Thursday, 25 August 2016

Hunting the focus of infection

Finding a focus for infection in a child is one of those things that we all know we ‘must do’.  That can be more difficult than it sounds.  Often, no focus is easily found and then the questions are, “Where do I look?  What if I can't find a focus?  I don’t know when to stop looking!”

How many children are seen with significant temperatures, where the eardrum is not easily seen?   On probability alone, the focus is more likely to be a hidden upper respiratory tract infection rather than something else.  Is probability enough to go on? 

Then there are the things that could be called a focus, but are rather soft signs.  Is a runny nose a focus?  If so, how high is the temperature allowed to be?  What about vomiting and diarrhoea?  Is that a focus in its own right?  You could throw that question out to an audience of primary and secondary care clinicians and I could guarantee that the conversation (if it continued in a way that could be called that) would go on for quite some time.  The outcome would almost certainly be that many would agree to disagree.

If you ask me, the answer depends entirely on the circumstances because the focus of infection is not nearly so important as the global assessment and the specifics of the presentation.  If a child presents early in an illness, is relatively well and has just got a runny nose, then that might be enough to go on.  Good symptom management and careful safety netting are probably the most important things in these cases.

Example 1
A 3 year old has a temperature of 38.2 at home.  They have a runny nose and a cough but no other symptoms.  They have no convincing focus of infection in their throat or ears.  Chest is clear and there is no respiratory distress.  Heart and respiratory rate are normal.  During the consultation, they are running around and playing with the toys.

Example 2
A 3 year old has had a temperature of 38 to 39 on and off for three days.  They have a runny nose and a cough but no other symptoms.  They have no convincing focus of infection in their throat or ears.  Chest is clear and there is no respiratory distress.  Heart and respiratory rate are normal.  They are alert but neither cheerful nor very active.  They have just returned from a three week trip to an area where malaria is endemic.

Who would like to accept the runny nose and cough as a focus in child 2?

So when do I need to find a focus?  Here are a few examples of circumstances in which I would want to have something that is fairly definitive:

My two top tips for finding a focus are:

  1. Repeat the ENT examination unless you have already had really good views of tympanic membranes and pharynx
  2. Check a clean catch urine sample

When deciding about how hard to look and how invasive the search should be, don't start at the beginning, start at the end.  The child in front of you and the clinical scenario determine what the hunt will involve.

Edward Snelson
Variable Venator

Thursday, 4 August 2016

What makes a GP a specialist? The Primary Care Super Power and why GPs are gods of child health

Three Tests That You Probably Don’t Need to do for Children in Primary Care

A couple of times recently, I have referred children urgently to their GP.  To some people, it might seem an odd thing for a Consultant in Paediatric Emergency Medicine to do.  Those people have not yet worked out what general practice excels in. 

Patients often attend the Emergency Department for a second opinion soon after seeing their GP.  This may be driven by the belief that the hospital doctors are specialists, while GPs are not.  Of course this is wrong.  GPs are specialists and generalists at the same time.  To be a specialist, you need to understand a topic or achieve a level of skill above that possessed by you colleagues in other branches of medicine.  Although General Practice’s greatest challenge is to know enough about everything (and that is enough of a feat), this is not the skill that makes a primary care clinician special.  Their ultimate skill is harm avoidance.

Having worked on both sides of the Primary-Secondary Care divide, I see how easy it is to treat and test, and test and treat.  GPs have an incredible ability to know what to do without tests and to do as much nothing as is appropriate.  In paediatrics, this makes GPs no less than gods of child health.

Children should not have tests done on them to reassure parents or provide thinking time for clinicians.  Tests in children should always be part of a coherent question.  We are making decisions on their behalf, so we owe it to them to avoid unnecessary pain, distress and anxiety.

So, as an offering to the gods, here is my list of three tests that I think are rarely indicated in children in a primary care setting.

1. Chest X-ray for children who ‘always cough’

CXRs are often done for two reasons. Firstly a normal CXR is perceived as a good way to rule out pathology.  Secondly the test may be done to reassure parents.

Unfortunately, the ruling out with CXR thing is much more adult practice.  The first question should be ‘is there a daily cough for several weeks?’ and then ‘is it getting better?’  However, in children these questions are more about deciding who to refer than to investigate in Primary care.  CXR is unlikely to be helpful in a child who has not developed symptoms that have landed them acutely at the doors of Secondary Care.  In fact, it may not even be normal in a healthy child.  As so many of these are done in a post-infective period, there are often streaks of something to be seen.  How then can we reassure the parents that all is ‘normal’?  I recommend watchful waiting for intermittent or resolving coughs, and referral for persistent and worsening coughs.

2. Full Blood Count for children who ‘always have infections’

Much of what applied in 1 applies again here.

I am going to propose a study into the sensitivity and specificity of FBCs in these children who are perceived to have a lot of infections.  I would guess that both are poor.  Again, the strength of General Practice becomes the answer.  Empirical evidence should win the day.  Is the child otherwise normal?  Are they growing well?  Do they get normal infections and then fight them off?  The answer is more likely there than in a blood test.

3. ECGs for chest pain and faints in children

Causes of chest pain and collapse that can be detected on a 12-lead ECG are relatively common in adults.  In children, chest pain is almost always non-cardiac and collapses are almost always vasovagal syncope.  Once again though, ‘abnormalities’ are commonplace on paediatric ECGs.  Usually these are due to age or habitus and should not be over interpreted.  The question, as always, is ‘does the symptom fit a benign cause?’  For vasovagal syncope, for example, were the three ‘P’s present? (Prodrome, posture and precipitant)  If there are red flags in the history, a 12 lead ECG is not reassuring since the event remains unexplained even if the ECG is normal.

I am not saying that these tests are worthless or should never be done.  They simply should not be done for the wrong reasons:

It is also important, before doing a test, to know what to do with borderline results or common ‘abnormalities’.

If in doubt, you can always call the relevant team and ask them if a test is useful or if the child will need to be referred regardless of the result.  If you don’t get a helpful answer, ignore them.  After all, you are the specialist.

I need to descend from Mount Olympus now and leave you to your excellent job of keeping children from harmful tests.  Now, where is that child I was seeing just now?  I remember now, they’re in CT…

Edward Snelson

Disclaimer - If you have a medical tricorder, you should definitely use that to do more tests.

This post was originally written for the Network Locums educational blog site.