Trial by Inhaler - Bronchiolitis vs Viral Wheeze

With wheeze in children becoming a major presentation again, it feels like a good time to explore the issue of deciding whether a child has bronchiolitis or viral induced wheeze.  There are various way that people do this in practice.  Many stick to a strict 12 month cut off.  This method works reasonably well and is rarely problematic.  Bronchospasm is rare below this age and if it is going to be problematic under the age of 12 months, in my experience the infant is severely distressed and gets bronchodilators out of desperation rather than a diagnostic trial.

I have already explored a method of determining whether the pathology causing wheeze is predominantly wetness (bronchiolitis) or tightness (viral induced wheeze/ bronchospasm) by using age combined with the story.

Slow accumulation of moisture and mucous tends to cause worsening of symptoms over days whereas bronchospasm causes acute change over hours.  My opinion is that in the majority of cases, the age and the story will correlate.

Where the patient is in the overlap zone (e.g. 10-15 months old) and the story is clear (e.g. snotty/ coughing on Monday, struggling with feeds on Tuesday, noisy breathing on Wednesday and fast breathing on Thursday) then the story gives the diagnosis.  With age/ story correlation or where the age allows ambiguity but the story is clear, the diagnosis is made.

So what about simply trying an inhaler to see if it works?  This alternative approach to the age of overlap sounds straightforward and is reasonably common in practice, but is it logical?

A therapeutic trial works best when a clinical effect is guaranteed and unambiguous.  Neither of these things is true in this situation.  With viral wheeze, which should respond to salbutamol, clinically apparent response may require increased or repeated doses.  Bronchiolitis, which will not respond, is famous for mini-fluctuations in work of breathing.  This is caused by mucous plugging or the clearing of secretions.

When you think of it in these terms, trying an inhaler doesn't meet the quality standards required of a valid test.

Trial by inhaler is also problematic due to human bias.  Uncertainty is fertile ground for biases to mislead us when an inhaler is given to make a diagnosis rather than as treatment.  It is better to use beta-agonists therapeutically where appropriate and to see non-response as a reason to reconsider a presumed diagnosis of viral wheeze.  If viral wheeze is the problem, we should not allow the lack of effect to refute the diagnosis.

Edward Snelson

@sailordoctor

Disclaimer - when I wrote this, I briefly thought that you could bring logic to medicine.  I know, right?!?

Ipratropium for infant wheeze - a Christmas stocking stuffer

On the run-up to Christmas, this site will be delivering some rather minimalist FOAMed.  Instead of comprehensive explanations, there will be some short but hopefully useful posts for you to enjoy.  Think of them like a stocking stuffer rather than your main present.  Perhaps you'll like this format even better.  [I will never forget the year that my children played more with one of their stocking stuffers than with their main present.  That stocking filler present was a whoopee cushion.]

Here it is:

That little caveat at the end is about the use of ipratropium as an additional agent in the treatment of severe/ life-threatening brochospasm due to viral wheeze.  In that scenario, it's still very much all about the salbutamol.

That's all folks.  If you wanted something bigger, you'll have to wait until we're opening the main Christmas presents, or you could read this post that goes into more detail about infant wheeze diagnosis.

I hope you're looking forward to your next stocking stuffer.

Edward Snelson

@sailordoctor

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

Should I prescribe antibiotics for a child with otitis media and discharge from eardrum rupture?

The answer to that question is much more complicated than most guidelines will lead you to believe.

The headline statement recommending the use of antibiotics in this scenario has buried the evidence in multiple layers of interpretation.  To get to the truth, we have to look at the lierature ferred to in the decision to make that recommendation.

Guideline writers put in huge amounts of work looking at all the available evidence and then turning that into simple statements.  When these recommendations are truly simple and make sense in clinical practice, we tend to just follow them.  In a recent Twitter poll of over 600 people, this was far from the case.

If over half of clincians would avoid treatment, that suggests that there is something about the recommendation that is misaligned with our front-line work.  When you deconstruct the recommendation, it becomes clear why that is.

First of all though, let’s look at simple otitis media without rupture of the eardrum (tympanic membrane).

Otitis media is a common childhood infection.  It starts off with a cold and then progresses to an infected middle ear.  It is important to be aware that neither ear pain nor a red tympanic membrane is diagnostic of otitis media.

• An inflamed tympanic membrane is a common finding in uncomplicated viral upper respiratory tract infections (URTI).  In such cases the tympanic membrane is red but not bulging.
• Ear pain (otalgia) may be caused by eustachian tube blockage even when there is no middle ear infection.  In these cases the tympanic membrane is typically retracted.
• A painful ear with a red bulging tympanic membrane is the usual presentation of otitis media.

The evidence for antibiotics being effective in the treatment of otitis media is pretty poor.  In a Cochrane review of this subject (1) it is reported that antibiotics have no effect on pain at 24 hrs and that you need to treat 16 children in order to see one of those children having less pain at 2-3 days.  In line with previous discussions re antibiotics, the same review noted that antibiotics had no effect on the rate of complications.  With a similar number of children being made unwell by the antibiotics, it is questionable what their role is at all in uncomplicated otitis media.

Many guidelines list exceptions to this rule.  One that often confuses clinicians is the scenario of the child who presents with a sudden onset of purulent discharge from the ear.  In these circumstances, there is often a recommendation to treat with antibiotics.

So where does this recommendation come from?  Peeling back the layers is quite interesting and what lies beneath the recommendation shows that it is far from a straightforward "must do" for antibiotics in children when the otitis media bursts the tympanic membrane.

Starting with a commonly cited recommendation, the NICE CKS for acute otitis media (2) states "...immediate antibiotic prescription could be considered in children... ...of any age with both AOM and ear discharge..."  The basis for this recommendation is cited as the aforementioned Cochrane Review (1).  This Review states "Antibiotics are most useful in children under two years of age with bilateral AOM, or with both AOM and otorrhoea. For most other children with mild disease in high-income countries, an expectant observational approach seems justified."

The Cochrane Review conclusion itself is based on a paper (3) that looked at the features that made it more likely that antibiotics would have an effect.  In the case of otitis media with otorrhoea, it found that the NNT improved to 3.  That sounds good, so why would most people avoid treating?

The answe is simple.  In the published evidence, the effect of antibiotics was still to do with symptom (mainly pain) improvement.  That is clinicaly important because in many cases pain is resolved when the discharge occurs.  Presumably this is because the pain was due to the stretching of the tympanic membrane rather than due to the inflammation of soft tissues.

If the pain is resolved, the NNT to treat becomes irrelevant.  How can you improve pain that has gone away? Even if there is still some discomfort, if this is controlled by analgesia, isn't that a better option than antibiotics?

Therefore, when a child presents with otorrhoea due to otitis media, rather than faithfully following a recommendation to give antibiotics, we consider the applicability to the child in front of us.  If the pain has gone or is easily controlled with analgesia, we can hold off.  The appearance of the discharge may be alarming but it is often the beginning of the end of the illness.

What about topical antibiotics?  These are also frequently recommended.  In answer to these recommendations I would point out that neither the NICE CKS nor the Cochrane review have recommended antibiotic ear drops for this clinical scenario.  In addition, there is BMJ paper (4) that states "Topical antibiotics are associated with fewer systemic side effects and a lower risk of antibiotic resistance than oral antibiotics, but there is no strong direct evidence to support their use in this condition."

So there you have it - the bottom line:

Once the recommendation to treat is deconstucted, it all makes sense.  In this case, it seems that taking it apart and looking inside reveals why most of us still don't give antibiotics when nasty green stuff starts pouring out of a child's ear.

Edward Snelson
Guideline Deconstrucivist
@sailordoctor

Disclaimer - One time I took a guideline apart and couldn't work out how to put it back together. It's still in my cellar.

References

1. Cochrane Database of Systematic Reviews Antibiotics for acute otitis media in children
2. Acute Otitis Media Clinical Knowledge Summary, NICE
3. Rovers M at al, Antibiotics for acute otitis media: a meta-analysis with individual patient data, The Lancet, Vol 368, Issue 9545, 21–27 October 2006, Pages 1429-1435
4. P Venekamp et al, Are topical antibiotics an alternative to oral antibiotics for children with acute otitis media and ear discharge?, BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i308

Should you give ibuprofen to a child on an empty stomach?

In the previous post, I gave some general principles about prescribing for children.  One person took the time to get in touch about the issue of ibuprofen on an empty stomach.  This is an interesting controversy and is an issue well worth understanding.

Ibuprofen is a useful medication when it comes to symptom control in the unwell child.  Studies on the benefits of ibuprofen when co-administered with paracetamol (acetaminofen) have tended to show that there is no additional benefit when it comes to controlling fever.  However, pyrexia is no longer generally thought to be the enemy and there is no clear indication to normalise an unwell child's temperature.  That doesn't mean that the child will not benefit from analgesia.  One of the issues with children who have upper respiratory tract infection (URTI) is that they are often reluctant to drink, either due to a general feeling of being unwell or due to the pain associated with trying to drink.  If paracetamol and ibuprofen have a clear role in managing the unwell child it is this: making the child feel comfortable and well is an important part of giving them the best possible chance to have good oral intake.  If fever is not the enemy then dehydration certainly is.  If an unwell child is refusing fluids and a combination of paracetamol and ibuprofen resolves that, why wouldn't you?

One of the anxieties that this situation causes is the fear that these are the very children at risk of the complications of ibuprofen.  Ibuprofen, being a non-steroidal anti-inflammatory drug (NSAID) is associated with renal impairment and gastrointestinal (GI) bleeding.  Should it then be avoided in children with poor oral intake?

First, let's look at the renal issue.  The short answer is that while renal impairment is a risk in dehydrated children (1), it is safe in children who are not dehydrated (2), even if at risk of dehydration.  If ibuprofen can potentially aid oral hydration, it seems safe to use, providing the child is not already showing signs of dehydration.  It is also worth noting that in the study reporting acute kidney injury (AKI) in children taking ibuprofen, all made a full recovery.

Second, the issue of GI bleeding.  Although case reports of children having GI bleeds during short term use of ibuprofen exist (3), these are associated with incorrect administration.  Significant GI complications of ibuprofen are associated with long term use, concomitant steroid use, known GI ulceration or coagulation defects (4).  Short term, correct use of ibuprofen in children without risk factors seems to be safe.

The way that ibuprofen risks GI complications is a systemic effect.  It reduces prostaglandin production, thereby reducing the natural protection of the gastric mucosa.  Although we are often told that ibuprofen should be taken with food to reduce GI side effects, there is a debate about whether this should be the case at all.

Advising that analgesia should be given with or after food delays the effect (5) of the pain-killers without clear benefit in terms of gastric protection.  It is unclear as to whether taking ibuprofen with food reduces side effects such as nausea but it shouldn't have an effect on the risk of GI bleeding. As one publication puts it: "Apart from providing unsubstantiated ‘safety’ information by advocating food intake with NSAIDs it may be more appropriate to advocate OTC NSAIDs be taken on a fasting stomach in order to achieve a rapid onset of action and hence avoid an ‘extra’ dose of the drug because the rapidity of pain relief did not meet the patient's expectations." (6)

The bottom line is that as long as a sensible clinical assessment has taken place, ibuprofen can be given to a child who has not eaten.  It may even be best practice.

Edward Snelson
Unintentionally inflammatory
@sailordoctor

Many thanks to Gina Johnson for her comment on the previous post.  Keep them coming! 

References

1. Balestracci A. et al, Ibuprofen-associated acute kidney injury in dehydrated children with acute gastroenteritis, Pediatr Nephrol. 2015 Oct;30(10):1873-8. doi: 10.1007/s00467-015-3105-7. 
2. Lesko SM, Mitchell AA, Renal function after short-term ibuprofen use in infants and children, Pediatrics. 1997 Dec;100(6):954-7
3. Mărginean, M et al, Ibuprofen, a Potential Cause of Acute Hemorrhagic Gastritis in Children - A Case Report, J Crit Care Med (Targu Mures). 2018 Oct; 4(4): 143–146
4. Berezin et al, Gastrointestinal Bleeding in Children Following Ingestion of Low-dose Ibuprofen, Journal of Pediatric Gastroenterology and Nutrition: April 2007 - Volume 44 - Issue 4 - p 506–508, doi: 10.1097/MPG.0b013e31802d4add
5. Moore R. et al, Effects of food on pharmacokinetics of immediate release oral formulations of aspirin, dipyrone, paracetamol and NSAIDs – a systematic review, Br J Clin Pharmacol. 2015 Sep; 80(3): 381–388.
6. Rainsford K, Bjarnason I, NSAIDs: take with food or after fasting?, J Pharm Pharmacol. 2012 Apr;64(4):465-9.

Prescribing for children - Top tips

Prescribing for children can be tricky. Getting the right medication, dose and formulation should make all the difference to the effectiveness of the treatment plan. Getting one of those wrong is all too easy.

What are the things that we need to know and tips for getting it right?  Here is a detailed list.  There's a shorter and more condensed list below this.

• Only use medication that has a clear indication.
• Prescribe a licensed medicine for a licensed indication where possible.
• Any reasons for prescribing an unlicensed medicine should be clearly and accurately documented.
• Don't give medication for the sake of doing something.
• Use a children's specific formulary.
• Children are less likely to recognise and associate side effects with their medication. This lack of insight by the child is another reason for being judicious about prescribing.
• Know the weight of the child. Even if doses are age banded, if the child is very large for their age you might choose to go up a little before their birthday.
• If there is a choice between age banded doses and weight defined doses, go by weight unless overweight for height.
• Most weight based doses have an upper limit (e.g. nebulised adrenaline), and this can be reached at an early age so always check what the maximum dose should be.
• When calculating a weight-based dose, check that it looks like a reasonable number.  Calculation errors with a factor of 10 are made all too easily. Don't just copy off the calculator onto the prescription.  Ask if it seems like a dose that makes sense compared with an adult dose.
• Use a syringe to give the medicine.  It is often better tolerated than a spoon, and the dose can be more accurately measured.  The correct dose can be marked onto the syringe.
• Use a formulation that the child will tolerate.
• If a child is sick less than 30 minutes from when medicine is administered, it is OK to repeat the dose as a one-off.
• Consider alternative routes.  Children with neurodisabilities often have problems with oral medication but may tolerate suppositories.
• If newly prescribed medicines are to be administered by PEG/NG/NJ tube discuss with a pharmacist to determine the safest formulation and any special administration requirements (e.g. the need to avoid a formulation that will interact with components of the tubing or the need to dilute the dose to avoid blocking the tube).
• There is almost always a non-pharmacological aspect to any treatment.  Make sure that this is completed either first or as well as the pharmacological treatment.  For example, a hot, miserable child in four layers of clothes doesn't just need antipyretics.  They also need to take all or most of their clothes off.
• Don't assume that a rash or other symptom is a drug allergy.  (Full post link here)
• Don't scale down inhaled salbutamol to the size of the child.  Children may need more sprays. Telling a parent to give one spray to a two year old will not be effective.  (There is science behind this - click here for a link to the full explanation.)
• Don't assume that medication that has been prescribed is the correct dose.  Children grow out of their dose and may no longer be receiving a therapeutic dose. Check the weight of the child and make sure that their long term medication is in the therapeutic range.

Let's consider a few scenarios.

Child 1

A 20-month-old boy sees you with a cough, runny nose and a fever for two days. The child hasn't eaten all day. The parent is giving regular paracetamol, but the temperature is still a concern to them. Examination shows a red bulging left ear drum.

What about antibiotics?

The natural course of otitis media is to begin resolving after about the third day of symptoms. A significant number of children experience side effects such as vomiting or diarrhoea from antibiotics such as amoxicillin. On balance, an antibiotic is unlikely to cause benefit, and the risk of side effects is similar in size so at day two of symptoms it is probably better to maximise symptom relief.

How do we improve symptom relief?

1 - Optimise the dose of paracetamol
It is often assumed that a child being given paracetamol is receiving a therapeutic dose, but this is not always the case. Often the child is being given too little for some possible reasons:

Human factors-
The parent is using a bottle that was prescribed some time ago.  The dose was correct at the time but is no longer adequate. The parent will assume the dose is correct because the bottle has the child's name on it.
The parent has given the medication in the expectation of a cure. After a few doses of paracetamol, when the symptoms return, they assume that the medication is not effective and stop using it.
The parent is using both paracetamol and ibuprofen and has assumed that to use both, the dose of each needs to be halved. As a result, the child is having sub-therapeutic doses of each medication.
The parent is simply being cautious for fear of overdosing the child.

Pharmacological factors-
The dose is based on age banding. Age banded doses for drugs with a narrow therapeutic index (such as paracetamol) have to err on the side of caution.  The weight of a 20-month-old child can vary hugely.  Paracetamol is ineffective below 10mg/kg, and the BNFc recommends a dose of 15-20mg/kg 4 hourly, up to four times a day for post-operative pain. Otitis media is painful. It's time to weigh the child.

The child weighs 14 kg. What dose should of paracetamol should they have?

If the parent is giving 120mg/dose as per age banded doses in the UK, the child is receiving 8.5mg/kg which is subtherapeutic. The weight of a 20-month-old boy can vary from 9 kg (9th centile) to 13 kg (91st centile) according to the WHO growth charts.  Paracetamol is fat soluble and so overweight children should not have a full mg/kg dose.  It is generally agreed that paracetamol should be given to children based on their ideal body weight.  How to achieve that is debatable, and guidelines vary.

Option A - The scientific way: Check the child's weight. If it is over the 91st centile, check their height.  Look at the growth chart to wee what height centile they are. Then check the growth chart for the corresponding weight on the centiles. For this child, if height was 88cm, that sits on the 91st centile. The corresponding ideal weight would be 13 kg.Use that to calculate a 15mg/kg paracetamol dose. In this case 200mg/dose.

Option B - Use clinical judgement. Does the child look to be an appropriate weight for their height? If so the prescribing based on the child's actual weight is reasonable. Does the child look overweight for their height? If so, prescribing on actual weight may result in overdosing. Use age banded doses or option A to be safe.

Supposing the dose of paracetamol is already therapeutic and being given regularly, what do we do then? What should the parent do if optimising the paracetamol dose doesn't work?

2 - Adding in ibuprofen

Sometimes, paracetamol on its own is not enough to control symptoms. Otitis media is often one of those times. This clinical scenario presents a common dilemma. We are told that ibuprofen should be given after food to minimise the risk of gastritis. On the other hand, the child who is in pain and feeling unwell is unlikely to eat and sometimes will refuse to drink.

It is common practice to give ibuprofen in this scenario for short periods (a few days). In children, gastric bleeding is usually associated with prolonged NSAID use. In this situation, ibuprofen is likely to improve oral intake. The practice of giving ibuprofen to children refusing to eat or drink is based on a balance of risks. The risk of GI side effects from the NSAIDs is felt to be outweighed by the risks of not analgesing, which would mean inadequate oral intake.  For a fuller explanation of when and how to give Ibuprofen to a fasting child, read this post.

What about a cough medicine?

There is no good evidence for or against the use of over the counter cough medicines in children. Codeine-based medicines are not an option, and the rest are unproven regarding efficacy. In the absence of good evidence of benefit, it is usually best to avoid medication in children who are unwell. It can be hard enough for the parents to manage to give the medication that is likely to relieve symptoms without adding one that is unlikely to do so.


Child 2 

An 18-month-old girl-year-old presents with wheeze and some increased work of breathing. She started with a runny nose three days ago. She looks happy and well. She is well hydrated. There is a mild subcostal recession and a wheeze that is heard throughout the chest. The parent says that this happened the previous month and they were given a salbutamol inhaler which they were told to give one puff of four times a day.

How do we treat the wheeze acutely?

In this age, the likelihood is that this is a viral wheeze - bronchospasm triggered by a viral infection. Bronchiolitis, which mainly affects the under one-year-olds, does not respond to beta-agonists while viral wheeze does. Salbutamol will only work if it is given in effective amounts. So, the best thing to do here is to confirm the diagnosis and optimise the treatment by giving 6-10 spays of salbutamol from a metered dose inhaler (MDI) via an age-appropriate spacer.

1 - Get the dose right.

Although for most paediatric treatments, doses are an appropriate fraction of an adult dose, salbutamol is an exception. The reasons are multiple and involve a bit of science. I've written a full explanation of why children need bigger doses of salbutamol when wheezy here. Most guidelines recommend 6-10 puffs repeated at 15-20 minute intervals to gain improvement and 4-6 puffs every four hours to maintain that reduced bronchospasm.

2 - Get the formulation right

It is tempting to use a nebuliser to treat infants and small children. They tend not to comply with spacers unless they are used to them, so a nebuliser feels like an easier option. There are several problems with that practice, however. One issue is that it sends a message to the parents that the inhaler is not the ideal treatment and so may make them ambivalent about using an MDI and spacer, preferring instead to come for a healthcare professional to give them the magic mask. Another problem is that people learn by watching and through demonstration. A parent watching an expert use the devices will help them to do it optimally at home. Better still, if someone talks through some top tips while it is given, they will benefit from the experience. Nebulised salbutamol is best used when oxygen is needed concurrently.

3 - Get the technique right

Learning good inhaler technique is a process of explanation, demonstration and practice.  It should never be assumed that inhalers are being given in an ideal manner unless we have checked.  I start my 6-10 puffs by getting the adult to do the first two sprays, followed by me doing the second two and then getting the adult to do the rest, demonstrating any suggestions I have made to do it differently.

4 - Confirming the treatment is appropriate

If the correct drug has been given in the correct amount in the best way, the child will respond. If the child has a clear improvement we have proven the diagnosis and that our treatment is effective. If there is no clear response or the child gets worse, we need to rethink. The two main possibilities are a wrong diagnosis or inadequate treatment. As a rule, with a wheezy child who has increased work of breathing despite initial treatment, we need to escalate our treatment (which may involve calling for help) and consider other diagnoses at the same time.

What about oral steroids?

This is a good case to demonstrate how important it is to keep up to date with the evidence (or to regularly read some FOAMed that does that for you!)  In the past it was fairly normal to give oral steroids to any wheezy child.  There is now good evidence to show that steroids have no role in treating bronchiolitis.  The evidence also suggests that steroids have no significant effect in wheezy children under the age of five.  Unless a child under the age of five has a diagnosis of possible asthma (made by a paediatrician), steroids are generally avoided.

What about antibiotics?

The child has signs of an infection and has a breathing problem, so the temptation is to give antibiotics to cover possible pneumonia.  There are several reasons not to do this. Firstly, a lower respiratory tract infection (LRTI) is very unlikely because the child has a wheeze. There is good evidence that wheezing is a strong negative predictor of LRTI. (1) This also makes sense clinically. Pneumonia causes systemic unwellness and significantly increased work of breathing. If a child has a consolidation in some of their lung and bronchospasm in the rest, you won't be thinking, "maybe I should prescribe oral antibiotics.." you'll be thinking, "let's get this child admitted." (Link to post on this subject here)

Child 3 

A parent brings a six year old child with a barking cough and noisy breathing. When you get to see them, they have visible breathing difficulties and loud stridor. They have a significant recession and look pale/ slightly blue.

What is the priority?

1 - Non-pharmacological management.

This child almost certainly has severe croup. Whatever the cause of the stridor, they have a critical airway. The first thing to do is remain calm. The flow of air through the narrow airway could be suddenly compromised by forcing a change in position of by upsetting the child. This is a perfect time to bring in the non-pharmacological first rule. You need to reassure the parent and keep the child comfortable and able to find their own position to maintain their airway.  Now call for help and get out some epinephrine and oxygen.

2 - Pharmacological management

If the child tolerates it, give 15 litres/minute of oxygen via a mask with a reservoir. Grab the epinephrine (adrenaline) vial (this might be from the anaphylaxis kit in a community setting). The BNFc gives a dose of 400 micrograms/kg. How much does the child weigh? You might have a recent weight but if not, the formula [(age plus 4) times 2] is pretty accurate up to the age of six and gives a rough weight which is all we need in an emergency. So 0.4mg x 20 kg gives us an epinephrine dose of 8mg. However, the maximum dose is 5 mg.  So that is 5mls of 1/1000 epinephrine. In the nebuliser, it goes and onto the face of the child. This will buy some time while help arrives. If there are a really good response and the child will tolerate it, give 150 micrograms/kg of dexamethasone orally.

So in summary: Don't panic, do give oxygen, estimate weight, calculate the dose of nebulised epinephrine, realise that dose exceeds maximum dose, give a maximum dose and remain calm while doing all of that.

While prescribing for children is different, all of the usual principles apply.  There are a few things that are particular to paediatric prescribing, and I hope this has helped by giving some general advice and specific examples.

Edward Snelson
@sailordoctor

Disclaimer:  If this post is rubbish it's not my fault.  I brought in subcontractors from Scotland's Pharmacy in Practice team in the form of  Stephen-Andrew Whyte and Johnathan Laird.  If you think the post is brilliant then I suppose I must give some credit.  (Seriously though, thanks for your input both of you.  It was much appreciated.  Thanks also to all the people who shared their top tips with me.)

References

1. Hirsch, A et al, Estimating Risk of Pneumonia in a Prospective Emergency Department Cohort, The Journal of Pediatrics , Volume 204 , 172 - 176.e1
2. British National Formulary for Children
3. Medicines for Children online resource

Opiates in children - we need to talk about codeine

Things have changed a lot with regards to opiods and children and young people over the past few years.  In 2013, the UK Medicines and Healthcare products Regulatory Agency (MRHA) recommended that codeine should no longer be used under the age of 12 years old (1).

To kick off 2019, The American Academy of Paediatrics has published an article regarding the opiod epidemic in young people (2).  These two things actually had nothing to do with each other.  The MHRA advice was about side effects and not about addiction.

What are we supposed to use instead of codeine?  Well, the seemingly contradictory answer that you may or may not have heard is (wait for it...) that we should instead use morphine to provide moderate pain relief to children.  That's not as crazy at it first sounds but it does require some explanation.  The explanation begins with a bit of pharmacology.  Then by adding a bit of physiology it all starts to make sense.

First the pharmacology:  Codeine is not itself the thing that produces the opiate effect.  Codeine is metabolised to various things, the most important of which is morphine.  Essentially, when you prescribe codeine, you are prescribing morphine via the metabolism of the liver.

Secondly the physiology.  The codeine-morphine metabolism that occurs in the liver varies in speed and completeness from person to person.  It is estimated that about 2% of the population are fast metabolisers.

The end result is that when someone takes codeine, there is a variable conversion to morphine.  The morphine which results and has a clinical effect is produced in amounts and over a time frame that varies from person to person.  While slightly less information exists about Dihydrocodeine, it is similar enough to codeine to make all of the above applicable.

Is this possibility of harm all just speculation?  There is some weak evidence that codeine may be to blame for some child deaths, mainly in use as an analgesia following tonsillectomy. (3)  It was these cases which prompted the ban on the use of codeine under the age of 12 in the UK.  Although there are plenty of reasons why the deaths reported here are not generalisable to all children requiring strong analgesia, a recurring theme is that children who died often had the fast metabolism gene.

Despite concerns and rulings, codeine is still used frequently in children. (4)  Now it seems that young people are choosing it themselves more and more. (2)

The good news is that opiates are rarely needed in children outside of a hospital setting.  If strong analgesia is required on a temporary basis, oral morphine is often prescribed where codeine would have once been given.  This paradoxical move has come about through better understanding of how opiods work and the effect they can have in children and certain patient groups.

We need to be wary of opiates and opiods in children.  These drugs definitely have an important place and we shouldn't hesitate to use them appropriately when acute analgesia is needed.  A good first choice option for oral strong analgesia is oral morphine, while for a more rapid onset, intranasal diamorphine works very well.

It seems that in the past we were lulled into thinking that codeine in particular was a soft and safe option.  The evidence of recent years has told us that in terms of prescription use and abuse, this is not the safe drug that it was thought to be.

Edward Snelson
@sailordoctor

1. April 2015 Monthly Newsletter,  Medicines and Healthcare products Regulatory Agency
2. Sharon Levy, Youth and the Opioid Epidemic, Pediatrics Jan 2019, e20182752; DOI: 10.1542/peds.2018-2752
3. Kelly, Lauren et al, More Codeine Fatalities After Tonsillectomy in North American Children, Pediatrics May 2012, 129 (5) e1343-e1347; DOI: 10.1542/peds.2011-2538
4. Chua KP, Shrime MG, Conti RM. Effect of FDA investigation on opioid prescribing to children after tonsillectomy/adenoidectomy. Pediatrics. 2017;140(6):e20171765.

The Practicalities of Croup Management in the Community

This post is in response to a very specific question from a local GP. The question wasn't about recognising croup or even about the best evidence based treatment.  Recognising croup is fairly straightforward. There is pretty much consensus on the best management of croup. The question was about the practicalities.

The evidence for the ideal management of croup has given us a fairly straightforward and reasonably robust answer: a single 0.15mg/kg dose of oral dexamethasone.  Sounds simple doesn't it?  The difficulty is that a single dose is actually quite problematic from a pharmacy point of view. As a result the decision isn't always about the best available evidence.  It might also be about the best available medication and formulation.  To determine the answer to this question, we need to go back a couple of steps.

Croup is a clinical presentation involving barking cough, with or without stridor and respiratory distress.  This usually occurs in a relatively well child, though they will have the symptoms of a viral upper respiratory tract infection.  Like so many presentations in childhood, the underlying cause is a viral illness but the problem is due to the effect or response to the virus.  In the case of croup, that effect is upper airway inflammation and swelling.

When should croup be treated?

Croup is usually classified into mild, moderate or severe.  This can be done with or without a croup score.  While it is a minor oversimplification of what happens next, the likelihood is that severe croup will be treated with steroids and often admitted to hospital while moderate croup will usually be treated with steroids and discharged home after a period of observation.

It is the management of mild croup which often generates the most discussion.  The first question is whether it should be treated at all.  There is evidence that treating mild croup with corticosteroids (1) reduces symptoms.  There is the suggestion that it is safer to treat mild croup in that there is a reduction in time spent in hospital and reduced readmission rate for those that are treated.  However there is no specific evidence that not treating mild croup leads to an increased risk of severe or life threatening croup.  This leads some clinicians to the conclusion that if a child has a barking cough but no stridor or respiratory distress, they prefer to provide safety-netting advice and reassess if the child develops new signs.

How should croup be treated?

There is also evidence regarding the most effective steroid treatment for croup in children.  Oral dexamethasone outperforms oral prednisolone.  Both oral treatments outperform nebulised budesonide.  The suspicion is that dexamethasone outperforms prednisolone because it is better tolerated.  It's difficult for a medication to be effective if it's just been puked onto the floor.

If that's all so well evidence based, what's the problem?  Lets's get on with giving them all dexamethasone 0.15mg/kg. The problem with this is that is that dexamethasone liquid has done itself out of a job.

Dexamethasone is given as a single dose in the vast majority of cases.  The evidence shows that this works well, quickly (2) and with an effect which is sustained over several days.  It is quite potent, so small doses are effective.  These factors, combined with an unpredictable demand and a relatively short shelf life make dexamethasone liquid something that doesn't make business sense for pharmacies to stock.

I recently asked the twitter community about what they had available and while many did have dexamethasone liquid, it certainly wasn't routinely available.  The question also sparked a smattering of stories from people who had been sent from place to place looking for one that had some dexamethasone available.

This then presents a dilemma for the clinician in the community.  Do you prescribe the best tolerated and most effective treatment and take the risk that it will be unavailable?  Do you prescribe an alternative (soluble prednisolone) that is known to be slightly less effective and less well tolerated on the grounds that a medication can only be effective if it's actually been given?

There is also an opportunity to be proactive about the issue.  You could get a member of your team to contact the local pharmacies and ask if any of them do stock liquid dexamethasone.  If not, perhaps one would in which case they would be where you sent your children with croup for their treatment.

On a larger scale, primary care groups (e.g. Clinical commissioning groups in the UK) could coordinate something so that each locality has a pharmacy that stocks liquid dexamethasone.

Another way of looking at it is that there is a vicious cycle to break.  Because dexamethasone is not always available, not everyone provides it.  Because it is not prescribed often enough, it is not always stocked by pharmacists.  More prescribing of dexamethasone should make it more likely that dexamethasone will be stocked.

It is possible that liquid dexamethasone will become a more commonly prescribed medication since it has recently been suggested that it is as effective as prednisolone for childhood wheeze. (3)

What about age banding and using soluble dexamethasone?

Dexamethasone has a large therapeutic window.  The current recommended dose of 0.15mg/kg is a quarter of the dose of 0.6mg/kg which was previously the most often used dose.

This is good because age banding doses is very difficult.  A four year old can be anything from 13-22kg based on the 9th-91st centiles of the WHO growth charts.  Knowing the age is therefore nowhere near as good as having an actual weight.  Obtaining a child's weight does not require any special equipment.  If a child will not stand on a set of scales, simply weigh an adult carrying the child and without holding the child.  The difference is the child's weight.

If using Using the 9th-91st weight centiles and aiming for a dose of 0.15-0.3mg/kg gives the following results:

The ideal is definitely to have a weight and to have a liquid suspension available that would allow the precise dose of 0.15mg/kg to be given.  However, when thinking about a plan B, it seems a shame to go to Prednisolone which is known to be less effective, has more side effects and can only be given in aliquots of 5mg.  Why not do the same with dexamethasone, even if it does mean that the dose may be over in some cases?  Again, the therapeutic window of dexamethasone allows this to be possible.

Although liquid dexamethasone is not always on the shelves of the local pharmacy, it probably should be and possibly would be if it was more often used and the pharmacist knew that the bottle would get used.

Edward Snelson

Pharmacoeconomist of the year 2020

@sailordoctor

Disclaimer - If treatments are better but do not make sense financially, children should have to pay for that themselves.  If necessary, there are some coal mines near me that could be reopened, giving the children an opportunity to earn the money to pay for all the wasted dexamethasone that they are responsible for.

References

1. Russell KF, Liang Y, O’Gorman K, Johnson DW, Klassen TP, Glucocorticoids for croup (Review), 2012, Cochrane Database of Systematic Reviews
2. Bjornson C. and Johnson D, Croup in the paediatric emergency department, Paediatr Child Health. 2007 Jul; 12(6): 473–477.
3. Creasey N G252(P) Dexamethasone as an alternative to prednisolone for children with wheeze: A review of the literature Archives of Disease in Childhood 2016;101:A137-A138.

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

It's Not Easy Being Wheezy - about antibiotics and wheezy kids

In my formative postgaduate years as a doctor, I was told by more than one mentor that antibiotics were a good treatment for children who were wheezing. This advice was given by various people at different times and whether this was bronchiolitis, viral wheeze* or an exacerbation of asthma, the principles seemed to be the same. The logic is sound - we know that infection triggers all three, and we can never be certain of the infection being a straightforward viral episode.  That was how it was put to me anyway.
*If you are unsure about the difference between viral wheeze and bronchilitis, follow this link for an explanation.

I no longer believe in this strategy as a treatment option for wheezy kids, and this is why:

It's not easy being wheezy.  Children with tight lower airways are up against it but often cope extremely well with their bronchospasm or their bronchiolitis.  I am constantly delighted by the ability of these children to be cheerful despite quite significant breathing difficulty.

It's even worse to have a bacterial lower respiratory tract infection.  As well as the breathing difficulty that comes from the loss of functioning lung, there is the tiring effect of the illness.  Having pneumonia is unpleasant and often exhausting.  It would be unusual to see a child who was cheerful and well despite a bacterial lower respiratory tract infection.

Now imagine combining the two.  Doesn't look good does it?  Children with bronchiolitis and viral wheeze cope with the difficulties of wet or constricted airways because they are systemically well.  Add the lethargy of bacterial infection to this and you go from a child who can compensate to one who cannot.  In short, you won't think "maybe there's a bacterial LRTI as well as the bronchiolitis or viral wheeze."  You'll know it.

Evidence from research backs this up.  The Cochrane review of antibiotics for bronchiolitis concluded that there was no benefit from antibiotics. (1)

You could say, what's the harm in trying antibiotics?  There are many reasons why unnecessary antibiotics might be harmful and none of these are to do with drug resistance.

So, it's time to do away with the idea that antibiotics have a role in treating well children with bronchiolitis or viral wheeze.  I believe that you'll know the children who need antibiotics because they will be properly unwell.

Edward Snelson
Antibiotic Guardian of the Galaxy
@sailordoctor

Disclaimer:  Secretly we all know that antibiotics do treat viruses, but if you tell anyone, you'll be removed from the Magic Circle.

Reference

1. Farley R et al, Antibiotics for bronchiolitis in children under two years of age, Cochrane database of systematic reviews. 2010

The Random Goldfish - When confirmation bias met affective bias

In the previous post, I explored how confirmation bias can lead us to believe that something is causing a problem when really it isn't.  Although sometimes unexpected, this kind of news is not unwelcome.  Finding out that fever doesn't really cause febrile convulsions is a surprise to many, but usually a good one.  Telling people that their treatments don't work is much less popular.

Anyone who has been a clinician for a reasonable amount of time knows what it feels like to share good and bad news with someone.  When I am teaching about paediatrics in primary care, it sometimes feels like I am saying that very few treatments actually work.  This feels having something taken away form us.  The real headline is that children make themselves better in the vast majority of clinical scenarios.  It is our job as clinicians to do as much nothing as possible while looking for opportunities to give effective treatments.

One question that I am often asked is, "If these treatments don't work, why do people use them?" Good question.  I tend to assume that my sample cohort of co-workers is representative of clinicians and I work with good, conscientious people who want to give children the best treatment possible. Since I don't believe that clinicians are generally unintelligent, malicious or lazy, I will take a risk and say that there must be powerful forces at work if any of us are giving ineffective medicines to children.  The problem that leads us all to use ineffective treatments is our very desire to make children better and parents happy.

If you want something really badly and do something in an attempt to make it come about, when the thing happens, we are likely to believe that this was cause and effect.  This approach would work in a fixed environment,  For example, consider a person trying to solve a puzzle (like a Rubik's Cube).  The puzzle isn't going to solve itself, so if the person tries many different strategies and then something works, they have solved the puzzle.  This assumes that the puzzle has not been solved by chance, which in this case is extremely unlikely.

Now consider someone with a different problem.  He wants a picture of his goldfish next to the castle in the goldfish bowl.  He tries shining a light to get the goldfish to move into position.  He tries tapping the glass, placing some food and tries making waves in the tank.  Whatever he does just before the goldfish moves into position must have done the trick right?  Wrong.

Well, much of paediatrics is like that.  Childhood symptoms often fluctuate or resolve.  We want our treatments to work.  We want to make children better and parents to be happy.  These factors are the perfect ingredients for us to wrongly believe that what we did worked.  Sometimes though, the goldfish just moves.  Because it's a goldfish.

Enough about goldfish. Let's use a really common example of how confirmation bias leads us and our patients to believe in an effect that is not real.

If I tell someone that antibiotics will cure a child's throat infection within a week, you can imagine how that sounds plausible.  Then, the initial belief in my statement will be reinforced when the child does indeed get better.  The true believer does not consider that the alternative is just as plausible - that all (uncomplicated) throat infections get better with time.  You know that guy who still has the viral sore throat he caught when he was two years old?  No?  Neither do I.

Paediatrics is a branch of medicine where most illnesses will resolve with time and many symptoms that could be attributed to a treatable cause.  But we and the parents both want the problem to be treatable.  The problem is, you're too nice.  You want to help and you want everyone to leave happy. This is called affective bias (the thing that reinforces confirmation bias). The end result is that we can easily believe that we are treating a problem, when in fact it gets better on its own.

Now, bias gets a bad name in medicine, but I would like to defend bias.  Clinicians could never learn or make decisions without bias.  We would be permanently uncertain and unable to choose. Without confirmation bias, we would never notice a pattern.  Without affective bias we would never take the parents seriously or care about the child.

Bias is good.  There, I've said it.

Bias is your friend, but friends can be fickle.  The thing about friends is that despite their faults, they're still your friends.  It is good to know what to expect from them.  That way, you don't feel surprised when they do the thing that they always do.  In the case of bias, your friend wants to mislead you and get you do do things you shouldn't do.

So, what are the best examples of the confirmation bias of presumed effect in paediatrics?  I've already mentioned antibiotics for upper respiratory tract infection.  There are many more, but lets just look at one in detail as an example:

Confirmation bias (presumed effect) - 
Example number 2: Treatments for gastro-oesophageal reflux disease in infants

If there was ever a paediatric condition that fitted the brief for this subject, it is feeding problems in babies.  The symptoms that babies present with are so often simply withing normal limits for infancy.   Did you know that straining is a thing that 1 in 6 babies do and that it is called dyschezia, not constipation?  If you add regurgitation of milk (aka 'reflux'), colic and other common gastrointestinal complaints, most babies have some sort of symptom that we could treat if we chose to during the first few months of life.  With a few exceptions, these are normal for being a baby, and will resolve in time.

The cardinal sign of a self resolving problem is that there are treatments available without good evidence of efficacy.  (Cough medicines for children are a good example of this.)  By way of contrast, there are very few treatment strategies for the management of pneumonia.  I'm guessing that you probably use antibiotics.

The evidence for the available treatments for reflux disease is not good.  In many cases the evidence is that they have little effect.  Rather than posting several dozen references, I am simply going to signpost you to the NICE guideline for Gastro-oesophageal reflux disease in children and young people. (1)  In the full document there is an extensive literature review which makes for interesting reading.  The bottom line is that the evidence is usually lacking.  The evidence that we do have form research points toward little or no effect for alginates, H2 agonists and PPIs.  By their own admission, much of the advice in the guideline depends on the experience of the experts involved in the guideline writing process.

Of course the problem is that there are infants with genuine pathology.  These children often begin their visits to healthcare professionals with non-specific presentations which easily fit the bill for what is 'normal for infancy'.  If we are honest with ourselves, the niggling doubt that the child might have a significant problem is one of the factors that pushes us in the direction of pulling out our prescription pads.  After all, it won't look as bad when the child turns out to have a problem later if we were busy trying treatments instead of reassuring the parent that these symptoms are usually part of normal infancy.

Avoiding unnecessary treatments is gold standard care.  Alginates are the most frequently used medications for reflux symptoms but in my experience this treatment runs a high risk of causing constipation.  This is far from ideal if you are trying to make life easier for baby and parent alike.   Motility drugs have repeatedly been associated with dangerous cardiac side effects and PPIs have been shown to increase the risk of respiratory tract infection. (2)  The take home message from this is that, although medication is an option, we need to be sure that a treatment is really likely to be better than watchful waiting.

The NICE guidelines focus on consideration of how the infant is affected - severe distress or red flags (faltering growth, feed refusal etc.).  It is also important to consider other possible diagnoses such as UTI.

I said that there were quite a few problems that have a similar story.  Going through all of them in detail would take a long time, but here is a list of some of the treatments that lend themselves to this combined bias effect:

The evidence for all of these treatments in children is that they work rarely (antibiotics for URTI, inhalers for cough alone, suspected CMPA based on colic alone) or never (cough syrups, simethicone or lactase for colic in babies).  All of these clinical scenarios share a common theme- the likelihood that the symptom will resolve in time.

So lets come back to bias.  Confirmation bias will cause us to believe that a treatment is effective while affective bias will make us want to give something even when there is little or no benefit. "But earlier, you said that bias is good.  You said that bias is my friend!" you might well say.  I stand by that.  As long as you know how you expect your friends to behave, any misbehavior can be managed and they can still be your friends.

For confirmation bias, we need to have good evidence to justify treatment that is used for symptoms when the natural course is resolution with time.  For example, I don't need evidence to back up my belief that morphine works for pain when a child has a broken leg.  If the child feels less pain afterwards, it has nothing to do with a goldfish effect.  Conversely, I should want evidence that a treatment is effective for any of the symptoms listed above.

For affective bias, we need to harness our desire to be nice to parents and children.  That means not wasting their time with ineffective treatments or worse still causing new problems. Sometimes, doing nothing is the nicest thing that you can do.  Managing to treat where appropriate and avoid unnecessary treatment is the holy grail of paediatrics.  Ultimately, the child is the patient and we need to only give them medication that is more likely to help than harm.  At least, that's what we should be trying to do despite our biases.

Edward Snelson
Amateur Medical Errorist
@sailordoctor

Disclaimer - I am too biased to be taken seriously, even by myself.

References

1. NG1 - Guideline for Gastro-oesophageal reflux disease in children and young people, NICE
2. Orenstein et al., Multicenter, double-blind, randomized, placebo-controlled trial assessing the efficacy and safety of proton pump inhibitor lansoprazole in infants with symptoms of gastroesophageal reflux disease, J Pediatr. 2009 Apr;154(4):514-520