Non-specific abdominal pain and medically unexplained symptoms

In the early days of GPpaedsTips, I wrote about how I don't like to diagnose non-specific abdominal pain unless constipation has been ruled out.  I think that especially in the pre-teens, undiagnosed constipation is a big factor in mysterious abdominal pains.  In the child where such causes have been ruled out, it is curious that we have kept the term 'non-specific abdominal pain' (NSAP) or 'recurrent  abdominal pain' (RAP) when the label of 'medically unexplained symptoms' (MUS) fits just as well, if not better.

First of all, let's deal with the elephant in the room.  Medical terminology is always evolving and it is sometimes hard to keep up.  Many of us heard different terms used when we first studied medicine (such as functional or psychosomatic) for what seem to be the same clinical scenarios that are now labelled as MUS.  I don’t like perpetual re-labelling of problems. Medically unexplained symptoms, for me, is an exception to this dislike.  MUS removes the judgement of how much a problem is psychological and how much it is physical.  MUS acknowledges that there is always a combination of the physical and psychological.  How much of each component exists is neither measurable nor essential to know.  Is it 60:40 or 30:70?  I don’t know.

The other benefit of calling the situation MUS is that it recognises the possibility that an unknown physical cause may exist.  If a symptom has no medical explanation, the problem may be that medicine has failed to explain the symptom.  Although very few MUS scenarios end up with a eureka moment later on, a significant physical cause is sometimes found.

One definition of MUS is, "symptoms for which a treating physician or other healthcare providers have found no medical cause, or whose cause remains contested."(1)  When a young person presents with recurrent abdominal pains, once the physical medical causes have been ruled out, what we are left with is a medically unexplained symptom.  Labelling the scenario as NSAP is historical and has the potential to be revisited.

Is there anything wrong with the label of NSAP?  I can see two potential pitfalls, both of which arise from that way that it sounds a lot like a diagnosis.  The first problem is that both family and clinician may see the matter as closed.  This carries the risk that a diagnosis might be missed, especially if it is one that easily goes beneath the radar, such as coeliac disease.  This publication lists various pathologies that were found following a diagnosis of NSAP. (2)

Nor should we over-investigate.  As discussed in a recent review article on MUS in ADC (3), the problem here is the "impossibility of proving a negative."  Rather than give every child with abdominal pain an endoscopy, the middle way of leaving the diagnosis open while observing and looking for a recognisable pattern may be safer than labelling as NSAP.

The second problem is that any psychological component may not be addressed.  Is there a psychological component in NSAP?  I would say that there always is but for different reasons depending on the scenario.  The more physical the problem, the more distressing it is to have chronic symptoms that cannot be easily explained or be treated.  If the symptoms could be described as being secondary to a psychological cause, then the psychological component is self-evident.  There is no chronic abdominal pain scenario that I can think of that would not benefit from a dual physical-psychological approach.

I think that this dual approach is what tends to be done with NSAP already, whether it is managed by GP, paediatrician, gastroenterologist or surgeon.  An open minded and holistic approach is essential when managing medically unexplained abdominal pain in young people.


Managing medically unexplained abdominal pain in young people in Primary Care

In some cases, a cause of abdominal pain is obvious.  Common pathologies are constipation and reflux oesophagitis.  Both can be managed in Primary Care if there are no red flags and the problem responds to treatment.  Even when the cause is less obvious, the cause is often constipation, which is why it is worth really asking in detail about diet, bowel habit and the pain.  I also believe that a trial of macrogol laxatives is often a good strategy in the absence of an obvious cause.

In more extreme cases, there may be red flags such as weight loss, or bloody mucousy stools.  These children should be referred though an urgent route (inpatient or out-patient depending on the circumstances).  If the symptoms are severe enough to warrant immediate admission and investigation, laparoscopy finds a cause in about half of patients. (4)

There are also cases where there appears to be a psychological cause, often related to stresses such as school, bullying or even abuse.  It is still important to consider physical causes but there is nothing wrong with moving to address the psychosocial causes early on.

In some cases there is genuine ongoing uncertainty.  The usual pathway for these children is to refer to paediatric surgeons, paediatrics or paediatric gastroenterology for further investigation.  After this, clinical psychologists are often involved.  I don't know what they do.  Witchcraft or something.

Edward Snelson
@sailordoctor
Unexplained Medic

Disclaimer - If you can't explain it, it's not my fault.   You're clearly not trying hard enough.

References

1. Medically unexplained symptoms, Wikipedia
2. Sanders, D et al, A New Insight into Non-Specific Abdominal Pain, Ann R Coll Surg Engl 88(2); 2006 Mar
3. Cottrell, D, Fifteen-minute consultation: Medically unexplained symptoms, Arch Dis Child Educ Pract Ed 2016;101:114-118
4. Decadt, B. et al, Randomized clinical trial of early laparoscopy in the management of acute non-specific abdominal pain, British Journal of Surgery, Vol 86, Issue 11, pages 1383–1386, 1 November 1999

Sepsis in Children – What is in a Name?

I was recently asked, “How do you recognise sepsis?”  Answering that question would be so much easier if only we knew what sepsis was.  A recent convention of experts recently met in an attempt to define the term. (1) What they came up with was: “life-threatening organ dysfunction caused by a dysregulated host response to infection.”  All we need now is a definition of organ dysfunction and we’ve got this thing sorted.  (Sigh)

Sepsis is increasingly in the media and we are frequently told that:

• We are poor at recognising sepsis in children
• Recognising sepsis early saves lives
• Sepsis is recognisable

But coming back a step, I just said that sepsis is an unknown quantity.  How can any of the above be true then?  Unfortunately they, like all lies, have a basis in truth.  So the best thing is to look at a few facts and opinions and then, you can decide what to do with all of it.

We are poor at recognising sepsis in children

Sepsis is diagnosed at the point in the illness when it is clear that the infection has had a significant dysfunctional and systemic effect.  Since it is always preceded by an infection that is having some effect, that moment is difficult to define.  As a result some of the following things may occasionally happen:

• Someone will diagnose sepsis and than say that the last clinician to see the patient 'missed the diagnosis'.
• People make assumptions without speaking to the clinician who made the initial assessment.
• Something definite will happen such as a growth on a blood culture.  Bacteraemia, interestingly, does not equal septicaemia.  This sometimes causes confusion.

Sepsis, to be clear, is a response to infection.  It is a subjective global assessment of the effect of an infection on a child.  Unfortunately this does not wash when it comes to academia.  As a result people resort to things that are definable or binary.  SIRS is a perfect example of a clumsy attempt to define an intangible entity.  Many publications use positive blood cultures as evidence of sepsis.  The two things may sometimes go together but they are not at all the same.

All of that said, it is true that a large proportion of children later deemed to be septic have seen a primary care clinician in the 24 hrs before sepsis was recognised.  In many cases there is retrospective evidence that sepsis was present.  In many cases the child was probably not septic yet.  However, it is very difficult to remain constantly vigilant for a syndrome which is initially only subtlety different from all the non-sepsis.  Do we miss sepsis?  Of course we do, which is why we look for ways to improve the sensitivity of our assessment.

Recognising sepsis early saves lives

Logic dictates that sepsis left untreated is bad for you.  What is unknown is the potential harm caused by over-referral, over-investigation and over-treatment.  If we lower our threshold for treating presumed sepsis, how many children will come to harm for every child saved?  No-one has meaningfully looked at that.  Meanwhile, the only direction we seem to go in is towards caution, without a great deal of consideration for the possible dangers.

Sepsis is recognisable

This is where it gets tricky.  Those who are trying to improve recognition of sepsis through the writing of guidelines have to give the reader something solid.  There is little point in a guideline telling someone that they should make a gestalt assessment.  There are also learning tools such as spotting the sick child.  Reading the guidelines and these websites will raise as many questions as give answers.  That is because recognising sepsis is just not that easy.

I now return to the original question, “How do you recognise sepsis?”  Mainly, I do three things.

Although guidelines may emphasise the importance of abnormal physiology, I think that experienced clinicians quite rightly give weight to the child’s activity and behaviour.  That doesn’t mean that the heart rate is unimportant, just not the only or most important thing.

What about blood tests?  Well, this is also in the journals quite often at the moment.  In children, white cells go up quickly in any infection, making that unreliable.  CRP lags behind the infection so that by the time this is raised the child is often already clinically unwell.  Inflammatory markers can not be relied upon to rule in or rule out sepsis.  With one or two rather orthopaedic exceptions, I simply do not use blood tests to help me recognise serious infection.  I make a clinical decision and take blood tests as baseline markers when intravenous antibiotics are given for presumed sepsis.

As clinicians, what we are good at is pattern recognition.  So, I am going to tell you what you already know.  Children with serious infections have a different pattern to their illness.  It looks a bit like this:

If a child is returning to baseline and doing things that reassure you, you can say that they are not septic.  That doesn’t mean that they cannot become septic of course.  That can happen to any child.  That is where good safety-netting comes in.

Edward Snelson
Retrospectologist
@sailordoctor

Acknowledgement - this post was originally requested by and published on the network locum blogsite.  Thank you for that.

References

1. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), JAMA, February 23, 2016, Vol 315, No. 8
2. Spotting the sick child

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

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

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

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

Question 1 - Does it need to be fixed?

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

Fingers should look well aligned when relaxed.

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

Question 2 - Might there be a sneaky injury?

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

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

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

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

Question 3 - Does it need to be immobilised?

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

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

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

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

More on that story in a later post.

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

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

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

Edward Snelson
@sailordoctor
Southwest Sheffield Thumb War Champion 1994

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

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

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

The Dysfunctional Dictionary of Developmental Delay

Children who have not reached a developmental milestone frequently present to primary care.  Sometimes the concern is raised by a parent but often it is another family member, a teacher or a health care professional who spots the ‘delay’.   Often, there is no significant problem.  Some children just do their developing differently.  This is not developmental delay.  However, true developmental delay is quite prevalent and the terminology used is frankly misleading both to clinicians and parents.  Understanding what is wrong with the words used is the key to coming to grips with this difficult subject.

The Dysfunctional Dictionary of Child Development

Milestones – this word is used to describe the age at which a child should do a thing.  In the same way that children behave unpredictably, they may not meet these targets.  These ‘norms’ are based on population studies.  Because children vary they may not fall within a specific milestone norm.  Some children skip a milestone entirely (e.g. crawling) but hit their next milestone (e.g. cruising) normally.

Developmental delay – This term suggests that a child is simply late getting to a developmental level.  If there is a pathological developmental delay, this is unlikely to be the case.  If a child has true delay, they will almost certainly be permanently behind their chronological age. In other words they will not 'catch up'.  (see diagram above)

Developmental delay – Another problem is that the term implies there is always a neurodevelopmental cause.  This fails to give weight to the fact that delay can be due to something which obstructs development.

Global Developmental Delay – A child has GDD if they are delayed in at least two of the developmental domains.  They can be developing normally in the other two and is therefore a misnomer.

Developmental impairment – This is a more accurate term than developmental delay.  It’s just that I think that it doesn’t sound very nice.

Intellectual impairment – this is the correct term if we are talking about the over 5 year old.  Developmental delay or impairment should only be used for the under five year old.  Who knew?

Of course we need terminology and this vocabulary is what we have to work with.  We just need to know the limitations of the words we use so that they cause minimal confusion.

What is a primary care clinician to do when a child has a possible developmental delay?  Because there is so much variability in children it is reasonable to watch and wait (in the absence of red flags) when there is a ‘late’ milestone in an isolated domain.  If the delay persists or involves more than one domain then the chances of a significant problem is higher.

It is worth considering the causes of delay that can be relatively easily identified.  Delay in one domain is more likely to have such a cause.  For example, a child under the age of 2 who is not meeting their gross motor milestones may have dislocated hips.*  A child with speech delay may have ‘glue ear’.  These problems will obstruct development so early identification of such things can be life-changing.

Another cause that could be identified in Primary care is Muscular Dystrophy.  Although rare, this is an important cause of delayed mobility in boys.  A normal Creatinine Kinase (CK) is an easy way to rule this out if a boy is not achieving gross motor milestones.

What should I do in primary care?

• Take the history
• Examine the child including
• Primitive reflexes
• Tone and posture
• Head circumference
• If delay is limited to one domain, look for an identifiable/ treatable cause
• Speech – hearing test/ speech and language assessment
• Gross motor – check lower limbs including hip dislocation. Test CK in boys.
• Fine motor – test visual acuity
• Social – encourage environmental stimulation if appropriate.  Consider possible autistic spectrum disorder.
• Observe initially if appropriate or refer if red flags

While most cases of true developmental delay are idiopathic, advances in genetic testing mean that a cause can often be found. Although this rarely leads to specific treatment that does not mean that we should not investigate for a cause.  It is very important to most parents to find out why their child has developmental delay both for understanding and to help get appropriate support.  In addition a diagnosis may have a recurrence risk in future pregnancies.

Edward Snelson
@sailordoctor
Dysfunctional Lexicographer

*Congenitally dislocated hips is now more correctly named 'Developemental Dysplasia of the Hip')

Kids get hit in the head a lot

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Edward Snelson
PhD in age-specific phrenology
@sailordoctor

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

References

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

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

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

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

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

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

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

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

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

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

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

Edward Snelson
@sailordoctor

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

References

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

Refer All Patients (Easter egg - laryngomalacia)

Referral rates from Primary Care have risen over the past ten years yet children are having the same symptoms and illnesses.  Increased referral is sometimes because there are more treatments available and is therefore quite appropriate.  In the case of laryngomalacia, there are really only two treatments, time or surgery, so why should more children be seen by specialists?

I suspect that the answer is partly parental expectation and partly the undermining of the clinical independence of General Practice.  I believe that both of these can be affected by making sure that we know everything there is to know about such conditions.  This allows us to explain the problem confidently and manage it (where appropriate) ourselves.

Sometimes, clinicians in secondary care have anxieties about the ability of primary care to assess and manage a condition and they mitigate that by recommending that all are referred.  General Practice has been the place where uncomplicated laryngomalacia has traditionally been managed.  The case must then be made for that to change if necessary.

So, I will go through some things that you may or may not know about laryngomalacia.  Before I do that, I will give a quick overview.

Laryngomalacia is a condition caused by an abnormal laryngeal cartilage.  It is a dynamic problem that evolves from birth, partly to do with shape and partly to do with floppiness. The typical presentation is that of a child who starts making upper airways noises (video link here) especially when lying down.  Everyone know that upper airways problems are dangerous, yet at least 90% of laryngomalacia will resolve without causing significant problems.

In order to be confident in this we know a bit about it.  Here are the trade secrets.

1. Laryngomalacia is not truly congenital

Although the abnormality may be present or evolving at birth, it is not clinically apparent immediately.  There is something that happens to the larynx shortly after birth which completes the airway abnormality and so the typical clinical presentation occurs sometime in the first few weeks of life.  Stridor that is present immediately after birth is therefore a red flag.

2. Laryngomalacia has a sense of humour

Parents will present their children for assessment with anxiety and frustration in equal measures.  The anxiety is completely understandable.  Their baby makes a noise when it breathes!  The frustration comes from the child's apparent inability to perform during the consultation.  Often a description is all that is needed.  Smart phones make it possible for parents to bring recordings or alternatively you can show them the video link above for reference.  

3. There are pretenders
As always, there are conditions that present in a similar way to laryngomalacia.  Essentially any problem that causes chronic airways turbulence can cause a similar scenario of intermittent stridor.

Pretenders include:

• Vascular rings (blood vessels that encircle the trachea)
• Subglottic stenosis (e.g. due to endotracheal ventilation)
• Cysts
• Polyps
• Webs
• Haemangiomas

If the diagnosis of laryngomalacia is uncertain, it is best to refer so that the ENT specialists can do an endoscopy in an outpatient clinic.

4. Laryngomalacia has a  synergy with gastro-oesophageal reflux
If the laryngomalacia is problematic, the baby will compensate by increased work of breathing.  The greater negative pressures created to overcome the laryngomalacia then increase reflux of milk into the oesophagus.  This can in turn cause inflammation of the epiglottis, worsening the turbulence of the upper airway.  For this reason, anti-reflux medication is now often used is a baby has symptomatic laryngomalacia.

5. Most cases will follow a benign course
About 9 out of 10 babies with laryngomalacia will have no problems with feeding or breathing.  If there are signs of respiratory distress, or symptoms of feeding difficulties, I would normally refer for assessment by an Ear, Nose and Throat specialist.  Most of these children will still require no surgical intervention.

So, one approach would be to carefully assess whether the history and examination are consistent with laryngomalacia and that this is not adversely affecting the child.  If both of these are true then referral is not necessary for the clinician who is confident to provide good safety-netting advice and watchful waiting.

If you have any other strategies or thoughts on this subject please post a comment below.

Edward Snelson
Unknowingly uncertain but rarely indecisive
@sailordoctor

Disclaimer - If you ask ten doctors about this you will get nine different answers and one story that goes on indefinitely.

If it isn't broken

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

1.  Children injure themselves in different ways to adults

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

2.  Small children may not localise injuries well

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

3.  It is particularly desirable to avoid radiation in children

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

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

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

5.  Some children perceive and respond to pain differently.

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

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

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

7.  The injury should fit the mechanism

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

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

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

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

Edward Snelson
@sailordoctor

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

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

• Head injuries
• Finger injuries
• Pulled elbows

The Best Medicine

We all want to give the best medicine. If you are not part of that ideology, please stop reading. This is not for you.

Prescribing for children is tricky.  Sometimes dosing is about weight, sometimes age and sometimes it's not that simple such as when giving bronchodilators.  The choice of treatment is also difficult. I try to practice evidence based medicine but there is often a lack of good quality research on which to base my decisions.

In the brave new world of guideline driven medicine, there is one factor that I don't often consider and that's a shame because it can make all the difference.  That factor is the acceptability of the treatment to the child.

In our desire to make a child better (or at least feel better) it may be wise to consider what the child wants. I know, that's crazy talk.  But the best medicine may just be the one that the child will take.

Let's talk about a few examples.

What is the best corticosteroid for treating croup?

I recently ran through the management of croup.  In that I addressed a question that I am often asked by my GP colleagues: "Should we be giving dexamethasone or prednisolone?"  The evidence comes down gently in the favour of dexamethasone. However,  prednisolone is often cheaper and more readily available.  

But what would the child choose?  I have prescribed each of these steroids enough times that I've got a strong suspicion that a consumer survey would say dexamethasone is the customer's favourite.  This is based on the number of pens I have worn out writing that prednisolone can be re-administered since the first dose is now fluorescent decoration on a parent's clothes.  This is a lot easier to sort out while the child is sat near me in the ED.  It's less easy to resolve if they've picked up their medicine from a pharmacy and are at home when they vomit back their steroid.

I don't have the facts on how many children spit out or vomit back prednisolone versus dexamethasone.  It would be good to know so that I could offer more than a belief when someone asks the dex/ pred question.  In the absence of hard facts, I will continue to point to the dex bottle and mouth, "This one!" in a way that allows plausible deniability.

What is the best oral antibiotic for bacterial tonsillitis in children?

I recently read with interest an article in the Archives of Disease in Childhood about another treatment choice that would affect even more children.  This article had the bravery to question the well established practice of giving ten days of phenoxymethylpenicillin  to children with suspected or proven streptococcal tonsillitis.  Apparently the old thing about a high proportion of cases of Epstein-Barr virus (EBV) infection having florid rashes when prescribed amoxicillin is a myth.  Well, technically it is a misunderstanding (or mythunderstanding perhaps?) since the reaction described originally was to ampicillin.  The latest evidence is that there is no increased occurrence of rash when amoxicillin is given and EBV is present.  Can I trust no one?

The article goes on to mention (casually, as if to avoid hate mail) that since amoxicillin is better tolerated by children, perhaps we should prescribe this instead of phenoxymethylpenicillin.  Bonkers.

Now before anyone changes their practice, there is another consideration: antibiotic guardianship.  Amoxicillin has a broader spectrum of antimicrobial activity and with rising bacterial resistance we should be using broad spectrum antibiotics as infrequently as possible.  What is exciting to me is that someone has questioned our long-continued routine.  Better still, they have as good as involved the child in the discussion that should rightly follow.

Is phenoxymethypenicillin that bad?  Parents frequently tell me that the phenoxymethylpenicillin prescribed to their child has transformed them from a nice child with a febrile illness into some sort of rabid beast undergoing an exorcism.  It seems entirely reasonable therefore to ask that the writers of guidelines consider whether the evidence and stewardship of phenoxymethylpenicillin outweighs the acceptability of amoxicillin.  How many additional completed completed antibiotic courses would it take to allow amoxicillin to win in a straight fight?

I would not be me if I didn't mention the other option for the child who has a deep loathing for their antibiotic.  There are ten good reasons to make stopping the antibiotic the best way forward. There is only really one reason to change to something like amoxicillin: the child needs the antibiotic.

Edward Snelson
@sailordoctor
Medical mythologist

Disclaimer: Trust no one

References

1. Christine Chew, Anu Goenka "Does amoxicillin exposure increase the risk of rash in children with acute Epstein–Barr virus infection?" Arch Dis Child doi:10.1136/archdischild-2015-310364
2. johnathanlaird.com "The Ten Real Reasons Not to Prescribe Antibiotics"

Socrates to the Rescue - When "Why?" Becomes How to Recognise Child and Adolescent Mental Health Problems

How can a paediatric subspecialty be so difficult and shrouded in mystery?  Even the name, Child and Adolescent Mental Health Services, is complicated.

What do they do?  The mystery extends to the online world of open-access medical education.  Because I am putting together some resources for a university course at the moment, I went on my usual trawl for journal articles and online resources that might give me an idea about how we mere mortals should be doing our bit for child mental health problems.  Compared to similar advice for asthma, sepsis or even just the limping child, there is virtually nothing out there for the clinician who recognises child mental health as a personal educational need.

What to do?  Phone a friend.  Yes, I spoke to an actual person.  My expert told me that there are simple things that we can do to be a bit better at this.  We need to ask more questions.

In order to do this we must enter the mind of a two and a half year old...     ...or an ancient Greek philosopher.  You decide.

If you've never taken a two and a half year old for a quick jolly down to the shops then you've really missed out.  It goes something like this:

Socrates taught his students to question everything, including the answers to their questions.  In this way, the answer behind what was superficially apparent comes to you.  It's something that we all knew briefly when we were two and a half, but sometimes forget now that we are grown up and a bit dull.  What is superficially apparent can seem to be the end point, but in child and adolescent mental health, it probably isn't.

Let me apply Socratic (if Socrates was two and a half) method to some common presentations to General Practice or the Emergency Department:

A 12 year old has abdominal pains that only occur during school terms.
Obvious answer: School avoidance.
Ask the question, "Why school avoidance?" - Answer: Anxiety symptoms due to undiagnosed dyslexia.

A 13 year old is smoking cannabis every day.
Obvious answer: Bad parents and a chaotic home.
Ask the question, "Why?" - Answer: They have been having anxiety symptoms every day for nearly a year.  Months ago, they were given some cannabis to try and they found that it helped take away that feeling.  They started using it to feel more 'normal', not to get high.

A 15 year old has multiple symptoms for which there is no sensible medical explanation.
Obvious answer: Attention seeking
Ask the question, "Why?" - Answer: No obvious reason, so what else is going on?

The list of things that young people present with that are viewed as behavioural include cutting/self-harming and anorexia.  The reasons may be elusive, but they may also be identifiable.   There may be a safeguarding issue.  

Every one of these children deserve to have someone ask the question "why?"

In many cases they may not know why.  They may not be able or ready to articulate it even if they do know.  However, many young people can explain why they do what they do if someone is willing to give them a safe place to do so.

The important thing is to move away from making the obvious assumptions and instead always assume that there is more than meets the eye.  The evidence is that mental health problems in young people are often not recognised.

In Emergency Medicine there is a saying, "The easiest injury to miss is the second one."  That is equally true of child mental health. How do we make sure we always find the hidden problem? I don't know. Ask a two year old.

Edward Snelson
@sailordoctor