Paediatrics for Primary Care (and anyone else): COVID19

Showing posts with label COVID19. Show all posts

Sunday, 25 October 2020

The Decision Maker's Guide to Bronchiolitis Assessment

This bronchiolitis season is going to be different. While SARS-CoV2 virus does not seem to be a significant cause of wheeze in children (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.

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, click this link.

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.

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.

Does this child have bronchiolitis?
Should this child be managed at home or in hospital?
What treatment should the child be given?

Question 1: Does this child have bronchiolitis?

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.

Viral induced wheeze, 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.

Pneumonia 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.

Congestive cardiac failure (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.

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.

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.

If the diagnosis is bronchiolitis, we can move onto our next question:

Question 2: Should this child be managed at home or in hospital?

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.

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.

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.

Possibly the most controversial element of the decision making is the presence of risk factors. In the guidance, it is stated "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." 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.

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?

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.

If the decision is made to manage a child with bronchiolitis at home, the third and final question is:

Question 3: What treatment should the child be given?

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).

That makes this flowchart nice and simple:

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.

Edward Snelson
@sailordoctor

References

Sunday, 10 May 2020

COVID question number 6 - What is hyperinflammatory syndrome and how do I recognise it?

At the same time that we are seeing increasing evidence that COVID-19 is less common, less severe and less infectious in children (1), evidence is emerging of a new phenomenon that seems to be related to COVID-19 infection in children: hyperinflammatory syndrome (2).

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.

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.

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.

First, a few FAQs about hyperinflammatory syndrome in children:

What is hyperinflammatory syndrome?
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 Kawasaki Disease Shock Syndrome (3), a thing so rare that most of us had never heard of it before this recent surge of cases.

Is it caused by COVID-19 infection?
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.

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.

How do I recognise hyperinflammation in a febrile child?
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.
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.

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.

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.

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.

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.

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.

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.

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.

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.

Edward Snelson
@sailordoctor

References

Thursday, 9 April 2020

COVID Questions No 5 - How can I help? (Introducing the Zombie Apocalist)

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.

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.

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.

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.

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?

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.

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)

Febrile convulsion with full recovery
Uncomplicated preseptal cellulitis
Petechial rash in a child who is febrile but otherwise does not concern the clinician
Headaches without red flags
Mild laryngomalacia
Uncomplicated Henoch Schonlein Purpura
Reported reduced urine output in a child who is clinically hydrated
Chest pain with no red flags in history and normal cardiorespiratory examination
Transient synovitis of the hip
Infant feeding problems without red flags
Minor head injuries in an over 1 year old without red flags or clinical abnormality

[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.]

There are a number of reasons why people are referring or otherwise taking an over-cautious approach to these situations

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.

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 renaissance of pragmatism.

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.

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.

Edward Snelson
@sailordoctor

Thursday, 26 March 2020

COVID Questions No 3 - Should I stop examining children's throats?

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.

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.

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 appropriate personal protective equipment as per guidance. The third is to minimise the risk of the clinical encounter.

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:

Should I stop examining children's throats?

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.

On 25th March 2020 the RCPCH published guidance stating that in the current situation "the oropharynx of children should only be examined 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!

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?

Here are a few common questions in response to this radical change.

What if I need to know what the focus of infection is?
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.
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.
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.

When might I need to examine the throat?
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.
If you do feel that examining the throat is important to do, you must wear eye protection.

Don’t I need to determine if the child has tonsillitis?
Tonsillitis in children can always be treated symptomatically. The NICE guidance for treating sore throats 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.
Regardless of clinical findings, the symptom benefit from antibiotics is poor. The lack of evidence for significant benefit has led the Children's Hospital Melbourne to recommend no prescription of antibiotics in any case apart from high risk children or signs of complicated URTI.
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.

Should I therefore prescribe antibiotics empirically?
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.
"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.
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)"

I'm going to stick my neck out and suggest that this approach is wrong, for the following reasons:

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.
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 consider. It doesn't say give antibiotics for a FeverPAIN score above 4. It says consider. I consider that question every time and in most cases the answer is "The likelihood of benefit from antibiotics does not justify the risks."

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.

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.

Edward Snelosn
@sailordoctor

Monday, 23 March 2020

COVID Questions: No 1 - Should clinicians recommend the use of ibuprofen in a child with suspected COVID-19 infection?

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.

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.

The first question is: Should we recommend the use of ibuprofen for symptomatic relief in a child with a respiratory tract infection?

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.

Why was there such a disparity of recommendations? The answer is that your view will depend on your perspective.

Is there a possibility that ibuprofen could make COVID-19 infection worse? Yes. There is a hypothetical risk because the anti-inflammatory properties of ibuprofen include some elements of the immune response.

Is there any evidence that this biochemical effect has any clinical effect? No. There is no clinical evidence that ibuprofen actually makes COVID-19 infection worse.

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.

It is arguable that the single greatest risk of avoiding Ibuprofen is the unnecessary exposure to infection.

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.

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.

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.

Even if you have genuine anxieties about the use of ibuprofen in children with potential COVID-19 infection, I would suggest the following principle:

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.

Edward Snelson
@sailordoctor