Saturday, 27 June 2015

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

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

Thursday, 18 June 2015

The Doctor didn't examine my child properly

One of the challenges in paediatrics is examining children.  While some are cooperative and a few comply with a traditional examination, neurological examination is one of the most difficult aspects of the assessment to achieve.   The difficulties of achieving a ‘tone, power, reflexes, sensation and coordination’ examination in a toddler for example are substantial.  (If you ever want to see what a medical student looks like when their fight or flight response is kicking in, ask them to do cranial nerve examination in a baby.)

The thing is, neurological examination of children is easy.  In most cases they will do it for you.  You just need to know what you have accidentally examined.

Let’s take a scenario.  A three year old is brought for assessment.  The parent reports an episode that sounds like a classical reflex anoxic seizure.  There are no red flags (1) and you are confident in your diagnosis.  The child is however, completely uncooperative with examination.  Everything looks normal and you reassure the parent as well as giving a full explanation.  Later there is a complaint: ‘The doctor did not examine my child properly.’

I suspect that many clinicians would feel that they were in an impossible situation here.  They know that they assessed the child.  Is that the same as examining the child?  In paediatrics it may well be.

You see, cooperative children can be formally examined and uncooperative children can be passively examined.  They don’t mean to be helpful.  It just happens to be the case that they will give you everything you need.  All you need now is to prove it, which really requires very simple documentation.   For example: ‘cried and ran into corner of room and hid.’  Here we have cognition, visual acuity, use of the 7th, 9th, 10th and 12th cranial nerves as well as a fair assessment of power, gait and coordination.  Once you have added up all the behaviours observed, along with a little trickery you can cover most of the central and peripheral nervous system examination.

I will return to the subject of how to be clever about examining and assessing children.  For now though, there is only one simple message.  Think about what you saw and then ask yourself what you can tell from that observation.

Edward Snelson

Disclaimer:  Child walks into a bar... Not my fault - they should have been looking.  But, it tells me a lot about their neurology...

Red flags for cardiac syncope - (from GPonline, 3/9/08 by Dr Hindley  consultant paediatrician)
  • Syncope in a child with known congenital heart disease.
  • Syncope during exercise or when supine.
  • Family history of sudden death (especially if <30 years of age), prolonged QT syndrome or HOCM.
  • Syncope preceded by palpitations.
  • Heart murmur or other abnormalities on cardiovascular examination.

Saturday, 13 June 2015

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

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

Wednesday, 10 June 2015

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

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

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

Saturday, 6 June 2015

How do we deal with the messy bits? (Easter egg - Balanitis and foreskins in children)

In case you hadn't noticed, in the UK there is now a NICE guideline for everything.  It feels like a new ones come out so frequently that it is impossible to keep up.  That is despite the fact that  I can now ignore anything not relevant to children.   On top of that we get NHS England alerts, journal updates, e-bulletins and local guidelines.   It goes on.

So why are there still things that are surrounded in confusion that don’t need to be?  I think that the answer has to be that many of them are seemingly too minor and don’t belong to a bigger topic.   A good example of this is little boys’ foreskins.  It seems to me that there are misunderstandings that could easily be cleared up and yet no UK national guideline has done so.

At some point in my medical training I remember being taught that uncircumcised penises should easily retract by about 3-4 years old and that they should be kept clean.  Balanitis was seen as a marker of poor hygiene and so more cleaning was the presumed solution.  Foreskins that were ‘non-retractile’ were considered abnormal and if there was recurrent balanitis or ballooning, the child should be considered for circumcision.  We now believe that all of this is untrue.  It is quite normal for the foreskin of a boy to remain adhered to the glans until they hit puberty, whenever that may be.  Ballooning is within normal limits and balanitis is often due to unnecessary attempts to retract or clean under a foreskin.

So I know that I was taught something that later turned out to be untrue and I know that many clinicians in both primary and secondary care haven’t heard the good news.  Why?  I think it is because it only needs two boxes worth of information, so no-one gets round to it.  Well, here they are:

In case you were wondering what t’interweb has to tell people, I've saved you the bother.  On the first two pages of a Google search I found:
  • Four patient forums, starting each time with a parent who had been told by a doctor to ‘encourage’ their toddler’s foreskin to retract so that it could be cleaned underneath.
  • Four medical sites advocating retraction as being desirable in a baby or toddler.
  • Three sites quoting the expectation that foreskins should retract by the age of 3-4.
  • Seven sites recommending that the foreskin of a child should not be forcibly retracted but stopping short of suggesting that it should just be left alone.
  • Four sites unambiguously recommended that the foreskin of a child should be left alone completely other than to wash externally.

I was pleased to see that Australian websites were frequently up to date and unambiguous about leaving well alone.

Increasingly the guidelines available online are providing clearer advice about foreskins and the message is this:

So, since it is unlikely that there will be a foreskin summit any time soon, you might want to spread the word yourself.

Meanwhile, if you have any messy bits that you think could be covered in two or three boxes, please post your suggestions below and I'll do my best to deal with them

Edward Snelson
President of the Sir Lancelot Spratt Association

Disclaimer:  Don't worry.  Be happy.

Wednesday, 3 June 2015

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

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