Quick and Easy FOAMed - Fallacies and Facts About Foreskin Problems in Children

In case you hadn't noticed, there is now a guideline for everything.  It is impossible to keep up. FOAMed can be really useful in that respect because it should keep a finger on the pulse for you and give you a condensed version of the important things, allowing you to be selective about when you go into something in more detail.  The way it works is that I read the guideline, just in case you don't get the chance.  (insert cheeky winking emoji here)

Nor can you rely on guidelines, alerts and journals to cover everything, despite the sheer quantity of them.  The nature of FOAMed is that it often covers the things that haven't earned a guideline, are not deemed worthy of an alert and have too little academic value to have a published article.  Some things that are over-represented in practice are under-represented in paper.  By way of example, I give you foreskins in children.  I think that the lack of publications on the subject is surprising considering the number of children attending primary and secondary care with this problem, and considering how much is often misunderstood about foreskins in pre-pubertal children.

At some point in my medical training I remember being taught that uncircumcised penises should easily retract by about 3-4 years old and that they should be kept clean.  Balanitis was seen as evidence of poor hygiene and so we were told that more cleaning was the solution.  Foreskins that were ‘non-retractile’ were considered abnormal and if there was recurrent balanitis or ballooning, the child should be considered for circumcision.  We now believe that all of this is untrue.  It is quite normal for the foreskin to remain adhered to the glans until they hit puberty, whenever that may be.  Ballooning is within normal limits and balanitis is often due to unnecessary attempts to retract or clean under a foreskin.  Recurrent balanitis is usually an indication to leave the foreskin alone, rather than to cut it off.

So I know that I was taught something that later turned out to be untrue and I know that many clinicians in both primary and secondary care haven’t heard the good news.  Why?  Presumably because it isn't seen to be worth a guideline, alert or journal article.  There is stuff out there, but not a lot.  This was the best article that I found. (1)

But the lack of literature is not a problem in the brave new world of FOAMed.  FOAMed comes in many different shapes and sizes.  Often it takes the form of a written piece, but some have embraced the infographics approach.  Most notably there is the excellent library of infographics that has come out of the Derby Emergency Department. (2)  I was inspired by Ian Lewins making infographics sound like a good thing so I'm having a go with it.  Here's the result:

An infographic is, by nature, pithy and lacks detail but hopefully it gets the job done.  I've gone for substance over style. I know that if I had given the job to a medical student, they probably would have been much better with the visual effects.  They would also have made sure there were more pictures.  Somehow, this didn't seem like the best subject with which to take that step.

Edward Snelson
President of the Sir Lancelot Spratt Association
@sailordoctor

Disclaimer:  Anyone can do this stuff.  If you want to have a go at making infographics and want to find out more about rickrolling, click this link.

References

1. Drake T, Foreskin problems in boys, Trends in Urology and Men's Health, March/April 2014
2. http://www.peminfographics.com

Time for Child Advocacy - 10 things to keep kids safe

Don't you love it when someone brands something that you've always been doing?  Advocacy is nothing new, but by making a big deal of it, we are all prompted to think about how we can do more of it and do it better.  Every consultation involving a child or young person will tend to include a bit of advocacy.  I am doing it every time I tell a parent that when their febrile child is refusing to drink, that usually means that they are in pain.  Parents sometimes think that paracetamol and Ibuprofen are just for reducing fever.  Part of my job is to put analgesia on the agenda.  It is the perfect time to do it because this is when the parents want their child to feel as well as possible.

Similarly, the impact of safety advice is greatest following an injury.  So when a child or young person comes to me with a mishap, I try to work a bit of prevention in alongside the cure.

Injury is the leading cause of death in children over the age of one in the UK. (1)  So, while we worry about sepsis and meningitis, preventing injury may be the real battleground.  Injury is inherently preventable, as demonstrated by the massive difference between rates in different countries.  It is not just lethal injury that is important.  In fact, to the children themselves it is the debilitating injuries that really matter.  Missing a sporting event or the ability to swim just before a holiday is the end of the world.  Or at least it is when 'the future' is essentially the next month or so.

What I do is to try to throw in something relevant to the presentation.  Whether injury or ingestion, there are lots of ways that we can make the environments of children and young people safer.  Here are a few that are worth spreading the word about to parents and colleagues:

1. Warn parents of babies and toddlers about common choking hazards

Have you ever wondered why pen lids have a hole in the top?  Before that little innovation, these were common choking hazards.  Anything that fits neatly into the windpipe runs the risk of a fatal choking episode.  The list of dangerous things includes many food and playthings that parents readily give to their children.

I think that any household mishap is a good opportunity to warn parents about choking hazards.  Prevention can include avoidance.  Supervision is also great but only if you know what to do, and with choking, prevention really is better than cure.

2. Make sure that children can't get hold of button batteries

If you were not aware of this, button batteries are incredibly dangerous to children.  There is a misunderstanding about these miniature killers.  It is not the contents leaking that are dangerous, it is the electrical current which forms corrosive chemicals outside of the battery.  Button batteries have become more powerful, in order to meet the demands of today's toys and gadgets.  When swallowed, the current may burn a hole in the gut (usually the oesophagus) and bleeding can be fatal.  A swallowed button battery needs to be located as an emergency in case it is stuck, as these carry the highest risk.

I find that many parents don't know about this, so I often mention it when a child has swallowed something concerning but less harmful, like a diamond ring.

3. Make sure that liquid gel detergent capsules are kept away from children

Ask any ophthalmologist what common household item is most dangerous to children's eyes and I am willing to bet that they say liquid gel detergent capsules.  Why?  They are the perfect thing to cause massive damage.  Firstly, they look very appealing to a child.  They are brightly coloured and a bit like something that might be good to eat.  If bitten into, the contents come out under pressure, so the eye has no time to protect itself from the contents.  The contents themselves are a highly concentrated alkali which will burn and dissolve the thin layers of the eyeball.  While the industry has made some moves to warn people to keep these away from children, such messages can be interpreted as a standard bit of advice, which does no justice to the fact that these capsules are far more dangerous than the standard bottles or boxes of detergents.

So when a child has had a mishap with another item, I like to warn parents about other things that they may not have thought about.

4. Recommend that all children with a bike wear a bike helmet.

Heads injuries are the most common cause of fatal injury in children.  Bikes are great fun and a good way for children to keep fit.  Unfortunately, injury is all about physics.  I have yet to see a child run into something and have a significant head injury.  Bicycles however, allow a young person to gain enough momentum to do real damage even if another vehicle is not involved.  While it can be difficult to persuade young people to wear helmets, they are the must have accessory for anyone who likes their brain or their face.  Road rash on the face is not a good look and helmets do a decent job of protecting the face from being badly grazed in a fall from a bike.

I emphasise the facial injury as much as the head injury prevention as it often means more to the young person involved.

5. Advise a bit of trampoline safety

Trampolines are a favourite for all ages.  They are also one of the biggest sources of injuries that come into children's emergency departments.  While I am not suggesting that trampolines should be avoided, the risk of broken bones can be minimised.  One of the common factors in many of the worst trampolining injuries that I have seen is that there has been another person involved.  The worst injuries tend to occur when a small child is on the trampoline with an older child.  I would recommend that younger children in particular should never have someone larger than them on the trampoline.  Ideally, they should be on the trampoline alone, with onlookers cheering them on.

6. Make sure that parents lock up medicines

Medication packaging always has on it 'keep out of reach of children.'  What this fails to take into account is the incredible resourcefulness of children who may seem to small to get up to cupboards or high shelves.  I can tell you from experience that nowhere is safe.  The only completely safe place for a medicine is in a locked cupboard or box.  Nor can you rely on 'child proof' containers to prevent accidental poisoning.  Child proof containers seem to be adult proof (It can't be just me that struggles with the tops) while children who have time on their hands always seem to get them open in the end.

7. Know about the surprise household poison - plug in air fresheners

Many plug in air fresheners contain essential oils.  These chemicals are potentially incredibly poisonous due to their ability to dissolve into brain tissue.  Parents are frequently surprised by this fact so it is well worth letting people know about this dangerous household item.  People are also surprised by the ability of toddlers to drink the contents of these plug ins if they get hold of them.  I don't know how they do it.  And why won't they eat their vegetables???

8. Warn parents to beware of the sun

When the sun comes out and children quite rightly make the most of it, we often end up seeing children with quite severe sunburn.  Babies are especially at risk due to their thin skin and lack of protection from the sun.  Make sure that people know that children can get deep burns from the sun and that prevention is key.  Children are also vulnerable to the dangers of overheating so hydration and sun avoidance are important when the sun is out.

9.  Remind adolescents to respect water

It is great that young people use the opportunity of time off school to go and have a bit of an adventure.  One way that this sometimes goes very wrong is when water is involved.  Getting into trouble in water is all too easy.  The simplest way to avoid the danger is to make sure that all swimming is done in appropriate areas.  Tempting though it is to jump into a reservoir or an abandoned quarry full of water, this is very high risk.

10.  A surprise danger – twilight

Now for the sciency bit…  Twilight is a very dangerous time for pedestrians and young people are already very much at risk due to their lack of perceived mortality.  Why is it dangerous when the sun rises and sets?  The answer is probably due to a little known chemical (found in the eye) called rhodopsin.  This is the chemical that enables the eye to adjust to lower levels of light.  The trouble is that it takes many minutes to produce the chemical and only seconds for a flash of light to get rid of it completely.  As a result, drivers can have their ability to see reduced very suddenly by a moment of setting or rising sun, allowing a person in the shadows to become almost invisible. (3)

It is important to teach young people road safety, but also to let them know that at certain times of day, drivers may not see them at all.

We're already making every consultation matter.  Giving parents a little suggestion every now and then about how to make their child's environment a bit safer is just another way of adding to the difference we already make.  Paediatrics is so rarely about preventative medicine but when a child has a mishap, we have a golden opportunity to discuss ways to avoid the next accident.

Edward Snelson
Chronic Avoider
@sailordoctor

FOAMed is free.  The clue is in the name.  That said, if anyone would like to celebrate their enjoyment of the free open access education provided by GPpaedsTips by helping children to receive the best possible care, I have set up a donation page where I am raising money for a new Sheffield Children's Hospital Emergency Department.  For more information about this or to donate, click on the link in the Just Giving logo:

References

1. RCPCH, "Why children die: death in infants, children and young people in the UK"
2. AAP, "Prevention of Choking Among Children", February 2010
3. http://uxblog.idvsolutions.com/2014/01/a-meta-portrait-of-earths-surface.html

ECG in children - an amuse bouche (and what to do with one)

Food etiquette is a minefield.  I remember the first time I was presented with an amuse bouche.  I had no idea why it was, let alone what I was supposed to do with it.  One minute later, with the tasty morsel in my belly, I realised I had really over-thought the whole thing.  Also, I was still hungry.  Non-acute paediatric ECG is a lot like that.

Some tests are so simple, usually because they are quantitative.  You do a blood sugar and you get... a blood sugar.  Some tests are much more qualitative, such as Chest X-ray.  Show a chest X-ray to half a dozen radiologists and you may be surprised by the range of interpretations.  ECG in children definitely falls into the second category in that it is a test which requires interpretation.  The interpretation of an ECG is fairly standard, but I've never yet met a standard child or a standard clinician.

There are many reasons why an ECG might be done for a child.  I am not talking about during an acute presentation such as a severe tachycardia or other signs suspicious of a cardiac cause for a child to be unwell.  I am talking about ECG in a child who is well, but had a symptom that warranted an ECG.  If you want to know about the kind of critical care ECG interpretation best done wearing a cape and with underpants on the outside of your trousers, you might like to listen to the PEMplaybook.

If your cape is in the cupboard and underwear is wherever you normally keep it, then ECG is a more fickle friend.  When an ECG is normal normal then that's great but it's not the end of the story.  Often it appears abnormal, because paediatric ECGs look different much of the time.  In a BMJ article about ECGs, the authors write, "Chest pain in children is rarely cardiac in origin and is often associated with tenderness in the chest wall. Electrocardiography is not usually helpful in making a diagnosis, although a normal trace can be very reassuring to the family." (1) That is all very well if with a 12 lead ECG you can tell them that all is normal.

So what is the problem with paediatric ECG?  Well actually there are two problems.  The first is the issue of things that look abnormal and are not.

Much of the differences in paediatric ECG are to do with the initial right sided dominance.  The other thing that can be a factor is physics.  The ECG may show up as LVH, RVH, atrial enlargement etc, but this is often because there is just very little in the way of chest wall between the sticker and the myocardium.  You don't get this problem in children with a more substantial chest wall.  Simply put, in a small or skinny child, large waves are usually normal. If something appears big, look at the child and check the axis.  A skinny child and a normal axis means that the "LVH by voltage criteria" is probably a lie.

Knowing these things helps us to be able to say more often, "This is a normal ECG."

Then there is the opposite problem: a 12 lead ECG done when asymptomatic does not rule out significant pathology.  Take this case study as an example:

A 12 year old girl presents having had a collapse while playing tennis.  She had no palpitations or chest pain and simply recalls feeling faint just before she collapsed.  The adult playing tennis with her describes a sudden collapse, while she was walking t pick up a ball.  When they ran over, the young person was unresponsive for only a few seconds before slowly coming around.

Clinical examination is normal.  The only other history of note is in the family history - a sudden unexpected death in infancy of a 9 month old sibling.  

Would you be happy to rule out a cardiac arrhythmia based on a resting, asymptomatic 12 lead ECG?  With that history, I wouldn't recommend it.

So, if an ECG in a child who is currently asymptomatic has a lot of false positives and false negatives, what is it useful for?  The answer to that is that it should mainly be used to answer specific questions.  For example, in the case above, I want to know the corrected QT interval.  A 12 lead ECG will tell me that.  In fact, resting asymptomatic ECGs are mostly useful for checking rhythm and intervals.

Morphology and high voltage account for most of the false positives and normal rhythm can be a false negative.  Both these things are fine, because a 12 lead ECG is simply an amuse bouche.  If you aren't hungry (no red flags), an amuse bouche is simply a tasty mouthful which won't fill you up.  It is debatable whether it is even needed in a child who has had a typical faint with no red flags.

If you are hungry (red flags in the history or examination), don't rely on an amuse bouche, which should just be there to keep you happy until the real food arrives.  What you have for your main course depends on where you work.  Perhaps you have direct access to 24 hr ECG and cardiac echo. Me? I phone a friend to do these things for me.

Edward Snelson
The Gourmand of Child Health
@sailordoctor

Disclaimer - I may not have had all of the ECGs the right way up.  That could explain some of the abnormal morphology.

References

1. Steve Goodacre, Karen McLeod, Paediatric electrocardiography, BMJ 2002;324:1382
2. PEM playbook EKG killers