User blog: Rcgp Learning
May marks Action on Stroke Month, which is organised by the Stroke Association.
In 2011, Public Health England launched the ‘FAST – Face-Arm-Speech-Time’ campaign to increase awareness of the signs of a stroke and fast access to treatment. Treating at 90 minutes will result in 10% more patients being independent at three months post-stroke than if treatment is given at three hours. Stroke is often thought of as an illness of old age but 10-15% of ischaemic strokes occur in young adults1. ‘Young adults’ are broadly defined as aged between 18-50 years of age2.
The worldwide incidence of ischaemic stroke in those aged 18-50 has increased up to 40% in recent decades, with around 2 million people suffering ischaemic stroke each year2. In England, approximately 57,000 people had a stroke for the first time in 2016, 3% of whom were aged under 403.
Strokes in younger adults have a more significant economic impact due to patients being left disabled during their most productive years1. The prevalence of vascular risk factors for stroke in younger adults can differ from those in older adults and may not be as routinely screened for. The primary stroke prevention strategy is to reduce potential risk factors such as:
Atrial fibrillation (AF)
There are around 1.4 million people with AF in the UK4. It is the most common cardiac arrhythmia contributing to significant morbidity and mortality5. A 2015 study found that around 10% of young stroke patients (≥50) had AF6. The risk of stroke increases five-fold for people with AF and it contributes to around one in five strokes. AF related strokes are often more severe and have higher mortality and disability rates7. However, a quarter of people with AF remain undiagnosed. Our RCGP eLearning course on AF contains more information on its management, anticoagulation and risk assessment.
Hyperlipidaemia contributes to the development of atherosclerotic plaques, so statins are indicated for primary prevention when the 10 year risk of cardiovascular events is high. In secondary prevention of ischaemic stroke, a high intensity statin (such as atorvastatin 20-80mg daily) is used, with the aim of reducing non-HDL cholesterol by more than 40%8.
Hypertension affects around 9.5 million people in the UK and can triple the risk of stroke and heart disease9. Worldwide it is a contributing factor to approximately half of stroke episodes1. Lifestyle modifications, such as exercise, weight loss and reduced alcohol consumption, should be advised, but depending on an individual’s risk assessment, antihypertensives may be necessary.
Factors such as obesity, smoking, drinking alcohol and using recreational drugs can increase the risk of stroke. Drugs such as cocaine can acutely and markedly increase blood pressure. This can then lead to both ischaemic or haemorrhagic strokes. It’s estimated that around 6 out of 10 young adults were regularly engaging in smoking, alcohol abuse or recreational drug use at the time of their stroke9.
GPs can play a key role in preventing a stroke in a young adult by detecting, treating and monitoring AF. The Stroke Association’s ‘Detect, Protect and Perfect’ AF toolkit details the ways that CCGs can implement policies to identify those with AF and reduce their stroke risk. The data in this document focuses on London CCGs but the methodologies and resources can be applied throughout the UK. Examples of other CCGs that have used ‘Detect Protect and Perfect’ can be found here. The Stroke Association’s ‘AF: How can we do better?’ document, which was produced in partnership with the RCGP and other health organisations, looks at data in England but includes key messages that can be applied in all four countries. Regular reviews are vital for patients with AF, and any patient aged under 50 who has a stroke or TIA should be tested for antiphospholipid syndrome (APS). Patients with thromboembolic events and women who have recurrent miscarriages should also be considered for a test for APS.
For more information on stroke risks and contributing factors, you can access the following RCGP resources for free:
Atrial Fibrillation – 1 CPD point
Antiphospholipid syndrome (APS) – 0.5 CPD points
Alcohol: Identification and Brief Advice – 2 CPD points
Behaviour change and cancer prevention – 0.5 CPD points
Essentials of smoking cessation – 0.5 CPD points
Management of Obesity in General Practice – 5 minute screencast
RCGP members can also benefit from free access to the following resources:
1 Smajlović D. 2015. Strokes in young adults: epidemiology and prevention. Vascular health and risk management, 11, 157–164. DOI:10.2147/VHRM.S53203
2 Cited in: Ekker MS et al. 2018. Epidemiology, aetiology, and management of ischaemic stroke in young adults. The Lancet. Volume 17, issue 9, p790-801, 01 September 2018. DOI: https://doi.org/10.1016/S1474-4422(18)30233-3
3 Public Health England. 2018. Briefing document: First incidence of stroke. Estimates for England 2007 to 2016. [Online] Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/678444/Stroke_incidence_briefing_document_2018.pdf
4 Stroke Association. 2018. AF: How can we do better? [Online] Available at: https://www.stroke.org.uk/sites/default/files/af-data_2018_england_eng_2.pdf
5 Aggarwal, N., Selvendran, S., Raphael, C. E., & Vassiliou, V. 2015. Atrial Fibrillation in the Young: A Neurologist's Nightmare. Neurology research international, 2015, 374352. doi:10.1155/2015/374352
6 Sanak D., Hutyra M., Kral M., et al. 2015. Atrial fibrillation in young ischemic stroke patients: an underestimated cause. European Neurology. 2015;73(3-4):158–163.
7 NICE. 2018. Atrial fibrillation. Scenario: First or new presentation of AF. [Online] Available at: https://cks.nice.org.uk/atrial-fibrillation#!scenarioRecommendation:4
8 NICE. 2017. Clinical knowledge summary. Stroke and TIA. [Online] Available at: https://cks.nice.org.uk/stroke-and-tia#!scenario:2
9 Cited in: Stroke Association, 2018. State of the nation. [Online] Available at: https://www.stroke.org.uk/system/files/sotn_2018.pdf
World Parkinson’s Day takes place every year on 11th April. Parkinson’s UK is using this year’s event to highlight the realities of living with Parkinson’s disease, helping patients to feel more understood1.
Parkinson’s disease was first described in ‘An essay on the shaking palsy’, written by Dr James Parkinson, an English physician and surgeon, in 18172. This paper established Parkinson’s disease as a recognised medical condition, which NICE defines as: “a progressive neurodegenerative condition resulting from the death of dopamine-containing cells of the substantia nigra in the brain”3. The substantia nigra pars compacta plays an important role in controlling the body’s movement and coordination, in conjunction with the caudate nucleus and putamen.
Parkinson’s is one of the most common neurological conditions and it’s estimated that it affects up to 16 people per 10,0003. According to a report by Parkinson’s UK, the estimated prevalence in the UK for 2018 was 145,519. The charity also found that prevalence was 1.5 times higher in men than in women within the 50-89 age group. In terms of incidence, Parkinson’s UK estimates that approximately 1 in 37 people are diagnosed with Parkinson’s at some point in their lifetime. They predict that the prevalence of the disease will rise by 18% between 2018 and 2025, due to population growth and an increasingly ageing population4.
Typical presentations of Parkinson’s disease include symptoms and signs described as ‘Parkinsonism’: bradykinesia (slow movements), rigidity (abnormal stiffness), resting tremor (typically ‘pill rolling’) and postural instability (loss of balance)1. These symptoms are typically asymmetrical2.
Rigidity can present in different forms including lead-pipe (sustained rigidity, where the limb is heavy and resistant to passive movements) and cogwheel (intermittent rigidity, where the limb moves with jerky and ratcheting motions)5. A ‘pill rolling’ tremor is often seen and is so named because it looks like the patient is rolling a pill between their thumb and index finger. It occurs at rest and can often be alleviated by moving the affected limb. A resting tremor can also occur in other parts of the body such as the legs and lips5. Postural instability is a major reason why people with Parkinson’s disease are at risk of falls: Parkinson’s affects the basal ganglia, which have an inhibitory action on movement. Releasing this inhibition requires the release of dopamine, so the deficiency results in hypokinesia. Freezing gait can also contribute to falls as it can cause patients to stop involuntarily when walking. They may then find themselves unable to initiate movement for several seconds/minutes5. In addition, basal ganglia control balance through cortico-spinal pathways, including auto-adjustment of posture to maintain stability, so reflexes which try to prevent falling are significantly impacted.
Examples of bradykinesia and rigidity include2:
- reduced arm swing
- shuffled gait
- softened voice
- decreased blink rate and facial expression.
Non-motor symptoms include2:
- autonomic dysfunction
- sleep disturbance.
It’s important to note that some conditions may look like Parkinson’s disease. For example, progressive supranuclear palsy, multiple system atrophy or extra-pyramidal side effects of drugs, such as antipsychotics or antiemetics can cause Parkinsonian features3.
Parkinson’s disease is usually diagnosed in secondary care, so any suspected cases should be referred to a neurologist to be seen within 6 weeks3. There are no laboratory or imaging tests that can offer a definitive diagnosis, so diagnosis is usually made based on a detailed clinical history and examination3,6. A specialist in secondary care may use the Parkinson’s UK Brain Bank Criteria to assist with diagnosis6.
The majority of management is in secondary care and it is recommended that patients receive a follow up every 6-12 months with a specialist who monitors treatment and progression of the condition. Patients with Parkinson’s disease are usually assigned to a Parkinson’s Disease Nurse Specialist (PDNS) who can co-ordinate care with the patient, carer, GP and specialist6. Patients should also be given access to occupational therapy, physiotherapy and speech therapy - depending on the severity of their symptoms - to assist with their independence and safety6.
Medication is initiated in secondary care and can be prescribed by the GP after this, in accordance with the local shared care guidelines. Occasionally GPs may be involved with monitoring medication, in liaison with the PDNS6. The following medications are common pharmacological treatments for Parkinson’s disease:
This is a dopamine precursor that converts to endogenous dopamine in the brain. Itis offered to patients in the early stages of the disease, where motor symptoms are already having an impact on their quality of life3,6. Levodopa is considered the core medication in treating Parkinson’s, but it requires close monitoring to get the dosage right. If the dosage is too high, it can result in hallucinations and psychotic behaviour. As the disease progresses and higher doses are needed, adverse effects of levodopa, such as dyskinesias, are more common. Adjusting the dosage, timing and type of preparation can help to manage these effects6.
Another treatment option is the use of drugs that have a dopamine-like action. These stimulate dopamine receptors in the brain and can be used on their own or with levodopa. Patients are likely to experience less long-term side effects from dopamine agonists, but they can cause side effects such as nausea, dizziness and sickness if not introduced gradually. Older patients may experience hallucinations. A small percentage of Parkinson’s patients may experience impulsive and compulsive behaviour when taking dopamine agonists. These patients may also be more prone to ‘dopamine agonist withdrawal syndrome’ when their treatment is stopped or reduced6.
Other key medications in the treatment of Parkinson’s disease include MAO-B inhibitors and COMT inhibitors. The NICE guidance on Parkinson’s disease in Adults (NG71) and the NICE Clinical Knowledge Summary on Parkinson’s disease provides more information on these, as well as more comprehensive lists of Parkinson’s medications and possible side effects.
Some medications may be contraindicated as they may cause worsening of the disease by antagonising dopamine receptors. As mentioned before, antipsychotics and anti-sickness drugs can cause extra-pyramidal side effects. These drugs can increase the severity of the Parkinsonian symptoms, particularly rigidity and bradykinesia, and sometimes irreversibly. A list of drugs to avoid can be found in the ‘drug treatments’ section of the Parkinson’s UK website.
GPs are a great source of support for patients with Parkinson’s disease, along with their family members and carers. Through support from their GP, patients are encouraged to take part in decision making and judgements about their own care. As Parkinson’s can affect a patient’s cognition and communication, NICE recommend that any information that is communicated throughout their disease should be given both verbally and in written form3. Family members and carers should also be kept informed about the patient’s condition, advised about their entitlements as a carer, encouraged to request a carer’s assessment from the local authority, and signposted to support services3. As mentioned earlier on, patients with Parkinson’s disease can be prone to falls due to their hypokinesia and balance impairment, so GPs will need to bear this mind when managing other medical conditions connected to falls, such as blood pressure. Orthostatic hypotension is common in Parkinson’s so extra care is needed when prescribing antihypertensives.
As a patient’s disease progresses, GPs are advised to be vigilant to any cognitive impairment. Parkinson’s is associated with Lewy body dementia and if this is suspected, referral to a consultant in older person’s mental health is recommended. As with any chronic disease, GPs should also look out for any signs of depression and screen for this intermittently. Signs of depression may be harder to detect due to the impaired facial expression and verbal difficulties that patients with Parkinson’s disease can experience.
To find out more about Parkinson’s disease and the GP’s role, RCGP members can benefit from access to the following online resources:
1 Parkinson’s UK, 2019. Parkinson’s is. [Online] Available at: https://www.parkinsons.org.uk/get-involved/parkinsons-is
2 British Medical Journal, 2018. BMJ Best Practice – Parkinson’s disease. [Online] Available at: https://bestpractice.bmj.com/topics/en-gb/147
3 NICE, 2017. Parkinson’s disease in adults (NG71). [Online] Available at: https://www.nice.org.uk/guidance/ng71
4 Parkinson’s UK, 2018. The incidence and prevalence of Parkinson’s in the UK report. [Online] Available at:https://www.parkinsons.org.uk/professionals/resources/incidence-and-prevalence-parkinsons-uk-report
5 European Parkinson’s Disease Association, 2017. Motor symptoms. [Online] Available at: https://www.epda.eu.com/about-parkinsons/symptoms/motor-symptoms/
6 Guidelines, 2012. The GP’s guide to Parkinson’s – by Parkinson’s UK. [Online] Available at: https://www.guidelines.co.uk/neurology-/the-gps-guide-to-parkinsons/453864.article
'An essay on the shaking palsy by James Parkinson' image from Wellcome Collection.
World Bipolar Day takes place every year on 30th March and is organised by various international charity organisations, who support people with bipolar disorder. The aim of the awareness day is to inform people about bipolar disorder and to improve attitudes towards the condition by eliminating the social stigma around it1. Bipolar disorder (previously known as manic depression) is a lifelong mental health condition, consisting of recurring episodes of depression and mania or hypomania2. Whilst bipolar disorder is usually diagnosed in secondary care, patients are likely to present in primary care first. Therefore, it is important for GPs to be able to recognise the signs and symptoms in order to refer to secondary care for formal diagnosis.
The National Institute for Health and Care Excellence (NICE) estimate that the peak age of onset is 15-19 years old. As bipolar disorder can often be difficult to detect initially, there is usually a significant delay between onset and first contact with mental health services3,4.
The Adult Psychiatric Morbidity Survey, conducted in 2014, found that 2% of the English population screened positive for bipolar spectrum disorders2.
The elevated mood in bipolar may be hypomania or mania, the definitions of which are as follows6:
Mania – Abnormally and persistently elevated or irritable mood for a distinct period of at least one week (with or without psychotic symptoms).
Hypomania – Mild mood elevation with increased energy and irritability, that lasts for 4 or more continuous days.
Depressive symptoms are the most common initial presentation in primary care, which makes it difficult to recognise them as being part of bipolar disorder. Patients may present with symptoms such as depression, anxiety, mood swings, sleep disturbance, irritability, fatigue and difficulty in focus and concentration4. To make a distinction between depression and bipolar disorder, ask the patient about periods of elated, excited or irritable mood lasting four days or more. It is also recommended that GPs take a family history of mania and depression7.
Patients who have been diagnosed and treated in secondary care should return to primary care with a mutually agreed care plan in place. This includes their recovery goals, a crisis plan which indicates early warning symptoms of a relapse and what do in this instance, an assessment of their mental state, and a medication plan with a date for review3. Both the patient and their GP should have a copy of this plan so that the GP can begin monitoring their condition in primary care.
Following diagnosis and stabilisation, the primary care team’s role is to optimise physical health, check mental state and review the patient’s medication (as would happen in any chronic disease management). Unwell patients will need help from their mental health teams if destabilisation occurs which cannot be managed in primary care.
From the care plan provided, the GP should have all the details concerning the patient’s medication and when it should be reviewed. However, NICE states that the secondary care team should be responsible for monitoring the efficacy of the patient’s antipsychotic medication for at least the first 12 months, or until the patient’s condition has stabilised, whichever is longer3. Following this, the responsibility for this monitoring may transfer to primary care under shared-care agreements.
If the patient is on lithium, the psychiatry team should provide a target lithium level (typically 0.6-0.8 mmol/L, depending on the patient). It is recommended that GPs check the levels every three months and monitor and adjust accordingly7, but if the patient becomes unstable they should be referred back to secondary care, in line with local shared care guidelines. The NICE guideline on ‘Bipolar disorder: assessment and management’ includes more specific information about the different pharmacological options for bipolar disorder and their use.
Physical health checks
As well as monitoring medication, it is recommended that GPs perform a physical health check on patients with bipolar disorder at least annually. According to NICE, these checks should include3:
- Weight, BMI, diet and nutrition and levels of exercise
- Pulse and blood pressure
- Fasting blood glucose, glycosylated haemoglobin (HbA1c) and blood lipid profile
- Liver function
- Renal and thyroid function
- Calcium levels (for people taking long-term lithium)
It is estimated that the life expectancy for people living with severe mental illness is 15-20 years lower than the general population8. This statistic highlights the importance of carrying out the checks above and managing any potential comorbidities alongside treatment for bipolar disorder.
As part of their regular reviews, GPs should provide holistic support to bipolar disorder patients and their families/carers. This includes preparing for major life events: for example, all patients planning a pregnancy or who have become pregnant should be immediately referred to the perinatal mental health service to advise the patient on the management of their medication in relation to their pregnancy. A good social history during visits will reveal important life changes that might be detrimental to the patient’s health such as changes in social or family situations or their general wellbeing4. As well as building relationships with the patient and their families/carers, the GP can help carrying out the care plans from secondary care and help with recovery goals.
For more information about the diagnosis and management of bipolar disorder, RCGP members can access the following eLearning resources for free:
1 World Bipolar Day, 2019. About World Bipolar Day. [Online] Available at: http://www.worldbipolarday.org/about-wbd.html
2 Marwaha S, Sal N, Bebbington P, 2016. ‘Chapter 9: Bipolar disorder’ in McManus S, Bebbington P, Jenkins R, Brugha T. (eds) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. Available at:
3 NICE, 2014. Bipolar disorder: assessment and management (CG185). [Online] Available at: https://www.nice.org.uk/guidance/cg185/resources/bipolar-disorder-assessment-and-management-pdf-35109814379461
4 Culpepper L, 2010. ‘The role of primary care clinicians in diagnosing and treating bipolar disorder’. Primary care companion to the Journal of clinical psychiatry vol. 12, Suppl 1 (2010): 4-9. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2902189/
5 Merikangas, Kathleen R et al. “Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative” Archives of general psychiatry vol. 68,3 (2011): 241-51. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3486639/
6 Mind, 2018. What types of bipolar are there? [Online]. Available at: https://www.mind.org.uk/information-support/types-of-mental-health-problems/bipolar-disorder/types-of-bipolar/#.XFgoXFz7S70
7 Goodwin GM et al, 2016. Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendation from the British Association for Psychopharmacology. Journal of Pharmacology 2016, Vol 30(6) 495-553. Available at: https://www.bap.org.uk/pdfs/BAP_Guidelines-Bipolar.pdf
8 NHS England, 2018. Improving physical healthcare for people living with severe mental illness (SMI) in primary care: Guidance for CCGs. [Online] Available at: https://www.england.nhs.uk/publication/improving-physical-healthcare-for-people-living-with-severe-mental-illness-smi-in-primary-care-guidance-for-ccgs/
This February is “Raynaud’s Awareness Month”. This common dermatological phenomenon was named after Maurice Raynaud, who in 1862 described the condition afflicting a 26 year old female patient. Although epidemiology varies depending on local weather, work exposure and sex, most population-based surveys estimate its prevalence between 3 to 5%. Patients can be divided into two different groups: those with primary Raynaud’s phenomenon, which is diagnosed when no underlying disease is found; and those with secondary Raynaud’s phenomenon, which is diagnosed when there is an associated disease. The differentiation between the two of them is of importance, as secondary Raynaud’s has the potential for serious complications. Its associated diagnoses -systemic sclerosis, vasculitis, systemic lupus erythematosus, rheumatoid arthritis, peripheral vascular disease - are potentially serious and can cause deterioration in quality of life. As 30 to 50% of patients with primary Raynaud’s have a first degree relative condition, a genetic component is likely1.
Patients describe well demarcated, episodic blanching of one or more fingers (or toes, ears, nipples and ears) caused by peripheral vasospasm and triggered by a cold environment or emotional stress. This can be followed by a blueish, cyanotic colour (in a third of all patients), before the fingers turn bright red during a period of reperfusion, associated with stinging and throbbing. The symptoms can last for minutes and up to several hours.
Raynaud’s phenomenon isn’t the only diagnosis that can cause vascular symptoms in the periphery: exposure to the cold can cause physiological pallor, an acute cholesterol embolism can mimic the discolouration of Raynaud’s phenomenon (though doesn’t have its episodic nature) and thrombangitis obliterans (recurrent thrombosis of small/medium arteries and veins) can cause similar distal extremity ischaemia2.
Patients who present with primary Raynaud’s are usually younger (between 15 and 30 years of age), don’t appear to have symptoms affecting their thumbs and lack ulceration, digital pitting or gangrene. Patients presenting in general practice should be asked about the frequency and severity of the attacks, smoking and family history and for symptoms associated with the diagnoses underlying secondary Raynaud’s.
Examination should involve checks for peripheral vascular disease, blood pressure measurements and evidence of complications of secondary Raynaud’s. Examination of the capillaries of the nailbeds of the fingers can be attempted with an otoscope, ophthalmoscope or a dermatoscope, as dilated and distorted capillaries can point to underlying connective tissue disease3. Investigations should include FBC, ESR, ANA, U&Es, and urinalysis.
If examination and investigation points to primary Raynaud’s, pharmacological treatments are often not necessary, and lifestyle advice should be considered first: keeping warm, smoking cessation, avoiding exposure to cold weather. If non-pharmacological treatments in primary Raynaud’s are ineffective, calcium channel blockers such as nifedipine and nicardipine can be effective in reducing the frequency of attacks.
If treatment is ineffective or if there is suspicion of connective tissue disease or another underlying condition, the patient should be referred to the local rheumatology team4.
Images used with permission from the charity ‘Scleroderma & Raynaud’s UK’. Their website has extensive guidance for patients with Raynaud’s.
1 Fredrick M. Wigley and Nicholas A. Flavahan: Raynaud’s Phenomenon. August 11, 2016. N Engl J Med 2016; 375:556-565
2 Drerup, C; Ehrchen, J:Raynaud’s phenomenon. Practical management for dermatologists. Hautarzt 2019 · 70:131–141
3 Herrick, AL: Evidence-based management of Raynaud’s phenomenon. Ther Adv Musculoskel Dis, 2017, Vol. 9(12) 317–329
4 Pope, J: Raynaud’s phenomenon. BMJ Best practice. 2019. https://bestpractice.bmj.com/topics/en-gb/193
Young Carers Awareness Day takes place on 31st January 2019 and, according to the Carers Trust, the aim is to “identify young carers and raise awareness of the vital role that they play in supporting their sick and disabled family members”1. The number of young carers in England is difficult to determine; the latest census in 2011 found that there were around 175,0002, but a more recent survey by BBC News and Nottingham University estimates around 800,000 in secondary school alone3. One of the main reasons for this uncertainty is that young carers and their families are often reluctant to make themselves known to authorities for various reasons. This can make it extremely difficult for GPs to identify young carers in primary care and therefore support them effectively.
The theme of this year’s Young Carers Awareness Day is the importance of mental health, which can be significantly impacted when a child or young person is expected to juggle caring alongside their education and social life. Carers Trust estimates that around 45% of young adult carers have mental health problems4. The pressure of caring for one or multiple family members can cause a great deal of anxiety for both children and young adults, who are often the primary source of emotional support for the person/people they care for. The Dearden and Becker ‘Young Carers in the UK’ survey found that 82% of young carers provide emotional support as well as nursing-type care, intimate care and child care5.
It is not only a young carer’s mental health that is impacted by their caring role. Their physical health is often impaired due to lack of sleep, poor diet and having to lift a heavy adult6. These issues, combined with their responsibilities at home, can have a significant impact on their education and school life. It is estimated that young carers miss or cut short around 48 school days a year on average and only half have a person at school that knows about their caring role4. Barnardo’s, the children’s charity, highlight that young carers are often bullieddue to being ‘different’ from their peers and therefore feel isolated7. There are also limited opportunities for social activities and to build relationships outside of the family home. Around three quarters of young carers find the school holidays particularly difficult, due to feeling socially isolated and to the increase in their responsibilities at home4.
Whilst young carers face many difficulties, it is common for them to feel a sense of pride and independence due to their caring role. They also may not be fully aware that their life is different to their peers, which is one of the reasons why many young carers still remain ‘hidden’ from social services. Some families don’t recognise their children as ‘carers’, especially if the child helps their parents care for a sibling, so it is often not declared to local authorities. In other cases, the family is aware of their child’s caring role but worry about the repercussions of involving social services, such as interventions and the possibility of family separation8.
Without the involvement of social services, it is unlikely that a young carer would be known to their practice or GP. It is therefore important for GPs and practice teams to identify any young carers at the practice, so that they are aware of this during consultations and can signpost them to helpful resources. Young carers may also need to be involved in the care for the person they look after, such as appointments and medications. Some ways in which young carers can be identified include9:
- Putting posters and leaflets around in the waiting room, asking them to self-identify
- Adding a question in the new patient questionnaire at registration
- Looking out for any children or young people that bring an elderly, sick, disabled or frail patient in for an appointment and asking if they are the patient’s carer
- Ask any patients with chronic conditions that require a carer about who their carer is
For more information about identifying and supporting young carers, the RCGP has the following resources available to all healthcare professionals for free:
Supporting Carers in General Practice eLearning course – 3 CPD points
Taking Action to Support Carers in Practice Teams eLearning course - 2 CPD points
Carers Support clinical resource from the RCGP
RCGP Members can also access the following resources about carers:
GPs can also use the following resources to signpost patients and their families to:
1 Carers Trust. 2018. Young Carers Awareness Day 2019
2 Office for National Statistics. 2011. 2011 Census
3 BBC. 2018. Being a young carer
4 Carers Trust. 2015. Key facts about carers and the people they care for
5 Dearden, C. and Becker, S., 2004. Young carers in the UK: the 2004 report. London: Carers UK. Available from: https://dspace.lboro.ac.uk/2134/627
6 Carers Trust Professionals. 2014. Who are young carers?
7 Barnado’s. 2018. Young carers. http://www.barnardos.org.uk/what_we_do/our_work/young_carers.htm
8 Department for Education. 2016. The lives of young carers in England. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/498115/DFE-RR499_The_lives_of_young_carers_in_England.pdf
9 Royal College of General Practitioners. 2013. Supporting Carers in General Practicehttp://elearning.rcgp.org.uk/course/view.php?id=139
It is Anger Awareness Week during the first week of December, an event which aims to bring the issue of problematic anger out in the open and encourage people to manage their anger effectively. Whilst anger can be a significant problem for adults, it is also common in children. For many children and young people, anger is simply a basic emotion to navigate as they grow up, but for some it can develop into something more serious.
Anger is a powerful emotion and is considered a necessary tool for survival as it is closely linked to the ‘fight or flight’ response. It prepares the body for the ‘fight’ option by keeping the body and mind stimulated through the arousal of the sympathetic nervous system. The physical effects of this include an increase in heart rate, blood pressure, blood flow to voluntary muscles, blood glucose level, respiratory rate and sharpness of senses, which are all necessary when the body needs to be on high alert1. The feeling of anger is often brought on by a combination of factors; a trigger event, an individual’s personality and their perception of the situation2.
In children the behavioural expressions of anger can seem dramatic, with outbursts such as screaming, shouting and throwing objects. In young children this is a normal part of emotional development, as they start to become more independent and therefore frustrated by situations which challenge their autonomy3. As children get older it may become more apparent if anger is turning into a problem, where it starts getting out of control and harming the child and/or the people/things around them. According to the mental health charity Mind4, examples of unhelpful angry behaviour include:
- Outward aggression and violence – shouting, swearing, slamming doors, throwing objects and being physically violent or verbally abusive towards others.
- Inward aggression – self-loathing, denying basic needs (such as food or happiness), cutting off from the world and self-harming.
- Passive aggression – ignoring people, refusing to do tasks, deliberately doing things badly, late or at the last minute and being sarcastic and sulky.
If the anger starts having implications in a child’s daily life, such as school exclusions and physical fights, their parents may well approach their GP to seek advice. At this point it’s important to consider whether the anger is actually a symptom of an underlying health problem.
Anger plays a big part in conduct disorders which are relatively common mental health conditions in children and young people that cause defiant, aggressive or antisocial behaviour. Younger children may have ‘oppositional defiant disorder’ which is a type of conduct disorder that involves arguing and disobeying but exhibits less antisocial behaviour5. According to the NHS, conduct disorders are the most common reason that children are referred to mental health services and 5% of all children aged 5-16 years old are diagnosed with the condition, with higher rates of diagnosis in boys than in girls5. The NICE guideline on ‘Antisocial behaviour and conduct disorders in children and young people: recognition and management’ recognises the discussion around the possible social determination of these disorders and the risk of overmedicalisation. Nevertheless it argues that “advances in the last three decades have shown that in addition to social causes there are substantial genetic and biological contributions to conduct disorders/antisocial behaviour; therefore, the contribution of these factors needs to be assessed and factored into intervention plans”.
NICE recommends that any children or young people who are suspected of having a conduct disorder should be assessed by health or social care professionals. Referral to child and adolescent mental health services (CAMHS) may also be necessary if the condition requires a multidisciplinary team or if there is diagnostic uncertainty. The initial assessment involves checking for any coexisting mental health problems or a neurodevelopmental condition, such as attention deficit hyperactivity disorder (ADHD) or autism6. More information about conducting these assessments can be found here. If a conduct disorder is diagnosed or any other conditions are detected, it’s important to treat these issues first and assess whether there have been any improvements to the anger problems.
Whether there is an underlying cause or not, parents will need to be supported in dealing with their child’s anger. The NHS provides advice on how to tackle anger together with the child, helping them to recognise the triggers and then use strategies to manage it. This information can be found here. Young Minds also has a section about ‘Responding to anger’ which is aimed at parents who are struggling to deal with their child’s anger and aggression. Parent training programmes and resources may also help with developing skills to manage difficult behaviour. Links to more information about these programmes can be found below. 9, 10, 11, 12
1 Mental Health Foundation. 2008. Boiling Point: And What We Can Do About It. https://www.mentalhealth.org.uk/publications/boiling-point-anger-and-what-we-can-do-about-it
2 Mental Health Foundation. 2018. Anger and Mental Health. https://www.mentalhealth.org.uk/a-to-z/a/anger-and-mental-health
3 Royal College of Psychiatrists. 2017. Dealing with tantrums: for parents and carers. https://www.rcpsych.ac.uk/mental-health/parents-and-young-people/information-for-parents-and-carers/dealing-with-tantrums-for-parents-and-carers
4 Mind. 2018. How to cope with anger. https://www.mind.org.uk/information-support/types-of-mental-health-problems/anger/
5 NHS. 2013. New guidelines on child antisocial behaviour. https://www.nhs.uk/news/pregnancy-and-child/new-guidelines-on-child-antisocial-behaviour/
6 NICE. 2017. Antisocial behaviour and conduct disorders in children and young people: recognition and management. https://www.nice.org.uk/guidance/cg158
7 Priory Education and Children’s Services. 2018. ADHD and when misbehaving becomes more than “playing up”. https://www.priorychildrensservices.co.uk/news-blogs/adhd-and-when-misbehaving-becomes-more-than-playing-up/
8 National Autistic Society. 2018. Information for general practitioners. https://www.autism.org.uk/professionals/health-workers/gp-info.aspx
9 YouTube. 2014. Parentchannel.tv https://www.youtube.com/user/parentchannelvideos/videos
10Family Lives. 2018. Parents Together Online course. https://www.familylives.org.uk/how-we-can-help/online-parenting-courses/parents-together/
11 YouTube. 2017. Parent-Plus TV. Anger & Aggression in children. https://www.youtube.com/watch?v=6-IafKUklUk
12 Care for the Family. 2018. Time Out for Parents: Handling Anger in the Family. https://www.careforthefamily.org.uk/courses/parenting-courses-time-out/time-out-for-parents-handling-anger-in-the-family
Flu season starts in late September/early October and lasts until the following March/April. During this time, GP consultations for flu-like symptoms usually increase from a baseline of 30 per 100,000 population. If the consultation rate rises above 200 per 100,000 population, a flu epidemic is declared¹.
Anyone infected with the flu virus is contagious up to a day before the onset of symptoms and for 5-7 days after the symptoms start. Even if patients are asymptomatic, they can still pass the virus on to others¹. The flu vaccine is the most effective protection against flu offered in the UK, and although it doesn’t guarantee that patients won’t catch flu, it is likely that any flu-related illness they contract after the vaccination will be milder and short-lived². During the 2017/18 flu season it’s estimated that around 14 million adults and children in England were vaccinated against flu³, and changes to the 2018/19 flu vaccination programme mean that it will be offered to around 24 million people this year⁴. The recommended composition of the vaccines is determined by the World Health Organisation, who reviews the types of flu that have circulated in all parts of the world and chooses the strains to be included in the vaccine for the following autumn. A summary of the recommended vaccines for 2018/19 can be found here. In 9 out of 10 years, the vaccine matches the flu strains circulating that year but sometimes there can be unexpected changes to the virus that affect the efficacy of the vaccine³.
One of the biggest changes to the 2018/19 flu vaccination programme is the addition of a new vaccine, which will be offered to over 65s. The adjuvanted trivalent vaccine (aTIV) contains adjuvant MF59, a substance that strengthens the body’s immune response³, as older adults’ immune systems can get progressively weaker over time, leaving them more susceptible to catching flu and suffering complications due to a reduced production of B and T cells and reduced functioning of mature lymphocytes¹. The vaccine is inactivated and protects against the three strains which are most likely to circulate this season. Public Health England (PHE) predicts that the introduction of this vaccine could reduce GP consultations in England by 30,000, admissions by over 2,000 and prevent over 700 deaths from flu⁴.
The Office of National Statistics (ONS) estimated that there were around 34,300 excess winter deaths in the 2016/17 period, with one third due to respiratory illnesses⁵, concluding that this was likely to be due to the predominant strain that year having a significant impact on elderly patients. Catching flu can place a considerable strain on the body in elderly patients: current estimations are that around two thirds will be temporarily housebound and a quarter will become temporarily bedbound. Amongst those that survive hospitalisation, around 13% will face disability and potential loss of independence and quality of life¹. There is also a risk of fatal co-morbidities, such as stroke, congestive heart failure and pneumonia¹.
All healthcare professionals can access the RCGP’s new Influenza in the elderly eLearning course for free, which is worth 0.5 CPD points. A detailed description of the different 2018/19 flu vaccines can be found in PHE’s guide for healthcare professionals.
¹ Royal College of General Practitioners. Influenza in the elderly eLearning course. [Internet]. Available from: http://elearning.rcgp.org.uk/course/view.php?id=294
² NHS. Vaccinations. The flu vaccine. [Internet]. Available from: https://www.nhs.uk/conditions/vaccinations/flu-influenza-vaccine/
³ Oxford Vaccination Group. Inactivated Flu Vaccine. [Internet]. Available from: http://vk.ovg.ox.ac.uk/inactivated-flu-vaccine
⁴ Public Health England. Press release: New flu vaccine available this winter for those aged 65 and over. [Internet]. Available from: https://www.gov.uk/government/news/new-flu-vaccine-available-this-winter-for-those-aged-65-and-over
⁵ Office of National Statistics. Excess winter mortality in England and Wales: 2016 to 2017 (provisional) and 2015 to 2016 (final). [Internet]. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/excesswintermortalityinenglandandwales/2016to2017provisionaland2015to2016final
World Psoriasis Day takes place every year on 29th October. It aims to raise awareness of the condition and provide support to people with psoriasis, which affects around 2% of people in the UK. It can start at any age in both men and women, but it typically develops in adults under 35¹.
Psoriasis is a complex, chronic, multifactorial inflammatory skin condition with an increase in the epidermal cell turnover rate. Like other autoimmune diseases, psoriasis can wax and wane, with patients varying between mild and severe symptoms depending on systemic, environmental and personal factors. Normally, skin cells are produced and replaced every 3-4 weeks, but in areas affected by psoriasis this process only takes around 3-5 days. This results in a build-up of epidermal hyperplasia which creates patches of scaly and erythematous skin².
Its pathogenesis is still not completely understood. It is likely that there is a genetic susceptibility to psoriasis, although it is not a genetic condition in itself. Immune dysfunction can also contribute. Excessively rapid production of keratinocytes leads to infiltration of T cells, dendritic cells, macrophages and neutrophils, causing inflammation³.Flares in psoriasis can be caused by a variety of factors, including non-immunological problems. A list of the most common of these can be found here on the NHS website.
Aside from the physical symptoms of psoriasis, it is also a visible condition which can affect many areas of a patient’s life. The psychosocial impact of psoriasis is not always considered during treatment, but it can affect a person’s functioning in life, work, relationships and social situations. According to a membership survey conducted by the European Federation of Psoriasis Patient Associations (EUROPSO), 77% of respondents said that psoriasis was a problem or a significant problem for their lifestyle and well-being⁴. Another study, that focussed on patient experiences of living with psoriasis, reported that the emotional and social impacts were frequently mentioned during interviews with the participants. Feelings of anger, frustration, shame and self-consciousness were reported. The social impacts discussed included avoidance of social activities and meeting new people⁵.
Psoriasis can also affect the quality of life for families of patients with psoriasis. A 2006 study found that the lives of relatives and partners can be significantly affected by the condition. Only 8% of participants reported that their quality of life wasn’t affected at all. 57% stated that they were psychologically affected, with feelings of anxiety, upset and worry about their relative/partner’s future. 55% reported social disruption due to lack of confidence or embarrassment and 44% said that leisure activities were limited by their relative/partner’s psoriasis. The study concluded that clinicians should consider appropriate care strategies for not only the patients, but also their families⁶.
Although the psychosocial impact of psoriasis is often difficult to avoid, GPs can play an important role in helping patients to overcome any difficulties they may face as a result of their condition. A 2016 review about ‘The Potential Psychological Impact of Skin Conditions’⁷ outlines a few suggestions of how to do this during a consultation:
- Managing the patient’s expectations
Before treatment starts, discuss with the patient about what outcomes are most important to them, what they expect to see and how possible it is to achieve this. By discussing their expectations in a realistic and practical way, the patient is more likely to comply to the treatment and recognise if the treatment isn’t working for them.
- Encouraging patients to see beyond the symptoms
Patients can feel impaired by the symptoms of their psoriasis and the degree of impairment can vary between people. Support from the GP is needed for patients to see beyond this and recognise that their symptoms don’t need to rule their life. A way of addressing this is to ask the patient “what would/could you do if you did not have these symptoms?”. Referral to mental health professionals may also help to provide patients with coping mechanisms.
- Helping patients to explain their symptoms
A large part of a patient’s psychosocial issues may be that they feel self-conscious about their visible psoriasis symptoms. Having to explain their condition and face potentially negative reactions from other people can be a source of anxiety. GPs can equip patients with the right words to explain their psoriasis, giving them an appropriate and informed range of responses to use if necessary. This will empower them to take control in social situations and feel comfortable discussing their condition. The ‘living with psoriasis’ patient leaflets by Leo Pharma suggest some simple ways that patients can explain their condition.
You can find out more about psoriasis in our eLearning resources. RCGP members can benefit from free access to EKU12: Assessment & Management of Psoriasis and EKU Podcast: Assessment & Management of Psoriasis. All healthcare professionals can also access the ‘Inflammatory conditions’ in the Dermatology Library for free.
The ‘See Psoriasis: Look Deeper’ campaign has some useful documentation for patients, which you can access here. The following video ‘The skin I’m in’ also provides in-depth accounts from psoriasis patients. It was produced by See Psoriasis: Look Deeper, Dermatrust and The Royal Free Hospital.
¹ NHS. Psoriasis Overview. [Internet]. Available from: https://www.nhs.uk/conditions/psoriasis/
² NHS. Psoriasis Causes. [Internet]. Available from: https://www.nhs.uk/conditions/psoriasis/causes/
³ Cai, Y., Fleming, C., Yan, J. (2012) New insights of T cells in the pathogenesis of psoriasis. Cel Mol Immunol 9(4) 302-309. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4132586/
⁴ Dubertret L, Mrowietz U, Ranki A, et al. EUROPSO Patient Survey Group. European patient perspectives on the impact of psoriasis: the EUROPSO patient membership survey. Br J Dermatol 2006;155(4):729–36
⁵ David Pariser, Brad Schenkel, Chureen Carter, Kamyar Farahi, T. Michelle Brown, Charles N. Ellis & for the Psoriasis Patient Interview Study Group (2016) A multicenter, non-interventional study to evaluate patient-reported experiences of living with psoriasis, Journal of Dermatological Treatment, 27:1, 19-26, DOI: 10.3109/09546634.2015.1044492
⁶ Eghlileb, A. , Davies, E. and Finlay, A. (2007), Psoriasis has a major secondary impact on the lives of family members and partners. British Journal of Dermatology, 156: 1245-1250. doi:10.1111/j.1365-2133.2007.07881.x
⁷ Tuckman, A. (2016) The Potential Psychological Impact of Skin Conditions. Dermatol Ther (Heidelb) (2017) 7 (Suppl 1):S53–S57. DOI 10.1007/s13555-016-0169-7
Alopecia is a general term for hair loss. However, there are different types depending on the severity and underlying cause of the hair loss. Alopecia areata is a non-scarring hair loss, which results in a small, round patch of baldness on the scalp. It can also affect hair across the body, such as facial hair, body hair, eyebrows and eyelashes. For some people, larger areas can be affected, such as the whole scalp (alopecia totalis) or the whole scalp and body (alopecia universalis)².
Alopecia Awareness Month takes place in September and aims to raise awareness of alopecia and the impact it has on those it affects. It is estimated that the lifetime prevalence of alopecia areata in the UK is 1.7%, with both men and women affected¹. Patients with concerns about hair loss symptoms are likely to visit their GP initially, so it is useful to have some understanding of alopecia and the different ways it can present.
Alopecia areata is an autoimmune condition which occurs when T-lymphocytes attack the hair bulb. There is a genetic predisposition in some families and it can also be associated with other autoimmune conditions, such as thyroiditis, lupus erythematosus, vitiligo and psoriasis¹. Unfortunately, there is no known cure and hair regrowth cannot be guaranteed. The chances of the hair growing back depends on the amount that is lost in the first place. People with small bald patches may experience full regrowth within a year, whereas people who lose half of their hair may not make a full recovery².
Another cause of alopecia is androgenetic alopecia, which can affect men or women and for which there is a genetic link. Treatments for this include antiandrogens and hair transplants, which are not usually available on the NHS.
Telogen effluvium is another common form of alopecia. It occurs when hair follicles move from the anagen phase to the telogen phase too early. Around 85% of scalp hairs are in the anagen phase, which means that the hair grows by 0.5-1.5cm a month and lasts in the scalp around three-five years. Telogen is when the hair follicle is approaching the end of its lifecycle. The hair is fully keratinized and the follicle is dormant, lasting in the scalp around two-three months¹.
The normal hair cycle is illustrated in the diagram below:
Acute telogen effluvium can happen suddenly and generally comes on about three months after a trigger. Common triggers include childbirth, severe trauma or illness, a stressful or major life event, rapid weight loss, severe skin problems affecting the scalp or a new medication¹’³. Patients may notice large numbers of hairs on their pillow, hairbrush or in the plughole. In most cases, hair growth returns to normal within a few months¹. If the hair loss carries on for more than six months, this could suggest chronic telogen effluvium. It is more common in women and is linked to female pattern hair loss, thyroid disease and iron and vitamin D deficiencies¹.
The RCGP has recently developed an eLearning course with Alopecia UK, with the aim of increasing GPs’ knowledge of hair loss conditions. You can access the Alopecia eLearning course here. The course is FREE to access and gives you at least 0.5 CPD Credits upon completion. For more information on hair loss conditions, you can also visit the Alopecia UK website here.
¹ Royal College of General Practitioners. Alopecia eLearning course. [Internet]. Available from: http://elearning.rcgp.org.uk/course/view.php?id=283
² British Association of Dermatologists. Alopecia Areata Patient Information Leaflet. [Internet]. Available from: http://www.bad.org.uk/for-the-public/patient-information-leaflets/alopecia-areata
³ British Association of Dermatologists. Telogen Effluvium (a type of hair loss) Patient Information Leaflet. [Internet]. Available from: http://www.bad.org.uk/for-the-public/patient-information-leaflets/telogen-effluvium
The first week of August marks World Breastfeeding Week, which aims to encourage mothers around the world to breastfeed and therefore safeguard the health of their babies. August was chosen because the Innocenti Declaration was signed in August 1990 (and later updated in 2005) by governments and various health organisations to protect, promote and support breastfeeding¹. The awareness week is coordinated by World Alliance for Breastfeeding Action (WABA), a global network consisting of several organisations such as World Health Organisation (WHO), United Nations Children’s Fund (UNICEF) and La Leche League International (LLLI)². World Breastfeeding Week has taken place every year since 1992, and has a different theme and focus each time. As well as a theme, each year there are four objectives: Inform, Anchor, Engage and Galvanise.
The theme for this year’s World Breastfeeding Week is ‘Foundation of Life’, which references the health benefits that breastfeeding provides for both mother and baby: breastfeeding exclusively for 6 months can help protect against infections and therefore reduce newborn mortality. It also provides an important source of nutrients and energy in early life and reduces the likelihood of obesity in childhood and adolescence. For the mother, a longer duration of breastfeeding can reduce the risk of developing breast or ovarian cancer ³. According to a 2014 study on 10,000 new mothers in the UK, breastfeeding was also linked to lower rates in post-natal depression. Mothers who planned to breastfeed and actually went on to breastfeed were 50% less likely to suffer with post-natal depression than those who hadn’t planned to and didn’t breastfeed.⁴
To get the optimum benefits from breastfeeding, WHO and UNICEF recommend the following³:
- early initiation of breastfeeding within one hour of birth
- exclusive breastfeeding for the first six months of life
- combination of nutritionally adequate solid foods with continued breastfeeding up to two years of age and possibly beyond
Despite the benefits the rates for breastfeeding in the UK are among the lowest in the world⁵. According to the latest Infant Feeding Survey in 2010, only 34% of babies in the UK were receiving any breastmilk at six months⁶, compared to 49% in the US and 71% in Norway⁵. Breastfeeding initiation was at 81% and went down to 1% for exclusive breastfeeding by the six month mark⁶.
The Infant Feeding Survey also states that eight out of ten women stop breastfeeding before they want to. Common reasons for stopping breastfeeding included problems with the baby’s latch, painful breasts or nipples and feeling that they had an ‘insufficient’ milk supply⁶. Although most of these issues may be addressed initially with midwives, health visitors and lactation consultants, it’s important for GPs to have enough knowledge about them to advise mothers at their 6-8 week check. For more information about how to deal with these common problems appropriately, you can consult the NICE Clinical Guideline on ‘Postnatal care up to 8 weeks after birth’. NHS Choices also provides more information about specific conditions such as mastitis and tongue-tie. GPs can signpost patients to organisations such as The Breastfeeding Network and LLLI for further support and advice.
Although breastfeeding is the recommended infant feeding method by many health organisations, GPs may also be asked for advice on formula feeding as an alternative. While the role of the primary care team is crucial in promoting exclusive breastfeeding both pre and post natal, it is crucial to offer support to women who chose the alternative. The RCGP offers a FREE eLearning course on Infant Nutrition, which covers the basics of formula feeding and provides an understanding of common feeding problems.
For further information about breastfeeding and the GP’s role, the RCGP has recently launched an eLearning course on Breastfeeding, which is FREE to all healthcare professionals.
¹ World Health Organisation (WHO). World Breastfeeding Week 1-7 August 2016. [Internet} Available from: http://www.who.int/mediacentre/events/2016/world-breastfeeding-week/en/
² World Health Organisation (WHO). BREASTFEEDING: Foundation of Life. 2018. [Internet]. Available from: http://worldbreastfeedingweek.org/
³ World Health Organisation (WHO). Infant and young child feeding. February 2018. [Internet]. Available from: http://www.who.int/en/news-room/fact-sheets/detail/infant-and-young-child-feeding
⁴ Borra, C., Iacovou, M. & Sevilla, A. Matern Child Health J (2015) 19: 897. Available from: https://doi.org/10.1007/s10995-014-1591-z
⁵ Victora CG, Bahl R, Barros AJD, et al, for The Lancet Breastfeeding Series Group. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet 2016; 387: 475–90
⁶ McAndrew F, Thompson J, Fellows L, Large A, Speed M, Renfrew MJ (2012) Infant Feeding Survey 2010, Health and Social Care Information Centre. Available from: https://files.digital.nhs.uk/publicationimport/pub08xxx/pub08694/infant-feeding-survey-2010-consolidated-report.pdf