Eczema in ChildrenPaediatrics > Dermatology > Eczema in Children

Published: 14-Sep-2016 Valid until: 22-Dec-2017 Printed on: 02-Dec-2017 © Map of Medicine Ltd This care map was published by Whanganui District. A printed version of this document is not controlled so may not be up-to-date with thelatest clinical information.

Page 1 of 11

Consider differentialdiagnoses

Eczema assessment

Management includingpsychosocial support& assessment

EVERYDAYMANAGEMENT

FLARINGMANAGEMENT

INFECTIONMANAGEMENT

Avoidingenvironmental triggers

Baths

Emollients

Food

Itch

Consider scabies

Antiseptic baths

Antibiotics

Consider minor herpesinfection

Indications foradmission to hospital

Consider referral toNurse Services

Care mapinformation

Updates to this caremap

Information resourcesfor patients and carers

Consider infection

Increase everydaymanagement

AND start topicalsteroids

Referral for admission

Rule out EczemaHerpeticum

Pasifika

Review and follow-upin general practice

Information resourcesfor clinicians

Hauora Maori

Eczema in ChildrenPaediatrics > Dermatology > Eczema in Children

Published: 14-Sep-2016 Valid until: 22-Dec-2017 Printed on: 02-Dec-2017 © Map of Medicine Ltd This care map was published by Whanganui District. A printed version of this document is not controlled so may not be up-to-date with thelatest clinical information.

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1 Care map information

Quick info:Atopic eczema (AE) or atopic dermatitis (AD):

• is a dry, itchy, inflammatory, chronic skin disease that typically begins in early childhood

• affects around 30% of children

• condition can worsen and cause

• intractable pruritus, soreness, infection, sleep disturbance

• the onset of eczema is usually before 9 months and it follows a remitting and relapsing course

• most children will "grow out of" eczema before five years of age

• there is no cure for AE, however if treated and managed well the disease has less impact on daily living and is less likely tohave a negative effect on quality of life for the patient and family [5]

Referral criteria to Paediatrician:

• children under 1 year of age

• skin changes before 3 months of age

• child compliant with adequate treatment regimen for > 6 weeks with no improvement in eczema

• children with severe eczema [1,3]

Indications for admission to hospital (via Child Assessment Unit or Emergency Department):

• control of infection

• intensification of topical therapy

• controlling the itch/scratch cycle

Phone on call Paediatrician - 06 348 1234Eczema is estimated to affect:

• 15% of Maori children

• 16% of Pacific children in New Zealand

• compared to approximately 10% of children of other ethnicities

As it is often characterised by S. aureus colonisation, eczema significantly increases the risk of invasive bacterial infections.Managing eczema is therefore an important aspect of preventing recurrent skin infections. These “skin infections” are far moreprevalent within Maori and Pacific Island populations in particular the lower socioeconomic whanau [10] . See BPAC article

2 Information resources for patients and carers

Quick info:INFORMATION RESOURCES FOR PATIENTS AND CARERS:Print/email this attached list of all resources for parent/caregiver.Videos:

• eczema care - 3 easy steps

• eczema care - bathing

• eczema care - moisturiser

• eczema care - steroids

Patient Information:

• action plans:

• Advanced Form in Medtech or

• non-Medtech action plan

• bleach bath instructions:

• bleach bath picture instructions

• bleach bath instructions

• eczema care pamphlet:

• this pamphlet includes advice on eczema symptoms and triggers and handy hints on day to day management

Eczema in ChildrenPaediatrics > Dermatology > Eczema in Children

Published: 14-Sep-2016 Valid until: 22-Dec-2017 Printed on: 02-Dec-2017 © Map of Medicine Ltd This care map was published by Whanganui District. A printed version of this document is not controlled so may not be up-to-date with thelatest clinical information.

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• food and symptom diary

• itchykids:

• itchykids website

• financial assistance information

• Health Navigator website

• Australasian Society of Clinical Immunology and Allergy (ASCIA) website

Improving the home environment:

• How to have a healthy home

• further information to help impriove the home environment - energywise website

3 Information resources for clinicians

Quick info:INFORMATION RESOURCES FOR CLINICIANS:Scoring Assessments:

• SCORAD [2]

• Trouble with Skin (children)

• Patient-Oriented Eczema Measure (POEM)

Photos of:

• atopic eczema in Infants

• atopic eczema in Pre-schoolers

• atopic eczema in School aged children

• scabies and other infestations

• infected eczema

• Eczema Herpeticum

Steroids:

• check whether the cream or ointment you are prescribing is fully funded by Pharmac

• potency of steroids and weight of cream required

• topical corticosteroid treatment for skin conditions

Oral antibiotics:

• Cephalexin

• Flucloxacillin

• Erythromycin

Antihistamines:

• cetirizine

Social Assessment:

• social assessment form [11]

Improving the home environment:

• WRHN healthy homes project - referral form or advice given to assist families to improve home environment from the HealthyHomes Co-ordinator 06 3480109 Ext 707

• How to have a healthy home

• further information to help impriove the home environment - energywise website

Whanau Ora Navigator through Te Oranganui Iwi Health Authority:

• Whanau Ora information leaflet

• Whanau Ora referral form

Public Health Nurse (Medical Officer of Health standing orders):

• referral form

Eczema in ChildrenPaediatrics > Dermatology > Eczema in Children

Published: 14-Sep-2016 Valid until: 22-Dec-2017 Printed on: 02-Dec-2017 © Map of Medicine Ltd This care map was published by Whanganui District. A printed version of this document is not controlled so may not be up-to-date with thelatest clinical information.

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WINZ:

• disability allowance information

• disability allowance application form - online

• disability allowance application form - hard copy

• disability allowance information for medical practitioners

4 Updates to this care map

Quick info:Date of publication: September 2014.Pathway republished after review in August 2015.For information on updates please view What's New document.For further information on contributors and references please see the care map's Provenance.

5 Hauora Maori

Quick info:As a practitioner you will work with Maori whanau/families. Each Maori whanau is diverse with their own set of values and beliefs,inherited, practised and passed down from generation to generation.There are some important things that you should be mindful of when working with Maori individuals and their whanau from a holisticapproach to working in a Whanau ora or family / whanau centred way.Key enablers that you should be aware of when working with Maori whanau/families are:

• building relationships and gaining trust

• effective communication with whanau /families

• understanding and involving whanau/ families in the treatment planning and care management

• practical things to be mindful of when working with Maori whanau so that you do not breech Tikanga/Principles and practicesthat are important in Te Ao Maori/the Maori world

Common terms and definitions are noted here.

6 Pasifika

Quick info:Quick InformationOur pasifika community:

• is a diverse and dynamic population:

• more than 22 nations represented in New Zealand

• each with their own unique culture, language, history, and health status

• share many similarities which we have shared with you here in order to help you work with pasifika patients more effectively

The main Pacific nations in New Zealand are:

• Samoa, Cook Islands, Fiji, Tonga, Niue, Tokelau and Tuvalu

Acknowledging The FonoFale Model (pasifika mode of health) when working with pasifika peoples and families.Acknowledging general pacific guidelines when working with pasifika peoples and families:

• cultural protocols and greetings

• building relationships with your pacific patients

• involving family support, involving religion, during assessments and in the hospital

• home visits

• pasifika phrasebook

Eczema in ChildrenPaediatrics > Dermatology > Eczema in Children

Published: 14-Sep-2016 Valid until: 22-Dec-2017 Printed on: 02-Dec-2017 © Map of Medicine Ltd This care map was published by Whanganui District. A printed version of this document is not controlled so may not be up-to-date with thelatest clinical information.

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7 Eczema assessment

Quick info:The UK Diagnostic Criteria for atopic eczema are [6]:

• Must have itch

• Plus 3 or more of the following:

• history of involvement in skin creases

• personal history of asthma or hayfever:

• or history of atopic disease in 1st degree relative if child is under 4 years of age

• a history of dry skin in the last year

• onset under the age of 2 years (if child now 4 years or older)

• visible flexural eczema

RAST testing NOT indicated as a screen for allergy [1]Photos of Atopic Eczema in [7]:

• Infants

• Pre-schoolers

• School aged children

8 Consider differential diagnoses

Quick info:Differential diagnoses include:

• psoriasis

• contact dermatitis − allergic and irritant

• seborrhoeic dermatitis

• fungal infection

• scabies and other infestations [8]

9 Management including psychosocial support & assessment

Quick info:Management of infections and flares is in addition to everyday management of eczema [1].Photos of Eczema in [7]:

• infants

• pre-schoolers

• school aged children

Social Assessment:

• social assessment form [11]

Scoring Assessments:

• SCORAD [2]

• Trouble with Skin (children)

• Patient-Oriented Eczema Measure (POEM)

10 INFECTION MANAGEMENT

Quick info:Secondary bacterial infection of eczema is a common complication.Bacterial infection is suspected if there is:

Eczema in ChildrenPaediatrics > Dermatology > Eczema in Children

Published: 14-Sep-2016 Valid until: 22-Dec-2017 Printed on: 02-Dec-2017 © Map of Medicine Ltd This care map was published by Whanganui District. A printed version of this document is not controlled so may not be up-to-date with thelatest clinical information.

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• crusting

• weeping

• erythema

• cracks

• frank pus or multiple excoriations

• increased itch

The usual organism is Staphylococcus aureus.Secondary herpes simplex infection is characterised by a sudden onset of:

• grouped, small white or clear fluid filled vesicles

• satellite or "punch out" lesions

• pustules, and erosions

It is often tender, painful and itchy [5].See images of infected eczema.

11 FLARING MANAGEMENT

Quick info:A flare (an acute deterioration) is indicated by increasing erythema and itch [1].Look at providing an action plan using the Advanced Form in Medtech (alternatively you can use this action plan) includinginformation on eczema care.Follow the treatment path below to control symptoms.

12 EVERYDAY MANAGEMENT

Quick info:The main aims of eczema management are to:

• identify and minimise exposure to factors that exacerbate eczema

• maintain the barrier function of skin with emollients

• use anti-inflammatory treatment to control exacerbations [5, 6]

The treatments in the pathway below are ongoing regardless of the presence or absence of eczema [1].Consider a referral to Whanau Ora Navigator if whanau are wanting additional support through Te Oranganui Iwi Health Authority:

• Whanau Ora information leaflet

• Whanau Ora referral form

13 Rule out Eczema Herpeticum

Quick info:Urgent referral is required if eczema herpeticum is suspected. This is a severe form of herpes simplex virus infection in a patientwith atopic eczema which presents as:

• rapidly worsening, painful plaques

• clustered vesicles or punched out erosions

• often associated with fever and malaise [3,5]

Photos of Eczema Herpeticum [7]

14 Consider infection

Quick info:Possible signs of infections:

Eczema in ChildrenPaediatrics > Dermatology > Eczema in Children

Published: 14-Sep-2016 Valid until: 22-Dec-2017 Printed on: 02-Dec-2017 © Map of Medicine Ltd This care map was published by Whanganui District. A printed version of this document is not controlled so may not be up-to-date with thelatest clinical information.

Page 7 of 11

• yellow crusts and weeping

• skin swabs are not useful unless failure of antibiotics (when complete course taken) [1]

See images of infected eczema.

15 Avoiding environmental triggers

Quick info:These include:

• soap

• shampoo or bubbles in the bath

• perfumes

• grass

• perfumed washing powder

• heat

• cold and dry

Nails should be cut short and cotton clothes should be worn next to skin.Reduction of house dust mite exposure can be achieved by encasing mattress, base and pillows in special covers and by hot water(>55°C) washing of bedding each week [4, 6].Improve/assess home environment:

• improving home environment:

• insulation for homes can be obtained through the WRHN healthy homes project- referral form or advice given to assistfamilies to improve home environment from the Healthy Homes Co-ordinator 06 3480109 Ext 707

• How to have a healthy home

• further information to help impriove the home environment - energywise website

WINZ:

• disability allowance information

• disability allowance application form - online

• disability allowance application form - hard copy

• disability allowance information for medical practitioners

16 Consider scabies

Quick info:Permethrin lotion 5% can not be applied to broken skin [1].See images of scabies.Click here for more information on diagnosis and management of scabies.

17 Increase everyday management

Quick info:Review everyday management - see "Everyday management" section of pathway.You may need to increase:

• use of emollients up to 20 times per day

• baths up to twice per day

• prescribe antihistamines if child is finding it difficult to settle to sleep and/or to sleep through the night because of increased itch

The first choice is Cetirizine or other non-sedating antihistamine prior to use of Promethazine[1].

18 Baths

Eczema in ChildrenPaediatrics > Dermatology > Eczema in Children

Published: 14-Sep-2016 Valid until: 22-Dec-2017 Printed on: 02-Dec-2017 © Map of Medicine Ltd This care map was published by Whanganui District. A printed version of this document is not controlled so may not be up-to-date with thelatest clinical information.

Page 8 of 11

Quick info:Bathing:

• eczema care video - bathing

• consider bleach bath once a week:

• bleach bath picture instructions

• bleach bath instructions

• dissolve a ¼ cup of emulsifying ointment under the hot tap as a bath oil to hydrate skin

• bath needs to be warm (not hot) and for at least 15-20 minutes

• avoid the use of soaps, emulsifying ointment can be used as a soap substitute [1]

• pat skin dry and apply corticosteroids (if needed) and moisturiser immediately after the bath

19 Antiseptic baths

Quick info:Oilatum Plus or QV Flare up are good antiseptic bath oils. However, they are not fully funded [1].Bleach bath:

• bleach bath picture instructions

• bleach bath instructions

• instructions:

• add normal household bleach (e.g. 2.2% Budget Bleach) to bath:

• 1 cap full of 2.2% budget bleach to a baby's bath

• 1/2 cup 2.2% budget bleach to 1/4 filled (10cm) adult sized bath

• 1 cup of 2.2% budget bleach to 1/2 filled (20cm) adult sized bath

• add 1/2 cup melted emulsifying ointment to the bath [1,4]

• bath needs to be warm (not hot)

• the scalp and face should also be washed whilst bathing

• this does have a tendency to dry the skin so should not be used every day; pat skin dry and immediatelyapply moisturiser

• at least once per week or as recommended on action plan

20 AND start topical steroids

Quick info:Topical steroids:

• eczema care video - steroids

• steroids should not be used continuously for weeks or months, 2 weeks is usually sufficient

• always check whether the cream or ointment you are prescribing is fully funded by Pharmac (can be checked via the Pharmacwebsite)

• in general, 1% hydrocortisone is sufficient for facial eczema and for eczema on infants under one year

• for school age children, eczema on the body (excluding face, neck, groin) usually requires a potent steroid

• Clobetasol (e.g. dermol) is rarely needed for childhood eczema and should only be used with caution and upon specialistadvice

• steroid side effects on the skin are rarely seen in children. They are more likely to be seen with use of very potent preparations,use under occlusion (including in the flexures) or with continuous use for months at a time (even of mild preparations)

• use of a stronger preparation for short bursts is generally preferable to ongoing use of a milder preparation

• ensure that efficient quantities of steroid cream are prescribed

• oral steroids are associated with rebound and although they can be useful in some circumstances, should be used with caution. if oral corticosteroids are used, they need to be replaced with another systemic agent or weaned slowly, usually over months

The potency of steroids and weight of cream required.

Eczema in ChildrenPaediatrics > Dermatology > Eczema in Children

Published: 14-Sep-2016 Valid until: 22-Dec-2017 Printed on: 02-Dec-2017 © Map of Medicine Ltd This care map was published by Whanganui District. A printed version of this document is not controlled so may not be up-to-date with thelatest clinical information.

Page 9 of 11

For more information on topical corticosteroid treatment for skin conditions see this BPAC article.

21 Emollients

Quick info:Emollients:

• eczema care video - moisturiser

• emollients are essential and frequently under used

• they should be applied liberally and as often as is required to keep the skin well hydrated to help maintain its barrier functioneven when the eczema is well controlled (hourly if necessary)

• ensure adequate quantities are prescribed (at least 1kg per fortnight)

• ointments (e.g. emulsifying ointment) are greasier and more effective

• oily creams (e.g. HealthE fatty cream) are midway between creams and ointments in effectiveness and are usually cosmeticallyacceptable

• creams (e.g. Cetomacrogol - sorbolene cream) are less greasy but may be cosmetically more acceptable (apply as many timesas needed to keep skin moist regardless of presence/absence of eczema)

• sorbolene cream is supplied in pump bottles

• lotions are lighter still and generally not effective in eczema [1,4]

Aqueous cream should not be prescribed as it is not effective [1,9].

22 Antibiotics

Quick info:Oral antibiotics in order of preference:1. Cephalexin orally:

• 12.5 - 25mg/kg per dose (max 500mg per dose) BD for 14-28 days

2. Flucloxacillin orally:

• Capsules 250mg (under 30kg) per dose, 500mg (over 30kg) per dose qid, for 14-28 days

• NB: flucloxacillin suspension is unpalatable and should not be prescrbed. Capsules can be prescribed to children who are ableto swallow them

3. Erythromycin orally:

• 10mg/kg per dose qid (max 500mg per dose) if penicillin-allergic, or

• 20mg/kg BD (BD dose would increase adherence compared to QID)

NB: Skin swabs are not useful unless failure of antibiotics (when complete course taken) [1]

23 Food

Quick info:Food may be one of many triggers for eczema in children.Food allergy is more likely to be a factor in young infants with severe generalised eczema.Evaluation of food allergy in children with eczema is fraught as these children are usually atopic, and allergy tests can reflectsensitization rather than clinically relevant allergy [4].Unless food allergy has been clearly identified, diets should not be restricted [4].If food allergy is suspected optimise standard treatment and referral to Paediatrician (phone on call Paediatrician).Advise parent/caregiver to start a food and symptom diary.

24 Consider minor herpes infection

Quick info:Avoid topical steroids during HSV infection.

Eczema in ChildrenPaediatrics > Dermatology > Eczema in Children

Published: 14-Sep-2016 Valid until: 22-Dec-2017 Printed on: 02-Dec-2017 © Map of Medicine Ltd This care map was published by Whanganui District. A printed version of this document is not controlled so may not be up-to-date with thelatest clinical information.

Page 10 of 11

Oral acyclovir:

• under 2 years 100mg/dose 5 times per day for 5 days

• over 2 years 200mg/dose 5 times per day for 5 days [1]

25 Itch

Quick info:Itch can be difficult to control, but adequate use of emollients will relieve itch.Occasional use of antihistamines may be appropriate [1].First choice is cetirizine. Promethazine should be reserved for severe itch for one or two nights. Caution in children under two years [1].Avoid overheating, wool next to skin and long fingernails.

26 Consider referral to Nurse Services

Quick info:If problems with eczema management and requiring additional support and education refer to:

• Practice Nurse Champion (GP standing orders)

• Well Child Nurses (if registered with either of the below, and 0-3 year olds):

• Tamariki Ora:

• phone 027 467 7014

• Plunket:

• via referral letter

• fax to 06 345 2011

• Public Health Nurse (Medical Officer of Health standing orders):

• referral form

• Iwi Health Providers:

• Ngati Rangi Community Health Centre (Ohakune)

• fax 06 385 9380

• Te Puke Karanga, Waimarino Health Centre (Raetihi)

• fax 06 385 5021

• Mokai Patea (Taihape)

• fax 06 388 9129

If ongoing issues, refer to Multi Disciplinary Team (MDT) via:

• Children's Home Care Nurses (Paediatric standing orders):

• via referral letter to Children's Ward WDHB

• fax to 06 348 1257

• Well Child Nurses (if registered with either of the below, and 0-3 year olds):

• Tamariki Ora:

• phone 027 467 7014

• Plunket:

• via referral letter

• fax to 06 345 2011

• Public Health Nurse (Medical Officer of Health standing orders):

• referral form

• Iwi Health Providers (via referral letter):

• Ngati Rangi Community Health Centre (Ohakune)

• fax 06 385 9380

Eczema in ChildrenPaediatrics > Dermatology > Eczema in Children

Published: 14-Sep-2016 Valid until: 22-Dec-2017 Printed on: 02-Dec-2017 © Map of Medicine Ltd This care map was published by Whanganui District. A printed version of this document is not controlled so may not be up-to-date with thelatest clinical information.

Page 11 of 11

• Te Puke Karanga, Waimarino Health Centre (Raetihi)

• fax 06 385 5021

• Mokai Patea (Taihape)

• fax 06 388 9129

27 Indications for admission to hospital

Quick info:Indications for admission to hospital (via Child Assessment Unit, Emergency Department):

• eczema herpeticum

• control of infection

• intensification of topical therapy

• controlling the itch/scratch cycle [1, 4]

For advice prior to referral contact Dr David Montgomery:

• 027475792

• david@millipaed.co.nz

28 Review and follow-up in general practice

Quick info:Progress report from Nurse Services either:

• entered into Medtech or

• sent to patients GP practice and scanned into notes

29 Referral for admission

Quick info:For advice prior to referral contact Dr David Montgomery:

• 027475792

• david@millipaed.co.nz

Phone on call Paediatrician - 06 348 1234A referral must be accompanied by a Severity Scoring of Atopic Dermatitis Index (SCORAD) assessment form - include score innotes on referral form.

Provenance Certificate – Eczema in Children

Overview | Accreditations | Editorial methodology | References | Contributors | Disclaimers

Overview

This document describes the provenance of Whanganui District Health Board’s Eczema in Children Pathway. This localised pathway was last updated on 17th September 2014. The purpose of implementing the CCP Programme in our DHB is to:

Enhance accuracy of referrals

Use best practice guidelines

Have all information found in one place

Enhance partnerships and collaboration across services

Improve patient outcomes through seamless care across primary and secondary care

To cite this pathway, use the following format: Map of Medicine – Eczema in Children Pathway - Whanganui View. Map of Medicine; 2014.

Editorial methodology This care map has been based on a Map of Medicine Care Map developed according to the Map of Medicine editorial methodology. The content of the Map of Medicine care map is based on high quality guidelines and practice-based knowledge provided by contributors with front-line clinical experience (see contributors section of this document). This localised version of the evidence-based, practice informed care map has been peer-reviewed by the WDHB and WRHN Collaborative Clinical Directors and Leaders Forum and with stakeholder groups.

Consumer engagement Development of the Whanganui Collaborative Clinical Pathways focuses on person-centred care and an experience based co-design approach where consumers are invited to consult with the Health Promoter / Community Developer (who sits on each pathway working group). Consumers are asked prior if possible, or if not at the very start of the pathway process to share their experiences to assist in designing services that work for them and their families, critiquing and feeding back on suitable consumer information and resources which can then be incorporated into the pathways. Feedback obtained ensures we address consumer challenges and needs within the pathway and provide suitable services, information and resources for consumers. Additional information on patient centred care is provided by following this link and experience based co-design of health care services at http://www.kingsfund.org.uk/projects/ebcd.

References 1 Contributors representing the Child Health Collaborative Clinical Pathway Working Group – MidCentral

DHB (2012)

2 MidCentral DHB (2011) Scoring of Eczema Severity [Form]ID: MDHB-5987

3 Oakley, A (2009) Managing Eczema Best Practice Journal (BPJ) Issue 23 pp 24 – 32.

4 Starship Hospital (2009) Starship Children’s Health Clinical Guideline: Eczema. Auckland, New Zealand

5 Royal Children's Hospital, Melbourne. (2012). Clinical Guidelines: Eczema Management.

6 British Association of Dermatologists & Primary Care Dermatology Society (2006). Guidelines on the

management of atopic eczema. Reviewed Jan 2010.

7 New Zealand Dermatological Society Incorporated (Dermnet) www.dermnet.org.nz

8 Clinical Knowledge Summaries (CKS). Eczema - atopic. Version 1.4. Newcastle upon Tyne: CKS; 2008.

Available from: http://www.cks.nhs.uk/eczema_atopic#323349001

9 Mohammed D, Matts PJ, Hadgraft J, et al. (2011). Influence of Aqueous Cream BP on corneocyte size,

maturity, skin protease activity, protein content and transepidermal water loss. British Journal of

Dermatology, 164(6): 1304-1310

10 Best Practice Journal (2012) Managing skin infections in Māori and Pacific families Issue 45 pp 14 – 20.

11 Starship child eczema pathway http://www.healthpointpathways.co.nz/northern/a-z/eczema/paediatric-

eczema/ (social assessment form)

Contributors

The following individuals have contributed to this care map:

Dr David Montgomery, Paediatrician, WDHB

Dr Antonia Hughes, GP, Taihape Health Centre

Bruce Jones, Public Health Nurse, WDHB

Donna Woollaston, Practice Nurse, Taihape Health Centre

Dr Lachlan Smith, GP, Aramoho Health Centre

Trish Silk, Community Paediatric Nurse, WDHB

Sala Tikoimaleya, Pharmacist Facilitator, WRHN

Sharon Duff, Health Promotion Advisor, WRHN

Carmel Malcolm, Tamariki Ora Nurse, Te Waipuna Medical Centre

Rihi Karena, Maori Health Clinical Services Manager, WDHB

Julie Nitschke, Clinical Director Primary Care Services, WRHN (Facilitator)

Dr Rick Nicholson, GP, Aramoho Health Centre (Facilitator)

Alaina Glue, CCP Project Facilitator, WRHN (Editor)

Disclaimers

CCP Leadership Team, Whanganui

It is not the function of the CCP Leadership Team to substitute for the role of the clinician, but to support the

clinician in enabling access to know-how and knowledge. Users of the Map of Medicine are therefore urged to use

their own professional judgement to ensure that the patient receives the best possible care. Whilst reasonable

efforts have been made to ensure the accuracy of the information on this online clinical knowledge resource, we

cannot guarantee its correctness and completeness. The information on the Map of Medicine is subject to change

and we cannot guarantee that it is up-to-date.