Please Help
Me to Change My Practice
In January 2015 NICE published the first of their newly
branded ‘CG’s which happened to be Gastro-oesophageal reflux disease:
recognition, diagnosis and management in children and young people. I don’t know how you decide which NICE
guidelines to look at but my filter is based on relevance and the extent to
which they might make me cry into my coffee.
This one scored a 10, partly because I see lots of vomiting babies (with
accompanying parent – this is usually the one I’m more worried about) and
partly because we have known for a long time that the available treatments are
inconsistent at best. In the absence of
a guideline it is much easier to work through the various non-pharmacological interventions
and then take a stepwise approach to treatment, while hopefully the underlying
predisposition to create laundry and sleep deprive your parents gradually
resolves in time for me to take all the credit.
The truth is that when I see a child with reflux, things are
usually pretty desperate for the family.
They are tired, smell of vomit and feel that every time they see a
different doctor or nurse they are told something that contradicts previous
advice. I then find it difficult to
admit that the problem with which they present is going to follow a course over
which I have little influence. Certainly
I do make a difference where possible. I
explore the way that feeds are being given and often find that the volume of feed is
excessive. Occasionally I discover a
previously undiagnosed urinary tract infection and get to feel like a real
doctor. More often there is no easy
answer and I reach for my prescription pad to prescribe an alginate.
The thing is that NICE have now said that the initial
treatment should be a feed thickener if the child is formula fed. That should be a simple thing to change but
for me it isn’t.
From CG1 2015
From CG1 2015
I remember well how in
General Practice I used to do this process change. One day I would find out something, next I
would have a quick chat with my GP colleague and then I would get on and do
it. No major fuss. How things have changed. Now that I work in a hospital it takes months
to change most things. Certainly when
there is an urgent need we get that turned around much faster. (I won’t say how long faster is. It depends.) However if the change is less urgent it
requires consensus, consultation and committees to the Nth degree.
In the interest of balance I should extol the virtues of
this more cumbersome approach. It would
be chaos if there was no way of ensuring consistency of practices within the
various teams of any hospital. That
consistency only comes if guidelines are agreed and well governed. Achieving that sometimes feels ungainly but
is far better than conflicting practices within the same organisation or
changes that are ill thought through and are not universally agreed.
The good news is that in the case of these vomiting children
it hasn’t been a problem. The dilemma
that I might have faced was taken away because thankfully the last few children
that I have seen with gastro-oesophageal reflux were all being treated with
feed thickeners and not an alginate.
Since previously the latter was the norm I can only assume that these GPs have decided to lead the way. No
fuss, no committees and no delay. How
wonderful that GPs are playing to their strengths and getting on with changes
that take much longer for Secondary Care to implement.
So thank you for providing some true medical
leadership. For those of us working in
hospital, we need you in General Practice to lead the way for us. I’m sure we’ll catch up eventually.
Edward Snelson
Kiddie Doctor
@sailordoctor #GPpaedsTips
Disclaimer: All disclaimers are nonsense.
More treats from the Easter egg:
1) NICE doesn't want us diagnosing 'silent reflux' so much
2) Some red flags here suggesting that there may be another diagnosis or that the GORD warrants rapid referral
More treats from the Easter egg:
1) NICE doesn't want us diagnosing 'silent reflux' so much
2) Some red flags here suggesting that there may be another diagnosis or that the GORD warrants rapid referral
