Thursday, 12 November 2020

A Whole New World - Honesty in Paediatrics

Paediatrics is a specialty where lying about a diagnosis is normal practice.  It's not because we're bad people.  When you think about the challenges of diagnosis in children combined with the expectation of a diagnosis, it is completely unsurprising.  The adult accompanying the child would like a diagnosis (please and thank you) and the clinician would very much like to give one (you're welcome).

While that all seems very reasonable, in child health it often isn't entirely truthful.  It is one of the mantras of medicine that the diagnosis is going to come from history and examination in most cases.  Hurrah for clinical diagnoses.  In paediatrics, the history is often from a third party and will have an inevitable element of bias.   The examination will also contain more uncertainties more of the time.  You have to accept a significant lack of information when interpreting examination finding in children.

The result of this is that clinical diagnosis is more challenging in paediatrics.  Here's the paradox: clinical diagnosis is the default position in child health.  Why?  Because we don't want to do tests on children or give them treatments "in case" unless these investigations or therapies are very likely to benefit the child.

This week, something big happened and it didn't even hit the news.  The General Medical Council released some new and updated guidance: "Guidance on professional standards and ethics for doctors Decision making and consent."  While much of the content is old news, there is a new emphasis on honesty when there is diagnostic uncertainty that is hugely relevant to paediatric practice, thanks to the fact that uncertainty is where we work.

So, when are we lying to our patients or the adults that accompany them?  The truth is that there is a spectrum of how far what we tell people lies from the truth.  What we should probably do in the light of the new GMC guidance is to re-evaluate our approach to a variety of clinical presentations and ask, "Should I change what I say about this?"

You could argue that nothing is certain in medicine, so what are the thresholds of uncertainty that decide when we should be honest in this way?  That's a fair comment.  We need to apply some measure here - enter the certometer.

The certometer takes the things that we are already using in our diagnostic approach and gives us an idea of how truthful it is to give that diagnosis.  Last week, I asked the medical Twitter world for a few suggestions of diagnoses that we could feed into the Certometer and this seems like a good time to give this contraption a go.

First up is an intriguing suggestion:  Diagnosis - Viral illness.
In my experience this diagnosis is usually given to children with a fever and signs or symptoms of upper respiratory tract infection without signs or symptoms of a more specific diagnosis.

Let's imagine a common scenario then: a 2yr old previously healthy child with a fever for 2 days.  They have a runny nose but no cough.  They have no respiratory abnormality.  Pharynx and both tympanic membranes are inflamed.

The pre-test probability of this being a viral illness is high. It's a child with a fever so the probability that the illness is viral is around 90%.

Positive predictors of a viral cause do exist and include wheeze and urticarial rash in children. This child has none of these things.

Good negative predictors of a diagnosis of viral illness in this sort of case would be some signs of suppurative complications such as mastoiditis.  We haven't seen any signs to suggest this.

So having looked for something specific that truly discriminates and found none, what you are left with is your pre-test probability, dialled down slightly by virtue of the absence of signs of another diagnosis.  In other words, all we have truly achieved is to rule out complications.  Since complications are rare, we're essentially no more certain this is a virus than before we started.

Calling it a viral illness implies that we've added some certainty to the underlying cause that in reality, we haven't.  In fact, by calling it "a virus" we have admitted that there are no specific finding identifying a particular viral illness.

What we have done is far more important.  We have looked for signs of complications and more serious infection (sepsis, meningitis etc) and found none.  What we can say with honesty and certainty is that this is an uncomplicated upper respiratory tract infection.

To emphasise the point about how often the lack of specific signs and symptoms is the norm in paediatrics, I'll give a couple of examples of common, clinical diagnoses that are usually made with enough certainty to be considered completely honest.
  • Croup
  • Chickenpox
  • Febrile convulsion
  • Vasovagal syncope
Yep, that's pretty much it.  Most other common problems are really labels given with real uncertainty due to the lack of specific signs or symptoms with good positive or negative predictive value.

Here are a few other examples of diagnoses that are commonly given in what is in reality a great deal of uncertainty that this problem is causing the symptoms or signs.
  • Infant reflux disease
  • Cow's milk protein allergy (non-IgE)
  • Asthma
    • in the under 5 yr old child
    • where the diagnosis is based on chronic cough without wheeze
  • Mesenteric Adenitis
  • Hypermobility
Then there's a whole new level of diagnostic uncertainty.  At the beginning I used colic as an example.   Let's try feeding a classic colic presentation into the Certometer.  You see a three week old baby whose only symptom is "crying all the time".  The pregnancy and birth were uncomplicated.  The baby examines normally and is thriving.  They are feeding well and passing urine and stools normally.

What is the pre-test probability that this is colic?  Unfortunately there's no good answer to that because it's not an actual disease.  There is no pathology or treatment.   Colic is simply a label to be given to crying infants that have no pathology.  If you try to put this through the Certometer, you will break it because you can't have any certainty of something that doesn't exist.

It is often argued with colic that the label is therapeutic.  The new GMC guidance should give us an opportunity to re-evaluate that approach.  What would be wrong with telling the parent of the infant described above that their baby is normal and healthy?  That would be honest and potentially just as therapeutic.  We could then use the time that we might have spent (explaining a condition that doesn't exist) on being supportive and encouraging to the parent.  The crying excessively phase does settle and in the meantime, it's all about making sure that it doesn't break the parent.

Here are a couple of other examples of diagnostic labels in children that are without evidence for any disease process.  Neither of these has ever had any pathology associated or been shown to respond to any treatment:
  • Growing pains
  • Non-specific abdominal pain
Is it time to embrace the idea of greater honesty when we diagnose and explain symptoms in children?  I certainly find that an explanation without a diagnosis is entirely acceptable to families when it comes to a situation where in the past I might have given a non-diagnosis.  Changing that practice is relatively straightforward.  You simply stop saying the thing.

For the situations where we are dealing with an actual diagnosis but there is significant uncertainty, we've got a few options.  The infant with crying and regurgitation of feeds is a good example.  Perhaps we should be stricter about starting off with a label of "possible GORD"?  Perhaps we should go further and start with "Feeding symptoms under observation and follow-up."  Increasingly, I don't give a diagnosis.  Instead I tell the parents that (in the absence of red flags such as fatering growth) "crying and regurgitation can be normal, it can be early symptoms of reflux disease and it can be rarer problems such as allergy.  We don't want to give unnecessary treatments to babies but we also want to treat problems when it's going to help.  This is how we're going to try to get the right balance between those two things..."  

It's a whole new world being honest about our uncertainty but it does work and it works like this:
Edward Snelson
@sailordoctor

Sunday, 25 October 2020

The Decision Maker's Guide to Bronchiolitis Assessment

 This bronchiolitis season is going to be different.  While SARS-CoV2 virus does not seem to be a significant cause of wheeze in children (1), all the other usual viruses are still out there and will be causing wheeze soon in a child near you.  What might have changed is how we make decisions about that child.

For the purposes of exploring our decision making, it is important to define bronchiolitis as a condition that is a virally induced inflammation of the small airways of the lungs in a child, typically under the age of 1.  It is clinically distinctive from viral induced wheeze which is virally induced bronchospasm of the large airways, typically in a child over the age of 1.  For a separate article on differentiating these two conditions, click this link.

The necessary decisions regarding bronchiolitis haven't changed.  What might change during a global pandemic is the outcome of those decisions.  Hospitals have always been dangerous places, with a significant risk of hospital acquired infection.  That risk has escalated due to the prevalence of the highly infective SARS-CoV2 virus.  Though very unlikely to cause COVID-19 infection in children, there is that risk, the risk of PIMS-TS and the risk of COVID-19 to the accompanying adults.

The aim in bronchiolitis decision making has always been to keep as many children out of hospital as is safe to do so.  In order to do that expertly, we just need to make three decisions.
  1. Does this child have bronchiolitis?
  2. Should this child be managed at home or in hospital?
  3. What treatment should the child be given?
Question 1: Does this child have bronchiolitis?

Most children under the age of 1 year presenting with a tight cough, wheeze, respiratory signs and poor feeding have bronchiolitis.  There are other possible explanations for that presentation however and it is important to know about these other possibilities.

Viral induced wheeze, which involves bronchospasm is separate from bronchiolitis.  Clues that it may be viral induced wheeze include the age of the child (most commonly over 1 year) and previous episodes of viral induced wheeze.  The other clue is the onset of the respiratory changes.  Bronchiolitis is a slow accumulation of wetness in the airways and the history is typically of a gradual and progressive worsening of symptoms over days.  Viral induced wheeze, due to the bronchospasm involved, presents with a more sudden onset of wheeze and distress, often going from normal to significantly abnormal over a few hours.

Pneumonia is almost never associated with wheeze in children (2).  Focal crepitations are often heard in a viral lung infection of any kind.  The presence of wheeze strongly suggests that the signs and symptoms are virally induced in some way.  Infants with pneumonia will tend to be significantly unwell.  The simple rule of thumb is this:  If the infant has a wheeze and is well enough to be managed in a pre-hospital setting, they do not have bacterial pneumonia.

Congestive cardiac failure (CCF) due to haemodynamically significant yet undetected congenital cardiac abnormalities is a rare mimic of bronchiolitis but one that is important to be aware of.  The typical cause is a large ventricular septal defect (VSD) causing a significant left to right shunt.  This increased pressure through the lung circulation causes pulmonary odema which manifests as poor feeding, fine crepitations and wheeze.  Thankfully, most significant heart defects are detected before a baby is discharged from postnatal care, but occasionally one slips through and the signs and symptoms are easily mistaken for bronchiolitis.

There are usually clues however.  A murmur is the most obvious clue but this can be difficult to hear at >160bpm.  An excessive tachycardia is a possible sign of CCF.  A significant hepatomegaly (normal babies often have up to a centimetre of palpable liver) is highly suspicious of CCF.  Finally, the progression of symptoms does not fit for bronchiolitis as they continue to get worse after the 3-4 days in which bronchiolitis reaches its peak.

Putting these things together, it is usually possible to be confident in diagnosing bronchiolitis as long as the history and findings are consistent with bronchiolitis and not one of the other pretenders.
If the diagnosis is bronchiolitis, we can move onto our next question:

Question 2: Should this child be managed at home or in hospital?

Most children with bronchiolitis can be managed in the community.  Keeping people away from hospital where it safe to do so has never been more important.  In the UK, the NICE guidelines for bronchiolitis (3) give recommendations for when to refer and when to consider referral.

Referral is always recommended for red flags.  In the NICE guidelines, these are a combination of signs of potential respiratory failure.  Notably, apnoeas are included as a stand-alone red flag.  That means that a child without any chest signs of severe respiratory distress should still be referred if they have had episodes where they appear to stop breathing.  The reason for this is that in such cases, immature respiratory drive may be a factor.  Following an apnoea, a baby can temporarily seem much improved but may go on to have further events and deteriorate suddenly.

Feeding and hydration is probably the least well defined element of the decision making element.  The guidelines ask the clinician to consider a variety of factors, however being able to assess whether the amount of feeding is adequate is next to impossible apart from overt signs of dehydration.  We never know how much a breast fed baby is getting unless the answer is "nothing."  If the baby is bottle fed, applying a percentage to that as being adequate doesn't take into account the fact that many bottle fed babies take much larger volumes as a baseline.  As a result, the most objective measure of adequate feeding has to be signs of hydration or dehydration.  For that reason, I have included clinical dehydration in the list of red flags and beyond that, feeding difficulties remain a matter of clinical judgement when it comes to referral.

Possibly the most controversial element of the decision making is the presence of risk factors.  In the guidance, it is stated "When deciding whether to refer a child with bronchiolitis to secondary care, take account of any known risk factors for more severe bronchiolitis such as... (e.g.) premature birth, particularly under 32 weeks."  The guideline evidence statement lists the basis for each risk factor listed and with the exception of neuromuscular disease, the committee acknowledged that there is no credible published evidence for the other risk factors.  Apart from neuromuscular disease, they are all consensus opinion recommendations.

So what are you supposed to do when you see an 8 month old baby with mild bronchiolitis, no red flags and adequate feeding when you know that they were born at 31 weeks gestation?  Do you send them to secondary care in case because they have a risk factor for severe bronchiolitis or do you keep them well away from hospital because they don't have severe bronchiolitis and you don't want to add a hospital acquired infection to their list of problems?

Balancing risk vs benefit is what it is all about here.  There is a known risk of hospital acquired infection vs an unknown risk of severe bronchiolitis.  There is also no evidence that admitting high risk children with bronchiolitis is any safer than good safety-netting advice.

If the decision is made to manage a child with bronchiolitis at home, the third and final question is:

Question 3: What treatment should the child be given?

There has been a load of research done to try to find an effective treatment for bronchiolitis.  Supportive interventions (oxygen, CPAP etc) in the cases where respiratory support are needed have been shown to be effective.  Each and every other therapy have in turn shown to have no benefit for mild to moderate uncomplicated bronchiolitis.  Therapies proven to be ineffective include β-agonists, ipratopium, hypertonic saline, antibiotics and corticosteroids.  The bottom line is that for a child being managed in the community, no pharmacological treatment should be given.  This recommendation is consistent  across guidelines from the UK, USA and Australia (3,4,5).

That makes this flowchart nice and simple:

Finally, you might be asking yourself if you are an expert decision maker when it comes to a small person who has a cough and wheeze.  Hopefully this post helps you to feel that you are.  Decision making in such children is all about recognition, knowing the red flags and above all, learning that if in doubt, looking at the child will almost always give you your answer.

Edward Snelson
@sailordoctor

References

  1. Roland D, Teo KW, Bandi S, et al COVID-19 is not a driver of clinically significant viral wheeze and asthma Archives of Disease in Childhood Published Online First: 16 October 2020. doi: 10.1136/archdischild-2020-320776
  2. Hirsch A, Monuteaux M, Neuman M, Bachur R, Estimating Risk of Pneumonia in a Prospective Emergency Department Cohort, Paediatrics, Vol 204, p172-176.E1, Jan 01, 2019 doi:10.1016/j.jpeds.2018.08.077
  3. Bronchiolitis in children: diagnosis and management, NICE guideline [NG9] Published date: 01 June 2015
  4. American Academy of Pediatrics Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis, Pediatrics November 2014, 134 (5) e1474-e1502; doi: 10.1542/peds.2014-2742
  5. The Royal Children's Hospital Melbourne Clinical Practice Guidelines: Bronchiolitis

Wednesday, 19 August 2020

Periorbital cellulitis in children

Eye infections in children are common.  The majority consist of simple infections of the conjunctiva (the layer that covers the sclera and the inside of the eyelid).  While these infections can be viral or bacterial, the tendency is for both to self-resolve and so infection confined to the conjunctiva can be managed conservatively.  The likelihood of benefit from topical antibiotics is low and there is a significant risk of the ingredients of antibiotic eye drops creating a chemical conjunctivitis and making things worse.  As a result, NICE suggests a limited number of scenarios in which topical antibiotics may be worthwhile in conjunctivitis.

It is worth mentioning two things about conjunctivitis:
  • Atypical conjunctivitis infections are more problematic.  If herpetic, chlamydia or gonococcal infection is suspected specialist input is advisable.
  • Neonates are the exception to this conservative approach to conjuntivitis.  For a full explanation regarding why and how to manage the newborn baby with an eye infection, click this link.
When infection spreads to the periorbital tissues, it is a different matter.  Infection of the skin and subcutaneous infections around the eye is usually bacterial and is associated with more invasive infection.
Image from Wikimedia Commons, the free media repository
Complications of invasive infection include:
  • Loss of eyesight (optic nerve damage, retinal detachment, retinal artery thrombosis)
  • Meningitis
  • Intracranial abscess
  • Cavernous sinus thrombosis
Although these complications are serious, they are mainly associated with orbital, or post septal cellulitis - infection of the tissues in the orbit (eye socket).  Infection confined to the pre-septal tissues is usually uncomplicated and low risk.
[Medical illustration credit to Naomi Snelson]

Telling the difference between pre-septal cellulitis and orbital cellulitis is about looking for signs and symptoms that could indicate orbital cellulitis.  In the absence of red-flag symptoms, it is assumed that the infection is pre-septal.

The management of pre-septal cellulitis has evolved considerably over time.  Many centres used to treat even pre-septal cellulitis as an inpatient with antibiotics given intravenously to begin with.  It is now much more normal to treat pre-septal cellulitis with oral antibiotics.
While some who have made this move choose to follow up and review the patient (often at about two days into their oral antibiotics) there are strong arguments for safety-netting and no planned follow-up.  When a child is sent home on oral antibiotics for pre-septal cellulitis, things will go one of two ways.  If treatment is successful, there will be significant improvement within the first two days.  If that happens, follow-up adds nothing.

If treatment is unsuccessful, signs and symptoms will worsen.  If that happens, there is a risk that a planned follow-up will delay escalation of treatment.  If things are getting worse, the child needs to be seen and admitted for intravenous antibiotics immediately, rather than waiting for their review appointment.

Safety-netting advice for children discharged on oral antibiotics for pre-septal cellulitis
Return for immediate assessment if-
  • the child becomes febrile or unwell
  • the swelling becomes visibly worse
  • eye movements are affected
  • vision is affected
  • the child is unable to take their antibiotics
  • the child starts vomiting
This simple approach is another great way to safely keep children out of hospitals.  That has always been a good thing but there has never been a better time to avoid unnecessary admissions than now.

Edward Snelson
@sailordoctor

Wednesday, 22 July 2020

There, I've Said It: There is No Such Thing as Early Sepsis

Words are really important when it comes to communication.  Certainly, non-verbal communication counts for a lot, but words are very powerful ways of getting a message across.  We should be responsible about how we use them.

Diagnostic error in paediatrics is a very emotive issue.  If a clinician is wrong (always in retrospect) and a child is involved, it can be difficult to be objective.  No-one is right all the time though, and diagnoses  that are later apparent are sometimes easy to miss or even too elusive to reasonably detect in their early stages.

There is one important exception to this: sepsis, because there is no such thing as early sepsis.  This is really important because clinicians are both criticised and self-critical when a child has been diagnosed with sepsis and there was an earlier clinical contact.

You're going to want me to back this one up no doubt.  I haven't got any academic references, but I don't need them since it's a case of simple logic.  I'm going to Spock the heck ot of the idea of early sepsis.
Starting with the terminology that we are working with, there is already difficulty with the definition of sepsis.  Ever since the word ceased to mean infection in any form and came to be used for an effect of the infection, sepsis has remained impossible to decisively define.

The best definition that we have of sepsis "a life-threatening organ dysfunction caused by a dysregulated host response to infection," comes from the 2016 Third International Consensus Definitions for Sepsis and Septic Shock.  This definition is inherently subjective.  There is no formula and no test.  Note also the lack of attempt to define early sepsis at this event.
Why do I care if people use the term early sepsis?  Because words.

The term early sepsis implies that there is a clearly definable and therefore recognisable entity which has therefore earned its own name.  Implications are more dangerous than overt statements because they go unchallenged and become part of the profession's assumption that because a term is used, it must be valid.

The harm of the term being given validity is that (again with the logic) if it is a definable entity, whenever a child is diagnosed with sepsis and they had an earlier contact with a clinician, that person has failed to recognise early sepsis.  In reality, they will have seen a child with features that are attributable to sepsis.  These features are also commonly found in children who are febrile but not sepstic.

How damaging is that?  Apart from the medicolegal implications, the negative impact on a clinician's confidence and reputation is potentially huge.  Using the term early sepsis risks leaving a string of second victims in its wake.

Just to be clear, I am 100% behind the idea of recognising sepsis early.  Swapping those words around is all it takes to make them functional again.  I'm also all for anything that improves the early recognition and treatment of sepsis.  So far, no strategy has proved successful in achieving earlier diagnosis of sepsis in children.  Awareness, careful clinical assessment are key, as is treating every illness as dynamic.  That is why appropriate observation and good safety-netting are key interventions.  Whether the child is managed at home or in a health-care setting, no illness is 100% safe until the child is better.

The focus on sepsis over the past decade or so has improved the timely treatment when sepsis is diagnosed, but making that decision in the first place remains a complex business.  Here's a nice oversimplifiaction of that process:
The red and green patients are relatively easy in terms of decision making.  The amber patients represent a small uncertainty which needs to be managed expertly.  In the small proportion that later become red and therefore relatively easy to define as having sepsis, retrospectively calling the preceding illness "early sepsis" defies logic and undervalues the difficulties of managing a large volume of moderately unwell children.

Next time you hear someone talk about recognition of early sepsis, politely challenge them and explore whether they mean early recognition of sepsis.  Sepsis is a thing.  The point when an illness goes from not sepsis to sepsis is not sudden and therefore easily missed.  Implying that there is a clearly definable and recognisable thing called early sepsis risks the vilification of front line clinicians in both primary and secondary care.

Edward Snelson
@sailordoctor

Tuesday, 30 June 2020

The Work Hack I Never Expected - How a Rainbow Badge Transformed Mental Health Consultations

Adolescent mental health is an area of practice where we need to take opportunities when they present themselves. This post is about something that has been a huge game changer for me.
When a young person comes with a mental health problem we look at various factors that are involved.  One of the most important factors that affect mental health is sense of self.  Like all elements of mental health, sense of self is complicated.  It is important that young people feel safe and accepted in order to be resilient to the stresses of adolescence.  This is a time of life where identity is being formed, and to do that safely requires an environment which allows a young person to explore who they might be.

If a young person feels that any element of who they are or might be is unsafe in any way, this creates anxiety.

While sexual orientation is only one element of a young person’s sense of self, in a world where heterosexuality is considered normal, a young person may not feel that discussing any other sexuality is a safe thing to do.  They may be concerned that they will experience rejection by family, friends or anyone that they discuss their sexuality with.  In many cases, they have already risked discussing this issue and experienced a negative response.

As health care professionals, we should be routinely asking the right questions to identify any issue that may be a factor in a mental health presentation in adolescents.  We should ask about stressors in general but it is also routine to ask specifically about common anxieties.  The more likely it is that the thing may not be volunteered, the more important it is to ask.

There are many reasons why health care professionals might themselves feel anxious about asking a young person about sexuality.  Here are a few of the common ones:

We don’t have experience of discussing sexuality with young people.  If you don’t have a framework for doing this, you’re not alone.  Very few of us grew up in an environment where anything other than heterosexuality was considered normal.  Unless you have experience of a society where any sexuality is accepted without judgement, it is likely that you will feel a little bit weird about discussing these issues.  The irony is that we might feel anxious that we will somehow get it wrong.

The solution: just do it.  The best way to get past the weird is to be brave and trust that your attempt will be well received.  Step out in faith.

We are worried that the parent(s) may be angry that we have this discussion with their child.  Our anxiety is often seated in our knowledge that society is still heteronormalised and that some people are fearful or uncertain of any other sexuality.  There may also be a fear based in the misconception that by asking about sexuality, we somehow alter or influence it.  That is an interesting and unfounded belief.  There is no evidence that an open discussion can result in a change in sexuality.

The solution: Speak to the young person on their own.  This should be a normal part of a mental health assessment in a young person.  We wouldn't allow a parent to be a barrier to acting in their child's best interest in any other circumstance, so why let a social anxiety be harmful now?

We are worried about the response that we might get from the young person.   I’ll be honest here, this fear is reasonably rational.  If you ask a young person about their sexual orientation they may well give you a funny look and a muted response.  That’s fair.  When you are 15 years old, it is not something that comes up in conversation with an adult that you just met 10 minutes ago.

The solution:  Expect the question to make some young people feel awkward, but put them at ease by asking the question like it’s just another question.

There is another thing that can help with all of the above.  Last year I started wearing a rainbow badge.  The badge is small but always visible.  The idea is that it lets people know that I don’t judge people based on their sexuality.  To me, people are people.  While there are things that will change my opinion of someone, sexual orientation is not one of these.

When I started wearing the badge, I thought that my patients wouldn’t notice or wouldn’t know what the message behind the badge was.  I was wrong.

Immediately after I started wearing the badge, I noticed a change in the way that mental health consultations went.  When asking open questions about stressors, a significant number of young people started volunteering that their sexuality was a major factor in their presentation.  The stories varied from young people who were unsure about their sexuality but were afraid to discuss this with anyone to those who knew that they were not heterosexual but had experienced unpleasant responses to that when telling their family or friends.

I think that starting to wear a rainbow badge has been one of the most important innovations in my career.  I never expected such a small thing to make my life easier in such a big way.  I’m now somewhat concerned that the use of the rainbow as a symbol in the COVID-19 pandemic may have diluted the impact of my rainbow badge but I hope it hasn’t.

It may not have been designed as an part of a mental health toolkit, but for me, the rainbow badge has become an essential piece of equipment for my job.  2020 has been an odd year.  It turns out that I don’t need a tongue depressor, but I do need a rainbow badge.

Edward Snelson
Also ship-shape award badge owner
@sailordoctor

Monday, 22 June 2020

Heat Related Problems in Children

As a heatwave hits the UK, we can expect a significant number of children to present with heat related problems.  In the vast majority of cases, these will be benign and self-limiting.  In a small proportion, heat can cause serious illness.

The effects of excessive environmental heat in children are well described but there is a lack of a decent evidence base regarding incidence and effectiveness of treatment.  It is often stated that children are more at risk due to their increased body surface area to weight ratio, however true heat related illness is rare in children and admission to hospital is even less common.  It is likely that there are several protective factors including their robust physiological compensatory mechanisms and human factors which help to keep them from becoming seriously unwell.

Common heat related presentations in children

Heat rash (Miliaria)

Also called prickly heat or sweat rash, a raised erythematous itchy rash is a common problem during a heatwave.  The pathogenesis is to do with increased sweat gland secretion and the inflammatory effects of this.  Miliaria is not harmful but it is uncomfortable.

The child with miliaria will be well and there are no systemic effects.

Prevention and non-pharmacological treatment are one and the same for miliaria.  Avoiding prolonged exposure to excess heat is the single most important intervention.  Parents should enable the child to rest in a cool environment out of the sun.  Unsurprisingly hydration is also important.

Pharmacological interventions include calamine lotion and antihistamines.

Swollen hands and feet (Heat oedema)

Heat oedema is less common than heat rash but also seen in significant numbers of children during a heatwave.  The mechanism for this occurring is the physiological peripheral dilation of the peripheries.  As with miliaria, there will be no systemic effects on the child, who should be otherwise and obviously well.

Non-pharmacological treatments are also the mainstay of treatment of heat oedema.  Diuretics should never be used due to the risk of precipitation dehydration or electrolyte imbalance.  Cooling down, resting and drinking are what these children need.

Phytodermatitis

This is not really a heat related problem but is seen much more commonly during a heatwave.  When the sun is out, children often play outdoors with more skin exposed.  Certain plants leave chemicals on the skin which are activated by sunlight.  This then leads to dermatitis.

Children with phytodematitis will be well but have an itchy papular rash in areas of exposed skin, sparing the area that was clothed at time of exposure.  The rash is usually self-limiting but in some cases can go on to cause hyperpigmentation.  Acutely treatment is symptomatic with antihistamines and a short course of topical steroids as pharmacological options.

Sunburn

Again, sunburn is not caused by heat but by exposure to sunlight.  Significant sunburn can be a contributing factor to dehydration.  It should therefore be included in the assessment of risk when a child presents with more significant heat related symptoms.

Syncope

Children and young people are well known to have a high incidence of vasovagal syncope.  The reason for this peak, often seen in adolescents is not fully understood.  Heat related syncope is also a reasonably common presentation in children and young people.  As with vasovagal syncope, the assessment of heat related syncope in children is all about establishing a typical history and excluding red flags.

The child with heat syncope who has made a good recovery should be managed with preventative measures to avoid a further episode - rest, a cool environment and good hydration.  Note that there is no specific evidence to recommend any specific hydration fluid over another for these minor heat related illnesses.  Water is probably as good a place to start as any.



























Uncommon heat related presentations in children

Heat related illness that makes a child systemically unwell is relatively uncommon.  When it does occur, there are usually risk factors or extreme and prolonged exposure to excessive heat.  Paediatric patients most at risk of significant heat related illness are those who cannot regulate their own fluid intake or clothing/ environment such as babies and children with neurodisability that impairs the ability to self-care.

The greatest risk usually comes from the combination of risk factor and environment, such as a baby left in a car on a hot day.

Another risk factor is the extremem change in environmental temperature.  Humans have an ability to adapt to different environments, a process that occurs over the space of weeks.  This allows us to cope with the change in seasons.  When weather goes from a relatively cool period to very hot weather suddenly (i.e. a heat wave), that adaptation can't happen, thus the sudden rise in heat related illnesses disproportionate to the actual outside temperature.

Significant heat related illness is different from the above conditions because there are systemic manifestations of a combination of over-heating and dehydration.  The range of presentations is a spectrum of illnesses which include heat stress, heat exhaustion and heat stroke.

Heat stress

Heat stress is the mildest form of heat related illness with systemic effect.  With heat stress, the child is feeling the effects of heat and they will let you know about it in an age appropriate way.  Children with heat stress may be tired, grumpy, and have headache or general aches and pains.  Babies will cry excessively or be fussy with feeds.

A key feature of heat stress is that body temperature is not raised and there is normal function.  Heart rate is normal if the child is settled.

Heat stress should be managed with paracetamol (acetaminophen) for the pain*, rest, oral fluids and a cool environment.  This can be done in a pre-hospital setting with safety-netting advice.

*Paracetamol does not reduce body heat when it is due to environment and dehydration.

Heat exhaustion

Heat exhaustion is a more extreme systemic effect from the same combination of excessive heat and poor hydration.  Children with heat exhaustion will be more unwell and are on a downward spiral as they may start to vomit or have diarrhoea.  They will be more affected by how unwell they feel, but their conscious level should be normal.

The child with heat exhaustion is likely to have a raised body temperature somewhere above 38°C but below 40°C.  Dehydration and the heat effect will manifest as tachycardia and the child will look more unwell.  End organ function is still normal at this stage, but the child is at risk of deterioration due to the cycle of symptoms impairing hydration.

The management of heat exhaustion is similar to heat stress but with the addition of active cooling.  The most commonly recommended method for this is to place the child in a cool bath.  The temperature of water for this intervention is ill-defined but it should feel cool and not be cold enough to make the child shiver.  An alternative way of cooling is the use of cool wet towels.

Children with heat exhaustion may be managed in an Emergency Department or Paediatric acute ward and discharged when they are normalising.  Oral hydration is normally achievable.  If vomiting is an issue, anti-emetics or nasogastric fluids are options.

Heat Stroke

Heat Stroke is rare in children.  It is the seriously ill end of the spectrum of heat related illness.  Like sepsis, it has a definition that doesn't work well in the initial assessment of the child.  For the front line clinician, the bottom line is that the child who looks seriously unwell due to heat exposure should be presumed to have heat stroke.

One of the most consistent features is the central nervous system effects of heat stroke.  Children become severely confused or agitated to begin with and then progress to coma.  Seizures are a common problem in heat stroke and risk further increasing body temperature.

As with all heat related illness, simple measures are still important.  The child should have clothing removed and placed in a cool environment as soon as possible.  Applying cool wet towels can be used to begin the cooling process.  Once in a hospital setting the child will need critical care level management.  Airway management, venous access and intravenous fluids (room temperature normal saline) are all key interventions while getting expert help.  For the hospital physician wanting more information about the ongoing management of heat stroke in children, I would recommend this article.
So, while rashes, swollen peripheries and simple faints are the things that you are most likely to see, there is always the risk that the overheated child is on the slippery slope of heat related illness.  Children who are alert and able to drink can be managed with good advice and safety-netting.  Stay cool, rest up, drink plenty and come back if you're getting worse.

Enjoy the sunshine but stay safe.  If the UK weather does what it normally does, next week's topic will be the management of the hypothermic child.

Edward Snelson
@sailordoctor

Friday, 5 June 2020

Transient Synovitis of the hip (Irritable hip)

A common presentation in young children is the mysterious limp.  Transient synovitis (irritable hip) of the hip is the most common cause of an unexplained limp under the age of 6.  The current usual practice is to make the diagnosis of irritable hip on clinical grounds.  It is no longer routine practice to support this diagnosis with blood tests or imaging.  This development in practice opens the possibility for a young child with a mysterious limp to be managed outside of a hospital setting where appropriate.

What is transient synovitis of the hip (irritable hip)?
The cause of transient synovitis of the hip is unclear.  It is presumed that most cases are a reactive arthritis with a viral trigger.  Injury can also be implicated but it is unclear whether such associations are causal or simply bring the problem to someone’s attention.  It is also common to find typical features of transient synovitis of the hip in children who have no history of viral illness or injury.  There is therefore no need to rely on a history of a possible trigger to make the diagnosis.

As the name suggests, there is inflammation of the synovium of the hip.  Ultrasound may show or synovial thickening or increased fluid.  Inflammatory markers are not usually significantly raised.  Neither of these investigations is reliable and no longer done routinely since the gold standard is clinical diagnosis.

How is transient synovitis of the hip diagnosed?
Typical features of transient synovitis of the hip are:

  • Unexplained onset of limp (no history of more significant injury consistent with fracture)
  • Well and afebrile child with no signs or symptoms of other significant acute illness
  • Unilateral hip signs – painful or reduced range of movement
If a child has these features and no signs of another cause, the diagnosis is almost certainly irritable hip.  Other important diagnoses to consider are:
  • Septic arthritis - usually presents with fever and complete refusal to weight bear
  • Osteomyelitis - usually febrile and there is localised tenderness or swelling in the bone
  • Toddler fracture - undisplaced fracture of the tibia usually presents with complete refusal to weight bear and has localising signs in the tibia (tender or slightly warm to touch)
  • Other significant fractures are usually accompanied by localised swelling or tenderness and are clinically obvious.
  • Juvenile idiopathic arthritis (JIA) - This is very uncommon under the age of 6.  Obvious swelling of a single joint (without signs of infection) may indicate a transient arthritis of a joint other than the hip.  If the affected joint is the hip and the diagnosis is JIA, this will probably be clinically indistinguishable from irritable hip.  However the child would only need to be referred if the arthritis persisted for several weeks, so analgesia and watchful waiting is the initial management in any case.  If multiple joints are involved or symptoms cannot be managed easily, early referral is indicated.
  • Perthe's disease - The cause of this disease of the hip is unknown.  The femoral head becomes avascular and breaks down.  The typical age is a school age child but there is some overlap with the age at which irritable hip presents.  The unexplained limp in a child over the age of six should raise suspicion of Perthes disease.  Under the age of six, progressive symptoms or symptoms that fail to improve after a few days are concerning.
  • Non- musculoskeletal - Limp may be a sign of pathology unrelated to the lower limb.  Abdominal pain or scrotal pain can cause a child to limp.
One of the best discriminators between all of these problems is the course of the symptoms.  While symptoms can vary in any illness, a significant fluctuation in pain and limp is most indicative of transient synovitis of the hip.  While syptoms may be still present after three days, it is unusual not to see significant improvement in that time.

A typical presentation, absence of red flags and a classical course of the symptoms usually make it obvious when the problem is irritable hip.  If all of these things apply, management is watchful waiting with good safety netting advice.

Edward Snelson
@sailordoctor

Sunday, 10 May 2020

COVID question number 6 - What is hyperinflammatory syndrome and how do I recognise it?

At the same time that we are seeing increasing evidence that COVID-19 is less common, less severe and less infectious in children (1), evidence is emerging of a new phenomenon that seems to be related to COVID-19 infection in children: hyperinflammatory syndrome (2).

In a time when people are being encouraged to self-manage febrile illness at home, and primary care has moved to do more remote assessments, the emergence of such a serious clinical entity is worrying.  Although the number of cases remains relatively small, it represents a significant number of seriously unwell children.  Considering how much we focus on the recognition of sepsis in children, current cases of hyperinflammatory syndrome are being reported in numbers comparable to and possibly greater than numbers of children with severe sepsis.

This does not mean that all febrile children should now have a face to face assessment or that all febrile children should be referred to secondary care.  Like sepsis, it is impossible to recognise an entity like hyperinflammatory syndrome before it is clinically apparent.  There is no predictive test.

Like sepsis, we need to be aware of hyperinflammatory syndrome and recognise it where it is manifest, rather than over-diagnose it to the detriment of children with uncomplicated viral illnesses.  So how do we get that balance right?  The answer lies in recognising what is unusual about the illness rather than focusing on the most common features, since these are not necessarily good discriminators.

First, a few FAQs about hyperinflammatory syndrome in children:

What is hyperinflammatory syndrome?
Like sepsis, definitions of hyperinflammation vary and reflect the fact that it is a clinical diagnosis without a binary test or decision tool.  The published literature reflects an uncertainty about pathophysiology but describes a significant number of cases (20 in North London in less than a month) of children with a similar clinical presentation.  The features have been described as most similar to Kawasaki Disease Shock Syndrome (3), a thing so rare that most of us had never heard of it before this recent surge of cases.

Is it caused by COVID-19 infection?
When the initial reports of cases were being circulated without details, it was unclear as to whether this was simply a case of something happening during the COVID-19 pandemic or because of it.  While no official source has yet declared that COVID-19 is definitely the cause, there is plenty of evidence that this is the case.  First, the numbers are highly unusual (4) and there is a pandemic at the moment.  Secondly, many of the children have tested positive for SARS-CoV-2/COVID-19.  While a small proportion testing positive could be explained by the background rate of COVID-19 in the community, the positive test rate in these cases seems too high.  At the moment the sample size is too small to be conclusisve.  Finally, the demographic of affected children mirrors that of severe COVID-19 in adults, with a predilection for males and BAME children.  It therefore seems most likely that these cases are related to the COVID-19 pandemic.

The hyperinflammation syndrome that is being reposted is thought to be a post-infection phenomenon, rather than a complication of acute infection.  The exact mechanism for this is unclear.  Clinically, it has features similar to Kawasaki Disease (for which the mechanism is unknown) and some overlap with toxic shock syndrome (which is seen in bacterial infection) so we're on the back foot when it comes to working out pathophysiology.

How do I recognise hyperinflammation in a febrile child?
The reported features of the children presenting with hyperinflammation are a mixture of non-specific signs and symptoms with a few more unusual elements that may help the front-line clinician.
While gastroenterological symptoms were common, I would suggest that this information is of little help to a clinician who sees acutely unwell children.  Diarrhoea, abdominal pain and painful swallowing were all common features in children who later developed hyperinflammation but are also frequently found in other viral illnesses.

In the case series reported in the Lancet, tachycardia was sometimes present and sometimes heart rate was unremarkable.  This is somewhat surprising since this hyperinflammatory syndrome seems to affect the cardiovascular system most severely.  It is also consistent with other serious paediatric presentations, where heart rate is one of the least specific clinical signs, being both falsely concerning and falsely reassuring on many occasions.

Tachypnoea, also a common feature occurring when the child presented with hyperinflammation is a more specific feature.  Uncomplicated viral illnesses in children do not tend to affect breathing other than in the form of a transient tachypnoea while febrile.  Unexplained, consistently fast breathing should therefore be considered clinically significant.  This was reflected in the Lancet case series, the majority of whom had tachypnoea.  Note that the cases reported did not tend to have pneumonia, thus the qualifier of "unexplained".  Other explanations for fever and abnormal breathing remain more likely.

The other feature that was most consistent and helpful in discriminating from uncomplicated viral illness was an unrelenting fever.  In children with an uncomplicated viral illness, pyrexia can be dramatic and associated with alarming features such as shivering, cold peripheries, blue lips and mottled skin.  Typically, this is followed by a dramatic improvement, often with the aid of antipyretic medication.

In the cases reported with suspected hyperinflammation secondary to COVID-19 infection, the fever was noted to have been persistently high (38-40 C/ 100.4-104 F) which is much less commonly seen in uncomplicated viral illness.  This may therefore be one of the more useful ways of telling the two apart.

























Other features reported include a "variable rash" and painful extremities.  Rashes and pains are common features of uncomplicated viral infection but in combination with the more specific features may help clinicians recognise the syndrome early.
Recognising hyperinflammation (presumed to be related to COVID-19 infection in children) early may therefore be a case of recognising the unusual, looking for alternative explanations such as pneumonia and if no other pathology explains how unwell the child is, looking at how many of the less specific symptoms are present.  If that sounds familiar, that's because it is a similar approach to recognising Kawasaki disease.

The disease then tends to progress to a phase with more significant cardiac involvement, with a profound effect on circulation in many cases.  Shock refractory to fluid boluses is a commonly reported feature.

If signs of shock develop, this will make it more straightforward to recognise that the child does not have an uncomplicated viral illness.  Distinguishing hyperinflammatory shock syndrome from sepsis and other similar presentations brings its own challenges for emergency medicine and acute paediatrics.

Edward Snelson
@sailordoctor
References
  1. Munro APS, Faust SN, Children are not COVID-19 super spreaders: time to go back to school Archives of Disease in Childhood Published Online First: 05 May 2020. doi: 10.1136/archdischild-2020-319474
  2. Riphagen S., Gomez X., Gonzalez-Martinez C., Wilkinson N., Theocharis P., Hyperinflammatory shock in children during COVID-19 pandemic, Lancet, May 07, 2020 doi:https://doi.org/10.1016/S0140-6736(20)31094-1
  3. Kanegaye JT, Wilder MS, Molkara D, et al. Recognition of a Kawasaki disease shock syndrome. Pediatrics. 2009;123(5):e783‐e789. doi:10.1542/peds.2008-1871
  4. HEALTH ADVISORY: PEDIATRIC MULTI-SYSTEM INFLAMMATORY SYNDROME POTENTIALLY ASSOCIATED WITH CORONAVIRUS DISEASE (COVID-19) IN CHILDREN, 06 May 2020, New York State Department of Health (NYS DOH) Bureau of Communicable Disease Control (BCDC)

Wednesday, 6 May 2020

What am I missing? The child with fever but no obvious cause

The fear that a significant illness wil go unreconised in a child is one that is always present for the clinician who sees acutely unwell children.  The stories that we hear of infections and other illnesses being "missed" fuels that anxiety.  The common sense side of us tells us that significant illness should manifest itself in an obvious way, but that doesn't stop us from asking the question, "What am I missing?" when we see a child with a febrile illness and no apparent cause?

Scenario

You have just seen Billy, a 1 year old child with a fever that started today.  They have no cough or runny nose.  They appear well and have a heart rate of 120.  Chest is clear, heart sounds are normal and abdomen is soft.  Tympanic membranes are not inflamed.  You may or may not have looked at their throat but if you did, there is nothing obvious to see.

What do you do?

The answer to this is to understand what the possible causes of fever are, know how to exclude them and have an idea of how likely they are.  The latter brings us onto an important question:

How likely is significant or dangerous infection in a child?

That depends on the child.

The most common risk factor that we encounter is the infant.  The likelihood of an unwell newborn having a significant infection is high.  This is further compounded by their non-specific symptoms and lack of physiological response in the first few weeks of life.  The risk of serious infection multiplied by the risk of underestimating the illness makes a baby under the age of 60 days a high risk patient.

After those first few weeks, the infant becomes less reliant on maternal antibodies and begins to produce a more vigorous response to infection, most of which are now viral.  As a result, the risk diminishes inversely.

Other risky patients are those with ongoing reasons to either have more significant infections or less obvious signs of serious illness.  These include children with neurodisability, immunodeficiency or chronic illness.

For the usually healthy child beyond early infancy, the very great probability is that an illness will be benign and that those infections that are dangerous will manifest themselves in some significant way.  This itself brings a challenge: complacency.  We become so used to good outcomes and fruitless investigations that we start to think that everything is an uncomplicated viral infection.
It usually is, but what if it isn't?  That brings us on to the next question:

What are the less common causes of fever in a child?

One way to think about the causes is within categories:
When there are so many possibilities, it is often best to consider the least common first.  Let's start with the non-infective.  These illnesses cause inflammation without active infection.  They are all very uncommon compared to other things on the list but that makes them easy to forget and therefore miss.

Kawasaki Disease - This is a vasculitis which can look like a prolonged viral illness.  The cause has not yet been identified but it is presumed to be a post-infective phenomenon.  If a child has had a fever for five or more days without a clear cause, we should check if the child fulfils the criteria for Kawasaki disease.  You can check the criteria in a book or use an online tool such as this one linked here.

Leukaemia - Haematological malignancy in children occasionally presents as an unexplained and prolonged pyrexia.  More often there are other symptoms and signs such as increasing lethargy, weight loss, pallor, bruising, bleeding and unexplained pains.

Systemic Onset Juvenile Idiopathic Arthritis (JIA) - this subtype of JIA is rare but is one possible cause of unexplained fever.  Often the fever is accompanied by a typical salmon pink rash and joint pains, even if there is no clinically obvious joint swelling yet.

These non-infective causes of fever should not be over-thought.  The presenting symptoms of childhood illness are often so non-specific that it can be all to easy to imagine zebras instead of horses.  The key to not missing these is to be aware of them as entities and to look for features of these in the child with unexplained fever, especially when that fever is prolonged.

Next, the sepsis question.  Every febrile child should be assessed for sepsis, whether a focus the fever is found or not.  That decision can be made easy for you in one of two ways.  Either the child is very well to the extent that sepsis can be ruled out, or the child is so unwell that sepsis is presumed.  Everything in between is a case of careful assessment, including risk factors and the trajectory of the illness.
So, if we have considered the very rare and the sepsis question, what we should be left with is a child who we think does not have sepsis and yet has a fever without an immediately obvious focus.  At this point we return to the list of possibilities.
The task in a child with fever and no clear focus is to rule these possibilities out, which is usually based on clinical assessment.  Start with the complications of upper respiratory tract infection (URTI) as these are the most common significant infections in children.

Mastoiditis - infection of the mastoid is usually a complication of otitis media infection there should be evidence of that.  Mastoiditis is excluded clinically if there is no erythema, swelling or significant tenderness of the mastoid process.

Peritonsillar abscess - A collection of pus in the peritonsillar tissues is manifested by swelling which displaces the tonsil.  At the time of writing this, throat examination is not routinely performed due to the COVID-19 pandemic.  However, peritonsillar abscess is highly unlikely in a child who is willing to drink or eat.  If the child is refusing all oral intake, it may be necessary to use droplet PPE, including eye protection, to visually exclude peritonsillar abscess.

Lymph node abscess - Inflamed or enlarged lymph nodes are a common finding in children with URTI. Occasionally, the lymph node becomes bacterially infected.  When this happens, the lymph node is more enlarged and painful.  The overlying skin is often erythematous.  Another common feature is that the child becomes reluctant to turn their neck due to the pain from inflammation of the surrounding tissues.  These infected lymph nodes may respond to high dose oral antibiotics, however they may require incision and drainage.  Discussion with or referral to ENT is therefore advisable.

Osteomyelitis and septic arthritis - This is a good example of something that is rare but also often missed when it is a cause of unexplained fever.  Infection in a bone or joint can be visible or hidden.  If a parent has noticed a swollen, red or hot area or that the child has localising signs in a limb, that can lead to early diagnosis.  It is also the case that in a significant number of cases, the infection is not identified early on.  It is no surprise when a febrile child is miserable and moves less.  It is not common practice for clinicians to examine every bone and joint in a febrile child.  However, this is something that needs to be done if a child has an unexplained fever.  If limbs have not been examined for swelling, hot spots or erythema at first presentation, I would suggest that this should be done at the second assessment should fever persist and remains unexplained.

Urinary tract infection (UTI) - UTI is probably the most common cause of fever without a clinically obvious focus in children.  The younger the child, the less likely they are to present with specific symptoms.  Fever without obvious cause is an indication to screen the child for UTI.  Blind treatment with antibiotics is not recommended.  Urine should ideally be sent for culture so that treatment is based on the most robust result - a significant bacterial growth.

Meningitis and encephalitis - Central nervous system (CNS) infection is the most feared of the causes of fever without focus.  In the younger child, symptoms are less specific.  Infants may be irritable, jittery and not feeding well.  Vomiting and excessive sleeping are also common features but again, non-specific.  In an infant with an open fontanelle, this should be examined.  A bulging fontanelle (when not crying) is a red flag sign.  Older children may exhibit classical signs of neck stiffness, headache and photophobia.  Younger children are more likely to stand out because they just won't settle or have an abnormal tone or conscious level.  CNS infection is usually ruled out by the child demonstrating normal interaction or behaviour, often after adequate analgesia has been provided.

Appendicitis - In an older child, recognising appendicitis is done in a similar way to adult practice.  Appendicitis is rare in younger children but when it does occur, it can easily be missed.  Guarding tends to be a later sign in the pre-school child because their abdominal wall muscles are not very strong.  Children often cry or otherwise appear distress when their abdomen is examined, leaving the clinician uncertain.  Analgesia and reassessment is a good way of clinically ruling out appendicitis if the initial assessment is ambiguous.

Pneumonia and empyema - Lower respiratory tract infection (LRTI) is common in children.  Cough and fever are non-specific symptoms and are not grounds for diagnosing LRTI on their own.  Hearing crepitations on auscultation is also a common finding that should not be given too much weight.  Many LRTIs in children are viral and self-limiting.  Important discriminators are how unwell the child is, their work of breathing and more specific focal signs such as localised reduced air entry or a dull percussion note.
Tropical diseases - If a child has an unexplained fever and has recently returned from an area with e.g. malaria, they need to be referred to secondary care for investigation.

And finally...

So if Billy looks well and behaves in a way that effectively rules out sepsis and meningitis, his fever without clear focus means that we should look just a bit harder.  A urine sample should be taken to exclude UTI; blind treatment with antibiotics is not recommended without good evidence of UTI.

If there are reasons to suspect one of the less common (than uncomplicated viral infection) causes of fever, referral to secondary is likely to be the way forward.  If there is no evidence of a significant cause and what you are left with is a reasonably well child with an unexplained fever, the final question is, "should I refer this child or send them home with safety-netting advice?"

Both options are valid and the choice should be made in the best interest of the child.  In secondary care, the assessment of the child should be clinical in the majority of cases.  As such, referral may simply add a further clinical history and examination.  If a second opinion or physical period of observation is felt to in the child's interest, that is fine.  If not, it may be best to keep the child away from hospital and the risks associated with a secondary healthcare setting/

Before a final decision is made, risk should be considered.  For the majority of healthy children presenting to Primary Care (including the Emergency Department) with no specific risk factors, the likelihood of any febrile illness being a serious bacterial illness is very low.  That makes it perfectly reasonable for a child who has had a careful clinical assessment to be managed conservatively and with good safety-netting advice.

There are children who have a significantly higher risk.  As mentioned above, the most commonly encountered risk factor is the baby.  If your patient is a baby, especially if not yet started on their primary vaccinations, fever without focus warrants a referral to paediatrics.
Fever in a child who does not have an immediately obvious focus is a clinical conundrum for all of us.  Many children can be managed with a thorough history and examination.  If there are significant risk factors or specific findings then appropriate referral is likely to be the next step.

Edward Snelson
99% Type 1 decision maker
@sailordoctor

Disclaimer: If it's the clinician who has no focus, there's nothing I can do for you.

Thursday, 9 April 2020

Uncomplicated febrile convulsions in children - where and who to diagnose?

This is the first in a series of posts that explore the clinical scenarios that can be managed entirely in a pre-hospital setting but are often or sometimes sent for further assessment.  In each case, I know that some primary care clinicians do fully manage these problems without involving secondary care.  The aim of these posts is to explore the possibility that the condition can be managed without secondary care.

Clinical scenario

A two year old has been managed symptomatically by their parents for what seems to them to be a viral illness.  The child developed a fever this morning which led the parents to give paracetamol.  Shortly afterwards, the child became stiff and then had rhythmic jerking of all four limbs.  This continued for less than a minute.  During the seizure the child was completely unresponsive and went slightly blue.  Their eyes were fixed and staring.

The jerking movements ceased spontaneously and the child was then sleepy for a few minutes, followed by some crying.

In less than an hour, the child is back to their normal self.  They are alert, settled, interactive and mobilising.

If they manage to get to see a primary care clinician, should they be referred to secondary care for further assessment?

While in the majority of such cases parents will present to secondary care, first febrile convulsions can present to General Practice or be seen initially by a paramedic advanced clinical practitioner.  To explore the value of ensuring a secondary care assessment, we need to look at the answers to a few other questions.

What is a febrile convulsion (seizure)?

A febrile convulsion is like an epileptic seizure in every way other than that it is symptomatic of an illness rather than being due to underlying idiopathic epilepsy.  Anyone who doesn't have epilepsy can have a symptomatic seizure (e.g. due to head injury or hypoglycaemia).  Epilepsy is different - the tendency to have seizures without a specific cause.

A febrile convulsion will look the same as an epileptic seizure.  You can presume that a seizure is a febrile convulsion if it fulfils the following criteria:

  • Typical age of 1-6 years old
  • Child has a febrile illness (the timing of the fever and seizure are unimportant as long as the illness is current)
  • Child has no underlying neurological or developmental abnormality
  • The seizure is followed by a full return to normal for the child

A febrile convulsion can be atypical, prolonged or focal in which case the possibility of significant pathology is increased and those children should be seen urgently in secondary care.

What causes a febrile convulsion?

The current thinking is that the illness is the thing that somehow causes the seizure.  The idea that the fever itself causes the convulsion was first questioned in an article in ADC in 2003.  Since there is a lack of correlation between the timing of the fever and the seizure, and there is a lack of evidence that antipyretics are preventative, it is likely that the illness causes the seizure and the fever.

Does a febrile seizure indicate serious pathology?

Although medical literature contains list of possible underlying pathology, a true febrile convulsion by definition cannot have an underlying cause.  If a seizure is caused by an underlying CNS infection or other neuropathology, the diagnosis is not a febrile convulsion.  If a child with meningitis has a seizure, the diagnosis is meningitis with seizure.

This is why the return to baseline (i.e. as well as can be expected for an uncomplicated viral illness) is arguably the most important part of the diagnosis.  If, post seizure the child fails to demonstrate their wellness and neurological normality, the seizure may be symptomatic of CNS infection or other abnormality. An atypical, prolonged or focal seizure also changes the index of suspicion greatly.

What tests are needed following a febrile convulsion?

If the diagnosis of febrile convulsion is as above and was a self-limiting generalised tonic-clonic seizure, no tests are required.

So what happens when a child is seen in secondary care following an uncomplicated febrile convulsion?

The history and examination is repeated.  Unless there are specific indications for further tests (clinical suspicion of CNS infection or abnormality) everything else is unnecessary.

Essentially the endpoint in straightforward cases is a history and examination which leads to a diagnosis of febrile convulsion.  So, if the diagnosis is already made, making it again adds absolutely nothing.






























Who makes the diagnosis, when and where is more about timing, availability and clinical knowledge/ ability.  If you're the right clinician in the right place at the right time, congratulations.  It's you.

Edward Snelson
@sailordoctor