Guidelines for the appropriate prescribing of Specialist Paediatric Formulas in Berkshire East Primary Care

Transcription

1 Guidelines for the appropriate prescribing of Specialist Paediatric Formulas in Berkshire East Primary Care Approved by East Berkshire Drugs & Therapeutics Committee, October 2014 Breast feeding is the best form of nutrition for infants and should be encouraged and promoted wherever possible. Adapted from the Berkshire West guidelines written by Catherine Blaikley, Specialist Prescribing Support Dietitian. ~ 1 ~

2 Contents: Page number: Introduction 3 Purpose of the guidelines / Local referral arrangements / Key 3 Patient expectations / Dietetic advice / Acknowledgments 4 Guidance on feed volumes to prescribe for infants 5 Guidance on prescribing, reviewing and stopping infant formulas: Clinical condition: Overview of Cow s Milk Protein Allergy (CMPA) 6 Algorithm for CMPA taken from the MAP guidelines 7 Cow s Milk Protein Allergy (CMPA) 9 Faltering Growth 13 Pre-term infants 14 Gastro-Oesophageal Reflux (GOR) 15 Secondary lactose intolerance 16 Galactosaemia 17 References 18 Appendix 20 ~ 2 ~

3 Introduction These guidelines are to advise on appropriate prescribing of specialist infant formulas. However breast feeding is the best form of nutrition for infants and should be encouraged and promoted wherever possible. Purpose of the guidelines These guidelines aim to provide information for GP s and Health Visitors on the appropritae prescribing of specialist infant formulas. They aim to provide guidance on which formula to use and timelines of when to start, review and stop a formula appropriately. Local referral arrangements GP s and Health Visitors are able to refer to the local community dietetic department to be seen in a paediatric clinic. Referral to the allergy paediatrician at RBH is also available, they will then refer to the RBH paediatric dietitians, if not already been seen by the community paediatric dietitians. Please see appendix 1 for details of the paediatric dietetic referral pathway. Please see appendix 2 for the general outpatient referral form (suitable for paediatrics) referral form East and West Please see appendix 3 for the CYPIT referral form. Please see appendix 4 for the Children s and Young People s Intergrated Therapies Service (CYPIT) information leaflet Key (Based on formulary guidance in Berkshire- Abbott products first line due to contract if available, then ordered by price per 100mls.) 1 st line 2 nd line If 1 st line is unsuccessful 3 rd Line Should be bought OTC by parent/carer ~ 3 ~

4 Patient expectations This policy is designed to assist you in the appropriate prescribing of paediatric formulas, giving advice on quantities, types of formula and when it is appropriate to review and stop such formulas. Please make it explicitly clear to the parents/families/carers of these children that the prescriptions of such formulas are temporary. They will be reviewed and will only be continued if deemed absolutely necessary. Once the child is thriving and no longer needs a prescription formula, the parents/families/carers will then be expected to purchase the appropriate formula for the child. Dietetic advice Please be aware that if a patient has been seen by a dietitian they may make recommendations which exceed formula quantity requirements or choose a product which is not detailed as first line here, it is hoped that their dietetic expertise and advice will be followed. The dietitian will write and detail why they have made such recommendations if they do not completely fall within this policy. Furthermore dietitians should be treated as a specialist with regards to the continuation of a prescription beyond one year. Acknowledgements BHFT and RBH Nutrition and Dietetic Departments, RBH Allergy Clinic, HWPH pharmacy, paedatric and dietetic departments: Dani Barker Balvinder Bhumber Serena Burgin Suzi Burch Rati Gill Louise Gubb Solenne Guest Carol Harfield Carina Joanes Tim Langran Federica Luis Abigail Macleod Peter Sebire Rashmi Selli ~ 4 ~

5 Age Category Guidance on feed volumes to prescribe for infants Royal College Nursing feed guidance Suggested intake per day Up to 2 weeks 7-8 feeds per day 60-70mls per feed mls/day ml/kg/day weeks 6-7 feeds per day mls /day - 2 months mls per feed ml/kg/day months 5-6 feeds per day mls/day mls per feed ml/kg/day months 5 feeds per day mls/day mls per feed ml/kg/day (3-4 months) 150 ml/kg/day (4-5 months) 120 About 6 4 feeds per day months mls per feed ~ 5 ~ Quantity of powder per day (approx.) Equivalent in tins per week (approx.) Equivalent in tins per 4 weeks (approx.) 70-90g/day 2 x400g tins 8 x 400g g/day 2 x400g tins 8 x 400g g/day 3 x400g tins 12 x 400g g/day 3 x400g tins 12 x 400g g/day 3 x400g tins 12 x 400g ml/kg/day 120 General guidance on feeding: These guidelines below are for average weight kids who are not exclusively enterally fed. EXCEPTION: If a child is under the paediatric dietitians, they will provide guidance on monthly prescription quantity. 7-9 months 4 feed per day 150mls per feed feeds per day months 200mls per feed 1-2 years 3 feeds per day mls per feed Table One: Adapted from the First Steps Nutrition Trust. About 600mls per day 90g/day 2 x400g tins 1 x900g tin About 600mls per day 90g/day 2 x400g tins 1 x900g tin About 400mls per day of whole cow s milk or other suitable milk drink 7 x400g 3 x 900g 7 x400g 3 x 900g 70g/day 2 x400g tins 5 x400g

6 Guidance on prescribing, reviewing and stopping infant formulas CMPA presents itself in different ways: COW S MILK PROTEIN ALLERGY (CMPA) Furthermore they can be split into: - IgE-mediated (validated via skin prick test or RAST) -Non-IgE-mediated (No validated test, however avoid all CMP then re-introduce, in mild-moderate cases only) - Mild- Moderate IgE-mediated - Severe IgE-mediated. AND: - Mild- Moderate Non-IgE-mediated - Severe Non-IgE-mediated. To determine which category an infant falls into, firstly a detailed allergy focussed history needs to be taken: Ask the following: - Any personal early or family (parents or siblings) history of atopic disease - The infant's feeding history - Presenting symptoms and signs that may be indicating possible CMPA - Details of previous management, including any medication and the perceived response to any management. - Was there any attempt to change the diet and what was the outcome? Refer to NICE guidelines (Food Allergy in Children and Young People, Feb 2011) - guidance.nice. org.uk/cg116 for history taking and symptoms. KEY: Formula fed: Exclusively fed via formula milk Mixed feeding: Combination of feeding via breast milk and formula milk Breast fed: Exclusively breast milk fed EHF: Extensively Hydrolysed Formula, e.g. Similac Alimentum / Aptamil Pepti 1 and 2 / Nutramigen Lipil 1 and 2 / Althera AAF: Amino Acid Formula e.g. Nutramigen AA / Neocate / Alfamino. Infants who do not tolerate one formula may tolerate another. Therefore it is worth prescribing only 1 or 2 tins initially and if not tolerated or taken after perseverance, try another comparable formula. i.e. the second line formulas. This advice has been taken from: The Milk Allergy in Primary Care algorithms. Please see these in the following pages. ~ 6 ~

7 The Milk Allergy in Primary Care algorithms ~ 7 ~

8 The Milk Allergy in Primary Care algorithms, continued: ~ 8 ~

9 Condition/ Indication Cow s Milk Protein Allergy (CMPA) Mild- Moderate NON- IgEmediated Diagnosis Symptoms Treatment/Review Criteria Delayed onset of symptoms - Mostly within 2-72 hours after ingestion of cow s milk protein - Formula fed, exclusively breastfed or at onset of mixed feeding NOTE: Lactose free formulas are not suitable for treating CMPA, however be cautious of those children who have had a recent GI problem and are suffering with transient 2 O lactose intolerance (see p.16). NOTE: Infants to be managed in Primary Care by the GP and dietitian. Can also be managed by general paediatrician (not allergy specialist). One or more of the following: SKIN: Pruritus, erythema Severe atopic eczema GASTROINTESTINAL: Colic, Reflux- GORD Food refusal or aversion Loose or frequent stools Perianal redness, Constipation, Abdominal discomfort, blood and/or mucus in stools in an otherwise well infant RESPIRATORY: Catarrhal airway symptoms (usually in combination with one or more of the above symptoms) Cow s Milk Free Diet Refer to dietitian. Formula/mixed fed infant: Commence an Extensively Hydrolysed Formula (ehf)* Breast fed: Maternal exclusion of CMP. The taste of hydrolysed formulae is unpleasant and it has a bitter smell therefore compliance can be improved by using a bottle, closed cup or a straw. Younger infants take hydrolysed formulas more readily than older infants. ~ 9 ~ Name of Formula First Line: Similac Alimentum (Abbott) Althera (SMA Nutrition/ Nestle) Aptamil Pepti 1 or 2 (Milupa) Nutramigen Lipil 1 or 2 (Mead Johnson) Third Line: Purchase Infasoy (Cow & Gate) Or Wysoy (SMA Nutrition) Age restrictions Birth to 2 years Birth to 2 years < 6 months: - Pepti 1 - Nutramigen Lipil 1 6months-2yrs: - Pepti 2 - Nutramigen Lipil 2 6 months to 1 year DO NOT USE SOYA MILK IN INFANTS UNDER 6 MONTHS Criteria for stopping Formula Maintain CMP elimination diet until 9-12 months of age, but for at least 6 months before re-introduction. Stop formula once infant has grown out of allergy or they are 2 years old. Soya formula can be considered in infants >6 months, in infants who will not take a hypoallergenic formula. From 1 year, supermarket calciumenriched soya milk (i.e. Alpro Soy Junior 1+) should be recommended if the infant refuses the specialist formula. NOTE: Please note soya milks SHOULD NOT be prescribed, instead advise the parent/carer to buy OTC as similar cost to standard infant formula Additional notes: *An AAF may be indicated as first line in children with Failure to Thrive or those with complex needs as identified by a dietitian or as a trial if not settling. NOTE: All other mammalian milks should not be used due to cross reactivity. Oat milk should not be used in children under 2 years due to its lesser calorie content. Rice milk should not be used in children under 5 year, due to its high arsenic content.

10 Condition/ Indication Cow s Milk Protein Allergy (CMPA) SEVERE NON- IgEmediated Diagnosis Symptoms Treatment/Review Criteria Delayed onset of Severe persisting of one or symptoms more symptoms of: Cow s Milk Free Diet - Mostly within 2-72 hours after ingestion of cow s milk protein - Formula fed, exclusively breast-fed or at onset of mixed feeding SKIN: Severe atopic eczema +/- Faltering Growth GASTROINTESTINAL: Vomiting, diarrhoea, abdominal pain, food refusal or food aversion, significant blood and/or mucus in stools, irregular or uncomfortable stools +/- Faltering Growth Formula/mixed fed infant: Commence an Amino Acid Formula (AAF) Breast fed: Maternal exclusion of CMP. Ensure an (urgent ) referral to: - General paediatrician - Paediatric dietitian (Paediatrician will refer to the acute paediatric dietitians, but for a community paediatric dietetic assessment, GP to refer directly) Name of Formula First Line: Nutramigen AA (Mead Johnson) Neocate LCP (Nutricia) Neocate Advance (Nutricia) Neocate Active (Nutricia) Alfamino (SMA Nutrition/ Nestle) Age restrictions Birth to 2 years Birth to 1 year Nutritionally complete feed From 1 year+ Nutritionally complete feed, to be used as sole source of nutrition From 1 year+ Not nutritionally complete feed, not to be used as a sole source of nutrition for supplement use only. Birth to 2 years Criteria for stopping Formula Maintain CMP elimination diet until 9-12 months of age, but for at least 6 months. Stop formula once infant has grown out of allergy or they are 2 years old. ~ 10 ~

11 Condition/ Indication Cow s Milk Protein Allergy (CMPA) Mild- Moderate IgEmediated Diagnosis Symptoms Treatment/Review Criteria Acute onset of symptoms - Mostly within minutes of ingestion of cow s milk protein - Mostly formula fed or at onset of mixed feeding One or more of the following: SKIN: Acute pruritus, erythema, urticarial, angioedema. Acute flaring of atopic eczema GASTROINTESTINAL: Vomiting, diarrhoea, abdominal pain/colic RESPIRATORY: Acute rhinitis and/or conjunctivitis Cow s Milk Free Diet Formula/mixed fed infant: Commence an Extensively Hydrolysed Formula (ehf)* Breast fed: Consider Maternal exclusion of CMP. IgE skin prick testing needed after 12 months of age Refer to dietitian. Name of Formula First Line: Similac Alimentum (Abbott) Suitable for <6months and for >6months Althera (SMA Nutrition/ Nestle) Aptamil Pepti (Milupa) < 6 months: Pepti 1 > 6 months: Pepti 2 Nutramigen Lipil (Mead Johnson) Age restrictions Birth to 2 years Criteria for stopping Formula Maintain CMP elimination diet until 9-12 months of age, but for at least 6 months. Stop formula once infant has grown out of allergy or they are 2 years old. < 6 months: Nutramigen Lipil 1 ~ 11 ~ > 6 months: Nutramigen Lipil 2 Additional notes: *An AAF may be indicated as first line in children with Failure to Thrive or those with complex needs as identified by a dietitian or as a trial if not settling. Infants to be seen at allergy clinic with allergy specialist paediatrician annually.

12 Condition/ Indication Cow s Milk Protein Allergy (CMPA) SEVERE IgEmediated Diagnosis Symptoms Treatment/Review Criteria ANAPHYLAXIS Immediate reaction with severe respiratory and/or CVS signs and symptoms -rarely a severe gastrointestinal reaction. EMERGENCY TREATMENT AND ADMISSION Cow s Milk Free Diet Commence an Amino Acid Formula (AAA) Urgent referral to both: - Allergy specialist paediatrician - Paediatric dietitian Name of Formula Age restrictions Criteria for stopping Formula First Line: Nutramigen AA (Mead Johnson) Neocate LCP (Nutricia) Neocate Advance (Nutricia) Birth to 2 years Birth to 1 year Nutritionally complete feed From 1 year+ Nutritionally complete feed, to be used as sole source of nutrition From 1 year+ Maintain CMP elimination diet until 9-12 months of age, but for at least 6 months. Neocate Active (Nutricia) Not nutritionally complete feed, not to be used as a sole source of nutrition for supplement use only. Stop formula once infant has grown out of allergy or they are 2 years old. Alfamino (SMA Nutrition/ Nestle) Birth to 2 years Additional notes: Amino Acids Formulas are only indicated in severe CMPA or when ehf does not resolve symptoms or when there is evidence of severe (anaphylactic) or multiple allergies. Do not use as a diagnostic tool. Immediate referral to secondary or specialist care should occur after starting an amino acid formula in primary care if the infant has a history of severe (anaphylactic) reaction to cow s milk. ~ 12 ~

13 Condition/ Indication Diagnosis Treatment/Review Criteria Name of Formula Age restrictions Criteria for stopping Formula Faltering growth Faltering growth is indicated when the weight of an infant falls below the bottom centile (0.4th) or crosses 2 centiles downwards on a growth chart. The height, as well as weight, needs to be measured in order to properly interpret changes in the latter. It is not possible to detect growth faltering without using appropriate growth charts. NOTE: It is important to rule out possible disease-related/ medical causes for the faltering growth. It is important to consider the reason for faltering growth e.g. iron deficiency anaemia, constipation, GOR or a child protection issue and treat accordingly. Before commencing a high energy formula ensure parents/carers are offered food first advice on suitable high calorie foods if the infant is weaned. Refer any infant being commenced on a high calorie formula to a dietitian or for appropriate food fortification advice. Refer to dietitian for advice. The NDR Help my child gain weight leaflet is used to support appropriate dietary advice. Before Prescribing: Please encourage food first and fortification advice for those children over 6 months and who have been weaned First Line: Similac High Energy (Abbott) 1.0 kcal/ml SMA High Energy (SMA) 0.9 kcal/ml Infatrini (Nutricia) 1.0 kcal/ml From birth to 18 months or 8 kg These formulas should be used until 18 months or 8kgs. However the child should be reviewed by a dietitian before the formula is stopped. NOTE: All infants on a high energy formula will need growth (weight and length/height) monitoring to ensure catch up growth and appropriate discontinuation of formula to minimise excessive weight gain. ~ 13 ~

14 Condition/ Indication Diagnosis Treatment/Review Criteria Name of Formula Age restrictions Criteria for stopping Formula Pre-term Infants These children will have had their formula commenced in hospital. It is started for babies born before 37 weeks gestation weighing less than 2.5kg at birth. NOTE: This formula should not be used in primary care to promote weight gain other than for those born prematurely. Any infant discharged on these formula should have their growth (this includes weight, length and head circumference) monitored by the health visitor. Any concerns regarding the baby should be referred to the dietitians. These infants should be under regular review by the paediatrician who will recommend the appropriate specialist formula. First Line: SMA Gold Prem 2 powder (SMA) =524kcals/100g Use up to 6 month corrected age (i.e. six months plus the number of weeks premature added on) Up to 6 months corrected age. These formulas should be stopped if the child is weaned or there is excessive weight gain, as determined by the growth chart centiles. If there is concerns regarding growth refer to the dietitian Prescription should not exceed: 11 x400g tin Or 5x 900g tin Nutriprem 2 powder (Cow and Gate) =491kcals/100g NOTE: Please ensure a prem feed powder is prescribed and NOT the ready-to-drink prem formulas. ~ 14 ~

15 Condition/ Indication Gastrooesophag eal Reflux (GOR) ce.org.uk/g ord-inchildren#!s cenariorec ommendati on:2 Diagnosis Treatment/Review Criteria Name of Formula Age restrictions Criteria for stopping Formula STEP ONE: Step One: If baby is vomiting persistently (not projectile) but the baby is Reassure patient and give Up to 1 year To continue treatment until thriving and not distressed, advice as detailed. GOR resolves. reassure parents and monitor. Please advise regular trips Provide advice on: to baby clinic to be NOTE: Around 50% - feeding positioning weighed and monitored. of all babies will If on a thickened formula, - avoidance of over feeding experience some once vomiting resolves return - no bouncing following a feed Step Two: reflux <3 months, to standard formula, - calm atmosphere but only poses a assuming GOR has now - small, frequent feeds problem for few resolved. - check teat size and flow children. A diagnosis of GOR is made clinically from a history of effortless vomiting occurring after meals. Rule out overfeeding by establishing volume of feed as initial treatment Symptoms of GOR may include: Regurgitation of a significant volume of feed Reluctance to feed Distress / crying at feed times Small volumes of feed being taken STEP TWO: Try a thickened formula to be bought OTC, not prescribed. These formulae should not be used in conjunction with antacid medication or thickeners. Review after one month. If no improvement in symptoms, may need further investigation by a paediatrician. These infants require regular review- refer to a dietitian for advice if needed. Try thickened formula To be purchased SMA Stay down (SMA Nutrition) OR Enfamil A-R (Mead Johnson) NOTE: Please note these stay-down/ anti-reflux milks SHOULD NOT be prescribed, instead advise the parent/carer to buy OTC as similar cost to standard infant formula ~ 15 ~ This drops to 5% at aged >10 months. Weaning baby from breast feeding to formula feeding will not improve this condition. NOTE: Alert parents to different procedure for making up feed on tin (required fridge cooled pre-boiled water and cannot be made up in advance). Additional notes: Other ideas to try: 1. A thickening agent such as Carobel may also be used to thicken milk, which is convenient for those wishing to have more flexibility with feeding times as it can be made up in advance, for example for those expressing milk. 2. If the bottle fed infant is not settled and not gaining weight trial with thickening agent i.e. infant Gaviscon. 3. Try a H2 Receptor antagonist, i.e. Ranitidine, alongside a normal formula.

16 Condition/ Indication Secondary Lactose Intolerance NOTE: Secondary lactose intolerance is usually acute and resolves fairly quickly. NOTE: Primary lactose intolerance is less common than secondary intolerance and does not usually present until later childhood or adulthood Diagnosis Treatment/Review Criteria Name of Formula Age restrictions Criteria for stopping Formula Usually occurs following an infectious gastrointestinal illness. Possible symptoms include: abdominal bloating wind increased (explosive) and loose, green stools Lactose intolerance should be suspected in infants who have had symptoms that persist for more than 2 weeks Diagnosis is the resolution of symptoms, usually within 48 hours, once lactose is removed from the diet Treatment with lactose free formula for 4-8 weeks to allow symptoms to resolve. Then reintroduction to standard formula/milk products slowly into the diet. If symptoms do not resolve on commencing standard infant formula then refer to a dietitian Under 1 year For treating lactose intolerance in infants who have been weaned these listed formula should be used in conjunction with a milk free diet Over 1 year If an infant presents with suspected Lactose intolerance at one year or older and is on cow s milk, then a lactose free full fat cow s milk can be used for the treatment period. - This is available in supermarkets NOTE: the use of lactase drops is not common practice, e.g. Colief. Lactose Free Formulas: To be purchased SMA LF (SMA Nutrition) OR Enfamil O-Lac (Mead Johnson) NOTE: Please note lactose-free milks SHOULD NOT be prescribed, instead advise the parent/carer to buy OTC as similar cost to standard infant formula Birth to 1 year Can be used for a maximum of 8 weeks without review and trial of discontinuation of treatment When over 1 year, please recommend use of supermarket lactose free milk if still necessary. If symptoms do not resolve when standard formula/milk products are reintroduced to the diet, refer to secondary or specialist care. ~ 16 ~

17 Condition/ Indication Diagnosis Treatment/Review Criteria Name of Formula Age restrictions Criteria for stopping Formula Galactosaemia Lactose is usually broken down to galactose and glucose, then the galactose is broken down further however in galactosaemia there is an absence of the enzyme due to a deficient or absent mutation in the DNA, so it cannot be broken down completely. Galactose then builds up in the blood and leads to serious illness that occurs within the first few weeks of life once the baby is fed on lactose containing milk. Galactosaemia is rare in the UK about 1 in 45,000 children are born with this condition which is lifelong. For such patients please refer to the paediatricians and paediatric dietitians who will recommend appropriate treatment. Breast feeding and cow s milk based infant formulas are contraindicated for the infant with galactosaemic because they contain lactose, which is also advocated by the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). There is no clear advice which feed is best, generally soya milk is recommended for such children over the age of 6 months. Furthermore if the patient has liver disease, an extensively hydrolysed formula maybe indicated such as those used for mild-moderate cow s milk protein allergy. FURTHER NOTES: The NDR cow s milk free weaning leaflet is used to support appropriate dietary advice. Where cow s milk allergy is combined with faltering growth and/or insufficient hypo-allergenic formula intake to ensure calcium adequacy, a hypoallergenic weaning supplement (i.e. Neocate Spoon) can be prescribed from age 6 months or from commencement of weaning. Guideline intake is ½ to 1 x 37g sachet of Neocate Spoon daily. This should be discontinued when the child can meet their micronutrient requirements via food alone, generally by 2 years of age. ~ 17 ~

18 References: 1. BNF for Children Published by BMI Group by Pharmaceutical Press, RCPCH PUBLICATIONS LTD 2. Clinical Knowledge Summaries GORD in Children. [last accessed ] 3. Clinical Paediatric dietetics rd edition. Blackwell Publishing. 4. Dietary Products used in infants for treatment and prevention of food allergy. Joint statement of the European Society for Paediatric Allergology and Clinical Immunology (ESPACI) Committee on Hypoallergenic Formulas and the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee on Nutrition. Arch Dis Child 1990;81: European society for paediatrics Gastroenterology, Hepatology, and Nutrition/European Society for Paediatric Infectious Diseases Evidence-based Guidelines for the Management of Acute Gastroenteritis in Children in Europe. A, Guarino et al. Journal of Paediatric Gastroenterology and Nutrition 46;S81 S Infant milks in the UK: A practical guide for health professionals. June First Steps Nutrition Trust. By Dr Helen Crawley and Susan Westland 7. Koletzko et al Diagnostic Approach and Management of Cow s-milk Protein Allergy in Infants and Children: ESPGHAN GI Committee Practical Guideline. JPGN. August 2012: 55 (2): National Childbirth Trust What is Reflux? [last accessed ] 9. Clinical Guideline 116 Food Allergy in Young People. NICE 2011www.nice.org [last accessed ] 10. Paediatric group position statement on Use of Soya Protein for Infants. British Dietetic Association. February PrescQIPP June Prescribing Specialist Infant Formulas in Primary Care guidelines 12. Taylor et al. May Cost-effectiveness of using an extensively hydrolysed formula compared to an amino acid formula as first-line treatment for cow milk allergy in the UK. Paediatric Allergy Immunology. 23(3): ~ 18 ~

19 13. Vandenplas et al. Algorithm for the diagnosis and management of cow s milk protein allergy in formula fed infants, References continued: 14. Venter et al Diagnosis and management of non-ige-mediated cow s milk allergy in infancy - a UK primary care practical guide. Clinical and Translational Allergy 2013, 3: NICE. GORD in children, Last revised in December 2009, Management in primary care/ Galacotoseamia support group ~ 19 ~

20 Appendix: Please see appendix 1 for details of the paediatric dietetic referral pathway. Please see appendix 2 for the general outpatient referral details (suitable for peadiatrics) - EAST and WEST Please see appendix 3 for the CYPIT referral form. Please see appendix 4 for the Children s and Young People s Intergrated Therapies Service (CYPIT) information leaflet ~ 20 ~

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22 Appendix 2 for the general outpatient referral details (suitable for peadiatrics) - EAST and WEST REFERRALS Please note that all Nutrition & Dietetic referrals (Berkshire-wide for adults and children) are WITH IMMEDIATE EFFECT to be referred via the Health Hub. Referrals should NO longer be sent (fax/post/ ) directly to the Nutrition & Dietetic department. If you wish to refer a patient to our service, please inform the Health Hub using the contact details below: Health Hub Contact Number: Health Hub bks-tr.healthhub@nhs.net Health Hub Fax Number: Your co-operation with this new procedure is very much appreciated. THANK YOU ~ 22 ~