A Whole New World - Honesty in Paediatrics

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).

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.

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.

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.

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?"

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.

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.

First up is an intriguing suggestion:  Diagnosis - Viral illness.

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.

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.

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%.

Positive predictors of a viral cause do exist and include wheeze and urticarial rash in children. This child has none of these things.

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.

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.

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.

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.

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.

• Croup
• Chickenpox
• Febrile convulsion
• Vasovagal syncope

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.

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.

• Infant reflux disease
• Cow's milk protein allergy (non-IgE)
• Asthma
• in the under 5 yr old child
• where the diagnosis is based on chronic cough without wheeze
• Mesenteric Adenitis
• Hypermobility

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.

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.

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.

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:

• Growing pains
• Non-specific abdominal pain

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.

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..."  

It's a whole new world being honest about our uncertainty but it does work and it works like this:

Edward Snelson
@sailordoctor

Disclaimer: I am not certain about any of that, or that you or I exist.

Reference

General Medical Council UK, Guidance on professional standards and ethics for doctors Decision making and consent, 9 November 2020

Core Principles of Paediatrics

Treating sick kids is a lot of fun.  If you can deal with any fear factor, it becomes a real pleasure most of the time.  Children are very different from adults.  While much that you know about adult medicine is useful, it usually needs a big modification to apply into practice when assessing and treating a child.  This post is going to cover some of the core principles of paediatrics as well as giving some specific examples.

Let's start with some basics:

The paediatric consultation is inherently different.  In most situations the child is part of a consultation which involves a third party, usually a parent.  That dynamic needs to be handled carefully and it is important to never forget that the child is still the patient.

When it comes to examining a child, it can be a little daunting.  In most cases, it is possible to get cooperation by making the examination fun.  There are various ways to do that but my go-to method is the "Find the food" game.  A full explanation of how that works is here.  In many cases you just have to be opportunistic and accept that there is no set piece for the examination.  In paediatrics, we can only base our assessment on the examination that is achievable.  Incomplete information goes with the territory, but it is usually possible to make an assessment.  Thankfully, the most important information usually comes from the history and from the hands-off element of the examination.

When it comes to making an assessment and deciding on a management plan, it is important to consider the age of the child.  Children get different problems at different stages of childhood and the way they respond to infections changes considerably at different ages.

Babies*

• Immune system is heavily reliant on maternal antibodies
• Simple viral illnesses are uncommon
• When a baby is febrile or unwell, the likelihood of serious bacterial infection (SBI) is high.  
• The response to SBI is sometimes vague and does not make it easy to recognise SBI.  Babies who are "off feeds" or "not their normal selves" should be taken seriously.
• Physiological reserves are low in this age group.  Babies can compensate to a degree but are prone to sudden deterioration is moderately unwell, especially when the lower respiratory tract is affected.
• The lack of any ability to report symptoms means that certain problems such as urinary tract infection (UTI) and surgical abdominal problems can easily go unrecognised.

*I have deliberately not attributed an age range to the term baby.  Everything here is more true for a 2 day old than it is for a 2 month old but the same principles apply.  If you really want to know if it's a baby, put it on the floor in the middle of the room.  If your patient is exactly where you left them 5 minutes later, it's a baby.

There are some simple principles to apply when assessing a baby:

• Take any abnormal temperature (low or high) seriously.  Unless there is good evidence of a benign cause (wearing too many layers or fever post vaccination) and the baby is well, presume SBI.  In primary care/EM that means referring.  In paediatrics that means a period of observation as a minimum and in many cases the outcome is investigation and presumptive treatment.
• Absence of fever is not absence of significant infection.
• Take into account risk factors such as prematurity
• Remember to do a few specifics in the examination - assess posture and limb movement, feel the fontanelle, weigh the baby (and measure head circumference in many cases) and feel femoral pulses.
• Babies can seem "a bit off and" then be absolutely fine when assessed/ observed.  When sending the baby home, make sure that the parents know how important it is to be reassessed if there is deterioration or new symptoms.  They must never hold back from seeking assessment due to fear of being perceived as an anxious parent.
• Conversely, many of the things that parents might worry about are often within normal, including regurgitation of feed, frequent crying and straining at stool.  In general, if the baby looks well, grows well and examines normally, these things are likely to be part of normal infancy.

Toddlers and Pre-school Children

• No longer relying on maternal antibodies and not yet an educated immune system, this age group has a cunning survival plan - the immune system that goes crazy with every simple infection.  Simple upper respiratory tract infections provoke high fevers, high white cell counts and produce an array of other phenomena in this age group.
• The phenomena that occur relating to viral infections in this age group include transient synovitis (irritable hips), viral induced wheeze and febrile convulsion.
• The fact that these children get so many viral illnesses coupled with the fact that they can seem quite unwell with simple viral illnesses means that a large proportion of healthcare presentations at this age are for viral illnesses.  In contrast to babies (rule out SBI/ sepsis) the approach in this group is more usually rule in SBI/ sepsis.
• The low probability of SBI/ sepsis in this age group presents many challenges to front line clinicians.  It is essential to remain vigilant and to approach even the most straightforward illness as though it could be or become SBI/ sepsis.
• The prevalence of asthma in this age group is very low.  There are plenty of presentations that could be misdiagnosed as asthma but it is important not to be misled.

Older Children and Young People

• The transition into this stage of childhood is more gradual.  Viral infections continue to occur frequently to begin with (especially as the child first goes to a new school) but become less common.
• Response to infections is slightly less vigorous and the phenomena associated with the previous stage suddenly become rare.
• Asthma now becomes a more significant possibility.
• As this stage of childhood develops, the pattern of disease and clinical presentation becomes progressively more adult like.
• The non-clinical needs of the patient tend to remain childlike more than clinicians sometimes realise.  It's daunting being a patient when you're not an adult.

Much of paediatrics is about understanding these stages of childhood.  In each stage, the challenges are different.  This "stages of immune system development" maps well to the approach to illness at each stage as well as to the various causes of childhood wheeze.

The Pitfalls

It's good to know what might catch you out.  Here are a few of the common pitfalls.

Extrapolating adult practice into paediatrics-  This rarely works.  The probabilities are different, the way that they present are different and the therapeutics are different.  Here are few examples of major differences in common problems that can occur in children and adults.

• Atraumatic back pain - Common in adults.  In the absence of red flags a watch and wait approach is entirely valid.  It is a very uncommon in children.  Up to half will have significant pathology.  It is more often appropriate to investigate early to detect that pathology.
• Constipation and UTI - In adults these usually present with specific symptoms.  In children this is almost never the case.  In younger children, these problems are not detected unless actively sought out in the children with vague and unexplained non-specific symptoms.

Doing something-  For many childhood presentations, paediatrics is the art of doing as much nothing as possible.  It can feel like doing a test or giving a treatment "in case" is the safe option but there is no such thing as a zero-harm test or treatment in paediatrics.  Where a test or treatment is absolutely indicated you are on safe ground.  For example with croup, dexamethasone is never wrong.  In many scenarios, a test could be done or a treatment could be given.  If that is the case, always consider the possible harm.

For example:

• Upper Respiratory Tract Infections - antibiotics can often be justified and this can feel like a satisfactory way of dealing with parental expectations.  However, antibiotics often cause vomiting and diarrhoea and the likely benefit is small.  Antibiotic prescribing risks shifting the focus from good symptom control and the perception that antibiotics are a safe option is misleading.
• Bronchiolitis - doing a chest X-ray (CXR) may feel like a good way of completing a clinical assessment.  The reality is that it does not add value exept in extreme cases.  The great likelihood is that the CXR will show something that can be interpreted as bacterial LRTI, leading to a prescription of antibiotics despite the evidence that wheeze virtually exludes bacterial LRTI.  Now you have a baby with bronchiolitis who is being given antibiotics when what they most need is to hydrate orally and be allowed to cope with thier wet lungs without unecessary upset.

In paediatrics, careful assessment, observation if needed and careful safetynetting are the cornerstones of safe practice.  Doing tests and giving treatments "in case" are not as safe as they feel.

Feeling the pressure-  Worrying about knowledge gaps or inexperience with paediatric presentations is quite normal.  It is common for clinicians to have niggling anxieties about their assessment of a child.  If in doubt do the following things:

• Look at the child.  Their appearance and behavior will often tell you whether that concern may be valid.
• Use every contact as a learning opportunity.  If you have worries about something, learn about that presentation for the next time.
• Don't hesitate to ask for help or advice.  If you have doubts about the best management of something you feel you can deal with yourself, discuss that plan with someone experienced.  In many cases, that will be someone in your team but it can also be a paediatrician on call.  They might want to see the child but they may be happy to discuss and advise.  If you do refer a child for further assessment, find out what happened next.  That way you can educate your own clinical judgement.

Finally, if you are or become that person that someone goes to for advice or a further opinion, be helpful.  Remember how daunting it is when you first started seeing children and how much uncertainty is entirely appropriate.  If you end up seeing the child and they don't need any investigation or intervention, remember how much childhood illness can fluctuate in severity.  As the expert, you will undoubtably add value, even if it is simply in the form of an experienced assessment and brilliant safetynetting.

Edward Snelson
Induction agent
@sailordoctor

Disclaimer - Remember that when you look at a child, wear full personal protective equipment.  If you're new to seeing children, you're in for a viral rollercoaster.

Mugglevision - Being a clinician to a child with learning difficulties

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

What if your patient has a very different perception of the world to the one you have?  Many of our patients fit into a group that experience the world quite differently to us.  This group includes children and young people with what would be classified medically as having a syndrome, neurodisability, learning difficulties, special educational needs or other such labels.  The trouble with labels is that they are just that - a label.  Labels can be dehumanising and sometimes irritating.  So, to avoid this trap and because it facilitates a theme, I shall refer to any such child as magical.  That makes you and me the muggles in the encounter.

When a muggle meets a person from the magical world, it can be a little difficult to know what to say or do.  That's normal.  What can happen in such circumstances is that the clinician (muggle) retreats to a place of safety, concentrating on the medical aspect of the consultation and communicating primarily with the family (who are also likely to be muggles).

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

What the (magical) young people tell us:

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

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

Edward Snelson
Magical world liaison officer
@sailordoctor

Many thanks to Liz Herrieven for help with this post.

Resources

1. Liz Herrievan, Learning Difficulties in the ED, RCEM Learning
2. https://www.makaton.org/training/
3. https://pecs-unitedkingdom.com/pecs/

I'm On Your Side - How to stop the URTI-antibiotic discussion becoming an ordeal

The antibiotic debate is a big one for several good reasons.  One of those reasons is that times have changed and change can be challenging.  Antibiotics were used liberally by previous generations of clinicians.  We and our patients now find ourselves in a world where antibiotics are being used less often.  This culture change is a major contributor to the conflict that arises due to expectation of antibiotics as a treatment for sore throats and painful ears in young children.

The good news is that if you are prescribing fewer antibiotics then you are part of a growing trend.  In the UK and many other countries, antibiotics prescribing rates have fallen over the past few years.  This means a lot more children are benefiting from symptomatic treatment without the added side effects of antibiotics.  So far the evidence is that this reduction has not been the cause of a rise in bacterial complications such as peritonsillar abscess and rheumatic fever.(1)

If you work in a country with a low incidence of complications of streptococcal infections, that tells you more about the pathogenicity of your local bacteria than about your prescribing rates.  We therefore greatly rely on our Public Health team to facilitate the safety of the no-antibiotic approach to managing URTI/AOM/tonsillitis.  The Public Health team monitors the rates of complications of streptococcal infection and alerts you when there is a more pathological strain of strep and will make recommendations regarding temporary changes in prescribing practices.

It's great to know that Public Health have our backs, but it's a little complicated to explain to patients and parents in the time restrictions of a consultation.  Explaining the rationale for avoiding antibiotics for sore throats and ears can be tricky.  While many of of us are finding that it is problematic less often than it used to be, it is still one of the most important skills that we should have.  The question is, what can we do to make it likely that this discussion goes well and goes quickly?

The first thing to do is make sure that we're coming at this from the point of view of the best interests of the child.  I understand the need for antibiotic guardianship but quite frankly when it comes to each clinical encounter, I'm always going to choose what will be best for my patient.  If this is what is driving our avoidance of antibiotics then the parents will hopefully sense that we want what they want -their child to be as well as possible as soon as possible.  What this child centred approach achieves is that we then have the right attitude towards the subject of antibiotics.  We don't come across as having a hidden agenda.  It's all about the child and wee hope that parents will respond well to that.

When we have the discussion it is important to be considered when choosing our words.  If we talk about "not needing" antibiotics, it might come across as them not having fulfilled the criteria for what they see as the ultimate treatment.  Instead, talk in terms of antibiotics not helping.

It is fairly standard at this point to mention the side effects of antibiotics.  I don't tend to mention allergic reactions, partly because they are not that common and partly because we are trying to get away from parents thinking that everything that happens while taking antibiotics is an allergic reaction.  What I do emphasise is that common side effects are abdominal pain, vomiting and diarrhoea.  I make sure that the parents know that the main reason for wanting to avoid antibiotics is that I don't want to do that to the child and I don't want to make life harder for the parents.

Because most people don't seek a medical opinion about what not to do, this is the ideal time to discuss what does work.  Analgesia is key and parents will sometimes need encouragement in this regard.  One thing that causes much confusion is the issue of what the medicine is for.  There has been an unhealthy emphasis on controlling temperature which sometimes means that paracetamol (acetominophen) and ibuprofen are not used as analgesia when the child is afebrile but refusing to drink.

This is all important information and yet at the same time it is way too much information for a parent.  In many ways, the complexity of the information is part of what perpetuates the overuse of antibiotics.  It is far simpler for the parents and the clinician to simply say, "Your child needs antibiotics."  Unfortunately this is the illusion of simplicity.

So what we need are strategies to simplify the complicated. A leaflet is a very good way to achieve this.  We know what the questions that most people tend to ask, so why not give them some answers?  Here is a simple leaflet, in a question and answer format:

You could even start the process in the waiting room.  A poster that gives a bit of context might soften the ground for the discussion to be allowed to focus on more important things.

If you would like access to either the leaflet or the poster then please let me know and I can give you a fully editable copy.  You will need to register a free account at canva.com  When you have done that, either send me a direct message via social media or post a comment at the end of this blog.  (You don't need to worry about anyone seeing the comment.  I get to review all comments before they are published and if you start your comment with "not for publishing" I will keep it for my eyes only.)  Give me your email address that you used to register the canva.com account and I will share the templates of the leaflets or poster if that is of use to you.  You can then use these to edit and personalise.  

There are lots of leaflets, posters and websites available.  You should use them both to inform and to simplify.  My view is that they should be basic but contain the important information.

Finally, make sure that the parents know that they need to be looking out for signs of secondary infection and sepsis.  Complications of URTI are thankfully low where I practice but we should all be thinking of URTI as pre-sepsis.  I think that this safety-netting discussion can actually be used to support  the no-antibiotic element of the consultation.  Parents need to know that the clinician realises that their child is genuinely ill.  For that reason, we should avoid the phrase "just a virus".  It may be meant as reassurance but is often perceived as dismissive.  By completing the consultation with and explanation of signs of complicated URTI and when to re-attend we are helping the parent to see that we have taken the child's illness seriously.

Edward Snelson
Very Serious Doctor
@sailordoctor

Disclaimer:  The online content of this blog may have been corrupted by pixies and as such the responsibility for anything that turns out to be wrong sits with the Fairy King.

Reference

1. Sharland M, et al, Antibiotic prescribing in general practice and hospital admissions for peritonsillar abscess, mastoiditis, and rheumatic fever in children: time trend analysis, BMJ 2005;331:328

Decision Fatigue and What to Do About It - When to Use Antibiotics for URTI, AOM and Tonsillitis in Children

Recently I was speaking to a GP colleague about the ways to protect oneself from decision fatigue.  Decision fatigue is a serious issue for anyone in a high volume, high turnover medical job.  He had some great insights into the problem and the solutions.

What are the effects of decision fatigue?  In the short term, your decision making ability gradually declines.  In the long term there is a risk of burnout.  From your patient’s point of view, your fatigue could mean that because you have already made too many decisions, you will not make the right decision when it really matters.  It is possible that this could lead to harm to a  patient.  Decision fatigue affects our ability to show compassion or provide patient centred care.  Subconsciously we protect ourselves from too many decisions by caring less and being more directive.

My GP friend’s solution to all of this was elegantly simple: make fewer decisions.  His rationale was this: there is only so much that we can give and we need to choose when to use our decision making energy.  If decision making is a finite resource then to use it indiscriminately is could even be seen as irresponsible.

So, how do you choose what to stop deciding?  Well, I would start with a commonly occurring dilemma that creates a great deal of uncertainty.  How about antibiotics for sore throats and ears in children?

You will notice I don’t talk about tonsillitis, URTI or otitis media.  These terms all imply an aetiology.  That is a presumption that is completely misleading.  Tonsillitis may be viral and red throat without exudate may be streptococcal.  The truth is that we don’t have a reliable way of discriminating between viral and bacterial aetiology when we examine throats and ears.  So we can't know who to give antibiotics to.  Rather than exhausting ourselves trying to get it right, perhaps we should just stop, but is that safe and justifiable? I am not the first person to ask that question. (1)

The decision that we are all faced with, to antibiotic or not-antibiotic, has to have a valid goal.  So the next question has to be, “What is the benefit in giving antibiotics?”

Do we give antibiotics to prevent complications?  In the UK this is not the case.  The evidence is very much against a need to give antibiotics as a way of preventing complications of URTI.  Antibiotic prescribing rates are falling and yet there is no crisis caused by increased numbers of invasive infection or the sequelae of streptococcal infection.(2)  Logically, if there was a quantifiable risk of complications related to reduced antibiotic prescribing, we would all have to justify each decision not to prescribe.  As previously mentioned, there is no reliable discriminator, so shouldn’t we be hearing from the public health authorities that we need to be more proactive in our antibiotic prescribing.  That’s not the message we are getting at all.  Why?  Because prescribing antibiotics for sore throats and sore ears in children (in a country with a low prevalence of complications such as rheumatic fever) is not part of a strategy for prevention of secondary infection, invasive infection, sepsis or any other complication.(3)

Should we be giving antibiotics to control symptoms?  Let’s look at that as a reason to prescribe antibiotics.  What are the facts?

• The odds of antibiotics helping the symptoms of any one child are low.  The actual number varies by age, study and whether we are talking about ear or throat symptoms but they are all in the same region.  The odds of benefit are in the region of 10-20%.  
• Decision tools such as Centor and FeverPain are designed to improve the odds that antibiotics will help symptoms but there are  major problems with these aids.  Firstly, they are not validated in the younger children who account most of the presentations of sore ears and sore throats.  Secondly, these tools imply a binary outcome.  If you score above a certain number, antibiotics will help right?  Wrong.  A high score means slightly less awful odds that antibiotics will help.  Again, that is only validated if your patient is an older child. (4,5)
• Rapid antigen testing has been validated as a way of reducing antibiotic prescribing but has not been shown to have a high sensitivity from the point of view of directing treatment to where it is effective.  These two things are very different. (6)
• There is a significant harm done by antibiotics in children.  Depending on the antibiotic and the study, the odds of making a child unwell (vomiting, abdominal pain, diarrhoea) with an antibiotic is 5-10%.  

So where have we heard 10% before.  Wasn’t it something to do with odds of benefit?  What would a statistician say if they looked at the odds of benefit and the odds of harm and saw that they overlapped.  In all truthfulness I couldn’t stay awake for the full answer but the gist was that there’s not a lot of point in such a treatment being used as a way to manage symptoms.

Finally, here are two things that make a nonsense of the whole question.

1. Children often refuse the antibiotics we give them.  Phenoxymethyl penicillin in particular is disgusting and children tend to be quite discerning in their medicine preferences.  Often the outcome of a difficult decision over whether to give antibiotics is later made meaningless as the child decides for all involved that the antibiotics are not going to happen.  The parent, remembering that it was a choice rather than a must-do usually gives up the fight.
2. The issue of antibiotics for tonsillitis and otitis media fails an important test: Snelson's Safeguarding Test.  It goes like this:  A parent brings a 2 year old to you with a fever and a cough.  You see exudate on the tonsils and are about to prescribe penicillin.  The parent says that they prefer not to treat their child with antibiotics.  You have confidently ruled out sepsis, meningitis and pneumonia.  What are you going to do? Get a court order to force the parent to give the antibiotics?  Refer the child to social services?  I don't think so.

So if the parents and the child are allowed to refuse antibiotics for sore throats and ears, how important can they be?  We wouldn't allow these barriers to get in the way if the child's life was at risk or even if the child was going to suffer as a result of non-treatment.  This way of looking at it is a good way of identifying the children who should be having antibiotics:

• Children with severe symptoms despite maximal analgesia
• Children with complications of URTI (such as infected lymph nodes)
• Scarlet fever (typical rash and oral inflammation alongside pharyngitis/tonsillitis and febrile illness) implies a more pathological strain of steptococcal infection
• Children with prolonged symptoms e.g. no signs of improvement after five days of illness

So next time you see a child with URTI, ask yourself, could I insist that this child should have antibiotics?  If not, save yourself a decision.  You know it makes sense.  All we have to do is convince the parents that this is the right thing to do.  (more on that very soon)

Edward Snelson
Vacilatologist
@sailordoctor

Disclaimer: I was replaced by a robot three years ago.

References

1. Morton P. Should we treat strep throat with antibiotics? Canadian Family Physician. 2007;53(8):1299.
2. Kvaerner KJ, Bentdal Y, Karevold G., Acute mastoiditis in Norway: no evidence for an increase, Int J Pediatr Otorhinolaryngol. 2007 Oct;71(10):1579-83. Epub 2007 Aug 20.
3. NICE, Sore Throat (acute): Antimicrobial Prescribing, NG84, January 2018
4. Little Paul, Hobbs F D Richard, Moore Michael, Mant David, Williamson Ian, McNulty Cliodna et al. Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management) BMJ 2013; 347 :f5806
5. Roggen I, van Berlaer G, Gordts F, et al Centor criteria in children in a paediatric emergency department: for what it is worth BMJ Open 2013;3:e002712. doi: 10.1136/bmjopen-2013-002712
6. Little Paul, Hobbs F D Richard, Moore Michael, Mant David, Williamson Ian, McNulty Cliodna et al. Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management) BMJ 2013; 347 :f5806

Paediatrics is Not a Specialty - top tips for working with young people

Paediatrics is difficult to define as a specialty.  At one point the RCPCH talked about “doctors who look at specific health issues, diseases and disorders related to stages of growth and development.”  Now the RCPCH careers site has a very different note stating, "Whether a paediatrician, GP, children's nurse or pharmacist, our job is to help babies, children and young people thrive." I'm guessing that the RCPCH realised that it wasn't just doctors and it certainly wasn't just paediatricians who fitted the original description.

In fact paediatrics may not be a specialty at all.  It could be defined as the art of treating children differently from adults by knowing what diseases affect them, how they respond to illness and how to use that knowledge to help them during their illness or prevent them from becoming ill.

Anyone who works with children in a healthcare setting should study of the art of paediatrics.  We all need to develop our skills in assessing and treating ill children as well as becoming experts in all the other aspects of child health including safeguarding, growth and development.  Children and young people are different in so many ways and it takes a bit of effort to get good at working with them but it is completely worth it.

What is different about children and young people that requires a different approach and different skills?

Children respond differently to illness - Physiological changes can be dramatic in uncomplicated viral illness making the recognition of complicated infection difficult
Children may not localise, report or recognise symptoms - This is why constipation and UTI are often only diagnosed when they have been prolonged.
Children often present with something normal - This often happens because an adult is concerned and doesn't know that the symptom is normal.  One example is knock knees in children.
The overall likelihood of significant pathology is low - Much of paediatrics is about diagnosing normality or at least that the illness is uncomplicated and does not require medical intervention.  The other side of this coin is that the routine nature of a good outcome can lead to complacency and impairs our awareness of complications and significant pathology.
Children are vulnerable - As well as the safeguarding element of caring for children and young people, we have to consider how difficult it is for them to feel safe in a healthcare setting.  It is confusing and intimidating and it is too easy to forget to keep the child at the centre of the process.
There is a lot of uncertainty that goes with the assessment of children - paediatrics is often compared to veterinary medicine because we end up relying more on what we see.  It is fairly usual to find that we can't get specific symptoms and that our ability to examine is limited by the child's interaction.

Last week, I went onto TwitFace and asked the people who were online what their top tips are for working with children an young people.  What follows is based on some of the great responses I recieved.

Starting with the general advice:

There were also loads of tips for examining children:

I haven't been able to include everything and in some cases there were recurring themes which I have categorised together.  There were quite a few specific things that people have found to be useful in paediatric examination, some of which are listed here:

• The guess what's in the tummy game.  I have a high success rate with guessing sausages.  However you go about it I would highly recommend this approach to abdominal examination.  It's probably quite scary for a child to have a stranger press their tummy, but if it's a game that seems to be a different matter.
• For assessing gait, get the child to walk towards their parent rather than away from them.
• For ENT examination:  Tell the child: "I have a magic fairy/dragon detector (ear thermometer) that goes beep when a fairy is in the room. If it beeps I have to check their ears and throat with my magic torch to make sure it isn’t hiding in there."  I have to try that one.
• For respiratory exam, ask them to blow out the candles on an imaginary birthday cake.

One place even had a departmental rabbit.  I can imagine that would work to settle many an otherwise inconsolable child!

Paediatrics may not be a specialty but it is an art.  How you approach that art is up to you but whichever you go about it the end result should be the same:  The child will get the best care possible and you might be having some fun at the same time.

Edward Snelson
Possibly not a Paediatrician
@sailordoctor

Disclaimer - All the views expressed here are solely those of the author.  Any references to Royal Colleges are entirely fictional and should not be used as a reason to revoke the author's invitation to the annual RCPCH cheese night.

Acknowledgements: Thank you to all the people who shared their tips and tricks via social media or face to face.  More importantly, thank you to all the children who put up with us while we figure out how to do the whole paediatric examination thing.  Your patience and tolerance is appreciated.

Assessing Pain in Children - How Green Was Your Valley?

What is the best approach the assessment of pain in a child?  That is a big can of worms.  We want to understand the pain so that we can treat both the pain and the underlying cause but much of what we do comes from adult practice.  Rethinking our approach requires an understanding of what pain is to a child.  Pain is a very different thing for a child and so our approach must also be different.

Pain is an abstract thing, and the younger the child, the less abstract their thinking is. 

The internet has plenty of comical examples of things that children have written or said that are reminiscent of the story of the Emperor’s New Clothes.  In fact one of the most endearing things about children is the way that they often combine straight talking with unspeakable truths.  The ability to think abstractly and interpret what someone means (rather than what they are saying) develops as children grow.  We tend to develop what is needed for these situations based on experience of past events. To give you an example of adult thinking, I give you this excerpt, involving a word game, taken from a radio comedy with Benedict Cumberbatch and Roger Allam.  I think that this is a great example of how adults use words in bizarre ways and still manage to make sense.

Why does this word play make sense to any of us?  Years of having our minds messed with is the only answer that I can suggest.  Expressing feelings like pain relies on similar processes to that of understanding complicated jokes.

In order to account for these difficulties, some people adopt a standardised approach that allows children to choose how they express the magnitude of their pain.  I carry a card with the Wong-Baker faces (pictures of faces that go from smiley to sad)  and, if appropriate, ask the child to use the faces, words or numbers to say how bad their pain is.  My experience is that even this seemingly child friendly approach gives us the illusion that we are getting a meaningful answer because I am effectively speaking a different language.

When we are asking children about pain, how can we expect them to respond if they have not experienced that feeling before and lack the ability to describe it?  Imagine a nine year old presenting with abdominal pain.  All of the following questions are commonly asked of children in that assessment.  The responses are all real as well.  What I have taken the liberty to add is the internal response (I) that the child is having in their head.

Q. What does your pain feel like?  Is it sharp, burning, aching or colicky?

I. It feels bad.  Burning feels bad.  May be that’s the right answer. Someone called it tummy ache.  That must be it.  Aching.  If I say aching, the doctor will stop looking at me like that.

A. Aching I guess

Q. Does your pain come and go?

I. It hurts now.  It hurt yesterday. I’m not sure what the doctor means.  Why is the doctor still looking at me?

A. (Shoulder shrug)

Q. How bad is your pain? We use these numbers and faces here to help you chose an answer. (Shows Wong Baker Faces scale)

I. What is with all these questions?  Bad is bad.  My tummy hurts and it feels bad.  That’s not one of the choices on the list.  ‘Hurts more’ is there though and my tummy has definitely got worse while I’ve been sat here.

A. Points to ‘Hurts a lot more’ (6/10 on Wong Baker scale)

So what should we be doing?  I am not saying that questions or pain assessment tools are unhelpful, just that they should not be applied unthinkingly.  The trouble is that the child wants to give you an answer.  I think that sometimes they want to give an answer so much that they might give one for the sake of giving an answer. I think that there are two simple things that do work really well with children.

1. Just ask them what their pain is like.  A nice open question will tell you one of two things.  Either the child will describe their pain in a way that makes sense to them or they will make it obvious that they don’t really understand how to describe their pain.  Having no answer is better than a forced answer.  If they seem able to begin to describe their pain, you can progress to more closed questions and a scoring system perhaps.

2. Look at how they are behaving.  A significant tummy pain will usually manifest itself in some way in the child’s posture, activity or interaction.  A child who walks in and plays but says they have severe pain may be proving my point about understanding and describing pain.

Next time you see a child and want to know about their pain.  Ask them in a way that allows them to say what they want to say, in the way that they want to say it.

Edward Snelson
@sailordoctor

Reference
John Finnemore, Cabin Pressure, BBC Radio Comedy

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

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

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

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

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

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

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

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

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

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

Edward Snelson
@sailordoctor

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

References

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

Fairy logic - how to avoid the understanding gap

I recently realised that my medical advice is not as good as it could be.  I tell parents and young people what will help their treatment have the maximum chance of success, but I do so without always thinking about how the advice might fall into an understanding gap.  From now on I am going to try to apply fairy logic whenever I give my explanation of what to do next.

Fairy logic?  Let me explain: In popular mythology, fairies are often need permission from people to do things.  As a result they look for opportunities to interpret what is said to them in inventive ways.  For example if a fairy wants to enter your abode, they need permission.  If they are told, "You can't come in my house" they may see the loophole and go into the garage instead.  In consultations, I think that this misunderstanding of convenience happens often, albeit unintentionally.

For example, with eczema treatment, I will advise that soap should be avoided.  I should probably include shampoo and shower gel in that to avoid misinterpretation.

Other examples include

• "Stopping milk" when cow's milk protein allergy is suspected (should be stopping milk and anything containing milk, milk products like cheese or having these as an ingredient)
• "Smoking in the house is associated with chest problems in children" (should be that having a smoker who lives in the house is associated with chest problems in children.  Avoiding smoking in the house and car is good, but quitting is better.)

I know that time is at a premium when there are lots of patients to be seen.  However to avoid that misinterpretation you have to be specific and be comprehensive.  If you have examples of circumstances which benefit from this, why not post them in the comments section?  I suspect that there will be plenty of times that I am not aware of when I need to apply fairy logic to avoid the gap.

Edward Snelson
@sailordoctor

Disclaimer: I am largely basing my knowledge of fairies and their way of thinking on the writings of Eoin Colfer, but I'm not even sure he's ever really met a fairy.