What was your question? (Easter egg - tests for bruising in children)

Fairly often, when a junior colleague is talking to me about a case I find myself asking, “What is your question?”  Sometimes the question comes at the end and sometimes not at all.  The thing is, I would prefer to have the question first and the details of the case second.  That helps me to understand everything that I am being told and it allows me to ask pertinent questions so that I can give useful advice.  I like it when people make things simple for me.

I realise however that this assumes that the person knows what their question is.  They might not.  Now this might seem like a bad thing but I have come to realise that it is not.  When someone comes to me without a clear idea of what is going on it means is that they have chosen me as a way of figuring out what their question is.  That is perfect.

What would be worse would be to do a test of some kind.  It might feel like this will add information, buy time, and clarify the question but it won’t.  If you don’t have a good idea of what the answer is before you do a test then you need to make sure that you know what your question is. 

Why is it particularly important to avoid unnecessary tests in paediatrics?  For two reasons:

• Investigations in children should not be done lightly.  They have a tendency to cause anxiety, pain or involve radiation.  Children rarely consent to having investigations so we have an obligation to avoid tests unless they are really needed.
• Most diagnoses in paediatrics can be made clinically and, if necessary, confirmed by an investigation.  It is unusual to use an investigation to look for a problem rather than to confirm it.  (The most significant exception to this is in testing urine in pre-school children.)

In most cases, one of two things is needed instead of tests:

• A more detailed history and examination
• Phone a friend

This brings me back to the discussions with my junior colleagues at work.  Discussing a case with a colleague is a superb way of clarifying your thoughts.  In many cases, the person who comes to me for advice has worked out what they want to in the process of discussing the case.  Sometimes I get phone calls from GPs who, half way through, decide they don’t need me any more.  If you work in primary or secondary care, this is the way to investigate a case, whether you know what your question is or not.

I was at the Trent Regional Paediatric Society yesterday and talking to Dr Suri from Rotherham who I know to be a very busy man.  Despite being so busy his genuine wish was that he was called more often for advice from his colleagues in primary care (and from the Emergency Department, I presume).  I realise that there is often little time to deal with a hospital switchboard but I would say that it should take less time than filling out a form for a test and later working out what to do with the result.

A good example of this effect of tests bringing more uncertainty is the child with bruises.  If you do a clotting screen I bet you will get one of the many results reported as being just outside the normal range.  Is that significant?  I don’t know.  What was the question?  If the question was “does this child have Haemophilia?” then the tests for that are complex and usually only done by a haematologist.  If the question was “can I rule out a clotting problem?” then even a normal clotting screen doesn't fully do that.

What is more likely to answer the question is a history that includes family history of bleeding disorders, excessive bleeding such as during dental procedures and cuts that never stopped bleeding.  An examination looking for lymphadenopathy, hepatosplenomegaly, joint problems, bruises in unusual places and petechiae anywhere is indicated.  In most cases I will not need to go ahead and do any test.  If I do want a test I might get a full blood count.  In that case I know what my question is: does this patient have thrombocytopaenia (e.g. ITP)?  A clotting screen will not answer that question so I don’t add it on just because I am taking blood.   The bottom line is that a clotting screen is not a good way to rule in or rule out clotting disorders in well children.  If in doubt I phone a friend.

What is certainly true is that a test might confuse the situation but discussing the case with someone who wants to help never should, assuming that they are experienced and helpful.  So, if you find yourself wanting the answer to a question or even unsure what your question is, phone a friend.  That could be a colleague where you work.  Alternatively, and if you can get hold of us easily, I hope that you will find your consultant colleagues in secondary care better value than the test you were wondering if you should do.   Another clinician willing to discuss the case is so much better than a test.  Why?  Well you can question a colleague; you can get their experience in addition to your own; they will bring new perspectives.  You can even disagree with them.  I tried arguing with a test result once.  It didn't work.

What I have learned from all this is to stop asking my colleagues at work, “What is your question?” and instead to enquire if the person has a question.  If not, that’s great.  Now I know that we are figuring out what the question is together.

Edward Snelson
@sailordoctor

Disclaimer:  I may occasionally forget all this and ask you what your question is.  I am probably tired.  Please make allowances.

Antibiotics - why I almost never prescribe them

Recently, during a session where I was teaching a large group of primary care nurse practitioners, one of the students interrupted and asked, "So, do you just never prescribe antibiotics?"  This was on about the third face to face day of the Core Principles module of the Paediatrics in Primary Care Diploma at Sheffield Hallam University.

When it comes to the issue of prescribing antibiotics in the various clinical scenarios we discuss on the course, I bring a fairly non-interventional approach.  My rationale for this is not however based on the reasons that I was taught when I was a medical student or even a GP trainee.  My avoidance of antibiotics comes from the simple realisation that they cause so many problems and are very rarely the solution to the presenting scenario.

This week I was asked to provide a guest blog for Johnathan Laird who has a site which gives practical advice about therapeutics in general.  Without hesitation I submitted my 10 reasons to avoid antibiotics in children.  None of the ten reasons are to do with resistance or oral thrush.  Here are two of the reasons:

Although it is probably my most strongly worded piece, I would like to add that I have without a doubt prescribed antibiotics that were not needed and that caused many of the problems listed.  All that I am trying to do is to be clear about why we should avoid antibiotics.  I do realise that a 100% appropriate prescribing rate is a nonsense.

So in answer to my student, I do prescribe antibiotics about three times every month.  Once for a pneumonia where the child is well enough to be treated at home, once for a urinary tract infection and once for a soft indication such as a throat or ear infection.  For the pneumonia and UTI the denominator is one, whereas for ears and throats the denominator is about fifty.  So do I just never prescribe antibiotics?  Not never but certainly with a high threshold and that threshold exists for ten good reasons.

Edward Snelson
Winner of the Connecticut State Science Fair
@sailordoctor

Disclaimer:  If my children so much as sneeze I give them broad spectrum antibiotics.  Any self respecting doctor does the same for their children.

I learned a new word today... (Easter eggs - 'Constipation' in babies and things you might not know about lactulose)

Why I have stopped using lactulose to treat babies

This month’s Archive of Disease in Childhood published an interesting paper on defecation patterns in infants. (1)  The most interesting thing for me was that I learned a new word: dyschezia.  The definition of dyschezia is difficulty with defaecation.  While it might seem like a superfluous word to those of us who use terms like constipation and painful, in the context of this article it has an important place in medical terminology because it makes a valuable distinction.

It has long bothered me that babies are referred to as being constipated.  Certainly they might go for days without passing stools and when they finally do they often do their best tomato impression.  While constipation is not the wrong word for what babies go through, it creates the impression that there is significant overlap with the constipation that is so common among older children and this is just not the case.

So what is happening to babies?  The truth is that we just don’t know.   Babies seem to be born with a tendency for their gastrointestinal tract to cause all sorts of alarming symptoms.  We use diagnoses such as colic and posseting in an attempt to give labels to things that seem to be normal phenomena in babies.  These problems are self-limiting however and are probably a feature of a GI tract that is 'learning' how to function effectively.  The trouble with each of these is that they have significant counterparts made up of a list of less common but very significant medical problems. 

Every baby who presents with symptoms that could be due to abdominal pathology should be carefully assessed to exclude such problems including urinary tract infection and surgical problems.  The full list of possibilities is much longer of course but the major clues that the baby does not have these is that they should be alert but settled, thriving and hydrated, afebrile and have no alarming signs or symptoms.

So if we are left with a baby which is not opening its bowels, straining at stool and intermittently getting upset, what do we do?  One thing that I am quite convinced of is that lactulose is not the best medicine for babies no matter what the problem. 

This brings me back my new word: dyschezia.  When babies fail to pass stools, or they strain and show signs of discomfort, they don’t have constipation in the way that a six year old has constipation.  The baby has a gut that is doing something but ineffectively while the six year olds guts are just not doing the thing at all.  “That’s fine,” you may say. “Lactulose is a stool softener so it will help the baby pass stool in this way.”  That’s what I used to believe too until a helpful pharmacist told me about how lactulose really works.  Lactulose does have an osmotic effect but it is also an irritant because when metabolised by the gut bacteria the result is chemicals such as acetic acid, lactic acid and formic acid.

So if a baby is failing to open its bowels because it’s a baby then I prefer not to use lactulose.  If I think that the problem is that the baby has guts that are trying, then driving them harder seems unfair.  I like to think about what we advise parents about how sensitive baby skin is.  How much more sensitive will their gut lining be?

What does work?    If anything is going to work, a glycerine suppository could be tried and in my experience is often successful.  More often the answer is time.  Essentially dyschezia is a common and transient phenomenon which will eventually resolve and is not a risk factor for constipation later in childhood. (1)  As is often the way in paediatrics, time spent looking for the correct diagnosis and explaining things properly to the parents is time well spent.

Finally, I think that dychezia is a terrible word, right up there with erythema toxicum on the list of things that I will never say to parents that their child has.  Can anyone out there suggest a better one?

Edward Snelson

Junior gunner, Crimson Permanent Assurance

@sailordoctor

If you found this helpful you might also like:

Feed histories in refluxy babies

Non-specific abdominal pain - why I haven't made that diagnosis for quite some time

References:

(1) Defecation patterns in infants: a prospective cohort study (Kramer et Al, Arch Dis Child, doi:10.1136/archdischild-2014-307448)

http://adc.bmj.com/content/early/2014/12/24/archdischild-2014-307448.abstract

Disclaimer:  I don’t know what babies are thinking either.

Schrodinger’s Safeguarding Case

Whether you've been practising medicine for 30 minutes or 30 years, dealing with the issue of safeguarding is one of the biggest challenges for any of us.  We are told that there are several must do’s such as:

Wait a minute...   I know the list goes on but those first two are quite enough to deal with before we process any more.  What those two statements mean in practice is that the minute I've thought of a way that this could be a safeguarding issue, I am doing mental gymnastics trying to figure out the following things: 

If this comes easily to you then you have my admiration.   For the mortals among us it is so challenging that at some point most of us have wished that there was no concern or that we didn't have to be the one that brought it up.  You have to be careful though, because when you find yourself wishing for these things you might just do something to make them happen.  It is within your power to explain the concern away.  It is possible to refer to someone else who will take your concern further without telling the parents.  Neither of these are good ‘ways out’.

The problem is that we often see the way forward as a choice or a judgement on the situation.  This choice forces us to feel as though we are choosing sides which is intuitively at odds with our instinct to be on the side of the parents.

There is a solution that I believe does work: Schrodinger’s safeguarding.   [If you don’t know about Schrodinger’s cat (a mixture of quantum physics and animal abuse that makes sense in a strange way) then don’t worry.]  The principle that I want you to get you head around is this:

In this way you can overcome all the barriers to dealing with the problem.

Because you treat the concern as fully real:

• You will act in the best interest of the child.  You will explore the concern until satisfied.
• You will involve all the right people.
• You will ask all the right questions and document things in far more detail than you would normally.
• You will tell the parents that you have a concern because you can’t do the first three things adequately without them noticing that something is going on.

Because you treat the concern as fully false you will come across differently and the parents will sense your open-mindedness:

• You will come across as non-judgemental.   You will be able to be matter of fact about the need for the safeguarding concern to be raised and answered and they will sense that you have not judged them.
• You will keep the health of the child as a top priority.  The parents will have come with their own agenda and you will remember to address that just as you would have normally.  This also helps parents to see that you have not de-humanised them.

So next time you have a safeguarding concern, do put it back in the box.  Not a Pandora’s box but a Schrodinger’s box.  You're not making a judgement but you do need to do both of your jobs.

Edward Snelson

@sailordoctor

Disclaimer:  Damn it Jim, I'm a doctor not a quantum physicist.

In Praise of Doing Nothing (Easter Egg – good safety-netting and saving lives)

When I ask parents if they have seen their GP about an illness they often reply, “Yes but they didn't do anything.”  I am most encouraged whenever I hear this.  So, no-one has done any tests or prescribed any treatment?  “Excellent” say I, “and your child is the healthier for it.” 

Here's why:

So, if you are one of these clinicians who are doing a lot of nothing, you have my thanks and admiration, because I know how much work it takes.   All I would like to do is add my top tips for making sure that the child with… let’s say a viral URTI, is sent out into the world with the best possible advice and safety-netting.  Why?  Because safety-netting is what makes all the difference when a child with an uncomplicated viral illness develops a secondary infection (or other complication).

• Try not to say the words ‘just a virus’ or ‘only a virus.’  Parents will tend to feel that you have not recognised how unwell their child is.  Acknowledge that the child is unwell and explain that viruses can make children quite unwell.
• To balance this, (lest they ignore signs of serious illness) explain that the hallmark of viral illness is that the child will intermittently pick up and look reasonable, often quite suddenly.  Children with sepsis and meningitis do not go from playing to lethargic and back again every few hours.
• Explain that children with a viral illness do sometimes get another infection added on which is usually more serious.  For this reason they must seek reassessment if the child is not picking up or if new problems develop such as abnormal breathing etc.  This part is especially important as occasionally I will see children brought in who are severely septic and the parents have delayed seeking another assessment because they were given what sounded to them like an ‘everything is fine and will be fine’ appraisal by the clinician that they saw.
• Advise regular paracetamol, fluids and to avoid overdressing the child.
• Do not tell parents that if the illness continues they should go to their emergency department to be assessed.  If they are well enough to be sent home then persistence of symptoms does not really warrant an ED attendance.  Save the ED option for the child who is worsening despite paracetamol etc.

It is truly an art to get that balance between being reassuring enough and safety-netting well.  However the worst possible thing would be to add tests to uncertainty or treatments to cover improbabilities.  So thank you and please keep doing nothing.

Edward Snelson

@sailordoctor

Disclaimer:  Safety-netting was invented by Roger Neighbour or possibly Houdini.  Check Wikipedia if you want.

Referrals – Inappropriate, Inconvenient or Unprofessional? (Easter egg - umbilical granuloma)

But first: why the hospital doctor who thinks that they have had an inappropriate referral probably has an educational need.

Every day, around the world, there is tutting by hospital doctors about the inappropriate referrals that they receive from primary care.   If we assume that both clinicians believe in good patient care and the best use of resources then someone must have an educational need for this situation to take place.  My question is: who has that need?

Let’s take a fictional yet real example: a baby with an umbilical granuloma.  The child has apparently been sent to the paediatric emergency department by the clinician who saw them in Primary Care.  The emergency department doctor sees the child, noting the inappropriate use of the ED to filter referrals from a GP.  They complain but accept their lot and assess the child but then send the child back to the GP.

Imagine that we could get the two clinicians to sit down and discuss what happened.  What the GP trainee who saw the child would say was that they thought that the child had an infection of their umbilicus, which they know to be a risk for sepsis in babies.  They tried to refer the child but they were passed back and forth between the paediatricians on call who said that this was a lump and therefore surgical, while the surgeons said that umbilical infections should be referred to the paediatricians.  In the end there was confusion and in the process both teams thought that the other had accepted it and the faxed letter from the GP never found an owner.

So the ED doctor might have been more sympathetic and less likely to say that the ‘referral’ was inappropriate when they found out that it was not a referral.  What the GP trainee might have learned is that umbilical granulomas often have a degree of discharge and look messy but that doesn’t equal infection.  They may have been interested to know that many clinicians are adopting a ‘leave it alone’ approach to umbilical granulomas since they have a natural tendency to resolve. (1) Some advocate hypertonic saline (2) as a topical treatment but ultimately if left alone, these unsightly lumps will go away if you ignore them for long enough.  Most will welcome the move away from the game of ‘hit the moving target with a silver nitrate stick’ while hoping that there is no accidental application onto healthy skin.

Lets hope that the joint RCPCH and RCGP document 'Facing the Future Together' with its 11 recommendations will provide an impetus for better communication between primary and secondary care.  I am particularly hopeful that point 4 becomes a reality because educational meetings can work both ways.

Facing the Future together: The first four standards-

So whenever something seems ‘inappropriate’, it may be a misunderstanding or there may be a genuine opportunity to share something between two professionals.  I accept that there are GPs who don’t care about inconveniencing patients or overloading their local emergency department but these are a vanishingly rare breed.  More often, if I get in touch to clear something up that is exactly what happens and I am just as likely to be the one set straight.  The important thing is to talk to each other and not about each other.  That really would be inappropriate.

Edward Snelson

Naturalised Citizen of the People's Republic of South Yorkshire

@sailordoctor #GPpaedsTips

Easter egg - for more on umbilical granuloma follow the links below

1. Umbilical granulomas: a randomised controlled trial J Daniels, F Craig, R Wajed, M Meates Arch Dis Child Fetal Neonatal Ed 2003;88:F257 doi:10.1136/fn.88.3.F257 http://fn.bmj.com/content/88/3/F257.1.full

2. http://www.ruh.nhs.uk/patients/patients_leaflets/paediatrics/Umbilical_Granuloma_patient_info.pdf
3. www.banglajol.info/index.php/BJCH/article/download/10360/7648  BANGLADESH J CHILD HEALTH 2010; VOL 34 (3): 99-102 Therapeutic Effect of Common Salt (Table/ Cooking Salt) on Umbilical Granuloma in Infants AKM ZAHID HOSSAIN, GAZI ZAHIRUL HASAN, KM DIDARUL ISLAM

Disclaimer: All the opinions expressed here are someone else's.

Why I need GPs to be medical leaders (Easter egg - GORD in babies)

Please Help Me to Change My Practice

In January 2015 NICE published the first of their newly branded ‘CG’s which happened to be Gastro-oesophageal reflux disease: recognition, diagnosis and management in children and young people.  I don’t know how you decide which NICE guidelines to look at but my filter is based on relevance and the extent to which they might make me cry into my coffee.   This one scored a 10, partly because I see lots of vomiting babies (with accompanying parent – this is usually the one I’m more worried about) and partly because we have known for a long time that the available treatments are inconsistent at best.  In the absence of a guideline it is much easier to work through the various non-pharmacological interventions and then take a stepwise approach to treatment, while hopefully the underlying predisposition to create laundry and sleep deprive your parents gradually resolves in time for me to take all the credit.

The truth is that when I see a child with reflux, things are usually pretty desperate for the family.  They are tired, smell of vomit and feel that every time they see a different doctor or nurse they are told something that contradicts previous advice.  I then find it difficult to admit that the problem with which they present is going to follow a course over which I have little influence.  Certainly I do make a difference where possible.  I explore the way that feeds are being given and often find that the volume of feed is excessive.  Occasionally I discover a previously undiagnosed urinary tract infection and get to feel like a real doctor.  More often there is no easy answer and I reach for my prescription pad to prescribe an alginate. 

The thing is that NICE have now said that the initial treatment should be a feed thickener if the child is formula fed.  That should be a simple thing to change but for me it isn’t.   

From CG1 2015

I remember well how in General Practice I used to do this process change.  One day I would find out something, next I would have a quick chat with my GP colleague and then I would get on and do it.  No major fuss.  How things have changed.  Now that I work in a hospital it takes months to change most things.  Certainly when there is an urgent need we get that turned around much faster.  (I won’t say how long faster is.  It depends.)   However if the change is less urgent it requires consensus, consultation and committees to the Nth degree.

In the interest of balance I should extol the virtues of this more cumbersome approach.  It would be chaos if there was no way of ensuring consistency of practices within the various teams of any hospital.  That consistency only comes if guidelines are agreed and well governed.  Achieving that sometimes feels ungainly but is far better than conflicting practices within the same organisation or changes that are ill thought through and are not universally agreed.

The good news is that in the case of these vomiting children it hasn’t been a problem.  The dilemma that I might have faced was taken away because thankfully the last few children that I have seen with gastro-oesophageal reflux were all being treated with feed thickeners and not an alginate.   Since previously the latter was the norm I can only assume that these GPs have decided to lead the way.  No fuss, no committees and no delay.  How wonderful that GPs are playing to their strengths and getting on with changes that take much longer for Secondary Care to implement.

So thank you for providing some true medical leadership.  For those of us working in hospital, we need you in General Practice to lead the way for us.  I’m sure we’ll catch up eventually.

Edward Snelson

Kiddie Doctor

@sailordoctor #GPpaedsTips

Disclaimer: All disclaimers are nonsense.

1. http://www.nice.org.uk/guidance/NG1/chapter/1-recommendations

More treats from the Easter egg:

1) NICE doesn't want us diagnosing 'silent reflux' so much

2) Some red flags here suggesting that there may be another diagnosis or that the GORD warrants rapid referral

Non-specific or non-diagnosis? Non-specific abdominal pain (Easter Egg: Constipation in Children)

Non-specific abdominal pain - why I haven't made that diagnosis for quite some time

I think that I have now heard more than a dozen definitions of constipation and diarrhoea, starting from a lecture that I recall well from when I was at medical school.  The lecturer gave scientific definitions based on volumes and frequency of stool passed in a 24 hr period that led me to believe that I would be able to conclusively diagnose or rule out constipation if only I took a thorough history and a large set of scales with me.

I also recall first hearing about non-specific abdominal pain in children.  It seemed mysterious and yet strangely credible.  It was, I was told, a diagnosis of exclusion.  Presumably the diagnosis of constipation in these children was being excluded by the use of CCTV installed in the child’s toilet and a rigorous measuring of the amount and consistency of everything brown before it was flushed.

I now know the reality, which is that the diagnosis of constipation in children is usually a guess, albeit it a good guess and hopefully an educated one.  Every week I see at least one child of the many who present to our Emergency Department with what turns out to be constipation.  In most cases the most significant symptoms have been present for many days and if one enquires, the clues have been there for months or years.  These children have usually had various people consider what the cause is - parents, GPs and Emergency Physicians.  Often the parents have been given no diagnosis; on other occasions non-specific abdominal pain might have been given as the cause. In reality, the well child with unexplained abdominal pain (once an acute abdomen and a urinary tract infection have been ruled out) almost always turns out to have constipation.

So my question is, how was constipation excluded in the diagnosis of exclusion that is non-specific abdominal pain?  I suspect that there are two things getting in the way.  The first is that it is almost impossible to get a good history about the bowel habit of a child.   They think that whatever they do is normal and their parents are unlikely to know what they are passing and how often.  The second factor is time.  I know that there is limited time to assess a child in Primary Care and let’s be honest, there are other more pressing diagnoses to exclude if a child presents with abdominal pain.  Ruling out a surgical abdomen and a urinary tract infection is always going to be the priority and I can’t do that in less than 10 minutes either.

I feel that there are opportunities being missed though and childhood constipation is one of the best diagnoses to make in primary care for several reasons.

1. It is a difficult diagnosis to make.  All clinicians want to be the first on the scene at a difficult diagnosis and this is your chance.
2. It requires good explanation and consultation skills in order to engage the family with understanding what is happening and what to do about it.  No further comment needed.
3. This is a condition that can be managed entirely in primary care without interference from anyone else.
4. It is a really satisfying condition to treat.  So much childhood illness either gets better on its own, responds poorly to treatment or is untreatable that we should be genuinely excited when we find a condition that probably won’t get better until we diagnose it and do something about it.
5. The effect on quality of life for the child and family is enormous.

I would suggest that non-specific abdominal pain is so often code for undiagnosed constipation that we only use it when constipation has been thoroughly ruled out.  I have been working to this for many years now and I find that once challenged, the evidence for constipation almost always comes out just in the history of children with abdominal pains.  If not in the history then often the examination might reveal hard stools or just a fullness in the left lower quadrant.  A normal examination does not exclude constipation.  Finally, if the pains have been consistent for a while and a macrogol laxative (1) has not yet been tried then this is the controversial bit:  I would not make a diagnosis of non-specific abdominal pain without first attempting to treat as constipation and reviewing early to assess the result.

Does non-specific abdominal pain exist?  I’m told it does but I haven’t yet seen a case myself.

Edward Snelson

Consultant in Paediatric Emergency Medicine

@sailordoctor

1)    Constipation in children and young people: Diagnosis and management of idiopathic childhood constipation in primary and secondary care https://www.nice.org.uk/guidance/cg99

Note: This material is created by the author for the sole use of qualified clinicians.  It is meant as a viewpoint and not intended to replace any applicable guidelines.  Any change in practice is solely the responsibility of the clinician.

Conflict of Interest: Loads

Easter egg: Constipation in Children - key recommendations

• Suspect constipation whenever a child presents with abdominal pain
• UTI is a common co-existing problem and should be ruled out concurrently. The finding of a urine infection increases the index of suspicion for constipation rather than ruling it out.
• Do not treat with lifestyle measures only (1)
• Treat all presentations of constipation with a macrogol laxative (either clear out or maintenance as indicated) (1)
• Continue this treatment for at least several week. It is likely that several months will be needed to prevent recurrence. (1)