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

Croup - proof that a number is never enough information

Croup has to be one of the easiest upper respiratory tract infection diagnoses to make.  You can literally hear the child coming.  The classical croup picture is one of a child who has a cold for a few days and then develops a cough that sounds like a seal.  Although there are differentials listed in the textbooks these can also be excluded clinically:

• Inhaled foreign body - has not inhaled a foreign body
• Bacterial tracheitis and epiglottis - child does not look that unwell and is able to swallow their own saliva

So, it is a simple case of, "this is croup!"  The next job is that you have to ask yourself how bad the croup is.  The good news is that there are scoring systems available.  The problem with scoring systems is that they create the impression that the game is over.  It really isn't.

If you do use a croup score, you should see it for what it is: a snapshot which attempts to quantify what you see and hear.  As is often the case, these scoring systems are developed for the purposes of research and have been adopted into clinical practice.  It is equally valid to take the signs and symptoms and qualify these into a mild, moderate or severe croup.  You might find a scoring system helpful but it is not mandatory.  Whether you use a qualitative or quantitative method, the severity is only part of the picture.

One thing that guidelines often struggle to emphasise well is the importance of the trajectory.

All three children in the figure above have a Westley croup score of 4 when seen by a clinician.

Child A was found in the morning with a stridor and significant respiratory distress. As often happens, when the parents rushed the child to be seen, child A improved and now has the tail end of a soft stridor.

Child B was coughing, had a soft stridor all night and refuses to move out of croup limbo.

Child C was not so bad when they set off to see you but has got noticeably worse in the time leading up to the consultation. The game is just beginning for child C.

The score (or your qualitative mild/ moderate/ severe assessment) and the trajectory are the most important factors. I would also consider risk factors including co-morbidities and previous life threatening episodes of croup.

That brings us to croup management-

Turbulent flow of air creates more than twice as much resistance as laminar air flow. Children who have croup will tend to position themselves and breathe optimally if left alone to do so. Distressing the child either directly or via the parent can cause sudden decompensation.


If the child is in the severe category then facial oxygen should be given followed rapidly by nebulised adrenaline (epinephrine). Doses as per your formulary but at the time of writing that is 5mg for a child 2 and up where I work.  If not already at hospital, a child with severe croup should be moved there quickly. If already in an ED then the child may need further escalation but in many cases the adrenaline will buy time and avoid the need for airway management.


For mild and moderate croup the best evidence is for systemic steroids.(1)  There is evidence that dexamethasone is more effective than prednisolone.(1) Studies have also compared different doses of dexamethasone and found that there is no difference between giving the larger dose 0.6 mg/kg and the smaller dose 0.15mg/kg.(1) I have been using the lower dose for many years but have no hesitation in repeating the dexamethasone if the child vomits afterwards and it is uncertain as to whether the first dose stayed down.


Be warned, my GP land colleagues: dexamethasone liquid can be difficult to source from community pharmacies. NICE says that "Providers of urgent care services should ensure that dexamethasone is available."(2)  This may not be within your control.  Unless you know that your patients can get it easily, prednisolone may be the pragmatic choice.

I am very aware that treating mild croup is a relatively new phenomenon. If you fear change, please take comfort in knowing that I do too. However my dislike of medicalising childhood illnesses does not extend to croup. This is for two reasons. The first is to do with the aforementioned trajectory. I don't know which mild croups are going to become moderate or severe but some will and theses children may become victims of another fact of science.

The flow of air through a tube is reduced by the reduction in diameter to the power 4. If a child with croup gets worse and their airway haves in diameter then they will only be able to shift one sixteenth of the air. If that air flow becomes turbulent then you won't need a score to tell you how bad they are. So mild croup is not a thing to dismiss. It is level one of the game of croup. Level 1 is deceptively easy but unlike most games, level 2 is much harder and level 3 completely unexpected.

Edward Snelson
@sailordoctor

Disclaimer: It's not a game.

References:

1. Cochrane library review, Glococorticoids for croup
2. NICE, Clinical Knowledge Summary for Croup

Asthma, Overdiagnosis, Underdiagnosis and all that

A storm is coming and it's set to be a force 10.  There is much debate about how asthma should be diagnosed in children.  There are two opposing views and (guess what?) they are both right.  This conundrum, which occurs whenever a diagnosis is complex, is always the perfect setting for the perfect storm as clinicians struggle with the "right way" to diagnose an illness.

This week an article was published in the BJGP, talking about the overdiagnosis of asthma.

Overdiagnosis is an issue close to my heart because it causes morbidity through tests, treatments and time spent being medicalised, none of which are necessary because the patient does not have the disease.  In paediatrics there is a particular tendency to overdiagnosis due to the lack of precise information (what does the abdominal pain feel like to a 2 year old? It would really help to know!) and the desire to make the child better.  Being cute will have that effect.

Of course overdiagnosis is also at risk of distracting from the real diagnosis, thus robbing the patient of treatment that would be beneficial.

The above mentioned article contains some results that will make most of us sit up and take notice. Set in the four Dutch primary care centres, they found that in "more one-half (53.5%, n = 349) of the children the signs and symptoms made asthma unlikely and thus they were most likely overdiagnosed."

Very well, so essentially this shows that when you apply a new diagnostic pathway (retrospective analysis of signs and symptoms plus a generous use of tests including spirometry), it disagrees with the old diagnostic pathway, which was presumably based mainly on history and examination.  That doesn't feel very applicable to the 'real world' of diagnosing childhood asthma in a front line clinical setting.  Well get ready, because your 'real world' may be about to be rocked.

Earlier this year, NICE published a draft guideline for the diagnosis of asthma, including children.  This contains one particular proposed recommendation that surprised me: "Do not use symptoms alone without objective tests to diagnose asthma. (in children from the age of 5)"  Boom.

So, a six year old comes in with an acute wheezy episode.  This was not triggered by a cold.  It started when they visited an animal shelter.  The child has eczema and the parents are both atopic. When you see them, the child responds to the salbutamol that you give.  In further history the parents had noticed that the child coughs at night quite a lot.  Time to do some tests?

I await the final version of the NICE guideline with interest.  Meanwhile I am a big fan of the British Thoracic Society guidelines which stratify into three groups - low, intermediate and high probability of asthma.  These guidelines list the features that make asthma more likely:

• More than one of the following symptoms - wheeze, cough, difficulty breathing, chest tightness
• Personal history of atopic disorder
• Family history of atopic disorder and/or asthma
• Widespread wheeze heard on auscultation
• History of improvement in symptoms or lung function in response to adequate therapy.

And the features that make asthma less likely:

• Isolated cough in the absence of wheeze or difficulty breathing
• History of moist cough
• Prominent dizziness, light-headedness, peripheral tingling
• Repeatedly normal physical examination of chest when symptomatic
• Normal peak expiratory flow (PEF) or spirometry when symptomatic
• No response to a trial of asthma therapy
• Clinical features pointing to alternative diagnosis

Testing with spirometry etc. is reserved for times of diagnostic subcertainty.

Does this approach lead to overdiagnosis?  I am sure that it does, for the reason that that children with intermediate probability of asthma still might not have asthma.  While tests can add to the available information, the diagnosis of asthma remains clinical.

So how bad is overdiagnosis?  If I could avoid overdiagnosis then I would, but in medicine that is just not possible unless there is a perfect test available.  In most cases we have to set ourselves the challenge of being rigorous with our diagnoses without being overcautious.  Cautiousnesses leads to underdiagnosis  which is also problematic, depending on the burden of the disease.  I am happy to overdiagnose sepsis in babies for example.  I know that the alternative is disastrous. I am equally happy to underdiagnose colic.  Colic is not harmful and there is no effective treatment.

When it comes to asthma, there is a huge morbidity and mortality associated with this disease.  So while I agree with the study authors about the burden of unnecessary treatment when a child does not have asthma, I believe that the effect of moving our diagnostic goalposts needs to be considered carefully.  Will there be more underdiagnosis as the pendulum swings away from making the diagnosis of asthma on clinical grounds?  That is a real possibility and as far as I can tell no-one has looked at the burden of that change.

The bottom line is that asthma is a diagnosis that can be overdiagnosed and yet underdiagnosis is equally detrimental.  However, without turning to complicated investigations, overdiagnosis and underdiagnosis can both be avoided by considering all the factors that make a diagnosis more or less likely as per the BTS guidelines.

Edward Snelson
Over and under most days
@sailordoctor

This post has been all about diagnosing asthma in the 5-15 year old age group.  If you would like to find out more about the under five year olds you might like to read:

• How is your wheezer wired? Asthma vs Viral wheeze in the under 5 year old.
• High Voltage - What the diagnosis plus severity means for management of viral wheeze

References

1. Looijmans-van den Akker et Al, Overdiagnosis of asthma in children in primary care: a retrospective analysis, BJGP, 1 March 2016
2. Draft NICE Guideline for Consultation: Asthma: diagnosis and monitoring of asthma in adults, children and young people
3. British Thoracic Society /Scottish Intercollegiate Guidelines Network - British guideline on the management of asthma (Quick Reference Guide)

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