Wednesday, 14 March 2018

Paediatric Orthopaedic Problems of the Legs Pt 1 - Greater love hath no colleague than to give guidance rather than a guideline

Last month, the paediatric orthopaedic surgeons at Sheffield Children's Hospital sent out a call for the Primary Care community to ask them questions about common presentations. Unsurprisingly many of the questions were regarding things to do with growing legs.  Although there seems to be a guideline for everything, there is none for such problems.  While it would be possible to make such a guideline, referral pathways vary and guidelines do not always apply to every child.

It is a common concern: Are my child's legs normal?  Much of the time, children’s legs seem to be a 'funny shape'.  The vast majority of the time, these legs are normal.  This is the problem with paediatrics though: for everything that is normal or benign, there is an evil twin.  A relatively rare problem that is neither normal nor benign.  These complex problems usually have a considerable overlap with the simple ones and so can be difficult to spot.

To break with convention, we've put together some guidance which should apply across all the common presentations of growing legs.  That way, clinicians have a framework that allows them to make an assessment, rather than a rigid decision tool that tells people what to do and what not to do.  How refreshing!

The first thing to cover, is what is normal in growing legs.  As a general rule, things start to point out, then in and then straighten up as a child grows into their adult body.  

Fig 1. From birth, children's knees will tend to go into varus and then valgus before becoming a normal adult shape.  Bandy legs (also called bow legs) are therefore expected in a child under the age of three and knock knees are considered normal until roughly 8 years old.  Genu valgum may persist into adolescence without any need for intervention.

The other simple rule of thumb is that normal legs are symmetrical, function normally and are not associated with any other abnormality.  This applies to pretty much every scenario - Genu valgum, genu varus, in-toeing, flat feet, hypermobility, "growing pains" and tiptoe walking.

In general terms, the following presentations are normal unless there is reason to think otherwise (see red flags above):
  • Bow legs (genu varus), in a child up to the age of 2 years
  • Knock knees (genu valgum), in a child up to the age of 3 years or up to the age of 10 if resolving
  • In-toeing gait (also called pigeon toe) up to the age of about 9
  • Flat feet on weight bearing
  • Tip toe walking in toddlers
  • Hypermobility

The lovely thing about all of them is that the history and examination required is usually brief.  It is rare to need to refer or investigate.  What's wrong with  this child's legs?  Usually nothing, but more on that in the next GPpaedsTips post.

Many thanks to the paediatric orthopaedic team at Sheffield Children's Hospital for taking the time to answer questions and to turn their expertise into guidance.  At a time when Primary Care Guidelines are often written by Secondary Care clinicians, I find it most refreshing that someone is willing to give their time to share insights and provide general guidance which facilitates rather than dictates management in Primary Care.

Edward Snelson
The Hitchcock of Free Open Access Medical Education

Disclaimer:  All of the above is based on a standard number of legs.  For any variation on two legs, discuss with your local orthopaedic surgeon or possibly a vet.

Sunday, 4 March 2018

Paediatric Sepsis - the Facts, the Myths, How We Got Here and Where We Need to Go Next

(Note that there is a call for questions about orthopaedic problems at the end - please read and respond)

You may be wondering if you're the only one confused about what's happening with paediatric sepsis.  You're not.  I work in paediatric emergency medicine and I just about get it.  Just.

I am frequently asked questions about what people (in both Primary and Secondary Care) should be doing now with regards to sepsis.  Everything seems to be changing so quickly that it is difficult to keep up.  As intelligent clinicians, we like to understand the reasons for change as well as what changes are occurring.  In the case of sepsis, research evidence is only part of the explanation for the changes that are happening.  That doesn't seem very reasonable but there are valid reasons.  As you're the one having to change your practice, it's probably time that you received a full and honest explanation for why you should do this in the absence of robust evidence.

Sepsis has always been with us.  We might have changed but sepsis has always been the same - a dysfunctional response to infection, manifesting as an exaggerated response to the illness or as organ dysfunction.

Some things have changed in our understanding of sepsis, while other aspects remain frustratingly beyond comprehension.  What we know and what we don't know are key elements to understanding the evolving approach to paediatric sepsis.

What we know:
  • Sepsis carries a high morbidity and mortality
  • Early treatment with antibiotics reduces morbidity and mortality
  • Undertreatment of sepsis increases morbidity and mortality
That's about it for what we know.  It's a short list.

What we don't know:
  • We don't have a good definition of sepsis in children.  The Third International Consensus Definitions for Sepsis and Septic Shock (1) gave a definition of "life-threatening organ dysfunction caused by a dysregulated host response to infection."  This is in many ways spot on but at the same time suitably subjective so as not to be specific when it comes to a clinical decision.  The other commonly used definition of SIRS (systemic inflammatory response syndrome) is very specific (if you have an abnormal temperature and tachycardia, you fulfil the SIRS criteria) and has the opposite problem.  It is very prescriptive and very often wrong.  Hot, tachycardic children are not hard to come by.  A few of these will have sepsis but most will not.
  • We don't have a good way of deciding if a child has sepsis.  Various approaches have been tried.  Decision tools have always been hampered by poor sensitivity and specificity.  No blood test or combination of blood tests has been found to be reliable either in the ruling in or ruling out of sepsis in children.  If there was a reliable method we would all be using it. Telling the difference between a febrile viral child and a child with early sepsis is as much of a challenge now as it was in years past.
Image taken from with kind permission from Damian Roland.
  • We don't know the impact of the various paediatric decision tools that have been introduced in recent years.  In an attempt to improve the recognition of sepsis, there have been many campaigns, guidelines and decision tools landing in your inbox over the past few years.  Driven by the fact that sepsis is often diagnosed late and that the consequences can be fatal, these initiatives inevitably push for increased diagnosis, using a lower threshold. Increased diagnosis can only be through a lower threshold at the moment, since we have failed to find a way to improve sensitivity and specificity together.  What nobody knows is whether this move to a lower threshold is having a positive or a negative effect.  If for every case that is diagnosed earlier, 1000 have unnecessary treatment (totally made up numbers of course), is the overall effect good or bad?
  • We don't know how many cases of sepsis can be diagnosed earlier.  The main problem of course is that retrospective analysis of cases of paediatric sepsis are inherently flawed.  The outcome is known, therefore all tachycardia becomes evidence of sepsis, despite the fact that other causes are possible.  Most children who present with sepsis will have had one or more contacts with a clinician in the days preceding their diagnosis of sepsis.  In some cases the symptoms will have been due to a viral infection which preceded the sepsis and in other cases the symptoms may have been due to the developing sepsis.  It is rarely possible to be certain which of these was the case.

It is therefore with a large number of uncertainties that we go forward.  There is no doubt that we are getting better at treating sepsis, but recognising it remains an area that we have a serious amount of work to do.

So why have we changed practice in the absence of evidence?  The answer is that, although we are all coming at the problem from a different point of view and with different agendas, we all want to do this better.  With the evidence pointing towards a benefit from early recognition and more aggressive treatment, changes are afoot to try to achieve these outcomes.  We need to alter our perspective and awareness of the problem of sepsis even if we do not yet have the answer to the question of how to better recognise it in children.

How should I change my practice?

Taking Damian Roland's sepsis spectrum and simplifying it, there are three clinical scenarios that I think are generally true by the end of consultation with an ill child.

Scenario 1 - the child with a febrile illness who has demonstrated their wellness to the point that sepsis is extremely unlikely

For these children, we should no longer be talking in terms of them having 'just a virus.'  They have a virus and they have no signs of sepsis, however, they are now in a group that is at risk of developing sepsis.  Worse still, if sepsis should develop, the signs might not be recognised as they will be attributed to the viral illness.

What should now be standard practice is a safety-netting conversation at the close of the consultation which makes clear what the red flags are and when to seek further assessment or advice.  Parents should feel that they are empowered to seek this without fear of being seen as over anxious people.

Scenario 3 - the child who appears to be seriously unwell

If you work outside of a centre which has acute paediatrics, get them there.  If you are the person at the other end, make sure that the child is seen quickly, a decision is made to treat ASAP and that there is no delay to treatment with a full Sepsis 6 bundle as appropriate.  These children might have had multiple cannulation attempts over a long period of time in the past, but now it's time to get out that drill.

Scenario 2 - all the children in between 1 and 3

In between those two set pieces is where we make the big decisions and make them very carefully.  As mentioned above, there is no good decision tool available, no test and no easy answer.  Decision making in these circumstances is complicated (2) and the explanation of how these decisions are made cannot be oversimplified.

What can be simplified are the guiding principle for assessing these children who occupy the uncertain zone.
  • Gut feel is an important part of the decision making process.  This means that you should listen to your gut feel and to the anxieties of the parents and your colleagues.
  • Persistence of abnormal signs is concerning.  While signs (heart rate, level of activity) fluctuate significantly during an uncomplicated viral illness, children with a significant infection tend to be persistently unwell.  Persistent tachycardia, tachypnoea, lethargy or other signs of illness should be taken very seriously.
  • No one factor will give you the answer.  Making these decisions would be a lot easier if there was a solid rule.  Can you send someone home with a pyrexia? Often.  Can you send someone home with tachycardia? Sometimes.  
  • You can only work with the information that you have.  What do I do if it is 2am, the child is asleep and is suitably grumpy when woken?  In this situation, the doctor-patient banter that I rely on to rule out sepsis is not available to me, so I am forced to look at all the other information that I have.   Admittedly, I look at it very carefully before making a decision.  I can only work with what I've got though and I'm not going to keep the child till morning just to tick the "I've seen them smile and run around" box.
  • The sepsis assessment never ends.  If the initial assessment leaves uncertainty, there are several options including referral, observation and discharge, depending on the degree of suspicion.  In all of these cases, we need to be clear about the need to take persistent, worsening or new symptoms seriously. 

Early sepsis is difficult to detect, so we need to use every tool available to us to make sure that the diagnosis is made at the earliest possible opportunity.  Until we have something better, creating that opportunity means as many clinical assessments as needed depending on the scenario.

What has changed over the past few years?  Hopefully we have.  We now better recognise the importance of early recognition of and immediate treatment of sepsis.  What we shouldn't forget is that while we have set rules for ourselves that achieve the latter, we haven't yet found a way to consistently do the former.  So that leaves us with a need to do what we can to make the best clinical decision possible for each of our patients, while being patient with the academics who will hopefully one day come up with a magic test.

Edward Snelson
Medical Historian or Historical Medic?

Disclaimer - very little research into the actual history of sepsis went into this article.  By little, I may mean none.  Still, the leeches bit is probably true.

The paediatric orthopaedic surgeons from Sheffield Children's Hospital would like to invite questions about children's orthopaedic problems from the Primary Care community. We will be publishing the questions and answers in a GPpaedsTips post in the near future.  If you have anything that has always confused you; if you have a niggling doubt about the need to refer a problem; if you want to know what they do with a certain condition, send me your questions.  You can do this by posting as a comment below, via a twitter message to me or via Facebook.
Please note that this Q&A session is for clinicians only and the only questions that will be entertained are generic questions. In other words, something like "Can the orthopaedic team help a child with Osgood Schlatters or should we just manage them in General Practice?" is perfectly acceptable. "My child has zika virus in their left wrist and I wanted to know..." is not.

  1. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), JAMA, February 23, 2016
  2. Roland D, Snelson E ‘So why didn’t you think this baby was ill?’ Decision-making in acute paediatrics Archives of Disease in Childhood - Education and Practice Published Online First: 01 March 2018. doi: 10.1136/archdischild-2017-313199

Thursday, 15 February 2018

Adding my uncertainty to your uncertainty – how to decide when there are conflicting signs

It’s always nice when a clinical assessment ends with a clear way forward.  If a child presents in the community with a severe exacerbation of asthma, there are clear guidelines for pre-hospital treatment and referral.  There is usually no dilemma in what to do if a child presents with fever and signs of meningitis to Primary Care.  Similarly, it is usually obvious what to do with a child brought with signs of an uncomplicated viral upper respiratory tract infection.

What is more challenging is when a child has conflicting or paradoxical signs and symptoms.  This is especially true when all the evidence points towards an illness that can and should be managed in Primary Care, yet one small piece of information is inconsistent.  What should you do with that?

Let me give an example:
A four year old boy presents with a history of diarrhoea and vomiting for 24 hours.  It is now 6pm.  The history of the illness is typical of a straightforward viral gastroenteritis.  The child looks well and is alert, interactive and surprisingly willing to mobilise when he spots the toys available.  He has wet mucous membranes and has no signs of dehydration.  Abdominal examination is normal as is the rest of his systemic exam.  All physiological observations are normal.  There is an unexpected snag: the parent with him reports that he has not passed urine since he went to sleep the previous night. 
So, with all but one piece of information in favour of a pathway that involves symptomatic management and oral hydration, what should one do?

Should this child be referred to Secondary Care?  I think you will get different answers from different people for this kind of situation.  On one hand the reported lack of urine output is a clear red flag.  On the other hand it is completely at odds with the wellness and clinical hydration of the child.  The child could be referred, but would that change anything?

There are many reasons for referring a child to Secondary Care.  I the initial examples, the reason is for undisputable and necessary management.  If the child is referred in the case of the paradoxical urine output, there may be an assumption that someone in the hospital will be better able to make a decision than the person making the referral.  This may or may not be true.  If it is true, it is probably not because they will have further information that could not have been obtained by the referrer.  It is probably not because the person receiving the referral has some sort of child assessment super power.  They may not even have more confidence in their gut feeling (that the child is fine and can safely be managed as an uncomplicated gastroenteritis) than the referrer.  What they will mostly have is their uncertainty to add to the referrer’s uncertainty.

Let’s say that you do refer this child.  Let’s assume that I see them shortly after you have seen them and that nothing has changed apart from the child having a bit more to drink in the meantime.  I now have the same information that you had and the same dilemma: to go one way or another.  I can do blood tests and consider intravenous fluids, but my gut tells me that this is an unnecessary torture of a child best managed with analgesia and oral fluids.  I could give symptomatic treatment advice and safety-netting advice and send them home but that is difficult to justify in the face of the reported anuria.  I could keep them for observation, but what would be the end point of that or the purpose.  If I am confident enough to do no active management in hospital, why am I keeping them?  Observing moderately unwell children while awaiting an expected move towards wellness is one thing but observing a well hydrated and clinically well child to prove that they are going to pass urine seems to have little value over allowing the same outcome at home.

When faced with conflicting information, it is important to have a way of deciding which information carries more weight and has more validity.  In ill children, it is often useful to categorise according to effort and efficacy. 

Effort is the body’s way of responding to illness.  There is usually some sort of physiological response to illness which is often a way of compensation for an effect of the illness.  Efficacy is everything to do with the end point of how effective the increased effort is.  In other words effort tells you that the child is trying to cope with an illness and efficacy tells you if it is working.  A good example is the happy wheezer.  If an infant with bronchiolitis has an increased respiratory rate, that tells you that there is some effort to compensate for what is happening in the chest.  The smile tells you that this is being effective.

Inevitably, efficacy is more important than effort when it comes to clinical decision making.  It’s not that the compensatory efforts should be ignored, it’s that the effect of that effort is of greater importance. 

So in this case, I would say that whatever is happening with this gastroenteritis, all the evidence that I can see tells me that it is having the desired effect.  The child is well and has no signs of dehydration.  Even if we were to believe the lack of urine output (and to disbelieve is not to disbelieve the parent) then a reduced urine output would be part of an effort to appropriately retain fluid during an illness.  I’ll say that is being quite effective in this case.

Do I have any niggling doubts?  I am certainly not dismissive of the contradictory report of anuria.  I am aware of my own fallibility and would only chose to ignore the lack of history of good urine output if I felt that to do so was in the child’s best interests.  In short, I would love complete certainty but I’m not being given that so I can either make a decision or find another way.  What I don’t want to do is a test or treatment that I don’t believe in.

But it isn’t strictly true that I’m no further forward than the referring clinician.  After all, I’ve got their uncertainty to add to my own.  If I’m lucky, it will be clear from the referral that when you referred this child for further assessment, you were very happy with the hydration and general wellness of the child.  You, like I am now, were perplexed more than concerned by the lack of history of passage of urine.

I have no super-powers and no particular clinical skills that you don’t have.  I am also lacking a 100% certainty about this case, but it’s time to make a decision.  Adding my certainty to your certainty means that between us we are 198% certain that there is nothing about this child requiring a blood test or a night on an intravenous infusion.  Let’s go with that then shall we?
There’s nothing wrong with referring a child for a further opinion when there is some uncertainty about the best management.  It is particularly helpful to know what the opinion is along with everything else in the referral.  That way I know that my uncertainty is the same, which in itself is useful information.

There’s also nothing wrong with trusting your assessment, in the knowledge that in secondary care we may well have little to add other than another appraisal of the same paradox.  Of course there is always the phone call to discuss the uncertainty.  How much fun would that be?

Edward Snelson
Medical astrologist

Disclaimer: I'm not even certain what I'm disclaiming.

Wednesday, 31 January 2018

A genuinely useful test - Blood sugar in acutely unwell children

When your patient is a child, the decision to do investigations is a complex one.  On one hand, it is often the case that at the end of history taking and examination there is some uncertainty which tempts the clinician to gather more information in the form of tests.  Parental anxiety might seem to be best managed through investigations either to demonstrate normality or to show that concerns have been taken seriously.

The reality is that these reasons for doing tests are all dubious and can achieve the opposite to the desired result.  There are few paediatric medical problems for which a test is more valid than clinical assessment.  For example, upper respiratory tract infections - If the symptoms are all well controlled by simple analgesia, what useful information could tests add?

Worse still, many tests are potentially misleading or might cause anxiety.  I like a full blood count as much as the next medic but goodness me don't they have a lot of information in them?  Does it mean something when the lymphocyte count is just below the reference range if the total white cell count is normal?  Sometimes the result can be alarming.  "Toxic lymphocytes" are a good example of something that you don't want to get on the lab report, especially when the child is climbing up the shelves in your consulting room while you try to work out how to answer the question, "Was the blood test result normal?"

But it's not all me, me, me.  The truly difficult part of all of this is that we should not use tests to reassure.  No matter how much another person wants a child to have a test for their own reassurance, we should only be doing tests which are in the best interest of the child.  Although a tough rule to live by, it is important to remember that the child is the patient, not the parent. 

The good news is that tests rarely tell you something of great value once a child has been clinically assessed.  Tests are most useful when they give you a number which has a clear clinical significance and where you could not have made a diagnosis without that test.  This criteria applies very nicely to testing blood sugar for an acutely unwell child, in certain curcumstances.  

Here are two cases where a simple skin prick glucose test has made all the difference:

Case 1

A three year old boy has been vomiting and febrile for 24 hours.  Clinically they are not dehydrated (they have wet mucous membranes, normal skin turgor, their eyes are not sunken and they are passing urine reasonably well) and they are neither septic nor meningitic.  In fact what is odd about them is that they seem subdued and grumpy despite having a normal heart rate and normal temperature.

Blood sugar is tested and found to be significantly low.

Why do unwell children get low blood sugar?  This happens for one of two reasons.  The most common reason is that the child has exhausted their available supplies of glucose.  The child's body has a limited reserve and if consumption exceeds supply then the child will eventually run out of glycogen, the most readily available way of mobilising energy in times of need.

The second possible reason is that the child has a metabolic problem.  Some children have a disorder in their metabolism which is normally masked by the almost constant supply of carbohydrate that they receive.  When this supply is interrupted, it unmasks the fact that one of the chemical pathways (needed in times of crisis) is faulty.  No plan B, no blood sugar.

How do children with low blood sugar look?  The brain is a complicated thing but it runs on two main things: oxygen and sugar (or backup substances but let's keep this simple).  If a child has a low blood glucose then the first signs are usually neurological.  Most commonly the child is not fully alert and is often unhappy.  I believe the term is hangry.  They will be less active but they may also be combative.

How should low blood sugar be treated?  The first thing to mention here is a pitfall.  Do not use glucagon to treat hypoglycaemia in children when the reason for their low blood sugar is that they have run out of reserves.  It simply won't work.

If the child is able to swallow safely, they can be given a sugary drink.  If not then what happens next depends on where you work.  If you are outside of a hospital setting, then a glucose gel rubbed into the oral mucosa will be a good plan.  In hospital, most places will give an intravenous bolus of dextrose 10%.  (ALSG recommends 2ml/kg) When the cannula goes in, there are usually some blood tests that need to be taken, depending on local guidelines.

The response to initial treatment should be assessed and further intervention given as needed.  If there is a good response, it is important to realise that this is not 'job done'.  To become hypoglycaemic, the child had to have exhausted their reserves, so a single bolus will have a very temporary effect.  It is essential to continue the carbohydrate supply, often in the form of maintenance intravenous fluids.

Case 2

A 5 year old girl presents with abdominal pain and vomiting.  They started being non-specifically unwell two days ago.  Yesterday they started having abdominal pains and overnight they started to vomit.  The child is drinking well and passing urine.

The child has no significant past medical history.  On examination the child is subdued and miserable.  The abdomen is soft.  The child is tachycardic but has a normal temperature.

When a blood glucose is checked, it reads three times the upper limit of normal.

Why do children get high blood sugar?  Although any significant illness can cause a moderately raised blood sugar level, hyperglycaemia of this magnitude always means diabetic ketoacidosis. (Well, that's not strictly true.  Occasionally it means that there is sugary residue from a drink or snack on the finger that was tested.  That's why you need to clean the finger first.)  Of course, it is possible (and preferable) to make the new diagnosis of type 1 diabetes before it gets as far as DKA.  If the blood sugar is high, type 1 diabetes should be the presumed diagnosis.

How does diabetic ketoacidosis (DKA) present?  DKA is a difficult diagnosis for all sorts of reasons:
  • Symptoms are somewhat non-specific.  Abdominal pain and vomiting are good examples.
  • DKA is rare and gastroenteritis is common
  • Clinicians tend to check that a child is drinking and passing urine enough, but may not ask if oral intake and urine output is excessive
  • The onset of symptoms can be surprisingly gradual.
  • While less common, type 1 diabetes can occur at very young ages.  Unsurprisingly, it is not the first diagnosis that people think of when seeing an unwell young child.

Most commonly, the illness is initially mistaken for a viral URTI or gastroenteritis.  Polyuria and polydipsia are unusual symptoms in a child with a viral illness who is significantly unwell and should be major clues.  Abnormal breathing is a feature of the acidosis and should also prompt the clinician to think of DKA.  However there is one feature that rather tidily applies to both high and low blood sugar: the child will be subdued and lethargic.

How should DKA or newly diagnosed type 1 diabetes be treated?

This is fairly specialised stuff so these children will all need to be referred.  The acute management of DKA is rather complicated and requires careful fluid management to reduce the risk of developing cerebral oedema.  According to the NICE guidelines (1), fluids should be the priority for the first 1-2 hrs after which insulin can be started for DKA.

As tests go, blood glucose is much more useful that many, and the result and meaning are usually clear.  Blood glucose is a test to go for in children who have atypical symptoms or are significantly subdued.  High or low, an abnormal result is a game changer and early recognition of the problem will make a huge difference.

Edward Snelson
Tricorder trainer

Disclaimer: While it would be wrong to do an unnecessary test on a child, it is perfectly acceptable to Feng Shui them. They then need careful monitoring to see the effect of the intervention.

  1. NICE guideline [NG18], Diabetes (type 1 and type 2) in children and young people: diagnosis and management

Thursday, 18 January 2018

Investigations in Bronchiolitis - Help a Brother Out

One of the things that a crisis should do is to bring people together.  As the UK's National Health Service experiences a winter that is bringing  it to it's knees, we should be more aware than ever that Primary and Secondary Care need to work together as a team so that we all come out the other end of this intact.  There are those in each camp that are so entrenched in the us-and-them mentality that this idea of teamwork is against  their very being.  If you think that General (family) Practitioners (GPs) are lazy idiots or you think that hospital doctors are arrogant and lack communication skills, I'm not sure that I've got anything to help you.  (Perhaps a hug?)  If you are willing to believe that we are all part of a team and that any divisions are both understandable and resolvable, read on.

The issues that cause division are (in my experience) usually due to misunderstanding and a lack of insight into the part that we play in creating these disparities.  The irritations that I cause my colleagues, whether in Primary or Secondary Care, tend to be completely unintentional.  Sometimes it can be what seems like the smallest thing and I have no idea of the impact it has on someone else.  That's why it's so important to talk to each other.

Let me describe an example: the seemingly simple act of requesting a chest X-ray for a baby with bronchiolitis.

Bronchiolitis is usually a set piece.  An infant, usually under 12 months old, gets inflammation in their airways during a viral respiratory tract infection.  This leads to a three to five day period of increasing symptoms that usually consist of cough, wheeze, difficulty feeding and increased work of breathing.  In practical terms, that might play out like this:

Monday - A three month old is snotty and coughing but well and feeding nicely.  Breathing will probably be normal at this stage.

Tuesday - The parents have now noticed some noisy breathing and that feeding isn't as good as it normally is.  like many people in these circumstances, they seek a medical opinion and so go to their GP.  They are seen and the diagnosis of bronchiolitis is explained.  The clinician advises frequent small feeds and gives safety-netting advice for what to look out for in case this child becomes one of the very small minority who develop breathing or feeding difficulties that require support as an inpatient.  In keeping with NICE guidelines (1), they do no tests and give no treatments.

Wednesday - The parents have noticed a slight worsening of the feeding and are unsure about whether this is bad enough to need something to be done.  They hold off doing anything during the day but when their baby refuses an evening feed they take their precious bundle to the local emergency department.  There the child gets a thorough assessment.  Clinically the infant is well hydrated and although they have wheeze and mild recession they are looking happy and have oxygen saturations of 95% in air. Despite the earlier feed refusal, they now take 100 mls of milk. The assessing clinician hears a few crackles in the chest and decides to do a chest X-ray, just to be sure that today's worsening symptoms are not due to a bacterial pneumonia developing.

When is it necessary to do a chest X-ray for babies with bronchiolitis?

There are many possible complications of bronchiolitis.  In theory, these should be apparent on a chest X-ray.  There are also conditions that mimic simple bronchiolitis, most notably congestive cardiac failure.  So, a chest X-ray seems a sensible thing to do to add value to the assessment.  Except that it doesn't, for two main reasons.

These are the reasons why a chest X-ray doesn't add value to the assessment of a typical presentation of bronchiolitis:

  • There is always something to be seen on the X-ray.  If you are looking for normal, you are unlikely to find it.
  • If the infant has bronchiolitis, that is enough explanation for their clinical condition.  If they had a complication such as lobar pneumonia as well, you would't be doing the chest X-ray to see if there is a problem, you'd be doing it because the child is seriously unwell.

Coming back to our little one with bronchiolitis, let's assume that the chest X-ray shows what it always shows in bronchiolitis - something of uncertain significance.  There will be a little fluffy shadow somewhere due to the mucous plugging and atelectasis that is part and parcel of bronchiolitis.  Often, there is something to be seen at the right heart border (or as a wise radiologist once redefined for me: "the area of radiological romance") which may or may not be something.  Once seen, it is very difficult not to feel the need to treat for possible bacterial infection.  This brings me on to the next few reasons for not doing a chest X-ray.

Doing a chest X-ray in bronchiolitis is associated with increased antibiotic prescribing rates.  Bacterial superinfection in bronchiolitis is rare and is usually clinically apparent.  Bronchiolitis is reason enough to have respiratory symptoms.  If a baby also develops pneumonia, they are usually quite unwell and have a marked degree of distress.  So, following that logic, for our baby the antibiotics are simply unnecessary, in which case they may do harm.  Since one of the problems that comes with bronchiolitis is feeding and hydration, why give these babies a gastric irritant?

Finally, there is a second victim here: the clinician who saw the baby on Tuesday.  Despite sterling work by the GP, the parents are likely to believe in retrospect that they were given a poor service.
All the evidence is there:

  • The person that they saw in the community did nothing and their child became worse.  
  • The experts in the hospital did a test which showed that their baby needed antibiotics.
  • Antibiotics were given and eventually the bronchiolitis got better. 

Why didn't the GP do something when we went the first time?

Of course both clinicians in this story were trying to do their best for the patient.  Neither of them had anything on their mind other than trying to ensure the best outcome for the child. There was no disrespect intended and no one wanted to cause anyone any problems.  We are all just trying to get through the day and to keep our patients safe and well.

Thankfully, it turns out that in bronchiolitis, keeping your patient safe and well is probably best done without the use of chest x-ray and antibiotics.  So, we in Secondary Care can help our colleagues in Primary Care out by making the assessment that needs to be made: in or out (of hospital)?  That decision is made on clinical grounds and if they need to be admitted, a chest X-ray may be useful.  Maybe.

Edward Snelson
Vice President of the Guild of Doing as Much Nothing as Possible

Disclaimer:  I did a chest X-ray for bronchiolitis once.  There was a white patch at the right heart border but it turned out to be tippex on the screen.


  1. Bronchiolitis in children: diagnosis and management, NICE guideline [NG9] Published date: June 2015

Tuesday, 5 December 2017

Something Old and Something New - Social Media and Young People's Mental Health

And now for something completely different...

While we tend to associate winter with infections and respiratory complaints in children and young people, it is also a time of increased mental health problems in young people.  It is often asked, "Is there a genuine rise in mental health problems in young people?  Are we just recognising it better?  Have we simply moved the goalposts so that what was once called normal is now labelled as mental heath problems?"  There has been an apparent increase in mental health problems in young people in the UK according to the best evidence.  Various factors are thought to be contributing, and the rise of social media use is one of these factors.

Allow me a story to give some context to the world in which we now live.  Since we are currently within the centenary of the first world war (WW1), this story I'm going to tell you is one of modern times.

Three months after the outbreak of WW1, a German warship, the SMS Emden, had been causing havoc in the Pacific.  She had captured or sunk ships running into double figures and the captain decided that it was time for the ship to have some repairs and the crew to get some shore leave.  He steamed into the island of Diego Garcia, which was at the time under the control of the British.  Despite being three months into a war between these two countries, not only was there no resistance from the British garrison but the local force welcomed the cruiser, helped with the repairs and presumably made them all tea.  Why?  Because the British Garrison didn't know that they were at war.  No information about the hostilities between the two nations had reached them.  True story.

Fast forward a few generations and think about the world that our young people live in.  Everything is fast, if not immediate.  Everything comes with an expectation (I know what a few dozen people think about the next hotel I'm going to stay in) and gets rated and reviewed.  One of the problems of modern times is that this is happening to our young people, not just to hotels and restaurants.  they are themselves being rated and given instant, sometimes brutal feedback every time they go online.

One of the known risks to mental health is any detrimental effect on self esteem.  If the world tells  a young person that they should be thin and beautiful and rich often enough, this has an effect on their self esteem.

Another problem that comes with social media is that it is a fickle friend.  Young people need to feel accepted or validated as part of a healthy psyche.  When something brings you down, it helps to have a solid person in your life to let you know that you are an OK human being.  Social media has made it possible for young people to be connected to hundreds of others.  The trouble is that what these 'friends' or followers say or don't say can be detrimental. Online interaction can be any degree of unpleasant and all varieties of negativity are seen in various forms.

Social media gives you a value.  How many online friends do you have?  How does that compare to other people?  How many 'likes' did your latest selfie get?  Why so few when someone else in your class got 300 likes?

The online world brings a great deal of opportunities for young people but it also brings risk.  If a young person is vulnerable to mental illness, then the negative effects of social media can be the trigger. (1)

What can be done about the risk?  If a young person is showing signs of mental health problems then we need to be able to offer helpful advice.  The debate about how to intervene is never-ending.  This week, Facebook was in the news for its new under 13 year old version of Messenger, which Facebook is currently testing.  Facebook argue that since 12 year olds simply pretend to be older online, it is preferable to have a safer version of Facebook, specifically designed for this age group.

Most discussions around the issue of social media and the risk to young people's mental heath centre around parental controls and managing the media.  Another way to approach the issue is to concentrate on everything but the social media itself.  Emphasise everything that is likely to have a positive effect on that young person's mental health:

  • Stable relationships
  • Positive family interaction
  • Affirmation
  • Participation in hobbies and sport

Many parents and carers find that it is an impossible or divisive task to police and interfere with a young person's social media use.  Parents need to know that they can intervene positively in their child's social media use.  However, if that seems to be exacerbating any stresses, it may be more constructive to fill the voids in that young person's life with things other than social media.

To return to the original question, mental health problems in young people do appear to be on the rise.  Recognition of mental illness is just one of the challenges that we face.  Prevention and treatment are seemingly unachievable within the resources available, however we need to take the issue of mental health as seriously as we do any other group of  childhood illnesses.

It is probably unnecessary to get caught up in a debate about whether social media is to blame for the rise.  Adolescence is a time of emotional vulnerability and any trigger can be to blame for a mental illness.  The negative effects of social media are one possible trigger.  We need to be aware of this and share this knowledge with families who present with concerns about the mental health or an adolescent.

Edward Snelson
Looking for validation elsewhere thankfully

Disclaimer:  Rather than my usual nonsense, I would like to allow myself a serious footnote.  Over the time I have been writing GPpaedsTips, I have noticed what gets the most and the least attention.  If I was to maximise the numbers of shares and clicks, I would never mention mental health ever again.  Although we should indeed be interested in treating asthma and sepsis, suicide remains a leading cause of death in young people (2) and the impact of mental health problems in adolescence is massive.  Although I wouldn't normally ask, please share this post.  How else will I be a valid person if I don't get enough likes?  If I get enough clicks on this post, I promise to write about sepsis next time.
  1. O'Keeffe, G. et al, The Impact of Social Media on Children, Adolescents, and Families - Pediatrics April 2011, Vol 127, Issue 4
  2. Pearson. G et al, Why children die: avoidable factors associated with child deaths, Arch Dis Child (2010). doi:10.1136/adc.2009.177071

Thursday, 23 November 2017

Is Montelukast Too Easy?

How much does the acceptability of a treatment matter when compared to the efficacy of that treatment?  This is a decision that we all make, consciously or unconsciously when prescribing for children.

For example, ten to twenty years ago, it was not uncommon for children to be given salbutamol in a liquid preparation.  The decision to give this preparation (rather than via MDI and spacer) probably went something like this:
  1. A very small person is wheezy
  2. A parent wants a treatment for the wheezy small person
  3. It is difficult to give inhaled bronchodilators to small people
  4. There is a liquid preparation of salbutamol available
At the time, there was probably also an element of inertia which came from the era before the invention of the spacer.  Until spacers came on the market, liquid preparations were the only option for young children.  So despite the change in what was available, it is not surprising that some continued to use what  they had used previously.  Now, I never see children on salbutamol syrup.  Inhaled therapy is the best treatment option and ease of administration is overruled by the superiority of child-friendly spacer devices.

Ease of administration, acceptability of taste and lack of side effects all make a considerable difference to the effectiveness of medicines in children.  One of the most common examples of this is phenoxymethypenicillin, often used for suspected streptococcal throat infections.  It has a vile taste and is often rejected by the child after the first few doses.  It can't work if the child won't take it.  Fortunately it is often not needed, so it doesn't matter when the child votes with their feet.

By contrast, montelukast is one of the great success stories of child-friendly medicines of recent times.  It comes in a chewy tablet or sprinkles.  It's like being Dr Willy Wonka when you prescribe montelukast for children.

Acceptability is not the only factor when it comes to effectiveness.  There has to be a proven clinical efficacy.  Otherwise, montelukast becomes the salbutamol syrup of our generation.  Just because it's a medication for wheezy children doesn't mean it will work in every clinical scenario.  Just because it is easy to administer doesn't mean it should be the first line treatment.

A recent article in the Archives of Disease in Childhood (1) did an excellent job of exploring the evidence for montelukast as a treatment in the various phenotypes of childhood wheeze.  This was no mean feat considering how many there are and that these phenotypes are variously defined and hotly debated.

Here is a summary of what they found:

Bronchiolitis* and montelukast

Unsurprisingly, montelukast can be added to the list of things that don't work when a child under the age of two has wet, inflamed airways (without bronchospasm).  No doubt we will coninue to look for an effective treatment but so far nothing has worked.  The management of bronchiolitis remains the art of doing as much nothing as possible, while knowing exactly when to do something.

* Bronchiolitis is defined slightly differently in the UK  to the USA.  In the UK, it is mainly infants under the age of 12 months with wet lungs of viral aetiology who are given the label bronchiolitis.  In the USA, the definition includes young children with viral induced bronchospasm.  This is why the UK guidelines recommend that bronchodilators are not used, while the guidance in the USA is that they an be tried.

Viral Wheeze (Viral Episodic Wheeze) and montelukast

There is some conflicting evidence for the use of montelukast both as prevention and as rescue treatment for pre-school children who develop bronchospasm only when they get a viral URTI (i.e. no other triggers and no chronic symptoms).  However, a Cochrane review (2) did not find the evidence needed to support the use of montelukast as rescue therapy or as a preventative treatment for viral wheeze.  So it seems that it's not really useful for these children either.

Multi-trigger Wheeze (aka asthma in the under 5 year olds) and montelukast

If you weren't already aware, there is debate about whether children under the age of five should be diagnosed as asthmatic even when they have interval symptoms and wheezy episodes which are not exclusively triggered by viral episodes.  Some are calling this asthma and some call it viral wheeze.  Arguably, it doesn't matter too much what it is called so long as we use evidence based treatment and we avoid mislabelling children who do not fit this phenotype.  For example, it would be a mistake to say that viral episodic wheeze is the same as asthma since the latter benefits from inhaled corticosteroids (ICS) and the former does not.  With multi-trigger wheeze and asthma in the under five year-olds, we essentially have two names for the same clinical scenario.

The article in ADC notes that the BTS/SIGN guidance recommends leukotrine receptor antagonists (LTRAs) as the next step after low dose inhaled corticosteroids or as first line treatment where the ICS is not tolerated.

The authors go on to note that while there is good evidence for benefit in this group of children, the effects of montelukast are moderate and clinically inferior to ICS.  Also, there is no evidence to show that montelukast is effective above and beyond the benefit of ICS therapy.  So, if there is a treatment with good evidence for superiority, how badly does a child have to not tolerate that treatment before you reach for the next option?

Since effect and tolerance are both important factors in the efficacy of a treatment, we need to consider both factors.  Clearly if one factor is the same between two option, then the other is the deciding factor.  In the case of the asthmatic/ MTW three year old, you may be faced with a difficult choice:
  • Inhaled corticosteroids, which their parents are struggling to give
  • Montelukast which is clinically inferior to inhaled corticosteroids but which the child might happily take
If only we had a formula to help us decide...  So, I made one up.  After all, paediatrics is full of things that were invented by clinicians based on what they believed to be true.
So let's try this out.  Say that ICS therapy has a 90% likelihood of improving symptoms and that montelukast has a 20% likelihood.  Then say that parents will manage to give the montelukast every day and that they would manage to give the inhaled corticosteroids half of the time.  This gives us a BS cubed number of 0.11 for the steroid inhalers and 0.2 for the montelukast.

Although the formula is made up, the point is valid.  Efficacy and concordance are the key factors in determining effectiveness.  Since we can't change the efficacy of a treatment, we are only able to influence the concordance.  In the example given above, if we could improve the concordance then this is a complete game changer.  This is where a full team approach comes in.  The prescribing clinician can emphasise the superiority of ICS over other treatments.  The pharmacist can make a huge difference by a good explanation and demonstration.  This can all be reinforced by a practice nurse who reviews technique and encourages the use of the inhaler, giving tips and tricks about how to get the child to take their inhalers.

Persistence counts for a lot with inhaler therapies.  There are few (if any) children who immediately take to the idea of having a mask put on their face and few parents who find it easy to use the inhaler/ spacer combination well with a moving target to begin with.  In time, children come to accept that the inhalers will be given and parents usually find that giving them becomes easier.

If the easy treatment was also the most effective, that would be brilliant wouldn't it?  For some reason, that rarely seems to be the case.  Is montelukast too easy?  If it makes us choose it over trying everything possible to get the inhaled therapy to work, then the answer is yes.

So, choose the treatment with the biggest boom and maximise the sweetness of the delivery.  It that way, the child who will benefit gets the best possible treatment in the most effective way.

Edward Snelson
Order of the Philosophers of Mathematics

Disclaimer - although a made up formula, there is good reason for applying a factor to the concordance.  In very few cases does half the treatment have half the effect.  Small moves away from the centre of the therapeutic window of a drug make a very big difference to the effect that it will have.  I wanted to use a round number for simplicity but I would be willing to bet that the reality for most treatments lies somewhere between squared and cubed.  Wouldn't it be great if the answer was really that the factor was pie?

  1. Haq et al, Should we use montelukast in wheezy children? Archives of Disease in Childhood, October 2017
  2. Brodie M et al, Leukotriene receptor antagonists as maintenance and intermittent therapy for episodic viral wheeze in children Cochrane Database Syst Rev. 2015 Oct 19