Sunday, 8 September 2019

It’s all about the sequence - Reflex anoxic seizures and breath-holding attacks in children

There are a couple of childhood phenomena that every clinician should know about.  These events are terrifying to parents yet they are safe and not harmful.  When children have a reflex anoxic seizure or a breath holding episode, it will sound alarming to the clinician to whom the child presents.  The extreme nature of the event might suggest a diagnosis of epilepsy or head injury.  It is possible to distinguish these phenomena from their better known counterparts.  The best bit about diagnosing reflex anoxic seizures and breath holding episodes is that no tests are needed – it’s all about the sequence.

Let’s look at two cases:

Case One – Gina

Gina is an 18 month old toddler who has always been fit and well apart from the usual respiratory tract infections that go with the territory of being a young child.  Gina was born by normal delivery, following a healthy pregnancy and was well at birth.

Gina’s parents have attended following an event which occurred this morning.  Gina was playing when her older sister took away her toy.  Gina cried for a minute while her mother negotiated with the older sister to resolve the situation.  Gina’s mother then noticed that Gina’s crying sounded quieter and looked to see that Gina was turning a deep purple colour.  There were no objects that Gina could be choking on.  As her mother went to pick her up, Gina stopped breathing altogether and then went floppy.  While still unresponsive, Gina then started breathing and slowly her colour returned to normal.  As she improved in colour, she became responsive.  Within minutes she seemed completely normal.  Her parents have brought her to find out what happened.

Gina is now looking very cheerful and is exploring the room you are in.  She has a normal cardiorespiratory examination.  Her neurological examination is normal for her age.

What did happen to Gina?

Gina has had a breath-holding attack.  This is a phenomenon in which disordered breathing leads to prolonged expiration and a temporary failure to inhale.  Sometimes these events simply result in a blue episode and then self-resolve.  In some cases, the child may actually stop breathing and collapse.  When this occurs, the normal respiratory drive re-sets and the child recovers as a result.

Case 2 – Tina

Tina is a 2 year old child who is usually fit and well.  Tina has been brought by her parent following an event that has just happened this morning.

Tina was running around and having a lot of fun in her house this morning. She then banged her head on a door handle.  Her mother was there when it happened and there says that Tina started crying immediately.  After just a few seconds of crying Tina, suddenly went pale and collapsed to the floor.  She looked as though she was dead for a few seconds and then she went stiff.  After that she had a few jerking movements and then stopped.  Her colour then improved and she started to make some normal movements.  Tina then slowly returned to being her normal self over about 30 minutes.

When you examine Tina, she is back to normal and trying to climb onto the chair.  She is laughing and interactive.  She has a normal cardiorespiratory examination.  Her neurological examination is normal for her age.

What happened to Tina?

Tina has had a reflex anoxic seizure.  This is another phenomenon seen almost exclusively in young children.  A noxious stimulation (pain or surprise or emotional upset) causes an extreme vagal response.  This leads to hypotension and bradycardia.  Circulation is briefly arrested causing a collapse and the alarming change of colour.  In some cases the episode resolves from this point.  In some cases the sudden loss of cerebral perfusion leads to a seizure, which is usually brief.
Whether a seizure occurs or not, the child will reset and recover.  It is likely that the collapse itself stops the vagal overstimulation.

Breath-holding attacks and reflex anoxic seizures have many features in common with each other.  Both occur in young children.  Both cause colour change, collapse and self-resolve.  Both phenomena are terrifying for a parent to witness.
The way to tell the difference between a breath holding attack, reflex anoxic seizure and other cause of collapse is by listening to the sequence of events.

Telling the difference between a breath-holding attack and a reflex anoxic seizure is not crucial.  The management of the child who has had one is exactly the same.  The most important thing is to tell the difference between these two phenomena and a traumatic or idiopathic seizure.

Following a reflex anoxic seizure (or reflex anoxic spell without seizure) or breath-holding attack, the most important things to do are as follows:
  • Examine the child.
  • Ensure the child has a normal cardiorespiratory and normal neurological examination.
  • Explain the event to the parent.
  • Tell the parent that these episodes fix themselves because the child’s breathing and circulation have an automatic restart mechanism that is not affected by the breath holding or reflex anoxic seizure.
  • Explain that it is possible that the child may have further episodes.  If this occurs they should allow the child to collapse to a lying position.  Holding the child up delays the return of circulation.
In which case, trust the sequence. It is worth pointing them to a good information source such as the STARS patient information (Reflex anoxic seizures).

If the diagnosis is clear and the examination is normal, there is no need for investigation or follow-up.  Some clinicians will do an ECG but if there is genuine suspicion about an underlying arrythmia, a resting 12 lead ECG is not an adequate test.  If there are suspicious features in the history or examination, a 12 lead ECG should be a stepping stone to further investigations such as a 24 monitor.

In most cases the diagnosis is apparent and the examination is normal.

Edward Snelson
Consequential clinician

Disclaimer - If you get a Fibonacci sequence, that's worth a case report.

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.

  • 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

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.

Sunday, 30 June 2019

Chest X-rays in children - The Wimbledon Rules

We've come a long way in terms of reducing unnecessary tests in paediatrics.  It is within my career that it was standard to obtain a chest X-ray (CXR) for any child presenting with their first episode of wheeze.  Now, such an approach is seen as outdated.  This is a good thing.  In fact the vast majority of acute and sub-acute respiratory presentations in children can be managed without needing a CXR.

In some ways it was a lot easier to know when to do a CXR 20 years ago.  The answer was pretty often.  Every lower respiratory tract infection (LRTI), every first episode of wheeze and every persistent cough tended to result in a CXR.  Now, we should rarely do CXR in those circumstances.  Rarely doesn't mean never though, so how do you know if you're doing too many?  Enter the Wimbledon Rules for CXR in children…  I’ll come to that later.  First, I’ll explore a little bit about the complexities of doing CXRs in paediatrics.

The problem with CXR in children is that it can be misleading.  The most common scenario in which this is true is for the wheezy child.  Wheeze is a strong negative predictor of pneumonia(1).  This makes sense clinically when you think about it.  If an infant or child has restricted lower airways, that is reason enough to have respiratory distress.  If you then take a section of lung out of action, you won't be wondering if they might have a problem.  It is likely to be very obvious from how unwell they are and how abnormal their breathing is.  As a rule, children with tight airways and pneumonia together are in a very bad way.

While wheeze is a strong negative predictor of pneumonia, a CXR in wheezy children is rarely clear.  In many cases there is a patchy white area on the CXR.  This is often at the right heart border, or as it is sometimes called, "the area of radiological romance."  If you do a CXR too often in wheezy children, this will happen fairly frequently and it may be difficult to ignore.

Even if a child does have a LRTI, CXR is not necessary in many cases.  The British Thoracic Society (BTS) guidelines for community acquired pneumonia (CAP) recommend the following:

  • Chest radiography should not be considered a routine investigation in children thought to have community acquired pneumonia. 
  • Children with signs and symptoms of pneumonia who are not admitted to hospital should not have a chest x-ray.

These recommendations are based on two important facts.

  • Children with clear clinical signs of CAP may have a normal CXR
  • Children with abnormal findings on a CXR often do not have clinically significant CAP (2)

So when should we do CXR in children?

Let’s start with the times when CXR is not recommended routinely:

  • Bronchiolitis not requiring admission to a critical care unit (PCCU)
  • Episodes of asthma and viral wheeze (no matter how severe or whether it is the first episode of wheeze for that child) which are responding to treatment
  • Community acquired pneumonia without atypical features and which responds to treatment within the first two days
  • Most cases of cough without other features
  • Chest pain in children

CXR is usually most helpful in children in these circumstances

  • Severe exacerbations of asthma or viral wheeze which are getting worse despite appropriate treatment 
  • Community acquired pneumonia which has atypical features or fails to respond to appropriate treatment
  • Daily cough with any of the following features
    • Lasting more than 8 weeks
    • Progressively worsening over several weeks, esp. if moist cough
    • Red flag features (daily fever, night sweats, weight loss)
    • Known exposure to TB
    • History consistent with inhaled foreign body

The other side of the problem is that there is no gold standard test for many of those clinical scenarios where CXR is not routinely recommended.  There is often poor correlation between clinical and radiological findings, but which is more valid?  For example if you take pneumonia in children and treat based on radiological findings versus clinical findings you will end up treating different children.  Clinical findings will be falsely positive and falsely negative just as radiological findings are.

Therefore we need to get a balance between clinical common sense and judicious use of CXR in children.  A simplistic approach which could be applied looks like this:
Whether a CXR is necessary or not is highly subjective.  Ask ten clinicians and you'll get ten different answers, due to the human factors.  It's a little like an umpire in a tennis game.  They're not right all of the time.

For this reason, in a major tournament tennis game, players are allowed to appeal.  However the players appeals are limited.  If they appeal against a decision and that appeal is upheld, they retain the number of appeals that they had before the appeal.  So wrong once, they can appeal again.  Wrong twice and they're out of appeals.

I suggest that clinicians should apply the same rules to the use of CXR in children.  Before doing a CXR, we should ask ourselves the question, "What would I do based on a purely clinical assessment?"  After doing a CXR, we should then ask, "Has the CXR added genuinely useful information to my clinical decision?"

Having a CXR result in a child which doesn't alter our clinical decision, or which dysfunctionally suggests a pathology in the absence of a congruous clinical picture should make us rethink our approach to our use of CXR.  If we're going to apply the Wimbledon CXR rule, when we get one completely normal CXR (or one with a non-descript small white fluffy patch which makes us want to give antibiotics when we wouldn't have done so before the CXR) we should think about more cautious use of CXR. If we get two, we should stop and re-read the rules.

Just as tournament tennis players don't have an unlimited number of appeals, we shouldn't think of CXRs as an unlimited diagnostic resource.  We should use them when they are most likely to change our game.

Edward Snelson
Unappealing Paediatrician

Disclaimer: If you turn the umpire off and back on, the number of appeals resets.
  1. Hirsch, A. et al., Estimating Risk of Pneumonia in a Prospective Emergency Department Cohort, The Journal of Pediatrics, Volume 204, 172 - 176.e1
  2. Virkki R, et al. Radiographic follow-up of pneumonia in children. Pediatr Pulm 2005;40:223e7.

Sunday, 9 June 2019

Mugglevision - Being a clinician to a child with learning difficulties

We all see the world through our own eyes.  It is normal to assume that the person we are communicating with has a similar enough perception of the world to mean that the rules of communication and interaction are fairly standard.

What if your patient has a very different perception of the world to the one you have?  Many of our patients fit into a group that experience the world quite differently to us.  This group includes children and young people with what would be classified medically as having a syndrome, neurodisability, learning difficulties, special educational needs or other such labels.  The trouble with labels is that they are just that - a label.  Labels can be dehumanising and sometimes irritating.  So, to avoid this trap and because it facilitates a theme, I shall refer to any such child as magical.  That makes you and me the muggles in the encounter.
When a muggle meets a person from the magical world, it can be a little difficult to know what to say or do.  That's normal.  What can happen in such circumstances is that the clinician (muggle) retreats to a place of safety, concentrating on the medical aspect of the consultation and communicating primarily with the family (who are also likely to be muggles).

There is a better way than this.  Being a muggle doesn't mean you have to worry about getting it wrong.  If you ask the child and their family what works well, they'll be happy to tell you.  Here are a few of the things they are likely to tell you:

What the (magical) young people tell us:

What the (muggle) family of the (magical) young people tell us:

Next time you encounter a child (regardless of their label) who has learning difficulties, have these as useful rules of thumb.  Each child is different, so if your not sure how best to behave with a magical person, ask them and the muggles they bring with them.

Edward Snelson
Magical world liaison officer

Many thanks to Liz Herrieven for help with this post.
  1. Liz Herrievan, Learning Difficulties in the ED, RCEM Learning

Wednesday, 29 May 2019

Should I prescribe antibiotics for a child with otitis media and discharge from eardrum rupture?

The answer to that question is much more complicated than most guidelines will lead you to believe.
The headline statement recommending the use of antibiotics in this scenario has buried the evidence in multiple layers of interpretation.  To get to the truth, we have to look at the lierature ferred to in the decision to make that recommendation.

Guideline writers put in huge amounts of work looking at all the available evidence and then turning that into simple statements.  When these recommendations are truly simple and make sense in clinical practice, we tend to just follow them.  In a recent Twitter poll of over 600 people, this was far from the case.
If over half of clincians would avoid treatment, that suggests that there is something about the recommendation that is misaligned with our front-line work.  When you deconstruct the recommendation, it becomes clear why that is.

First of all though, let’s look at simple otitis media without rupture of the eardrum (tympanic membrane).

Otitis media is a common childhood infection.  It starts off with a cold and then progresses to an infected middle ear.  It is important to be aware that neither ear pain nor a red tympanic membrane is diagnostic of otitis media.
  • An inflamed tympanic membrane is a common finding in uncomplicated viral upper respiratory tract infections (URTI).  In such cases the tympanic membrane is red but not bulging.
  • Ear pain (otalgia) may be caused by eustachian tube blockage even when there is no middle ear infection.  In these cases the tympanic membrane is typically retracted.
  • A painful ear with a red bulging tympanic membrane is the usual presentation of otitis media.
The evidence for antibiotics being effective in the treatment of otitis media is pretty poor.  In a Cochrane review of this subject (1) it is reported that antibiotics have no effect on pain at 24 hrs and that you need to treat 16 children in order to see one of those children having less pain at 2-3 days.  In line with previous discussions re antibiotics, the same review noted that antibiotics had no effect on the rate of complications.  With a similar number of children being made unwell by the antibiotics, it is questionable what their role is at all in uncomplicated otitis media.
Many guidelines list exceptions to this rule.  One that often confuses clinicians is the scenario of the child who presents with a sudden onset of purulent discharge from the ear.  In these circumstances, there is often a recommendation to treat with antibiotics.

So where does this recommendation come from?  Peeling back the layers is quite interesting and what lies beneath the recommendation shows that it is far from a straightforward "must do" for antibiotics in children when the otitis media bursts the tympanic membrane.

Starting with a commonly cited recommendation, the NICE CKS for acute otitis media (2) states "...immediate antibiotic prescription could be considered in children... ...of any age with both AOM and ear discharge..."  The basis for this recommendation is cited as the aforementioned Cochrane Review (1).  This Review states "Antibiotics are most useful in children under two years of age with bilateral AOM, or with both AOM and otorrhoea. For most other children with mild disease in high-income countries, an expectant observational approach seems justified."

The Cochrane Review conclusion itself is based on a paper (3) that looked at the features that made it more likely that antibiotics would have an effect.  In the case of otitis media with otorrhoea, it found that the NNT improved to 3.  That sounds good, so why would most people avoid treating?

The answe is simple.  In the published evidence, the effect of antibiotics was still to do with symptom (mainly pain) improvement.  That is clinicaly important because in many cases pain is resolved when the discharge occurs.  Presumably this is because the pain was due to the stretching of the tympanic membrane rather than due to the inflammation of soft tissues.

If the pain is resolved, the NNT to treat becomes irrelevant.  How can you improve pain that has gone away? Even if there is still some discomfort, if this is controlled by analgesia, isn't that a better option than antibiotics?

Therefore, when a child presents with otorrhoea due to otitis media, rather than faithfully following a recommendation to give antibiotics, we consider the applicability to the child in front of us.  If the pain has gone or is easily controlled with analgesia, we can hold off.  The appearance of the discharge may be alarming but it is often the beginning of the end of the illness.

What about topical antibiotics?  These are also frequently recommended.  In answer to these recommendations I would point out that neither the NICE CKS nor the Cochrane review have recommended antibiotic ear drops for this clinical scenario.  In addition, there is BMJ paper (4) that states "Topical antibiotics are associated with fewer systemic side effects and a lower risk of antibiotic resistance than oral antibiotics, but there is no strong direct evidence to support their use in this condition."

So there you have it - the bottom line:
Once the recommendation to treat is deconstucted, it all makes sense.  In this case, it seems that taking it apart and looking inside reveals why most of us still don't give antibiotics when nasty green stuff starts pouring out of a child's ear.

Edward Snelson
Guideline Deconstrucivist

Disclaimer - One time I took a guideline apart and couldn't work out how to put it back together. It's still in my cellar.
  1. Cochrane Database of Systematic Reviews Antibiotics for acute otitis media in children
  2. Acute Otitis Media Clinical Knowledge Summary, NICE
  3. Rovers M at al, Antibiotics for acute otitis media: a meta-analysis with individual patient data, The Lancet, Vol 368, Issue 9545, 21–27 October 2006, Pages 1429-1435
  4. P Venekamp et al, Are topical antibiotics an alternative to oral antibiotics for children with acute otitis media and ear discharge?, BMJ 2016; 352 doi:

Wednesday, 15 May 2019

The simple bit of equipment that will transform your child and adolescent mental health assessments

Mental health problems in children and young people (CYP) are common and on the rise.  Identifying these problems in CYP is particularly challenging due to a variety of barriers.  Some of those barriers exist within ourselves (misconceptions) or our working environments (time pressures).  Often the barriers come from the child or young person.   All of these barriers can be overcome.  Let’s look at how that is possible.

The first place to start is with ourselves.  We need to make sure that our attitude towards CYP and their mental health is such that we are open to see and hear the signs that indicate what is going on.  A positive attitude is also essential so that the CYP and their family are likely to want to disclose what they need to in order to get a good picture of what is happening.   All the usual things that apply to working with young people apply in a mental health assessment but are more important than ever due to the patients mental state.
Next we need to look at our working environment.  The time pressure issue is a big one.  The bottom line is that unless we find a way to make time for mental health presentations, we can’t expect these contacts to be effective.  There are many other environmental factors to consider which are key to helping CYP access the help that they need.
Finally there are the barriers that seem to come from the CYP.  As suggested above, it is a good thing to see any such barriers as expected.  The worse the situation, the bigger the barriers are likely to be, and the greater the need to have these barriers overcome.  The right attitude and environment are both hugely important in overcoming these barriers.  It also helps to name them with the patient and their family.  That goes something like this:

With the family present- "I know that it is really difficult to put how you feel into words.  It’s also usual to be thinking that if you tell me what you’ve been thinking, I will think you’re crazy.  I won’t.  Anything that you can tell me will be really helpful.  Just tell me in your own words and take your time.  You’ll get a chance to talk to me without your family being there so feel free to save anything that you’d rather talk about without them there for then."

With the young person on their own – "We always give people a chance to talk about what is happening without their family sitting in.  That’s important for a couple of reasons.  Firstly these things are complicated and quite often young people feel that their family either don’t understand what’s happening or have strong opinions that make it difficult for you to say things the way you see them.  Here on your own you can talk about things and know that I’m just interested in what you want to tell me about what’s happening and how you are feeling.  Secondly, there are some times that there are things that really need some privacy to be able to talk about.  That can be things that you feel you can’t tell your family about, like taking drugs, or it can be things that I need to know such as if someone is harming you in any way.  I’ll treat things you tell me with confidentiality wherever possible.  If someone is harming you then I would need to act on that to keep you safe."

Even when you go through all of that, it is sometimes the case that all you get is shrugs and a marked lack of usable interaction.  At that point, you have another ace to play.  It is a valuable piece of equipment in CYP mental health assessment and it looks like this:
Giving the patient the opportunity and the space to write instead of speaking is a game changer in ways that you might not expect.  In a spoken interaction, CYP in a mental health crisis are likely to find it difficult to find the words to say how they have been feeling and thinking.  They will worry about the response that they will get to what they say.  This fear of being appraised can be paralysing.  Even if the person they speak to does everything perfectly in terms of verbal and non-verbal communication, the CYP may over-think everything they see.  Such is their hyper-acute mental state that this happens easily.  “They just frowned slightly.  Does that mean that they don’t believe me?  Perhaps it means that what I said is completely mental.”

A piece of paper doesn’t have an opinion and there is no response to misinterpret.  It doesn’t rush you and you don’t have to worry about getting your words right.  You can write it down and see if it looks OK before anyone else sees it.  A piece of paper accepts everything you put on it without interrupting or giving your family the opportunity to tell your story differently.

Try it out as a strategy the next time a child or young person is struggling to communicate in a mental health consultation.  You might be very surprised and pleased with the results.

Edward Snelson

Tuesday, 30 April 2019

Rashes in children: What is the diagnosis? - Probably a virus

A rash is a very common feature of a paediatric presentation and is often the primary reason for seeking medical advice.

I think that clinicians also sometimes feel a bit of anxiety about rashes.  What does the rash mean?  Should I be able to diagnose the illness based on the rash?

The rash can be diagnostic but often it is not.  Even when the rash gives a specific diagnosis, that diagnosis is usually a virus and treatment remains symptomatic and supportive.

These are some important questions to have answers to when assessing a child with a rash.
  • Is the child well? If not, how unwell are we talking about and for how long?
  • Is the child febrile?
  • How did the rash start?
  • How has the rash changed since it started?
  • Is the rash itchy?
When examining the child, it is important to avoid the temptation to focus excessively on the rash.  The child should have a systemic examination that will identify any cardio-respiratory, abdominal or neurological abnormality.

The rash itself is then in context of an assessment that has determined whether the child is significantly unwell or has any significant abnormal findings.  What this tells us is whether the rash is of importance because the child is quite unwell, or more of interest since the child is well.  In the well child with no significant abnormal findings, a diagnostic rash can still give useful information in terms of prognostication and the ability to give specific advice about what to do from a infection control point of view.

Let’s look at some specific rash related diagnoses that are accompanied by non-specific symptoms such as pyrexia-

Roseola Infantum
What does it look like?
This infection is most commonly seen between the ages of 6 months and 3 years.  The classical presentation is of a significant fever but a surprisingly well child with non-specific symptoms such as coryza and pharyngitis.  Essentially, the child has all the signs of a viral upper respiratory tract infection (URTI) but with an impressive fever.

A macular patchy erythematous rash often appears as the fever starts to resolve.  Typically the rash is more prominent on the trunk than limbs.
What causes it?
Human herpes virus 6

What specific advice is there for this diagnosis?
None.  Treatment is symptomatic.

What does it look like?
Chickenpox is a vesicular (small fluid filled lesions) rash which is usually found all over the body.  Children are usually either mildly febrile and unwell in the first few days, or not unwell at all.  The rash is often itchy.
What causes it?
Varicella zoster virus

What specific advice is there for this diagnosis? 
There is no specific treatment.  If the child seems unwell then paracetamol (acetaminophen) is the preferred treatment for systemic symptoms.  While there is some concern about using ibuprofen, the evidence strongly suggests that this concern is unfounded.  However, most children do not become significantly unwell with chickenpox and it is unusual for symptoms to require more than paracetamol.  If a child with chickenpox is very unwell, that is a clinical situation that mandates a careful assessment to consider the possibility of sepsis, usually in the form of invasive streptococcal infection.
Itching can be treated with antihistamines.  In the UK, it is usual practice to ask that the child is kept out of school or nursery until day 7 of the rash, at which point new lesions are not forming and the existing spots are crusting.

Hand, foot and mouth disease
What does it look like?
Vesicles on the face around the mouth, ulcers inside the mouth, vesicles on the hands and feet and perianal vesicles or ulceration.  (Somehow the perianal bit got left out when naming this childhood infection)  The child is usually systemically well but when the rash is appearing may be a little miserable and pyrexial.

What causes it?
Coxackie virus

What specific advice is there for this diagnosis?
Treatment is symptomatic.  This is a good opportunity to practice the philosophy of “treat the child, not the fever.  Many children with hand, foot and mouth disease are not febrile but may be in significant discomfort from the oral lesions.  The importance of analgesia to help the child be comfortable enough to drink should be emphasised.
The UK public health advice for hand, foot and mouth disease is that in itself, it does not mandate and absence from school or nursery.

Pityriasis rosea
What does it look like?
The classical pityriasis rosea rash starts with a herald patch in the form of a well localised erythematous area somewhere, usually on the trunk.  This may go unnoticed and if seen rarely causes alarm.  The generalised rash that follows is what usually leads to the seeking of a medical opinion.  This rash is an impressive patchy pink rash with the pattern of the patches following the lines of the dermatomes of the skin on the trunk, forming what is described as a “Christmas tree” distribution.

What causes it?
Human herpes virus

What specific advice is there for this diagnosis?
The child is usually well at the time of the Christmas tree-like rash appearing so no specific treatment is needed.  It should be explained that the rash may last for a few weeks.  There is no need for the child to be excluded from school or nursery.

Slapped Cheek Syndrome (Fifth Disease)
What does it look like?
Most of the features are non-specific: Fever, coryza, sore throat.  The name comes from the typical bright red rash which appears (usually) on both cheeks.  The redness is both more impressive and more consistent than the flushed cheeks seen in febrile children.  This is often followed by a more non-specific, patchy, popular, blanching erythematous rash on the rest of the body.

What causes it?

What specific advice is there for this diagnosis?
For the purposes of managing the child, treatment is symptomatic.  Most cases of slapped cheek resolve without complications.

A rare but significant complication of parvovirus is an aplastic crisis secondary to the effect of the virus on the bone marrow.   A history of recent parvovirus infection followed shortly afterwards by significant or atypical illness or pallor should prompt the testing of a full blood count.

Parvovirus infection in pregnancy carries a risk of miscarriage or hydrops fetalis (due to the same aplastic crisis).  Parvovirus is not treatable and most pregnant women are immune.  In most places, the advice for pregnant women who come in contact with parvovirus is to seek medical assessment if they subsequently become ill, especially if they develop a rash of any kind.  If serology confirms parvovirus infection then the pregnant woman should be referred to the fetomaternal team.  Through the marvels of modern medicine, it is now possible to transfuse a baby in utero and potentially keep them well long enough to reach a gestation where it delivery is an option.

What does it look like?
Typically the child is febrile, coryzal and coughing for a couple of days before the rash appears.  The rash itself is an erthematous maculopapular rash which usually starts on the head before spreading to the rest of the body.
Kopliks spots are diagnostic but rarely seen as they don't hang around for long.  These are small white spots that appear on the inside of the cheeks, opposite the molars.
Measles should be suspected when a child has significant non-purulent conjunctivitis or is particularly miserable despite analgesia.  Unlike uncomplicated viral illnesses, the child is usually quite unwell several days into the illness when the rash appears. (Consider a differential diagnosis of Kawasaki Disease in the child who has had fever for five days as many of the features overlap.  Unlike Measles, early specific treatment for Kawasaki Disease is essential)

What causes it?
Measles virus

What specific advice is there for this diagnosis?
Measles infection requires specific infection control measures and in the UK is a notifiable disease.  There is no specific treatment for Measles and at presentation, the key decision is about how unwell the patient is.  If well enough to be managed at home, it is very important to avoid unnecessary admission to hospital as this might lead to infection of those most at risk.  However if the child is showing signs of significant infection (mainly encephalitis) then admission is probably necessary.  If referring to secondary care it is essential that the accepting team are aware that Measles is suspected so that the child can be kept away from others from the moment of arrival to hospital.

Viral Urticaria
What does it look like?
It looks like an allergic reaction or nettle sting.  The itchy, raised red and white rash can be seen in any part of the body and can be quite alarming.  Typically this rash appears as the illness is getting better.  Lesions appear and disappear several times a day.  If the onset of the rash is accompanied by other symptoms appearing (such as wheeze, oral swelling or vomiting) then acute IgE mediated allergy should be suspected.  Viral urticarial should not be accompanied by the appearance of these symptoms.

What causes it?
One of many possible viruses

What specific advice is there for this diagnosis?
It should be explained that the rash is caused by the virus and the child’s immune system.  The rash doesn’t tell us anything specific about the infection and doesn’t mean anything bad about the illness or the child.   While anthistamines may reduce the itching, they do not seem to make the rash go away any faster.  The rash will usually resolve spontaneously over the space of several days.

It is notable that children who develop viral urticaria are sometimes taking antibiotics when the rash appears.  This can cause concern regarding possible drug allergy.  The evidence suggests that a large number of children developing rashes while taking antibiotics are simply manifesting a viral rash (including urticaria).  This association is contributing to the overdiagnosis of antibiotic allergy.  Many specialists are now advising that a label of antibiotic allergy is not given to a child if they have an acute illness that could be viral, the only symptom is a rash and it is the first time the child has had a rash while taking antibiotics.

Non-specific Viral Rash
What does it look like?
These rashes can appear during the acute infection or recovery phase of the illness.  Typically the rash is a diffuse, patchy erythema.  It may be macular or papular.  In the majority of cases, all of the rash blanches.  Occasionally, a few petechiae can be found.  In a population vaccinated against most strains of meningococcus, a small number of petechiae is most likely to be part of a viral rash.  Indeed, finding one or two petechiae is within normal for a well child at any point. (1)
What causes it?
Any virus that is on the rash B-team could be responsible.  If it's not a diagnostic rash, you can't make a specific diagnosis.

What specific advice is there for this diagnosis?
It's important to explain that the rash doesn't have any specific meaning. For example, a child with this rash does not need to be kept out of school, for infection control reasons at least. Safety-netting advice should mainly centre around the illness, not the rash.  The rash may well persist after the child's illness has resolved.

Many specific rashes start of as non-specific so if the rash changes significantly they may need to be reassessed.  In particular they should know how to assess for non-blanching rash.

Erythema Multiforme
What does it look like?
As the name (What, no Latin?) suggests, it is a rash with multiple forms.  The rash varies from place to place rather than being uniform in appearance.  The rash varies in appearance and texture.  The typical target lesions that also help make the diagnosis are circular and have a dark red centre.
What causes it?
The rash is in many ways very similar to urticaria in children.  It may be a drug reaction but is more commonly triggered by a virus.  That virus is not usually specifically identified.  Atypical bacterial infection, most commonly mycoplasma, may also trigger erythema multiforme.

What specific advice is there for this diagnosis?
Essentially the same applies to Erythema Multiforme as applies to viral urticaria and non-specific viral rashes.  If there is no obvious specific cause, safety-netting for the illness is most important.

Because Erythema Multiforme can rarely progress to Stevens-Johnson Syndrome, it is worth advising the family to seek reassessment if the child develops an inflamed mouth.

Henoch-Schonlein Purpura (HSP)
What does it look like?The typical HSP rash is a purpuric rash on the lower limbs, predominantly on the buttocks and extensor surfaces.  This is often fully apparent at presentation but sometimes the initial rash is not purpuric.  In some cases other symptoms precede the rash.
Typical symptoms of HSP include leg pains and abdominal pains, though in some cases HSP is asymptomatic.

What causes it?
The cause is unknown, however it is presumed that this vasculitic process is triggered by infection.  In that sense, it can be considered a viral rash.

What specific advice is there for this diagnosis?
Most cases of HSP are suitable for outpatient management and in many cases this is well within the remit of the General Practitioner.  A full explanation of the condition, possible complications and how to manage/ followup can be found here.

Bringing it all together
So there you have it - a reasonably comprehensive list of common rashes seen in childhood infections.  In most cases, the rash will not give a specific cause.  In every case, the clinical condition of the child is by far the more important part of the assessment.  After all, it's probably a virus and you probably can't treat that.

Edward Snelson
Rash decision maker

Disclaimer - it might not be.
  1. Downes AJ, Crossland DS, Mellon AF Prevalence and distribution of petechiae in well babies Archives of Disease in Childhood 2002;86:291-292.