Wednesday, 30 March 2016

Socrates to the Rescue - When "Why?" Becomes How to Recognise Child and Adolescent Mental Health Problems

How can a paediatric subspecialty be so difficult and shrouded in mystery?  Even the name, Child and Adolescent Mental Health Services, is complicated.

What do they do?  The mystery extends to the online world of open-access medical education.  Because I am putting together some resources for a university course at the moment, I went on my usual trawl for journal articles and online resources that might give me an idea about how we mere mortals should be doing our bit for child mental health problems.  Compared to similar advice for asthma, sepsis or even just the limping child, there is virtually nothing out there for the clinician who recognises child mental health as a personal educational need.

What to do?  Phone a friend.  Yes, I spoke to an actual person.  My expert told me that there are simple things that we can do to be a bit better at this.  We need to ask more questions.

In order to do this we must enter the mind of a two and a half year old...     ...or an ancient Greek philosopher.  You decide.

If you've never taken a two and a half year old for a quick jolly down to the shops then you've really missed out.  It goes something like this:

Socrates taught his students to question everything, including the answers to their questions.  In this way, the answer behind what was superficially apparent comes to you.  It's something that we all knew briefly when we were two and a half, but sometimes forget now that we are grown up and a bit dull.  What is superficially apparent can seem to be the end point, but in child and adolescent mental health, it probably isn't.

Let me apply Socratic (if Socrates was two and a half) method to some common presentations to General Practice or the Emergency Department:

A 12 year old has abdominal pains that only occur during school terms.
Obvious answer: School avoidance.
Ask the question, "Why school avoidance?" - Answer: Anxiety symptoms due to undiagnosed dyslexia.

A 13 year old is smoking cannabis every day.
Obvious answer: Bad parents and a chaotic home.
Ask the question, "Why?" - Answer: They have been having anxiety symptoms every day for nearly a year.  Months ago, they were given some cannabis to try and they found that it helped take away that feeling.  They started using it to feel more 'normal', not to get high.

A 15 year old has multiple symptoms for which there is no sensible medical explanation.
Obvious answer: Attention seeking
Ask the question, "Why?" - Answer: No obvious reason, so what else is going on?

The list of things that young people present with that are viewed as behavioural include cutting/self-harming and anorexia.  The reasons may be elusive, but they may also be identifiable.   There may be a safeguarding issue.  

Every one of these children deserve to have someone ask the question "why?"
In many cases they may not know why.  They may not be able or ready to articulate it even if they do know.  However, many young people can explain why they do what they do if someone is willing to give them a safe place to do so.

The important thing is to move away from making the obvious assumptions and instead always assume that there is more than meets the eye.  The evidence is that mental health problems in young people are often not recognised.

In Emergency Medicine there is a saying, "The easiest injury to miss is the second one."  That is equally true of child mental health. How do we make sure we always find the hidden problem? I don't know. Ask a two year old.

Edward Snelson

Tuesday, 15 March 2016

Croup - proof that a number is never enough information

Croup has to be one of the easiest upper respiratory tract infection diagnoses to make.  You can literally hear the child coming.  The classical croup picture is one of a child who has a cold for a few days and then develops a cough that sounds like a seal.  Although there are differentials listed in the textbooks these can also be excluded clinically:

  • Inhaled foreign body - has not inhaled a foreign body
  • Bacterial tracheitis and epiglottis - child does not look that unwell and is able to swallow their own saliva

So, it is a simple case of, "this is croup!"  The next job is that you have to ask yourself how bad the croup is.  The good news is that there are scoring systems available.  The problem with scoring systems is that they create the impression that the game is over.  It really isn't.

If you do use a croup score, you should see it for what it is: a snapshot which attempts to quantify what you see and hear.  As is often the case, these scoring systems are developed for the purposes of research and have been adopted into clinical practice.  It is equally valid to take the signs and symptoms and qualify these into a mild, moderate or severe croup.  You might find a scoring system helpful but it is not mandatory.  Whether you use a qualitative or quantitative method, the severity is only part of the picture.

One thing that guidelines often struggle to emphasise well is the importance of the trajectory.

All three children in the figure above have a Westley croup score of 4 when seen by a clinician.

Child A was found in the morning with a stridor and significant respiratory distress. As often happens, when the parents rushed the child to be seen, child A improved and now has the tail end of a soft stridor.

Child B was coughing, had a soft stridor all night and refuses to move out of croup limbo.

Child C was not so bad when they set off to see you but has got noticeably worse in the time leading up to the consultation. The game is just beginning for child C.
The score (or your qualitative mild/ moderate/ severe assessment) and the trajectory are the most important factors. I would also consider risk factors including co-morbidities and previous life threatening episodes of croup.

That brings us to croup management-

Turbulent flow of air creates more than twice as much resistance as laminar air flow. Children who have croup will tend to position themselves and breathe optimally if left alone to do so. Distressing the child either directly or via the parent can cause sudden decompensation.

If the child is in the severe category then facial oxygen should be given followed rapidly by nebulised adrenaline (epinephrine). Doses as per your formulary but at the time of writing that is 5mg for a child 2 and up where I work.  If not already at hospital, a child with severe croup should be moved there quickly. If already in an ED then the child may need further escalation but in many cases the adrenaline will buy time and avoid the need for airway management.

For mild and moderate croup the best evidence is for systemic steroids.(1)  There is evidence that dexamethasone is more effective than prednisolone.(1) Studies have also compared different doses of dexamethasone and found that there is no difference between giving the larger dose 0.6 mg/kg and the smaller dose 0.15mg/kg.(1) I have been using the lower dose for many years but have no hesitation in repeating the dexamethasone if the child vomits afterwards and it is uncertain as to whether the first dose stayed down.

Be warned, my GP land colleagues: dexamethasone liquid can be difficult to source from community pharmacies. NICE says that "Providers of urgent care services should ensure that dexamethasone is available."(2)  This may not be within your control.  Unless you know that your patients can get it easily, prednisolone may be the pragmatic choice.

I am very aware that treating mild croup is a relatively new phenomenon. If you fear change, please take comfort in knowing that I do too. However my dislike of medicalising childhood illnesses does not extend to croup. This is for two reasons. The first is to do with the aforementioned trajectory. I don't know which mild croups are going to become moderate or severe but some will and theses children may become victims of another fact of science.

The flow of air through a tube is reduced by the reduction in diameter to the power 4. If a child with croup gets worse and their airway haves in diameter then they will only be able to shift one sixteenth of the air. If that air flow becomes turbulent then you won't need a score to tell you how bad they are. So mild croup is not a thing to dismiss. It is level one of the game of croup. Level 1 is deceptively easy but unlike most games, level 2 is much harder and level 3 completely unexpected.

Edward Snelson

Disclaimer: It's not a game.


  1. Cochrane library review, Glococorticoids for croup
  2. NICE, Clinical Knowledge Summary for Croup

Wednesday, 2 March 2016

Asthma, Overdiagnosis, Underdiagnosis and all that

A storm is coming and it's set to be a force 10.  There is much debate about how asthma should be diagnosed in children.  There are two opposing views and (guess what?) they are both right.  This conundrum, which occurs whenever a diagnosis is complex, is always the perfect setting for the perfect storm as clinicians struggle with the "right way" to diagnose an illness.

This week an article was published in the BJGP, talking about the overdiagnosis of asthma.

Overdiagnosis is an issue close to my heart because it causes morbidity through tests, treatments and time spent being medicalised, none of which are necessary because the patient does not have the disease.  In paediatrics there is a particular tendency to overdiagnosis due to the lack of precise information (what does the abdominal pain feel like to a 2 year old? It would really help to know!) and the desire to make the child better.  Being cute will have that effect.

Of course overdiagnosis is also at risk of distracting from the real diagnosis, thus robbing the patient of treatment that would be beneficial.

The above mentioned article contains some results that will make most of us sit up and take notice. Set in the four Dutch primary care centres, they found that in "more one-half (53.5%, n = 349) of the children the signs and symptoms made asthma unlikely and thus they were most likely overdiagnosed."

Very well, so essentially this shows that when you apply a new diagnostic pathway (retrospective analysis of signs and symptoms plus a generous use of tests including spirometry), it disagrees with the old diagnostic pathway, which was presumably based mainly on history and examination.  That doesn't feel very applicable to the 'real world' of diagnosing childhood asthma in a front line clinical setting.  Well get ready, because your 'real world' may be about to be rocked.

Earlier this year, NICE published a draft guideline for the diagnosis of asthma, including children.  This contains one particular proposed recommendation that surprised me: "Do not use symptoms alone without objective tests to diagnose asthma. (in children from the age of 5)"  Boom.

So, a six year old comes in with an acute wheezy episode.  This was not triggered by a cold.  It started when they visited an animal shelter.  The child has eczema and the parents are both atopic. When you see them, the child responds to the salbutamol that you give.  In further history the parents had noticed that the child coughs at night quite a lot.  Time to do some tests?

I await the final version of the NICE guideline with interest.  Meanwhile I am a big fan of the British Thoracic Society guidelines which stratify into three groups - low, intermediate and high probability of asthma.  These guidelines list the features that make asthma more likely:
  • More than one of the following symptoms - wheeze, cough, difficulty breathing, chest tightness
  • Personal history of atopic disorder
  • Family history of atopic disorder and/or asthma
  • Widespread wheeze heard on auscultation
  • History of improvement in symptoms or lung function in response to adequate therapy.

And the features that make asthma less likely:
  • Isolated cough in the absence of wheeze or difficulty breathing
  • History of moist cough
  • Prominent dizziness, light-headedness, peripheral tingling
  • Repeatedly normal physical examination of chest when symptomatic
  • Normal peak expiratory flow (PEF) or spirometry when symptomatic
  • No response to a trial of asthma therapy
  • Clinical features pointing to alternative diagnosis

Testing with spirometry etc. is reserved for times of diagnostic subcertainty.

Does this approach lead to overdiagnosis?  I am sure that it does, for the reason that that children with intermediate probability of asthma still might not have asthma.  While tests can add to the available information, the diagnosis of asthma remains clinical.

So how bad is overdiagnosis?  If I could avoid overdiagnosis then I would, but in medicine that is just not possible unless there is a perfect test available.  In most cases we have to set ourselves the challenge of being rigorous with our diagnoses without being overcautious.  Cautiousnesses leads to underdiagnosis  which is also problematic, depending on the burden of the disease.  I am happy to overdiagnose sepsis in babies for example.  I know that the alternative is disastrous. I am equally happy to underdiagnose colic.  Colic is not harmful and there is no effective treatment.

When it comes to asthma, there is a huge morbidity and mortality associated with this disease.  So while I agree with the study authors about the burden of unnecessary treatment when a child does not have asthma, I believe that the effect of moving our diagnostic goalposts needs to be considered carefully.  Will there be more underdiagnosis as the pendulum swings away from making the diagnosis of asthma on clinical grounds?  That is a real possibility and as far as I can tell no-one has looked at the burden of that change.

The bottom line is that asthma is a diagnosis that can be overdiagnosed and yet underdiagnosis is equally detrimental.  However, without turning to complicated investigations, overdiagnosis and underdiagnosis can both be avoided by considering all the factors that make a diagnosis more or less likely as per the BTS guidelines.

Edward Snelson
Over and under most days

This post has been all about diagnosing asthma in the 5-15 year old age group.  If you would like to find out more about the under five year olds you might like to read:

  1. Looijmans-van den Akker et Al, Overdiagnosis of asthma in children in primary care: a retrospective analysis, BJGP, 1 March 2016
  2. Draft NICE Guideline for Consultation: Asthma: diagnosis and monitoring of asthma in adults, children and young people
  3. British Thoracic Society /Scottish Intercollegiate Guidelines Network - British guideline on the management of asthma (Quick Reference Guide)