When a dilemma presents, take a five year old for a pint

Because most interactions involving a parent and clinician are harmonious, it can be perplexing to find ourselves at odds with a parent or carer.  If there is a difference of opinion about what the best management plan is, I try very hard to find a way to address the parent’s agenda.  It is also important to remember that the best interests of the child should always come first.  Of course, the best interests of the child may be very different to the child's agenda.  The GMC 0-18 guidance (1) says that we need to consider both.

Including the child’s agenda is difficult and at all ages it is easy to allow the fact that children and young people either can’t or won’t articulate their wishes in a useful way to lead to their wants being lost in the course of problem solving.

The fact is that as clinicians, we must always act in the best interests of the child.  This is more complicated than it sounds.  Sometimes that means compromising our plan to help a parent, even when we don’t necessarily agree with their health beliefs.  Sometimes it can mean that we have to insist on a course of action that the parent disagrees with.  If we are faced with the second scenario, we must make every effort to help the parent or carer to understand the reasons for this determination.

I don’t like conflict.  It makes it difficult to think logically and clearly.  It is so much easier to be sure when all parties are in agreement.  The ability to doubt yourself is an essential part of being a good decision maker.  However, facing outright opposition to what feels like the best plan can lead to poor decision making, especially if you like to keep people happy.  So when a conflict cannot be resolved, I take a mental step back and ask the child.  I am not talking about asking the child in front of their parent.  I need to get them on their own and take them for a pint.

Next time you find yourself in a conflict over what to do, try this thought experiment:

Imagine that the child involved is now an adult, able to fully understand all the dilemmas involved.  They have read their medical records and want to talk to you about the thing.  You meet them as an adult and sit down over a pint – beer or tea, it doesn’t matter too much.  (This is a thought experiment so the medical regulatory body can’t strike you off the register.)  So now you can explain to them adult to adult, without a third party involved, why you did what you did .  The agenda of the parent or carer will still be a factor, but the only person that you have to convince is the (now adult) patient.

So how will that go?  Will you be able to tell them that you acted in their best interests?  Will you be able to tell them that you did what you thought that they would want?  If the outcome of the thought experiment is a clear conscience then at least you have fully tried to act in the best interest of the child.  Whether you make the right choice or not is always a retrospective decision.

Often, the best interests of the child are clear in which case I put all my efforts into resolving conflict.  When there is uncertainty or the conflict clouds my judgement, I find that this thought experiment helps.

 Interestingly this thought experiment has always had a pleasant side effect on me.  Afterwards I feel much more relaxed.  I think it is something to with the fact that I have always got on really well with these children turned adults and they have been very understanding.  It’s also nice to have refreshment, even if imaginary.  Of course if I am at work, it has to a pint of tea but sometimes I do this while walking home, in which case I enjoy a pint of Woodfordes (2).  Nothing beats it.

Edward Snelson
@sailordoctor

Disclaimer – no-one should ever take a five year old for a pint of beer.  I am so heretical that I was once discontinued by the Pope.

References

1. General Medical Council 0-18 Guidance 
2. Woodfordes Wherry Ale, Woodbastwick, Norfolk

Refer All Patients (Easter egg - laryngomalacia)

Referral rates from Primary Care have risen over the past ten years yet children are having the same symptoms and illnesses.  Increased referral is sometimes because there are more treatments available and is therefore quite appropriate.  In the case of laryngomalacia, there are really only two treatments, time or surgery, so why should more children be seen by specialists?

I suspect that the answer is partly parental expectation and partly the undermining of the clinical independence of General Practice.  I believe that both of these can be affected by making sure that we know everything there is to know about such conditions.  This allows us to explain the problem confidently and manage it (where appropriate) ourselves.

Sometimes, clinicians in secondary care have anxieties about the ability of primary care to assess and manage a condition and they mitigate that by recommending that all are referred.  General Practice has been the place where uncomplicated laryngomalacia has traditionally been managed.  The case must then be made for that to change if necessary.

So, I will go through some things that you may or may not know about laryngomalacia.  Before I do that, I will give a quick overview.

Laryngomalacia is a condition caused by an abnormal laryngeal cartilage.  It is a dynamic problem that evolves from birth, partly to do with shape and partly to do with floppiness. The typical presentation is that of a child who starts making upper airways noises (video link here) especially when lying down.  Everyone know that upper airways problems are dangerous, yet at least 90% of laryngomalacia will resolve without causing significant problems.

In order to be confident in this we know a bit about it.  Here are the trade secrets.

1. Laryngomalacia is not truly congenital

Although the abnormality may be present or evolving at birth, it is not clinically apparent immediately.  There is something that happens to the larynx shortly after birth which completes the airway abnormality and so the typical clinical presentation occurs sometime in the first few weeks of life.  Stridor that is present immediately after birth is therefore a red flag.

2. Laryngomalacia has a sense of humour

Parents will present their children for assessment with anxiety and frustration in equal measures.  The anxiety is completely understandable.  Their baby makes a noise when it breathes!  The frustration comes from the child's apparent inability to perform during the consultation.  Often a description is all that is needed.  Smart phones make it possible for parents to bring recordings or alternatively you can show them the video link above for reference.  

3. There are pretenders
As always, there are conditions that present in a similar way to laryngomalacia.  Essentially any problem that causes chronic airways turbulence can cause a similar scenario of intermittent stridor.

Pretenders include:

• Vascular rings (blood vessels that encircle the trachea)
• Subglottic stenosis (e.g. due to endotracheal ventilation)
• Cysts
• Polyps
• Webs
• Haemangiomas

If the diagnosis of laryngomalacia is uncertain, it is best to refer so that the ENT specialists can do an endoscopy in an outpatient clinic.

4. Laryngomalacia has a  synergy with gastro-oesophageal reflux
If the laryngomalacia is problematic, the baby will compensate by increased work of breathing.  The greater negative pressures created to overcome the laryngomalacia then increase reflux of milk into the oesophagus.  This can in turn cause inflammation of the epiglottis, worsening the turbulence of the upper airway.  For this reason, anti-reflux medication is now often used is a baby has symptomatic laryngomalacia.

5. Most cases will follow a benign course
About 9 out of 10 babies with laryngomalacia will have no problems with feeding or breathing.  If there are signs of respiratory distress, or symptoms of feeding difficulties, I would normally refer for assessment by an Ear, Nose and Throat specialist.  Most of these children will still require no surgical intervention.

So, one approach would be to carefully assess whether the history and examination are consistent with laryngomalacia and that this is not adversely affecting the child.  If both of these are true then referral is not necessary for the clinician who is confident to provide good safety-netting advice and watchful waiting.

If you have any other strategies or thoughts on this subject please post a comment below.

Edward Snelson
Unknowingly uncertain but rarely indecisive
@sailordoctor

Disclaimer - If you ask ten doctors about this you will get nine different answers and one story that goes on indefinitely.

If it isn't broken

Minor injuries in children are common.  Quite often, parents will present their children to General Practice, a Minor Injury Unit or an Emergency Department seeking reassurance.  This is often possible without the need for any investigations.  This post will explore some of the general principles of assessing and treating minor injuries in children.  I hope that by understanding some of the subtleties of how children's injuries work you will feel a bit more confident about managing these injuries when appropriate.  Over the next few weeks, there will be a smattering of posts that give specifics about injured body parts.  First, as my science teachers told me, we must return to first principles.

1.  Children injure themselves in different ways to adults

In fact, each part of childhood has a different pattern of injuries.  The main reason for this is engineering.  Children's bones are less brittle, especially when they are very young.  They are also very flexible creatures.  The combination of these mean that sprains are far less common in the under five year olds.  It also means that small children can fracture bones with seemingly innocuous injuries.  The best example of this is the toddler's fracture, which can occur with a simple tumble from running.

2.  Small children may not localise injuries well

There are several reasons for this and nobody really knows what they are.  I suspect that it is a combination of not being aware of specific body parts (have you ever seen a 3 year old draw a person?) and basic stupidity inherent to being a small child.  Whatever the reason, it is wise to look at least one joint above and below the reportedly injured part before deciding what to do.

3.  It is particularly desirable to avoid radiation in children

Because children are more susceptible to the dangers of X-rays, unnecessary radiation should be avoided.  X-rays should be done if there is a good chance that they will change management.  They should not be done for reassurance or as part of defensive medicine.

4.  If a child has normal use of the limb after analgesia then they are very unlikely to have a significant injury.

The ability to move a joint well is a good rule out (for the exception to this, see below), but persistent pain after analgesia does not always mean a treatable injury.

5.  Some children perceive and respond to pain differently.

Children with neurological or developmental problems including ADHD and ASD are more capable of having significant fractures despite seemingly normal limb function.  These children require a higher index of suspicion and a more interventional approach.

6.  Sometimes, the injury is not an injury (as such)

Amazingly, young people often ignore niggling pains.  They do so until whatever is a problem is suddenly made worse through exertion or an injury.  For this reason, some things that present as injuries are more significant and long term problems.  That doesn't mean that you have to disbelieve every injury.  However if something is slow to resolve or doesn't fit then it is wise to look again.  There are certain presentations, (e.g. as adolescents with hip pain after an injury) that should always be investigated carefully.

7.  The injury should fit the mechanism

This applies for several reasons.  The one that most will think of is the issue of safeguarding.  However it is equally true that when the mechanism does not really explain the injury, there may be a medical reason for this.  For that reason, keep an open mind. (Ref Shrodinger's Safeguarding)

Assessing and treating minor injuries in children is relatively straightforward and rewarding.  If you know what to look for and what the pitfalls are, it is often possible to be pragmatic.  Investigations are not always necessary and children heal quickly, given the chance.

GPpaedsTips is written for clinicians.  We all have to work within our own competencies.  However I don't think that minor injuries are more complicated than minor illness in children.

If it isn't broken give them analgesia and a sticker.  But how do I know????   That's easy.  Sometimes you just know because the child shows you how uninjured they are, sometimes it doesn't necessarily matter (that will be covered in the specific injury posts coming soon) and sometimes I doubt myself and do an X-ray.  And that's fine too.

Edward Snelson
@sailordoctor

Disclaimer: On no account is anyone to ask my children about my ability to recognise a significant injury.

This post is the first in a series of posts about injury.  Click these links to read about specific injuries and when to treat, refer etc. -

• Head injuries
• Finger injuries
• Pulled elbows

The Best Medicine

We all want to give the best medicine. If you are not part of that ideology, please stop reading. This is not for you.

Prescribing for children is tricky.  Sometimes dosing is about weight, sometimes age and sometimes it's not that simple such as when giving bronchodilators.  The choice of treatment is also difficult. I try to practice evidence based medicine but there is often a lack of good quality research on which to base my decisions.

In the brave new world of guideline driven medicine, there is one factor that I don't often consider and that's a shame because it can make all the difference.  That factor is the acceptability of the treatment to the child.

In our desire to make a child better (or at least feel better) it may be wise to consider what the child wants. I know, that's crazy talk.  But the best medicine may just be the one that the child will take.

Let's talk about a few examples.

What is the best corticosteroid for treating croup?

I recently ran through the management of croup.  In that I addressed a question that I am often asked by my GP colleagues: "Should we be giving dexamethasone or prednisolone?"  The evidence comes down gently in the favour of dexamethasone. However,  prednisolone is often cheaper and more readily available.  

But what would the child choose?  I have prescribed each of these steroids enough times that I've got a strong suspicion that a consumer survey would say dexamethasone is the customer's favourite.  This is based on the number of pens I have worn out writing that prednisolone can be re-administered since the first dose is now fluorescent decoration on a parent's clothes.  This is a lot easier to sort out while the child is sat near me in the ED.  It's less easy to resolve if they've picked up their medicine from a pharmacy and are at home when they vomit back their steroid.

I don't have the facts on how many children spit out or vomit back prednisolone versus dexamethasone.  It would be good to know so that I could offer more than a belief when someone asks the dex/ pred question.  In the absence of hard facts, I will continue to point to the dex bottle and mouth, "This one!" in a way that allows plausible deniability.

What is the best oral antibiotic for bacterial tonsillitis in children?

I recently read with interest an article in the Archives of Disease in Childhood about another treatment choice that would affect even more children.  This article had the bravery to question the well established practice of giving ten days of phenoxymethylpenicillin  to children with suspected or proven streptococcal tonsillitis.  Apparently the old thing about a high proportion of cases of Epstein-Barr virus (EBV) infection having florid rashes when prescribed amoxicillin is a myth.  Well, technically it is a misunderstanding (or mythunderstanding perhaps?) since the reaction described originally was to ampicillin.  The latest evidence is that there is no increased occurrence of rash when amoxicillin is given and EBV is present.  Can I trust no one?

The article goes on to mention (casually, as if to avoid hate mail) that since amoxicillin is better tolerated by children, perhaps we should prescribe this instead of phenoxymethylpenicillin.  Bonkers.

Now before anyone changes their practice, there is another consideration: antibiotic guardianship.  Amoxicillin has a broader spectrum of antimicrobial activity and with rising bacterial resistance we should be using broad spectrum antibiotics as infrequently as possible.  What is exciting to me is that someone has questioned our long-continued routine.  Better still, they have as good as involved the child in the discussion that should rightly follow.

Is phenoxymethypenicillin that bad?  Parents frequently tell me that the phenoxymethylpenicillin prescribed to their child has transformed them from a nice child with a febrile illness into some sort of rabid beast undergoing an exorcism.  It seems entirely reasonable therefore to ask that the writers of guidelines consider whether the evidence and stewardship of phenoxymethylpenicillin outweighs the acceptability of amoxicillin.  How many additional completed completed antibiotic courses would it take to allow amoxicillin to win in a straight fight?

I would not be me if I didn't mention the other option for the child who has a deep loathing for their antibiotic.  There are ten good reasons to make stopping the antibiotic the best way forward. There is only really one reason to change to something like amoxicillin: the child needs the antibiotic.

Edward Snelson
@sailordoctor
Medical mythologist

Disclaimer: Trust no one

References

1. Christine Chew, Anu Goenka "Does amoxicillin exposure increase the risk of rash in children with acute Epstein–Barr virus infection?" Arch Dis Child doi:10.1136/archdischild-2015-310364
2. johnathanlaird.com "The Ten Real Reasons Not to Prescribe Antibiotics"