Do something for you today - reduce a pulled elbow

At least once a day, I like to think I have just simply fixed something.  Since I am not very good at DIY, that means finding some other way to scratch the itch.  Reducing a pulled elbow is hugely satisfying and anyone can do it if they know when and how to do so.

Pulled elbow (also called nursemaid's elbow) is not a true dislocation of the elbow but rather a subluxation of the radial head within the annular ligament of the elbow.

Based on empirical evidence, a pulled elbow hurts.  Additionally, there is often a second victim: the person who was involved in causing the pulled elbow (although there isn't always another person involved).  In fact, I was once hugged by a grateful relative after I reduced a child's pulled elbow.  What they don't know is that I already wanted to hug them for bringing me the elbow to fix.

Whatever specialty you work in, there are times when too much of what you do is intangible.  Sometimes I can see patient after patient and despite pouring my heart and soul into what I do, I don't get the feeling that I have really made anyone better.  These days are when I need a pulled elbow to shake that feeling off.  If you ever get the chance, I highly recommend doing it.  It is a fairly easy thing to do and, as I discovered recently, there are so many ways to do it.


When to attempt reduction of a pulled elbow

Before discussing technique, knowing how to do it isn't nearly as important as knowing when to do it.  There are some things that need to be considered before attempting a reduction.  Anyone can fix a pulled elbow, as long as they ask the right questions beforehand.

Is the child the right age?  There is bound to be a bell shaped curve for the age at which a child can get a pulled elbow. I would be sceptical about that diagnosis from the age of five up.

Does the mechanism fit with a pulled elbow?  Typical mechanisms include toddlers being swung around by fun uncles, toddlers being grabbed to keep them from running into the road etc.  A fall from a height is not likely to be a pulled elbow.

Are there signs that are inconsistent with a pulled elbow?  With distraction (not the anatomical kind), have a gentle feel of the elbow.  There shouldn't be any swelling.  There may be tenderness at the radial head but not in the distal humerus.  Feel all of the limb from the clavicle to the hand.  The two places that you are most likely to find point tenderness are the clavicle or the distal radius.

Often, children have had a previous episode.  If everything points towards a pulled elbow, there is no need to do an X-ray before attempting reduction.

How to reduce a pulled elbow

When I first did paediatric emergency medicine, I was taught to extend and supinate the elbow to reduce it.  That seemed to work most of the time.

Then, when I returned to work in a paediatric emergency department, I was told that flexing and pronating was better.  I have been doing it that way since then and it feels like it works more often.

 Of course the scientist in me is sceptical about the change.  Maybe something else affected  my success rate.  So what does the evidence say?  I was intrigued to find studies including other methods that I had not heard of, such as flexion with supination. (1)  I even found a Cochrane Review (2) which looked at the question.  It dodged the flexion vs extension question but concluded that pronation was probably successful more often than supination and possibly less painful.

So, I asked people on twitface which method they tend to use.

While finding it reassuring that two thirds of my colleagues were doing it 'my way', I was also interested to see that many will use a different method and that every possibility of twist and bend/ straighten is felt to be valid. 

I was pleased that nobody said anything about having to put firm pressure on the radial head.  I believe that all recommendations to do this are based in myth.  There is no logical reason why the radial head needs any guidance and I certainly don't press on the painful bit while applying my swift twist and bend.

I was also pleased that someone pointed out that if necessary, these can be left alone to resolve.  They always do, although it might take a day or two to finally slip back into place, during which time there will be discomfort.  I would still advocate reduction as success means that the resolution of pain is pretty much immediate.

Which brings me back to my original point.  How you do it is very much secondary to when you do it.  So, instead of worrying about technique, when the time is right, do something for you and fix a pulled elbow.

Edward Snelson
Notanosteopath
@sailordoctor

Disclaimer - I say that there are lots of methods, but my way is the right way.

For general principles of assessing children's injuries, follow this link.

References

1. Macias CG et al, A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations, Pediatrics. 1998 Jul;102(1):e10
2. Krul M et Al, Manipulative interventions for reducing pulled elbow in young children, Cochrane Library

Assessing Pain in Children - How Green Was Your Valley?

What is the best approach the assessment of pain in a child?  That is a big can of worms.  We want to understand the pain so that we can treat both the pain and the underlying cause but much of what we do comes from adult practice.  Rethinking our approach requires an understanding of what pain is to a child.  Pain is a very different thing for a child and so our approach must also be different.

Pain is an abstract thing, and the younger the child, the less abstract their thinking is. 

The internet has plenty of comical examples of things that children have written or said that are reminiscent of the story of the Emperor’s New Clothes.  In fact one of the most endearing things about children is the way that they often combine straight talking with unspeakable truths.  The ability to think abstractly and interpret what someone means (rather than what they are saying) develops as children grow.  We tend to develop what is needed for these situations based on experience of past events. To give you an example of adult thinking, I give you this excerpt, involving a word game, taken from a radio comedy with Benedict Cumberbatch and Roger Allam.  I think that this is a great example of how adults use words in bizarre ways and still manage to make sense.

Why does this word play make sense to any of us?  Years of having our minds messed with is the only answer that I can suggest.  Expressing feelings like pain relies on similar processes to that of understanding complicated jokes.

In order to account for these difficulties, some people adopt a standardised approach that allows children to choose how they express the magnitude of their pain.  I carry a card with the Wong-Baker faces (pictures of faces that go from smiley to sad)  and, if appropriate, ask the child to use the faces, words or numbers to say how bad their pain is.  My experience is that even this seemingly child friendly approach gives us the illusion that we are getting a meaningful answer because I am effectively speaking a different language.

When we are asking children about pain, how can we expect them to respond if they have not experienced that feeling before and lack the ability to describe it?  Imagine a nine year old presenting with abdominal pain.  All of the following questions are commonly asked of children in that assessment.  The responses are all real as well.  What I have taken the liberty to add is the internal response (I) that the child is having in their head.

Q. What does your pain feel like?  Is it sharp, burning, aching or colicky?

I. It feels bad.  Burning feels bad.  May be that’s the right answer. Someone called it tummy ache.  That must be it.  Aching.  If I say aching, the doctor will stop looking at me like that.

A. Aching I guess

Q. Does your pain come and go?

I. It hurts now.  It hurt yesterday. I’m not sure what the doctor means.  Why is the doctor still looking at me?

A. (Shoulder shrug)

Q. How bad is your pain? We use these numbers and faces here to help you chose an answer. (Shows Wong Baker Faces scale)

I. What is with all these questions?  Bad is bad.  My tummy hurts and it feels bad.  That’s not one of the choices on the list.  ‘Hurts more’ is there though and my tummy has definitely got worse while I’ve been sat here.

A. Points to ‘Hurts a lot more’ (6/10 on Wong Baker scale)

So what should we be doing?  I am not saying that questions or pain assessment tools are unhelpful, just that they should not be applied unthinkingly.  The trouble is that the child wants to give you an answer.  I think that sometimes they want to give an answer so much that they might give one for the sake of giving an answer. I think that there are two simple things that do work really well with children.

1. Just ask them what their pain is like.  A nice open question will tell you one of two things.  Either the child will describe their pain in a way that makes sense to them or they will make it obvious that they don’t really understand how to describe their pain.  Having no answer is better than a forced answer.  If they seem able to begin to describe their pain, you can progress to more closed questions and a scoring system perhaps.

2. Look at how they are behaving.  A significant tummy pain will usually manifest itself in some way in the child’s posture, activity or interaction.  A child who walks in and plays but says they have severe pain may be proving my point about understanding and describing pain.

Next time you see a child and want to know about their pain.  Ask them in a way that allows them to say what they want to say, in the way that they want to say it.

Edward Snelson
@sailordoctor

Reference
John Finnemore, Cabin Pressure, BBC Radio Comedy

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.