 in 1 booster)

meningococcal groups A, C, W and Y disease

Question 9

what is food allergy?

Answer 9

this occurs when pathological IMMUNE response against a specific food protein
usually develops in infancy, often with eczema, and this is predictive of asthma and allergic rhinitis in later life
usually IgE mediated-histamine release
usually primary-pt never developed immune tolerance to the food
if secondary, child tolerates food but later becomes allergic to it, usually result of cross reactivity between proteins e.g. those present in pollens: child can eat apples but may later develop allergy to them if birch tree pollen allergy they share similar protein=oral allergy syndrome
often milk, egg and peanut in infants, peanut, tree nut, fish and shellfish in older children
can be mixed IgE and non IgE mediated reactions

*different from food intolerance: non immunological hypersensitivity reaction to specific food. NO SUCH THING AS A COW’S MILK INTOLERANCE.

Question 10

clinical features of IgE mediated food allergy?

Answer 10

urticaria
angioedema
anaphylaxis
occurring 10-15min post food ingestion
often 1st occasion food knowlingly ingested

Question 11

features of non IgE mediated food allergy?

Answer 11

T cell mediated response
GI symptoms hours after food ingestion e.g. diarrhoea and/or constipation, vomiting, abdo pain, and sometimes failure to thrive
colic,eczema or reflux may also be present
sometimes blood in stools in 1st few wks of life from proctitis

good to keep a food diary as symptoms are delayed but can then relate to part. foods eaten previously.

Question 12

diagnosis of food allergy?

Answer 12

good clinical hx and examination
IgE mediated: skin prick testing and specific IgE antibodies in the blood (RAST test)
non IgE: hx and examination, endoscopy and intestinal biopsy showing eosinophilic infiltrates would support diagnosis
in cases of doubt, gold standard=exclusion, under dietician supervision
followed with double blind placebo controlled food challenge-increasing amounts of the food or placebo given
diagnosis=exclusion of food relieves symptoms and re-introduction causes them to come back.

Question 13

clinical manifestation of IgE mediated cow’s milk allergy?

Answer 13

young infant e.g. 6mnths, breast fed then developed allergic reaction with widespread urticaria and itchy skin, facial swelling-lips, face, around eyes, within 10 mins of 1st formula feed (defo within 1st 2 hrs)
erythema
oral pruritus
nausea, colicky abdo pain, D+V
rhinorrhoea with/without conjunctivitis
skin prick strongly +ve to cows milk
severe reaction-wheeze, stridor, abdo pain, vomiting, diarrohea, shock, collapse

Question 14

clinical manifestation of non IgE mediated cow’s milk allergy?

Answer 14

e.g. 4mnth old infant formula fed since birth has loose stools and is failing to thrive
symptoms manifest up to 48hrs or even 1 wk after cows milk protein ingestion
atopic eczema, pruritus, erythema
diarrhoea with blood or mucus
GOR
infantile colic
constipation
perianal erythema
food refusal
pallor and tiredness
skin prick -ve
elimination of cow's milk causes symptom resolution (should do trial for at least 2-6wks) which return on trial re-introduction

Question 15

clinical manifestation of temporary lactose intolerance?

Answer 15

older infant, prev. well, develops diarrhoea and vomiting
vomiting settles, watery diarrhoea continues for several wks
stool sample +ve for reducing substances

Question 16

overall management of food allergy?

Answer 16

r/f to secondary or specialist care
advise pt on diagnostic tests and their limitations e.g. skin prick and specific IgE Ab testing in blood
relevant food avoidence, advice from paed. dietician, possible planned rechallenge or initial food reintroduction procedure
written self-management plans and adequate training for acute attacks and anaphylaxis
antihistamines for mild reactions e.g. cetirizine
IM adrenaline e.g. epipen for severe reaction, must ensure carried round at all times
info about support groups

Question 17

anaphylaxis acute management in children?

Answer 17

GET HELP!
remove trigger, maintain airway, give 100% oxygen
IV fluids
IM adrenaline-10 micrograms (0.01ml) per kg of body weight to max of 0.5mg/0.5ml per dose of 1mg/ml, onto vastus lateralis
neb salbutamol if wheezing, and neb adrenaline if croupy
antihistamines-slow to act, do not prevent mediator release, may be useful after adrenaline when pt stable to prevent symptom relapse, oral or IM chlorpheniramine (under 2yrs) or loratadine
IV corticosteroids following adrenaline

observe for at least 4 hrs, up to 24hrs if moderate to severe anaphylaxis

Question 18

how can food intolerance be caused?

Answer 18

enzyme deficiencies e.g. lactase following an acute episode of gastroenteritis (secondary lactose intolerance)
pharamcological agents
naturally occurring substances

Question 19

what is cow’s milk allergy?

Answer 19

immune mediated allergic response to PROTEINS in milk-casein and whey fractions, each of which have 5 protein components

Question 20

if an infant is exclusively breast fed, could a cow’s milk protein allergy still be considered as a cause of vomiting and diarrhoea?

Answer 20

YES, as cow’s milk protein in maternal diet can be transferred to baby through breast milk.

Question 21

clinical features of secondary lactose intolerance?

Answer 21

watery diarrhoea following acute episode of gastroenteritis-loss of superficial mucosal cells containing lactase, this persists for several days, and is suspected part. if temp resolved over this time
stools=low pH (less than 6), and presence of reducing substances (lactose)-more than 0.5%

if bottle fed, can change to lactose free milk
soy milk can be used in those over 6mnths but contain oestrogens
revert back to cows milk once symptoms resolved
if breast fed need no change and symptoms should eventually resolve.

Question 22

after obtaining allergy focused hx, when should r/f to secondary or specialist care be considered?

Answer 22

child or young person has:
faltering growth in combination with 1 or more GI symptoms e.g. diarrhoea, vomiting, infantile colic
not responded to a single-allergen elimination diet
had 1 or more acute systemic reactions
had 1 or more severe delayed reactions
confirmed IgE-mediated food allergy and concurrent asthma
significant atopic eczema where multiple or cross-reactive food allergies are suspected
or there is:
persisting parental suspicion of food allergy (especially in children or young people with difficult or perplexing symptoms) despite a lack of supporting history
strong clinical suspicion of IgE-mediated food allergy but allergy test results are negative
clinical suspicion of multiple food allergies

Question 23

6 mnth old baby has erythematous and scaly rash over face and scalp with multiple excoriations, and a FH of asthma and allergic rhinitis, what is the likely diagnosis and would you request any investigations to confirm this?

Answer 23

atopic eczema-facial involvement common at his age, erythema and scaling-dry skin, multiple excoriations-suggestive of itchy rash, and FH of atopy.
No investigations needed for diagnosis confirmation, but may consider skin prick testing or specific IgE antibody testing in future if very difficult to control eczema-may be food allergy which requires management for good eczema control.

Question 24

how can children with non IgE mediated cow’s milk protein allergy be managed in primary care?

Answer 24

strict avoidence of cows milk-diet should be for at least 6mnths or until child 9-12mnths old
involve input from paed dietician
-in exclusively breastfed babies, advise mum to exclude cows milk protein form diet and consider prescribing daily supplement of 1000 mg calcium and 10 micrograms of vitamin D to mother to prevent nutritional deficiencies.
-in formula-fed or mixed-fed infants, advise the parents or carers to replace cows’ milk-based formula with hypoallergenic infant formulas, such as extensively hydrolysed formulas (EHFs) (tolerated by 90% of children with cows’ milk protein allergy) e.g. aptamil 1 or 2 or amino acid formulas e.g. alfamino, neocate.
-In weaned infants and older children, advise the child and/or parents or carers to exclude cows’ milk protein from the child’s diet.

ensure regular monit of weight and height if not being seen by paed dietician

Question 25

general advice to parents for managing a child with difficult to control eczema?

Answer 25

ensure child’s fingernails cut short and kept clean
regular emollient use
avoid soap, use soap substitute and bath oil
keep limbs covered with long sleeves or trousers
use only cotton clothes against skin, avoid woolen or synthetic clothes
ensure bare hand isn’t used by parent in tub of emollient, use a spatula to avoid bacterial contamination increasing likelihood of skin infection in child e.g. impetigo-staph aureus

Question 26

why might a child have a breakdown in the control of their eczema?

Answer 26

secondary bacterial infection e.g. impetigo
eczema herpeticum-HSV, -widespread vesicular rash with clusters of monomorphic itchy blisters, break down to form punched out erosions with crusting, often blood-stained, unwell pt with fever, malaise and lymphadenopathy. viral skin swab-viral culture, direct fluorescent antibody stain.
non compliance with treatment-not regularly using emollients, no soap substitute
antigen exposure to which pt sensitive e.g. HDM
heat
unwell
stress
food allergens

Question 27

what blood test may be done when unsure if anaphylaxis reaction?

Answer 27

mast cell tryptase-elevated in allergic reactions, but normal level does not exclude anaphylaxis, level peaks at 1-2hrs and remains elevated for 4-6hrs.

Question 28

discharge medication required after anaphylaxis presentation in children?

Answer 28

anti-histamine: diphenhydramine or non-sedating antihistamine for 72hr
oral pred 1mg/kg for 72hr for biphasic response
JEXT-adrenaline autoinjector, with instructions on usage

need allergy clinic f/u for evaluation of cause and education

Question 29

causes of anaphylaxis in children?

Answer 29

FOOD-peanuts, tree nuts, milk, eggs, shellfish, seeds, grains, fruits
drugs, radio-contrast media, chemotherapeutics, blood products
hymenoptera venom-bee or wasp stings
latex
allergen immunotherapy
vaccinations
idiopathic
exercise-food-specific, post prandial

Question 30

types of hypoallergenic milk formulas?

Answer 30

extensively hydrolysed formulas (EHFs)-based on whey or casein but extensively broken down into smaller peptides less recognised by immune system e.g. aptamil, nutramigen lipil 1 and 2
amino acid formulas (AAFs)-alternative if cannot tolerate EHFs or severe symptoms, e.g. neocate and nutramigen puramino

Question 31

predictors of persistence of cows milk protein allergy?

Answer 31

immediate onset symptoms vs. delayed onset
large SPT weal size or higher sIgE level at diagnosis
comcomitant asthma and/or allergic rhinitis
presence of other food allergies, espec. egg
reactivity to baked milk on 1st challenge or exposure

Question 32

diagnostic evaluation of immediate onset cows milk protein allergy?

Answer 32

skin prick test more than 3mm when typical symptoms

more than 5mm if atypical or absent symptoms

Question 33

what is typhoid fever? how does it present?

Answer 33

bacterial infection caused by salmonella typhi
high fever, diarrhoea/constipation, abdo pain, headache
requires prompt antibiotic treatment-7 to 14 days PO antibiotics if mild disease