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
@sailordoctor

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

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
@sailordoctor

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?

References

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

A Paediatric Guide to Anatomy (Things You Should Know about Constipation and Urinary Tract Infection in Children)

Last week, Norfolk and Norwich University Hospitals announced the opening of the UK's first Senior Emergency Department.  A Senior Emergency Department is much like a Paediatric Emergency Department, except that this one will meet the needs of patients over the age of 80, instead of those under the age of 16.  The concept is the same - there is a specific patient group with a different set of needs and who present in different ways to the rest of the adult population.

Children have been able to access paediatric emergency departments for a long time now.  Children benefit from a child-friendly waiting area, an assessment that recognises the way that children are different from adults and treatment by clinicians who are specifically trained in child health.  Perhaps that makes it all sound very exclusive and mysterious.  What are these differences of which you speak?  Well, none of them are a great secret, but as is often the case, having something explained often helps it to be understood better, even if you already knew it.

So, here's something that you probably already knew, but was a fact that you hadn't necessarily known what to do with: Children have a considerable lack of body awareness. 

A child's approach to anatomy and physiology is fairly simple:  I eat, I wee and I poo.  I pick things up if I want them.  If I want to do any of those things in a different location then I move.  If the world isn't the way I want it to be, I make noises.

One of my top tips when teaching paediatric clinical examination is that children don't have a chest before they go to school.  To them, the space between mouth and stomach is presumably some sort of giant food processing area.  Functions like breathing and circulation only truly become a reality when a child is much older.  For that reason I never tell a young child that I am going to listen to their chest.  It only confuses them if you say that.  I tell them I am going to listen to their tummy and tell them what I can hear.  Usually, the answer is sausages.

Besides helping me to know what to say to children, my knowledge of their lack of body awareness is crucial when it comes to understanding visceral presentations in children.  The important thing to understand is that children seem mostly unable to recognise the significance of visceral symptoms.  In other words, the feelings in their bowel and bladder either make no sense to them, or they are unable to articulate these feelings.  For whatever reason, young children have a tendency to leave bowel and bladder symptoms unreported, and so the presentation of problems such as urinary tract infection (UTI) and constipation are always delayed.

Take this case history example:
A two year old child presents with a 12 hour history of dysuria and frequency of urine.  They have no fever or abdominal pain.

Well, that's all very well, but that's just not how it goes.  Let's try something more realistic:
A two year old presents with a three day history of fever.  The child first presented two days ago and was diagnosed as having viral gastroenteritis.  The child is vomiting intermittently.  There is no blood or bile in the vomit.  The child does not have diarrhoea.
Today the parents have noticed that their child is more unsettled and they think that the child has abdominal pain, although the child has not specifically said that their tummy hurts.

Why is it important to recognise this peculiarity of children?

The first reason is that we need to be aware that UTI is a diagnosis that we have to actively  seek in children.  UTI in younger children does not have specific (urinary) symptoms.  Instead, all of the features are those also found in the more common viral infections such as gastroenteritis or URTI.

This does not mean that all unwell children should have a urine tested.  Routine testing would be great if it were painless for the family and the clinician.  Neither of these things are true.  Getting an uncontaminated sample (a 'clean catch') is hard work much of the time.  Interpreting the results and making sense of conflicting information is a challenge once a sample is obtained.  For that reason I would not routinely ask for a urine sample in a child who has an obvious otitis media for example.

The things that make UTI more likely in children include:

• previous UTI
• abdominal pain/ tenderness
• vomiting without diarrhoea
• a report of odd smelling urine
• absence of signs or symptoms of URTI
• new urinary symptoms (enuresis, dysuria)

The second reason is that we need to be aware that both UTI and constipation are likely to be well established by the time they are diagnosed.   This means that in children, we have to take each of these diagnoses a little more seriously.

Although most children with UTI are well at presentation, they probably have an infection that is a little more than what would be considered cystitis.  They may not have a proper pyelonephritis yet, but they are likely to have a more established infection than a young adult would have.  It is for this reason that we need to make sure that we do pick up a diagnosis of UTI as early as possible.  Every day left untreated increases the risk of renal scarring.

With constipation, the significance of the way it presents is more to do with the length of treatment needed to resolve the problem than the urgency to start treatment (as with UTI in children).  By the time that the child and parent are aware of the problem, constipation is usually very well established.  The child's bowel has been full of stool for weeks or months.  The bowel is stretched, weak and insensitive.  Prune juice and porridge are simply not going to do the job of resolving the constipation by the time that a child gets as far as their first medical assessment.

At this point, a short course of treatment for constipation simply will not suffice to truly resolve the problem.  Macrogol laxatives (the treatment recommended by the UK's NICE guideline) will do a great job, in almost every case, of clearing out the bowel.  This is not the same as treating the underlying condition.  We need to continue treatment until the bowel has a chance to do its thing again.

The effective treatment of idiopathic constipation in children requires two things.  Firstly, it requires adequate doses the right laxative (I avoid lactulose) for as long as it takes to allow the return of strength, shape and sensation to the bowel.  The consensus on this is that this will take about six months of maintenance therapy to achieve.

The second thing needed is some sort of modification to lifestyle that will help to avoid the return to constipation once treatment is stopped.  Changing diet, fluid intake and toileting habits may make all the difference, once the treatment has given the child their normal bowel back.

So I would suggest that we never think in terms of 'just a UTI' or 'a little bit of constipation' in children.  The delay in presentation, coupled with the extra time it may take us to actually get to the diagnosis means that neither of these terms apply.

I suspect that this could all be applied to the elderly with a little modification, but I'm not about to start GPseniorsTips.blogspot.com.  I'll just leave that thought with my innovative colleagues at the Norfolk and Norwich University Hospitals.

Edward Snelson
Part-time Vicerologist
@sailordoctor

Disclaimer - While I know deep down that it would be a terrible idea, part of me wants to combine a Paediatric Emergency Department with a Senior Emergency Department.  I can imagine how the two patient groups would be quite good for each other.  And that folks, is why I should never be allowed to have ideas.

Never Tell Me The Odds! (Does Atopy Matter When Making a Diagnosis in Children?)

The quote "never tell me the odds" is from the late great Han Solo.  His reckless approach to problem solving may not be the model that you strive for in clinical practice, but his attitude towards statistics is remarkably relevant in the context of diagnosing certain conditions in children.

Many of us have been taught to consider a personal or family history of atopy when making certain diagnoses in children.  Although it might seem like this is an important factor, the logic for including the history of atopy has several flaws.  It is notable that some guidelines are de-emphasising the value of such factors when considering a diagnosis of another atopic condition.

The first thing that is wrong with the use of the family history of atopy is that it is often itself wrong.  We know that many diagnoses of asthma in children turn out to be wrong and that people can misinterpret what they were told.  Were they given a diagnosis of asthma or were they told that their symptoms could possibly be due to asthma.  Many patients don't understand what a maybe diagnosis is, no matter how comfortable we are with the concept.  Similarly, there is much overdiagnosis of allergy, especially antibiotic allergy.  The end result of all this is that there are many people with a history of an atopic condition but who never had that condition.

It is also worth factoring in that (depending on which study you read) there is a significant possibility that the stated father is not the biological father.  It's not a major factor, but if we're going to consider odds, it is a factor.

The most important argument for me is to do with the way that the diagnosis is made.  The question is, do you rely on something in the history in order to make a diagnosis?  For example, a child presents with a fever and no clear focus.  They have never left the UK in their life, so that pretty much rules out malaria.

Conversely, a ten year old child presents with a history of recurrent wheeze.  This seems to have multiple triggers and is no just related to viral infections.  The wheeze responds well to inhaled salbutamol.  The child has never had eczema and neither parent has any history of any atopic conditions.  Well that rules out asthma then doesn't it?  Of course not.

The idea that a personal or family history of atopy should be a deciding factor may well be responsible for much of the overdiagnosis of certain conditions.  For example, a three year old presents with four episodes of wheeze in the space of a few weeks.  Each episode has been preceded by a runny nose and each has resolved over the course of a few days, with only a salbutamol inhaler for symptomatic treatment.  The child's parent asks if the child has asthma.  Both parents were given a diagnosis of asthma in childhood.  Also, this child had eczema as a baby.

Already I can feel the gravitational pull of the asthma diagnosis.  The personal and family history of atopy feel like compelling evidence, especially if we are slightly unsure about a diagnosis.  However, it doesn't change the fact that the clinical picture is one of viral wheeze and not asthma.  For this reason, the British Thoracic Society guidelines have de-emphasised the importance of the family history of atopy in diagnosing asthma in children. "The diagnosis of asthma in children and adults is based on the recognition of a characteristic pattern of respiratory symptoms, signs and test results and the absence of any alternative explanation for these." (1)

When it comes to uncertain diagnoses, we are rarely more unsure of ourselves than when considering a diagnosis of non-IgE cow' milk protein allergy (CMPA).  It doesn't help that there is no test that we can rely on or that the symptoms are all non-specific.  CMPA, more than most diagnoses, relies very much on the recognition of a best-fit.  Often and quite rightly, it is a diagnosis which is considered after other more likely diagnoses have been initially presumed.  Should the infant having eczema or a parent with a history of atopy influence that process?

I think that there is no simple answer to this.  What is certainly true is that just because a baby has eczema does not mean that their crying and regurgitation of feeds indicates a CMPA.  Conversely, just because a child has no eczema and no family history of atopy does not mean that we should delay a cow's milk protein free trial if the clinical scenario suggests CMPA as a diagnosis.

What you really want to know now of course is the increase in statistical probability of CMPA which is associated with eczema and family history of atopy.  I don't know the answer to that. If you know, keep it to yourself.  Never tell me the odds.

Edward Snelson
Epidiminihilist
@sailordoctor

Disclaimer - Han Solo's death is in no way proof that you should know the odds.  His long and successful career is proof enough that reckless and uninformed decision making is the best way to go about things.

1. British guideline on the management of asthma, British Thoracic Society & Scottish Intercollegiate Guidelines Network

School Time Safety Netting

Safety netting is one of the most important interventions in acute paediatrics, whether you work in Primary or Secondary Care.  When we give safety netting advice, it is usually in the context of a medical problem that we expect to run a benign course and then resolve.  This is plan A.  Safety netting advice allows us to inform the patient (or responsible carer) when to activate plan B.

Plan B might be needed for a number of reasons:

The principles behind good safety netting are simple.

All of these factors are key to the success of the safety netting process.  Leaflets can be a very useful supplement to explanation and discussion.  The opportunity to ask questions is also essential.  Most importantly the parent should feel empowered to make an assessment and to return without feeling that they will be seen as over-anxious.

Recently, there was a lively discussion online (sparked by Damian Roland's writings about safety netting) about this subject, including some great tips about how to do it well and ways that it can go wrong.  One of the pitfalls that were mentioned was the possibility that discussion about the appropriateness of the attendance might get in the way of the touchy-feely aspect of the safety netting.  The gist was that if you discussed when not to come, this would be a barrier to appropriate attendance.  While I agree that this can happen, I don't believe that by discouraging attendance we are running this risk, as long as it is all done in a positive way.

The idea that discussing appropriate attendance is inherently negative is based on a false assumption: namely that the parent wants to come to the doctor.  Even where healthcare is free at the point of delivery there are many, many reasons why people do not want to see a doctor, with inconvenience being one of the most common.

Another issue is that the anxiety associated with the perceived need for a medical assessment is itself an unpleasant experience.  I think that doctors under-appreciate this because we are made to feel like the hero of the hour.  Someone was worried about a symptom and now we are the person to tell them that everything is almost certainly going to be fine.  Go us!

Probably the most common example that I can think of is the way that parents often think that a cough and fever equals a chest infection.  This is sometimes compounded by the belief that chest infection is often fatal - a rare outcome in a healthy child who is given appropriate treatment.

When I hear someone say that they have come to see me because they believe that their child has a chest infection and the child promptly runs off to play with the toys, I could be forgiven for having a 'why me?' moment.  I could use this opportunity to explain why this is an inappropriate attendance since the child is so very well.  That would be a tad self indulgent since I'm not the one with the worry.  Instead, I should make sure that my consultation finishes on a positive note, with good safety netting advice that encourages re-attendance, right?

Well, I think that the two things (good safety netting and discouraging unnecessary attendances) are far from mutually exclusive.

If anything, the two things work together in beautiful harmony and create the opportunity to take safety netting to a platinum standard.

What might this look like in practice?  For the child with the not-a-chest-infection, my school time safety netting might go like this:

It is absolutely important that parents do not feel criticised.  If fear of criticism leads to a child not being brought for assessment when needed, that is of course a bad thing.  So, we have to have the best of intentions when we talk about when and when not to seek medical advice.

I have no interest in doing myself out of a job by reducing attendances.  If anything, reducing avoidable attendances.   It takes me 2 minutes and zero stress to assess the child who has had a minor bump to the head.  If the parents who bring their child to see me when all that's happened is that they fell over and cried for a few seconds stop coming "because it's always best to get checked isn't it doctor?" then I'll just have to see more patients that take time and challenge my thought processes.  So why do I take the time to explain to every single parent the things that would constitute a reason to seek assessment for the next bumped head?

The answer is that it is in the best interests of the parent and child, so why wouldn't I?

Edward Snelson
Founder of MediLeaks
@sailordoctor

Disclaimer:  Exploring health beliefs can be hazardous.  Always wear a helmet.

I would love it if you would post the things that you educate parents about (in a positive way).  You could do that here, on Twitter or on Facebook.  If you post a comment here, don't worry if it doesn't appear straight away.  I have to check all comments before they are published.  (There are a lot of spammers out there!)

It's Not Easy Being Wheezy - about antibiotics and wheezy kids

In my formative postgaduate years as a doctor, I was told by more than one mentor that antibiotics were a good treatment for children who were wheezing. This advice was given by various people at different times and whether this was bronchiolitis, viral wheeze* or an exacerbation of asthma, the principles seemed to be the same. The logic is sound - we know that infection triggers all three, and we can never be certain of the infection being a straightforward viral episode.  That was how it was put to me anyway.
*If you are unsure about the difference between viral wheeze and bronchilitis, follow this link for an explanation.

I no longer believe in this strategy as a treatment option for wheezy kids, and this is why:

It's not easy being wheezy.  Children with tight lower airways are up against it but often cope extremely well with their bronchospasm or their bronchiolitis.  I am constantly delighted by the ability of these children to be cheerful despite quite significant breathing difficulty.

It's even worse to have a bacterial lower respiratory tract infection.  As well as the breathing difficulty that comes from the loss of functioning lung, there is the tiring effect of the illness.  Having pneumonia is unpleasant and often exhausting.  It would be unusual to see a child who was cheerful and well despite a bacterial lower respiratory tract infection.

Now imagine combining the two.  Doesn't look good does it?  Children with bronchiolitis and viral wheeze cope with the difficulties of wet or constricted airways because they are systemically well.  Add the lethargy of bacterial infection to this and you go from a child who can compensate to one who cannot.  In short, you won't think "maybe there's a bacterial LRTI as well as the bronchiolitis or viral wheeze."  You'll know it.

Evidence from research backs this up.  The Cochrane review of antibiotics for bronchiolitis concluded that there was no benefit from antibiotics. (1)

You could say, what's the harm in trying antibiotics?  There are many reasons why unnecessary antibiotics might be harmful and none of these are to do with drug resistance.

So, it's time to do away with the idea that antibiotics have a role in treating well children with bronchiolitis or viral wheeze.  I believe that you'll know the children who need antibiotics because they will be properly unwell.

Edward Snelson
Antibiotic Guardian of the Galaxy
@sailordoctor

Disclaimer:  Secretly we all know that antibiotics do treat viruses, but if you tell anyone, you'll be removed from the Magic Circle.

Reference

1. Farley R et al, Antibiotics for bronchiolitis in children under two years of age, Cochrane database of systematic reviews. 2010

The Cheater's Guide to Complex Paediatric Problems

If ill children worry clinicians, then the child with a complex medical background must be terrifying.  Paediatrics is full of syndromes, most of which are so rare that you will probably never encounter them, but these syndromes number so many that the total number ends up being significant.  The end result is that if you work in General Practice or an Emergency Department, you are guaranteed to see a child with an underlying syndrome every so often.

These syndromes are not the only reasons for children to have complex medical histories.  Sometimes a single disease is enough to dramatically change how a child presents and responds to illness.  Intuitively, these children make all of us anxious, and I include paediatricians in that collective of worriers.

So what should you do when faced with a child who comes to you and has a complex medical history?  Most of us would like to practice medicine well within our area of expertise and this scenario is going to be way outside of that?  Well, it doesn't have to be a case of complete panic and run.  No, when faced with unfair odds, if you choose to engage, you just need to know how to balance the playing field.  My approach is simple.  I cheat.

Here's a clinical scenario to illustrate what I am talking about:

A three year old girl presents with a history of pulling her ear. She has had a raised temperature but this has responded well to antipyretic medicine.  Examination is normal apart from a runny nose and a left sided inflamed tympanic membrane.

You see from the child's medical records that she has Aicardi syndrome and has regular followup with a paediatrician for this.

I'm guessing that this all felt safe for the first bit.  There is something particularly unnerving however about finding that a child has a thing that you've never even heard of.  This is a protective instinct that clinicians have (quite rightly) to let them know that they are outside of their area of expertise.

However, you do have options here.

You should of course look at the child's medical records.  This will often give you the diagnosis but not the detail about what the specifics of the thing, how the thing affects this child, or what the plan is for a child with the thing when they become unwell.

You could ask the internet for information about Aicardi syndrome.  Clinicians often feel that this would make them look foolish or lacking in knowledge.  The truth is that the parents do not expect you to have the first clue about their child's rare condition.  If you ask for two minutes to get a bit of information about the thing, they are most likely just relieved that you are not planning to ignore the fact that their child is different.  If anything, they will be pleased that you are taking the time.

The next option is to ask the parents what the deal is with their child's condition.  This approach works really well, assuming that the parents are reasonably in the know.  While the internet can give you an overview of a syndrome, no disorder ever affects two individuals in the same way.  For this reason, I find it useful to ask the following questions:

Note that this is cheating at the highest level.  You can't just expect to be this good straight away, but it's something I feel everyone should be aiming for.

What I've done there is to find out about the underlying medical problem, exactly how it affects this child in front of me and to find out what is expected of me.  This immediately gets me past a few of the most common barriers:

• Possible gaps in knowledge of the condition
• The way that a disease/ syndrome manifests is variable
• There may be specific requirements or expectations when a child with this underlying problem becomes unwell
• It is very difficult to spot an unwell child if you don't know how they look and behave when they are well.
• The gut feel that we use when assessing children is less reliable if a child has a complex medical problem.

The reason for going to all of this is all of this trouble is to do with the way that children with complex underlying medical problems develop and respond to illness.

These children may or may not have good immune systems.  What they all have in common is that they will not respond to illness in the same way that a child who has no underlying medical problems would.  The reasons for this may be physiological, neurological or even due to human factors.  These children with complex medical backgrounds experience a normalisation of illness that other children do not.  As a result, they do not necessarily even know how sick they are themselves.

Putting a little bit of extra work into the assessment of these children does make a big difference.  It maximises the chances that the will get seen by the right person, in the right place, at the right time.  Sometimes there are specific things that can be done early on, which will help the child to get better.

Sometimes, being admitted or referred is not the best thing for the child or the parent. I the case of the child above, it turns out that Aicardi Syndrome doesn't affect immunity and that this child is not one of those severely affected.  The end result is that Mum is confident that she can recognise when her child is seriously unwell.  Today she feels that the problem is pain rather than concern about being dangerously ill.

More importantly, Mum has a physiotherapy appointment in an hour, so a referral 'just in case' is going to make her miss that.  After applying the full list of cheats, you decide to manage the child's illness yourself.

Epilogue:  The following week, you find a card and a box of chocolates on your desk.  They are thanking you for taking the time to manage this girl's illness rather than refer to the local hospital, which is what often happens to her.

Edward Snelson
Finding the easy way since 1996
@sailordoctor

Disclaimer: Cheating is only wrong if you get caught.

If you have your own tips and tricks for looking after children with complex medical problems, please post something in the comments box below.

Everything Wrong With Infantile Colic

One thing that I have enjoyed from time to time is a series of YouTube videos called "Everything wrong with..."   Here is an example of someone slickly dismantling the 1999 version of the film "The Mummy" which gives you an idea of how this works.  Egyoptologists will particularly enjoy this.

There are many things in paediatrics which lend themselves to a similar style of critique, none perhaps more than colic.  Infantile colic is diagnosed in countless numbers of babies every day.  Advice is given and treatments sometimes prescribed.  All of it is nonsense from start to finish, so here is my "Everything wrong with Infantile Colic."

1 - Colic is not a diagnosis

The commonly touted diagnostic criteria for colic is, "Infantile colic is a benign process in which an infant has paroxysms of inconsolable crying for more than three hours per day, more than three days per week, for longer than three weeks" (1)

What you have there is a definition of a lot of crying.  The implication that this excessive crying equals a diagnosis is utterly ridiculous.  Babies cry for all sorts of reasons.  Also, why is this particular pattern (3x3x3) of any significance compared to any other pattern?  What if the baby is crying for 2 hrs and 45 mins, 7 days per week for 2 weeks and 5 days?  Shall we tell the parent to come back in two days time and suggest that the child steps up to the plate because they're just not bringing their A-game?

If this was any other measurable value, we would be plotting it on a centile chart and monitoring the trend.  There is a reason that we don't have centile charts for the normal amount of crying in babies, and if you don't know what is normal, how can you define what is abnormal?

In any case, this is simply an impractical definition.  How much a child is crying and how much it seems like they are crying (to the parent) are likely to be two very different things.  Why have such a precise definition when the information given will be subjective?  I'm not suggesting that we do try to get precise figures, but maybe there is an app for that.


2 - Colic is not a pathology

Pathology is the study of the cause of disease.  Firstly, it is debatable as to whether colic is a disease, mainly because we don't know what it is.  Secondly, when we give a label of colic, we are saying that we have excluded pathology.  There are plenty of reasons why a baby might be crying excessively and these need to be considered.

Gastro-oesophageal reflux disease
Non-IgE allergy (usually CMPA)
Urinary tract infection
Non-accidental injury

Meningitis
Osteomyelitis
Hair tourniquet
Injury (accidental and non-accidental)

Many possibilities have been suggested as causes for infantile colic.  No specific cause has been found that would explain why some otherwise healthy babies seem to cry excessively in the first few weeks of life.  What that leaves us with is supposition.  It is often said that the crying is due to the sensations that a baby is experiencing in their abdomen.  Perhaps they are getting used to normal peristalsis of the bowel (which does not occur in utero).  Nobody knows.


3 - Colic is not treatable

As mentioned before, there have been several propositions made as to the pathology of colic.  None have been substantiated but that doesn't stop the door from having been opened to treatments being offered.  "It might be low-grade lactose intolerance..." - thus one of the popular colic treatments having lactase as the active ingredient.  "It might be bowel gas causing discomfort..." - thus another containing dimethicone.  I have no problems with a  process of hypothesis and experimentation.  This is how we get evidence for effective treatments.  What is then needed is good evidence that a treatment that might (in theory) work, is genuinely effective.  In my opinion, there is no good evidence that any effective treatments available for infantile colic.  Of all the patient groups where we should avoid the use of ineffective medication, surely this is top of the "don't do it" list?

Bear in mind that to prove efficacy in a condition such as colic, the method would have to be a large double blinded randomised controlled trial.  If not, the effect of the natural resolution of symptoms would make any treatment appear to be effective.  For example, if we suggested that the family plant some potatoes and that this will treat the colic, by the time the potatoes are ready to harvest, the condition will have resolved.  How impressed will they be?  D'ya know something?  I  think I might write a book and create a web page about that.  There's money to be made here.

While offering a treatment might seem both benign and helpful, I feel that it is neither of these things.  Previous treatments for colic have been withdrawn from use due to cardiac side effects.  A drug might be used for many years before the harmful effects are known.  Pessimistic possibilities aside, my main issue with any ineffective treatment is that it can make things harder for the parents.  When given a treatment (or suggested remedy), there is an expectation of symptom resolution which simply does not materialise.  This is psychologically quite hard for a parent who is likely to feel quite desperate.

Instead, I prefer to be honest and tell the parents the truth.

The last point in that list is most important.  Having a baby that cries a lot has a huge effect on parents and can potentially be a factor in parental mental health problems.  Also, the frustrations caused by a baby that cries and cries have been implicated in safeguarding cases.  While we can't take away the exhaustion or the stress, we do have the ability to absolve the parents of the feeling that they must always stop their baby from crying.  I tell parents that if the baby has been cleaned, clothed, fed and loved, then there are times when it is necessary to walk away and leave the child to cry.  If possible, family support should be made use of.  Well meaning relatives need to understand that colic is harmless to babies in the long term, but harmful to parents in the short term.

Edward Snelson
Potato therapist
@sailordoctor

Disclaimer - Potato therapy requires years of training.  Do not attempt to practice potato therapy without the appropriate qualifications.

Reference

1. Infantile Colic: Recognition and Treatment, Johnson J, Cocker K, DO; Chang E, Am Fam Physician. 2015 Oct 1;92(7):577-582

Heart Murmurs in Children

Heart murmurs are a reasonably common finding in children.  Excluding the newborn and early infancy assessments, most of the murmurs that we hear are benign, physiological or flow murmurs.  All of those terms basically mean the same thing – the anatomy is normal, the child is healthy and yet there is an extra noise heard on auscultation of the heart.  The reason that this usually occurs is that children’s physiology responds vigorously to illness and stress.  The heart pumps faster and harder, often making a structurally normal heart into a noisy heart.

In short, heart murmurs are almost always nothing to worry about.  Almost.

The trouble is that everything in paediatrics has an evil twin.  So what are the possible more significant  pathologies and how can these be recognised amongst the far more common benign diagnoses?  When children present with an acute illness, a cardiac cause for their symptoms is not usually top of our list of differential diagnoses because respiratory and musculoskeletal cases are far more common reasons for chest pain or dyspnoea.  This coupled with the way that cardiac problems present (with vague symptoms easily attributable to more common illnesses) make these rare clinical scenarios into the stuff of our worst fears.

Let’s look at a few made up cases to illustrate how to approach the “Oooh-I’ve-heard-a-murmur-what-now?” scenario.

Case 1

A 3 year old child presents with a febrile illness.  Let’s say that they have an otitis media.  They have a heart rate at the top of the reference range for their age and you hear a murmur.  The murmur is soft, easily heard (but not loud), systolic and heard best at the left sternal edge.  There is no radiation.

What now?

In primary care, we are all about the focussed history and examination.  We have to be in order to make time for our other patients.  That ergonomic approach works well, but when we find something that we weren’t expecting, we need to go back and get more information.  In this case, we want to know if the child is known to have a heart murmur.  Have they had an echo done in the past?  We also need to feel the precordium for heaves and thrills and be happy that the pulses have a normal character and volume.  Make sure that the femoral pulses are palpable, with no brachio-femoral delay.  Check for hepatomegaly.  Most importantly, make sure that the child does not have increased work of breathing and does not seem unexpectedly unwell.  Ideally, we need to get a blood pressure checked.

What next?

We need to refer a child with a murmur acutely (usually to general paediatrics) if

• they are more unwell than expected
• they have respiratory symptoms which are otherwise unexplained
• there are concerning clinical examination finding (e.g. hepatomegaly)

A well child with none of the above ‘red flags’ probably needs an outpatient echo if

• The murmur is loud
• The murmur is diastolic
• The murmur radiates outside of the precordial area

If the child is well, there are no red flags and the murmur sounds benign (as in the original description for this case) then common practice is to follow the child up when they are well again.  The presumption is that this is a physiological murmur which has been heard because the illness is causing increased cardiac output and therefore turbulent blood flow.

It is likely that when they are seen, the murmur will no longer be heard.  In these circumstances: case closed.  If the murmur persists, they can be referred then (either for an echo or to paediatrics if they don’t have direct access to this), assuming that the child remains red-flag-free.

Case 2

A two month old baby presents with a runny nose, cough and a low grade temperature.  The parent has noticed that their baby has started to have slightly fast breathing and has not been feeding as well as they normally do.  On examination, the baby has a slight wheeze, mild recession and basically looks like the other babies with bronchiolitis that you have seen that month.  All except for one thing: they have a soft systolic murmur that you can just about hear over the wheeze.

What now?

In short, refer to the acute paediatric medical team.  This child might have bronchiolitis and a flow murmur, but there is every chance that they are just pretending to have bronchiolitis.  Babies who have a ventricular septal defect (VSD) might not be picked up on screening (newborn baby checks etc.) and may have no overt symptoms, until they get their first cold.  Then, shortly after becoming snotty, the illness tips them into heart failure.  What does heart failure look like in a baby?  Well, they have increased work of breathing, a bit of a wheeze and struggle to feed.  Does that sound like bronchiolitis or does that sound like bronchiolitis?

Other clues that give these mimics away are:

• Excessive tachycardia
• Hepatomegaly
• More pale or mottled
• The course of the illness is different – they continue to get worse, while bronchiolitis symptoms peak at day 3-4 of the illness.

Case 3

A fourteen year old presents a few days into a flu-like illness.  They have been seen by a couple of doctors in the past few days, and have been told that they have a viral illness.  On both occasions they were advised about symptomatic treatment.  The parents are concerned that the young person is not getting better.  On examination, there is a barely audible systolic murmur.

What now?

Don’t presume this to be a flow murmur.  Firstly, in the context of viral illness, flow murmurs are most commonly heard in younger children. Also, the the murmur was not heard on previous visits.   One possible diagnosis here is viral myocarditis.  Other possibilities include bacterial endocarditis.

What next?

Refer this child acutely to the paediatric medical team.


One general rule which works quite well for symptoms in children (in the context of heart problems) is this: An isolated sign or symptom is rarely indicative of significant pathology.  Two signs or symptoms is always worth taking very seriously.  Take chest pain in children.  I don’t expect chest pain to be due to a cardiac cause in children (because it almost never is).  I know that the vast majority of children who have a syncopal episode will be having straightforward vasovagal events.  However, chest pain in combination with syncope, dyspnoea or palpitations is presumed by me to be pathological until said pathology is excluded.

So, as with many presentations in children, everything is normal except when it isn’t.

Edward Snelson
Postcordiologist
@sailordoctor

Many thanks to Dr. Carrie Mackenzie (Consultant paediatrician) who helped with the original version of this piece which is on the excellent RCEM learning site.

The Everest-Lifeboat Test (Easter Egg - Investigating apparent faints in children)

Paediatric guidelines always have to take into account one of the most important maxims of Child Health - the test or treatment must always be in the best interest of the child.  This means a particular discernment about the value of a test or treatment.  Guidelines rarely discriminate between which treatments and tests are essential and which are simply recommended.  When writing a guideline, it is relatively easy to put in a recommendation, often giving the impression that it is a must-do when this is simply not the case.

One of the things that I am most often asked (whether at work or giving and educational session) is "Do I have to do X?  The guideline says to but..."  So how does one discriminate between the must-do's and the would-be-good-if we-could recommendations?  That's easy - apply the Everest-Lifeboat Test.

The Everest-Lifeboat Test is simply a two part thought exercise.  The first part is to ask the following question:  If the person involved was at an advanced stage of climbing Everest, should they turn back to get this test or treatment or could they reasonably continue to the summit?  This part of the test asks if we are doing something just because we can rather than because we have to.  We are purely focusing on the immediate need at this point.

The second part is the lifeboat question:  Imagine that this patient was in a lifeboat, drifting across the ocean.  When they are rescued several weeks later, would they most likely be fine despite their current clinical situation?  This part of the Everest-Lifeboat Test forces us to look forward and consider the medium and long term consequences of action versus inaction.

Let's try this on a fictional patient.

A 10 year old child is brought to you having had an unexplained collapse.  The history given to you is vague and there is no first hand account of the episode as it happened in front of classmates at school.  However, in your further history taking, you find that this child has been having headaches that are worse in the morning.  Also, teachers have noticed that there has been a deterioration in performance at school over the past four weeks.  The child is slightly ataxic and has nystagmus on examination.

Concerned, you discuss the need for further investigations.  In response, the parents say that they are happy to get the tests done but could it please wait a few weeks?  They were just coming to get a medical opinion before they catch a plane to go away for a couple of weeks for their holiday.  They were assuming that this was just a fainting episode and really only came to get their child checked because grandma told them to.

So, what do you think?  This seems like a clear fail of the Everest-Lifeboat Test to me.  I wouldn't be happy to put investigations on hold, despite the obvious inconvenience to the family.

How about this scenario?:

A 12 year old girl comes to be assessed.  She was in school and had been stood in the heat when she began to feel sweaty and nauseous.  Her vision went black and she slumped to the floor.  She was reported to look pale and floppy.  She was unresponsive for a few seconds and then came around slowly over a few minutes.  A few hours later, she feels fine.  There is no history of unexplained deaths in her family.  When you examine her, all is normal.

You check a relevant guideline and see that it recommends that you perform a 12 lead ECG. She flatly refuses to have this test done and will not be persuaded.  What should you do?

Applying the Everest-Lifeboat test would go like this:

Would you advise abandoning the final attempt on the summit?  Well, she had an obvious precipitant and prodrome for her apparent faint.  We can advise how to avoid precipitants and what to do if a prodrome is recognised.  The event appears to be a classical vasovagal syncope without red flags in the history or examination.  So, forcing the issue seems to be unnecessary.

Would a few weeks in a lifeboat be an issue?  This brings us back to the guidelines that recommend investigation.  What are they trying to protect us from?  Much of the practice of ECG screening comes from adult medicine, where pathology is much more likely.  In paediatrics, there are a few arrhythmias that we need to worry about, but a standard 12 lead ECG is not the perfect screening test that we might hope it is.  The sensitivity and specificity of 12 lead ECGs in children is poor (1).  Ask yourself why the guidelines don't say, "Don't bother with history and examination.  The ECG is the crucial bit of information."

A quick look at the guidelines gives some useful insights to help us with the Everest-Lifeboat Test.  The NICE guideline "Transient loss of consciousness (‘blackouts’) management in adults and young people" (2) actually only relates to the over 16 year-olds.  This in itself acknowledges that an adult approach cannot be extrapolated to the child who has had a collapse.

Then there is the European Society of Cardiology's guideline for the diagnosis and management of syncope (version 2009). (3) It does take the view that children and adults can be investigated similarly and recommends ECG for all children who have had a faint.  However, this recommendation seems to be based on the assumption that an ECG is clearly useful additional information and fails to consider the possibility that a thorough history and examination gets you to a point where and ECG would not add value.

The American College of Cardiology/American Heart Association guideline (4) does seem to consider this possibility.  There is a strong emphasis on the value of a good history and examination.  Regarding ECG, it points out that ECG is a simple and available test that might identify a tendency to arrhythmia.  However it also states: "Despite the benefit of identifying a likely cause or potential clue about the cause of syncope from the ECG, prospective studies did not conclude that ECG findings significantly affected subsequent management.  The prognostic value of an abnormal ECG in patients with syncope has been questioned as well."

So there it is.  An honest declaration that, while the experts would recommend that we all do a test, it is unclear what the value of the test is.

I know that it might seem as though I just want to avoid doing work here, but there are genuine risks with tests.  The first risk is that they stop us from thinking.  If the sensitivity and specificity of history and examination is excellent, while that of ECG is poor, why introduce a deceptive piece of information?  The second risk is that of getting information that I don't want.  If I do an ECG on a child, it is almost always to look at the rate, rhythm and QT interval.  While those things are usually fine, the diagnostic report usually sports a bit of LVH and right atrial enlargement.  Of course the child has neither of these things, but the machine is just trying to make sense of the voltage it has been given.  If I were to take these things seriously, I might cause unnecessary anxiety for the child and parents.

So, what does my patient really need?  I need to take a good history and establish that the episode that sounds like a faint truly sounds like a faint.  This means asking about the three P's of vasovagal syncope.

If it sounds like a classic faint, I still need to make sure that I consider my red flags.

If the history given is of a straightforward faint, without red flags, I think that allowing the child to refuse the ECG passes the Everest-Lifeboat Test.

When we are forced out of our normal process, it is a good time to evaluate our routine practice.  If a deviation from the norm passes the Everest-Lifeboat Test, I would question the norm.  You may just have discovered that you are doing a test or a treatment that you don't believe in.  Here is a little list of things that have passed the Everest-Lifeboat Test for me at various times in the past (i.e. I was going to treat, something got in the way of that and I went with the the no treatment option):

That's a short list of times when the option of doing nothing became the right thing despite what was routine practice.  In the case of umbilical granuloma, I am pleased to say that doing nothing is now becoming the norm.

I hope that you find the Everest-Lifeboat Test useful at some point.  As to whether every child who has had a faint needs an ECG, versus it is good to get one or it is simply not needed unless there is a specific reason - this is a debate that is lacking input from the good people of the primary care and emergency medicine communities.  My solution?  Stick a cardiologist, a paediatrician, an emergency medicine doctor and a general practitioner in a lifeboat and leave them there till they've sorted it out.  I'm fairly sure they'd be fine...

Edward Snelson
Precordiologist
@sailordoctor

Disclaimer: The Everest-Lifeboat Test was originally described in 1055 by Egbert the Uncertain, a monk who died at the Battle of Hastings before writing down his idea.  I therefore take full credit for inventing the test myself.

1. Kapoor WN, Evaluation and outcome of patients with syncope, Medicine, 1990 May;69(3):160-75.
2. NICE guideline "Transient loss of consciousness (‘blackouts’) management in adults and young people"
3. Diagnosis and management of syncope, European Society of Cardiology, European Heart Journal (2009) 30, 2631–2671
4. Guideline for the Evaluation andManagement of Patients With Syncope,  A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society