Wednesday, 15 May 2019

The simple bit of equipment that will transform your child and adolescent mental health assessments

Mental health problems in children and young people (CYP) are common and on the rise.  Identifying these problems in CYP is particularly challenging due to a variety of barriers.  Some of those barriers exist within ourselves (misconceptions) or our working environments (time pressures).  Often the barriers come from the child or young person.   All of these barriers can be overcome.  Let’s look at how that is possible.

The first place to start is with ourselves.  We need to make sure that our attitude towards CYP and their mental health is such that we are open to see and hear the signs that indicate what is going on.  A positive attitude is also essential so that the CYP and their family are likely to want to disclose what they need to in order to get a good picture of what is happening.   All the usual things that apply to working with young people apply in a mental health assessment but are more important than ever due to the patients mental state.
Next we need to look at our working environment.  The time pressure issue is a big one.  The bottom line is that unless we find a way to make time for mental health presentations, we can’t expect these contacts to be effective.  There are many other environmental factors to consider which are key to helping CYP access the help that they need.
Finally there are the barriers that seem to come from the CYP.  As suggested above, it is a good thing to see any such barriers as expected.  The worse the situation, the bigger the barriers are likely to be, and the greater the need to have these barriers overcome.  The right attitude and environment are both hugely important in overcoming these barriers.  It also helps to name them with the patient and their family.  That goes something like this:

With the family present- "I know that it is really difficult to put how you feel into words.  It’s also usual to be thinking that if you tell me what you’ve been thinking, I will think you’re crazy.  I won’t.  Anything that you can tell me will be really helpful.  Just tell me in your own words and take your time.  You’ll get a chance to talk to me without your family being there so feel free to save anything that you’d rather talk about without them there for then."

With the young person on their own – "We always give people a chance to talk about what is happening without their family sitting in.  That’s important for a couple of reasons.  Firstly these things are complicated and quite often young people feel that their family either don’t understand what’s happening or have strong opinions that make it difficult for you to say things the way you see them.  Here on your own you can talk about things and know that I’m just interested in what you want to tell me about what’s happening and how you are feeling.  Secondly, there are some times that there are things that really need some privacy to be able to talk about.  That can be things that you feel you can’t tell your family about, like taking drugs, or it can be things that I need to know such as if someone is harming you in any way.  I’ll treat things you tell me with confidentiality wherever possible.  If someone is harming you then I would need to act on that to keep you safe."

Even when you go through all of that, it is sometimes the case that all you get is shrugs and a marked lack of usable interaction.  At that point, you have another ace to play.  It is a valuable piece of equipment in CYP mental health assessment and it looks like this:
Giving the patient the opportunity and the space to write instead of speaking is a game changer in ways that you might not expect.  In a spoken interaction, CYP in a mental health crisis are likely to find it difficult to find the words to say how they have been feeling and thinking.  They will worry about the response that they will get to what they say.  This fear of being appraised can be paralysing.  Even if the person they speak to does everything perfectly in terms of verbal and non-verbal communication, the CYP may over-think everything they see.  Such is their hyper-acute mental state that this happens easily.  “They just frowned slightly.  Does that mean that they don’t believe me?  Perhaps it means that what I said is completely mental.”

A piece of paper doesn’t have an opinion and there is no response to misinterpret.  It doesn’t rush you and you don’t have to worry about getting your words right.  You can write it down and see if it looks OK before anyone else sees it.  A piece of paper accepts everything you put on it without interrupting or giving your family the opportunity to tell your story differently.

Try it out as a strategy the next time a child or young person is struggling to communicate in a mental health consultation.  You might be very surprised and pleased with the results.

Edward Snelson

Tuesday, 30 April 2019

Rashes in children: What is the diagnosis? - Probably a virus

A rash is a very common feature of a paediatric presentation and is often the primary reason for seeking medical advice.

I think that clinicians also sometimes feel a bit of anxiety about rashes.  What does the rash mean?  Should I be able to diagnose the illness based on the rash?

The rash can be diagnostic but often it is not.  Even when the rash gives a specific diagnosis, that diagnosis is usually a virus and treatment remains symptomatic and supportive.

These are some important questions to have answers to when assessing a child with a rash.
  • Is the child well? If not, how unwell are we talking about and for how long?
  • Is the child febrile?
  • How did the rash start?
  • How has the rash changed since it started?
  • Is the rash itchy?
When examining the child, it is important to avoid the temptation to focus excessively on the rash.  The child should have a systemic examination that will identify any cardio-respiratory, abdominal or neurological abnormality.

The rash itself is then in context of an assessment that has determined whether the child is significantly unwell or has any significant abnormal findings.  What this tells us is whether the rash is of importance because the child is quite unwell, or more of interest since the child is well.  In the well child with no significant abnormal findings, a diagnostic rash can still give useful information in terms of prognostication and the ability to give specific advice about what to do from a infection control point of view.

Let’s look at some specific rash related diagnoses that are accompanied by non-specific symptoms such as pyrexia-

Roseola Infantum
What does it look like?
This infection is most commonly seen between the ages of 6 months and 3 years.  The classical presentation is of a significant fever but a surprisingly well child with non-specific symptoms such as coryza and pharyngitis.  Essentially, the child has all the signs of a viral upper respiratory tract infection (URTI) but with an impressive fever.

A macular patchy erythematous rash often appears as the fever starts to resolve.  Typically the rash is more prominent on the trunk than limbs.
What causes it?
Human herpes virus 6

What specific advice is there for this diagnosis?
None.  Treatment is symptomatic.

What does it look like?
Chickenpox is a vesicular (small fluid filled lesions) rash which is usually found all over the body.  Children are usually either mildly febrile and unwell in the first few days, or not unwell at all.  The rash is often itchy.
What causes it?
Varicella zoster virus

What specific advice is there for this diagnosis? 
There is no specific treatment.  If the child seems unwell then paracetamol (acetaminophen) is the preferred treatment for systemic symptoms.  While there is some concern about using ibuprofen, the evidence strongly suggests that this concern is unfounded.  However, most children do not become significantly unwell with chickenpox and it is unusual for symptoms to require more than paracetamol.  If a child with chickenpox is very unwell, that is a clinical situation that mandates a careful assessment to consider the possibility of sepsis, usually in the form of invasive streptococcal infection.
Itching can be treated with antihistamines.  In the UK, it is usual practice to ask that the child is kept out of school or nursery until day 7 of the rash, at which point new lesions are not forming and the existing spots are crusting.

Hand, foot and mouth disease
What does it look like?
Vesicles on the face around the mouth, ulcers inside the mouth, vesicles on the hands and feet and perianal vesicles or ulceration.  (Somehow the perianal bit got left out when naming this childhood infection)  The child is usually systemically well but when the rash is appearing may be a little miserable and pyrexial.

What causes it?
Coxackie virus

What specific advice is there for this diagnosis?
Treatment is symptomatic.  This is a good opportunity to practice the philosophy of “treat the child, not the fever.  Many children with hand, foot and mouth disease are not febrile but may be in significant discomfort from the oral lesions.  The importance of analgesia to help the child be comfortable enough to drink should be emphasised.
The UK public health advice for hand, foot and mouth disease is that in itself, it does not mandate and absence from school or nursery.

Pityriasis rosea
What does it look like?
The classical pityriasis rosea rash starts with a herald patch in the form of a well localised erythematous area somewhere, usually on the trunk.  This may go unnoticed and if seen rarely causes alarm.  The generalised rash that follows is what usually leads to the seeking of a medical opinion.  This rash is an impressive patchy pink rash with the pattern of the patches following the lines of the dermatomes of the skin on the trunk, forming what is described as a “Christmas tree” distribution.

What causes it?
Human herpes virus

What specific advice is there for this diagnosis?
The child is usually well at the time of the Christmas tree-like rash appearing so no specific treatment is needed.  It should be explained that the rash may last for a few weeks.  There is no need for the child to be excluded from school or nursery.

Slapped Cheek Syndrome (Fifth Disease)
What does it look like?
Most of the features are non-specific: Fever, coryza, sore throat.  The name comes from the typical bright red rash which appears (usually) on both cheeks.  The redness is both more impressive and more consistent than the flushed cheeks seen in febrile children.  This is often followed by a more non-specific, patchy, popular, blanching erythematous rash on the rest of the body.

What causes it?

What specific advice is there for this diagnosis?
For the purposes of managing the child, treatment is symptomatic.  Most cases of slapped cheek resolve without complications.

A rare but significant complication of parvovirus is an aplastic crisis secondary to the effect of the virus on the bone marrow.   A history of recent parvovirus infection followed shortly afterwards by significant or atypical illness or pallor should prompt the testing of a full blood count.

Parvovirus infection in pregnancy carries a risk of miscarriage or hydrops fetalis (due to the same aplastic crisis).  Parvovirus is not treatable and most pregnant women are immune.  In most places, the advice for pregnant women who come in contact with parvovirus is to seek medical assessment if they subsequently become ill, especially if they develop a rash of any kind.  If serology confirms parvovirus infection then the pregnant woman should be referred to the fetomaternal team.  Through the marvels of modern medicine, it is now possible to transfuse a baby in utero and potentially keep them well long enough to reach a gestation where it delivery is an option.

What does it look like?
Typically the child is febrile, coryzal and coughing for a couple of days before the rash appears.  The rash itself is an erthematous maculopapular rash which usually starts on the head before spreading to the rest of the body.
Kopliks spots are diagnostic but rarely seen as they don't hang around for long.  These are small white spots that appear on the inside of the cheeks, opposite the molars.
Measles should be suspected when a child has significant non-purulent conjunctivitis or is particularly miserable despite analgesia.  Unlike uncomplicated viral illnesses, the child is usually quite unwell several days into the illness when the rash appears. (Consider a differential diagnosis of Kawasaki Disease in the child who has had fever for five days as many of the features overlap.  Unlike Measles, early specific treatment for Kawasaki Disease is essential)

What causes it?
Measles virus

What specific advice is there for this diagnosis?
Measles infection requires specific infection control measures and in the UK is a notifiable disease.  There is no specific treatment for Measles and at presentation, the key decision is about how unwell the patient is.  If well enough to be managed at home, it is very important to avoid unnecessary admission to hospital as this might lead to infection of those most at risk.  However if the child is showing signs of significant infection (mainly encephalitis) then admission is probably necessary.  If referring to secondary care it is essential that the accepting team are aware that Measles is suspected so that the child can be kept away from others from the moment of arrival to hospital.

Viral Urticaria
What does it look like?
It looks like an allergic reaction or nettle sting.  The itchy, raised red and white rash can be seen in any part of the body and can be quite alarming.  Typically this rash appears as the illness is getting better.  Lesions appear and disappear several times a day.  If the onset of the rash is accompanied by other symptoms appearing (such as wheeze, oral swelling or vomiting) then acute IgE mediated allergy should be suspected.  Viral urticarial should not be accompanied by the appearance of these symptoms.

What causes it?
One of many possible viruses

What specific advice is there for this diagnosis?
It should be explained that the rash is caused by the virus and the child’s immune system.  The rash doesn’t tell us anything specific about the infection and doesn’t mean anything bad about the illness or the child.   While anthistamines may reduce the itching, they do not seem to make the rash go away any faster.  The rash will usually resolve spontaneously over the space of several days.

It is notable that children who develop viral urticaria are sometimes taking antibiotics when the rash appears.  This can cause concern regarding possible drug allergy.  The evidence suggests that a large number of children developing rashes while taking antibiotics are simply manifesting a viral rash (including urticaria).  This association is contributing to the overdiagnosis of antibiotic allergy.  Many specialists are now advising that a label of antibiotic allergy is not given to a child if they have an acute illness that could be viral, the only symptom is a rash and it is the first time the child has had a rash while taking antibiotics.

Non-specific Viral Rash
What does it look like?
These rashes can appear during the acute infection or recovery phase of the illness.  Typically the rash is a diffuse, patchy erythema.  It may be macular or papular.  In the majority of cases, all of the rash blanches.  Occasionally, a few petechiae can be found.  In a population vaccinated against most strains of meningococcus, a small number of petechiae is most likely to be part of a viral rash.  Indeed, finding one or two petechiae is within normal for a well child at any point. (1)
What causes it?
Any virus that is on the rash B-team could be responsible.  If it's not a diagnostic rash, you can't make a specific diagnosis.

What specific advice is there for this diagnosis?
It's important to explain that the rash doesn't have any specific meaning. For example, a child with this rash does not need to be kept out of school, for infection control reasons at least. Safety-netting advice should mainly centre around the illness, not the rash.  The rash may well persist after the child's illness has resolved.

Many specific rashes start of as non-specific so if the rash changes significantly they may need to be reassessed.  In particular they should know how to assess for non-blanching rash.

Erythema Multiforme
What does it look like?
As the name (What, no Latin?) suggests, it is a rash with multiple forms.  The rash varies from place to place rather than being uniform in appearance.  The rash varies in appearance and texture.  The typical target lesions that also help make the diagnosis are circular and have a dark red centre.
What causes it?
The rash is in many ways very similar to urticaria in children.  It may be a drug reaction but is more commonly triggered by a virus.  That virus is not usually specifically identified.  Atypical bacterial infection, most commonly mycoplasma, may also trigger erythema multiforme.

What specific advice is there for this diagnosis?
Essentially the same applies to Erythema Multiforme as applies to viral urticaria and non-specific viral rashes.  If there is no obvious specific cause, safety-netting for the illness is most important.

Because Erythema Multiforme can rarely progress to Stevens-Johnson Syndrome, it is worth advising the family to seek reassessment if the child develops an inflamed mouth.

Henoch-Schonlein Purpura (HSP)
What does it look like?The typical HSP rash is a purpuric rash on the lower limbs, predominantly on the buttocks and extensor surfaces.  This is often fully apparent at presentation but sometimes the initial rash is not purpuric.  In some cases other symptoms precede the rash.
Typical symptoms of HSP include leg pains and abdominal pains, though in some cases HSP is asymptomatic.

What causes it?
The cause is unknown, however it is presumed that this vasculitic process is triggered by infection.  In that sense, it can be considered a viral rash.

What specific advice is there for this diagnosis?
Most cases of HSP are suitable for outpatient management and in many cases this is well within the remit of the General Practitioner.  A full explanation of the condition, possible complications and how to manage/ followup can be found here.

Bringing it all together
So there you have it - a reasonably comprehensive list of common rashes seen in childhood infections.  In most cases, the rash will not give a specific cause.  In every case, the clinical condition of the child is by far the more important part of the assessment.  After all, it's probably a virus and you probably can't treat that.

Edward Snelson
Rash decision maker

Disclaimer - it might not be.
  1. Downes AJ, Crossland DS, Mellon AF Prevalence and distribution of petechiae in well babies Archives of Disease in Childhood 2002;86:291-292.

Tuesday, 9 April 2019

What is the deal with fever?

Fever scares parents.  The internet is full of scaremongery about what fever can do to you.  For the uninformed parent, fever not only suggests the possibility of serious infection, it is the enemy.  It must be stopped before it harms the child.

Fever confuses clinicians.  For the clinician, fever indicates an infection (most of the time).  Can it tell me what kind of infection and where it is though?  Fever is sometimes associated with raised heart rate, cool peripheries and general malaise.  This picture can be very difficult to discern from sepsis.  Fever therefore presents a dilemma.  If the tachycardia and lethargy could be simply associated with a febrile moment, do I wait to see if the red flags resolve when the fever settles?  If that resolution happens (by far the most likely outcome), I have avoided unnecessary treatment and admission, both of which are at best unpleasant and inconvenient (at worst they both carry their own small risk of morbidity and mortality).  If it later turns out that the child was septic (unlikely but always possible), then the delay, intended to remove the confounder of fever, may have caused harm.
So if fever causes confusion and anxiety, it’s probably a good thing to be clear about a few things to do with fever.   Let’s work through some common questions.

Is fever helpful or necessary in fighting infections?

This is something that is frequently posed: that fever is a normal feature of an immunological process.   It is then suggested that we should not interfere with it.  I’m afraid that this argument holds little water.  Unless there is good evidence that the height of the fever correlates with better outcome (and unsurprisingly this is not the case) then we can’t attribute the death of the microbes to a thermal effect.  Yes, fever may be a part of a process but that doesn’t make it necessary or desirable.  Are fumes a normal outcome from an engine running?  Yes.  Would it be great if we could get the same performance from our engines with less or no fumes?  Yes.  Fever is a sign that the immune system is doing something but there is no good evidence that reducing fever is harmful to the body’s business of fighting the infection.

Is fever harmful to the brain?

The simple answer is that no, fever itself is not harmful as long as it is due to a functional immune response.  That doesn’t mean that the infection couldn’t be harmful, but a fever is not harmful in itself as far as we know.
(There is such a thing as malignant pyrexia which has a high morbidity and mortality rate.  Malignant pyrexia is not a normal physiological response, fever during an infection is.)

Is fever always significant?

Not always.  Sometimes a raised temperature is not even a fever.  It can be environmental.  Babies in particular are prone to getting hot if overdressed or in a hot room.

If a raised temperature is due to infection, the issue of how determined we should be when we look for a focus is a complicated one.  Different circumstances will require different approaches.  The history and examination are important but so is the age of the child.  Babies have a much higher incidence of sepsis and serious bacterial infections.  The threshold for investigation is far lower in a three week old than a three year old.

Consider these two scenarios:

  • A three year old presents with the parent saying that they were really hot at home that morning.  They now have a normal temperature.  Examination is completely normal and the child looks well.  Heart rate and other parameters are all normal.
  • A three week old presents with the parent saying that they were really hot at home that morning.  They now have a normal temperature.  Examination is completely normal and the child looks well.  Heart rate and other parameters are all normal.

In the first scenario the pre-test probability of significant infection is low as long as there are no special circumstances (returning traveller etc.) but in the second they are far higher.

Does fever cause febrile convulsions?

Probably not.  A review article (1) previously reported that the available evidence showed that antipyretic use was not associated with a reduced rate of febrile convulsions.  This is entirely plausible as two events which repeatedly occur together do not have to be one causing the other.  It makes perfect sense that both the fever and the fit could be caused by biochemical changes brought about by either the infection or the body’s response to it.

There was a new paper (2) published in 2018 in which the authors claimed to have clearly demonstrated that antipyretics reduced the recurrence rate of febrile convulsion in children who had already had a fit.  The recurrence rate of fits during the same illness was so high in this study as to suggest that either the data was skewed or that the population was so different to normal as to make the results difficult to apply to practice.  Although this latest publication did challenge the accepted view that lack of fever control is not to be blamed for febrile convulsion, many have seen it as a blip rather than a reason to change their practice.  I remain open minded but still in the “fever does not directly cause the fit” camp.

Does the height of the fever indicate a more serious infection?

The answer to this is, “not really.”  A fever of 40C is slightly more likely to indicate a serious bacterial infection (SBI) than a temperature of 38C in an unwell child.  Despite this weak correlation, height of fever is an unreliable indicator of SBI.  Ultimately the decisions and diagnosis should be made based on other findings.  A child with a fever of 40C, a red throat, red ears and no signs of SBI probably has a viral URTI.  A child with a temperature of 38C with cough, grunting and focal reduced air entry and coarse crepitation in the chest is presumed to have pneumonia.  The number of the temperature itself is of little use in making those decisions.  Undoubtedly, a high fever might act as a speed bump to a clinician, making them look twice and think carefully.  That’s no bad thing.  However a higher temperature shouldn’t mandate a different diagnosis or course of action.
Should we be treating fever in children?

Fever, it seems, is neither harmful nor beneficial.  The medicines that we give to children should in theory be administered with the aim of reducing pain and general malaise.  In practice, children who are febrile usually display signs of feeling unwell.  This means that we end up giving them medication anyway.  The reason may be different but the end result is the same.

If a child is febrile but seems to feel entirely well and demonstrates no evidence of pain, it seems entirely reasonable to not treat the fever for the fever’s sake.  That scenario does happen but is reasonably uncommon.

We should probably de-emphasise the role of fever in the clinical assessment.  The presence of fever is an important piece of information in the acute assessment of a child but only to trigger a search for a focus.  Once it is known that the child has an infection, the focus should be on useful discriminators such as appearance, behaviour, duration and pattern of the illness.
Fever is an important feature of history and examination.  The significance and cause of the fever is the question which then occupies the clinician’s mind.  If the cause and effect of the symptoms are found to be benign, the fever becomes a detail, not a task.  We treat the child not the fever.

Saturday, 30 March 2019

We should talk more often - Treating CMPA in infants and assumptions between primary and secondary care

It's not uncommon for parents to bring their infant with a feeding problem to an emergency department.  Although that might seem like a problem best managed by a GP or other primary care clinician, it is also understandable that parents seek answers wherever they can find them when their baby seems to be constantly miserable.

The natural tendency of many infant presentations to self-resolve (colic, mild reflux etc.) means that rather than always medicalise the situation, watchful waiting is often the best strategy.  If the problem is non-IgE cow's milk protein allergy (CMPA) then delay in intervention leads to prolonging the infant's misery.  Getting the balance between overdiagnosing CMPA and avoiding a delay in diagnosis is not easy.  It involves careful history taking and thorough examination alongside a sympathetic but objective approach.

During this process, it is common for parents to feel that they are not being taken seriously or that no-one is doing anything.  The reality is almost certainly that they are being taken seriously and that a lot of work is being put in by the clinician seeing them.  However, it can be that the parent feels that they are no further forward and so come to the Emergency Department (ED) to seek what they percieve to be a more specialist opinion.

If an infant genuinely does have non-IgE CMPA, that diagnosis will rarely be made at first presentation because the symptoms are too vague and non-specific.  Gastro-oesophageal reflux disease (GORD) is more common and in many cases this is the presumed diagnosis for the miserable infant regurgitating some of their feeds.  The diagnosis of CMPA is often not made until the third or fourth attendance.  This is entirely reasonable since it takes time to establish a pattern of symptoms and to consider other possible diagnoses.

Let's imagine that the third or fourth time that the parents of a formula fed infant seek help is the time they go to the ED.  They are seen by one of the doctors and that person thinks that on balance, management as possible CMPA is the logical next step.  What should that clinician do - change the milk or send them back to their General Practitioner?  This question of who should do what is an interesting one that causes much debate.

There are plenty of arguments for the ED clinician to make the change.
  • The ED clinician has decided that they think it is the right thing to do.  There is an ethical mandate to either do it or facilitate the change in milk.  Sending the parents away without making the change themselves poses a risk.
  • Changing the milk avoids some duplication of work for the GP.
  • There is no guarantee that the parents will be able to get an early appointment with their GP and any delay might mean unnecessary suffering for infant and parents.
There are also arguments against the ED clinician changing the formula:
  • Assuming there has been some continuity at the GP end, the GP will have a better idea of the full picture rather than just the one presentation to the ED.
  • By changing the milk, there is potential to undermine the GP ("My GP did nothing but the hospital diagnosed and treated...") and reinforce the belief that the ED is the place to go for everything.
  • There is a possibility that by doing so, the GP's equally valid but slightly different plan is derailed.  Once the change is made, it is extremely difficult to undo that change.
We want the infant to have the right treatment in a timely way but we also know that it is in everyone's interest that we don't end up undermining the relationship between that family and their GP.

Another factor that affects the decision is the uncertainty that is brought about by the primary-secondary care divide.  Each group will tend to have its own opinion about the best way forward.  Due to a woeful lack of converstaion between primary and secondary care, there are often assumptions made rather than actual converstions about such matters.  In the digital age, there is no real excuse for a lack of discussion about these things so I decided to ask both sides what they thought.

First of all I asked the primary care community what they thought should happen.  Three quarters thought that the ED clinician should change the milk.  About a quarter thought that the child should then stay under secondary care.  Another quarter wanted to retain control of the decision making in primary care.
Next I asked the EM community what they thought they should be doing.  The results were remarkably similar.
I found that very interesting.  While there was no overwhelming consensus on the best action in these cases, there was good agreement and certainly nothing that could be described as opposite views.  As well as suggesting that changing the formula and returning the child to the care of their GP is likely to be the most acceptable way forward, it shows that there may be times when the assumption that the two communities will have very different views will be wrong.

There are many percieved differences between the views of primary and secondary care clinicians.  If we go about it the right way, we might be able to explore those perceptions in a functional and constructive way.  We might better understand the differences in approach if they do exist and learn from each other.  We might, as in this case, find out that the imagined differences are not all that real.  Of course, done badly, it will end up with upset and opposition.  Let's not do that - we're all on the same team.  Whatever we do, we should come at these discussions with positivity and an open mind.  In the era we are in, there is no good reason to allow percieved differences to remain unchallenged or unresolved.

Thanks to everyone who took part in both polls.  If you have any other suggestions for similar issue that could be explored, let me know (post in comments below or contact me via social media).

We should definitely talk more often.

Edward Snelson

If anyone is wanting to get involved in the conversations on Twitter but feels cautious about it, there was a great guide written recently by the Don't Forget the Bubbles team which would be useful for anyone who would apprectiate a little guidance in what to do when starting up on Twitter.

Leo, G. Don’t Forget The Twitter, Don't Forget the Bubbles, 2019.

Tuesday, 26 February 2019

Too much choice - What milk do you need to give a baby with a feeding problem?

To paraphrase one of my favourite comedians (John Finnemore) - Once upon a time there was too little choice.  Then around 1980, there was just the right amount of choice.  Now, there is way too much choice.  In paediatrics, this is perhaps more true for special milks than any other treatment decision we make.

Have you been to a supermarket recently to buy some milk?  Just trying to find what you want when you know what you want can be overwhelming.  Should it be 0% fat?  1%? 2%? Organic? Cow's milk? Goat's milk? Filtered? I could go on but you get the idea.  There is just too much choice.

The same is true when trying to decide which milk to use* for a baby with a feeding problem.  There are so many possibilities that it can be quite confusing.  Don't worry though - all the choice is an illusion.  There are only a few real differences which can easily be explained.  The best way is probably by going through the problems rather than the milks.  So here we go.

*Note that this only applies to choice of formula in formula fed infants.  While breastfed babies less commonly develop problems such as milk allergy, the solution is not to change them to a formula feed.  It should be possible to continue breatfeeding no matter what the problem is.


What is it?  Nobody knows. No cause has been found to really explain why some children cry a lot of the first few months of life.

Which special milk helps this condition?  There is no good medical evidence from RCTs published in peer reviewed journals that I know of to support the use of any special milk.  The keystones of managing colic are to rule out other pathology and to give a good explanation of the condition to the parents.  Ultimately, the only thing that really works to resolve colic is the passage of time.

Gastro-oesophageal reflux disease (GORD)

What is it?  It is normal for babies to reflux/ regurgitate milk.  GORD is the term used to label reflux associated with significant symptoms such as marked and persistent distress.  The amount of milk that the infant brings back is not what separates GORD from physiological reflux.  If a baby has several large regurgitations a day but is minimally affected, this is not considered to be a disease. (1)

The first thing to do is to make sure that the infant is not overfeeding.  This is a surprisingly common scenario that is reasonably simple to manage.
If you suspect that the distress and vomiting is related to overfeeding, try reducing feeds to 150ml/kg/day under the age of three months and to 120ml/kg/day if over the age of three months.  Those targets are a rough guide and overfeeding is only likely to be the issue if the volume of feed is well over those guideline amounts.

Which special milk helps GORD? Most infants with GORD are symptomatic due to reflux of milk, rather than having a problem with acid reflux.  This is almost certainly why the evidence for routine use of acid suppression treatment (PPIs and H2 blockers) suggests little or no effect.

For infant GORD without red flags the mainstay of treatment is to avoid over-feeding, and to use a thickener in a standard feed.  Alginate preparations should be used as second line treatment since they have a high risk of causing constipation.  There are reflux milks on the market which are essentially standard milks with thickener already blended in.  These are not usually prescribed.

Lactose Intolerance

What is it?  Inadequate production of the enzyme lactase in the bowel means that lactose (the sugar in milk) is left undigested.  Bacteria then ferment this sugar and produce noxious chemicals which inflame the bowel, further diminishing the ability to produce lactase.

Lactose intolerance is often secondary to an episode of viral gastroenteritis, in which case it will resolve (and more quickly so with the right milk).  Primary lactose intolerance is actually very rare according to the epidemiologists.  There is an inexplicably large difference between the epidemiology of lactose intolerance, and the frequency with which it is diagnosed by parents and clinicians.

Possible reasons for the overdiagnosis of lactose intolerance include:
  • Lack of specific symptoms - normal infant crying and colic might be labelled as lactose intolerance
  • Confusion with Cow's Milk Protein Allergy, which is more common.
  • Confirmation bias - Colic and reflux symptoms both have a tendency to resolve in time.  If the resolution of symptoms happens to occur after a change in milk, this will give the wrong impression that the special milk caused the improvement in symptoms.
Which special milk helps this condition?  If an infant genuinely has lactose intolerance then a lactose free milk will result in a dramatic resolution of symptoms, usually within days.  There are numerous lactose free formulas which are commercially available.  Soy milk is also lactose free but is not recommended for infant boys as the effect of phytoestrogens is unknown.

Lactose free milk does have the potential to cause more dental caries than standard milk, so there is good reason to avoid the overdiagnosis of lactose intolerance.

Cow's Milk Protein Allergy (CMPA)

What is it?  Well, confusingly, there are two types of CMPA.  IgE type CMPA is what you might call a classic allergy.  With this immediate type of response to cow's milk protein, typical symptoms include wheeze, urticaria, swelling etc.  Usually, it is quite obvious that the child is having an allergic reaction, leaving the main question to be what the allergen was.

In most cases, infants usually have a non-IgE CMPA.  This is sometimes referred to as milk intolerance, which causes it to get confused with lactose intolerance.  I prefer to avoid that term to avoid this misunderstanding.  Non-IgE CMPA is predominantly an enteritis, without systemic features.  As such the symptoms are vague and difficult to distinguish from other conditions such as GORD and colic.

Clues that an infant may have non-IgE CMPA include
  • Onset of symptoms at an age which is atypical for GORD (e.g. over 6 months old)
  • Symptoms that may originally have suggested GORD but fail to respond to treatment or progress despite treatment
  • Lower GI symptoms
  • Significant eczema.  The relationship between eczema and CMPA is complicated.  Eczema is quite common and colic is also common.  As a result, it would be foolish to say that eczema + unsettled child = CMPA.  However, there are many infants whose eczema and unsettled behaviour seemed to resolve as soon as they were treated as CMPA.
Which special milk helps this condition?  The best way to stop an an allergic reaction is to remove the allergen.  In order to reduce the allergenicity of the formula, CMPA milks have the proteins broken down to varying degrees.  While there are partially hydrolysed feeds available, an extensively hydrolysed feed (EHF) is recommended for a child with CMPA.  There are many EHFs available.

One pitfall in the prescribing of milks to children with CMPA is to confuse lactose free milk with EHF.  Another is to accidentally prescribe an amino acid formula, because these are also licenced for use in CMPA.  Amino acid formulas are only used for extreme cases of CMPA.  These feeds are quite unpleasant and rather expensive, so EHFs should be first line unless there is a specific reason to chose an amino acid feed.
Amino acid feeds (AAFs) are generally reserved for use in secondary care.  This type of milk is the ultimate in hypoallergenicity (real word?) but is also very expensive and rather unpleasant to taste.  AAFs are usually resorted to rather than being chosen first line.  Indications include severe IgE type allergy or non-IgE allergy that does not respond to an ECF.

One alternative to use first line is soy milk.  This may or may not be successful as a treatment strategy.  The problem with soy milk is that although it does not contain cow's milk protein, it is not in itself hypoallergenic.  Many infants who have reacted to cow's milk also react to soy milk so you end up no further forward when that happens.  There is some caution regarding the phyto-oestrogens that are found in soy milk.  Although it is an unproven risk, the concern is that these chemicals may have an effect on infants and so it is sometimes recommended that soy milk is not given to boys under the age of six months old.

Parents may also want to try other mammalian milks (e.g goat).  Most dietitians recommend that these are avoided due to the poor nutritional content.  Again, these milks are not hypoallergenic and there is significant risk of further reaction.

The most important part of managing non-IgE CMPA is that the diagnosis is a three part process.  First the diagnosis is suspected.  Then, is the infants symptoms settle with treatment the diagnosis is provisional.  Only when the infant is re-established on a standard formula and the symptoms return is the diagnosis confirmed.
When introducing an ECF, it is worth considering that the infant may object to the taste of the new milk.  Although nowhere near as unpalatable as an AAF, ECFs do have a distinctive taste difference from standard feeds.  A sudden switch can cause problems at feeding times.  One strategy to avoid this is to blend the new milk in over a few days.  If the infant is on a 6oz feed, use 5oz of standard feed mixed with 1oz of ECF on the first day.  On the second day, increase that to 2oz of ECF and 4oz of standard feed.  After a few days, the infant should be fully established on the new ECF feed.

The best way to avoid the problem of too much choice is to simplify things.  Find out a locally available ECF or check your local guideline/ formulary.  That way you only need to know one milk- choice doesn't get more simple than that.

Edward Snelson

Disclaimer - I frequently buy the wrong milk.
Gastro-oesophageal reflux disease in children and young people: diagnosis and management
NICE guideline [NG1] January 2015

Edward is fundraising for the development of the Sheffield Children's Hospital Emergency Department.  If you found this post useful and would like to support that cause, this link will take you to the donations page.  GPpaedsTips is free to all and produced without expectation of any such donation, but if you don't ask...

Wednesday, 13 February 2019

Should you give ibuprofen to a child on an empty stomach?

In the previous post, I gave some general principles about prescribing for children.  One person took the time to get in touch about the issue of ibuprofen on an empty stomach.  This is an interesting controversy and is an issue well worth understanding.

Ibuprofen is a useful medication when it comes to symptom control in the unwell child.  Studies on the benefits of ibuprofen when co-administered with paracetamol (acetaminofen) have tended to show that there is no additional benefit when it comes to controlling fever.  However, pyrexia is no longer generally thought to be the enemy and there is no clear indication to normalise an unwell child's temperature.  That doesn't mean that the child will not benefit from analgesia.  One of the issues with children who have upper respiratory tract infection (URTI) is that they are often reluctant to drink, either due to a general feeling of being unwell or due to the pain associated with trying to drink.  If paracetamol and ibuprofen have a clear role in managing the unwell child it is this: making the child feel comfortable and well is an important part of giving them the best possible chance to have good oral intake.  If fever is not the enemy then dehydration certainly is.  If an unwell child is refusing fluids and a combination of paracetamol and ibuprofen resolves that, why wouldn't you?

One of the anxieties that this situation causes is the fear that these are the very children at risk of the complications of ibuprofen.  Ibuprofen, being a non-steroidal anti-inflammatory drug (NSAID) is associated with renal impairment and gastrointestinal (GI) bleeding.  Should it then be avoided in children with poor oral intake?

First, let's look at the renal issue.  The short answer is that while renal impairment is a risk in dehydrated children (1), it is safe in children who are not dehydrated (2), even if at risk of dehydration.  If ibuprofen can potentially aid oral hydration, it seems safe to use, providing the child is not already showing signs of dehydration.  It is also worth noting that in the study reporting acute kidney injury (AKI) in children taking ibuprofen, all made a full recovery.

Second, the issue of GI bleeding.  Although case reports of children having GI bleeds during short term use of ibuprofen exist (3), these are associated with incorrect administration.  Significant GI complications of ibuprofen are associated with long term use, concomitant steroid use, known GI ulceration or coagulation defects (4).  Short term, correct use of ibuprofen in children without risk factors seems to be safe.

The way that ibuprofen risks GI complications is a systemic effect.  It reduces prostaglandin production, thereby reducing the natural protection of the gastric mucosa.  Although we are often told that ibuprofen should be taken with food to reduce GI side effects, there is a debate about whether this should be the case at all.

Advising that analgesia should be given with or after food delays the effect (5) of the pain-killers without clear benefit in terms of gastric protection.  It is unclear as to whether taking ibuprofen with food reduces side effects such as nausea but it shouldn't have an effect on the risk of GI bleeding. As one publication puts it: "Apart from providing unsubstantiated ‘safety’ information by advocating food intake with NSAIDs it may be more appropriate to advocate OTC NSAIDs be taken on a fasting stomach in order to achieve a rapid onset of action and hence avoid an ‘extra’ dose of the drug because the rapidity of pain relief did not meet the patient's expectations." (6)

The bottom line is that as long as a sensible clinical assessment has taken place, ibuprofen can be given to a child who has not eaten.  It may even be best practice.

Edward Snelson
Unintentionally inflammatory

Many thanks to Gina Johnson for her comment on the previous post.  Keep them coming! 
  1. Balestracci A. et al, Ibuprofen-associated acute kidney injury in dehydrated children with acute gastroenteritis, Pediatr Nephrol. 2015 Oct;30(10):1873-8. doi: 10.1007/s00467-015-3105-7. 
  2. Lesko SM, Mitchell AA, Renal function after short-term ibuprofen use in infants and children, Pediatrics. 1997 Dec;100(6):954-7
  3. M─ârginean, M et al, Ibuprofen, a Potential Cause of Acute Hemorrhagic Gastritis in Children - A Case Report, J Crit Care Med (Targu Mures). 2018 Oct; 4(4): 143–146
  4. Berezin et al, Gastrointestinal Bleeding in Children Following Ingestion of Low-dose Ibuprofen, Journal of Pediatric Gastroenterology and Nutrition: April 2007 - Volume 44 - Issue 4 - p 506–508, doi: 10.1097/MPG.0b013e31802d4add
  5. Moore R. et al, Effects of food on pharmacokinetics of immediate release oral formulations of aspirin, dipyrone, paracetamol and NSAIDs – a systematic review, Br J Clin Pharmacol. 2015 Sep; 80(3): 381–388.
  6. Rainsford K, Bjarnason I, NSAIDs: take with food or after fasting?, J Pharm Pharmacol. 2012 Apr;64(4):465-9.

Sunday, 27 January 2019

Prescribing for children - Top tips

Prescribing for children can be tricky. Getting the right medication, dose and formulation should make all the difference to the effectiveness of the treatment plan. Getting one of those wrong is all too easy.

What are the things that we need to know and tips for getting it right?  Here is a detailed list.  There's a shorter and more condensed list below this.
  • Only use medication that has a clear indication.
  • Prescribe a licensed medicine for a licensed indication where possible.
  • Any reasons for prescribing an unlicensed medicine should be clearly and accurately documented.
  • Don't give medication for the sake of doing something.
  • Use a children's specific formulary.
  • Children are less likely to recognise and associate side effects with their medication. This lack of insight by the child is another reason for being judicious about prescribing.
  • Know the weight of the child. Even if doses are age banded, if the child is very large for their age you might choose to go up a little before their birthday.
  • If there is a choice between age banded doses and weight defined doses, go by weight unless overweight for height.
  • Most weight based doses have an upper limit (e.g. nebulised adrenaline), and this can be reached at an early age so always check what the maximum dose should be.
  • When calculating a weight-based dose, check that it looks like a reasonable number.  Calculation errors with a factor of 10 are made all too easily. Don't just copy off the calculator onto the prescription.  Ask if it seems like a dose that makes sense compared with an adult dose.
  • Use a syringe to give the medicine.  It is often better tolerated than a spoon, and the dose can be more accurately measured.  The correct dose can be marked onto the syringe.
  • Use a formulation that the child will tolerate.
  • If a child is sick less than 30 minutes from when medicine is administered, it is OK to repeat the dose as a one-off.
  • Consider alternative routes.  Children with neurodisabilities often have problems with oral medication but may tolerate suppositories.
  • If newly prescribed medicines are to be administered by PEG/NG/NJ tube discuss with a pharmacist to determine the safest formulation and any special administration requirements (e.g. the need to avoid a formulation that will interact with components of the tubing or the need to dilute the dose to avoid blocking the tube).
  • There is almost always a non-pharmacological aspect to any treatment.  Make sure that this is completed either first or as well as the pharmacological treatment.  For example, a hot, miserable child in four layers of clothes doesn't just need antipyretics.  They also need to take all or most of their clothes off.
  • Don't assume that a rash or other symptom is a drug allergy.  (Full post link here)
  • Don't scale down inhaled salbutamol to the size of the child.  Children may need more sprays. Telling a parent to give one spray to a two year old will not be effective.  (There is science behind this - click here for a link to the full explanation.)
  • Don't assume that medication that has been prescribed is the correct dose.  Children grow out of their dose and may no longer be receiving a therapeutic dose. Check the weight of the child and make sure that their long term medication is in the therapeutic range.

Let's consider a few scenarios.

Child 1

A 20-month-old boy sees you with a cough, runny nose and a fever for two days. The child hasn't eaten all day. The parent is giving regular paracetamol, but the temperature is still a concern to them. Examination shows a red bulging left ear drum.

What about antibiotics?

The natural course of otitis media is to begin resolving after about the third day of symptoms. A significant number of children experience side effects such as vomiting or diarrhoea from antibiotics such as amoxicillin. On balance, an antibiotic is unlikely to cause benefit, and the risk of side effects is similar in size so at day two of symptoms it is probably better to maximise symptom relief.

How do we improve symptom relief?

1 - Optimise the dose of paracetamol
It is often assumed that a child being given paracetamol is receiving a therapeutic dose, but this is not always the case. Often the child is being given too little for some possible reasons:

Human factors-
The parent is using a bottle that was prescribed some time ago.  The dose was correct at the time but is no longer adequate. The parent will assume the dose is correct because the bottle has the child's name on it.
The parent has given the medication in the expectation of a cure. After a few doses of paracetamol, when the symptoms return, they assume that the medication is not effective and stop using it.
The parent is using both paracetamol and ibuprofen and has assumed that to use both, the dose of each needs to be halved. As a result, the child is having sub-therapeutic doses of each medication.
The parent is simply being cautious for fear of overdosing the child.

Pharmacological factors-
The dose is based on age banding. Age banded doses for drugs with a narrow therapeutic index (such as paracetamol) have to err on the side of caution.  The weight of a 20-month-old child can vary hugely.  Paracetamol is ineffective below 10mg/kg, and the BNFc recommends a dose of 15-20mg/kg 4 hourly, up to four times a day for post-operative pain. Otitis media is painful. It's time to weigh the child.

The child weighs 14 kg. What dose should of paracetamol should they have?

If the parent is giving 120mg/dose as per age banded doses in the UK, the child is receiving 8.5mg/kg which is subtherapeutic. The weight of a 20-month-old boy can vary from 9 kg (9th centile) to 13 kg (91st centile) according to the WHO growth charts.  Paracetamol is fat soluble and so overweight children should not have a full mg/kg dose.  It is generally agreed that paracetamol should be given to children based on their ideal body weight.  How to achieve that is debatable, and guidelines vary.

Option A - The scientific way: Check the child's weight. If it is over the 91st centile, check their height.  Look at the growth chart to wee what height centile they are. Then check the growth chart for the corresponding weight on the centiles. For this child, if height was 88cm, that sits on the 91st centile. The corresponding ideal weight would be 13 kg.Use that to calculate a 15mg/kg paracetamol dose. In this case 200mg/dose.

Option B - Use clinical judgement. Does the child look to be an appropriate weight for their height? If so the prescribing based on the child's actual weight is reasonable. Does the child look overweight for their height? If so, prescribing on actual weight may result in overdosing. Use age banded doses or option A to be safe.

Supposing the dose of paracetamol is already therapeutic and being given regularly, what do we do then? What should the parent do if optimising the paracetamol dose doesn't work?

2 - Adding in ibuprofen

Sometimes, paracetamol on its own is not enough to control symptoms. Otitis media is often one of those times. This clinical scenario presents a common dilemma. We are told that ibuprofen should be given after food to minimise the risk of gastritis. On the other hand, the child who is in pain and feeling unwell is unlikely to eat and sometimes will refuse to drink.

It is common practice to give ibuprofen in this scenario for short periods (a few days). In children, gastric bleeding is usually associated with prolonged NSAID use. In this situation, ibuprofen is likely to improve oral intake. The practice of giving ibuprofen to children refusing to eat or drink is based on a balance of risks. The risk of GI side effects from the NSAIDs is felt to be outweighed by the risks of not analgesing, which would mean inadequate oral intake.  For a fuller explanation of when and how to give Ibuprofen to a fasting child, read this post.

What about a cough medicine?

There is no good evidence for or against the use of over the counter cough medicines in children. Codeine-based medicines are not an option, and the rest are unproven regarding efficacy. In the absence of good evidence of benefit, it is usually best to avoid medication in children who are unwell. It can be hard enough for the parents to manage to give the medication that is likely to relieve symptoms without adding one that is unlikely to do so.

Child 2 

An 18-month-old girl-year-old presents with wheeze and some increased work of breathing. She started with a runny nose three days ago. She looks happy and well. She is well hydrated. There is a mild subcostal recession and a wheeze that is heard throughout the chest. The parent says that this happened the previous month and they were given a salbutamol inhaler which they were told to give one puff of four times a day.

How do we treat the wheeze acutely?

In this age, the likelihood is that this is a viral wheeze - bronchospasm triggered by a viral infection. Bronchiolitis, which mainly affects the under one-year-olds, does not respond to beta-agonists while viral wheeze does. Salbutamol will only work if it is given in effective amounts. So, the best thing to do here is to confirm the diagnosis and optimise the treatment by giving 6-10 spays of salbutamol from a metered dose inhaler (MDI) via an age-appropriate spacer.

1 - Get the dose right.

Although for most paediatric treatments, doses are an appropriate fraction of an adult dose, salbutamol is an exception. The reasons are multiple and involve a bit of science. I've written a full explanation of why children need bigger doses of salbutamol when wheezy here. Most guidelines recommend 6-10 puffs repeated at 15-20 minute intervals to gain improvement and 4-6 puffs every four hours to maintain that reduced bronchospasm.

2 - Get the formulation right

It is tempting to use a nebuliser to treat infants and small children. They tend not to comply with spacers unless they are used to them, so a nebuliser feels like an easier option. There are several problems with that practice, however. One issue is that it sends a message to the parents that the inhaler is not the ideal treatment and so may make them ambivalent about using an MDI and spacer, preferring instead to come for a healthcare professional to give them the magic mask. Another problem is that people learn by watching and through demonstration. A parent watching an expert use the devices will help them to do it optimally at home. Better still, if someone talks through some top tips while it is given, they will benefit from the experience. Nebulised salbutamol is best used when oxygen is needed concurrently.

3 - Get the technique right

Learning good inhaler technique is a process of explanation, demonstration and practice.  It should never be assumed that inhalers are being given in an ideal manner unless we have checked.  I start my 6-10 puffs by getting the adult to do the first two sprays, followed by me doing the second two and then getting the adult to do the rest, demonstrating any suggestions I have made to do it differently.

4 - Confirming the treatment is appropriate

If the correct drug has been given in the correct amount in the best way, the child will respond. If the child has a clear improvement we have proven the diagnosis and that our treatment is effective. If there is no clear response or the child gets worse, we need to rethink. The two main possibilities are a wrong diagnosis or inadequate treatment. As a rule, with a wheezy child who has increased work of breathing despite initial treatment, we need to escalate our treatment (which may involve calling for help) and consider other diagnoses at the same time.

What about oral steroids?

This is a good case to demonstrate how important it is to keep up to date with the evidence (or to regularly read some FOAMed that does that for you!)  In the past it was fairly normal to give oral steroids to any wheezy child.  There is now good evidence to show that steroids have no role in treating bronchiolitis.  The evidence also suggests that steroids have no significant effect in wheezy children under the age of five.  Unless a child under the age of five has a diagnosis of possible asthma (made by a paediatrician), steroids are generally avoided.

What about antibiotics?

The child has signs of an infection and has a breathing problem, so the temptation is to give antibiotics to cover possible pneumonia.  There are several reasons not to do this. Firstly, a lower respiratory tract infection (LRTI) is very unlikely because the child has a wheeze. There is good evidence that wheezing is a strong negative predictor of LRTI. (1) This also makes sense clinically. Pneumonia causes systemic unwellness and significantly increased work of breathing. If a child has a consolidation in some of their lung and bronchospasm in the rest, you won't be thinking, "maybe I should prescribe oral antibiotics.." you'll be thinking, "let's get this child admitted." (Link to post on this subject here)

Child 3 

A parent brings a six year old child with a barking cough and noisy breathing. When you get to see them, they have visible breathing difficulties and loud stridor. They have a significant recession and look pale/ slightly blue.

What is the priority?

1 - Non-pharmacological management.

This child almost certainly has severe croup. Whatever the cause of the stridor, they have a critical airway. The first thing to do is remain calm. The flow of air through the narrow airway could be suddenly compromised by forcing a change in position of by upsetting the child. This is a perfect time to bring in the non-pharmacological first rule. You need to reassure the parent and keep the child comfortable and able to find their own position to maintain their airway.  Now call for help and get out some epinephrine and oxygen.

2 - Pharmacological management

If the child tolerates it, give 15 litres/minute of oxygen via a mask with a reservoir. Grab the epinephrine (adrenaline) vial (this might be from the anaphylaxis kit in a community setting). The BNFc gives a dose of 400 micrograms/kg. How much does the child weigh? You might have a recent weight but if not, the formula [(age plus 4) times 2] is pretty accurate up to the age of six and gives a rough weight which is all we need in an emergency. So 0.4mg x 20 kg gives us an epinephrine dose of 8mg. However, the maximum dose is 5 mg.  So that is 5mls of 1/1000 epinephrine. In the nebuliser, it goes and onto the face of the child. This will buy some time while help arrives. If there are a really good response and the child will tolerate it, give 150 micrograms/kg of dexamethasone orally.

So in summary: Don't panic, do give oxygen, estimate weight, calculate the dose of nebulised epinephrine, realise that dose exceeds maximum dose, give a maximum dose and remain calm while doing all of that.
While prescribing for children is different, all of the usual principles apply.  There are a few things that are particular to paediatric prescribing, and I hope this has helped by giving some general advice and specific examples.

Edward Snelson

Disclaimer:  If this post is rubbish it's not my fault.  I brought in subcontractors from Scotland's Pharmacy in Practice team in the form of  Stephen-Andrew Whyte and Johnathan Laird.  If you think the post is brilliant then I suppose I must give some credit.  (Seriously though, thanks for your input both of you.  It was much appreciated.  Thanks also to all the people who shared their top tips with me.)

  1. Hirsch, A et al, Estimating Risk of Pneumonia in a Prospective Emergency Department Cohort, The Journal of Pediatrics , Volume 204 , 172 - 176.e1
  2. British National Formulary for Children
  3. Medicines for Children online resource