Time for Child Advocacy - 10 things to keep kids safe

Don't you love it when someone brands something that you've always been doing?  Advocacy is nothing new, but by making a big deal of it, we are all prompted to think about how we can do more of it and do it better.  Every consultation involving a child or young person will tend to include a bit of advocacy.  I am doing it every time I tell a parent that when their febrile child is refusing to drink, that usually means that they are in pain.  Parents sometimes think that paracetamol and Ibuprofen are just for reducing fever.  Part of my job is to put analgesia on the agenda.  It is the perfect time to do it because this is when the parents want their child to feel as well as possible.

Similarly, the impact of safety advice is greatest following an injury.  So when a child or young person comes to me with a mishap, I try to work a bit of prevention in alongside the cure.

Injury is the leading cause of death in children over the age of one in the UK. (1)  So, while we worry about sepsis and meningitis, preventing injury may be the real battleground.  Injury is inherently preventable, as demonstrated by the massive difference between rates in different countries.  It is not just lethal injury that is important.  In fact, to the children themselves it is the debilitating injuries that really matter.  Missing a sporting event or the ability to swim just before a holiday is the end of the world.  Or at least it is when 'the future' is essentially the next month or so.

What I do is to try to throw in something relevant to the presentation.  Whether injury or ingestion, there are lots of ways that we can make the environments of children and young people safer.  Here are a few that are worth spreading the word about to parents and colleagues:

1. Warn parents of babies and toddlers about common choking hazards

Have you ever wondered why pen lids have a hole in the top?  Before that little innovation, these were common choking hazards.  Anything that fits neatly into the windpipe runs the risk of a fatal choking episode.  The list of dangerous things includes many food and playthings that parents readily give to their children.

I think that any household mishap is a good opportunity to warn parents about choking hazards.  Prevention can include avoidance.  Supervision is also great but only if you know what to do, and with choking, prevention really is better than cure.

2. Make sure that children can't get hold of button batteries

If you were not aware of this, button batteries are incredibly dangerous to children.  There is a misunderstanding about these miniature killers.  It is not the contents leaking that are dangerous, it is the electrical current which forms corrosive chemicals outside of the battery.  Button batteries have become more powerful, in order to meet the demands of today's toys and gadgets.  When swallowed, the current may burn a hole in the gut (usually the oesophagus) and bleeding can be fatal.  A swallowed button battery needs to be located as an emergency in case it is stuck, as these carry the highest risk.

I find that many parents don't know about this, so I often mention it when a child has swallowed something concerning but less harmful, like a diamond ring.

3. Make sure that liquid gel detergent capsules are kept away from children

Ask any ophthalmologist what common household item is most dangerous to children's eyes and I am willing to bet that they say liquid gel detergent capsules.  Why?  They are the perfect thing to cause massive damage.  Firstly, they look very appealing to a child.  They are brightly coloured and a bit like something that might be good to eat.  If bitten into, the contents come out under pressure, so the eye has no time to protect itself from the contents.  The contents themselves are a highly concentrated alkali which will burn and dissolve the thin layers of the eyeball.  While the industry has made some moves to warn people to keep these away from children, such messages can be interpreted as a standard bit of advice, which does no justice to the fact that these capsules are far more dangerous than the standard bottles or boxes of detergents.

So when a child has had a mishap with another item, I like to warn parents about other things that they may not have thought about.

4. Recommend that all children with a bike wear a bike helmet.

Heads injuries are the most common cause of fatal injury in children.  Bikes are great fun and a good way for children to keep fit.  Unfortunately, injury is all about physics.  I have yet to see a child run into something and have a significant head injury.  Bicycles however, allow a young person to gain enough momentum to do real damage even if another vehicle is not involved.  While it can be difficult to persuade young people to wear helmets, they are the must have accessory for anyone who likes their brain or their face.  Road rash on the face is not a good look and helmets do a decent job of protecting the face from being badly grazed in a fall from a bike.

I emphasise the facial injury as much as the head injury prevention as it often means more to the young person involved.

5. Advise a bit of trampoline safety

Trampolines are a favourite for all ages.  They are also one of the biggest sources of injuries that come into children's emergency departments.  While I am not suggesting that trampolines should be avoided, the risk of broken bones can be minimised.  One of the common factors in many of the worst trampolining injuries that I have seen is that there has been another person involved.  The worst injuries tend to occur when a small child is on the trampoline with an older child.  I would recommend that younger children in particular should never have someone larger than them on the trampoline.  Ideally, they should be on the trampoline alone, with onlookers cheering them on.

6. Make sure that parents lock up medicines

Medication packaging always has on it 'keep out of reach of children.'  What this fails to take into account is the incredible resourcefulness of children who may seem to small to get up to cupboards or high shelves.  I can tell you from experience that nowhere is safe.  The only completely safe place for a medicine is in a locked cupboard or box.  Nor can you rely on 'child proof' containers to prevent accidental poisoning.  Child proof containers seem to be adult proof (It can't be just me that struggles with the tops) while children who have time on their hands always seem to get them open in the end.

7. Know about the surprise household poison - plug in air fresheners

Many plug in air fresheners contain essential oils.  These chemicals are potentially incredibly poisonous due to their ability to dissolve into brain tissue.  Parents are frequently surprised by this fact so it is well worth letting people know about this dangerous household item.  People are also surprised by the ability of toddlers to drink the contents of these plug ins if they get hold of them.  I don't know how they do it.  And why won't they eat their vegetables???

8. Warn parents to beware of the sun

When the sun comes out and children quite rightly make the most of it, we often end up seeing children with quite severe sunburn.  Babies are especially at risk due to their thin skin and lack of protection from the sun.  Make sure that people know that children can get deep burns from the sun and that prevention is key.  Children are also vulnerable to the dangers of overheating so hydration and sun avoidance are important when the sun is out.

9.  Remind adolescents to respect water

It is great that young people use the opportunity of time off school to go and have a bit of an adventure.  One way that this sometimes goes very wrong is when water is involved.  Getting into trouble in water is all too easy.  The simplest way to avoid the danger is to make sure that all swimming is done in appropriate areas.  Tempting though it is to jump into a reservoir or an abandoned quarry full of water, this is very high risk.

10.  A surprise danger – twilight

Now for the sciency bit…  Twilight is a very dangerous time for pedestrians and young people are already very much at risk due to their lack of perceived mortality.  Why is it dangerous when the sun rises and sets?  The answer is probably due to a little known chemical (found in the eye) called rhodopsin.  This is the chemical that enables the eye to adjust to lower levels of light.  The trouble is that it takes many minutes to produce the chemical and only seconds for a flash of light to get rid of it completely.  As a result, drivers can have their ability to see reduced very suddenly by a moment of setting or rising sun, allowing a person in the shadows to become almost invisible. (3)

It is important to teach young people road safety, but also to let them know that at certain times of day, drivers may not see them at all.

We're already making every consultation matter.  Giving parents a little suggestion every now and then about how to make their child's environment a bit safer is just another way of adding to the difference we already make.  Paediatrics is so rarely about preventative medicine but when a child has a mishap, we have a golden opportunity to discuss ways to avoid the next accident.

Edward Snelson
Chronic Avoider
@sailordoctor

FOAMed is free.  The clue is in the name.  That said, if anyone would like to celebrate their enjoyment of the free open access education provided by GPpaedsTips by helping children to receive the best possible care, I have set up a donation page where I am raising money for a new Sheffield Children's Hospital Emergency Department.  For more information about this or to donate, click on the link in the Just Giving logo:

References

1. RCPCH, "Why children die: death in infants, children and young people in the UK"
2. AAP, "Prevention of Choking Among Children", February 2010
3. http://uxblog.idvsolutions.com/2014/01/a-meta-portrait-of-earths-surface.html

Do something for you today - reduce a pulled elbow

At least once a day, I like to think I have just simply fixed something.  Since I am not very good at DIY, that means finding some other way to scratch the itch.  Reducing a pulled elbow is hugely satisfying and anyone can do it if they know when and how to do so.

Pulled elbow (also called nursemaid's elbow) is not a true dislocation of the elbow but rather a subluxation of the radial head within the annular ligament of the elbow.

Based on empirical evidence, a pulled elbow hurts.  Additionally, there is often a second victim: the person who was involved in causing the pulled elbow (although there isn't always another person involved).  In fact, I was once hugged by a grateful relative after I reduced a child's pulled elbow.  What they don't know is that I already wanted to hug them for bringing me the elbow to fix.

Whatever specialty you work in, there are times when too much of what you do is intangible.  Sometimes I can see patient after patient and despite pouring my heart and soul into what I do, I don't get the feeling that I have really made anyone better.  These days are when I need a pulled elbow to shake that feeling off.  If you ever get the chance, I highly recommend doing it.  It is a fairly easy thing to do and, as I discovered recently, there are so many ways to do it.


When to attempt reduction of a pulled elbow

Before discussing technique, knowing how to do it isn't nearly as important as knowing when to do it.  There are some things that need to be considered before attempting a reduction.  Anyone can fix a pulled elbow, as long as they ask the right questions beforehand.

Is the child the right age?  There is bound to be a bell shaped curve for the age at which a child can get a pulled elbow. I would be sceptical about that diagnosis from the age of five up.

Does the mechanism fit with a pulled elbow?  Typical mechanisms include toddlers being swung around by fun uncles, toddlers being grabbed to keep them from running into the road etc.  A fall from a height is not likely to be a pulled elbow.

Are there signs that are inconsistent with a pulled elbow?  With distraction (not the anatomical kind), have a gentle feel of the elbow.  There shouldn't be any swelling.  There may be tenderness at the radial head but not in the distal humerus.  Feel all of the limb from the clavicle to the hand.  The two places that you are most likely to find point tenderness are the clavicle or the distal radius.

Often, children have had a previous episode.  If everything points towards a pulled elbow, there is no need to do an X-ray before attempting reduction.

How to reduce a pulled elbow

When I first did paediatric emergency medicine, I was taught to extend and supinate the elbow to reduce it.  That seemed to work most of the time.

Then, when I returned to work in a paediatric emergency department, I was told that flexing and pronating was better.  I have been doing it that way since then and it feels like it works more often.

 Of course the scientist in me is sceptical about the change.  Maybe something else affected  my success rate.  So what does the evidence say?  I was intrigued to find studies including other methods that I had not heard of, such as flexion with supination. (1)  I even found a Cochrane Review (2) which looked at the question.  It dodged the flexion vs extension question but concluded that pronation was probably successful more often than supination and possibly less painful.

So, I asked people on twitface which method they tend to use.

While finding it reassuring that two thirds of my colleagues were doing it 'my way', I was also interested to see that many will use a different method and that every possibility of twist and bend/ straighten is felt to be valid. 

I was pleased that nobody said anything about having to put firm pressure on the radial head.  I believe that all recommendations to do this are based in myth.  There is no logical reason why the radial head needs any guidance and I certainly don't press on the painful bit while applying my swift twist and bend.

I was also pleased that someone pointed out that if necessary, these can be left alone to resolve.  They always do, although it might take a day or two to finally slip back into place, during which time there will be discomfort.  I would still advocate reduction as success means that the resolution of pain is pretty much immediate.

Which brings me back to my original point.  How you do it is very much secondary to when you do it.  So, instead of worrying about technique, when the time is right, do something for you and fix a pulled elbow.

Edward Snelson
Notanosteopath
@sailordoctor

Disclaimer - I say that there are lots of methods, but my way is the right way.

For general principles of assessing children's injuries, follow this link.

References

1. Macias CG et al, A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations, Pediatrics. 1998 Jul;102(1):e10
2. Krul M et Al, Manipulative interventions for reducing pulled elbow in young children, Cochrane Library

Minor injuries - three questions that will determine what to do every time (Easter Egg - Finger injuries)

What is a minor injury?  What is minor to you or to me may not be minor to the child or parent.  Many a time I have been surprised by how pleased a child is to need a cast, or how distressed they are to be given a splint or dressing that needs to be kept dry.  I seem to ruin many a trip to Skeg Vegas in this way.

So, since our opinion seems unimportant, we must ask the important questions.  There are only three:

Lets try these questions on an injured finger.  Jacinda has injured a couple of fingers when they were hyperextended (bent back) by a basketball.

Question 1 - Does it need to be fixed?

Fingers are quite good in this respect because they are easy to inspect and (most) people have a finger on the other side to compare to.  So we allow the finger to fall as it is and see how it aligns with the other fingers.  If a finger is angulated or rotated it will need to be fixed.

Fingers should look well aligned when relaxed.

If there is an apparent angulation or rotation, this needs to be corrected before the fracture sets otherwise there may be a long term functional defect.

Question 2 - Might there be a sneaky injury?

That is very unlikely, but then that is what is so sneaky about sneaky injuries.  They come too rarely for us to expect them.  In fingers, there are three possibilities.

Possibility one is a flexor tendon rupture.  All we need to do to check for this is check flexion twice.  The first time is a simple flexion to test the deep flexor tendon (FDS) and the second is with the other fingers held in extension by the examiner.  This inactivates the deep flexor tendon  so that the superficial tendon (FDS) can be tested.

Possibility two is an extensor tendon rupture.  This is essential to detect and easy to test for.  The finger must be extended against the examiner's finger in order to exclude the 'mallet finger' injury.

Possibility three is a collateral ligament rupture. Gentle lateral force will detect any instability of the interphalangeal joints.

Question 3 - Does it need to be immobilised?

Jacinda's finger wasn't bent or twisted on examination.  Nothing was ruptured.  It just hurts.  It may even have a fracture.  The question remains, can and should it be immobilised?

The figure below, from Elselvier Journals "Isolated finger injuries in children — incidence and aetiology" shows that fingertips are the most common finger injury in children.

The thing about fingertips is that you can't really immobilise them and they don't really need it.  The fibrous sheath does that job for you.  You can immobilise the distal interphalangeal joint if needed but in doing so you will put pressure on the fingertip.  So, immobilisation can make pain worse as well as better.  Each injury is judged on its own merits.

Immobilisation can also make things worse by making things stiff.  Taking an extreme example, when someone comes out of a cast after a month or more- their joint is so stiff that it may not move at all.  If immobilisation is not needed, it is best to avoid making things worse.

More on that story in a later post.

Finally, one of the most easily treated finger injuries.  As per the above research, finger tips are often injured.  One common problem is the subungual haematoma.  Because nailbeds are sensitive, the pressure of a collection of blood trapped under a finger nail is very painful.

A hole made in the middle of the nail overlying the haematoma will relieve that pressure and reduce the pain considerably.  This can be done with a special tool but if you are patient, a standard needle also gets there in the end.

Many thanks to the hand models for consenting to their fingers to be photographed in the name of science. So, go ahead and treat a finger.  All you have to do is answer three questions.

Edward Snelson
@sailordoctor
Southwest Sheffield Thumb War Champion 1994

Disclaimer: All rights reserved on images in this post.  Feel free to post your reservations.

Reference
N.V Doraiswamy, Isolated finger injuries in children — incidence and aetiology, Injury

You might also like to read about the general principles of treating (and not treating) minor injuries in children.

Kids get hit in the head a lot

A few weeks ago, I wrote about some general principles for assessing minor injuries in children.  I promised to follow this up with posts about specific injuries and instead wrote about some other nonsense.  But then I do get hit in the head a lot.

Head injury is the most common type of minor trauma presentation in children.  This is not just because they bump their heads easily.  It is also because there is a fear that there will be more significant consequences from that injury.  Because the head contains the brain, there is a concern that there may be some internal damage that cannot be seen.  This anxiety is obvious in the parents but is also often there in the clinician.  We therefore need to know when to worry and when not to, otherwise too many children have unnecessary time spent in emergency departments or worse still, have unnecessary investigations.  The good news is that anxiety is often unnecessary.

Thanks to much research on the subject, there is a lot known about what is likely to indicate a significant head injury.  As a result, those working on the front line have good evidence to back up a clinical, common sense approach to assessing children following a head injury.

Firstly, let me remind clinicians of the ‘special patient’ rule, since that is either absent or poorly emphasised in most guidelines.

For the rest, there are two main questions to be asked:

• What happened at the time of the injury?
• How is the child now?

The ‘what happened?’ question is about two things.  Firstly, what was the mechanism?  The amount of force delivered and the way that it was delivered are both important.  If a child falls 8m and lands on a snow drift, they might be OK.  If they fall out of a ground floor window onto a hard surface they will still probably be OK.  If they fall 5m out of a window head first onto a rock, then they have a good chance of a skull fracture.  Mechanism is especially useful in children who are more difficult to assess such as neonates.  A study published last year (2) found that "Infants, dropped from a carer's arms, those who fell from infant products, a window, wall or from an attic had the greatest chance of ICI (intracranial injury) or skull fracture."

The second part of ‘what happened?’ is the effect on the child.  The absence of red flags occurring immediately after the injury is very reassuring.

This is where things can become a little tricky.  History and examination of children following head injuries can be full of vague and uncertain information.  That is not a problem.  First of all find out what you can be sure of, and then decide about what to do with the rest.  Often, the certainties make the uncertainties irrelevant.

Note that it is not necessary to assume the worst.  Many injuries are not directly witnessed.  Even when they are, the information may be confused or unreliable.  That is fine.  I think that it all depends on how the child is when they present.  If they are back to normal, it is safe to take the approach of only counting definite loss of consciousness as having occurred.  Being briefly unrousable is probably too vague.  Similarly, if the child is confused or lethargic at presentation, there is no need to deliberate about whether there was or wasn’t enough vomiting to be called persistent.  The child’s condition now over-rules that speculation.

That brings us onto how the child is when they present for assessment.  This is the most important filter.  In most cases, a child will declare themselves fully fit.  A child who is back to being their normal self and shows interest in normal activities is telling you that their highest brain functions are normal.  You should take that as the gift that it is.

Again, there may be some uncertainties.  It is always difficult if the child is now tired or grumpy to be sure that they are back to normal.  If the mechanism was benign and there were no ‘at the time’ red flags, it is often possible to avoid over-caution even in these circumstances.  However, if there is uncertainty about a loss of consciousness and about how alert the child is, caution is probably wise.

But what about the lump?  This is the subject of one of the great paediatric myths.  Parents are always worried that a lump is a bad sign.  Of course in a baby, it is.  A growing skull has enough give so that soft tissue swellings are rare.  There just isn’t usually much energy transmitted to the soft tissue.

When a baby gets a swelling on their head after an injury this is often a haematoma.  The presumption is that this has been caused by skull fracture and the subsequent bleeding.  For this reason, a ‘boggy’ (squishy) swelling on a baby’s skull is a skull fracture until proven otherwise.  They may not even appear unwell since their open sutures allow the brain to avoid any pressure effects (initially).

In an older child, a swelling in a well child is not the same deal at all.  If a 12 year old gets a swelling on their head after a knock, but are otherwise well, they almost certainly have a soft tissue swelling.  It takes a lot of force to fracture the skull of a 12 year old and such injuries should flag themselves up in some other way than simply as a lump.

The NICE guidelines for head injury published in 2014 (2) made this distinction by specifying that it is the under one year old group for whom lumps on heads are a concern.

So, there are often uncertainties but these should rarely get in the way.  Children will present to many health care setting with head injuries and if they declare themselves well, it should not matter too much who or where you are.  What matters is that you have the skills to assess a child and evaluate what you see and hear.  If you hear and see nothing bad, then it really is as simple as that.  But don’t take my word for it.  I get hit in the head a lot.

Edward Snelson
PhD in age-specific phrenology
@sailordoctor

Disclaimer: If you’re uncertain about your uncertainties, it is probably best to send them my way so that I can be uncertain for you.  After all, that is my job.

References

1. P. Burrows et al, Head injury from falls in children younger than 6 years of age, Arch. Dis. Child. 2016;0:2016 archdischild-2015-308424v-archdischild-2015-308424
2. Head Injury: Assessment and Early Management, NICE, 2014

If it isn't broken

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

1.  Children injure themselves in different ways to adults

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

2.  Small children may not localise injuries well

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

3.  It is particularly desirable to avoid radiation in children

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

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

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

5.  Some children perceive and respond to pain differently.

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

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

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

7.  The injury should fit the mechanism

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

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

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

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

Edward Snelson
@sailordoctor

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

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

• Head injuries
• Finger injuries
• Pulled elbows