Coughing children - Persistent, Perplexing or Paradoxical? Probably not asthma!

In the previous post, I gave a little guidance about patterns of cough in children.  Now, I'll add a little probability to the mix.  After all, good medicine relies heavily on knowing the likelihood of a given disease in a particular scenario.

As someone who occasionally mentions medi-facts that came from articles that I have long since lost track of, I was pleased to be able to re-find an article from Chest (the journal of the American College of Chest Physicians) that I have been using in both practice and teaching.  It asked the question, In persistent cough, can we extrapolate an adult based approach to be used in children? (1)

The resounding answer was no.

Once again, children are shown not to be mini-adults.  Paediatricians everywhere breathe a sigh of relief...

What is perhaps surprising is the number of children with a persistent cough who have evidence that pertussis is the culprit.  In several studies now, the proportion has been shown to about 20-40 % of children who have been coughing for more than two or three weeks.  That large number includes studies that have been done since the ramping up of vaccination campaigns. (2)

Pertussis is a significant illness which still has a mortality of around 3% in unvaccinated babies.  Although less of a menace since the introduction and later improvement of vaccination programs, pertussis is still endemic.  It should be suspected whenever a baby presents with an acute cough.  The typical cough is paroxysmal and there are features that often make the diagnosis more obvious.  Some children get the classic 'whoop' at the end of a coughing paroxysm while some will vomit or have (hopefully brief) apnoeas. It seems from the studies into persistent cough that not all pertussis is obvious acutely.   Early detection reduces both symptoms and transmission.  Guidance on this from the Public Health England can be found here.

So, before thinking that a persistent cough in the absence of wheeze might be asthma think: 'Could this be pertussis?'  The advantages of this are:

1. There is no test for asthma.  There is a test for pertussis.
2. As well as diagnosing the index case, you may help to identify the cause of other persistent coughs that are troubling the family and friend of this little one.
3. You may save a life.  If the pertussis is passed onto (for example) a new born baby this could be devastating.  By recognising pertussis you may prevent transmission.
4. You avoid the trap of confirmation bias.  If you are tempted to 'try' an inhaler for a few weeks, you may be tricked into believing that it helped when the cough gradually resolves, as it should in time with post-pertussive cough.

Edward Snelson
@sailordoctor

Disclaimer: Of course if we're going to talk probabilities, it's probably a virus...

https://www.facebook.com/PaedsTips

References

1. Marchmont et al, Evaluation and Outcome of Young Children With Chronic Cough, Chest Journal, May 2006, Vol 129, No. 5
2. Wang et al, Whooping cough in school age children presenting with persistent cough in UK primary care after introduction of the preschool pertussis booster vaccination: prospective cohort study, BMJ, 2014;348:g3668
3. Public Health England, Pertussis factsheet for healthcare professionals

Better FOAM - are you getting the picture? (Easter egg - persistent cough in children)

I have an apology to make.  When I wrote about how to tell the difference between bronchiolitis and viral induced wheeze, I talked too much.  I know this thanks to a wonderful audience of GPs who are attending a series of paediatric masterclasses here in Sheffield.  When I described the way to use the prodrome of the illness (as described in the post linked above) I could tell from the faces in the audience that my explanation hadn't yet hit the mark.  Then I put up this slide:

This, coupled with a description of the presenting complaint* for the two conditions seemed to work and I'd like to think that everyone then understood what I was saying.
* With bronchiolitis, the parent usually describes a day by day gradual worsening of the symptoms; with viral wheeze the child often goes from snotty to very wheezy over the space of a few hours.

Pictures, coupled with explanations are a powerful tool for teaching.  I don't have the time to make pictures as much as I would like to, but I will try to do so more often.  Thankfully I learned my lesson just in time, as I was going to write about children who present with persistent cough this week.  Once again, pictures will be needed.  Here I go:

Persistent or Chronic Cough in Children

Children are often brought to GPs and EDs with a cough as the primary symptom.  It is not uncommon for the cough to be reported as having been there for weeks or months.  These histories of protracted coughs tend to cause a variety of responses including a mixture of scepticism and anxiety.  My initial thought of, 'Has this child really been coughing for weeks?' is followed by 'Could it be tuberculosis?'  Both responses are valid.

There are essentially four groups of cough that are present over the space of weeks or months.  The first and most common of these is the cough that comes and goes.  These children are almost invariably having repeated viral upper respiratory tract infections (URTI).  For this reason, the first task is to establish whether the cough ever resolves, leaving periods of normality, however brief.

The second group is those that have a dry but persistent cough that never seems to get worse but never goes away.  In the absence of any red flags (see below) or other clues, this may be normal.  About one in five children (1) are reported to have a daily cough.  Most have no underlying abnormality.  Some have a behavioural element or a relatively benign cause such as post-nasal drip.

The third group is the slowly resolving cough.  Coughs often persist for weeks after an infection has gone.  Even following a simple viral URTI, a large proportion of children cough for weeks afterwards.  Sometimes, such as with bronchiolitis or pertussis, the cough takes even longer.  (2) The important thing is to establish whether the cough is resolving, however slowly.

The final group is the one to watch out for.  If the cough is getting worse, and lasts for more than eight weeks and is getting worse then the likelihood of pathology is much higher.  Most children will present well before eight weeks, so a single course of broad spectrum antibiotics will usually have been tried.  If the cough is getting worse despite this or there are other red flags, the child should be referred.

The red flags that suggest that referral is needed are fairly intuitive:

Where a benign cause is suspected, then treatment can be directed accordingly:

In all cases, smoking cessation is likely to help.

Suspected infection - if there has been a temporary improvement from antibiotics and the child has a chronic wet cough, this may need a longer course (e.g. two weeks) of a second line antibiotic (e.g. Co-amoxiclav)

Post nasal drip - steroid nasal spray/ antihistamines

Behavioural - reassure and advise to distract the child.  The family must avoid any reinforcing behaviours of their own.

One thing that is not recommended is a trial of systemic steroids in chronic cough.(3)  Cough as an isolated symptom, without any wheeze or other indication is very unlikely to be due to asthma.  Steroids may however, mask a mediastinal lymphoma in rare cases.

Symptomatic treatment of the cough is also best avoided.  There are no effective cough remedies in children that do not have significant adverse effects.

So, when a child presents and you are told that the cough has been going on for 6-8 weeks that doesn't mean a lot without the pattern of cough and associated features.

In most cases no treatment is needed.  If explaining that doesn't go down well with the parent, instead of prescribing something anyway, why not draw them a picture?

Edward Snelson
Head of the Sheffield Medical Artists Consortium
@sailordoctor

References

1. J C de Jongste, M D Shields,  Chronic cough in children, Thorax 2003;58:998-1003 doi:10.1136/thorax.58.11.998
2. Thompson, M, Duration of symptoms of respiratory tract infections in children: systematic review, BMJ 2013;347:f7027
3. Chang, A, "Isolated cough: probably not asthma" Arch Dis Child. 1999 Mar; 80(3): 211–213

Who should write your guidelines? Sepsis and the happy GP

In January 2016 NICE announced the consultation period for the draft guideline about sepsis and soon afterwards a sad news story hit the headlines.  The story was about a boy who had tragically died of sepsis.  There is a temptation to allow such emotive events to be drivers when writing guidelines but this needs to be balanced by considering the effect of any referral or treatment threshold on the whole population of children presenting to GPs and EDs.

As a user of guidelines, I would like to explore the complexities of any protocolised approach to recognising sepsis.  There are elements of the process that are simple, and elements that are less so.

First of all, let me be clear.  I welcome a guideline that aims to raise the awareness of clinicians to the possibility that a child may have sepsis.  I welcome the push to speed the diagnosis and shorten the time to receiving intravenous antibiotics.  However, greater sensitivity usually comes at the cost of poorer specificity.  In this case that probably means referring more well children and treating more well children in hospital.  That does not just have implications for the workload of emergency departments and inpatient wards.  It also affects every child who did not have sepsis but was flagged up on the flowchart as being high risk.  Referral to hospital and admission as an inpatient both have an associated morbidity.  We need to be careful not to repeat the bronchiolitis admission effect. (2)

In a recent BMJ, there was an article about why Dutch GPs are happier.  One of the reasons given was that Primary Care write their own guidelines in Holland.  In the UK, guidelines are more often developed in a more secondary-care-centric fashion.   I wonder whether having Primary Care take the lead on writing their own guidelines would help avoid the over-diagnosis effect.

What would a guideline for sepsis look like if it was being written by GP’s for GP’s?  I think it might look a bit like this…

• Always consider sepsis if a person presents with signs or symptoms that indicate possible infection.  In primary care the presumption is that the febrile patient is unlikely to have sepsis.  However a small proportion do and detecting this requires vigilance.
• Finding a simple explanation for signs and symptoms does not mean that a person does not have sepsis.  The possibility of sepsis is less about the specifics and more about the severity of signs (such as tachycardia) and symptoms (such as feeling very unwell or being significantly affected by the illness).
• Be especially thorough if a patient or parent is especially concerned or attends repeatedly for the same illness.  This does not necessarily indicate sepsis but should prompt a thorough re-evaluation of the patient’s wellness.
• Be aware that communication difficulties put patients at higher risk.
• Be aware of high risk groups and have a lower threshold for referral.
• The seriously unwell patient is usually easy to recognise.  The difficulty lies in recognising the patient who is in the early stages of sepsis.  It is also these patients who are the most likely to benefit from early recognition.

…or something similar.

I think that most of that would be agreeable to most clinicians.  After that, I find myself struggling to agree with myself over the nitty-gritty of the what to do when in each circumstance.  The reason for that is that there are so many common scenarios that make a sepsis pathway virtually impossible to write.  Some of these scenarios are the post immunisation baby with a fever, the six month old with bronchiolitis and tachycardia and the 2 year old with viral wheeze.  Each of these cases bring an interesting sensation to the mix.  I inherently feel that sespis is much less likely in these children and yet each will be spat out of my decision tool with a tequila coloured label of some kind.

What is the solution?  I feel that sepsis guidelines need to promote the rule-out value of wellness.  Wellness seems vague but it is really a combination of gestalt (gut feel) and what we see a child do.  Gestalt is valid as long as it is built on plenty of valid clinical experience.  What we see a child do is valid because when a child smiles and plays, it tells us that the frivolous centres of the brain are perfused and not toxic.

Will wellness be in your sepsis guideline?  I don't know, but there is one way to be sure.  Write it yourselves.  Meanwhile, the NICE guideline is still in consultation and if you are in the UK there is time to register as a stakeholder and send comments.

There is also one last chance to take part in the survey that is seeking to gain consensus on the factors that clinicians everywhere use as part of their rule-out process in ill children.  Please do take part.  It takes less than five minutes.

Edward Snelson
Simplologist
@sailordoctor

Disclaimer: Simple is easy when you're not actually writing the guidelines.

References

1. Sepsis - NICE guideline in development (closing date for comments 22nd Feb 2016)
2. Green et al., Admission to hospital for bronchiolitis in England: trends over five decades, geographical variation and association with perinatal characteristics and subsequent asthma, Arch Dis Child doi:10.1136/archdischild-2015-308723

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.