Tuesday, 30 July 2019

Core Principles of Paediatrics

Treating sick kids is a lot of fun.  If you can deal with any fear factor, it becomes a real pleasure most of the time.  Children are very different from adults.  While much that you know about adult medicine is useful, it usually needs a big modification to apply into practice when assessing and treating a child.  This post is going to cover some of the core principles of paediatrics as well as giving some specific examples.

Let's start with some basics:

The paediatric consultation is inherently different.  In most situations the child is part of a consultation which involves a third party, usually a parent.  That dynamic needs to be handled carefully and it is important to never forget that the child is still the patient.
When it comes to examining a child, it can be a little daunting.  In most cases, it is possible to get cooperation by making the examination fun.  There are various ways to do that but my go-to method is the "Find the food" game.  A full explanation of how that works is here.  In many cases you just have to be opportunistic and accept that there is no set piece for the examination.  In paediatrics, we can only base our assessment on the examination that is achievable.  Incomplete information goes with the territory, but it is usually possible to make an assessment.  Thankfully, the most important information usually comes from the history and from the hands-off element of the examination.
When it comes to making an assessment and deciding on a management plan, it is important to consider the age of the child.  Children get different problems at different stages of childhood and the way they respond to infections changes considerably at different ages.

Babies*
  • Immune system is heavily reliant on maternal antibodies
  • Simple viral illnesses are uncommon
  • When a baby is febrile or unwell, the likelihood of serious bacterial infection (SBI) is high.  
  • The response to SBI is sometimes vague and does not make it easy to recognise SBI.  Babies who are "off feeds" or "not their normal selves" should be taken seriously.
  • Physiological reserves are low in this age group.  Babies can compensate to a degree but are prone to sudden deterioration is moderately unwell, especially when the lower respiratory tract is affected.
  • The lack of any ability to report symptoms means that certain problems such as urinary tract infection (UTI) and surgical abdominal problems can easily go unrecognised.
*I have deliberately not attributed an age range to the term baby.  Everything here is more true for a 2 day old than it is for a 2 month old but the same principles apply.  If you really want to know if it's a baby, put it on the floor in the middle of the room.  If your patient is exactly where you left them 5 minutes later, it's a baby.

There are some simple principles to apply when assessing a baby:
  • Take any abnormal temperature (low or high) seriously.  Unless there is good evidence of a benign cause (wearing too many layers or fever post vaccination) and the baby is well, presume SBI.  In primary care/EM that means referring.  In paediatrics that means a period of observation as a minimum and in many cases the outcome is investigation and presumptive treatment.
  • Absence of fever is not absence of significant infection.
  • Take into account risk factors such as prematurity
  • Remember to do a few specifics in the examination - assess posture and limb movement, feel the fontanelle, weigh the baby (and measure head circumference in many cases) and feel femoral pulses.
  • Babies can seem "a bit off and" then be absolutely fine when assessed/ observed.  When sending the baby home, make sure that the parents know how important it is to be reassessed if there is deterioration or new symptoms.  They must never hold back from seeking assessment due to fear of being perceived as an anxious parent.
  • Conversely, many of the things that parents might worry about are often within normal, including regurgitation of feed, frequent crying and straining at stool.  In general, if the baby looks well, grows well and examines normally, these things are likely to be part of normal infancy.
Toddlers and Pre-school Children
  • No longer relying on maternal antibodies and not yet an educated immune system, this age group has a cunning survival plan - the immune system that goes crazy with every simple infection.  Simple upper respiratory tract infections provoke high fevers, high white cell counts and produce an array of other phenomena in this age group.
  • The phenomena that occur relating to viral infections in this age group include transient synovitis (irritable hips), viral induced wheeze and febrile convulsion.
  • The fact that these children get so many viral illnesses coupled with the fact that they can seem quite unwell with simple viral illnesses means that a large proportion of healthcare presentations at this age are for viral illnesses.  In contrast to babies (rule out SBI/ sepsis) the approach in this group is more usually rule in SBI/ sepsis.
  • The low probability of SBI/ sepsis in this age group presents many challenges to front line clinicians.  It is essential to remain vigilant and to approach even the most straightforward illness as though it could be or become SBI/ sepsis.
  • The prevalence of asthma in this age group is very low.  There are plenty of presentations that could be misdiagnosed as asthma but it is important not to be misled.
Older Children and Young People

  • The transition into this stage of childhood is more gradual.  Viral infections continue to occur frequently to begin with (especially as the child first goes to a new school) but become less common.
  • Response to infections is slightly less vigorous and the phenomena associated with the previous stage suddenly become rare.
  • Asthma now becomes a more significant possibility.
  • As this stage of childhood develops, the pattern of disease and clinical presentation becomes progressively more adult like.
  • The non-clinical needs of the patient tend to remain childlike more than clinicians sometimes realise.  It's daunting being a patient when you're not an adult.
Much of paediatrics is about understanding these stages of childhood.  In each stage, the challenges are different.  This "stages of immune system development" maps well to the approach to illness at each stage as well as to the various causes of childhood wheeze.
The Pitfalls

It's good to know what might catch you out.  Here are a few of the common pitfalls.

Extrapolating adult practice into paediatrics-  This rarely works.  The probabilities are different, the way that they present are different and the therapeutics are different.  Here are few examples of major differences in common problems that can occur in children and adults.

Doing something-  For many childhood presentations, paediatrics is the art of doing as much nothing as possible.  It can feel like doing a test or giving a treatment "in case" is the safe option but there is no such thing as a zero-harm test or treatment in paediatrics.  Where a test or treatment is absolutely indicated you are on safe ground.  For example with croup, dexamethasone is never wrong.  In many scenarios, a test could be done or a treatment could be given.  If that is the case, always consider the possible harm.

For example:
  • Upper Respiratory Tract Infections - antibiotics can often be justified and this can feel like a satisfactory way of dealing with parental expectations.  However, antibiotics often cause vomiting and diarrhoea and the likely benefit is small.  Antibiotic prescribing risks shifting the focus from good symptom control and the perception that antibiotics are a safe option is misleading.
  • Bronchiolitis - doing a chest X-ray (CXR) may feel like a good way of completing a clinical assessment.  The reality is that it does not add value exept in extreme cases.  The great likelihood is that the CXR will show something that can be interpreted as bacterial LRTI, leading to a prescription of antibiotics despite the evidence that wheeze virtually exludes bacterial LRTI.  Now you have a baby with bronchiolitis who is being given antibiotics when what they most need is to hydrate orally and be allowed to cope with thier wet lungs without unecessary upset.
In paediatrics, careful assessment, observation if needed and careful safetynetting are the cornerstones of safe practice.  Doing tests and giving treatments "in case" are not as safe as they feel.

Feeling the pressure-  Worrying about knowledge gaps or inexperience with paediatric presentations is quite normal.  It is common for clinicians to have niggling anxieties about their assessment of a child.  If in doubt do the following things:
  • Look at the child.  Their appearance and behavior will often tell you whether that concern may be valid.
  • Use every contact as a learning opportunity.  If you have worries about something, learn about that presentation for the next time.
  • Don't hesitate to ask for help or advice.  If you have doubts about the best management of something you feel you can deal with yourself, discuss that plan with someone experienced.  In many cases, that will be someone in your team but it can also be a paediatrician on call.  They might want to see the child but they may be happy to discuss and advise.  If you do refer a child for further assessment, find out what happened next.  That way you can educate your own clinical judgement.
Finally, if you are or become that person that someone goes to for advice or a further opinion, be helpful.  Remember how daunting it is when you first started seeing children and how much uncertainty is entirely appropriate.  If you end up seeing the child and they don't need any investigation or intervention, remember how much childhood illness can fluctuate in severity.  As the expert, you will undoubtably add value, even if it is simply in the form of an experienced assessment and brilliant safetynetting.

Edward Snelson
Induction agent
@sailordoctor

Disclaimer - Remember that when you look at a child, wear full personal protective equipment.  If you're new to seeing children, you're in for a viral rollercoaster.

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