Tuesday, 30 June 2020

The Work Hack I Never Expected - How a Rainbow Badge Transformed Mental Health Consultations

Adolescent mental health is an area of practice where we need to take opportunities when they present themselves. This post is about something that has been a huge game changer for me.
When a young person comes with a mental health problem we look at various factors that are involved.  One of the most important factors that affect mental health is sense of self.  Like all elements of mental health, sense of self is complicated.  It is important that young people feel safe and accepted in order to be resilient to the stresses of adolescence.  This is a time of life where identity is being formed, and to do that safely requires an environment which allows a young person to explore who they might be.

If a young person feels that any element of who they are or might be is unsafe in any way, this creates anxiety.

While sexual orientation is only one element of a young person’s sense of self, in a world where heterosexuality is considered normal, a young person may not feel that discussing any other sexuality is a safe thing to do.  They may be concerned that they will experience rejection by family, friends or anyone that they discuss their sexuality with.  In many cases, they have already risked discussing this issue and experienced a negative response.

As health care professionals, we should be routinely asking the right questions to identify any issue that may be a factor in a mental health presentation in adolescents.  We should ask about stressors in general but it is also routine to ask specifically about common anxieties.  The more likely it is that the thing may not be volunteered, the more important it is to ask.

There are many reasons why health care professionals might themselves feel anxious about asking a young person about sexuality.  Here are a few of the common ones:

We don’t have experience of discussing sexuality with young people.  If you don’t have a framework for doing this, you’re not alone.  Very few of us grew up in an environment where anything other than heterosexuality was considered normal.  Unless you have experience of a society where any sexuality is accepted without judgement, it is likely that you will feel a little bit weird about discussing these issues.  The irony is that we might feel anxious that we will somehow get it wrong.

The solution: just do it.  The best way to get past the weird is to be brave and trust that your attempt will be well received.  Step out in faith.

We are worried that the parent(s) may be angry that we have this discussion with their child.  Our anxiety is often seated in our knowledge that society is still heteronormalised and that some people are fearful or uncertain of any other sexuality.  There may also be a fear based in the misconception that by asking about sexuality, we somehow alter or influence it.  That is an interesting and unfounded belief.  There is no evidence that an open discussion can result in a change in sexuality.

The solution: Speak to the young person on their own.  This should be a normal part of a mental health assessment in a young person.  We wouldn't allow a parent to be a barrier to acting in their child's best interest in any other circumstance, so why let a social anxiety be harmful now?

We are worried about the response that we might get from the young person.   I’ll be honest here, this fear is reasonably rational.  If you ask a young person about their sexual orientation they may well give you a funny look and a muted response.  That’s fair.  When you are 15 years old, it is not something that comes up in conversation with an adult that you just met 10 minutes ago.

The solution:  Expect the question to make some young people feel awkward, but put them at ease by asking the question like it’s just another question.

There is another thing that can help with all of the above.  Last year I started wearing a rainbow badge.  The badge is small but always visible.  The idea is that it lets people know that I don’t judge people based on their sexuality.  To me, people are people.  While there are things that will change my opinion of someone, sexual orientation is not one of these.

When I started wearing the badge, I thought that my patients wouldn’t notice or wouldn’t know what the message behind the badge was.  I was wrong.

Immediately after I started wearing the badge, I noticed a change in the way that mental health consultations went.  When asking open questions about stressors, a significant number of young people started volunteering that their sexuality was a major factor in their presentation.  The stories varied from young people who were unsure about their sexuality but were afraid to discuss this with anyone to those who knew that they were not heterosexual but had experienced unpleasant responses to that when telling their family or friends.

I think that starting to wear a rainbow badge has been one of the most important innovations in my career.  I never expected such a small thing to make my life easier in such a big way.  I’m now somewhat concerned that the use of the rainbow as a symbol in the COVID-19 pandemic may have diluted the impact of my rainbow badge but I hope it hasn’t.

It may not have been designed as an part of a mental health toolkit, but for me, the rainbow badge has become an essential piece of equipment for my job.  2020 has been an odd year.  It turns out that I don’t need a tongue depressor, but I do need a rainbow badge.

Edward Snelson
Also ship-shape award badge owner

Monday, 22 June 2020

Heat Related Problems in Children

As a heatwave hits the UK, we can expect a significant number of children to present with heat related problems.  In the vast majority of cases, these will be benign and self-limiting.  In a small proportion, heat can cause serious illness.

The effects of excessive environmental heat in children are well described but there is a lack of a decent evidence base regarding incidence and effectiveness of treatment.  It is often stated that children are more at risk due to their increased body surface area to weight ratio, however true heat related illness is rare in children and admission to hospital is even less common.  It is likely that there are several protective factors including their robust physiological compensatory mechanisms and human factors which help to keep them from becoming seriously unwell.

Common heat related presentations in children

Heat rash (Miliaria)

Also called prickly heat or sweat rash, a raised erythematous itchy rash is a common problem during a heatwave.  The pathogenesis is to do with increased sweat gland secretion and the inflammatory effects of this.  Miliaria is not harmful but it is uncomfortable.

The child with miliaria will be well and there are no systemic effects.

Prevention and non-pharmacological treatment are one and the same for miliaria.  Avoiding prolonged exposure to excess heat is the single most important intervention.  Parents should enable the child to rest in a cool environment out of the sun.  Unsurprisingly hydration is also important.

Pharmacological interventions include calamine lotion and antihistamines.

Swollen hands and feet (Heat oedema)

Heat oedema is less common than heat rash but also seen in significant numbers of children during a heatwave.  The mechanism for this occurring is the physiological peripheral dilation of the peripheries.  As with miliaria, there will be no systemic effects on the child, who should be otherwise and obviously well.

Non-pharmacological treatments are also the mainstay of treatment of heat oedema.  Diuretics should never be used due to the risk of precipitation dehydration or electrolyte imbalance.  Cooling down, resting and drinking are what these children need.


This is not really a heat related problem but is seen much more commonly during a heatwave.  When the sun is out, children often play outdoors with more skin exposed.  Certain plants leave chemicals on the skin which are activated by sunlight.  This then leads to dermatitis.

Children with phytodematitis will be well but have an itchy papular rash in areas of exposed skin, sparing the area that was clothed at time of exposure.  The rash is usually self-limiting but in some cases can go on to cause hyperpigmentation.  Acutely treatment is symptomatic with antihistamines and a short course of topical steroids as pharmacological options.


Again, sunburn is not caused by heat but by exposure to sunlight.  Significant sunburn can be a contributing factor to dehydration.  It should therefore be included in the assessment of risk when a child presents with more significant heat related symptoms.


Children and young people are well known to have a high incidence of vasovagal syncope.  The reason for this peak, often seen in adolescents is not fully understood.  Heat related syncope is also a reasonably common presentation in children and young people.  As with vasovagal syncope, the assessment of heat related syncope in children is all about establishing a typical history and excluding red flags.

The child with heat syncope who has made a good recovery should be managed with preventative measures to avoid a further episode - rest, a cool environment and good hydration.  Note that there is no specific evidence to recommend any specific hydration fluid over another for these minor heat related illnesses.  Water is probably as good a place to start as any.

Uncommon heat related presentations in children

Heat related illness that makes a child systemically unwell is relatively uncommon.  When it does occur, there are usually risk factors or extreme and prolonged exposure to excessive heat.  Paediatric patients most at risk of significant heat related illness are those who cannot regulate their own fluid intake or clothing/ environment such as babies and children with neurodisability that impairs the ability to self-care.

The greatest risk usually comes from the combination of risk factor and environment, such as a baby left in a car on a hot day.

Another risk factor is the extremem change in environmental temperature.  Humans have an ability to adapt to different environments, a process that occurs over the space of weeks.  This allows us to cope with the change in seasons.  When weather goes from a relatively cool period to very hot weather suddenly (i.e. a heat wave), that adaptation can't happen, thus the sudden rise in heat related illnesses disproportionate to the actual outside temperature.

Significant heat related illness is different from the above conditions because there are systemic manifestations of a combination of over-heating and dehydration.  The range of presentations is a spectrum of illnesses which include heat stress, heat exhaustion and heat stroke.

Heat stress

Heat stress is the mildest form of heat related illness with systemic effect.  With heat stress, the child is feeling the effects of heat and they will let you know about it in an age appropriate way.  Children with heat stress may be tired, grumpy, and have headache or general aches and pains.  Babies will cry excessively or be fussy with feeds.

A key feature of heat stress is that body temperature is not raised and there is normal function.  Heart rate is normal if the child is settled.

Heat stress should be managed with paracetamol (acetaminophen) for the pain*, rest, oral fluids and a cool environment.  This can be done in a pre-hospital setting with safety-netting advice.

*Paracetamol does not reduce body heat when it is due to environment and dehydration.

Heat exhaustion

Heat exhaustion is a more extreme systemic effect from the same combination of excessive heat and poor hydration.  Children with heat exhaustion will be more unwell and are on a downward spiral as they may start to vomit or have diarrhoea.  They will be more affected by how unwell they feel, but their conscious level should be normal.

The child with heat exhaustion is likely to have a raised body temperature somewhere above 38°C but below 40°C.  Dehydration and the heat effect will manifest as tachycardia and the child will look more unwell.  End organ function is still normal at this stage, but the child is at risk of deterioration due to the cycle of symptoms impairing hydration.

The management of heat exhaustion is similar to heat stress but with the addition of active cooling.  The most commonly recommended method for this is to place the child in a cool bath.  The temperature of water for this intervention is ill-defined but it should feel cool and not be cold enough to make the child shiver.  An alternative way of cooling is the use of cool wet towels.

Children with heat exhaustion may be managed in an Emergency Department or Paediatric acute ward and discharged when they are normalising.  Oral hydration is normally achievable.  If vomiting is an issue, anti-emetics or nasogastric fluids are options.

Heat Stroke

Heat Stroke is rare in children.  It is the seriously ill end of the spectrum of heat related illness.  Like sepsis, it has a definition that doesn't work well in the initial assessment of the child.  For the front line clinician, the bottom line is that the child who looks seriously unwell due to heat exposure should be presumed to have heat stroke.

One of the most consistent features is the central nervous system effects of heat stroke.  Children become severely confused or agitated to begin with and then progress to coma.  Seizures are a common problem in heat stroke and risk further increasing body temperature.

As with all heat related illness, simple measures are still important.  The child should have clothing removed and placed in a cool environment as soon as possible.  Applying cool wet towels can be used to begin the cooling process.  Once in a hospital setting the child will need critical care level management.  Airway management, venous access and intravenous fluids (room temperature normal saline) are all key interventions while getting expert help.  For the hospital physician wanting more information about the ongoing management of heat stroke in children, I would recommend this article.
So, while rashes, swollen peripheries and simple faints are the things that you are most likely to see, there is always the risk that the overheated child is on the slippery slope of heat related illness.  Children who are alert and able to drink can be managed with good advice and safety-netting.  Stay cool, rest up, drink plenty and come back if you're getting worse.

Enjoy the sunshine but stay safe.  If the UK weather does what it normally does, next week's topic will be the management of the hypothermic child.

Edward Snelson

Friday, 5 June 2020

Transient Synovitis of the hip (Irritable hip)

A common presentation in young children is the mysterious limp.  Transient synovitis (irritable hip) of the hip is the most common cause of an unexplained limp under the age of 6.  The current usual practice is to make the diagnosis of irritable hip on clinical grounds.  It is no longer routine practice to support this diagnosis with blood tests or imaging.  This development in practice opens the possibility for a young child with a mysterious limp to be managed outside of a hospital setting where appropriate.

What is transient synovitis of the hip (irritable hip)?
The cause of transient synovitis of the hip is unclear.  It is presumed that most cases are a reactive arthritis with a viral trigger.  Injury can also be implicated but it is unclear whether such associations are causal or simply bring the problem to someone’s attention.  It is also common to find typical features of transient synovitis of the hip in children who have no history of viral illness or injury.  There is therefore no need to rely on a history of a possible trigger to make the diagnosis.

As the name suggests, there is inflammation of the synovium of the hip.  Ultrasound may show or synovial thickening or increased fluid.  Inflammatory markers are not usually significantly raised.  Neither of these investigations is reliable and no longer done routinely since the gold standard is clinical diagnosis.

How is transient synovitis of the hip diagnosed?
Typical features of transient synovitis of the hip are:

  • Unexplained onset of limp (no history of more significant injury consistent with fracture)
  • Well and afebrile child with no signs or symptoms of other significant acute illness
  • Unilateral hip signs – painful or reduced range of movement
If a child has these features and no signs of another cause, the diagnosis is almost certainly irritable hip.  Other important diagnoses to consider are:
  • Septic arthritis - usually presents with fever and complete refusal to weight bear
  • Osteomyelitis - usually febrile and there is localised tenderness or swelling in the bone
  • Toddler fracture - undisplaced fracture of the tibia usually presents with complete refusal to weight bear and has localising signs in the tibia (tender or slightly warm to touch)
  • Other significant fractures are usually accompanied by localised swelling or tenderness and are clinically obvious.
  • Juvenile idiopathic arthritis (JIA) - This is very uncommon under the age of 6.  Obvious swelling of a single joint (without signs of infection) may indicate a transient arthritis of a joint other than the hip.  If the affected joint is the hip and the diagnosis is JIA, this will probably be clinically indistinguishable from irritable hip.  However the child would only need to be referred if the arthritis persisted for several weeks, so analgesia and watchful waiting is the initial management in any case.  If multiple joints are involved or symptoms cannot be managed easily, early referral is indicated.
  • Perthe's disease - The cause of this disease of the hip is unknown.  The femoral head becomes avascular and breaks down.  The typical age is a school age child but there is some overlap with the age at which irritable hip presents.  The unexplained limp in a child over the age of six should raise suspicion of Perthes disease.  Under the age of six, progressive symptoms or symptoms that fail to improve after a few days are concerning.
  • Non- musculoskeletal - Limp may be a sign of pathology unrelated to the lower limb.  Abdominal pain or scrotal pain can cause a child to limp.
One of the best discriminators between all of these problems is the course of the symptoms.  While symptoms can vary in any illness, a significant fluctuation in pain and limp is most indicative of transient synovitis of the hip.  While syptoms may be still present after three days, it is unusual not to see significant improvement in that time.

A typical presentation, absence of red flags and a classical course of the symptoms usually make it obvious when the problem is irritable hip.  If all of these things apply, management is watchful waiting with good safety netting advice.

Edward Snelson