tag:blogger.com,1999:blog-19056700547513429972024-03-14T00:22:32.773-07:00Paediatrics for Primary Care (and anyone else)Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comBlogger134125tag:blogger.com,1999:blog-1905670054751342997.post-17814509762218878172022-12-15T04:08:00.001-08:002022-12-15T04:08:50.156-08:00Group A Streptococccal Infections in Children - What Has Changed?<p>At the time of publication, the UK is experienced the effects of an increase in cases of group A streptococcal (GAS) infections in children. Scarlet Fever cases are more prevalent and there are more cases of invasive infection than in an average year. Most importantly the number of deaths in children related to GAS infection is high and the associated news coverage has been significant.</p><p>When our clinical landscape changes, the question should always be: What has changed and what should I be doing differently? Let's look at each element of practice around GAS infections and see what has or should have changed.</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi3h_bFAIHSRsbS3QuJ4NHCN5wyeqqpmotmFIHPYhs-_ADaJdOhwrt51F1ZnePc_prqSXQIH21LX2aCw5G6OQbQ2zAS-m7k6fCqKDvjHEMWch8m0eLDqASApAogpcijv3JwxNzyCY4Epdclchbs7mHpANapBwSLkqj6fTP3ZnuuVJrSzNKAnoWod5I/s1538/GAS%20recommendations.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="864" data-original-width="1538" height="297" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi3h_bFAIHSRsbS3QuJ4NHCN5wyeqqpmotmFIHPYhs-_ADaJdOhwrt51F1ZnePc_prqSXQIH21LX2aCw5G6OQbQ2zAS-m7k6fCqKDvjHEMWch8m0eLDqASApAogpcijv3JwxNzyCY4Epdclchbs7mHpANapBwSLkqj6fTP3ZnuuVJrSzNKAnoWod5I/w529-h297/GAS%20recommendations.png" width="529" /></a></div><p>Recognising the seriously unwell child</p><p>The clinical task of recognising the unwell child is actually business as usual. It remains the case that the vast majority of children who are unwell have uncomplicated upper respiratory tract infections with very low likelihood of developing complications or invasive infection.</p><p>The UKHSA has stated that the GAS infections are of normal pathogenicity which in the UK means very low risk of complications or invasive infection. The number of viral infections circulating has also risen substantially which means that the probability of any one febrile child having GAS is likely to be similar to normal times.</p><p>In any case our task of recognising the seriously unwell child remains the same as at any other time. It is and always has been a complex business which cannot be reduced to a formula. It is also the case that any febrile child, no matter how well, can go on to develop a serious illness such as sepsis or meningitis. That has always been true and all the information we are getting suggests that the risk of that happening to a child without signs of invasive infection at the time of assessment remains very small.</p><p>Diagnosing Uncomplicated Group A Streptococcal Infection</p><p>This remains as problematic as ever. GAS infection has always been a reasonably common cause of URTI including tonsillitis. Scarlet fever aside, there is no one clinicial feature with a high predictive value for GAS infection. Decision tools such as FeverPAIN are misleadingly named because they only moderately separate children into groups with different risks of having GAS. As the score goes up the likelihood of GAS also goes up but a significant number of children will have GAS infection with a low score. </p><p>Tools such as CENTOR and FeverPAIN were never introduced to help clinicians to treat GAS more often. Quite the opposite - these tools were developed to reduce antibiotic prescribing in a culture of default antibiotic use for all sore throats.</p><p>Throat swabs are often used as a means of identifying who definitely has GAS. There are two big problems with bacterial throat swabbing though. The first is that GAS is a normal commensal in throats and can be found even in asymptomatic cases. The second is that the result takes time. Due to pressures on microbiology services that time is likely to be longer at the moment. The usefulness of a swab result two to three days into an illness is therefore questionable.</p><p>The current recommendation from the UKHSA is to prescribe antibiotics to children with a FeverPAIN score of 3 or more. Throat swabs are only recommended for cases of invasive infection, scarlet fever or diagnostic uncertainty. I have assumed that diagnostic uncertainty cannot refer to being unsure as to whether an URTI/ tonsillitis is viral or bacterial as we can never be certain in any case, regardless of FeverPAIN score.</p><p>Antibiotic Choice</p><p>This has been very interesting. The UKHSA continues to recommend Penicillin V as the first choice antibiotic both for uncomplicated URTI/ tonsillitis and for scarlet fever despite the known very low compliance rate. Pen V tastes very unpleasant and as a result less than half of children will complete a course. This recommendation to use Pen V has always been based on the low risk posed by GAS infection, balanced against the risk to the population of liberal use of broad spectrum antibiotics. The continued recommendation to use Pen V as first line implies a continuation of where we were before. The effect of antibiotics is too small to change to antibiotics with better compliance rates as the harm from using broad spectrum antibiotics is believed to be greater than the benefits.</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjsIL2-FC2AFhhCWd99w5Wabql1__2SUhbSPK2Ffc0_eYAVWk7gPaJH0d3VQsbQxRqXRFNH0dFXD7lu9kqDvemhKYUdIPVq5KLCFRJGMf8uwOPsg2e3Ap9azk93Z4nTrd5nrrayW5VejjrzEB2sUz2aLfZeGgCjZKxOAf8zhJ-0xGxi7avTzVTASbo/s2316/GAS%20what%20has%20changed.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2316" data-original-width="1543" height="763" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjsIL2-FC2AFhhCWd99w5Wabql1__2SUhbSPK2Ffc0_eYAVWk7gPaJH0d3VQsbQxRqXRFNH0dFXD7lu9kqDvemhKYUdIPVq5KLCFRJGMf8uwOPsg2e3Ap9azk93Z4nTrd5nrrayW5VejjrzEB2sUz2aLfZeGgCjZKxOAf8zhJ-0xGxi7avTzVTASbo/w508-h763/GAS%20what%20has%20changed.png" width="508" /></a></div>The element that has changed the most is probably the numbers seeking a medical assessment of their child, anxieties about the dangers of GAS and an increased expectation of antibiotics. If you're already good at managing all of those things then you are equipped for this moment in time. If you're still learning how to manage anxieties then this situation will be a great learning opportunity!<div><br /></div><div>What parents often worry about - fever and rashes, are some of the least important factors in recognising serious illness in children. Fever is not a predictor of serious illness and even a sandpaper rash indicates Scarlet Fever which is still low risk for invasive GAS.</div><div><br /></div><div>This brings us back to the issue of recognising the unwell child. That is still the most important task in each assessment, even if the chance of finding a child with invasive infection is small. Here's a very condensed guide to separating the unwell children into groups. Note that neither fever nor rash make the shortlist of key features.</div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg4bo3aoKKbT8nYHWXIM_7OBrQ61nPsFWZ9f4QTTV0jIR5c3GoDixpSdNfwUAX-vormUujbn3CI-bZTZBY_EuHPFd6mv7fsfwrdHqDXkXNfejCagwvDDKFVCqzDnhaYWkOfK6QKm-0Dv_z4a1kAqdOGUPxFzlNi_kulV27SiVgWxVcAlI6y51Lvm-Y/s1221/A%20brief%20guide%20to%20recognising%20the%20unwell%20child.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="969" data-original-width="1221" height="402" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg4bo3aoKKbT8nYHWXIM_7OBrQ61nPsFWZ9f4QTTV0jIR5c3GoDixpSdNfwUAX-vormUujbn3CI-bZTZBY_EuHPFd6mv7fsfwrdHqDXkXNfejCagwvDDKFVCqzDnhaYWkOfK6QKm-0Dv_z4a1kAqdOGUPxFzlNi_kulV27SiVgWxVcAlI6y51Lvm-Y/w507-h402/A%20brief%20guide%20to%20recognising%20the%20unwell%20child.png" width="507" /></a></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjj6Z2SHp9FWWf55LQPmXveSFkQQhsclyEMMe1jN32K48wO8DVcgae1z33BRgU8n_IaFP0TkJXfuZrXQZvVnJHJsP9oPLOJjk-VZV9M10d9Z6KzZ9ezXuFuRxkEn8x9lOx4R9SUGi1RBPc6-4AimCJhrlLPjs5zhBeKZ4zyfXmbD1qyfykcIemXVOE/s1565/What%20to%20do%20next%20with%20an%20unwell%20child.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1565" data-original-width="1533" height="505" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjj6Z2SHp9FWWf55LQPmXveSFkQQhsclyEMMe1jN32K48wO8DVcgae1z33BRgU8n_IaFP0TkJXfuZrXQZvVnJHJsP9oPLOJjk-VZV9M10d9Z6KzZ9ezXuFuRxkEn8x9lOx4R9SUGi1RBPc6-4AimCJhrlLPjs5zhBeKZ4zyfXmbD1qyfykcIemXVOE/w494-h505/What%20to%20do%20next%20with%20an%20unwell%20child.png" width="494" /></a></div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;">The key things that have changed are volume of children presenting and the level of anxiety in the accompanying adults. The features of serious illness and the effectiveness of decision tools and antibiotics remain the same as always.</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;">Stay safe. Hopefully this post becomes redundant soon for all of the right reasons!</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;">Edward Snelson</div><div class="separator" style="clear: both; text-align: left;">@sailordoctor</div><div class="separator" style="clear: both; text-align: left;">Swabbing decks not throats</div>Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comtag:blogger.com,1999:blog-1905670054751342997.post-56195240575399007672022-11-29T22:05:00.001-08:002022-11-29T22:35:50.646-08:00Understanding Traffic Lights - The Unwell Child and What to Do Next<p>When I am driving and see a traffic light ahead the first thought is, "Am I supposed to stop or go?" My next thought is, "what might it change to and what do I do then?" Assessing the unwell child is like that. It's not just about the snapshot. Guidelines look a moment in time but the unwell child is in constant flux making that approach problematic.</p><p>The <a href="https://www.nice.org.uk/guidance/ng143/resources/support-for-education-and-learning-educational-resource-traffic-light-table-pdf-6960664333" target="_blank">traffic light system for unwell children</a> has been around for a very long time. It is used across Primary and Secondary care to aid clinicians in their attempts to risk assess febrile and unwell children with all of the non-specific signs and symptoms with which they present. </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBtSg6De_0x7djPXRgqLmmvM76tb5ZbWWl2hR2WeVshUofL21jhG-JKUne7doz8mANgkiPkn52-DFNzkENWXP8zuUW5fkWci14jl6WOiPNoaYAyeQUaTYzzx53FBaFhxqxCiV68YvGXd_7SvOmAvNxn5sVDECxnPfR8y3RU80ttxsfdR7Vd1ujPDU/s1054/Traffic%20Light%20Decision%20Making%20in%20the%20Unwell%20Child.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1054" data-original-width="1000" height="424" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBtSg6De_0x7djPXRgqLmmvM76tb5ZbWWl2hR2WeVshUofL21jhG-JKUne7doz8mANgkiPkn52-DFNzkENWXP8zuUW5fkWci14jl6WOiPNoaYAyeQUaTYzzx53FBaFhxqxCiV68YvGXd_7SvOmAvNxn5sVDECxnPfR8y3RU80ttxsfdR7Vd1ujPDU/w403-h424/Traffic%20Light%20Decision%20Making%20in%20the%20Unwell%20Child.png" width="403" /></a></div><p>I am often asked if I use the traffic light system in my own practice. The answer is yes and no. Yes - the system is a useful hierarchy of signs and symptoms. No - because most childhood illnesses are too dynamic for a snapshot to be completely valid. Things change constantly. A risk assessment based on a moment in time is far too simplistic.</p><p>That doesn't mean that observation of the child is necessary for decision making. In most cases it's simply a question of asking how the lights are changing and what I'm going to do with that.</p><p><b><span style="background-color: #ffa400;">Amber</span> turning <span style="background-color: #04ff00;">green</span></b></p><p>A 2 year old child presents with a cough, runny nose and a fever. The parent reports that a couple of hours ago they looked pale and lethargic. They were shivering, felt hot centrally but had cold hands and feet. Now they have none of those things happening. They are walking, talking and cheerfully interactive.</p><p>This is a very common scenario. Parents and carers will often express a certain paradoxical frustration with the apparent wellness of the child. The child appeared seriously unwell a couple of hours ago and the parent is now feeling that you will think that they have over-reacted. It is a good thing to acknowledge how unwell the child was and use that as an opportunity to explain why you as a clinician are happy with the child despite how concerning the child's appearance was. </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhpvS-uk2wMcUvLDygBDRmlPP0aMatBhEC7QbdGYb2uFlucNgIlc-uan74_TkwxhQNaIuhtOZfszEm15OJl6cqkok6v_pOjvU3qLUokbV0Xs_nw3UTgeStWN9Wtu18c0p3H5AsBT-tAvSZbuTi8GhbYrLoxLvpQXk10P7fbnDL4Z7K1qy9pErAVAdg/s1553/Example%20of%20safety-netting%20advice%20amber%20turning%20green.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1163" data-original-width="1553" height="436" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhpvS-uk2wMcUvLDygBDRmlPP0aMatBhEC7QbdGYb2uFlucNgIlc-uan74_TkwxhQNaIuhtOZfszEm15OJl6cqkok6v_pOjvU3qLUokbV0Xs_nw3UTgeStWN9Wtu18c0p3H5AsBT-tAvSZbuTi8GhbYrLoxLvpQXk10P7fbnDL4Z7K1qy9pErAVAdg/w581-h436/Example%20of%20safety-netting%20advice%20amber%20turning%20green.png" width="581" /></a></div><p>Giving or signposting to something written is also important.</p><p><b><span style="background-color: #04ff00;">Green</span> turning <span style="background-color: #ffa400;">amber</span></b></p><p>A 2 year old child presents with a cough, runny nose and a fever. When you see them they are miserable but alert and interactive. They have a temperature of 39.5, heart rate of 160 and are refusing to drink. They last had any symptomatic treatment 6 hours ago. The parent reports (you have to ask about this - it won't usually be volunteered) that 2 hrs ago they looked much better and were drinking a bit.</p><p>Unlike actual traffic lights, unwell children swing from green to amber and back to green quite normally during uncomplicated self-limiting infections. There is a reason that we mostly see unwell children between the age of 6 months and six years. It's not because they are high risk for dangerous infections. In fact quite the opposite - it is a <a href="http://gppaedstips.blogspot.com/2019/07/core-principles-of-paediatrics.html" target="_blank">stage of life characterised by extreme response to simple infections</a>. The normal physiological response can look bad but usually resolves to reveal a reassuring baseline. In many ways, a febrile unwell 2 week old is easier from a decision making point of view - that is a very high risk presentation. A febrile unwell 2 year old is low risk but that presents a different problem - how to recognise the small number that do have a serious illness.</p><p>What can be terribly inconvenient is the above situation. The snapshot we are given is not green but also not red. Red is also easier from a decision making point of view. Amber presentations make us have to decide what to do next. Here are your options:</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEivf8piCzlod4UMlQEqATnn7GLvOHq0_qgCSg3GDBtiHwwqKyYK6yKOntx47CuqyiQPyvJX4TDyhaLwX7l9gftg9rKSN13zAUz3xirKojXgtmejQY1DJ39YZc85GwolaROlCD5E_VbpbmRhF1R_YuvM3gcfhOi3APy9irfS6wG6SbBzAlPJC4_OBFo/s1565/What%20to%20do%20next%20with%20an%20unwell%20child.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1565" data-original-width="1533" height="607" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEivf8piCzlod4UMlQEqATnn7GLvOHq0_qgCSg3GDBtiHwwqKyYK6yKOntx47CuqyiQPyvJX4TDyhaLwX7l9gftg9rKSN13zAUz3xirKojXgtmejQY1DJ39YZc85GwolaROlCD5E_VbpbmRhF1R_YuvM3gcfhOi3APy9irfS6wG6SbBzAlPJC4_OBFo/w594-h607/What%20to%20do%20next%20with%20an%20unwell%20child.png" width="594" /></a></div><p>Every clinician will have a preferred option. Many working in Primary Care do not feel the need to have a face to face reassessment if the child improves in behaviour and activity. That is completely valid as such improvement is a good demonstration of physiological change and evidence that the baseline state of the child (active, interactive, good oral intake and no increased work of breathing) is not consistent with sepsis or meningitis for example.</p><p>Really good safety-netting advice empowers the parent to make that assessment in a way that is dynamic and continuous. A reassessment in whatever form (face to face or remote) facilitates documentation of improvement and adds value to the safety-netting advice by giving the opportunity for the parent to further discuss the illness, what to expect and when to worry.</p><p>Amber children are a fair bit of work but they are a great opportunity to do what we should consider core business. We can take a group of children who are reasonably low risk and look for signs (e.g. increased work of breathing, meningism or unexplained tachycardia) that this one is the one with something that needs immediate intervention. For those that are within what is expected of an uncomplicated infection we can make sure that they have symptomatic treatment in the assumption that they will demonstrate a baseline state of reasonable wellness that effectively rules out serious illness. Finally we can equip the person caring for that child with the ability to recognise signs of serious illness should those develop later. That is a lot of great care.</p><p>Edward Snelson<br />Paediatric off-roader<br />@sailordoctor</p><p><span style="font-size: x-small;">Disclaimer - drive on the road when you can, off the road when you have to but always get home safely. If you need help, call.</span></p><p><br /></p>Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comtag:blogger.com,1999:blog-1905670054751342997.post-12935308414179392812021-11-13T07:28:00.003-08:002021-11-13T07:37:41.465-08:00Where is Your Focus? Let's Play Spot the Ball.<p>I think that the hunt for a focus of infection in a child is a lot like a game called “Spot the Ball” in which people looked at a picture from a football game with the ball removed and tried to guess where the ball was.</p><p>Finding a focus of infection is a very interesting topic at the moment. More than ever, primary care clinical assessments are occurring remotely rather than face to face. Febrile children are being assessed without laryngoscopy or auscultation. This seemingly contradicts the tradition of the need to find a focus of infection. So what is the deal? I've been asked a lot of questions about this recently and I thought that the simplest thing to do was to bring together my answers.</p><p><b>Do I need to find a focus of infection?</b></p><p>No. There is no absolute need to find a focus of infection. Here are a few facts that disprove the idea that a febrile child needs a physical clinical assessment for focus of infection in every case:</p><p></p><ul style="text-align: left;"><li>If finding a focus was mandatory, parents and carers would have to have their febrile child assessed on every occasion. Self-care without medical assessment would be neglectful and therefore a safeguarding issue.</li><li>Even if you believe that medical assessment should take place, this only provides a snapshot. Childhood febrile illnesses are dynamic and the focus can change. A child who has an otitis media now could have mastoiditis before the day is over. If we always need to know the focus, you would never be able to send the child out of your sight.</li></ul><p></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgIk9q5D2y9J5cV4MD7OykZKQ1JpvrojyYBQ4AOt3LAN9O4bfXibqdBHQSo3TiLM_t9cR9wyU0-8T4GPhV2oevXH5BhqUfAb-nWADh_t8PljZM97F71cKs6rTKUGU99DGqF0lpe835MPLQ/s1583/Spot+the+ball+moving+focus.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1172" data-original-width="1583" height="299" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgIk9q5D2y9J5cV4MD7OykZKQ1JpvrojyYBQ4AOt3LAN9O4bfXibqdBHQSo3TiLM_t9cR9wyU0-8T4GPhV2oevXH5BhqUfAb-nWADh_t8PljZM97F71cKs6rTKUGU99DGqF0lpe835MPLQ/w403-h299/Spot+the+ball+moving+focus.png" width="403" /></a></div><div><div><b>Does finding a benign focus rule out serious infection?</b></div><div><br /></div><div>No. That’s not how that works. To illustrate the point, I'll tell you a story. A 4 month old child came in with a history of fever and irritability progressing to vomiting and unresponsiveness. On assessment they had a GCS of 8, heart rate of 200 and capillary refill time of 4 seconds. I looked in their ear, found that they had otitis media. We all celebrated the finding of the focus and discharged the patient with oral medication. </div><div><br /></div><div>That would never happen of course. While I give that as an ridiculous example, the principle does apply to the moderately unwell child also. Finding a focus can be a distraction or a premature conclusion. If we are misled into thinking that an upper respiratory focus is the end of the decision making, we're missing a bigger picture. We still need to step back and look at the overall clinical scenario. So in the need to rule out things like meningitis, sepsis and pneumonia, finding a focus could be diagnostic noise. Serious infections are ruled out on their own merits, not by finding another focus.</div><div><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhnBbP12Ki97VLd7poWwaFU4eQZrT_l134WKdZLicT3KQK0-6UBLd2BViMTyp0FHlpng4KTr-vpvPI_5JgTgU0SZOdaQClq_8pDgnW3-lqh3BA5YJxUGKa7OZhFmqM8_AD9qSuku68tMMo/s1811/Missing+the+bigger+picture.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1811" data-original-width="1428" height="444" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhnBbP12Ki97VLd7poWwaFU4eQZrT_l134WKdZLicT3KQK0-6UBLd2BViMTyp0FHlpng4KTr-vpvPI_5JgTgU0SZOdaQClq_8pDgnW3-lqh3BA5YJxUGKa7OZhFmqM8_AD9qSuku68tMMo/w350-h444/Missing+the+bigger+picture.png" width="350" /></a></div></div><div><p><b>Does a runny nose count as a focus of infection?</b></p><p>Yes, but the question of infection doesn't work like that. A child with a runny nose and a non-specific cough can be presumed to have an upper respiratory tract infection. The real question is, do they have features of another more significant focus? If they have difficulty breathing, are seriously unwell or specific features of something else (e.g. reduced conscious level) then the assumption flicks from "presumed uncomplicated URTI" to "presumed complication of URTI".</p><p>One of the values of giving credibility to non-specific respiratory symptoms is that it helps to answer the age-old question of "should I get a urine sample from this child?" That's a whole new can of worms. In a massively oversimplified answer, if they are well and have a cough and runny nose you don't need one. If they have no cough or runny nose you do need one, especially if they have abdominal pain, vomiting without diarrhoea or have strong smelling urine.</p><p><b>So if focus can be misleading and can change soon after I've assessed it anyway, what am I actually supposed to be doing? </b></p><p>Treat the assessment of an unwell child like a game of spot the ball. There will be clues and distractions. There will be things that direct and misdirect. The main task is to look for signs of a focus that needs to be treated. Uncomplicated upper respiratory tract infection (including tonsillitis and otitis media) are not on the list of things that must be identified and treated. What is interesting is that uncomplicated lower respiratory tract infection’s (LRTI/ pneumonia) place on the list is increasingly in question.</p><p><b>What is on the list of significant infections and how do I detect these?</b></p><p></p><ul style="text-align: left;"><li><b>Complications of URTI</b> are rare but significant. Externally, mastoiditis and lymph node abscess can be detected clinically. Internally, peritonsillar abscess should be looked for in a child who is unable to swallow despite adequate analgesia.</li><li><b>Central nervous system (CNS) infection</b> (meningitis, encephalitis, abscess) disproportionately affect function and behaviour. Reduced or focally abnormal CNS function is a red flag. Signs and symptoms are often non-specific in children but the non-specific signs such as inability to settle are persistent in a way that is unusual for uncomplicated infections.</li><li><b>Pneumonia</b>, when accompanied by significant respiratory distress or systemic effects is still going to be on the list. The fact that there is mounting evidence that pneumonia without significant effects does not mandate treatment simplifies the assessment of focus. Localised signs on auscultation is a focus but the need for antibiotics in the absence of more significant findings is questionable.</li><li><b>Urinary tract infection</b> is a paradoxical focus in children. While UTI can self resolve without significant likelihood of complications, these low grade infections often go undetected. The UTIs that are clinically apparent in children are the most severe UTIs. It is therefore normal to treat all UTIs especially in pre-school children. Urine samples should be tested if there is no clear focus elsewhere. In the child under three years old, ideally these samples are sent for microscopy and culture.</li><li>Finally, there is the focus that is not actually infection. <b> Inflammatory diseases</b> such as Kawasaki and PIMS-TS present with 5 or more days of unrelenting fever, mucousitis and a very miserable child. Consider this possibility when the child is worse or no better on day 5 of a febrile illness.</li></ul><p></p></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiJiT9m6EnYfJ3OL11xh8pG9H7awGpeb-1ft-qqwjdqRpQAHR30cThKLYUBnXVIobHXTSIH5pHdXX99c3yaY8B4YGxYrGALq8hS7T2GE4KYuqxl47KVyldtYdPO2_0z8uDXBGKsUq219ao/s1542/Finding+a+focus+of+infection+in+a+child.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="840" data-original-width="1542" height="335" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiJiT9m6EnYfJ3OL11xh8pG9H7awGpeb-1ft-qqwjdqRpQAHR30cThKLYUBnXVIobHXTSIH5pHdXX99c3yaY8B4YGxYrGALq8hS7T2GE4KYuqxl47KVyldtYdPO2_0z8uDXBGKsUq219ao/w616-h335/Finding+a+focus+of+infection+in+a+child.png" width="616" /></a></div><div>When you play spot the ball in the traditional way, you don't get to find out if you were correct until the next day. What could be more like hunting for the serious focus amongst the hundreds of febrile children you will see or assess remotely this year?</div><div><br /></div><div>Good hunting.</div><br /><div>Edward Snelson</div><div>@sailordoctor</div><div><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://www.facebook.com/PaedsTips" style="margin-left: 1em; margin-right: 1em;" target="_blank"><img border="0" data-original-height="279" data-original-width="1273" height="113" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhlvD3UWNZeAutQLARt8m2iVxrY-WZL7vuq_F76rhzgj3I5DymoqI5T98BosqbyYakz3k2cfIX96hD85mjSbyotjkOf32p74UHslILdcWHsWZyeNPAaNokSCMXREQkq_H2ms-JTJs6C6Dg/w517-h113/GPpaedsTips+Facebook+link.png" width="517" /></a></div><br /><div><br /></div><div><br /></div>Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comtag:blogger.com,1999:blog-1905670054751342997.post-14179176343746353912021-09-02T00:08:00.002-07:002021-09-02T00:08:45.465-07:00With every crisis an opportunity - How to use blood count in children<p><span style="font-family: arial;">Another week, another crisis - This time, in the UK we have a major shortage of blood bottles.</span></p><p><span style="font-family: arial;">Primary care have been advised to suspend non-urgent blood tests for the next few weeks during a major shortage in sample bottles. Personally, I blame the 5G mast they put up near the hospital.</span></p><p><span style="font-family: arial;">When we are faced with limited resources, we have to get even better than ususal at decision making. We have an opportunity to look with fresh eyes and recognise those areas of practice which may have become facile and revisit how we use available resources. In this post, I'll be looking at the use of blood counts in children. When are these tests likely to be genuinely helpful and when are they unlikely to be the best next step?</span></p><p><span style="font-family: arial;">First of all some general principles:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZ0Jf_GVjsBpHuhQzM8PXFbfGPRyKcFq6G5J8tYihfH68AQziFANYfx8xAAP8MxWoRaGo7T2poBwyCeBHA61QXkQ55ygx2hdZh4njp-dwiTzQvGtWq2YKxfsUaubzScI_VCEL_rYF1HcA/s1132/General+principles+of+doing+blood+tests+in+children.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: arial;"><img border="0" data-original-height="1132" data-original-width="863" height="538" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZ0Jf_GVjsBpHuhQzM8PXFbfGPRyKcFq6G5J8tYihfH68AQziFANYfx8xAAP8MxWoRaGo7T2poBwyCeBHA61QXkQ55ygx2hdZh4njp-dwiTzQvGtWq2YKxfsUaubzScI_VCEL_rYF1HcA/w410-h538/General+principles+of+doing+blood+tests+in+children.png" width="410" /></span></a></div><span style="font-family: arial;">The last one in that list is particularly relevant to the question of when to do a blood count. <br /></span><p class="MsoNormal" style="background-color: white; margin: 0px;"><span style="color: #222222; font-family: arial;">A blood count gives a wealth of information about various haematological parameters. Because there are so many being reported, it is reasonably likely that any report will include one parameter that is outside of the statistical norm. One of the reasons for this is that children have very active and responsive bone marrow and immune systems. Peaks and troughs in white cells are more common and extreme in children even if well. As a result, blood counts can be historical by the time they are reported.</span></p><p class="MsoNormal" style="background-color: white; margin: 0px;"><span style="color: #222222; font-family: arial;"><br /></span></p><p class="MsoNormal" style="background-color: white; margin: 0px;"><span style="color: #222222; font-family: arial;">It is very common to find an abnormal parameter (e.g. lymphopaenia) for which the recommendation is simply “repeat”. By the time the result is known by the requesting clinician, it may well be the case that the child has made plenty more of the lymphocytes in response to the dip reported by the test.</span></p><p class="MsoNormal" style="background-color: white; margin: 0px;"><br /></p><p class="MsoNormal" style="background-color: white; margin: 0px;"><span style="color: #222222; font-family: arial;">Of course, chronic and persistent abnormalities do exist. The next question is, are these usually a surprise finding on a blood test?</span></p><p class="MsoNormal" style="background-color: white; margin: 0px;"><span style="color: #222222; font-family: arial;"><br /></span></p><p class="MsoNormal" style="background-color: white; margin: 0px;"><span style="color: #222222; font-family: arial;">The simple answer is no.</span></p><p class="MsoNormal" style="background-color: white; margin: 0px;"></p><ul style="text-align: left;"><li><span style="color: #222222; font-family: arial;">Congenital immunodeficiency is extremely rare in children and does not usually present as a chance finding on a blood test done to investigate low-level concerns. It usually presents with severe and atypical infections and does so early in life. </span></li><li><span style="color: #222222; font-family: arial;">Acquired haematological problems (HIV/AIDS aside) will usually present with significant systemic signs and symptoms – chronic fatigue, pallor, weight loss or pyrexia of unknown origin.</span></li></ul><p></p><p class="MsoNormal" style="background-color: white; margin: 0px;"><span style="color: #222222; font-family: arial;">It is notable that it is exceedingly rare for children with cancer to present via the two week wait referral pathway(1) that exists in the UK. Instead, the vast majority present via the ED or as an acute referral from a clinician in Primary Care. The likely reason for this is that there are red flags apparent to the parent or the primary care clinician. The two week wait pathway tends to be used in cases where the child has a worrying feature without serious red flags. (e.g. a solitary palpable lymph node which is not growing and in the context of a well child) In other words, when a child is pale and lethargic and looks unwell, someone makes sure they are seen immediately. Serious illness usually presents with atypical signs or symptoms.</span></p><p class="MsoNormal" style="background-color: white; margin: 0px;"><br /></p><p class="MsoNormal" style="background-color: white; margin: 0px;"><span style="color: #222222; font-family: arial;">This brings us onto another rule of thumb:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiteUBEv5lF7V0pgNrx9PG7nBLPN6Q5psbcX0-gbQFH1NBkU6mCJ2uOTgoXK4FDzZIkqm6USfK86IjZe667nOLs6yFhgT4vRLCjteREwvp6gOcqpNxudSgRa9N4hoesPnSu-k8O9phfbFU/s1447/Tests+are+not+to+be+safe+or+just+in+case.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="683" data-original-width="1447" height="209" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiteUBEv5lF7V0pgNrx9PG7nBLPN6Q5psbcX0-gbQFH1NBkU6mCJ2uOTgoXK4FDzZIkqm6USfK86IjZe667nOLs6yFhgT4vRLCjteREwvp6gOcqpNxudSgRa9N4hoesPnSu-k8O9phfbFU/w444-h209/Tests+are+not+to+be+safe+or+just+in+case.png" width="444" /></a></div><p class="MsoNormal" style="background-color: white; margin: 0px;"><span style="color: #222222; font-family: arial;">The decision to perform blood tests is sometimes a sign of uncertainty. The clinician feels unable to be completely reassured yet is not able to reach a definitive diagnosis.</span></p><p class="MsoNormal" style="background-color: white; margin: 0px;"><span style="color: #222222; font-family: arial;"><br /></span></p><p class="MsoNormal" style="background-color: white; margin: 0px;"><span style="color: #222222; font-family: arial;">To illustrate this, let me give you a clear haematological example of a blood test being done to answer a specific question: </span></p><p class="MsoNormal" style="background-color: white; margin: 0px;"><span style="color: #222222; font-family: arial;"><b>A child presents one week after a viral illness. </b> They are well and afebrile but now have a diffuse petechial rash. There is no lymphadenopathy, pallor or hepatosplenomegaly. </span><span style="color: #222222; font-family: arial;">The clinician considers the possibility that the child has immune thrombocypaenia purpura and does a blood count to check platelets. The blood test confirms the diagnosis.</span></p><p class="MsoNormal" style="background-color: white; margin: 0px;"><span style="color: #222222; font-family: arial;"><br /></span></p><p class="MsoNormal" style="background-color: white; margin: 0px;"><span style="color: #222222; font-family: arial;">If a blood test is done without a specific question, or because the clinician hopes that the blood test with add weight to a diagnosis of normality, this is problematic. Due to the above mentioned fluctuations, there is a high probability that the result will not be completely normal. If the aim is to gain time, watchful waiting without a blood test is often the more valid approach.</span></p><p class="MsoNormal" style="background-color: white; margin: 0px;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj715fqylRUYmPRZynpkoVHUs2pU1ulIUYrMRxPxK8mD4gJKOy5xu1BPMZdNZ0rGGNbRoyrUwc9RBVAbZhN34FNgUz_XjXOvSgkpe1RHf6JLi6qtMfV_OH3TYTrY30VTiIykXQeLooODLc/s1607/Using+a+blood+count+in+children+in+the+context+of+illness.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1248" data-original-width="1607" height="344" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj715fqylRUYmPRZynpkoVHUs2pU1ulIUYrMRxPxK8mD4gJKOy5xu1BPMZdNZ0rGGNbRoyrUwc9RBVAbZhN34FNgUz_XjXOvSgkpe1RHf6JLi6qtMfV_OH3TYTrY30VTiIykXQeLooODLc/w443-h344/Using+a+blood+count+in+children+in+the+context+of+illness.png" width="443" /></a></div><p></p><p class="MsoNormal" style="background-color: white; margin: 0px;"><span style="color: #222222; font-family: arial;">The current crisis may be the perfect opportunity to ask questions about the role and importance of blood tests in children. When it comes to blood counts in children, these rarely give useful information in the absence of a pre-test clinical sign or symptom which already gives a very high probability of a haematological or immunological problem. Using a blood count to check something specific such as haemoglobin is a far more precise science. Ask a question, get an answer. Boom.</span></p><p class="MsoNormal" style="background-color: white; margin: 0px;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZfWJssZ1mXq8m0KiVqPaYvDyaKEfVsiV9cMkSDM2v3gwR2LGcKF6W4CVmfdfOe9pPU-y7QI-DvJ8OEiGusxrCRQ7yLWkwItEiGtPCTlu4MpYPnR9HZdyL8oOmewEp508tJrxsjYBcL8A/s1526/Blood+counts+best+use.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1089" data-original-width="1526" height="392" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZfWJssZ1mXq8m0KiVqPaYvDyaKEfVsiV9cMkSDM2v3gwR2LGcKF6W4CVmfdfOe9pPU-y7QI-DvJ8OEiGusxrCRQ7yLWkwItEiGtPCTlu4MpYPnR9HZdyL8oOmewEp508tJrxsjYBcL8A/w551-h392/Blood+counts+best+use.png" width="551" /></a></div><p></p><p class="MsoNormal" style="background-color: white; margin: 0px;"><span style="color: #222222; font-family: arial;">Edward Snelson</span></p><p class="MsoNormal" style="background-color: white; margin: 0px;"><span style="color: #222222; font-family: arial;">@sailordoctor</span></p><p class="MsoNormal" style="background-color: white; margin: 0px;"><span style="color: #222222; font-family: arial;"><br /></span></p><p class="MsoNormal" style="background-color: white; margin: 0px;"><span style="color: #222222; font-family: arial; font-size: x-small;">Disclaimer - Human factors may influence the decision to do a blood count. I have not included this in my analysis. Draw your own conclusions as to why this may be, human.</span></p><p class="MsoNormal" style="background-color: white; margin: 0px;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://www.facebook.com/PaedsTips" style="margin-left: 1em; margin-right: 1em;" target="_blank"><img border="0" data-original-height="279" data-original-width="1273" height="100" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiRBZhdTZBfOv3zTQ181iVLEGR9roH6obNbH3KveX06n0aWeXow6kf-CrvPWZRipoMEu00Qlc2Qb-pI5GJD2Qwh8cpjGzbyuRfh7FQd8-eOyTGOkt7HgWwXLowAl6aI-sy6OrhCx3h-7Nc/w457-h100/GPpaedsTips+Facebook+link.png" width="457" /></a></div><p></p><p class="MsoNormal" style="background-color: white; margin: 0px;"><span style="color: #222222; font-family: arial;">References</span></p><p class="MsoNormal" style="background-color: white; margin: 0px;"></p><ol style="text-align: left;"><li><span style="color: #222222; font-family: arial;">Roskin J, Diviney J, Nanduri VPresentation of childhood cancers to a paediatric shared care unitArchives of Disease in Childhood 2015;100:1131-1135.</span></li></ol><p></p>Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comtag:blogger.com,1999:blog-1905670054751342997.post-26160364908314010942021-08-16T02:18:00.003-07:002021-08-16T02:18:55.563-07:00Trial by Inhaler - Bronchiolitis vs Viral Wheeze<p></p><div class="separator" style="clear: both; text-align: left;">With wheeze in children becoming a major presentation again, it feels like a good time to explore the issue of deciding whether a child has bronchiolitis or viral induced wheeze. There are various way that people do this in practice. Many stick to a strict 12 month cut off. This method works reasonably well and is rarely problematic. Bronchospasm is rare below this age and if it is going to be problematic under the age of 12 months, in my experience the infant is severely distressed and gets bronchodilators out of desperation rather than a diagnostic trial.</div><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUiCih9sdms4c2iR9r_eAb-VfF5XCb5H5jA7Oe8Sb_5TDGSuSghlTrAa3i07T3DDRRqUDx31ml7WAhOYqWFyiglSyENT8FbknTt2A-POHjY91Z1EYvzG4DpmZ36dmAmb_j4Ml1c2z8zdI/s1513/Typical+ages+%25E2%2580%2593+Bronchiolitis+and+Viral+Wheeze.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1176" data-original-width="1513" height="297" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUiCih9sdms4c2iR9r_eAb-VfF5XCb5H5jA7Oe8Sb_5TDGSuSghlTrAa3i07T3DDRRqUDx31ml7WAhOYqWFyiglSyENT8FbknTt2A-POHjY91Z1EYvzG4DpmZ36dmAmb_j4Ml1c2z8zdI/w382-h297/Typical+ages+%25E2%2580%2593+Bronchiolitis+and+Viral+Wheeze.png" width="382" /></a></div><br /><a href="http://gppaedstips.blogspot.com/2018/04/why-do-different-children-wheeze.html" target="_blank">I have already explored</a> a method of determining whether the pathology causing wheeze is predominantly wetness (bronchiolitis) or tightness (viral induced wheeze/ bronchospasm) by using age combined with the story.<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiGwqyK7lUgrIdm5BpXe7_WyzRB48ASRrgsGCLGMyJJ4fl9n8gZCw1AzhDT9VJdkxhvCFo8kOwPmkFGGPEQ78ahXW7e9pmmBD-XCJDVB17RD3oPtDBdXzEcWy9VamkFKaJgeA-5fumG5ng/s1585/Viral+wheeze+vs+bronchiolitis+prodromes.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1121" data-original-width="1585" height="272" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiGwqyK7lUgrIdm5BpXe7_WyzRB48ASRrgsGCLGMyJJ4fl9n8gZCw1AzhDT9VJdkxhvCFo8kOwPmkFGGPEQ78ahXW7e9pmmBD-XCJDVB17RD3oPtDBdXzEcWy9VamkFKaJgeA-5fumG5ng/w385-h272/Viral+wheeze+vs+bronchiolitis+prodromes.png" width="385" /></a></div><p>Slow accumulation of moisture and mucous tends to cause worsening of symptoms over days whereas bronchospasm causes acute change over hours. My opinion is that in the majority of cases, the age and the story will correlate.</p><p>Where the patient is in the overlap zone (e.g. 10-15 months old) and the story is clear (e.g. snotty/ coughing on Monday, struggling with feeds on Tuesday, noisy breathing on Wednesday and fast breathing on Thursday) then the story gives the diagnosis. With age/ story correlation or where the age allows ambiguity but the story is clear, the diagnosis is made.</p><p>So what about simply trying an inhaler to see if it works? This alternative approach to the age of overlap sounds straightforward and is reasonably common in practice, but is it logical?</p><p>A therapeutic trial works best when a clinical effect is guaranteed and unambiguous. Neither of these things is true in this situation. With viral wheeze, which should respond to salbutamol, clinically apparent response may require increased or repeated doses. Bronchiolitis, which will not respond, is famous for mini-fluctuations in work of breathing. This is caused by mucous plugging or the clearing of secretions.</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjFyqP1S4CQQNGCaLw4GpN6NRKh9UNHViLgOhnpHcfejxaPpvj_9tgq1XTQUM0ihEZOJvRkGHl4fEK1oYorTkrxi6ThymgxM5dsRL-wyQ2UShdMlTH2-kiR1SnsDVACqiMSt9d7uqzC2-4/s1507/Overview+of+childhood+wheeze.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1066" data-original-width="1507" height="269" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjFyqP1S4CQQNGCaLw4GpN6NRKh9UNHViLgOhnpHcfejxaPpvj_9tgq1XTQUM0ihEZOJvRkGHl4fEK1oYorTkrxi6ThymgxM5dsRL-wyQ2UShdMlTH2-kiR1SnsDVACqiMSt9d7uqzC2-4/w381-h269/Overview+of+childhood+wheeze.png" width="381" /></a></div><div>When you think of it in these terms, trying an inhaler doesn't meet the quality standards required of a valid test.</div><div><br /></div><div>Trial by inhaler is also problematic due to human bias. Uncertainty is fertile ground for biases to mislead us when an inhaler is given to make a diagnosis rather than as treatment. It is better to use beta-agonists therapeutically where appropriate and to see non-response as a reason to reconsider a presumed diagnosis of viral wheeze. If viral wheeze is the problem, we should not allow the lack of effect to refute the diagnosis.</div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjfIJWGR17QjsWEfcgm2vJ6Fe5hgb8SlJC463l2t-6wzSrgJMRZBeVC03UIVbiS9n_9gvs-mg0JdpBF6nmsq0Z4rbSBS9v0O0gTgAoSj7uWL23n2zyDCqj_parx_Zr6bDBFEyPb_eRBOu0/s1610/Problems+with+a+trial+of+inhaler+in+a+wheezy+infant.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1249" data-original-width="1610" height="418" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjfIJWGR17QjsWEfcgm2vJ6Fe5hgb8SlJC463l2t-6wzSrgJMRZBeVC03UIVbiS9n_9gvs-mg0JdpBF6nmsq0Z4rbSBS9v0O0gTgAoSj7uWL23n2zyDCqj_parx_Zr6bDBFEyPb_eRBOu0/w539-h418/Problems+with+a+trial+of+inhaler+in+a+wheezy+infant.png" width="539" /></a></div>Edward Snelson<div>@sailordoctor<br /><p><span style="font-size: x-small;">Disclaimer - when I wrote this, I briefly thought that you could bring logic to medicine. I know, right?!?</span></p></div>Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comtag:blogger.com,1999:blog-1905670054751342997.post-68950390452643283352021-05-21T03:12:00.001-07:002021-05-21T03:12:42.787-07:00Joining The Dots - How to recognise the seriously unwell child<p><a href="https://gppaedstips.blogspot.com/2021/04/you-are-entitled-to-compensation-when.html" target="_blank">In the previous post, I outlined how to tell the difference between abnormal signs that are part of a functional and fully compensated response and those that are part of an illness that is having a more significant clinical effect.</a></p><p>The child who is completely well and the child who is visibly seriously unwell and decompensating are both fairly straightforward scenarios. The child who is very well causes no clinical concern. The child who is decompensating causes unambiguous and immediate clinical concern. If only decision making was always this easy.</p><p>The child who is febrile with tachycardia but a reassuring level of activity and interaction is also relatively straightforward. The trouble is that we end up having to make decisions about those children who have a reduced activity level or whose interaction is not completely reassuring. Often there is a disconnect between what guidelines tell us to worry about and how worried we actually are. I believe that this often occurs when we intuitively include something in our decision making that is rarely featured in guidelines: the pattern of the illness.</p><p>Everything written tends to be geared towards the snapshot:</p><p></p><ul style="text-align: left;"><li>What<b> is</b> the heart rate?</li><li>What<b> is </b>the temperature?</li><li>How active and interactive<b> is</b> the child?</li></ul><p></p><p>This is problematic in any acute specialty assessing febrile children. Catch the child at the wrong time and they seem to trigger multiple red flags. Base your assessment on the snapshot alone and you may be falsely reassured.</p><p>As covered in the previous post, physiology in young children (not so much babies and older children) responds to illness with what can be dramatic changes even in uncomplicated low-risk infections. Unfortunately the same abnormalities can be seen in more clinically significant infections. No one thing is particularly sensitive or specific when deciding whether to be worried.</p><p>So if a snapshot can be misleading and there is significant overlap between low-risk and high risk scenarios, how can we decide when a clinical presentation is high risk for sepsis or serious bacterial infection?</p><p>The pattern of symptom progression is probably the answer. In the past, research has concentrated on the snapshot, over-emphasising the assessment of various parameters at a single point in time. Human intelligence allows us to incorporate the more complex business of considering three very important factors that previous research has not often considered or emphasised:</p><p></p><ul style="text-align: left;"><li>The most recent worst state of the child</li><li>The most recent best state of the child</li><li>The pattern and progression of symptoms over time</li></ul><p></p><p>The evaluation of the best and worst states and the pattern may be include retrospective (history) and prospective (a period of observation) information. The likelihood is that you already put a great deal of weight on these factors in your decision making. It is also likely that you have recognised that there are two main patterns of illness in children. I have represented these in the following diagram, without labelling which is the low risk scenario and which is high risk.</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEin4Pf81sABgxvbObQFw1v0F56KfuKvT3Dbym9QCKVqXwBn45CTt9TAUUYDmYEqsHTj7ItZGBp4ANgynwmf-eOZDGgcZ-cGvzlJNTffDljPRhMI6j_7aV8eJwjgQdRKnrZzIbXT6d9Yggw/s1527/Paterns+of+childhood+febrile+illness.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1000" data-original-width="1527" height="396" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEin4Pf81sABgxvbObQFw1v0F56KfuKvT3Dbym9QCKVqXwBn45CTt9TAUUYDmYEqsHTj7ItZGBp4ANgynwmf-eOZDGgcZ-cGvzlJNTffDljPRhMI6j_7aV8eJwjgQdRKnrZzIbXT6d9Yggw/w603-h396/Paterns+of+childhood+febrile+illness.png" width="603" /></a></div>Intuitively, I would assume that you recognise the dotted line as the high risk pattern and the solid line as the typical pattern of a low risk clinical picture of childhood febrile illness.<div><br /><div>I suspect that the explanation for this is that the child represented by the solid line is exibiting a physiological reponse to an infection that does not cause organ dysfunction. Therefore as their immunological response fluctuates, they swing from one extreme to the other. The child represented by the dotted line is sufferng from an infection which is causing significant physiological dysfunction. The result is an inability to return to normal.</div><div><br /><div>If you buy that, have another look at the diagram and look at the lines in the first half from a time point of view. In the left hand part of the diagram, severity of symptoms is often worse for the child who swings from being more unwell to a return to baseline. I believe that this is the reason that formulaic risk-assessment for serious illness that is based on a snapshot is impractical and problematic.</div><div><br /></div><div>The end results of this over-emphasis on clinical information taken at a single point in time are twofold:</div><div><ul style="text-align: left;"><li>Using a snapshot will over-diagnose serious illness, simply due to the pre-test probability of sepsis and serious bacterial infection (SBI) in the low-risk (which is most children) child.</li><li>Over time, the repeated realisation that children usually have an uncomplicated, self-limiting illness despite the severity of symptoms and abnormal physiological parameters risks de-sensitises the clinician to the possibility of sepsis/SBI. Abnormality becomes normalised and we learn to ignore things that have poor specificity for a serious outcome.</li></ul></div><div>I would strongly encourge stepping back from the snapshot to see the big picture over time. Doing so, either through the history, observation or both might help you to recognise which children are best managed symptomatically and with good safety netting advice. It migh also allow earlier recognition of the less common scenario of the child who persistently fails to return to (or close to) baseline and is more likely to have a more significant illness.<br /><p>Telling the difference between self-liniting childhood illness and serious infection is complex and requires us to process an awful lot of information. When it comes to features like best and worst states and the pattern of symptoms over time, your intuition is probably already joining these dots for you. I think you should trust that intuition.</p><p>Edward Snelson<br />Dot-joiner but likes to colour outside the lines<br />@sailordoctor</p><div class="separator" style="clear: both; text-align: center;"><a href="https://www.facebook.com/PaedsTips" style="margin-left: 1em; margin-right: 1em;" target="_blank"><img border="0" data-original-height="279" data-original-width="1273" height="100" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiNB5ber9M17HvyX5H2xAPE5qoEnoqdgEddroT8om5qPjqs34GW01zZUtsszLo4DYw4IdXTs14cwtChG_kJeH7SJhIzjvEoUfzcjH9CSK0ITnc51sJ8IDuFW1XSgrJy8b-s63vU1a7wtao/w457-h100/GPpaedsTips+Facebook+link.png" width="457" /></a></div></div></div></div>Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comtag:blogger.com,1999:blog-1905670054751342997.post-48453541662252865632021-04-01T09:20:00.002-07:002021-04-01T09:20:44.979-07:00You are Entitled to Compensation - When does "abnormal" physiology mean that I should worry about an unwell child?<p> Assessing the severity of a respiratory problem in children is not entirely straightforward. Guidelines attempt to categorise according to specific parameters however it is not uncommon for the category given to contradict our gut feel. Sometimes the answer suggested by the guideline seems to be contradicted by the appearance of the child in frontof us. Why is that? What weight can we put on our gut feel? When should we be worried?</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg0eJHppt30d_7cCOzLjMh_kisgctwgJ4vI3SaO3shZVor0Wg4gspK3_JWTzaf2A_5nmB-OqpreVlprQkqnAsgfhV6Ii7pH3glsnoH6nPMzSTcYQtvhZGrjj1hS-bBF1POzPMQfMZX1GGs/s1430/When+to+be+worried.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="779" data-original-width="1430" height="220" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg0eJHppt30d_7cCOzLjMh_kisgctwgJ4vI3SaO3shZVor0Wg4gspK3_JWTzaf2A_5nmB-OqpreVlprQkqnAsgfhV6Ii7pH3glsnoH6nPMzSTcYQtvhZGrjj1hS-bBF1POzPMQfMZX1GGs/w405-h220/When+to+be+worried.png" width="405" /></a></div><p>To understand any severity system and to explore the nuances, I would ask the question, “What is the correlation between the words (mild/ moderate/ severe) and the clinical state of the patient?”</p><p>The clinical state of the patient could be categorised as follows:</p><p></p><ul style="text-align: left;"><li><b><span style="font-size: medium;">Normal physiology</span></b></li><li><b><span style="font-size: medium;">Fully compensating</span></b></li><li><b><span style="font-size: medium;">Partially compensating</span></b></li><li><b><span style="font-size: medium;">Decompensating</span></b></li></ul><p><b>Normal physiology</b></p><p>In a normal physiological state, circulation and respiration are unaffected. The child’s activity and interaction are normal. This normal behaviour is evidence of end-organ function – the brain is well perfused, hydrated and nourished.</p><p><b>Fully compensating</b></p><p>When a child becomes unwell, physiology alters to compensate for the illness. For example, a baby with mild bronchiolitis will breathe faster and heart rate will increase to mitigate the effect of the viral illness on their lungs. If this compensation is fully effective, activity and interaction will be unaffected. In this context, the infant is often referred to as a “happy wheezer”. Thus happy wheezer is not a diagnosis, but rather a clinical evaluation.</p><p><b>Partially compensating</b></p><p>As the effects of an illness become more significant, physiological compensation increases but there reaches a point where it is no longer fully effective. The brain is a sensitive organ and the early effects of reduced perfusion, hydration and respiration are usually apparent in the gross neurology of a child. Activity and interaction becomes reduced as an early sign that compensatory physiology is no longer fully effective.</p><p><b>Decompensating</b></p><p>If physiological compensation begins to fail, the child’s clinical state deteriorates rapidly. If the problem is primarily respiratory, the deleterious effects on the central nervous system and the respiratory muscles create a vicious cycle: tired muscles and a dysfunctioning brain are unable to continue driving the compensatory mechanisms. Respiration is further impeded which in turn reduces the oxygen delivery and CO2 clearance so badly needed for the child’s physiology to compensate.</p><p>If the problem is primarily circulatory the point of decompensation leads to reduced cerebral, cardiac, hepatic and renal perfusion. This accelerates the effects of poor perfusion through a combination of worsening cardiac output and biochemical changes that impair the metabolic functions needed to cope.</p><p>In either case, the effects of decompensation are dramatic. Conscious level is affected and the child is likely to be pale and look seriously unwell. Do not mistake a falling heart rate or respiratory rate for clinical improvement. What is happening is quite the opposite. The child’s physiology is failing – impending cardiorespiratory arrest is inevitable without critical care support.</p><div>Using this model for assessing the unwell child, we can see that "abnormal" physiology which is fully effective (e.g. a child with vial wheeze who has tachypnoea and mild recession but is running around and happy) is very different to abnormal physiology with evidence that there is only partial compensation (e.g a child with viral wheeze, tachypnoea, recession and reduced activity level).</div><div><br /></div><div>So when we assess a child and see that changes in physiology are fully effective, we can see this as a very different evaluation to that of the child with signs that may indicate compensation that is not fully effective.</div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqIGrPUYzb99sNuFU291IGY2AtmcCz55_Wb_h1d_kVzjizOgt-vj2bG9mI-r0uWcVw_eFXnWWwG8wAGDBAi4G7FRXt4snPjHjTLwi1WPL1pmid4WQqrgCsYoMWizF19PqN7jJUzmYsYpg/s1917/Effects+and+Effectiveness+of+Physiological+Compensation.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1563" data-original-width="1917" height="475" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqIGrPUYzb99sNuFU291IGY2AtmcCz55_Wb_h1d_kVzjizOgt-vj2bG9mI-r0uWcVw_eFXnWWwG8wAGDBAi4G7FRXt4snPjHjTLwi1WPL1pmid4WQqrgCsYoMWizF19PqN7jJUzmYsYpg/w582-h475/Effects+and+Effectiveness+of+Physiological+Compensation.png" width="582" /></a></div><div>So any score which gives excessive weight to more objective emasures will fail to distinguish the fully compensating child from the child who has a more clinically significant illness. Normal end organ function, usually manifested in the behavior and activity of a child, is probably the more important part of the assessment. Abnormal physiology tells us that the child is unwell, whereas the clinical effect is what should tell us when to be concerned. (1)</div><br /><div>That, dear friends, is why you find yourself perplexed when a guideline says that you need to treat "abnormal numbers" as red flags when the child you see in front of you seems to be basically well apart from these physiological changes. In other words, your gut feel that the child is fine is valid. It is valid because the child who is fully mobile and normally interactive either has no problem or has fully compensated for the problem. That's what they do. When they are not fully compensating, then it's time to worry.</div><div><br /></div><div>Edward Snelson</div><div>@sailordoctor</div><div><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://www.facebook.com/PaedsTips" imageanchor="1" style="margin-left: 1em; margin-right: 1em;" target="_blank"><img border="0" data-original-height="279" data-original-width="1273" height="104" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJY2BmpbP9sKqD6jjYhSV2bSCT72oTrDnEV9qwuKeSLMmPJc3Uy3eodoyuXba15LZLfVDMcpnUpWaPe5Czg18fy8SUC87S-nyBr2J9g9ZugYis9hmi6bZ5BB4TeFnsE1Q97PcE57T0R20/w477-h104/GPpaedsTips+Facebook+link.png" width="477" /></a></div><ol style="text-align: left;"><li><a href="https://pubmed.ncbi.nlm.nih.gov/29545408/" target="_blank">Snelson E, Ramlakhan S, Which observed behaviours may reassure physicians that a child is not septic? An international Delphi study, Arch Dis Child, 2018 Sep;103(9):864-867. doi: 10.1136/archdischild-2017-314339. Epub 2018 Mar 15.</a></li></ol><div><br /></div>Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comtag:blogger.com,1999:blog-1905670054751342997.post-47036733342215100682021-03-10T06:46:00.000-08:002021-03-10T06:46:07.867-08:00Newborn Presentations<p>People get worried about newborn babies. When presented with a baby problem, there are a few basic rules to apply:<br /></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgPMkjFtz4irJNljbUtdMqdtttLFWezQIbKW4_7y0_VZ-aAygPShjQIPqDGd5QXX6w4NjfSIo0K6CxWHEioeSM0z_m6zO7zhSj4MBM9zBvZX-9fa-yxRecMdmx6cEuUciwETpj8FtOMJxk/s1420/Newborn+problems+-+a+simple+guide.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1420" data-original-width="1028" height="613" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgPMkjFtz4irJNljbUtdMqdtttLFWezQIbKW4_7y0_VZ-aAygPShjQIPqDGd5QXX6w4NjfSIo0K6CxWHEioeSM0z_m6zO7zhSj4MBM9zBvZX-9fa-yxRecMdmx6cEuUciwETpj8FtOMJxk/w444-h613/Newborn+problems+-+a+simple+guide.png" width="444" /></a></div><br /><p>Most things that newborns present with are unlikely to have a significant cause. Some presentations are more concerning that others and while there are no absolutes, it is good to know which things to be more suspicious of.<br /></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg3TkG0WWMi0jX41tvB3RYuyNyRD43ONtb5KTGn6zZXcK3Z3x36pzjcV_F41NuWqw-V-VO2Af85D65Wj8wAKNxAZGRNE2Hs_fP5CAOTHeNQxCMI1io2WwuK1fTyxruqbTqgYp0gZ25FriE/s1490/Newborn+problems+pre-test+probability.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1490" data-original-width="1028" height="594" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg3TkG0WWMi0jX41tvB3RYuyNyRD43ONtb5KTGn6zZXcK3Z3x36pzjcV_F41NuWqw-V-VO2Af85D65Wj8wAKNxAZGRNE2Hs_fP5CAOTHeNQxCMI1io2WwuK1fTyxruqbTqgYp0gZ25FriE/w411-h594/Newborn+problems+pre-test+probability.png" width="411" /></a></div><br /><p>In many cases, it is possible to significantly change the index of suspicion by knowing the red flags to look out for.<br /></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhSpzLF6ByrzPoiu8ldD-roVE1Ail4WJ-7d_8ntZ2zLk3fjpISy3bAsxDL88tcdUf8zFSAPMNG2gbYtrDXz24Y8lMQcfby63mzjqZ0eBXLvAraV3yIwLlnvNi993wt9iH1jPfDXrPMZ7kA/s2093/Newborn+presentations+-+red+flags.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2093" data-original-width="1500" height="767" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhSpzLF6ByrzPoiu8ldD-roVE1Ail4WJ-7d_8ntZ2zLk3fjpISy3bAsxDL88tcdUf8zFSAPMNG2gbYtrDXz24Y8lMQcfby63mzjqZ0eBXLvAraV3yIwLlnvNi993wt9iH1jPfDXrPMZ7kA/w549-h767/Newborn+presentations+-+red+flags.png" width="549" /></a></div><br /><p>Let's look at a few examples:</p><p><b><span style="font-size: medium;">Imperfectly shaped head</span></b></p><p>Since the discovery that putting a baby to sleep on their back dramatically reduces the risk of sudden infant death, there has been a significant rise in the number of babies and infants with <span face=""Calibri","sans-serif"" style="font-size: 11pt; line-height: 115%; mso-ansi-language: EN-GB; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">asymmetrically</span> shaped heads.</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgxwZBpEfTO8e2MWdP_uvEhJfq9BXFYTtoY_yNdakQH6pPNl7e7qQ83D9rJwR0od8gVqRTkn7B4BVKcivqhlrUsQkJCtA04ySRjltfqqvFit0kYtvOR11QSL0bsJa8XRRQcuB9b5xyiGMM/s320/Plagiocephaly.JPG" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="320" data-original-width="272" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgxwZBpEfTO8e2MWdP_uvEhJfq9BXFYTtoY_yNdakQH6pPNl7e7qQ83D9rJwR0od8gVqRTkn7B4BVKcivqhlrUsQkJCtA04ySRjltfqqvFit0kYtvOR11QSL0bsJa8XRRQcuB9b5xyiGMM/s0/Plagiocephaly.JPG" /></a></div><br /><p><span style="font-size: x-small;">Picture credit: https://commons.wikimedia.org/wiki/File:Plagiocephalie.JPG</span></p><p>The vast majority of babies with this presentation will have plagiocephaly - the result of gravity on a compliant skull. Plagiocephaly has no apparent risk of harm and requires no intervention. However, this presentation nicely illustrates the general principles of assessing any presentation in a baby because there is a significant pathology that is rare but significant - craniosynostosis.</p><p>So while the head shape is very likely to be nothing to worry about, it is still necessary to look for evidence to support that decision. <a href="http://gppaedstips.blogspot.com/2018/07/paediatric-examination-by-book-easter.html" target="_blank">The head should be palpated and measured (and plotted), the baby should be given a neurological examination and development should be assessed.</a></p><p>It also follows another rule of newborn presentations: where there is no credible pathology, we should do as much nothing as possible. We should avoid unnecessary tests and treatments. Remember that the baby is your patient. Don't do anything to them that does not stand to benefit them directly.<br /><br /></p><p><b><span style="font-size: medium;">Sticky eyes</span></b></p><p>While the temptation is to presume that sticky eyes are due to infection, this is rarely the case in newborns. <a href="http://gppaedstips.blogspot.com/2020/01/something-or-nothing-why-topical.html" target="_blank">In most cases the problem is a blocked tear duct. True eye infections are uncommon and usually quite obvious. </a> This presentation nicely illustrates the general principles of:</p><p></p><ul style="text-align: left;"><li><b>Assess the problem</b> - Is the conjunctiva red? Is there periorbital redness and swelling?</li><li><b>Look at the baby</b> - Do they appear well?</li><li><b>Decide if there is a significant problem</b> (ophthalmia neonatorum)</li><li>If not, <b>don't do an unnecessary test</b> (swab) <b>or give an unecessary treatment</b> (antibiotic drops)</li></ul><p></p><p><b><span style="font-size: medium;"><br />Excessive crying</span></b></p><p>Babies cry. How much is excessive is hugely subjective and open to interpretation. Although excessive crying in the absence of pathology has been given a name (<a href="http://gppaedstips.blogspot.com/2017/08/everything-wrong-with-infantile-colic.html" target="_blank">colic</a>) this scenario demonstrates the principle that <b>we can't always offer a diagnosis.</b> Calling the problem colic implies that we know what causes the problem and validates an interventional approach. There is no treatment for excessive crying in the absence of pathology that has a good evidence base. <a href="http://gppaedstips.blogspot.com/2020/11/a-whole-new-world-honesty-in-paediatrics.html" target="_blank">Sometimes honesty about uncertainty and futility of intervention is the best policy.</a></p><p><b><span style="font-size: medium;"><br />Regurgitation of Feeds</span></b></p><p>Note the use of the word regurgitation. People often use the word vomiting or even "projectile vomiting" when neither is what is happening. Babies often bring back some milk after a feed. This is generally a passive event, as opposed to vomiting, which is what happens when peristalsis works in reverse or against an obstruction such as pyloric stenosis.</p><p>By now, you probably know what I'm going to suggest.</p><ul><li><b>Assess the problem</b> - Is regurgitation the only symptom? Are there red flag features (see above)? How long has the problem been occurring? Has it changed much and if so how rapidly?</li><li><b>Look at the baby</b> - Do they appear well? Do they appear well grown? Plot their growth on a chart.</li><li><b>Decide if there is a significant problem</b> (e.g. Pyloric Stenosis) or whether they could be in a <a href="http://gppaedstips.blogspot.com/2019/02/too-much-choice-what-milk-do-you-need.html" target="_blank">feed-cry cycle</a>.</li><li>If not, <b>don't do an unecessary test</b> <b>or give an unnecessary treatment.</b> If you give alginates to every regurgitating baby, you'll double your workload as they come back the next week with constipation and without the original symptom having improved.</li></ul><p><b><span style="font-size: medium;"><br />Not opening bowels for X number of days</span></b></p><p>Guess what? Yes: in most cases, <a href="http://gppaedstips.blogspot.com/2015/06/i-learned-new-word-today-easter-eggs.html" target="_blank">the baby who has not passed a stool for the past few days is usually going through something that is normal in the first few weeks of life.</a></p><p>As with all of the low risk newborn presentations, if the baby looks well, examines normally and is growing and developing normally, they are normal. If something is significantly wrong, it should manifest itself in the history or examination. In most cases, we should normalise this presentation rather that give something to treat it.</p><p>It can be really difficult to do nothing when faced with a baby and a concerned parent. However, a careful clinical assessment and evaluation are the most important interventions you can offer. If you have done that and not come up with something serious, explanation and safety netting are the premium service, not the economy class package.</p><p><b><span style="font-size: medium;"><br />Umbilical presentations</span></b></p><p>There are rare and significant pathologies that can affect the umbilicus. Most of these will present at birth or in a way that alerts the clinician to the fact that something is clearly not right, The more common presentations and the best approach to each are:</p><p></p><ul style="text-align: left;"><li><b>Umbilical granuloma</b> - <a href="http://gppaedstips.blogspot.com/2015/05/referrals-inappropriate-inconvenient-or.html" target="_blank">leave it alone</a></li><li><b>Umbilical hernia</b> - leave it alone</li><li><b>Umbilical stump being sticky and smelly</b> - leave it alone <a href="http://gppaedstips.blogspot.com/2020/01/something-or-nothing-why-topical.html" target="_blank">unless there is evidence of omphalitis</a></li></ul><p></p><p><b><span style="font-size: medium;"><br />Skin presentations</span></b></p><p>Lots of things can happen to the skin of a baby in the first few days and weeks. Most presentations are either normal phenomena (peeling skin), dysfunctional but harmless (erythema toxicum) or problematic but mostly uncomplicated (cradle cap).</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEikfnu0Gkwxo10Bmqv6pXVpmy20GurAWnLWPkEOtyEZ1M1nhMXAW7Qa4YoAdFnVWshyUlutE9GLhSTR9UahQ-yyFNjm9Avg-mlvRZDudr11oAzFSoh15yRuxA0pWHurWoU9Bruiy-DK9I4/s1024/E26-erythema-toxicum-1024x1024.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1024" data-original-width="1024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEikfnu0Gkwxo10Bmqv6pXVpmy20GurAWnLWPkEOtyEZ1M1nhMXAW7Qa4YoAdFnVWshyUlutE9GLhSTR9UahQ-yyFNjm9Avg-mlvRZDudr11oAzFSoh15yRuxA0pWHurWoU9Bruiy-DK9I4/s320/E26-erythema-toxicum-1024x1024.jpg" /></a></div><span style="font-size: x-small;">Picture credit: <a href="https://dftbskindeep.com/diagnoses-gallery/" target="_blank">Skin Deep - a DTFB project</a></span><br /><p>In each case there are simple questions to be answered</p><p></p><ul style="text-align: left;"><li><b>Peeling skin</b> - Is the baby well? Is there dermis exposed by the peeling skin (if so then epidermolysis bullosa is a possibile diagnosis)?</li><li><b>Erythema toxicum</b> - Is the baby well (erythema toxicum is completely harmless)?</li><li><b>Cradle cap</b> (seborrheaic dermatitis capitis) - Is the baby well? Does the skin have signs of infection?</li></ul><p></p><p>Peeling skin and erythema toxicum are best left alone. Cradle cap can be treated with olive oil in most cases. Occasionally it can become infected.</p><p><b><span style="font-size: medium;"><br />Jittery Movements</span></b></p><p><a href="https://www.youtube.com/watch?v=XUQKW9p2qWA" target="_blank"><b>Sleep myoclunus</b></a> is a normal phenomenon at all ages. In babies it can cause people to worry thet their child is having a seizure. This is partly due to the protective reflexes that they are born with such as the moro reflex.</p><p>Here we go again with the standard procedure for a newborn presentation:</p><ul><li><b>Assess the problem</b> - Are the movemments occuring during or around sleep time? Is the baby otherwise normal in between episodes?</li><li><b>Look at the baby</b> - Do they appear well? Are they developing normally. Measure and plot head circumference.</li><li><b>Decide if there is a significant problem</b> (e.g. Infantile spasms/ West syndrome)</li><li>If not, <b>don't do an unecessary test</b> <b>or give an unnecessary treatment.</b> Explain, reassure and give safetynetting advice.</li></ul><p>Demedicalising infancy is a good thing to do. The simple apprach of assess, look and decide will allow you to do that in the majority of cases. In the rare cases of the discovery of a red flag or atypical presentation, there are always the options of advice or referral.</p><p>Edward Snelson<br />@sailordoctor</p><div class="separator" style="clear: both; text-align: center;"><a href="https://www.facebook.com/practicalpaeds" imageanchor="1" style="margin-left: 1em; margin-right: 1em;" target="_blank"><img border="0" data-original-height="279" data-original-width="1273" height="98" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiNB5ber9M17HvyX5H2xAPE5qoEnoqdgEddroT8om5qPjqs34GW01zZUtsszLo4DYw4IdXTs14cwtChG_kJeH7SJhIzjvEoUfzcjH9CSK0ITnc51sJ8IDuFW1XSgrJy8b-s63vU1a7wtao/w447-h98/GPpaedsTips+Facebook+link.png" width="447" /></a></div><br /><p><br /></p>Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comtag:blogger.com,1999:blog-1905670054751342997.post-74004980222933779782021-02-25T11:59:00.001-08:002021-02-25T11:59:53.328-08:00Everything has changed - Non-blanching rash in children<p>If you told me that nothing has changed for you this past twelve months, I'd be quite surprised. This year has been a rollercoaster both in and out of work for every healthcare professional I know. As a finishing touch to the year that has changed everything, I have one more bit of news for you that will change your practice. Strap in. This one is huge.</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixZ5NTPA0h5alUAI65HtnXxmpjb8lNC6tdhM8rab_F7hN4w-y63rtPlfY-wcPrCeEVYUQDm7LqkxtSyeTDZRKu1t2yxtGvr9Z4s3RzMpP0IMi9sgFtuh3JPzrHx46CdgWB1taVYU38wYc/s1008/Tom+Waterfield+quote.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="527" data-original-width="1008" height="249" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixZ5NTPA0h5alUAI65HtnXxmpjb8lNC6tdhM8rab_F7hN4w-y63rtPlfY-wcPrCeEVYUQDm7LqkxtSyeTDZRKu1t2yxtGvr9Z4s3RzMpP0IMi9sgFtuh3JPzrHx46CdgWB1taVYU38wYc/w478-h249/Tom+Waterfield+quote.png" width="478" /></a></div>So how did we get there from where we used to be? - "Fever with non-blanching rash is meningococcal sepsis until proved otherwise."<div><br /></div><div>It has long been recognised that this outdated adage has become obsolete in a population with effective meningococcal vaccination. When it was first coined, the pre-test probability of meningococcal disease (MD) in a child with fever and non-blanching rash was around 1 in 5. In an unvaccinated population, the 20% chance of MD is more than enough reason to have a "treat in every case" approach in the absence of a rapid diagnostic test.</div><div><br /></div><div>Since the introduction of a very successful meningococcal vaccination program, the prevalence of MD has dropped dramatically. The absolute number of cases of MD (the numerator) became a fraction of the pre-vaccination years. We continued to see large numbers of children with fever and non-blanching rash (the denominator) but no-one was recording how many.</div><div><br /></div><div>Enter the <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30474-6/fulltext?rss=yes" target="_blank">PiC study</a>, (1) possibly the most significant academic publication of recent years regarding the management of the unwell child. This large UK based multicentre prospective study did a couple of very important things. Firstly, it collected data about the prevalence of meningococcal disease in children with fever and petechial rash. The number that it found was, as we had all hoped and expected, small. That number was about 1%.</div><div><br /></div><div>That was only part of the clinically important information that the study produced. After all, people might say that a 1/100 risk of MD is enough to justify the continued blind treatment of all such children.</div><div><br /></div><div>What if you could safely tell who to treat and not to treat though? The PiC study had enough information about clinical features and outcomes to be able to test the validity of any guideline. They simulated what would happen if all the children in the PiC study were managed according to a guideline's algorithm. This allowed them to see how sensitive and specific each guideline is.</div><div><br /></div><div>The NICE guideline (2) recommends treatment of all febrile children with non-blanching rash. So no surprises that the PiC study found the NICE approach to have 100% sensitivity but only 1% specificity. 99% of children treated in this way have unnecessary tests, treatment and time in hospital. <br /><p>Most major paediatric emergency departments in the UK have been deviating from the "treat every time" approach for many years. Most centres have guidelines which use a combination of clinical assessment and the use of inflammatory markers to select which children will not be treated. The PiC study also evaluated the sensitivity and specificity of 6 of these local guidelines. What this showed was that these guidelines retained 100% sensitivity but improved specificity. The best guideline (Barts London) achieved a specificity of 36%. That means that a lot of children are safely avoiding unnecessary treatment and time in hospital.</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhYaxhMsgzJB0UKS67Q6haeirDEzRoCd_OalD9R7MydpCWi2M4sCtCxJn-JpIMayoYD86QvYZA36JSAeryGKCE7IIdnmJR6Gh6NIGi9s5w2gDf2gpCW5nAIUZIHBEAm4U4DS0awnM09NZI/s990/PiC+study+findings.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="688" data-original-width="990" height="326" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhYaxhMsgzJB0UKS67Q6haeirDEzRoCd_OalD9R7MydpCWi2M4sCtCxJn-JpIMayoYD86QvYZA36JSAeryGKCE7IIdnmJR6Gh6NIGi9s5w2gDf2gpCW5nAIUZIHBEAm4U4DS0awnM09NZI/w470-h326/PiC+study+findings.png" width="470" /></a></div><p>If you are thinking that this is all very nice but changes nothing for the pre-hospital clinician, the best bit is still to come. A guideline that wasn't included in the PiC study was the Sheffield Children's Hospital Emergency Department (SCHED) Handbook. (I believe that the reason that it was not included at the time was that the guideline was being changed.) The direction of that change was away from using inflammatory markers as part of the decision making process. The SCHED (3) guideline uses pattern recognition and experienced decision making. Blood tests are not a recommended part of the process outside of specific circumstances (e.g. diagnosing haematological cause).</p><p>Although this guideline is not one of those in the PiC study, it has since been applied to the PiC study dataset of 1300 children with fever and non-blanching rash. The exciting result of this is that the Sheffield guideline also retains 100% sensitivity (95% CI 82-100%) but achieves an even higher specificity at 69% (95% CI 66-72%). (3)</p><p>The exciting thing about this approach is that it is a decision that can be made anywhere. What the decision is made up of is the following</p><p></p><ul style="text-align: left;"><li>Continuing default treatment in a few cases (rare but important)</li><ul><li>Fever and purpuric rash</li><li>Fever and petechial rash and clinically probable sepsis</li></ul><li>Identifying other possible causes (such as mechanical cause from vomiting) using pattern recognition to identify those at low risk</li><li>For those children who do not have another diagnosis or deemed to need default treatment, allowing an experienced decision maker to choose whether to treat or discharge.</li></ul>Here is an adapted flowchart from the Sheffield Children's Hospital Emergency Department Handbook:<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhR05GBc1ZtZ0nZPWKMXlNpY4-It1bd14CR6AapIN7cohP7PR7Ro9NMzqKX5t2h2rHqU0ms248GY74qT2KY1R1fiVPh_S-5gbiUVOymoaZu7lFTQOILmmak7HuvxZXn28bQ8VU3Gqw7BeU/s1801/The+pragmatic+approach+to+the+child+with+non-blanching+rash.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1801" data-original-width="1510" height="715" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhR05GBc1ZtZ0nZPWKMXlNpY4-It1bd14CR6AapIN7cohP7PR7Ro9NMzqKX5t2h2rHqU0ms248GY74qT2KY1R1fiVPh_S-5gbiUVOymoaZu7lFTQOILmmak7HuvxZXn28bQ8VU3Gqw7BeU/w599-h715/The+pragmatic+approach+to+the+child+with+non-blanching+rash.png" width="599" /></a></div>The next question you might be asking yourself is, "Am I an experienced decision maker?" when it comes to the child with fever and petechial rash. While there is no simple answer to this, the likey answer is yes if you have 5-10 years of postgraduate experience in a role that includes decision making about unwell children.<br /><p>Everything has changed in the management of the well child with petechial rash and fever. Thanks to vaccination and high quality research, we can take a very different approach and avoid overtreatment of what is now known to be a low risk clinical presentation.</p><p>Edward Snelson<br />@sailordoctor</p><div class="separator" style="clear: both; text-align: center;"><a href="https://www.facebook.com/PaedsTips/" style="margin-left: 1em; margin-right: 1em;" target="_blank"><img border="0" data-original-height="279" data-original-width="1273" height="94" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiNB5ber9M17HvyX5H2xAPE5qoEnoqdgEddroT8om5qPjqs34GW01zZUtsszLo4DYw4IdXTs14cwtChG_kJeH7SJhIzjvEoUfzcjH9CSK0ITnc51sJ8IDuFW1XSgrJy8b-s63vU1a7wtao/w430-h94/GPpaedsTips+Facebook+link.png" width="430" /></a></div><p>References</p><p></p><ol style="text-align: left;"><li><a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30474-6/fulltext" target="_blank">Waterfield T, Maney J-A, Fairley D, Lyttle MD, McKenna JP, Roland D, Corr M, McFetridge L, Mitchell H, Woolfall K, Lynn F, Patenall B, Shields MD, Validating clinical practice guidelines for the management of children with non-blanching rashes in the UK (PiC): a prospective, multicentre cohort study, The Lancet, November 2020</a></li><li>NICE. Meningitis (bacterial) and meningococcal septicaemia in under 16s: recognition,diagnosis and management | Guidance and guidelines | NICE. 2015 [cited 2017 Oct 10]</li><li><a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30936-1/fulltext" target="_blank">Snelson E, Waterfield T, Testing the limits of pragmatism in children with fever and non-blanching rash, Correspondence, The Lancet March 2021</a></li></ol><p><br /></p></div>Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comtag:blogger.com,1999:blog-1905670054751342997.post-88964031466244547342020-12-14T03:48:00.000-08:002020-12-14T03:48:17.624-08:00Labels in child and adolescent mental health presentations - A Christmas stocking stuffer<p> Here's another stocking stuffer. In the same way as last time, it's just a mini-FOAMed post.</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgmsrJ-4ePiVRUYpdigKndo9kTNma17d2C4X6TMiQ1bKLlFqn1_VcEfV0HyKT0cmv5nUOb5WTQMDOMRpnTX9kTLQnBNH2lecowLPTyfadmpXLGzxWuqJyzRN4RW4kUpGH3EDo78CA2GF3c/s2249/Child+and+adolescent+mental+health+layers.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2249" data-original-width="1400" height="760" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgmsrJ-4ePiVRUYpdigKndo9kTNma17d2C4X6TMiQ1bKLlFqn1_VcEfV0HyKT0cmv5nUOb5WTQMDOMRpnTX9kTLQnBNH2lecowLPTyfadmpXLGzxWuqJyzRN4RW4kUpGH3EDo78CA2GF3c/w473-h760/Child+and+adolescent+mental+health+layers.png" width="473" /></a></div>So next time you see a child or young person with a mental health presentation, I would suggest the following:<div><ul style="text-align: left;"><li>Don't think of behaviour as behavioral. Assume it is a symptom of something more complex.</li><li>Don't feel pressured to give a label. Many young people don't ever get a formal diagnosis.</li><li>See each contact as an opportunity to discover more about what is going on and why. While this may not always be something massive, sometimes it takes a lot of feeling safe for a young person to disclose something. The bigger the thing is to them, the more time and space it may take.</li></ul><p>Mental health problems in young people are complex and that can be daunting for us as front line clinicians. If you ever feel that you are not finding it easy, you are not alone.</p><p>Edward Snelson<br />@sailordoctor</p><div class="separator" style="clear: both; text-align: center;"><a href="https://www.facebook.com/PaedsTips" imageanchor="1" style="margin-left: 1em; margin-right: 1em;" target="_blank"><img border="0" data-original-height="70" data-original-width="320" height="102" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg85cCTB3DAwDlkEfRaRlnGuSk9baExbs8crDAroH065s2MWc5vAiNC-7Bz9TH2J-9Rs6GLPZJhx2msXNoda3Jwh9LIjxkN3q4CyeS0MgdObLpaknxcjAceEpwjmvGJ_DpTpiPkmc53Q5k/w467-h102/GPpaedsTips+Facebook+link.png" width="467" /></a></div><p><br /></p></div>Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comtag:blogger.com,1999:blog-1905670054751342997.post-46035854080924787192020-11-30T23:03:00.002-08:002020-11-30T23:03:22.998-08:00Ipratropium for infant wheeze - a Christmas stocking stuffer<p>On the run-up to Christmas, this site will be delivering some rather minimalist FOAMed. Instead of comprehensive explanations, there will be some short but hopefully useful posts for you to enjoy. Think of them like a stocking stuffer rather than your main present. Perhaps you'll like this format even better. [I will never forget the year that my children played more with one of their stocking stuffers than with their main present. That stocking filler present was a whoopee cushion.]</p><p>Here it is:</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjFjhlY5pOCfpG8mZrCK-Piq8JsOWNkiQ_Jrmjcfzt1_ajd0xMUsF73uMhMv3YDRlN6MYbkaGn8NIukPSuiJP7GyOma8fqLyuWNFy0Z9VuK0i7QvcBtiIdrXAo1gpqdb798o0l2XEZ4fig/s1500/Ipratropium+is+never+the+treatment+of+choice.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1244" data-original-width="1500" height="490" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjFjhlY5pOCfpG8mZrCK-Piq8JsOWNkiQ_Jrmjcfzt1_ajd0xMUsF73uMhMv3YDRlN6MYbkaGn8NIukPSuiJP7GyOma8fqLyuWNFy0Z9VuK0i7QvcBtiIdrXAo1gpqdb798o0l2XEZ4fig/w592-h490/Ipratropium+is+never+the+treatment+of+choice.png" width="592" /></a></div>That little caveat at the end is about the use of ipratropium as an additional agent in the treatment of severe/ life-threatening brochospasm due to viral wheeze. In that scenario, it's still very much all about the salbutamol.<div><br /></div><div>That's all folks. If you wanted something bigger, you'll have to wait until we're opening the main Christmas presents, or you could read <a href="https://gppaedstips.blogspot.com/2020/10/the-decision-makers-guide-to.html" target="_blank">this post that goes into more detail about infant wheeze diagnosis</a>.<div><br /></div><div>I hope you're looking forward to your next stocking stuffer.</div><div><br /></div><div>Edward Snelson</div><div>@sailordoctor</div><div class="separator" style="clear: both; text-align: center;"><a href="https://www.facebook.com/PaedsTips" style="margin-left: 1em; margin-right: 1em;" target="_blank"><img border="0" data-original-height="279" data-original-width="1273" height="102" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjiTpLZTiUeN4cYVGsXmmrSxV1vzK877pKq3u3J2yRTENjZU9V3bMABMKv4_LV9igYOSP4fOp1lFrjRJWMPbwGH7IrqZW_rtMg4qjESZwmYLmhIwBj_lT-F-FhecT0d7QQJi5qlziivcnA/w466-h102/GPpaedsTips+Facebook+link.png" width="466" /></a></div><div><p><br /></p><p><br /></p><p><br /></p></div></div>Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comtag:blogger.com,1999:blog-1905670054751342997.post-35169532971186390332020-11-12T00:34:00.000-08:002020-11-12T00:34:10.161-08:00A Whole New World - Honesty in Paediatrics<p>Paediatrics is a specialty where lying about a diagnosis is normal practice. It's not because we're bad people. When you think about the challenges of diagnosis in children combined with the expectation of a diagnosis, it is completely unsurprising. The adult accompanying the child would like a diagnosis (please and thank you) and the clinician would very much like to give one (you're welcome).</p><p>While that all seems very reasonable, in child health it often isn't entirely truthful. It is one of the mantras of medicine that the diagnosis is going to come from history and examination in most cases. Hurrah for clinical diagnoses. In paediatrics, the history is often from a third party and will have an inevitable element of bias. The examination will also contain more uncertainties more of the time. You have to accept a significant lack of information when interpreting examination finding in children.</p><p>The result of this is that clinical diagnosis is more challenging in paediatrics. Here's the paradox: clinical diagnosis is the default position in child health. Why? Because we don't want to do tests on children or give them treatments "in case" unless these investigations or therapies are very likely to benefit the child.<br /></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi6LAu75wo_cgRic8G2Em3ySPd3bm3IiK7FQersPzziMVa1qlKSzGnTn1il6noG0dmaPBpHwyxdGtHiAYoaVUWvKK9CjEnJteMbNt3GMfq1LwMxXZkeiHOFCD-COhBGyLrzQI0ixapgB14/s1553/Why+certainty+is+a+challenge.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1280" data-original-width="1553" height="413" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi6LAu75wo_cgRic8G2Em3ySPd3bm3IiK7FQersPzziMVa1qlKSzGnTn1il6noG0dmaPBpHwyxdGtHiAYoaVUWvKK9CjEnJteMbNt3GMfq1LwMxXZkeiHOFCD-COhBGyLrzQI0ixapgB14/w502-h413/Why+certainty+is+a+challenge.png" width="502" /></a></div><p>This week, something big happened and it didn't even hit the news. The General Medical Council released some new and updated guidance: "Guidance on professional standards and ethics for doctors
Decision making
and consent." While much of the content is old news, there is a new emphasis on honesty when there is diagnostic uncertainty that is hugely relevant to paediatric practice, thanks to the fact that uncertainty is where we work.</p><p>So, when are we lying to our patients or the adults that accompany them? The truth is that there is a spectrum of how far what we tell people lies from the truth. What we should probably do in the light of the new GMC guidance is to re-evaluate our approach to a variety of clinical presentations and ask, "Should I change what I say about this?"</p><p>You could argue that nothing is certain in medicine, so what are the thresholds of uncertainty that decide when we should be honest in this way? That's a fair comment. We need to apply some measure here - enter the certometer.</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjvUC2-4jZn1OOJhJsOUgx1hN1eT_QwourHrUAEbr0SGPCQHr_K0i0WHzDhsC5h4URp_pucaRnu1wS6ZwRJngjm2ghZjbwXOm-x1454Ba3Xwk5gJeq7jrJm9PFwVPBEOrzd_nZCijgVwkQ/s634/Diagnosis+Certometer.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="634" data-original-width="547" height="560" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjvUC2-4jZn1OOJhJsOUgx1hN1eT_QwourHrUAEbr0SGPCQHr_K0i0WHzDhsC5h4URp_pucaRnu1wS6ZwRJngjm2ghZjbwXOm-x1454Ba3Xwk5gJeq7jrJm9PFwVPBEOrzd_nZCijgVwkQ/w483-h560/Diagnosis+Certometer.png" width="483" /></a></div>The certometer takes the things that we are already using in our diagnostic approach and gives us an idea of how truthful it is to give that diagnosis. Last week, I asked the medical Twitter world for a few suggestions of diagnoses that we could feed into the Certometer and this seems like a good time to give this contraption a go.<div><br /></div><div>First up is an intriguing suggestion: Diagnosis - Viral illness.</div><div>In my experience this diagnosis is usually given to children with a fever and signs or symptoms of upper respiratory tract infection without signs or symptoms of a more specific diagnosis.</div><div><br /></div><div>Let's imagine a common scenario then: a 2yr old previously healthy child with a fever for 2 days. They have a runny nose but no cough. They have no respiratory abnormality. Pharynx and both tympanic membranes are inflamed.</div><div><br /></div><div>The pre-test probability of this being a viral illness is high. It's a child with a fever so the probability that the illness is viral is around 90%.</div><div><br /></div><div>Positive predictors of a viral cause do exist and include wheeze and urticarial rash in children. This child has none of these things.</div><div><br /></div><div>Good negative predictors of a diagnosis of viral illness in this sort of case would be some signs of suppurative complications such as mastoiditis. We haven't seen any signs to suggest this.</div><div><br /></div><div>So having looked for something specific that truly discriminates and found none, what you are left with is your pre-test probability, dialled down slightly by virtue of the absence of signs of another diagnosis. In other words, all we have truly achieved is to rule out complications. Since complications are rare, we're essentially no more certain this is a virus than before we started.</div><div><br /></div><div>Calling it a viral illness implies that we've added some certainty to the underlying cause that in reality, we haven't. In fact, by calling it "a virus" we have admitted that there are no specific finding identifying a particular viral illness.</div><div><br /></div><div>What we have done is far more important. We have looked for signs of complications and more serious infection (sepsis, meningitis etc) and found none. What we can say with honesty and certainty is that this is an uncomplicated upper respiratory tract infection.</div><div><br /></div><div>To emphasise the point about how often the lack of specific signs and symptoms is the norm in paediatrics, I'll give a couple of examples of common, clinical diagnoses that are usually made with enough certainty to be considered completely honest.</div><div><ul style="text-align: left;"><li>Croup</li><li>Chickenpox</li><li>Febrile convulsion</li><li>Vasovagal syncope</li></ul></div><div>Yep, that's pretty much it. Most other common problems are really labels given with real uncertainty due to the lack of specific signs or symptoms with good positive or negative predictive value.</div><div><br /></div><div>Here are a few other examples of diagnoses that are commonly given in what is in reality a great deal of uncertainty that this problem is causing the symptoms or signs.</div><div><ul style="text-align: left;"><li>Infant reflux disease</li><li>Cow's milk protein allergy (non-IgE)</li><li>Asthma</li><ul><li>in the under 5 yr old child</li><li>where the diagnosis is based on chronic cough without wheeze</li></ul><li>Mesenteric Adenitis</li><li>Hypermobility</li></ul></div><div>Then there's a whole new level of diagnostic uncertainty. At the beginning I used colic as an example. Let's try feeding a classic colic presentation into the Certometer. You see a three week old baby whose only symptom is "crying all the time". The pregnancy and birth were uncomplicated. The baby examines normally and is thriving. They are feeding well and passing urine and stools normally.</div><div><br /></div><div>What is the pre-test probability that this is colic? Unfortunately there's no good answer to that because it's not an actual disease. There is no pathology or treatment. Colic is simply a label to be given to crying infants that have no pathology. If you try to put this through the Certometer, you will break it because you can't have any certainty of something that doesn't exist.</div><div><br /></div><div>It is often argued with colic that the label is therapeutic. The new GMC guidance should give us an opportunity to re-evaluate that approach. What would be wrong with telling the parent of the infant described above that their baby is normal and healthy? That would be honest and potentially just as therapeutic. We could then use the time that we might have spent (explaining a condition that doesn't exist) on being supportive and encouraging to the parent. The crying excessively phase does settle and in the meantime, it's all about making sure that it doesn't break the parent.</div><div><br /></div><div>Here are a couple of other examples of diagnostic labels in children that are without evidence for any disease process. Neither of these has ever had any pathology associated or been shown to respond to any treatment:</div><div><ul style="text-align: left;"><li>Growing pains</li><li>Non-specific abdominal pain</li></ul></div><div>Is it time to embrace the idea of greater honesty when we diagnose and explain symptoms in children? I certainly find that an explanation without a diagnosis is entirely acceptable to families when it comes to a situation where in the past I might have given a non-diagnosis. Changing that practice is relatively straightforward. You simply stop saying the thing.</div><div><br /></div><div>For the situations where we are dealing with an actual diagnosis but there is significant uncertainty, we've got a few options. The infant with crying and regurgitation of feeds is a good example. Perhaps we should be stricter about starting off with a label of "possible GORD"? Perhaps we should go further and start with "Feeding symptoms under observation and follow-up." Increasingly, I don't give a diagnosis. Instead I tell the parents that (in the absence of red flags such as fatering growth) "crying and regurgitation can be normal, it can be early symptoms of reflux disease and it can be rarer problems such as allergy. We don't want to give unnecessary treatments to babies but we also want to treat problems when it's going to help. This is how we're going to try to get the right balance between those two things..." </div><div><br /></div><div>It's a whole new world being honest about our uncertainty but it does work and it works like this:</div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiAKZdxs6Xqu0FDnwTeeb54UwcrjlVQV1Zbn1vzMkMvF8cPazceNLyoRxuNUqOy6T7RV91cebAX0amJDb2W34UGweS1QowLEAelB2NS-4kq4iJmCcb1dL8r-AydXGcGclmqstw-WRch7ts/s1561/Honesty+in+Paediatric+Diagnosis.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1348" data-original-width="1561" height="523" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiAKZdxs6Xqu0FDnwTeeb54UwcrjlVQV1Zbn1vzMkMvF8cPazceNLyoRxuNUqOy6T7RV91cebAX0amJDb2W34UGweS1QowLEAelB2NS-4kq4iJmCcb1dL8r-AydXGcGclmqstw-WRch7ts/w606-h523/Honesty+in+Paediatric+Diagnosis.png" width="606" /></a></div><div>Edward Snelson<br />@sailordoctor</div><div><p><span style="font-size: x-small;">Disclaimer: I am not certain about any of that, or that you or I exist.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://www.facebook.com/PaedsTips" imageanchor="1" style="margin-left: 1em; margin-right: 1em;" target="_blank"><img border="0" data-original-height="279" data-original-width="1273" height="91" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhA6EUVRFhjv5msGXwCcb1DdO_2m3_JHgT0EhM3uNFppr0eeq0z8hrOFsO7Jt8taBwHX411VuYPnW-DmSDg5sdPVrrpjfjGsq2rkY6HkDZFSMKQkPrnoS97-cv7Hz9xMle6caL7eIT67uM/w418-h91/GPpaedsTips+Facebook+link.png" width="418" /></a></div><p></p><p>Reference</p><p><a href="https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/decision-making-and-consent?utm_campaign=11957117_Doctor%20News%20-%20November%202020%20%28Consent%29&utm_medium=email&utm_source=General%20Medical%20Council&dm_i=OUY,74A65,6EL8BI,SSFRM,1" target="_blank">General Medical Council UK, Guidance on professional standards and ethics for doctors Decision making and consent, 9 November 2020</a></p></div>Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comtag:blogger.com,1999:blog-1905670054751342997.post-76406565947509253032020-10-25T11:18:00.000-07:002020-10-25T11:18:44.804-07:00The Decision Maker's Guide to Bronchiolitis Assessment<p> This bronchiolitis season is going to be different. While <a href="https://adc.bmj.com/content/early/2020/10/15/archdischild-2020-320776.full" target="_blank">SARS-CoV2 virus does not seem to be a significant cause of wheeze in children</a> (1), all the other usual viruses are still out there and will be causing wheeze soon in a child near you. What might have changed is how we make decisions about that child.</p><p>For the purposes of exploring our decision making, it is important to define bronchiolitis as a condition that is a virally induced inflammation of the small airways of the lungs in a child, typically under the age of 1. It is clinically distinctive from viral induced wheeze which is virally induced bronchospasm of the large airways, typically in a child over the age of 1. For a separate article on differentiating these two conditions, <a href="http://gppaedstips.blogspot.com/2018/04/why-do-different-children-wheeze.html" target="_blank">click this link</a>.</p><div class="separator" style="clear: both; text-align: center;"><a href="http://gppaedstips.blogspot.com/2018/04/why-do-different-children-wheeze.html" style="margin-left: 1em; margin-right: 1em;" target="_blank"><img border="0" data-original-height="303" data-original-width="400" height="317" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiYIvtL5umWWDWQ9CO7uiQNxWo_EswVCac0u07XAun5UgueBQzDfdxZTt6BtuxrFrFvrwbSgcn_ZNCBUSjXNKur7s6-VFjVoBPmvAaYbOh_r0_u2nJRdkU-ooE5XEhwsErACAHcR7D9gc4/w420-h317/causes+of+wheeze.png" width="420" /></a></div>The necessary decisions regarding bronchiolitis haven't changed. What might change during a global pandemic is the outcome of those decisions. Hospitals have always been dangerous places, with a significant risk of hospital acquired infection. That risk has escalated due to the prevalence of the highly infective SARS-CoV2 virus. Though very unlikely to cause COVID-19 infection in children, there is that risk, the risk of PIMS-TS and the risk of COVID-19 to the accompanying adults.<div><br /></div><div>The aim in bronchiolitis decision making has always been to keep as many children out of hospital as is safe to do so. In order to do that expertly, we just need to make three decisions.</div><div><ol style="text-align: left;"><li><b>Does this child have bronchiolitis?</b></li><li><b>Should this child be managed at home or in hospital?</b></li><li><b>What treatment should the child be given?</b></li></ol></div><div><span style="font-size: large;"><b>Question 1: Does this child have bronchiolitis?</b></span></div><div><br /></div><div>Most children under the age of 1 year presenting with a tight cough, wheeze, respiratory signs and poor feeding have bronchiolitis. There are other possible explanations for that presentation however and it is important to know about these other possibilities.</div><div><br /></div><div><b>Viral induced wheeze</b>, which involves bronchospasm is separate from bronchiolitis. Clues that it may be viral induced wheeze include the age of the child (most commonly over 1 year) and previous episodes of viral induced wheeze. The other clue is the onset of the respiratory changes. Bronchiolitis is a slow accumulation of wetness in the airways and the history is typically of a gradual and progressive worsening of symptoms over days. Viral induced wheeze, due to the bronchospasm involved, presents with a more sudden onset of wheeze and distress, often going from normal to significantly abnormal over a few hours.</div><div><br /></div><div><b>Pneumonia</b> is almost never associated with wheeze in children (2). Focal crepitations are often heard in a viral lung infection of any kind. The presence of wheeze strongly suggests that the signs and symptoms are virally induced in some way. Infants with pneumonia will tend to be significantly unwell. The simple rule of thumb is this: If the infant has a wheeze and is well enough to be managed in a pre-hospital setting, they do not have bacterial pneumonia.</div><div><br /></div><div><b>Congestive cardiac failure</b> (CCF) due to haemodynamically significant yet undetected congenital cardiac abnormalities is a rare mimic of bronchiolitis but one that is important to be aware of. The typical cause is a large ventricular septal defect (VSD) causing a significant left to right shunt. This increased pressure through the lung circulation causes pulmonary odema which manifests as poor feeding, fine crepitations and wheeze. Thankfully, most significant heart defects are detected before a baby is discharged from postnatal care, but occasionally one slips through and the signs and symptoms are easily mistaken for bronchiolitis.</div><div><br /></div><div>There are usually clues however. A murmur is the most obvious clue but this can be difficult to hear at >160bpm. An excessive tachycardia is a possible sign of CCF. A significant hepatomegaly (normal babies often have up to a centimetre of palpable liver) is highly suspicious of CCF. Finally, the progression of symptoms does not fit for bronchiolitis as they continue to get worse after the 3-4 days in which bronchiolitis reaches its peak.</div><div><br /></div><div>Putting these things together, it is usually possible to be confident in diagnosing bronchiolitis as long as the history and findings are consistent with bronchiolitis and not one of the other pretenders.</div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpcP28FLSS7b4CrYsZCbCMPrQwTZlq5XC2nj19u9fvD_3yQJ9x-LXAgddKaK8QCLoq6bsUMkSyeQ6AEBdn6ZCRogMuV3EgYI9hkvCT5mZbUc-iOkHH40s7LVWmRhtqU-fxhTlnw9qSkNw/s1504/Is+this+bronchiolitis.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1486" data-original-width="1504" height="570" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpcP28FLSS7b4CrYsZCbCMPrQwTZlq5XC2nj19u9fvD_3yQJ9x-LXAgddKaK8QCLoq6bsUMkSyeQ6AEBdn6ZCRogMuV3EgYI9hkvCT5mZbUc-iOkHH40s7LVWmRhtqU-fxhTlnw9qSkNw/w576-h570/Is+this+bronchiolitis.png" width="576" /></a></div>If the diagnosis is bronchiolitis, we can move onto our next question:<div><br /><div><span style="font-size: large;"><b>Question 2: Should this child be managed at home or in hospital?</b></span></div><div><br /></div><div>Most children with bronchiolitis can be managed in the community. Keeping people away from hospital where it safe to do so has never been more important. In the UK, the NICE guidelines for bronchiolitis (3) give recommendations for when to refer and when to consider referral.</div><div><br /></div><div>Referral is always recommended for red flags. In the NICE guidelines, these are a combination of signs of potential respiratory failure. Notably, apnoeas are included as a stand-alone red flag. That means that a child without any chest signs of severe respiratory distress should still be referred if they have had episodes where they appear to stop breathing. The reason for this is that in such cases, immature respiratory drive may be a factor. Following an apnoea, a baby can temporarily seem much improved but may go on to have further events and deteriorate suddenly.</div><div><br /></div><div>Feeding and hydration is probably the least well defined element of the decision making element. The guidelines ask the clinician to consider a variety of factors, however being able to assess whether the amount of feeding is adequate is next to impossible apart from overt signs of dehydration. We never know how much a breast fed baby is getting unless the answer is "nothing." If the baby is bottle fed, applying a percentage to that as being adequate doesn't take into account the fact that many bottle fed babies take much larger volumes as a baseline. As a result, the most objective measure of adequate feeding has to be signs of hydration or dehydration. For that reason, I have included clinical dehydration in the list of red flags and beyond that, feeding difficulties remain a matter of clinical judgement when it comes to referral.</div><div><br /></div><div>Possibly the most controversial element of the decision making is the presence of risk factors. In the guidance, it is stated "<i>When deciding whether to refer a child with bronchiolitis to secondary care, take account of any known risk factors for more severe bronchiolitis such as... (e.g.) premature birth, particularly under 32 weeks.</i>" The guideline evidence statement lists the basis for each risk factor listed and with the exception of neuromuscular disease, the committee acknowledged that there is no credible published evidence for the other risk factors. Apart from neuromuscular disease, they are all consensus opinion recommendations.</div><div><br /></div><div>So what are you supposed to do when you see an 8 month old baby with mild bronchiolitis, no red flags and adequate feeding when you know that they were born at 31 weeks gestation? Do you send them to secondary care in case because they have a risk factor for severe bronchiolitis or do you keep them well away from hospital because they don't have severe bronchiolitis and you don't want to add a hospital acquired infection to their list of problems?</div><div><br /></div><div>Balancing risk vs benefit is what it is all about here. There is a known risk of hospital acquired infection vs an unknown risk of severe bronchiolitis. There is also no evidence that admitting high risk children with bronchiolitis is any safer than good safety-netting advice.</div><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiL0rS8pA0DH8L-EaYqP4BurTalxeCOWajsQsCpqsio-HzjdUC3VKfoWiVE0zcBrvJmvFl53f38Vciwu9CryCksjFvfy8puVfykSJJHZ_Qv2TuOTjDPUa9lzgoO3b6wl9iEdtk1rmdp3xE/s2077/Bronchiolitis+-+home+or+admit.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2077" data-original-width="1803" height="708" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiL0rS8pA0DH8L-EaYqP4BurTalxeCOWajsQsCpqsio-HzjdUC3VKfoWiVE0zcBrvJmvFl53f38Vciwu9CryCksjFvfy8puVfykSJJHZ_Qv2TuOTjDPUa9lzgoO3b6wl9iEdtk1rmdp3xE/w616-h708/Bronchiolitis+-+home+or+admit.png" width="616" /></a></div><br /><div>If the decision is made to manage a child with bronchiolitis at home, the third and final question is:</div><div><br /></div><div><b><span style="font-size: large;">Question 3: What treatment should the child be given?</span></b><p>There has been a load of research done to try to find an effective treatment for bronchiolitis. Supportive interventions (oxygen, CPAP etc) in the cases where respiratory support are needed have been shown to be effective. Each and every other therapy have in turn shown to have no benefit for mild to moderate uncomplicated bronchiolitis. Therapies proven to be ineffective include β-agonists, ipratopium, hypertonic saline, antibiotics and corticosteroids. The bottom line is that for a child being managed in the community, no pharmacological treatment should be given. This recommendation is consistent across guidelines from the UK, USA and Australia (3,4,5).</p><p>That makes this flowchart nice and simple:</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgLZ3n7dqeeHmgaX3nEl6BWZnfu3h8wsp2Y3_tjo_-fbtoSVqdAGEBHILCBvxpcwJllGsUofZdayk2TEVbNmc1Tu3qR9axud-LcKvz9HoPkW2c55RmNQ25OGnLlZis-pxOn-MbNnHKZ370/s1511/Bronchiolitis+Treatment.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1109" data-original-width="1511" height="458" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgLZ3n7dqeeHmgaX3nEl6BWZnfu3h8wsp2Y3_tjo_-fbtoSVqdAGEBHILCBvxpcwJllGsUofZdayk2TEVbNmc1Tu3qR9axud-LcKvz9HoPkW2c55RmNQ25OGnLlZis-pxOn-MbNnHKZ370/w623-h458/Bronchiolitis+Treatment.png" width="623" /></a></div>Finally, you might be asking yourself if you are an expert decision maker when it comes to a small person who has a cough and wheeze. Hopefully this post helps you to feel that you are. Decision making in such children is all about recognition, knowing the red flags and above all, learning that if in doubt, looking at the child will almost always give you your answer.<br /><p>Edward Snelson<br />@sailordoctor</p><p>References</p><p></p><ol style="text-align: left;"><li><a href="https://adc.bmj.com/content/early/2020/10/15/archdischild-2020-320776.citation-tools" target="_blank">Roland D, Teo KW, Bandi S, et al COVID-19 is not a driver of clinically significant viral wheeze and asthma Archives of Disease in Childhood Published Online First: 16 October 2020. doi: 10.1136/archdischild-2020-320776</a></li><li><a href="https://www.jpeds.com/article/S0022-3476(18)31251-4/abstract" target="_blank">Hirsch A, Monuteaux M, Neuman M, Bachur R, Estimating Risk of Pneumonia in a Prospective Emergency Department Cohort, Paediatrics, Vol 204, p172-176.E1, Jan 01, 2019 doi:10.1016/j.jpeds.2018.08.077</a></li><li><a href="https://www.nice.org.uk/guidance/ng9/chapter/1-Recommendations#assessment-and-diagnosis" target="_blank">Bronchiolitis in children: diagnosis and management, NICE guideline [NG9] Published date: 01 June 2015</a></li><li><a href="https://pediatrics.aappublications.org/content/134/5/e1474" target="_blank">American Academy of Pediatrics Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis, Pediatrics November 2014, 134 (5) e1474-e1502; doi: 10.1542/peds.2014-2742</a></li><li><a href="https://www.rch.org.au/clinicalguide/guideline_index/Bronchiolitis/" target="_blank">The Royal Children's Hospital Melbourne Clinical Practice Guidelines: Bronchiolitis</a></li></ol><p></p></div></div>Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comtag:blogger.com,1999:blog-1905670054751342997.post-52028847705704654602020-08-19T11:40:00.000-07:002020-08-19T11:40:29.987-07:00Periorbital cellulitis in children<div dir="ltr" style="text-align: left;" trbidi="on">
Eye infections in children are common. The majority consist of simple infections of the conjunctiva (the layer that covers the sclera and the inside of the eyelid). While these infections can be viral or bacterial, the tendency is for both to self-resolve and so infection confined to the conjunctiva can be managed conservatively. The likelihood of benefit from topical antibiotics is low and there is a significant risk of the ingredients of antibiotic eye drops creating a chemical conjunctivitis and making things worse. As a result, <a href="https://cks.nice.org.uk/conjunctivitis-infective" target="_blank">NICE suggests a limited number of scenarios in which topical antibiotics may be worthwhile in conjunctivitis</a>.<br />
<br />
It is worth mentioning two things about conjunctivitis:<br />
<ul style="text-align: left;">
<li>Atypical conjunctivitis infections are more problematic. If herpetic, chlamydia or gonococcal infection is suspected specialist input is advisable.</li>
<li>Neonates are the exception to this conservative approach to conjuntivitis. For a full explanation regarding why and how to manage the newborn baby with an eye infection, <a href="http://gppaedstips.blogspot.com/2020/01/something-or-nothing-why-topical.html" target="_blank">click this link</a>.</li>
</ul>
When infection spreads to the periorbital tissues, it is a different matter. Infection of the skin and subcutaneous infections around the eye is usually bacterial and is associated with more invasive infection.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijawWaFYHgMEzrRgEFnT223NyxyKFpjtm_7YjbXILyVoZvu3ZxbX5_4DorUUt2Y4mtjDA-eNhjPqOmZwMTG_f7RKHZsRRheLkJOdlAxf1ry3TUtmIVVWMBJsTXt0j-pXldtoPp66p5vko/s1600/Celulitis_Periorbitaria_%2528Preseptal%2529.JPG" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="675" data-original-width="1200" height="180" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijawWaFYHgMEzrRgEFnT223NyxyKFpjtm_7YjbXILyVoZvu3ZxbX5_4DorUUt2Y4mtjDA-eNhjPqOmZwMTG_f7RKHZsRRheLkJOdlAxf1ry3TUtmIVVWMBJsTXt0j-pXldtoPp66p5vko/s320/Celulitis_Periorbitaria_%2528Preseptal%2529.JPG" width="320" /></a></div>
<div style="text-align: center;">
<span style="font-size: x-small;">Image from Wikimedia Commons, the free media repository</span></div>
<div style="text-align: center;">
<div style="text-align: left;">
Complications of invasive infection include:</div>
</div>
<ul style="text-align: left;">
<li>Loss of eyesight (optic nerve damage, retinal detachment, retinal artery thrombosis)</li>
<li>Meningitis</li>
<li>Intracranial abscess</li>
<li>Cavernous sinus thrombosis</li>
</ul>
Although these complications are serious, they are mainly associated with orbital, or post septal cellulitis - infection of the tissues in the orbit (eye socket). Infection confined to the pre-septal tissues is usually uncomplicated and low risk.</div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgOaV_4k-t2mITCgmPqfGt6mEmTQYoVpn2ex89zlWDiv32xGTybD5dAPwoYszwB4_PjIwxH_k5OojpwrLHxGP-Yn1NekV-r83O4F6sg799O0YZEZ7FcosIkF8NYCklqOu39drWal5Vd3lM/s1970/The+anatomy+of+cellulitis+of+the+eye.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="1105" data-original-width="1970" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgOaV_4k-t2mITCgmPqfGt6mEmTQYoVpn2ex89zlWDiv32xGTybD5dAPwoYszwB4_PjIwxH_k5OojpwrLHxGP-Yn1NekV-r83O4F6sg799O0YZEZ7FcosIkF8NYCklqOu39drWal5Vd3lM/s640/The+anatomy+of+cellulitis+of+the+eye.png" width="640" /></a></div><div style="clear: both; text-align: center;"><span style="font-size: small;">[Medical illustration credit to Naomi Snelson]</span></div><div style="clear: both; text-align: center;"><span style="font-size: small;"><br /></span></div><div class="separator" style="clear: both; text-align: left;">Telling the difference between pre-septal cellulitis and orbital cellulitis is about looking for signs and symptoms that could indicate orbital cellulitis. In the absence of red-flag symptoms, it is assumed that the infection is pre-septal.</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;"><div class="separator" style="clear: both;">The management of pre-septal cellulitis has evolved considerably over time. Many centres used to treat even pre-septal cellulitis as an inpatient with antibiotics given intravenously to begin with. It is now much more normal to treat pre-septal cellulitis with oral antibiotics.</div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgf4rcxJZtM_68TRBPCG2rbsG3O3ktwg23s05ZnOkiIswBqpNVcC9nALZ4M6whuTUNBx7ooU8PmryoGg9lfvrVmPTRtGTuUaP6IX0pmPg10xQPKLwXzcjre16Frbut9DgjvJFLPzNkRi2o/s1539/Telling+the+difference+between+pre-septal+and+orbital+cellulitis+in+a+child.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="1270" data-original-width="1539" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgf4rcxJZtM_68TRBPCG2rbsG3O3ktwg23s05ZnOkiIswBqpNVcC9nALZ4M6whuTUNBx7ooU8PmryoGg9lfvrVmPTRtGTuUaP6IX0pmPg10xQPKLwXzcjre16Frbut9DgjvJFLPzNkRi2o/s640/Telling+the+difference+between+pre-septal+and+orbital+cellulitis+in+a+child.png" width="640" /></a></div><div class="separator" style="clear: both;">While some who have made this move choose to follow up and review the patient (often at about two days into their oral antibiotics) there are strong arguments for safety-netting and no planned follow-up. When a child is sent home on oral antibiotics for pre-septal cellulitis, things will go one of two ways. If treatment is successful, there will be significant improvement within the first two days. If that happens, follow-up adds nothing.</div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both;">If treatment is unsuccessful, signs and symptoms will worsen. If that happens, there is a risk that a planned follow-up will delay escalation of treatment. If things are getting worse, the child needs to be seen and admitted for intravenous antibiotics immediately, rather than waiting for their review appointment.</div><div class="separator" style="clear: both;"><br /></div><div class="separator" style="clear: both;"><b><u>Safety-netting advice for children discharged on oral antibiotics for pre-septal cellulitis</u></b></div><div class="separator" style="clear: both;">Return for immediate assessment if-</div><div class="separator" style="clear: both;"><ul><li>the child becomes febrile or unwell</li><li>the swelling becomes visibly worse</li><li>eye movements are affected</li><li>vision is affected</li><li>the child is unable to take their antibiotics</li><li>the child starts vomiting</li></ul></div></div><div dir="ltr" style="text-align: left;" trbidi="on">This simple approach is another great way to safely keep children out of hospitals. That has always been a good thing but there has never been a better time to avoid unnecessary admissions than now.</div><div dir="ltr" style="text-align: left;" trbidi="on"><br /></div><div dir="ltr" style="text-align: left;" trbidi="on">Edward Snelson</div><div dir="ltr" style="text-align: left;" trbidi="on">@sailordoctor<br /><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://www.facebook.com/PaedsTips" style="margin-left: 1em; margin-right: 1em;" target="_blank"><img border="0" data-original-height="279" data-original-width="1273" height="112" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiRBZhdTZBfOv3zTQ181iVLEGR9roH6obNbH3KveX06n0aWeXow6kf-CrvPWZRipoMEu00Qlc2Qb-pI5GJD2Qwh8cpjGzbyuRfh7FQd8-eOyTGOkt7HgWwXLowAl6aI-sy6OrhCx3h-7Nc/w512-h112/GPpaedsTips+Facebook+link.png" width="512" /></a></div>
Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comtag:blogger.com,1999:blog-1905670054751342997.post-42677228141725471652020-07-22T06:29:00.002-07:002020-07-22T06:29:59.965-07:00There, I've Said It: There is No Such Thing as Early Sepsis<div dir="ltr" style="text-align: left;" trbidi="on">
Words are really important when it comes to communication. Certainly, non-verbal communication counts for a lot, but words are very powerful ways of getting a message across. We should be responsible about how we use them.<br />
<br />
Diagnostic error in paediatrics is a very emotive issue. If a clinician is wrong (always in retrospect) and a child is involved, it can be difficult to be objective. No-one is right all the time though, and diagnoses that are later apparent are sometimes easy to miss or even too elusive to reasonably detect in their early stages.<br />
<br />
There is one important exception to this: sepsis, because there is no such thing as early sepsis. This is really important because clinicians are both criticised and self-critical when a child has been diagnosed with sepsis and there was an earlier clinical contact.<br />
<br />
You're going to want me to back this one up no doubt. I haven't got any academic references, but I don't need them since it's a case of simple logic. I'm going to Spock the heck ot of the idea of early sepsis.<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgcYO_OAGCERRKRZpTgUc_Hsi06_ijNPUQYbIP5m2MaJ7j-ECAEEkadiHr-YwG2vKGH-Knkrrvf-CjPCdU9-q6wrgfF-OVf-3bVA13HxZv2trVvlHkzTBWZO80BXxLE-Gjk3oGZvORzMsE/s1600/Early+sepsis+illogical.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1120" data-original-width="1513" height="236" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgcYO_OAGCERRKRZpTgUc_Hsi06_ijNPUQYbIP5m2MaJ7j-ECAEEkadiHr-YwG2vKGH-Knkrrvf-CjPCdU9-q6wrgfF-OVf-3bVA13HxZv2trVvlHkzTBWZO80BXxLE-Gjk3oGZvORzMsE/s320/Early+sepsis+illogical.png" width="320" /></a></div>
Starting with the terminology that we are working with, there is already difficulty with the definition of sepsis. Ever since the word ceased to mean infection in any form and came to be used for an effect of the infection, sepsis has remained impossible to decisively define.<br />
<br />
The best definition that we have of sepsis "a life-threatening organ dysfunction caused by a dysregulated host response to infection," comes from the 2016 <a href="https://jamanetwork.com/journals/jama/fullarticle/2492881" target="_blank">Third International Consensus Definitions for Sepsis and Septic Shock</a>. This definition is inherently subjective. There is no formula and no test. Note also the lack of attempt to define early sepsis at this event.<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj9N5r66YpDLgaLaFBXhITWTIpGK1GUO1PUSdc4xFLqBK58o7z4SWcY1e30Rugzqm5QSvX7QhSK4ybH1CaLM0gRYZQORU9gJid38RTpo_qW0kDbPxWFXF9SxXYyUsRHw0J-loelZ8qyiro/s1600/No+such+thing+as+early+sepsis.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1389" data-original-width="1594" height="346" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj9N5r66YpDLgaLaFBXhITWTIpGK1GUO1PUSdc4xFLqBK58o7z4SWcY1e30Rugzqm5QSvX7QhSK4ybH1CaLM0gRYZQORU9gJid38RTpo_qW0kDbPxWFXF9SxXYyUsRHw0J-loelZ8qyiro/s400/No+such+thing+as+early+sepsis.png" width="400" /></a></div>
Why do I care if people use the term early sepsis? Because words.<br />
<br />
The term early sepsis implies that there is a clearly definable and therefore recognisable entity which has therefore earned its own name. Implications are more dangerous than overt statements because they go unchallenged and become part of the profession's assumption that because a term is used, it must be valid.<br />
<br />
The harm of the term being given validity is that (again with the logic) if it is a definable entity, whenever a child is diagnosed with sepsis and they had an earlier contact with a clinician, that person has failed to recognise early sepsis. In reality, they will have seen a child with features that are attributable to sepsis. These features are also commonly found in children who are febrile but not sepstic.<br />
<br />
How damaging is that? Apart from the medicolegal implications, the negative impact on a clinician's confidence and reputation is potentially huge. Using the term early sepsis risks leaving a string of second victims in its wake.<br />
<br />
Just to be clear, I am 100% behind the idea of recognising sepsis early. Swapping those words around is all it takes to make them functional again. I'm also all for anything that improves the early recognition and treatment of sepsis. So far, no strategy has proved successful in achieving earlier diagnosis of sepsis in children. Awareness, careful clinical assessment are key, as is treating every illness as dynamic. That is why appropriate observation and good safety-netting are key interventions. Whether the child is managed at home or in a health-care setting, no illness is 100% safe until the child is better.<br />
<br />
The focus on sepsis over the past decade or so has improved the timely treatment when sepsis is diagnosed, but making that decision in the first place remains a complex business. Here's a nice oversimplifiaction of that process:<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgQNGI3It6sgFZbZQPdr3sZO64vnQVMvwvBRgrBKqA_KhiMOf31wF0BODjb3AeZ7Z9P7-H3j9Nl1f-AKuBl8xAdX_wrO4Clai8Ts-AcdyPD31MzFsZdJ7Zz_tthOIKBYKeYLmBahOrO6Eg/s1600/World%2527s+most+simple+sepsis+guideline.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="512" data-original-width="640" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgQNGI3It6sgFZbZQPdr3sZO64vnQVMvwvBRgrBKqA_KhiMOf31wF0BODjb3AeZ7Z9P7-H3j9Nl1f-AKuBl8xAdX_wrO4Clai8Ts-AcdyPD31MzFsZdJ7Zz_tthOIKBYKeYLmBahOrO6Eg/s400/World%2527s+most+simple+sepsis+guideline.png" width="400" /></a></div>
The red and green patients are relatively easy in terms of decision making. The amber patients represent a small uncertainty which needs to be managed expertly. In the small proportion that later become red and therefore relatively easy to define as having sepsis, retrospectively calling the preceding illness "early sepsis" defies logic and undervalues the difficulties of managing a large volume of moderately unwell children.<br />
<br />
Next time you hear someone talk about recognition of early sepsis, politely challenge them and explore whether they mean early recognition of sepsis. Sepsis is a thing. The point when an illness goes from not sepsis to sepsis is not sudden and therefore easily missed. Implying that there is a clearly definable and recognisable thing called early sepsis risks the vilification of front line clinicians in both primary and secondary care.<br />
<br />
Edward Snelson<br />
@sailordoctor<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://www.facebook.com/PaedsTips" target="_blank"><img border="0" data-original-height="70" data-original-width="320" height="87" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgHSe44A9rz2qITuHsJvejudeMFu-atyagXhLFDgoIGe7xPfTlq3yJ5M1WdN4i0mHb2SOTqVxFdVFh6M5qTN8Iyd9hWdszVxD4jClYATusMXW-z2-5OmJhNlf4xBOWUc7rhtSQz_jzI39Q/s400/GPpaedsTips+Facebook+link.png" width="400" /></a></div>
<br /></div>
Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comtag:blogger.com,1999:blog-1905670054751342997.post-22298048102472977362020-06-30T02:46:00.000-07:002020-06-30T02:46:01.961-07:00The Work Hack I Never Expected - How a Rainbow Badge Transformed Mental Health Consultations<div dir="ltr" style="text-align: left;" trbidi="on">
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.<br />
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgkLYP5wi_EbjNEFY_qGfLQYKPZzlygq93cWr2HbUsOecTzKufSwZbeDyRLZ-eegxvRCULSJ3ZSkPgg2igBZmdrqAhuHNSOGByNr59RihtKWf59M1OyrU6nQ2EeoLUac9he7CHj8OCjB8o/s1600/NHS+Rainbow+badge.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1253" data-original-width="1183" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgkLYP5wi_EbjNEFY_qGfLQYKPZzlygq93cWr2HbUsOecTzKufSwZbeDyRLZ-eegxvRCULSJ3ZSkPgg2igBZmdrqAhuHNSOGByNr59RihtKWf59M1OyrU6nQ2EeoLUac9he7CHj8OCjB8o/s400/NHS+Rainbow+badge.png" width="377" /></a></div>
</div>
<div class="MsoNormal">
When a young person comes with a mental health problem we
look at various factors that are involved.<span style="mso-spacerun: yes;">
</span>One of the most important factors that affect mental health is sense of
self.<span style="mso-spacerun: yes;"> </span>Like all elements of mental health,
sense of self is complicated.<span style="mso-spacerun: yes;"> </span>It is
important that young people feel safe and accepted in order to be resilient to
the stresses of adolescence.<span style="mso-spacerun: yes;"> </span>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.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
If a young person feels that any element of who they are or might be is unsafe in any way, this creates anxiety.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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.<span style="mso-spacerun: yes;"> </span>They may be concerned that they
will experience rejection by family, friends or anyone that they discuss their
sexuality with.<span style="mso-spacerun: yes;"> </span>In many cases, they have
already risked discussing this issue and experienced a negative response.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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.<span style="mso-spacerun: yes;"> </span>We
should ask about stressors in general but it is also routine to ask specifically
about common anxieties.<span style="mso-spacerun: yes;"> </span>The more likely
it is that the thing may not be volunteered, the more important it is to ask.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
There are many reasons why health care professionals might
themselves feel anxious about asking a young person about sexuality.<span style="mso-spacerun: yes;"> </span>Here are a few of the common ones:<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
<b>We don’t have experience of discussing sexuality with young
people.</b><span style="mso-spacerun: yes;"> </span>If you don’t have a framework
for doing this, you’re not alone.<span style="mso-spacerun: yes;"> </span>Very
few of us grew up in an environment where anything other than heterosexuality
was considered normal.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>The irony is that we might feel
anxious that we will somehow get it wrong.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
<b>The solution: just do it.</b><span style="mso-spacerun: yes;">
</span>The best way to get past the weird is to be brave and trust that your
attempt will be well received.<span style="mso-spacerun: yes;"> </span>Step out
in faith.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
<b>We are worried that the parent(s) may be angry that we have
this discussion with their child.</b><span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>There may also be a fear based in the
misconception that by asking about sexuality, we somehow alter or influence it.<span style="mso-spacerun: yes;"> </span>That is an interesting and unfounded
belief.<span style="mso-spacerun: yes;"> </span>There is no evidence that an
open discussion can result in a change in sexuality.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
<b>The solution: Speak to the young person on their
own.<span style="mso-spacerun: yes;"> </span></b>This should be a normal part of a
mental health assessment in a young person.<span style="mso-spacerun: yes;"> 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?</span><o:p></o:p><br />
<span style="mso-spacerun: yes;"><br /></span></div>
<div class="MsoNormal">
<b>We are worried about the response that we might get from the
young person.</b><span style="mso-spacerun: yes;"> </span>I’ll be honest here, this
fear is reasonably rational.<span style="mso-spacerun: yes;"> </span>If you ask
a young person about their sexual orientation they may well give you a funny
look and a muted response.<span style="mso-spacerun: yes;"> </span>That’s fair.<span style="mso-spacerun: yes;"> </span>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.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
<b>The solution:<span style="mso-spacerun: yes;"> </span>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.</b><o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
There is another thing that can help with all of the
above.<span style="mso-spacerun: yes;"> </span>Last year I started wearing a
rainbow badge.<span style="mso-spacerun: yes;"> </span>The badge is small but
always visible.<span style="mso-spacerun: yes;"> </span>The idea is that it lets
people know that I don’t judge people based on their sexuality.<span style="mso-spacerun: yes;"> </span>To me, people are people.<span style="mso-spacerun: yes;"> </span>While there are things that will change my
opinion of someone, sexual orientation is not one of these.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
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.<span style="mso-spacerun: yes;"> </span>I was wrong.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
Immediately after I started wearing the badge, I noticed a
change in the way that mental health consultations went.<span style="mso-spacerun: yes;"> </span>When asking open questions about stressors, a
significant number of young people started volunteering that their sexuality
was a major factor in their presentation.<span style="mso-spacerun: yes;">
</span>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.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
I think that starting to wear a rainbow badge has been one
of the most important innovations in my career.<span style="mso-spacerun: yes;">
</span>I never expected such a small thing to make my life easier in such a big
way.<span style="mso-spacerun: yes;"> </span>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.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
<a href="https://www.evelinalondon.nhs.uk/about-us/who-we-are/NHS-Rainbow-Badges.aspx" target="_blank">If you want to get information about sourcing rainbow badgesfor your organisation and the training that goes with the project, you can do that here.</a><o:p></o:p><br />
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<div class="MsoNormal">
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.<span style="mso-spacerun: yes;"> </span>2020 has been an
odd year.<span style="mso-spacerun: yes;"> </span>It turns out that I don’t need
a tongue depressor, but I do need a rainbow badge.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
Edward Snelson<br />
Also ship-shape award badge owner<br />
@sailordoctor<br />
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Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comtag:blogger.com,1999:blog-1905670054751342997.post-73387376465385161552020-06-22T23:20:00.001-07:002020-06-22T23:20:22.353-07:00Heat Related Problems in Children<div dir="ltr" style="text-align: left;" trbidi="on">
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.<br />
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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.<br />
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<b><span style="font-size: large;">Common heat related presentations in children</span></b><br />
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<b>Heat rash (Miliaria)</b><br />
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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.<br />
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The child with miliaria will be well and there are no systemic effects.<br />
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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.<br />
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Pharmacological interventions include calamine lotion and antihistamines.<br />
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<b>Swollen hands and feet (Heat oedema)</b><br />
<br />
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.<br />
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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.<br />
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<b>Phytodermatitis</b><br />
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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.<br />
<br />
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.<br />
<br />
<b>Sunburn</b><br />
<br />
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.<br />
<br />
<b>Syncope</b><br />
<br />
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 <a href="http://gppaedstips.blogspot.com/2018/05/ecg-in-children-amuse-bouche-and-what.html" target="_blank">red flags</a>.<br />
<br />
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.<br />
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<b><span style="font-size: large;">Uncommon heat related presentations in children</span></b><br />
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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.<br />
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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.<br />
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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.<br />
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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.<br />
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<b>Heat stress</b><br />
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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.<br />
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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.<br />
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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.<br />
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*Paracetamol does not reduce body heat when it is due to environment and dehydration.<br />
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<b>Heat exhaustion</b><br />
<br />
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.<br />
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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.<br />
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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.<br />
<br />
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.<br />
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<b>Heat Stroke</b><br />
<b><br /></b>
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.<br />
<br />
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.<br />
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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 <a href="https://dl.uswr.ac.ir/bitstream/Hannan/88546/1/2019%20PediatricsInReview%20Volume%2040%20Issue%203%20March%20%281%29.pdf" target="_blank">this article.</a><br />
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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.<br />
<br />
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.<br />
<br />
Edward Snelson<br />
@sailordoctor<br />
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Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comtag:blogger.com,1999:blog-1905670054751342997.post-71083901933856208052020-06-05T00:49:00.000-07:002020-06-05T00:49:10.079-07:00Transient Synovitis of the hip (Irritable hip)<div dir="ltr" style="text-align: left;" trbidi="on">
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.<br />
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<b>What is transient synovitis of the hip (irritable hip)?</b><br />
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.<br />
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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.<br />
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<b>How is transient synovitis of the hip diagnosed?</b><br />
Typical features of transient synovitis of the hip are:<br />
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<ul style="text-align: left;">
<li>Unexplained onset of limp (no history of more significant injury consistent with fracture)</li>
<li>Well and afebrile child with no signs or symptoms of other significant acute illness</li>
<li>Unilateral hip signs – painful or reduced range of movement</li>
</ul>
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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:<br />
<ul style="text-align: left;">
<li><b>Septic arthritis</b> - usually presents with fever and complete refusal to weight bear</li>
<li><b>Osteomyelitis</b> - usually febrile and there is localised tenderness or swelling in the bone</li>
<li><b>Toddler fracture - </b>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)</li>
<li><b>Other significant fractures</b> are usually accompanied by localised swelling or tenderness and are clinically obvious.</li>
<li><b>Juvenile idiopathic arthritis</b> (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.</li>
<li><b>Perthe's disease</b> - 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.</li>
<li><b>Non- musculoskeletal</b> - Limp may be a sign of pathology unrelated to the lower limb. Abdominal pain or scrotal pain can cause a child to limp.</li>
</ul>
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.<br />
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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.<br />
<br />
Edward Snelson<br />
@sailordoctor<br />
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Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comtag:blogger.com,1999:blog-1905670054751342997.post-26132908528559919662020-05-10T22:48:00.000-07:002020-05-10T23:48:22.932-07:00COVID question number 6 - What is hyperinflammatory syndrome and how do I recognise it?<div dir="ltr" style="text-align: left;" trbidi="on">
At the same time that we are seeing increasing <a href="https://adc.bmj.com/content/early/2020/05/05/archdischild-2020-319474" target="_blank">evidence that COVID-19 is less common, less severe and less infectious in children</a> (1), evidence is emerging of a new phenomenon that seems to be related to COVID-19 infection in children: hyperinflammatory syndrome (2).<br />
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In a time when people are being encouraged to self-manage febrile illness at home, and primary care has moved to do more remote assessments, the emergence of such a serious clinical entity is worrying. Although the number of cases remains relatively small, it represents a significant number of seriously unwell children. Considering how much we focus on the recognition of sepsis in children, current cases of hyperinflammatory syndrome are being reported in numbers comparable to and possibly greater than numbers of children with severe sepsis.<br />
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This does not mean that all febrile children should now have a face to face assessment or that all febrile children should be referred to secondary care. Like sepsis, it is impossible to recognise an entity like hyperinflammatory syndrome before it is clinically apparent. There is no predictive test.<br />
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Like sepsis, we need to be aware of hyperinflammatory syndrome and recognise it where it is manifest, rather than over-diagnose it to the detriment of children with uncomplicated viral illnesses. So how do we get that balance right? The answer lies in recognising what is unusual about the illness rather than focusing on the most common features, since these are not necessarily good discriminators.<br />
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First, a few FAQs about hyperinflammatory syndrome in children:<br />
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<b>What is hyperinflammatory syndrome?</b><br />
Like sepsis, definitions of hyperinflammation vary and reflect the fact that it is a clinical diagnosis without a binary test or decision tool. The published literature reflects an uncertainty about pathophysiology but describes a significant number of cases (20 in North London in less than a month) of children with a similar clinical presentation. The features have been described as most similar to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2848476/" target="_blank">Kawasaki Disease Shock Syndrome</a> (3), a thing so rare that most of us had never heard of it before this recent surge of cases.<br />
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<b>Is it caused by COVID-19 infection?</b><br />
When the initial reports of cases were being circulated without details, it was unclear as to whether this was simply a case of something happening during the COVID-19 pandemic or because of it. While no official source has yet declared that COVID-19 is definitely the cause, there is plenty of evidence that this is the case. First, the numbers are highly unusual (4) and there is a pandemic at the moment. Secondly, many of the children have tested positive for SARS-CoV-2/COVID-19. While a small proportion testing positive could be explained by the background rate of COVID-19 in the community, the positive test rate in these cases seems too high. At the moment the sample size is too small to be conclusisve. Finally, the demographic of affected children mirrors that of severe COVID-19 in adults, with a predilection for males and BAME children. It therefore seems most likely that these cases are related to the COVID-19 pandemic.<br />
<br />
The hyperinflammation syndrome that is being reposted is thought to be a post-infection phenomenon, rather than a complication of acute infection. The exact mechanism for this is unclear. Clinically, it has features similar to Kawasaki Disease (for which the mechanism is unknown) and some overlap with toxic shock syndrome (which is seen in bacterial infection) so we're on the back foot when it comes to working out pathophysiology.<br />
<br />
<b>How do I recognise hyperinflammation in a febrile child?</b><br />
The reported features of the children presenting with hyperinflammation are a mixture of non-specific signs and symptoms with a few more unusual elements that may help the front-line clinician.<br />
While gastroenterological symptoms were common, I would suggest that this information is of little help to a clinician who sees acutely unwell children. Diarrhoea, abdominal pain and painful swallowing were all common features in children who later developed hyperinflammation but are also frequently found in other viral illnesses.<br />
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In the case series reported in the Lancet, tachycardia was sometimes present and sometimes heart rate was unremarkable. This is somewhat surprising since this hyperinflammatory syndrome seems to affect the cardiovascular system most severely. It is also consistent with other serious paediatric presentations, where heart rate is one of the least specific clinical signs, being both falsely concerning and falsely reassuring on many occasions.<br />
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Tachypnoea, also a common feature occurring when the child presented with hyperinflammation is a more specific feature. Uncomplicated viral illnesses in children do not tend to affect breathing other than in the form of a transient tachypnoea while febrile. Unexplained, consistently fast breathing should therefore be considered clinically significant. This was reflected in the Lancet case series, the majority of whom had tachypnoea. Note that the cases reported did not tend to have pneumonia, thus the qualifier of "unexplained". Other explanations for fever and abnormal breathing remain more likely.<br />
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The other feature that was most consistent and helpful in discriminating from uncomplicated viral illness was an unrelenting fever. In children with an uncomplicated viral illness, pyrexia can be dramatic and associated with alarming features such as shivering, cold peripheries, blue lips and mottled skin. Typically, this is followed by a dramatic improvement, often with the aid of antipyretic medication.<br />
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In the cases reported with suspected hyperinflammation secondary to COVID-19 infection, the fever was noted to have been persistently high (38-40 C/ 100.4-104 F) which is much less commonly seen in uncomplicated viral illness. This may therefore be one of the more useful ways of telling the two apart.<br />
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Other features reported include a "variable rash" and painful extremities. Rashes and pains are common features of uncomplicated viral infection but in combination with the more specific features may help clinicians recognise the syndrome early.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjPkQbwNFNnJZbgOR5QvwuoU4h-m9byiWvSQsvPIVerIDuP6qF5RgtIzusqYkg8tKnyNddyDf6g0xC8RVSbhGF7YZAXWVz1t4NWKzXnj5t3cz9S4i0gBwslKp-U_yJtcxkoKQofkLNpiPY/s1600/symptoms+of+hyperinflammation.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1165" data-original-width="1531" height="303" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjPkQbwNFNnJZbgOR5QvwuoU4h-m9byiWvSQsvPIVerIDuP6qF5RgtIzusqYkg8tKnyNddyDf6g0xC8RVSbhGF7YZAXWVz1t4NWKzXnj5t3cz9S4i0gBwslKp-U_yJtcxkoKQofkLNpiPY/s400/symptoms+of+hyperinflammation.png" width="400" /></a></div>
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Recognising hyperinflammation (presumed to be related to COVID-19 infection in children) early may therefore be a case of recognising the unusual, looking for alternative explanations such as pneumonia and if no other pathology explains how unwell the child is, looking at how many of the less specific symptoms are present. If that sounds familiar, that's because it is a similar approach to recognising Kawasaki disease.<br />
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The disease then tends to progress to a phase with more significant cardiac involvement, with a profound effect on circulation in many cases. Shock refractory to fluid boluses is a commonly reported feature.<br />
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If signs of shock develop, this will make it more straightforward to recognise that the child does not have an uncomplicated viral illness. Distinguishing hyperinflammatory shock syndrome from sepsis and other similar presentations brings its own challenges for emergency medicine and acute paediatrics.<br />
<br />
Edward Snelson<br />
@sailordoctor<br />
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References<br />
<ol style="text-align: left;">
<li><a href="https://adc.bmj.com/content/early/2020/05/05/archdischild-2020-319474" target="_blank">Munro APS, Faust SN, Children are not COVID-19 super spreaders: time to go back to school Archives of Disease in Childhood Published Online First: 05 May 2020. doi: 10.1136/archdischild-2020-319474</a></li>
<li><a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31094-1/fulltext" target="_blank">Riphagen S., Gomez X., Gonzalez-Martinez C., Wilkinson N., Theocharis P., Hyperinflammatory shock in children during COVID-19 pandemic, Lancet, May 07, 2020 doi:https://doi.org/10.1016/S0140-6736(20)31094-1</a></li>
<li><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2848476/" target="_blank">Kanegaye JT, Wilder MS, Molkara D, et al. Recognition of a Kawasaki disease shock syndrome. Pediatrics. 2009;123(5):e783‐e789. doi:10.1542/peds.2008-1871</a></li>
<li><a href="https://www.health.ny.gov/press/releases/2020/docs/2020-05-06_covid19_pediatric_inflammatory_syndrome.pdf" target="_blank">HEALTH ADVISORY: PEDIATRIC MULTI-SYSTEM INFLAMMATORY SYNDROME POTENTIALLY ASSOCIATED WITH CORONAVIRUS DISEASE (COVID-19) IN CHILDREN, 06 May 2020, New York State Department of Health (NYS DOH) Bureau of Communicable Disease Control (BCDC)</a></li>
</ol>
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Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comtag:blogger.com,1999:blog-1905670054751342997.post-22282673365800885822020-05-06T23:35:00.000-07:002020-05-07T22:25:37.970-07:00What am I missing? The child with fever but no obvious cause<div dir="ltr" style="text-align: left;" trbidi="on">
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The fear that a significant illness wil go unreconised in a child is one that is always present for the clinician who sees acutely unwell children. The stories that we hear of infections and other illnesses being "missed" fuels that anxiety. The common sense side of us tells us that significant illness should manifest itself in an obvious way, but that doesn't stop us from asking the question, "What am I missing?" when we see a child with a febrile illness and no apparent cause?<br />
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<b>Scenario</b><br />
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You have just seen Billy, a 1 year old child with a fever that started today. They have no cough or runny nose. They appear well and have a heart rate of 120. Chest is clear, heart sounds are normal and abdomen is soft. Tympanic membranes are not inflamed. <a href="https://gppaedstips.blogspot.com/2020/03/covid-questions-no-3-should-i-stop.html" target="_blank">You may or may not have looked at their throat</a> but if you did, there is nothing obvious to see.<br />
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<b>What do you do?</b><br />
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The answer to this is to understand what the possible causes of fever are, know how to exclude them and have an idea of how likely they are. The latter brings us onto an important question:<br />
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<b>How likely is significant or dangerous infection in a child?</b><br />
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That depends on the child.<br />
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The most common risk factor that we encounter is the infant. The likelihood of an unwell newborn having a significant infection is high. This is further compounded by their non-specific symptoms and lack of physiological response in the first few weeks of life. The risk of serious infection multiplied by the risk of underestimating the illness makes a baby under the age of 60 days a high risk patient.<br />
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After those first few weeks, the infant becomes less reliant on maternal antibodies and begins to produce a more vigorous response to infection, most of which are now viral. As a result, the risk diminishes inversely.<br />
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Other risky patients are those with ongoing reasons to either have more significant infections or less obvious signs of serious illness. These include children with neurodisability, immunodeficiency or chronic illness.<br />
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For the usually healthy child beyond early infancy, the very great probability is that an illness will be benign and that those infections that are dangerous will manifest themselves in some significant way. This itself brings a challenge: complacency. We become so used to good outcomes and fruitless investigations that we start to think that everything is an uncomplicated viral infection.<br />
It usually is, but what if it isn't? That brings us on to the next question:<br />
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What are the less common causes of fever in a child?<br />
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One way to think about the causes is within categories:<br />
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When there are so many possibilities, it is often best to consider the least common first. Let's start with the non-infective. These illnesses cause inflammation without active infection. They are all very uncommon compared to other things on the list but that makes them easy to forget and therefore miss.<br />
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<b><a href="https://en.wikipedia.org/wiki/Kawasaki_disease" target="_blank">Kawasaki Disease</a></b> - This is a vasculitis which can look like a prolonged viral illness. The cause has not yet been identified but it is presumed to be a post-infective phenomenon. If a child has had a fever for five or more days without a clear cause, we should check if the child fulfils the criteria for Kawasaki disease. You can check the criteria in a book or use an online tool such as <a href="https://www.mdcalc.com/kawasaki-disease-diagnostic-criteria" target="_blank">this one linked here.</a><br />
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<b>Leukaemia</b> - Haematological malignancy in children occasionally presents as an unexplained and prolonged pyrexia. More often there are other symptoms and signs such as increasing lethargy, weight loss, pallor, bruising, bleeding and unexplained pains.<br />
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<b><a href="https://www.arthritis.org/diseases/systemic-juvenile-idiopathic-arthritis" target="_blank">Systemic Onset Juvenile Idiopathic Arthritis</a></b> (JIA) - this subtype of JIA is rare but is one possible cause of unexplained fever. Often the fever is accompanied by a typical salmon pink rash and joint pains, even if there is no clinically obvious joint swelling yet.<br />
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These non-infective causes of fever should not be over-thought. The presenting symptoms of childhood illness are often so non-specific that it can be all to easy to imagine zebras instead of horses. The key to not missing these is to be aware of them as entities and to look for features of these in the child with unexplained fever, especially when that fever is prolonged.<br />
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Next,<b> the sepsis question</b>. Every febrile child should be <a href="http://gppaedstips.blogspot.com/2018/03/paediatric-sepsis-facts-myths-how-we.html" target="_blank">assessed for sepsis</a>, whether a focus the fever is found or not. That decision can be made easy for you in one of two ways. Either the child is very well to the extent that sepsis can be ruled out, or the child is so unwell that sepsis is presumed. Everything in between is a case of careful assessment, including risk factors and the trajectory of the illness.<br />
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So, if we have considered the very rare and the sepsis question, what we should be left with is a child who we think does not have sepsis and yet has a fever without an immediately obvious focus. At this point we return to the list of possibilities.<br />
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The task in a child with fever and no clear focus is to rule these possibilities out, which is usually based on clinical assessment. Start with the complications of upper respiratory tract infection (URTI) as these are the most common significant infections in children.<br />
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<b>Mastoiditis</b> - infection of the mastoid is usually a complication of otitis media infection there should be evidence of that. Mastoiditis is excluded clinically if there is no erythema, swelling or significant tenderness of the mastoid process.<br />
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<b>Peritonsillar abscess</b> - A collection of pus in the peritonsillar tissues is manifested by swelling which displaces the tonsil. At the time of writing this, throat examination is not routinely performed due to the COVID-19 pandemic. However, peritonsillar abscess is highly unlikely in a child who is willing to drink or eat. If the child is refusing all oral intake, it may be necessary to use droplet PPE, including eye protection, to visually exclude peritonsillar abscess.<br />
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<b>Lymph node abscess</b> - Inflamed or enlarged lymph nodes are a common finding in children with URTI. Occasionally, the lymph node becomes bacterially infected. When this happens, the lymph node is more enlarged and painful. The overlying skin is often erythematous. Another common feature is that the child becomes reluctant to turn their neck due to the pain from inflammation of the surrounding tissues. These infected lymph nodes may respond to high dose oral antibiotics, however they may require incision and drainage. Discussion with or referral to ENT is therefore advisable.<br />
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<b>Osteomyelitis and septic arthritis</b> - This is a good example of something that is rare but also often missed when it is a cause of unexplained fever. Infection in a bone or joint can be visible or hidden. If a parent has noticed a swollen, red or hot area or that the child has localising signs in a limb, that can lead to early diagnosis. It is also the case that in a significant number of cases, the infection is not identified early on. It is no surprise when a febrile child is miserable and moves less. It is not common practice for clinicians to examine every bone and joint in a febrile child. However, this is something that needs to be done if a child has an unexplained fever. If limbs have not been examined for swelling, hot spots or erythema at first presentation, I would suggest that this should be done at the second assessment should fever persist and remains unexplained.<br />
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<b>Urinary tract infection (UTI)</b> - UTI is probably the most common cause of fever without a clinically obvious focus in children. The younger the child, <a href="https://gppaedstips.blogspot.com/2017/11/a-paediatric-guide-to-anatomy-things.html" target="_blank">the less likely they are to present with specific symptoms</a>. Fever without obvious cause is an indication to screen the child for UTI. Blind treatment with antibiotics is not recommended. Urine should ideally be sent for culture so that treatment is based on the most robust result - a significant bacterial growth.<br />
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<b>Meningitis and encephalitis</b> - Central nervous system (CNS) infection is the most feared of the causes of fever without focus. In the younger child, symptoms are less specific. Infants may be irritable, jittery and not feeding well. Vomiting and excessive sleeping are also common features but again, non-specific. In an infant with an open fontanelle, this should be examined. A bulging fontanelle (when not crying) is a red flag sign. Older children may exhibit classical signs of neck stiffness, headache and photophobia. Younger children are more likely to stand out because they just won't settle or have an abnormal tone or conscious level. CNS infection is usually ruled out by the child demonstrating normal interaction or behaviour, often after adequate analgesia has been provided.<br />
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<b>Appendicitis</b> - In an older child, recognising appendicitis is done in a similar way to adult practice. Appendicitis is rare in younger children but when it does occur, it can easily be missed. Guarding tends to be a later sign in the pre-school child because their abdominal wall muscles are not very strong. Children often cry or otherwise appear distress when their abdomen is examined, leaving the clinician uncertain. Analgesia and reassessment is a good way of clinically ruling out appendicitis if the initial assessment is ambiguous.<br />
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<b>Pneumonia and empyema</b> - Lower respiratory tract infection (LRTI) is common in children. <a href="https://gppaedstips.blogspot.com/2018/11/making-diagnosis-of-lower-respiratory.html" target="_blank">Cough and fever are non-specific symptoms and are not grounds for diagnosing LRTI on their own.</a> Hearing crepitations on auscultation is also a common finding that should not be given too much weight. Many LRTIs in children are viral and self-limiting. Important discriminators are how unwell the child is, their work of breathing and more specific focal signs such as localised reduced air entry or a dull percussion note.<br />
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<b>Tropical diseases</b> - If a child has an unexplained fever and has recently returned from an area with e.g. malaria, they need to be referred to secondary care for investigation.<br />
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<b>And finally...</b><br />
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So if Billy looks well and behaves in a way that effectively rules out sepsis and meningitis, his fever without clear focus means that we should look just a bit harder. A urine sample should be taken to exclude UTI; blind treatment with antibiotics is not recommended without good evidence of UTI.<br />
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If there are reasons to suspect one of the less common (than uncomplicated viral infection) causes of fever, referral to secondary is likely to be the way forward. If there is no evidence of a significant cause and what you are left with is a reasonably well child with an unexplained fever, the final question is, "should I refer this child or send them home with safety-netting advice?"<br />
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Both options are valid and the choice should be made in the best interest of the child. In secondary care, the assessment of the child should be clinical in the majority of cases. As such, referral may simply add a further clinical history and examination. If a second opinion or physical period of observation is felt to in the child's interest, that is fine. If not, it may be best to keep the child away from hospital and the risks associated with a secondary healthcare setting/<br />
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Before a final decision is made, risk should be considered. For the majority of healthy children presenting to Primary Care (including the Emergency Department) with no specific risk factors, the likelihood of any febrile illness being a serious bacterial illness is very low. That makes it perfectly reasonable for a child who has had a careful clinical assessment to be managed conservatively and with good safety-netting advice.<br />
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There are children who have a significantly higher risk. As mentioned above, the most commonly encountered risk factor is the baby. If your patient is a baby, especially if not yet started on their primary vaccinations, fever without focus warrants a referral to paediatrics.<br />
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Fever in a child who does not have an immediately obvious focus is a clinical conundrum for all of us. Many children can be managed with a thorough history and examination. If there are significant risk factors or specific findings then appropriate referral is likely to be the next step.<br />
<br />
Edward Snelson<br />
99% Type 1 decision maker<br />
@sailordoctor<br />
<br />
<span style="font-size: x-small;">Disclaimer: If it's the clinician who has no focus, there's nothing I can do for you.</span><br />
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Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comtag:blogger.com,1999:blog-1905670054751342997.post-81011273249301055022020-04-09T03:32:00.000-07:002020-04-09T03:32:04.369-07:00Uncomplicated febrile convulsions in children - where and who to diagnose?<div dir="ltr" style="text-align: left;" trbidi="on">
This is the first in a series of posts that explore the clinical scenarios that can be managed entirely in a pre-hospital setting but are often or sometimes sent for further assessment. In each case, I know that some primary care clinicians do fully manage these problems without involving secondary care. The aim of these posts is to explore the possibility that the condition can be managed without secondary care.<br />
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<b>Clinical scenario</b><br />
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<b>A two year old has been managed symptomatically by their parents for what seems to them to be a viral illness. The child developed a fever this morning which led the parents to give paracetamol. Shortly afterwards, the child became stiff and then had rhythmic jerking of all four limbs. This continued for less than a minute. During the seizure the child was completely unresponsive and went slightly blue. Their eyes were fixed and staring.</b><br />
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<b>The jerking movements ceased spontaneously and the child was then sleepy for a few minutes, followed by some crying.</b><br />
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<b>In less than an hour, the child is back to their normal self. They are alert, settled, interactive and mobilising.</b><br />
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<b>If they manage to get to see a primary care clinician, should they be referred to secondary care for further assessment?</b><br />
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While in the majority of such cases parents will present to secondary care, first febrile convulsions can present to General Practice or be seen initially by a paramedic advanced clinical practitioner. To explore the value of ensuring a secondary care assessment, we need to look at the answers to a few other questions.<br />
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<b><span style="font-size: large;">What is a febrile convulsion (seizure)?</span></b><br />
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A febrile convulsion is like an epileptic seizure in every way other than that it is symptomatic of an illness rather than being due to underlying idiopathic epilepsy. Anyone who doesn't have epilepsy can have a symptomatic seizure (e.g. due to head injury or hypoglycaemia). Epilepsy is different - the tendency to have seizures without a specific cause.<br />
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A febrile convulsion will look the same as an epileptic seizure. You can presume that a seizure is a febrile convulsion if it fulfils the following criteria:<br />
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<ul style="text-align: left;">
<li>Typical age of 1-6 years old</li>
<li>Child has a febrile illness (the timing of the fever and seizure are unimportant as long as the illness is current)</li>
<li>Child has no underlying neurological or developmental abnormality</li>
<li>The seizure is followed by a full return to normal for the child</li>
</ul>
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A febrile convulsion can be atypical, prolonged or focal in which case the possibility of significant pathology is increased and those children should be seen urgently in secondary care.<br />
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<b><span style="font-size: large;">What causes a febrile convulsion?</span></b><br />
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The current thinking is that the illness is the thing that somehow causes the seizure. The idea that the fever itself causes the convulsion was first questioned in <a href="https://adc.bmj.com/content/88/7/641.full" target="_blank">an article in AD</a>C in 2003. Since there is a lack of correlation between the timing of the fever and the seizure, and there is a lack of evidence that antipyretics are preventative, it is likely that the illness causes the seizure and the fever.<br />
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<span style="font-size: large;"><b>Does a febrile seizure indicate serious pathology?</b></span><br />
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Although medical literature contains list of possible underlying pathology, a true febrile convulsion by definition cannot have an underlying cause. If a seizure is caused by an underlying CNS infection or other neuropathology, the diagnosis is not a febrile convulsion. If a child with meningitis has a seizure, the diagnosis is meningitis with seizure.<br />
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This is why the return to baseline (i.e. as well as can be expected for an uncomplicated viral illness) is arguably the most important part of the diagnosis. If, post seizure the child fails to demonstrate their wellness and neurological normality, the seizure may be symptomatic of CNS infection or other abnormality. An atypical, prolonged or focal seizure also changes the index of suspicion greatly.<br />
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<b><span style="font-size: large;">What tests are needed following a febrile convulsion?</span></b><br />
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If the diagnosis of febrile convulsion is as above and was a self-limiting generalised tonic-clonic seizure, no tests are required.<br />
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<span style="font-size: large;"><b>So what happens when a child is seen in secondary care following an uncomplicated febrile convulsion?</b></span><br />
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The history and examination is repeated. Unless there are specific indications for further tests (clinical suspicion of CNS infection or abnormality) everything else is unnecessary.<br />
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Essentially the endpoint in straightforward cases is a history and examination which leads to a diagnosis of febrile convulsion. So, if the diagnosis is already made, making it again adds absolutely nothing.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh3zAXp3gtnYboG-e_8-S_GsWKyrCLrHcByMzQ7agN_bCz6Lc94fMAaOyRywEHxcD2wiiOLrI8IL0KW5fFrHtKaR79nwZoX_loBavBDVv9DpmRZKGPFHm-HuYZmb9MLLmVjePKAfa_WO9U/s1600/Diagnosing+febrile+convulsion.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="1276" data-original-width="1519" height="536" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh3zAXp3gtnYboG-e_8-S_GsWKyrCLrHcByMzQ7agN_bCz6Lc94fMAaOyRywEHxcD2wiiOLrI8IL0KW5fFrHtKaR79nwZoX_loBavBDVv9DpmRZKGPFHm-HuYZmb9MLLmVjePKAfa_WO9U/s640/Diagnosing+febrile+convulsion.png" width="640" /></a></div>
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Who makes the diagnosis, when and where is more about timing, availability and clinical knowledge/ ability. If you're the right clinician in the right place at the right time, congratulations. It's you.<br />
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Edward Snelson<br />
@sailordoctor<br />
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Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comtag:blogger.com,1999:blog-1905670054751342997.post-9390198403827794342020-04-09T03:31:00.000-07:002020-06-05T07:58:26.972-07:00COVID Questions No 5 - How can I help? (Introducing the Zombie Apocalist)<div dir="ltr" style="text-align: left;" trbidi="on">
As we enter the depths of the COVID-19 pandemic, most of us are asking, "How can I help?" Regardless of our trepidation, we recognise the gravity of the situation. I myself anticipate that over the next few weeks and months, my personal and professional comfort zones will be most likely obliterated. I cannot expect things to be business as usual.<br />
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However, this crisis also presents a unique opportunity for front line clinicians. We have an urgent need to be pragmatic in our practices. This need is driven by several factors.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgCmP3QQwRqysTMNZM1QTG40H3-Wu69Y09wdniNxDcSfiWQJ9pHUEiT3M7Y_TURrBT9n54LQmIqYoiIf0RVHfrEErQg3g9tCDDlgoJn__uOvFSRHxb_DA8nNn-MjN6TPAaJ_BnzP-7W1kQ/s1600/The+benefits+of+pragmatism.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="843" data-original-width="1540" height="217" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgCmP3QQwRqysTMNZM1QTG40H3-Wu69Y09wdniNxDcSfiWQJ9pHUEiT3M7Y_TURrBT9n54LQmIqYoiIf0RVHfrEErQg3g9tCDDlgoJn__uOvFSRHxb_DA8nNn-MjN6TPAaJ_BnzP-7W1kQ/s400/The+benefits+of+pragmatism.png" width="400" /></a></div>
In Paediatric Emergency Medicine, many of us are looking at ways that we can safely achieve a more pragmatic approach to a variety of situations for the benefit of staff, children and their families. Because COVID-19 has dramatically changed the risk/ benefit analysis for what we do, it is an opportunity to consider what is low risk and low benefit in our usual practice, and find ways of reducing the times when we might previously have observed, investigated or referred.<br />
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As it happens, I have had an opportunity to explore this question prior to the COVID-19 pandemic. I do a great deal of face-to-face education with a variety of clinicians who work in primary care and emergency or acute paediatrics. In those sessions, I often hear that there is a great deal of variation in practice for certain clinical scenarios. The clinicians involved make different decisions based on their experience, confidence and the environment in which they work. It is inevitable for example that a GP working in a remote setting is going to have a different view about referring a patient than someone who sees a similar patient in a city with easy access to a secondary care setting.<br />
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As a way of exploring the fringes of clinical practice, I sometimes ask the zombie apocalypse question. It goes like this: You've just said that you would normally refer this child for a secondary care review. Now imagine that something has happened that means that there is a risk to the patient from going for that assessment (e.g. zombie apocalypse). Would you still ask for that further assessment or would you feel that it is safer for the patient to be managed outside of hospital?<br />
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Whenever the answer is no, the condition goes on a list of things that need referral no matter what. In such cases, (e.g suspected meningitis) we are saying that there is a clear need for that referral. If the answer is that we felt that the change in the risk/ benefit analysis would lead us to a different decision, the condition goes on the zombie apocalist.<br />
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Here's a list of the things that commonly end up on the zombie apocalypse list, based on the consensus of the clinicians at various educational events. (Note: all are specific to patients who are children or young people)<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-DGwLvaab1ETbOJeWahWC3lxmpNCR7wY2y4fPWuu3Wf78nUyOuYqgyBcuXsDD-XiGrCsI1aKNjahAd87GUU8R7VRUHCzi3593YtjYca6SX_5iUWOtHjyOefRvD1XoCZbjjDdb7Z7TQnk/s1600/The+Zombie+Apocalist.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="1498" data-original-width="1576" height="608" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-DGwLvaab1ETbOJeWahWC3lxmpNCR7wY2y4fPWuu3Wf78nUyOuYqgyBcuXsDD-XiGrCsI1aKNjahAd87GUU8R7VRUHCzi3593YtjYca6SX_5iUWOtHjyOefRvD1XoCZbjjDdb7Z7TQnk/s640/The+Zombie+Apocalist.png" width="640" /></a></div>
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<ul style="text-align: left;">
<li><a href="https://gppaedstips.blogspot.com/2020/04/uncomplicated-febrile-convulsions-in.html" target="_blank">Febrile convulsion with full recovery</a></li>
<li>Uncomplicated preseptal cellulitis</li>
<li>Petechial rash in a child who is febrile but otherwise does not concern the clinician</li>
<li>Headaches without red flags</li>
<li>Mild laryngomalacia</li>
<li><a href="http://gppaedstips.blogspot.com/2017/04/henoch-shonlein-purpura-who-what-where.html" target="_blank">Uncomplicated Henoch Schonlein Purpura</a></li>
<li>Reported reduced urine output in a child who is clinically hydrated</li>
<li>Chest pain with no red flags in history and normal cardiorespiratory examination</li>
<li><a href="https://gppaedstips.blogspot.com/2020/06/transient-synovitis-of-hip-irritable-hip.html" target="_blank">Transient synovitis of the hip</a></li>
<li>Infant feeding problems without red flags</li>
<li><a href="http://gppaedstips.blogspot.com/2016/05/kids-get-hit-in-head-lot.html" target="_blank">Minor head injuries in an over 1 year old without red flags or clinical abnormalit</a>y</li>
</ul>
[For more detail on the safe assessment and management of each scenario, click on the problem for the link. If there is no link yet, it will be covered in a post in the near future.]<br />
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There are a number of reasons why people are referring or otherwise taking an over-cautious approach to these situations<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEih72cOAYquPI_2eNYRK9Z0hN-noNQejg3N7qDG9W5Yt8u77HfZu2CPAbzXIEvS1j5TlFYnFUm-AmcnXVK74zl7qJbr3bql3dYpGiD74uJwuuJoWpSBmZHuvbz5ZfhOZBpkR4iBG88VxHo/s1600/Drivers+of+clinical+overcaution.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="701" data-original-width="1564" height="177" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEih72cOAYquPI_2eNYRK9Z0hN-noNQejg3N7qDG9W5Yt8u77HfZu2CPAbzXIEvS1j5TlFYnFUm-AmcnXVK74zl7qJbr3bql3dYpGiD74uJwuuJoWpSBmZHuvbz5ZfhOZBpkR4iBG88VxHo/s400/Drivers+of+clinical+overcaution.png" width="400" /></a></div>
In each of the situations on the above list, the question that we should ask is, "What will observation, referral or investigation add?" If any of these actions is primarily intended to add a sense of reassurance for the clinician, we should question that practice in the light of COVID-19 risk. When I say we, I mean both primary and secondary care clinicians. If over-caution exists, it can only do so due to a lack of functional teamworking between primary and secondary care.<br />
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So when we're asking how can we help with the current crisis, it may not be a case of re-deployment but of adaptation. One change that could have a significant impact is a <span style="font-family: "calibri" , "sans-serif"; font-size: 11.0pt; line-height: 115%;">renaissance</span> of pragmatism.<br />
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My next task is to give a bit more flesh to the pragmatic approach to each of those clinical scenarios. The posts about each will follow over the next few weeks. I hope you find them useful in removing the reasons for possible over-caution listed above. Alternatively, they may simply validate what you are already doing or have always wanted to do but didn't know that it was acceptable practice.<br />
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In the meantime, all of the potential drivers of over-caution can also be remedied by a case discussion with an experienced paediatrician. You should find that your secondary care colleagues welcome the opportunity to allow you to safely manage these scenarios in a pre-hospital setting where appropriate.<br />
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Edward Snelson<br />
@sailordoctor<br />
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Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comtag:blogger.com,1999:blog-1905670054751342997.post-15026951712725950522020-03-26T02:47:00.000-07:002020-03-26T02:50:46.446-07:00COVID Questions No 3 - Should I stop examining children's throats?<div dir="ltr" style="text-align: left;" trbidi="on">
As increasing evidence comes out of the countries hit worst by the COVID-19 pandemic, there is growing concern about the number of healthcare workers being affected. A large number of COVID-19 positive tests in Italy (currently about 10%) have been healthcare workers.<br />
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It is important to emphasise that these statistics will inevitably have at least some bias. Healthcare workers are much more likely to be tested for COVID-19. It is a concerning figure nevertheless and it is well known that healthcare environments are inherently risky when it comes to acquiring infection.<br />
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There are three main ways to avoid getting infection as a healthcare worker. The first is to avoid patient contact where possible. The second is to use <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/874316/Infection_prevention_and_control_guidance_for_pandemic_coronavirus.pdf" target="_blank">appropriate personal protective equipment </a>as per guidance. The third is to minimise the risk of the clinical encounter.<br />
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Over the past few days, there has been a growing discussion amongst frontline clinicians about a radical cultural change in clinical practice. We have been asking his question:<br />
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<b><span style="font-size: large;">Should I stop examining children's throats?</span></b><br />
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Like any such suggestion, the first time the question was asked out loud was probably in a one-to-one conversation in a closed room after checking that the GMC hadn't bugged the place. Then, as the question was asked more and more, it became quickly apparent that there was a large proportion of frontline clinicians who felt that this was a sensible move in the current situation.<br />
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On 25th March 2020 the <a href="https://www.rcpch.ac.uk/sites/default/files/2020-03/tonsillar_examination_rcpch_bpaiig.pdf" target="_blank">RCPCH published guidance</a> stating that in the current situation "the oropharynx of<span style="white-space: pre;"> </span>children should only be examined<span style="white-space: pre;"> </span>if essential." Never before in my career have I seen such a change in practice go from whispers between colleagues to official college guidance in such a short period of time. Well done RCPCH! For the first time since the introduction of FAOMed, you're ahead of us!<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhpRVMM5xxwXzeEFEFK6HWsrdZOJwzRBvIc9u8_TaW3IvYO_CtjTtYG7_t0Co9VztTgQAsoiZgDfRNmwv0ONiXaM3OYKYLRDMqx3AjrInsZ_KIqULjrbzUBNgTbq0eR3EuqZuOji7mb0M4/s1600/Stop+Press+-+stop+examining+children%2527s+throats.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1033" data-original-width="1522" height="270" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhpRVMM5xxwXzeEFEFK6HWsrdZOJwzRBvIc9u8_TaW3IvYO_CtjTtYG7_t0Co9VztTgQAsoiZgDfRNmwv0ONiXaM3OYKYLRDMqx3AjrInsZ_KIqULjrbzUBNgTbq0eR3EuqZuOji7mb0M4/s400/Stop+Press+-+stop+examining+children%2527s+throats.png" width="400" /></a></div>
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While this move is entirely intended to reduce the risk of clinical contact during the COVID-19 pandemic, clinicians will at the very least have questions. When something is part of our routine and then taken away from us it will cause anxieties. As acute clinicians, our intuitive thinking relies on a reasonably consistent approach and in most paediatric encounters, we are used to looking in the throat. So the question is, is it OK to stop doing that routinely?<br />
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Here are a few common questions in response to this radical change.<br />
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<b>What if I need to know what the focus of infection is?</b><br />
Good question. This has always been a hugely subjective issue. Even before this pandemic, the majority of clinicians and organisations have been trying to encourage self-care for uncomplicated febrile illness in children. If a clinical confirmation of infection focus was essential, health care organisations would be getting the message out. "Never give your child fever medicines without seeing a doctor to check what the problem is." That's not a thing.<br />
A snotty febrile child has an URTI. URTI does not exclude other infections nor does it exclude sepsis so the redness of the throat should not reassure us if we think a child has another probable diagnosis such as UTI, LRTI or sepsis.<br />
The important question has always been, "does this child have signs of serious bacterial infection or sepsis?" If the answer is no then the throat exam won't really change things (see below). If the answer is yes, you're looking for a source and it probably isn't in the throat.<br />
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<b>When might I need to examine the throat?</b><br />
The necessity for this is probably going to be mainly to look for evidence of a significant pathology such as peri-tonsillar abscess. I would suggest that such a possibility can be all but excluded clinically if a child is well analgesed and is able to eat or drink.<br />
If you do feel that examining the throat is important to do, you must wear eye protection.<br />
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<b>Don’t I need to determine if the child has tonsillitis?</b><br />
<a href="http://gppaedstips.blogspot.com/2018/06/decision-fatigue-and-what-to-do-about.html" target="_blank">Tonsillitis in children can always be treated symptomatically. </a> The <a href="https://www.nice.org.uk/guidance/ng84/resources/visual-summary-pdf-4723226606" target="_blank">NICE guidance for treating sore throats</a> attempts to direct the clinician toward cases where a symptom benefit from antibiotics is more likely but does not mandate the use of antibiotic in any uncomplicated URTI/ tonsillitis. The reason there is no mandate is that there is no evidence that in this era in the UK, antibiotics prevent the rare complications of URTI/tonsillitis.<br />
Regardless of clinical findings, the symptom benefit from antibiotics is poor. The lack of evidence for significant benefit has led the <a href="https://www.rch.org.au/clinicalguide/guideline_index/Sore_throat/" target="_blank">Children's Hospital Melbourne to recommend</a> no prescription of antibiotics in any case apart from high risk children or signs of complicated URTI.<br />
So if the child is low risk (99.9% of children) and has no signs of complications from the infection, the visualisation of the tonsils is non-essential.<br />
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<b>Should I therefore prescribe antibiotics empirically?</b><br />
In the interests of openness and honesty, I need to say first that the RCPCH does advocate this. There is a reminder that under the age of three years old, FeverPAIN should not be used. Over the age of three, it is proposed that in the current climate we prescribe antibiotics as follows.<br />
<a href="https://www.rcpch.ac.uk/sites/default/files/2020-03/tonsillar_examination_rcpch_bpaiig.pdf" target="_blank">"If using the feverpain scoring
system to decide if antibiotics are indicated (validated in children 3 years and older), we suggest
that a pragmatic approach is adopted, and automatically starting with a score of 2 in lieu of an
examination seems reasonable. </a><br />
<a href="https://www.rcpch.ac.uk/sites/default/files/2020-03/tonsillar_examination_rcpch_bpaiig.pdf" target="_blank">Children with a total feverpain score or 4 or 5 should be prescribed antibiotics (we suggest children with a score of 3 or less receive safety netting advice alone)"</a><br />
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I'm going to stick my neck out and suggest that this approach is wrong, for the following reasons:<br />
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<ol style="text-align: left;">
<li>First and foremost, it contradicts the public health approach to containing the COVID-19 pandemic. People are being told that if they have a fever without signs of something that looks like a serious illness (difficulty breathing, poorly responsive etc.) they should stay at home, self-medicate and not seek a face to face clinical contact. This is for their benefit, to protect the health service and to reduce the spread of COVID-19. Lowering a threshold for prescribing antibiotics for sore throat at this time goes against that move.</li>
<li>Secondly, the RCPCH has misquoted the NICE guidance. In their speediness to protect clinicians from unnecessary risk, they have missed a word. Just the one but it the word from the guidance that frequently goes unnoticed. That word is <b>consider</b>. It doesn't say <b>give</b> antibiotics for a FeverPAIN score above 4. It says consider. <a href="http://gppaedstips.blogspot.com/2018/06/decision-fatigue-and-what-to-do-about.html" target="_blank"> I consider that question every time and in most cases the answer is "The likelihood of benefit from antibiotics does not justify the risks.</a>" </li>
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I feel (personal opinion) that since there is no mandate to treat low risk children who have no signs of complications of their URTI/tonsillitis, we should default to not prescribing antibiotics in these cases. To lower our threshold for prescribing instead of raising it at this time of such a high risk clinical environment feels wrong. It seems contrary to the need to protect children and their carers from the risks of a visit to a GP or hospital and it feels contrary to the drive to reduce the number of people bringing COVID-19 with them to those places.<br />
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Again, huge respect to the RCPCH for cutting through the red tape and rapidly producing guidance to protect healthcare workers. Whenever something is done in that sort of timeframe, it is likely that detail gets missed. That's where we come in. We notice the typos and consider the implications. We ask questions that deserve answers after the fact in lieu of the consultation period that couldn't happen due to the timescale needed.<br />
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Edward Snelosn<br />
@sailordoctor<br />
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Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comtag:blogger.com,1999:blog-1905670054751342997.post-31889448127180177552020-03-23T04:15:00.000-07:002020-03-23T13:17:44.046-07:00COVID Questions: No 1 - Should clinicians recommend the use of ibuprofen in a child with suspected COVID-19 infection?<div dir="ltr" style="text-align: left;" trbidi="on">
As the COVID-19 pandemic gains momentum, we're all going to find ourselves either much busier or stuck at home. Over the next few weeks I intend to publish a series of short articles for the FOAMed community, to provide some coffee break sized learning for clinicians on the front line. If you have any COVID questions of your own, please send them to me.<br />
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These posts will not be heavily referenced, if at all. We are in the very early stages of gathering evidence and the risk with early evidence is that it can be very misleading for various reasons. Much of what is coming out from this crisis is a renaissance of pragmatism. That pragmatism is born out of necessity but is based in the common sense and experience of the clinicians who look after children. Together we can figure out what's truly important and cut through the evidence, without ignoring it.<br />
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The first question is: <b>Should we recommend the use of ibuprofen for symptomatic relief in a child with a respiratory tract infection?</b><br />
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France's health minister, Olivier Véran created a great deal of anxiety for both clinicians and the public when he said that people should avoid using ibuprofen because it may make COVID-19 infection worse. This prompted a variety of responses from organisations around the world. Some recommended against using ibuprofen and some stating that there was no evidence that it made COVID-19 infection worse.<br />
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Why was there such a disparity of recommendations? The answer is that your view will depend on your perspective.<br />
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<b>Is there a possibility that ibuprofen could make COVID-19 infection worse? Yes.</b> There is a hypothetical risk because the anti-inflammatory properties of ibuprofen include some elements of the immune response.<br />
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<b>Is there any evidence that this biochemical effect has any clinical effect? No. </b> There is no clinical evidence that ibuprofen actually makes COVID-19 infection worse.<br />
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So with a hypothetical harm and no evidence that it is real, what should you recommend? That depends on whether you think that being able to take ibuprofen is important. If not, then you may as well avoid it. I would argue that there are plenty of reasons to think that avoiding the use of ibuprofen is harmful in children with respiratory tract infection.<br />
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<b>It is arguable that the single greatest risk of avoiding Ibuprofen is the unnecessary exposure to infection.</b><br />
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Children with uncomplicated respiratory tract infections are best managed symptomatically. Although parents often seek a clinical assessment, this rarely adds anything other than reassurance in the child who has no respiratory distress, signs of sepsis or dehydration. In normal circumstances, the clinical assessment itself is low risk. These times are not normal circumstances. Any healthcare setting is currently extremely high risk for acquiring COVID-19 infection, so anything that brings you to the doors of a hospital or community clinical environment is itself dangerous.<br />
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It therefore follows that anything that avoids this attendance is protective. Analgesia is a good way of helping a child with a respiratory tract infection to feel well and behave in a way that lets the parent know that they are not dangerously unwell. It is also a good way to give the child the best possible chance of hydrating orally, by resolving their sore throat, sore ear or general malaise.<br />
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It is interesting that the initial flurry of recommendations against the use of ibuprofen was followed by a steady stream of statements that there was no evidence for such avoidance and a series of retractions and clarifications. I think that the about turn was brought about by an alliance of evidence based medicine purists and front-line pragmatists who recognised that symptomatic relief is under-rated and has a genuinely important role in these times.<br />
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Even if you have genuine anxieties about the use of ibuprofen in children with potential COVID-19 infection, I would suggest the following principle:<br />
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While avoiding ibuprofen may feel safe, my opinion is that ibuprofen may be useful as a way to keep children and the adults who care for them safe by avoiding uneccessary clinical contact.<br />
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Edward Snelson<br />
@sailordoctor<br />
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Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.comtag:blogger.com,1999:blog-1905670054751342997.post-34532498316083224532020-01-08T22:53:00.000-08:002020-01-08T22:53:42.686-08:00Something or nothing - why topical antibiotics are not for neonates with eye and umbilical infections<div dir="ltr" style="text-align: left;" trbidi="on">
Newborn babies cause clinicians a lot of anxiety. The worry about infections can lead to the use of antibiotics "just to be safe." This is usually not the best approach. Most of the time, the symptoms are nothing, and when they are something more significant, sending the baby home with topical antibiotics is not the solution.<br />
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Let's look at two common scenarios.<br />
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<b><span style="font-size: large;">Scenario 1 - The baby with a sticky eye</span></b><br />
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A one week old presents with a unilateral sticky eye. The baby is otherwise well, feeding and growing. The left eye has a yellow discharge around the margin of the eyelid. The baby's examination is otherwise normal.<br />
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What's the problem? Something or nothing.<br />
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The nothing problem is the more common scenario. Many babies are born with a non-patent nasolacrimal duct. The inability to drain tears from the eye to the nose leads to the sticky eye. Tears are made up mainly of water and lipid (for lubrication). The water mostly evaporates leading to a thick secretion which accumulates. This is not a sign of an infection.<br />
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Most blocked tear ducts will self-resolve over weeks or months. It is unusual for them to persist until the infant's first birthday. If it does, an ophthalmologist can unblock the duct with a probe.<br />
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Rarely, there will be a cystic collection in the tear duct. This presents with the same sticky eye but with a swelling visible at the inner canthus of the eye. <a href="https://webeye.ophth.uiowa.edu/eyeforum/cases/166-dacryocystocele.htm" target="_blank">There are some good pictures of what that looks like here.</a> Although these do sometimes self resolve, dacrocystoceles can be problematic and should be referred to an ophthalmologist.<br />
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The something problem is infective conjunctivitis, but not as you know it in older children. Babies have all those lovely maternal antibodies to protect them from common viral infections, so viral conjunctivitis is relatively rare in newborns. In addition to the increased likelihood of bacterial infections, there are two other factors that make topical antibiotics a bad idea for newborn eye infections.<br />
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Firstly, the infection may be congenitally acquired. Chlamydia and gonorrhoea are two organisms that cause bacterial eye infections in neonates.<br />
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Secondly, the baby's immune system is heavily reliant on the aforementioned maternal antibodies. Their own immune system is immature and relatively unresponsive. That is one reason why newborns have vague symptoms during serious bacterial infections, while a one year old has a temperature of 39C and can look really unwell with an uncomplicated viral illness.<br />
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If this baby does have a bacterial eye infection, it is high risk both for the eye and the baby.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZKkDihkIYUrFXVwFsugP1M3OQqPNn3ul_2eixRpzeBjk8xIhmwoodRoxQNkNUZMAZN-P0NVul1vfN22uDXt1v2PtNlh4LtJKHk-vScb7vM4A1WeZ2M9EhnweCTCkYOF0_5dMQo-L2DNI/s1600/Gonococcal_ophthalmia_neonatorum.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="930" data-original-width="1600" height="185" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZKkDihkIYUrFXVwFsugP1M3OQqPNn3ul_2eixRpzeBjk8xIhmwoodRoxQNkNUZMAZN-P0NVul1vfN22uDXt1v2PtNlh4LtJKHk-vScb7vM4A1WeZ2M9EhnweCTCkYOF0_5dMQo-L2DNI/s320/Gonococcal_ophthalmia_neonatorum.jpg" width="320" /></a></div>
Opthalmia Neonatorum<span style="font-size: x-small;"> - from the Centers for Disease Control and Prevention's Public Health Image Library #3766</span><br />
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As a result of all of these factors, eye infections in newborns (ophthalmia neonatorum) should be taken seriously and referred for acute assessement and management by paediatrics or ophthalmology depending on your local pathways.<br />
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How do I tell the difference between the something and the nothing?<br />
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It's actually quite simple. There are a few quick things to check:<br />
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The answers to these questions give you the answer to what you should do next.<br />
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While it might feel like the safe option to just give topical antibiotics to every baby with a sticky eye, this is not the case. If the problem is a blocked tear duct, the eye drops may cause a chemical conjunctivitis and make things worse. If the problem is an infection, it is higher risk for the eye and the baby and so needs careful assessment and management.<br />
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<b><span style="font-size: large;">Scenario 2 - The baby with red skin around the umbilical stump</span></b><br />
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A three day old baby is brought to you by one of their parents. There is some redness around the umbilical stump.<br />
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What is the problem? Something or nothing.<br />
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The nothing option if the umbilical stump is still attached is non-infective inflammation. From the moment of birth, the umbilical stump is devitalised tissue. In the absence of a blood supply, it goes through a process that leads to separation, usually about a week or two after birth. During this time it can either just become dry and shrivelled or it can become a bit sticky and smelly. Often, the skin around the base has been repeatedly cleaned to remove any stickiness. This itself can cause a small halo of red skin.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjtOI2Q0wieSDdDuYDAzdvVAHNwpzBLk4x0U-V8lBKrDQSNlrdw30fxEG-AUzvuy6A9nVOrIp1_bElWkvNx-lUmzXKAC5ppXO6yYjt1dX5H3SpR_OdzrIcxRcYcvzEN5oW5jN-UQji1oOE/s1600/periumbilical+erythema.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="429" data-original-width="545" height="251" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjtOI2Q0wieSDdDuYDAzdvVAHNwpzBLk4x0U-V8lBKrDQSNlrdw30fxEG-AUzvuy6A9nVOrIp1_bElWkvNx-lUmzXKAC5ppXO6yYjt1dX5H3SpR_OdzrIcxRcYcvzEN5oW5jN-UQji1oOE/s320/periumbilical+erythema.jpg" width="320" /></a></div>
<span style="font-size: xx-small;">Image taken from the Stanford Newborn Nursery site and used with permission. This material was compiled by Janelle Aby, MD for educational purposes only. Reproduction for commercial purposes is prohibited. Utilisation of the materials for educating those who care for newborns is permitted with proper citation of source.</span><br />
The nothing option if the umbilical stump has separated is an umbilical granuloma. These benign growths are quite common and will self resolve. They have a tendency to produce some exudate. Again, repeated cleaning can cause a bit of inflammation to the surrounding skin.<br />
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The something scenario is omphalitis. Infection of the umbilical stump carries a high risk of invasive infection. This of course is partly due to the immunology of a newborn (see above). It is also because the umbilicus retains its connection to the circulation. The external part may be dead but the vessels inside are still patent and may help to seed the infection systemically.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEghhV_iGca6hcV-jU8c5Jnlqi-H2ESOz2wwr4ZOphmcxrudIBcE5x6T5ebAoY2vatRU32qdZrntp07UdM6Ghiz2UVesGve0uuIY3AIkvFrxSKlP7u_bfPRWkGChoGd_m99AAkBXQymf7G8/s1600/omphalitis.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="429" data-original-width="545" height="251" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEghhV_iGca6hcV-jU8c5Jnlqi-H2ESOz2wwr4ZOphmcxrudIBcE5x6T5ebAoY2vatRU32qdZrntp07UdM6Ghiz2UVesGve0uuIY3AIkvFrxSKlP7u_bfPRWkGChoGd_m99AAkBXQymf7G8/s320/omphalitis.jpg" width="320" /></a></div>
<span style="font-size: xx-small;">Image taken from the Stanford Newborn Nursery site and used with permission. This material was compiled by Janelle Aby, MD for educational purposes only. Reproduction for commercial purposes is prohibited. Utilisation of the materials for educating those who care for newborns is permitted with proper citation of source.</span><br />
Omphalitis is now a rare occurrence in the UK and other similar counties. It remains a more frequent presentation in countries with limited healthcare resources, especially where it is common to give birth in unclean environments.<br />
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Since most of these neonates will be cared for in a hospital setting, babies that present to GP or ED are likely to be low risk.<br />
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In a low risk baby, the decision about what to do is fairly straightforward.<br />
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While it might feel like the safe option to just give topical antibiotics to every baby with a sticky umbilicus, this is not the case. If the problem is non-infective inflamed skin, applying chemicals is only likely to make that worse. Inflamed and broken skin does not make a good barrier to infection. If the problem is an infection, it is a high risk situation best managed in a secondary care setting.<br />
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So if it's nothing, leave it alone. This of course always requires good safetynetting advice. If it is something significant, this is usually best managed in a secondary care setting. There's no real role for the practice of doing something to make us feel like we've done something.<br />
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Edward Snelson<br />
Cautious binarian<br />
@sailordoctor<br />
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Edward Snelsonhttp://www.blogger.com/profile/06324638958889935460noreply@blogger.com