8 out of 10 mothers - what do front line clinicians need to know about childhood obesity?

Childhood obesity is frequently in the news.  The proportion of children who are overweight or obese in countries such as the UK has risen considerably in the past few decades.  Most overweight children will go onto be overweight adults with all the implied risks.  It is often perceived that health issues in later life are the main reason for concern but many children have significant health problems and psychosocial problems (1) during childhood as a result of their weight.  Tackling the problem is made extremely difficult by a number of factors.  As front line clinicians, what are supposed to be doing about it when we see a child who is overweight?

The first problem is recognition.  How often are children brought to a GP surgery by a parent who is concerned that their child is overweight?  Last month, Archives of Disease in Childhood published a study with an outcome that will surprise few of us. It showed that only 18% of mothers of obese children perceived their child to be moderately overweight. (2) That means that if we take an opportunistic approach, four times out of five we have to break news as well as take the problem forward.  Like I said, not a surprising statistic but a sobering one.

The next problem is the identification of obesity.  Definitions vary and there is disagreement about the best method of determining if a child is obese.  The majority seems to rest with BMI being the least worst measure but then you need a weight, a height, a calculator and a paediatric BMI centile chart.

If you feel defeated already, wait for the punchline: the evidence for the effectiveness of interventions is poor or non-existent.  This is one of the reasons that there are currently no commissioned services specialising in childhood obesity in the UK.  Bariatric surgery aside, there are no interventions that have both a significant impact and a good evidence base, so should we even bother?

I think that the answer is yes, but you can choose your reason.  You may, for example, choose to embrace the idea of making every contact count.  Ideally we all address things like obesity opportunistically.  I can’t pretend to succeed there very often.  One of the problems is the feeling that people don't see it as a problem in the same way that clinicians do.

Alternatively you may wish to know what really needs to be referred to secondary care according to those who specialise in this group of patients.  In 2012, in the absence of guidance from a national body (that would mandate the provision of a clinical service) the Obesity Services for Children and Adolescents (OSCA) group of paediatricians produced a consensus statement (3).  These were the indications for referral according to that statement:

Possible underlying cause to obesity suggested by

• Short stature
• Dysmorphism
• Learning difficulties

Comorbidities suggested by

• Hypertension
• Symptoms of sleep apnoea
• Acanthosis Nigricans
• Evidence of Polycystic Ovary Syndrome
• Psychological morbidities
• Safeguarding concerns
• Impaired glucose intolerance, dyslipidaemia or liver dysfunction
• Family history of Type 2 diabetes before the age of 40 or cardiovascular disease before the age of 60 in a close relative

Acanthosis Nigricans (thickened and pigmented patches of skin in the neck and axillae) in children is often associated with insulin insensitivity.  (picture taken from commons.wikimedia)

I can’t argue with any of those as they all seem quite reasonable.  Essentially the experts are saying that children who might have a medical cause or effect of their obesity should be referred. 

The difficulty with this list is that it rather brings me full circle.  In order to know whether a child’s obesity might be secondary to something or might be causing another problem, I need to examine them and ask a few questions.  I can’t really do this without making the diagnosis of obesity.  For this I need to mention that the child might be overweight so I need to do a few measurements.  I should probably explain why I suddenly have an acute interest in the young person's armpits.  Even if I do explain myself, 8 out of 10 mothers will probably be a little surprised.

Edward Snelson
Counting every contact
@sailordoctor



References

1. Strauss RS, Social marginalization of overweight children, Arch Pediatr Adolesc Med. 2003 Aug;157(8):746-52.
2. Dowd et al, The association between maternal perceptions of own weight status and weight status of her child: results from a national cohort studyArch Dis Child 2016;101:28-32 doi:10.1136/archdischild-2015-308721
3. Vine et al, Assessment of childhood obesity in secondary care: OSCA consensus statement: Arch Dis Child Educ Pract Ed 2012;97:98-105 doi:10.1136/edpract-2011-301426

The Trouble with Training (Easter egg - when to do a Chest X-ray in children in the ED or General Practice)

I remember well how difficult it is to stay up to date across the thousands of clinical scenarios that face the General Practitioner.  When I was faced by something not in the top 100 weekly problems, I usually had to think back to my training.  That works well as long as what I recalled was accurate, and was best practice at the time and remained so.  What are the chances of all three being true even five years post-training?

Accurate recall (keep taking that thiamine) aside, the first issue is whether one's training involved the demonstration of standard care.  I was recently pulled into a twitter conversation about whether children with pneumonia required a chest X-ray (CXR).  The person facilitating the discussion was one of the local GP trainers who had himself been asked by one of the GP trainees here in Sheffield.  The trainee felt that they were getting mixed messages and wanted to know the right answer.  Of course a complete answer doesn't fit in a tweet.  Also, tweets are transient unless they are the kind that get you fired.  So a GPpaedsTips post seems to me to be the best place for a proper answer.  Since the question was about acute paediatrics, I can legitimately put a foot outside of the Primary Care remit of this site, but it seems the ideal opportunity to also address the question of when a CXR might be indicated for a child in a General Practice setting.

Continuing with the theme of see one do one, lets start with children with pneumonia in a secondary care setting in the UK.  The British Thoracic Society guidelines for community acquired pneumonia in children are, in my opinion, very good.  Their recommendation that "Chest radiography should not be considered a routine investigation in children thought to have community acquired pneumonia" is based on the old principle of 'if it doesn't change your management don't do it.'  Putting that into practice requires a little step back and for us to ask the question, 'what is a CXR for?'  I used to think it was needed to diagnose pneumonia.  That is a fallacy, since X-ray changes will have a time lag and a CXR can be a false negative.  So, is it to show the severity, or what kind of pneumonia it is?  No, the severity is a clinical assessment and the type of chest infection is determined by a combination of the clues in the assessment and the response to treatment.  According to the BTS guidelines, CXR in the ED or paediatric assessment unit should mainly be used for the cases which are a little bit different from the routine LRTI.  This might be repeated LRTI, a child who is severely unwell or a number of other reasons.  That doesn't mean find a reason.  It means find a good reason.  In particular, if you think the child is well enough to treat as an outpatient, BTS recommends never doing a CXR.  Never is a strong word but it's a good place to start and puts the GP CXR question in context.

Adults, with their risk of lung cancer, are different.  In children, signs and symptoms are usually all you need when making decisions about treatment or referral when it comes to children's respiratory problems.  In my opinion, doing a CXR for a child in primary care should be for a situation where the X-ray could give information that allows treatment to be given or a referral to be avoided.  I can't think of any situations where the CXR would do that but a history and examination would not.

I understand that one reason that CXRs are done for children in Primary Care is to reassure parents or clinicians.  I would be very wary of that plan.  CXRs often have findings on them, especially when a child has a viral illness.  A finding is not the same thing as a clinically significant abnormality, but it is not very reassuring either.

Then there is the possibility that a CXR might be done in the belief that one would be done for the same patient in a hospital setting.  That is also tricky since practices change.  The trouble is that they may change slowly and inconsistently.  I believe that the safest approach is to avoid second guessing what tests someone else will want.  I either ask them or leave them to request their own investigations.

So then there is the challenge of being up to date.  I would like to use this opportunity to tell all my secondary care colleagues how stupidly easy we have it in this regard.  The environment we work in continually provides us with updates and learning (if you are surrounded by the kind of clever yet pragmatic clinicians I work with).  I remember how General Practice is a relatively isolated learning environment and how difficult it is to keep abreast of changes in so very many areas.

That's the trouble with training and keeping up to date: these things have the tendency to look fun and manageable but actually have the tendency to expand exponentially and take over.  Meanwhile, we all have a ship to run. The solution: Cling on, outsource your troubles and let FOAMed give you the answers.

Snelson out


Disclaimer: I need reassurance too. I'm just not sure where to find it any more.

Reference:
BTS guideline for Community Acquired Pneumonia in Children

High Voltage - What the diagnosis plus severity means for management of viral wheeze

In the previous post, I concentrated on giving the correct label to the child under the age of five with recurrent episodes of wheeze.  I'd like to pretend that that makes the management simple but I just can't do that.  Not only are the diagnoses confusingly difficult to tell apart sometimes but there are overlaps with treatment options.  So are there actually distinct clinical entities at all?

There are important differences between the two main groups: viral wheeze and asthma/ multi-trigger wheeze.  Once again though, I have to emphasise that viral wheeze is not a lesser diagnosis and can cause life-threatening exacerbations.   It is possible that there are just these two entities and that the viral wheezers need different treatment at the more severe end of the spectrum.  After all, high voltage can do bad things to a circuit.

What is particularly confusing for the generalist is seeing children with a diagnosis like viral episodic wheeze being given a steroid inhaler.  You might be excused for exclaiming WTF!  (Wheeze Treatment Freestyle!)  Surely the whole point is to avoid giving steroid inhalers when the diagnosis is viral wheeze.  Well, as is often the case, yes and no.  Yes, most of the time but no, not always.

The vast majority of children who only get wheeze during a viral illness will do so relatively infrequently.  Also, the episodes in most cases will be mild or moderate and (more importantly) respond well to decent doses of bronchodilators.  The key differences between these children and the smaller number of children who have an atopic cause to their wheeze are that preventative steroid inhalers are not at all likely to prevent or blunt exacerbations of viral wheeze, and the evidence is that systemic steroids do not work for acute episodes.

However, not all viral wheezers were created equally.  Some get frequent exacerbations and some get frequent and severe exacerbations.  There is much debate about phenotypes, genotypes and other big words that don't mean much to the poor three year old who is getting the symptoms.  There is genuine uncertainty about whether there are multiple entities or overlaps and polymorphism.  My  hope is that the paediatric respiratory world find a way to identify the subgroups without over-complicating the list of possible diagnoses.

What we have at the moment is two main groups, with the more severe end of the viral wheeze group being treated in ways that look remarkably similar to the asthma group.  Similar, but not the same.

With the child under five who has an asthma pattern of wheezing, steroid preventer inhalers are a cornerstone of management.  If the diagnosis is recurrent viral wheeze, steroid inhalers are an option when exacerbations are very frequent, especially if severe.  The current advice is that a trial of steroid inhalers should be evaluated and should be stopped if not helpful.  How one knows whether the trial has worked is another question.  If anyone knows a cast iron way of deciding this please get in touch or post a comment.

Edward Snelson
@sailordoctor

Disclaimer: I am not a Respiratory Paediatrician, but sometimes I see so many children with wheeze, it feels like I should be.

How is your wheezer wired? Asthma vs Viral wheeze in the under 5 year old.

This week, I was asked a very good question by one of my colleagues in primary care: Why are children under the age of five who have recurrent wheeze and who are clearly atopic not given a diagnosis of asthma?  It's a question I have been asked many times before before, often accompanied by a frustrated and confused expression.

Are paediatricians allergic to diagnosing asthma in under five year olds?  It might seem like it.  The answer is no, but the diagnosis is avoided by most paediatricians and some have stopped using that term altogether (preferring multi-trigger wheeze for the under five year olds).  So when is it asthma?

Some children under the age of five with atopy and wheeze are asthmatic (or have multi-trigger wheeze if you like) but most are not.  Most have recurrent viral wheezing.  The difference is all in the circuitry. Remember circuit diagrams?  You may have intentionally blocked them out from your memory but for the purposes of this explanation it will be helpful, especially for the visual/ special learners, of which I am one. 

The thing is that lots of children have viral wheezing episodes and lots of children have atopy, usually in the form of eczema.  To find them both in the same child is reasonably common so association does not prove causation.  For that you need to establish whether the two things are happening in series or parallel.  This is where my circuit diagrams come in.

Fig 1. When a child has episodes of wheeze that are not related to anything other than viral illnesses, then any co-existing atopy is not thought to be part of the problem.  In these cases the diagnosis remains recurrent viral wheeze.

Fig 2. If there are episodes of wheeze that are unrelated to viral illnesses then coexisting atopy is the likely cause and these children are diagnosed with asthma.

Why does it matter what label we give this?  The main reason is that the chronic treatment is different.  In a review article in the BMJ, the evidence is summarised for treating acute episodes of viral wheeze with bronchodilators only, without either acute or prophylactic steroids.

When it comes to knowing whether your patient’s wheeze and atopy are wired in series or parallel, it all comes down to precipitants and interval symptoms.  If the precipitant is always a viral illness and there are no interval symptoms, then the wiring is in parallel (recurrent viral wheeze).  If there are episodes in the absence of viral illness, or there are interval symptoms (usually frequent cough or wheeze) then the wiring is in parallel (asthma).

Are there any drawbacks to having this separate diagnosis?  I can think of a few.  Firstly, having seen life-threatening exacerbations of viral wheeze I know that the acute episodes are just as capable as asthma attacks of becoming severe and deteriorating rapidly.  Recurrent viral wheeze is not a benign condition and children do die from it.

My next concern is whether or not these children get themselves into the system properly in primary care.  I know that with the current systems in place, children with asthma will be easily identified in a General Practice setting and thus get an annual review, inhaler technique checked and an invitation for an annual influenza vaccination.  Children with recurrent viral wheezing should probably also get these, but there is little guidance and no quality framework for recurrent viral wheezing. 

So how do we make sure that these children are managed appropriately?  The separate label of viral wheezing allows us to treat them consistently without giving treatments that are not going to help.  The same label risks putting these children on one side or implying that they are not at risk of severe episodes.

It does however make me wonder if the label of 'multi-trigger wheeze' is a step too far.  The European Respiratory Society Task Force defines a clinical entity "as a cluster of associated features that are useful in some way, such as in managing the child or understanding the mechanisms of disease."  Since the majority of these children are managed by general practitioners I would argue that the diagnosis of multi-trigger wheeze should be useful to them.  I am struggling to see a clear benefit.  Having labels that change and multiply can have a detrimental effect by confusing clinicians and parents alike.  In the pursuit of purism, we can end up with nomenclature which is more academic than practical.

So, let's stick with the terms recurrent viral wheeze and asthma for now.  That still leaves us with the need to ensure that the recurrent viral wheezers get treated as children with a debilitating and potentially dangerous respiratory problem.  So, can General Practitioners come up with solutions to this?  Part of the answer will be awareness and I hope that this little update has helped.  I suspect there is also a need for coding ingenuity.  It may be that others have recognised this conundrum and come up with novel solutions.  If so, please comment below and share your ideas.

Edward Snelson

Medical polyglot
@sailordoctor

Disclaimer: I fear change

References

1. Andrew Bush, Managing wheeze in preschool children BMJ 2014; 348 
2. Brand PL et al. Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach. Eur Respir J2008;32:1096-110

Is your wheezer happy or are they waving a red flag?

Once you have decided that a child has bronchiolitis, there is only one real decision to be made*: home or hospital?  In some cases this decision will be made clear but for others the clues may be more in need of detective work.

*Decisions re antibiotics, inhalers and steroids are easy: don't give them!

If possible, babies with bronchiolitis should be kept well away from hospital.  Nothing quite makes bronchiolitis worse than catching rotavirus gastroenteritis from the nice family in the waiting room, while you are waiting for your mother to see the paediatrician who will send you home.  But, if you need to go you need to go.  There are three main categories of things that necessitate admission:

• Inadequate feeding
• Ineffective breathing or excessive work of breathing
• A red flag symptom

Although they do not necessarily mandate referral, a risk factor that makes a sudden collapse more likely is the fourth factor in the referral risk assessment.

Inadequate feeding was covered in the last post.  Feel free to do the maths, work out what the baby is getting, look at the baby or all of the above.  For me, how alert and hydrated the child is will always be a better measure of adequacy.

Ineffective breathing or excessive work of breathing is based on many factors.  It is important to assess respiratory rate, intercostal recession and how loud the breath sounds are on auscultation.  I would say that it is even more important to look at the baby and get a gut feel for how they are coping.

The term "happy wheezer" has been around for as long as I can remember.  A happy wheezer is a baby with bronchiolitis who, often despite an impressively audible wheeze, looks ridiculously happy.  It's funny that none of the official guidelines legislate for the happy wheezer who is above the 91st centile for weight (catchy eh?).  I think that they deserve a pathway of their own.  They seem to cope well and manage far better than equivalent skinny babies with bronchiolitis.

There are two other considerations which affect the level of clinical concern.  These are risk factors and red flags.

Risk factors are important to ask about and will often not be volunteered unless the right questions are asked.  Risk factors in children with bronchiolitis include:

• Ex-prematurity
• Underlying respiratory problems e.g. chronic lung disease
• Age under three months old
• Underlying cardiac problem
• Underweight
• Known immunodeficiency
• Neurological problems

The presence of risk factors presents an interesting conundrum.  Take the baby with mild bronchiolitis who is two months old.  They do not currently need nasogastric feeding nor do they need supplemental oxygen.  So why refer?  The argument for is that they are more difficult to assess and they will decompensate more rapidly.  The argument against is that being at risk and in hospital can actually be a bad thing.

The presence of a risk factor does not change the clinical assessment of the child (they still have mild bronchiolitis after all) but it sometimes changes the decision to refer or get advice from an experienced paediatrician.  If in doubt, discuss.

The well baby with mild bronchiolitis and a risk factor is better not sent to the emergency department for all the reasons above.  If they need to come in they should be referred directly to paediatrics.

Finally, there are red flags.  These are great because they make the decision easy.  If a child with bronchiolitis has a red flag, they must be referred for observation as a minimum.  Most will need intervention.  Red flags include:

• Increasing pauses in breathing
• Grunting
• Refusing feeds
• Head bobbing
• Not waking for feeds
• Floppy
• Pale or cyanotic episodes
• Episodes which alarm parents

Some red flags tell you what you already know - bad things are happening for this baby.  Some red flags tell you that bad things are happening even when it is not obvious from looking at the baby.

So the decision to bounce a bronchiolitic in the direction of a paediatrician is usually straightforward.  If they're need help feeding or support with breathing then the paediatricians need to have them.  Also refer if there are red flag signs or symptoms.  If they are mild but have a risk factor, then either refer or discuss them with an experienced paediatrician.

If the episode is mild and there are no risk factors or red flags, keep them well away from hospital.  They are not good places to be.

Edward Snelson
@sailordoctor

Disclaimer:  If the baby is waving an actual red flag, they are probably fine.

Enough already! Adequate Feeding in Bronchiolitis

It can be difficult to know whether a child with bronchiolitis is best managed in the community with advice, or is one of the small proportion that should be referred for possible admission.  When NICE produced NG9 "Bronchiolitis in Children" there was a number put on how much feed a baby with bronchiolitis should be taken in order for that to be considered adequate.  Well, that's not quite true.  The guideline uses two numbers and a few words.  So how much do the guidelines say is enough?

The first number is "difficulty with breastfeeding or inadequate oral fluid intake (less than 75% of usual volume)" (1) which is listed as an indicator that the baby may need referral to secondary care.  Two pages later a similar but slightly different description of what inadequate feeding looks like is used: "difficulty with breastfeeding or inadequate oral fluid intake (50- 75% of usual volume, taking account of risk factors and using clinical judgement)" (2)

Unsurprisingly, the fact that these numbers are rather tidy and there is a little uncertainty expressed is due the the fact that they are based on expert opinion.  Fair enough but my question is, are we measuring the right thing?

There are lots of variables in the mix here.  Firstly, in breast fed babies, we have to guess what is going in.  As well as what is going in, there is the issue of what comes straight back out.  Finally, what is being used up in terms of calories and water depends on the work of breathing and other factors such as pyrexia.  It will also probably be affected by the amount of subcutaneous fat and renal function.  What is going in is only part of the equation and the formula looks much more like algebra than simple maths to me.  So, why don't we cheat and look at the answers?

The answers that I like to look at are energy levels and hydration.  Assessing a baby's energy levels will be easy in most cases.  If a baby is alert and smiling, it is probably safe to assume that a good supply of calories and water is reaching the most frivolous part of the baby's brain.  If that is the case, then the baby's carbohydrate economy is buoyant.  If this is not the case then something is wrong and whether inadequate feeding is an issue or not, a subdued or tired looking baby with bronchiolitis should be referred.

Assessing hydration is done the old fashioned way as well.  I look for wet mucous membranes in the mouth, good skin hydration, and wet nappies.  If I am really lucky I might have a weight from a couple of days ago to compare to.

The overall appearance, wellness and alertness of the child are always going to be a more valid assessment than comparing an uncertain number (how much we think the baby is getting) to a made up number (how much we think the baby needs).  So, once again, a victory for old school paediatrics and an adage which should never get old: "Look at the child."

Edward Snelson
Uncertaintologist
@sailordoctor

Disclaimer: If none of this makes sense, the NICE bronchiolitis guidelines are actually very good in my opinion.

References

1. Page 16, Full guideline NG9 Bronchiolitis in Children, NICE
2. Page 18, Full guideline NG9 Bronchiolitis in Children, NICE

Fairy logic - how to avoid the understanding gap

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

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

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

Other examples include

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

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

Edward Snelson
@sailordoctor

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

Outside-in or Inside-out? Top tips for making childhood eczema better

In developed countries the incidence of eczema has been increasing for several decades.  At the same time, children are tending to take longer to grow out of having eczema, leading to an even greater prevalence.  While it can be difficult to treat in a General Practice setting, eczema treatment is ripe for Primary Care expertise to make a big difference to a group of children who have an unpleasant but treatable condition.

Recently, I heard an experienced paediatric dermatologist try to squeeze all his eczema wisdom into about an hour long session.   What I learned was that by understanding the way that eczema works, I can be better at treating eczema.

There are many proposed models for what causes and perpetuates eczema.  Two of these are the ‘inside out’ and the ‘outside in’ models.  If you are interested in these things, there is much debate about whether eczema is caused by allergy and perpetuated by damaged skin versus being caused by a defective skin barrier which then leads to allergens penetrating the epidermis.  If you don’t care and just want to treat the eczema effectively, the answer is simple: do something about all the factors involved regardless of which is chicken or egg.

Here's how to do that:

1. Restoring the skin barrier

Think of the epidermis as being a brick wall.  In eczema all the mortar is falling apart and there are gaps between the bricks.  That means that the wall is leaky and does not protect the house from the elements.  What is needed is to repair the mortar.  In eczema, repairing the skin barrier requires oil.  This can be achieved in several ways.  The first thing that is needed is to use emollients. 

Of course there are many emollients available.  Whatever the treatment is, it needs to be one that the family will use often enough.  This requires the provision of large amounts so that the parents will be liberal in using it.  They need to be told to apply it often enough to keep the skin feeling greasy all the time.  Some creams are greasier than others.  Bigger is not always better though.  Sometimes families find the greasiest creams to be too oily and so they apply them less often.  It is important to make sure that they are happy with the cream prescribed.

As well as replacing oils, we need to make sure that whatever is there is not being taken away.  Soaps, shampoos and detergents need to be avoided.   Instead, encourage the use of water alone or with bath oils.  Aqueous cream contains sodium lauryl sulfate which is a mild detergent.  Aqueous cream should not be used as an emollient but can be used as hand soap (1).

2. Treating the inflammation

Returning to the inside out/ outside in way of thinking about eczema, restoring the barrier is not going to be effective on its own when there is inflammation present.  Inflammation requires steroid creams.  How strong a cream and how long it should be given depends on the severity of the eczema and how well it responds.  In short, the steroid cream should be prescribed at a strength that treats the eczema and for as long as necessary to resolve the inflamed skin.  It is very important to attack the eczema from every other angle at the same time so that the steroid cream is given the best possible chance to work and be stopped.

3. Addressing the itch

Treating eczema does not stop at using emollients and steroids.  The next issue to consider is the itch-scratch cycle.  Inflamed skin is itchy and scratched skin makes eczema worse.  Antihistamines can make a big difference during an exacerbation of eczema, not just to help with symptoms but also to speed recovery.

4. Treating drivers of inflammation

Another consideration is the possibility of something driving the inflammation.  Bacterial infection may be manifested as exudative or golden crusted areas.   Herpes virus infection will usually be evident either by the characteristic vesicles or the ulcerated lesions left behind.  Treatment of bacterial infection with oral antibiotics is sometimes needed.   Topical treatment with fucidic acid cream is often the preferred option.  Topical antibiotics must not be continued long term as this simply promotes resistant bacteria colonising the skin. 

Besides infection, there may be allergens that are identifiable.  Avoiding (e.g. specific foods) or minimising (e.g. house dust mite) these precipitants is important, though often difficult.

Having this four pronged approach is much more likely to be effective than being overly simplistic such as by just prescribing a steroid cream for a flare up of eczema.  Good explanation of the treatment and being supportive are both essential to the success of any plan.

I am told by paediatric dermatologists that they often don't use special secondary care treatments when they see children with eczema.  What they do is to use the same treatment that are available in primary care but use these treatments differently.  That sounds like an opportunity for us to make these dermatologists a bit more redundant.

Edward Snelson
@sailordoctor


Disclaimer: Other models of eczema pathogenesis are also available

References

1. National Eczema society - "Why Aqueous Cream is Bad for Eczema" http://www.eczema.org/aqeous
2. Drug Safety update - aqueous cream may cause irritation https://www.gov.uk/drug-safety-update/aqueous-cream-may-cause-skin-irritation

When it walks like a duck- Do I give salbutamol to this 11 month old?

This year saw the arrival of the NICE Bronchiolitis guidelines.  Like many guidelines, this requires the clinician to know that the problem that the child has is bronchiolitis. The trouble is that there are times when there is uncertainty.  It is an important distinction to make since bronchiolitis is best left well alone.  You should not prescribe inhalers, antibiotics or steroids.  Viral wheeze on the other hand requires the liberal use of inhalers for appropriate to the severity of the exacerbation.

As a medical student I was taught that beta-agonists such as salbutamol don't tend to work under the age of one.  That is only partly true.  Beta-agonists don't work for bronchiolitis and most children under 12 months with wheeze have bronchiolitis.  However when the problem is a viral induced wheeze the inhaled Beta agonist is exactly what is needed even if they child is below a year old.

Bronchiolitis and viral induced wheeze have a similar presentation but very different mechanisms which is why one responds and the other doesn't.  Bronchiolitis is essentially a problem of wetness.  The viral lower respiratory tract infection causes the airways to be constricted by the accumulation of secretions.  With viral induced wheeze, the infection has induced bronchospasm.

In both cases there will be a cough, coryza, wheeze and possibly some respiratory distress.  Only one needs inhalers or nebulisers to be given.  So how do I tell them apart?

The easiest way is to look at the child's age.  There seems to be a fairly good split between the typical age groups of the two conditions.  Bronchiolitis tends to affect those under 12 months old while viral induced wheeze tend to be seen in the over 12 month olds.  Using that as a cut off will leave you being correct a lot of the time.  Of course there are exceptions and they will usually be those children a few weeks or a couple of months either side of that cut off.

So for those who are well before their first birthday you can assume they have bronchiolitis.  If the child has already started to outgrow the clothes that they were given for their first birthday, you can assume they have a viral induced wheeze.  But what about the ones who are too close to call?

One thing that helps is the prodrome.  Typically, children with bronchiolitis have a few days of being snotty before the cough develops.  Then there is a daily worsening of cough followed by feeding difficulties.  By day 3 of the cough there may be fast breathing and an audible wheeze.

With viral induced wheeze there is a variable length of coryzal illness from a day to a week.  What is noticeably different is the onset of the wheeze and respiratory distress.  This will usually happen over the space of hours, not days.

The other factor that helps is the severity of the symptoms.  Consider our 11 month old with wheeze: If bronchiolitis affects children from birth to about 15 months of age, the most severely affected will be the littlest babies.  Wet lungs when you are a few weeks old is no walk in the park.  So by the time you are 11 months old, bronchiolitis is less likely to be severe.

Why not just try inhalers with all wheezers?  The answer is that it is possible that this might make the child worse.

If an infant has bronchiolitis, they fight the good fight against wet lungs.  They succeed against the odds since they are less able too feed and use more energy in the effort of breathing.  What we must do as clinicians is avoid making this worse.  Don't give unnecessary antibiotics that will fill and irritate their stomachs.  Don't send them home with ineffective inhalers which will result in a routine of upsetting and tiring out the child.

Conversely, make sure that children with viral induced wheeze get enough beta-agonist.  This might be quite a lot (the salbutamol paradox).

So, because it is an important distinction, use age, then prodrome and then severity in that order to decide if it is bronchiolitis or viral induced wheeze.

Edward Snelson
@sailordoctor

Hot topic - Should children who develop a rash while taking antibiotics be re-challenged in primary care?

These are the facts:

• The vast majority of children who have been labelled as allergic to penicillin have no evidence of allergy on patch-testing, prick testing or oral challenge.  
• The most common cause of acute urticaria in childhood is viral illness.
• For various reasons, many children are prescribed antibiotics for viral illnesses.  During the time that they are taking antibiotics they may develop a  rash (urticarial or non-specific) which might lead to the conclusion that the child is reacting to the antibiotics when in fact the rash is due to the viral illness.
• Anaphylaxis kills around 20 people per year in the United Kingdom.

In this post I would like to debate the pros and cons of what should happen next when a child has been labelled as allergic to penicillin.

The clinical scenario is this: While taking penicillin for an upper respiratory tact infection, a child develops an urticarial rash.  There are no other symptoms such as wheeze associated with the onset of the rash.  The rash settled after a few days.  The child has been labelled as penicillin allergic on the basis of this episode.

The child then presents three months later with an acute otitis media and fulfils the criteria for a prescription of amoxicillin.  What should you do?

One option is to prescribe an alternative antibiotic.  The argument for this is that there is a possibility that the urticaria was due to the penicillin.  Why take a risk?  Although the likelihood of a further reaction is small there is such a thing as penicillin allergy.  Furthermore the child could have a more significant reaction this time.  They could have an anaphylaxis or develop Stevens-Johnson syndrome.  Despite the small chances, the potential severity of the possible reaction makes avoidance of penicillin the best way forward.

The second option is to prescribe amoxicillin.  The attribution of the label 'allergic to penicillin' was not justified.  The vast majority of children who develop an acute episode of urticaria do so in response to the viral illness.  If anything, the appearance of such a rash probably indicates that the antibiotics were unnecessary rather than problematic.  Research has shown that only about 1 in 20 children labelled as allergic to penicillin actually have evidence of a reaction.  Furthermore, the fear of a more severe reaction is probably unfounded.  The only factors known to increase the severity of an allergic reaction are dose and route.  So if the same dose and route are used, the worst that should happen is a recurrence of the rash.  When compared to the increased probability of side effects with an alternative antibiotic, prescribing amoxicillin is the least harmful option.  It is simply a question of amoxicillin being the best drug for the job.

The third option is to prescribe amoxicillin but to have them take the first dose in your clinical setting and wait for up to an hour before leaving.  If the child has a label of penicillin allergy which we know is likely to be wrong, this option somewhat addresses the issues of having been told that they are allergic to penicillin.  The parents are likely to be anxious about giving the medicine.  If there is a reaction to the medicine then this can be assessed as it occurs so that there is no future doubt.  In most cases the reaction will again be mild.  If respiratory or systemic features occur then all of the drugs needed for the initial treatment of allergy and anaphylaxis can be given in Primary care.  In short, it is unlikely that a reaction will occur.  If it does it can be assessed.  It is very unlikely that the reaction will be anaphylaxis but if that occurs it can be treated and the child sent immediately to secondary care by ambulance.

So having heard the arguments, what do you think?  It's time to choose.  Here is the link to the poll: Click here

Alternatively you can join the debate and post a comment below.

Edward Snelson
Notanallergologist
@sailordoctor

Disclaimer:  I never prescribe antibiotics.  I use antibionics (much stronger)

References:

1. The role of penicillin in benign skin rashes in childhood: a prospective study based on drug rechallenge, J Allergy Clin Immunol. 2011 Jan;127(1):218-22
2. Penicillin Allergy in Children  Current Allergy & Clinical Immunology, June 2009 Vol 22, No. 2