In Praise of Doing Nothing (Easter Egg – good safety-netting and saving lives)

When I ask parents if they have seen their GP about an illness they often reply, “Yes but they didn't do anything.”  I am most encouraged whenever I hear this.  So, no-one has done any tests or prescribed any treatment?  “Excellent” say I, “and your child is the healthier for it.” 

Here's why:

So, if you are one of these clinicians who are doing a lot of nothing, you have my thanks and admiration, because I know how much work it takes.   All I would like to do is add my top tips for making sure that the child with… let’s say a viral URTI, is sent out into the world with the best possible advice and safety-netting.  Why?  Because safety-netting is what makes all the difference when a child with an uncomplicated viral illness develops a secondary infection (or other complication).

• Try not to say the words ‘just a virus’ or ‘only a virus.’  Parents will tend to feel that you have not recognised how unwell their child is.  Acknowledge that the child is unwell and explain that viruses can make children quite unwell.
• To balance this, (lest they ignore signs of serious illness) explain that the hallmark of viral illness is that the child will intermittently pick up and look reasonable, often quite suddenly.  Children with sepsis and meningitis do not go from playing to lethargic and back again every few hours.
• Explain that children with a viral illness do sometimes get another infection added on which is usually more serious.  For this reason they must seek reassessment if the child is not picking up or if new problems develop such as abnormal breathing etc.  This part is especially important as occasionally I will see children brought in who are severely septic and the parents have delayed seeking another assessment because they were given what sounded to them like an ‘everything is fine and will be fine’ appraisal by the clinician that they saw.
• Advise regular paracetamol, fluids and to avoid overdressing the child.
• Do not tell parents that if the illness continues they should go to their emergency department to be assessed.  If they are well enough to be sent home then persistence of symptoms does not really warrant an ED attendance.  Save the ED option for the child who is worsening despite paracetamol etc.

It is truly an art to get that balance between being reassuring enough and safety-netting well.  However the worst possible thing would be to add tests to uncertainty or treatments to cover improbabilities.  So thank you and please keep doing nothing.

Edward Snelson

@sailordoctor

Disclaimer:  Safety-netting was invented by Roger Neighbour or possibly Houdini.  Check Wikipedia if you want.

Referrals – Inappropriate, Inconvenient or Unprofessional? (Easter egg - umbilical granuloma)

But first: why the hospital doctor who thinks that they have had an inappropriate referral probably has an educational need.

Every day, around the world, there is tutting by hospital doctors about the inappropriate referrals that they receive from primary care.   If we assume that both clinicians believe in good patient care and the best use of resources then someone must have an educational need for this situation to take place.  My question is: who has that need?

Let’s take a fictional yet real example: a baby with an umbilical granuloma.  The child has apparently been sent to the paediatric emergency department by the clinician who saw them in Primary Care.  The emergency department doctor sees the child, noting the inappropriate use of the ED to filter referrals from a GP.  They complain but accept their lot and assess the child but then send the child back to the GP.

Imagine that we could get the two clinicians to sit down and discuss what happened.  What the GP trainee who saw the child would say was that they thought that the child had an infection of their umbilicus, which they know to be a risk for sepsis in babies.  They tried to refer the child but they were passed back and forth between the paediatricians on call who said that this was a lump and therefore surgical, while the surgeons said that umbilical infections should be referred to the paediatricians.  In the end there was confusion and in the process both teams thought that the other had accepted it and the faxed letter from the GP never found an owner.

So the ED doctor might have been more sympathetic and less likely to say that the ‘referral’ was inappropriate when they found out that it was not a referral.  What the GP trainee might have learned is that umbilical granulomas often have a degree of discharge and look messy but that doesn’t equal infection.  They may have been interested to know that many clinicians are adopting a ‘leave it alone’ approach to umbilical granulomas since they have a natural tendency to resolve. (1) Some advocate hypertonic saline (2) as a topical treatment but ultimately if left alone, these unsightly lumps will go away if you ignore them for long enough.  Most will welcome the move away from the game of ‘hit the moving target with a silver nitrate stick’ while hoping that there is no accidental application onto healthy skin.

Lets hope that the joint RCPCH and RCGP document 'Facing the Future Together' with its 11 recommendations will provide an impetus for better communication between primary and secondary care.  I am particularly hopeful that point 4 becomes a reality because educational meetings can work both ways.

Facing the Future together: The first four standards-

So whenever something seems ‘inappropriate’, it may be a misunderstanding or there may be a genuine opportunity to share something between two professionals.  I accept that there are GPs who don’t care about inconveniencing patients or overloading their local emergency department but these are a vanishingly rare breed.  More often, if I get in touch to clear something up that is exactly what happens and I am just as likely to be the one set straight.  The important thing is to talk to each other and not about each other.  That really would be inappropriate.

Edward Snelson

Naturalised Citizen of the People's Republic of South Yorkshire

@sailordoctor #GPpaedsTips

Easter egg - for more on umbilical granuloma follow the links below

1. Umbilical granulomas: a randomised controlled trial J Daniels, F Craig, R Wajed, M Meates Arch Dis Child Fetal Neonatal Ed 2003;88:F257 doi:10.1136/fn.88.3.F257 http://fn.bmj.com/content/88/3/F257.1.full

2. http://www.ruh.nhs.uk/patients/patients_leaflets/paediatrics/Umbilical_Granuloma_patient_info.pdf
3. www.banglajol.info/index.php/BJCH/article/download/10360/7648  BANGLADESH J CHILD HEALTH 2010; VOL 34 (3): 99-102 Therapeutic Effect of Common Salt (Table/ Cooking Salt) on Umbilical Granuloma in Infants AKM ZAHID HOSSAIN, GAZI ZAHIRUL HASAN, KM DIDARUL ISLAM

Disclaimer: All the opinions expressed here are someone else's.

Why I need GPs to be medical leaders (Easter egg - GORD in babies)

Please Help Me to Change My Practice

In January 2015 NICE published the first of their newly branded ‘CG’s which happened to be Gastro-oesophageal reflux disease: recognition, diagnosis and management in children and young people.  I don’t know how you decide which NICE guidelines to look at but my filter is based on relevance and the extent to which they might make me cry into my coffee.   This one scored a 10, partly because I see lots of vomiting babies (with accompanying parent – this is usually the one I’m more worried about) and partly because we have known for a long time that the available treatments are inconsistent at best.  In the absence of a guideline it is much easier to work through the various non-pharmacological interventions and then take a stepwise approach to treatment, while hopefully the underlying predisposition to create laundry and sleep deprive your parents gradually resolves in time for me to take all the credit.

The truth is that when I see a child with reflux, things are usually pretty desperate for the family.  They are tired, smell of vomit and feel that every time they see a different doctor or nurse they are told something that contradicts previous advice.  I then find it difficult to admit that the problem with which they present is going to follow a course over which I have little influence.  Certainly I do make a difference where possible.  I explore the way that feeds are being given and often find that the volume of feed is excessive.  Occasionally I discover a previously undiagnosed urinary tract infection and get to feel like a real doctor.  More often there is no easy answer and I reach for my prescription pad to prescribe an alginate. 

The thing is that NICE have now said that the initial treatment should be a feed thickener if the child is formula fed.  That should be a simple thing to change but for me it isn’t.   

From CG1 2015

I remember well how in General Practice I used to do this process change.  One day I would find out something, next I would have a quick chat with my GP colleague and then I would get on and do it.  No major fuss.  How things have changed.  Now that I work in a hospital it takes months to change most things.  Certainly when there is an urgent need we get that turned around much faster.  (I won’t say how long faster is.  It depends.)   However if the change is less urgent it requires consensus, consultation and committees to the Nth degree.

In the interest of balance I should extol the virtues of this more cumbersome approach.  It would be chaos if there was no way of ensuring consistency of practices within the various teams of any hospital.  That consistency only comes if guidelines are agreed and well governed.  Achieving that sometimes feels ungainly but is far better than conflicting practices within the same organisation or changes that are ill thought through and are not universally agreed.

The good news is that in the case of these vomiting children it hasn’t been a problem.  The dilemma that I might have faced was taken away because thankfully the last few children that I have seen with gastro-oesophageal reflux were all being treated with feed thickeners and not an alginate.   Since previously the latter was the norm I can only assume that these GPs have decided to lead the way.  No fuss, no committees and no delay.  How wonderful that GPs are playing to their strengths and getting on with changes that take much longer for Secondary Care to implement.

So thank you for providing some true medical leadership.  For those of us working in hospital, we need you in General Practice to lead the way for us.  I’m sure we’ll catch up eventually.

Edward Snelson

Kiddie Doctor

@sailordoctor #GPpaedsTips

Disclaimer: All disclaimers are nonsense.

1. http://www.nice.org.uk/guidance/NG1/chapter/1-recommendations

More treats from the Easter egg:

1) NICE doesn't want us diagnosing 'silent reflux' so much

2) Some red flags here suggesting that there may be another diagnosis or that the GORD warrants rapid referral

Non-specific or non-diagnosis? Non-specific abdominal pain (Easter Egg: Constipation in Children)

Non-specific abdominal pain - why I haven't made that diagnosis for quite some time

I think that I have now heard more than a dozen definitions of constipation and diarrhoea, starting from a lecture that I recall well from when I was at medical school.  The lecturer gave scientific definitions based on volumes and frequency of stool passed in a 24 hr period that led me to believe that I would be able to conclusively diagnose or rule out constipation if only I took a thorough history and a large set of scales with me.

I also recall first hearing about non-specific abdominal pain in children.  It seemed mysterious and yet strangely credible.  It was, I was told, a diagnosis of exclusion.  Presumably the diagnosis of constipation in these children was being excluded by the use of CCTV installed in the child’s toilet and a rigorous measuring of the amount and consistency of everything brown before it was flushed.

I now know the reality, which is that the diagnosis of constipation in children is usually a guess, albeit it a good guess and hopefully an educated one.  Every week I see at least one child of the many who present to our Emergency Department with what turns out to be constipation.  In most cases the most significant symptoms have been present for many days and if one enquires, the clues have been there for months or years.  These children have usually had various people consider what the cause is - parents, GPs and Emergency Physicians.  Often the parents have been given no diagnosis; on other occasions non-specific abdominal pain might have been given as the cause. In reality, the well child with unexplained abdominal pain (once an acute abdomen and a urinary tract infection have been ruled out) almost always turns out to have constipation.

So my question is, how was constipation excluded in the diagnosis of exclusion that is non-specific abdominal pain?  I suspect that there are two things getting in the way.  The first is that it is almost impossible to get a good history about the bowel habit of a child.   They think that whatever they do is normal and their parents are unlikely to know what they are passing and how often.  The second factor is time.  I know that there is limited time to assess a child in Primary Care and let’s be honest, there are other more pressing diagnoses to exclude if a child presents with abdominal pain.  Ruling out a surgical abdomen and a urinary tract infection is always going to be the priority and I can’t do that in less than 10 minutes either.

I feel that there are opportunities being missed though and childhood constipation is one of the best diagnoses to make in primary care for several reasons.

1. It is a difficult diagnosis to make.  All clinicians want to be the first on the scene at a difficult diagnosis and this is your chance.
2. It requires good explanation and consultation skills in order to engage the family with understanding what is happening and what to do about it.  No further comment needed.
3. This is a condition that can be managed entirely in primary care without interference from anyone else.
4. It is a really satisfying condition to treat.  So much childhood illness either gets better on its own, responds poorly to treatment or is untreatable that we should be genuinely excited when we find a condition that probably won’t get better until we diagnose it and do something about it.
5. The effect on quality of life for the child and family is enormous.

I would suggest that non-specific abdominal pain is so often code for undiagnosed constipation that we only use it when constipation has been thoroughly ruled out.  I have been working to this for many years now and I find that once challenged, the evidence for constipation almost always comes out just in the history of children with abdominal pains.  If not in the history then often the examination might reveal hard stools or just a fullness in the left lower quadrant.  A normal examination does not exclude constipation.  Finally, if the pains have been consistent for a while and a macrogol laxative (1) has not yet been tried then this is the controversial bit:  I would not make a diagnosis of non-specific abdominal pain without first attempting to treat as constipation and reviewing early to assess the result.

Does non-specific abdominal pain exist?  I’m told it does but I haven’t yet seen a case myself.

Edward Snelson

Consultant in Paediatric Emergency Medicine

@sailordoctor

1)    Constipation in children and young people: Diagnosis and management of idiopathic childhood constipation in primary and secondary care https://www.nice.org.uk/guidance/cg99

Note: This material is created by the author for the sole use of qualified clinicians.  It is meant as a viewpoint and not intended to replace any applicable guidelines.  Any change in practice is solely the responsibility of the clinician.

Conflict of Interest: Loads

Easter egg: Constipation in Children - key recommendations

• Suspect constipation whenever a child presents with abdominal pain
• UTI is a common co-existing problem and should be ruled out concurrently. The finding of a urine infection increases the index of suspicion for constipation rather than ruling it out.
• Do not treat with lifestyle measures only (1)
• Treat all presentations of constipation with a macrogol laxative (either clear out or maintenance as indicated) (1)
• Continue this treatment for at least several week. It is likely that several months will be needed to prevent recurrence. (1)