Aidan Baron: Crash course in LGBTQI+ at DFTB17

Cite this article as:
Team DFTB. Aidan Baron: Crash course in LGBTQI+ at DFTB17, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.13709

This talk was recorded live on the first day at DFTB17 in Brisbane. If you missed out in 2017 then why not book your leave for 2018 now. Tickets are on sale for the pre-conference workshops and the conference itself at www.dftb18.com.

The 8th Bubble Wrap

Cite this article as:
Grace Leo. The 8th Bubble Wrap, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.12183

With millions upon millions of journal articles being published every year it is impossible to keep up.  Every month we ask some of our friends from the world of paediatrics to point out something that has caught their eye.

Caring for children with disabilities

Cite this article as:
Lori Chait-Rubinek. Caring for children with disabilities, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.12145

`I recently completed my first rotation as a doctor in the Emergency Department. Prior to entering the medical workforce, I had spent most of my employed life as a respite carer looking after and assisting children with developmental disabilities. I thought about these kids and how difficult an Emergency Department (ED) environment would be for them, as it is a place of hyper-sensory overload – noisy, bright lights and with constant movement. Yet when I looked at the literature I found limited qualitative data describing this patient groups experience in this setting.

Schrodinger’s PANDAS

Cite this article as:
Henry Goldstein. Schrodinger’s PANDAS, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.11670

The existence of PANDAS and other Paediatric Acute Onset Neuropsychiatric Syndromes has been controversial for the last two decades.

 

What is PANDAS?

Paediatric Acute-Onset Neuropsychiatric Disorder Associated with Streptococcal infection, is a concept first mooted by Swedo, an American paediatrician in 1998, as a formé fruste (or incomplete form) of Sydenhams Chorea.

Swedo SE, Leonard HL, Garvey M, et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases. Am J Psychiatry. 1998 Feb;155(2):264-71.

She postulated that Group A Beta-Haemolytic Strep infection caused sudden onset explosive OCD symptoms with choreiform movements in prepubertal children. The criteria is: (click for quotes from Swedo’s original wording)

1. Must have OCD or Tic Disorder.

Presence of OCD and/or a tic disorder: The patient must meet lifetime diagnostic criteria (DSM-III-R or DSM-IV) for OCD or a tic disorder.”

2. Pre-pubertal.

 “Pediatric onset: Symptoms of the disorder first become evident between 3 years of age and the beginning of puberty (as is generally true for rheumatic fever).”

3. Abrupt/Explosive Onset.

 “Episodic course of symptom severity: Clinical course is characterized by the abrupt onset of symptoms or by dramatic symptom exacerbations. Often, the onset of a specific symptom exacerbation can be assigned to a particular day or week, at which time the symptoms seemed to “explode” in severity. Symptoms usually decrease significantly between episodes and occasionally resolve completely between exacerbations.”

4. Association with GABHS infection.

Association with GABHS infection: Symptom exacerbations must be temporally related to GABHS infection, i.e., associated with positive throat culture and/or elevated anti-GABHS antibody titers. Of note, the temporal relationship between the GABHS infection and the symptom exacerbation may vary over the course of the illness. In rheumatic fever, there is often a delay of 6–9 months between the last documented GABHS infection and the appearance of symptoms of Sydenham’s chorea; however, recrudescences follow the GABHS infections at a much shorter interval, often with a time lag of only several days to a few weeks . It appears that the pattern is similar for PANDAS. It should be further noted that because fever and other stressors of illness are known to increase symptom severity, the exacerbations should not occur exclusively during the period of acute illness. Furthermore, as in Sydenham’s chorea and rheumatic fever, some symptom recurrences may not be associated with documented GABHS infections, so the child’s lifetime pattern should be considered when making the diagnosis.

5. Abnormal neuro exam, but NOT chorea.

”Association with neurological abnormalities: During symptom exacerbations, patients will have abnormal results on neurological examination. Motoric hyperactivity and adventitious movements (including choreiform movements or tics) are particularly common. Of note, children with primary OCD may have normal results on neurological examination, particularly during periods of remission. Further, the presence of frank chorea would suggest a diagnosis of Sydenham’s chorea, rather than PANDAS. It is particularly important to make this distinction, since Sydenham’s chorea is a known variant of rheumatic fever and requires prophylaxis against GABHS; PANDAS does not.”

Think of it as rheumatic fever for the brain; specifically, the basal ganglia.

So, a specific set of patients, with a well-stated mechanism and a clear symptom cluster. That said, this diagnosis and its criteria have been mired in controversy throughout the last twenty years, due predominantly to incongruity, poor external validity and erratic reproducibility in a number of trials.

Given the many billions of words on the topic, there have been some agreed points and areas of controversy. Hence, it is generally agreed that;

  • Children with signs and symptoms compatible with Group A H Beta-Haemolytic Strep (GAS) infections should be evaluated for same.
  • GAS is one of several factors that can exacerbate OCD or tic disorder in a subset of patients.
  • Children with GAS infection and OCD/tic disorder require standard treatments for these problems (regardless of whether GAS and OCD/tic disorder are causally associated)
  • There is no indication for routine administration of the following therapies for children who meet PANDAS criteria; prophylactic antibiotics, steroids, plasma exchange, IVIG.

Controversy exists regarding;

  • It is unclear whether PANDAS is a discrete neuropsychiatric disorder sufficiently different from OCD/tic disorder to be considered a separate entity.
  • The role of GAS as a precipitant of OCD/tic disorders (+/- PANDAS), and whether this is a causal or incidental relationship.
  • The etiology of PANDAS as an autoimmune disorder.
  • The clinical utility of seeking evidence of GAS infection in children with OCD/tic disorders.

In 2010, the PANDAS criteria was redefined and re-labelled to Paediatric Acute Onset Neuropsychiatric Syndrome (PANS). This widened the age range to <17 years, added restricted food intake as an alternative major symptom, and postulated a much broader aetiology, including a larger number of infectious causes including mycoplasma, HIV, VZV, HSV and the common cold.

Chang K, Frankovich J, Cooperstock M, et al. Clinical evaluation of youth with pediatric acute-onset neuropsychiatric syndrome (PANS): recommendations from the 2013 PANS Consensus Conference. J Child Adolesc Psychopharmacol. 2015 Feb;25(1):3-13. doi: 10.1089/cap.2014.0084. Epub 2014 Oct 17.

By 2013, Singer proposed a move away from the term PANS to Childhood Acute onset Neuropsychiatric Syndrome (CANS), further amending the diagnostic criteria to broaden the causality and focus investigations on the exclusion of treatable causes. When none are found a diagnosis of Idiopathic CANS can be made.

Singer, HS., Gilbert DL., Wolf, DS., et al. Moving from PANDAS to CANS. J Pediatr. 2012 May;160(5):725-31. doi: 10.1016/j.jpeds.2011.11.040. Epub 2011 Dec 22.

 

So, what are the challenging parts of this diagnosis?

Firstly, it looks like OCD, and OCD is very common. 1 in 60 kids have an OCD diagnosis

CANS is extremely rare by comparison. Actually, it’s unclear the actual incience, but it is less prevalent than either choreiform disorders or Munchausen’s By Proxy, which are around 1 per 100,000.

Secondly, it’s supposed to be foudroyant, which means literally strikes as with lightning, sudden and overwhelming in effect, stunning and dazzling.”

This in itself is a challenge to identify, as everything must start somewhere. It is the point of noticeable symptoms that really matters. To extend the metaphor, we don’t actually have random lightning strikes, as realistically the weather changes, a storm rolls in, thunder is heard in the distance and then… bang.

Thirdly, Sydenham chorea, obsessive-compulsive disorder, and tic disorders share common anatomic areas: the basal ganglia of the brain and the related cortical and thalamic sites. Some patients with Sydenham’s chorea display motor and vocal tics, obsessive-compulsive symptoms, and ADHD symptoms, adding support to the possibility that, at least in some instances, these disorders share a common etiology.

Fourthly, a review by Murphy notes a study of PANS-OCD versus Non-PANS OCD which identifies an association between Non-PANS OCD and a Family history of same.

Murphy TK, Gerardi DM, Leckman JF. Pediatric acute-onset neuropsychiatric syndrome.Psychiatr Clin North Am. 2014 Sep;37(3):353-74. doi: 10.1016/j.psc.2014.06.001.

Murphy and colleagues suggest this could be seen as an association between the infectious/autoimmune trigger for PANS-OCD. The countervailing argument is that this is instead representative of tolerability of OCD symptoms within families. That is, by the time the child is functionally impaired and the diagnosis made, it’s not controversial and there is acceptance of the diagnosis within the family.

Fifthly, it’s worth noting that the data for most studies is from the USA, where entry into the health system is very different to Australian, New Zealand or UK, particularly around self-referral to specialists. I’d speculate that it is much more socially acceptable for a child to have a neurologic than a psychiatric condition. Thus, children with OCD with or without tics are might present to a neurologist and be more likely to receive a CANS diagnosis.

Pragmatically for general paediatricians, the diagnostic dilemma here is two-fold;

  1. How much to investigate?
  2. How can we treat it?

And this is where Schroedinger comes in. Every time this box is opened, unless we are able to do so in an incisive, foudroyant manner, the child risks becoming medicalised. Indeed, we risk leading them on that journey. By simply looking into the box, we’re disproportionately more likely to find PANDAS than a child with OCD.

I don’t know how to prevent this happening. I do know that the best care for patients with suspected CANS could include general paediatrics, psychiatry, neurology and rheumatology. Ideally, these teams would collaborate to consider diagnosis and management on a case by case basis.

Medical treatments for this constellation of diagnoses have included antibiotics, steroids, immunoglobulins and plasmapheresis. Recent recommendations have highlighted the paucity of evidence for any of these therapies.

Psychiatric treatments include clomipramine, SSRI and Cognitive Behavioural therapy, as for obsessive compulsive disorder; I have not yet seen robust evidence with these interventions specifically for CANS (if you have some, please link in the comments!)
In summary, a child with explosive onset obsessions, compulsions with or without tics might have CANS. Although, on balance, they are more likely to have OCD, considering the prevalence in the population. We need to keep an open mind about these presentations.

 

Selected references

Murphy TK, Gerardi DM, Leckman JF. Pediatric acute-onset neuropsychiatric syndrome.Psychiatr Clin North Am. 2014 Sep;37(3):353-74. doi: 10.1016/j.psc.2014.06.001.

Swedo SE, Leonard HL, Garvey M, et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases. Am J Psychiatry. 1998 Feb;155(2):264-71.

Pichichero, ME. PANDAS: Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci. UpToDate [Online database]. Accessed 22 Feb 2017.

Chang K, Frankovich J, Cooperstock M, et al. Clinical evaluation of youth with pediatric acute-onset neuropsychiatric syndrome (PANS): recommendations from the 2013 PANS Consensus Conference. J Child Adolesc Psychopharmacol. 2015 Feb;25(1):3-13. doi: 10.1089/cap.2014.0084. Epub 2014 Oct 17.

Singer, HS., Gilbert DL., Wolf, DS., et al. Moving from PANDAS to CANS. J Pediatr. 2012 May;160(5):725-31. doi: 10.1016/j.jpeds.2011.11.040. Epub 2011 Dec 22.

Adolescent Inpatient Psychiatry

Cite this article as:
Henry Goldstein. Adolescent Inpatient Psychiatry, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.11391

I’ve been lucky enough to be one of the few paediatric registrars allocated to an Adolescent Inpatient Mental Health ward for a 6 month rotation. Although I’d worked in (adult) Psych wards before, I had few well formed ideas about psychiatric theory or practice past how to “do a takedown”. In Shem’s House of God, the future psychiatrist repeatedly states that “Good medicine as doing as much nothing as possible”; and until this term, I wasn’t entirely sure what that was, and less about to expect when it came to the care of young people.

As this opportunity is becoming rarer by the year and the rarefied air of Inpatient Adolescent Psychiatry is far removed from most Paediatric practice; this series aims to help understand the work (and underpinning theories) seen on the inpatient unit, in four parts.

What is it all about?

Medicine is generally about defining a pathophysiological entity and having it go away, either actively or passively, in this regard, psychiatry is similar. And as much as it would be impossible to describe all of surgery, so it is with this series; hence this post considers just a few of the key underpinning ideas and theories of child and adolescent psychiatry.

Rather than presenting with epistaxis, arthritis or dyspnoea, patients present to psychiatry with their own set of symptoms and maladaptive coping strategies.

If we’re honest, the idea of “treating” psychotic, hungry, anxious, suicidal and lonely kids remains unpalatable to most clinicians, let alone wading into toxic family systems with the goal of “fixing” everyone, by “having a chat*”. This is not what we do.

But I’m getting ahead of myself.

In mental health, we don’t see young people as individuals, rather as a representative within a family system. This idea underpins the paediatric mental health model of care; that the young person in our care is the index or named patient, and they are part of a larger their family system.

The approach then, is about understanding the child, the family, how they function both on a “day to day” basis, and under stress, from a biological, social and psychological perspective.

Truthfully, a well functioning family system can hold a huge amount of distress in the community setting. These families spend many hour with our Community colleagues, School Guidance officers and therapists. It is when this system is put under further stress and strain that the young person ends up on the locked mental health ward.

In short, they are stuck. An inpatient mental health admission is, I suspect, rarer than major surgery in childhood, so you have to be pretty stuck to get admitted. And this is what we do: we seek to understand why a young person is stuck – their predicament – by asking three fundamental questions:

  • Why them?
  • Why now?
  • What does it mean?

These questions allow both a Diagnosis and a Formulation for the young person’s presentation.

Appreciating the difference between these two is essential to understanding the role of Psychiatry. A Diagnosis describes a constellation of symptoms and coping mechanisms. It facilitates comparisons and ultimately permits the use of evidence-based-medicine, therapies and science. It provides a label. Diagnosis is why everyone with this label is the same. Formulation is the opposite. It focuses on narrative, influences, attachment and coping styles and the dynamics of a situation. In short, Formulation is why this person is different.

 

How do you even talk to teenagers? What do you ask them?

My peers asked me this on numerous occasions throughout the term, and I’d defer heavily to the benefits of the environment. Young people presenting with full-blown mania or untreated psychosis are almost always keen to talk.

Equally, by the time young people make it to the ward, there’s usually been some time between the awfully risky, intense, angry situation that has seen them arrive via Emergency.

On the ward, we sit in a quiet room with small unobtrusive windows and give the young person our undivided attention. This layer of environmental influence cannot be underestimated. Most young people are keen to talk by the time they meet the inpatient Psych team; they see them as the gatekeepers! That said, the role of the clinician is to help, remain nonjudgemental, understand, facilitate, support, challenge the young person.

Another frequent observation is that “it must be awful to see and hear all of that”, mainly, I suspect because as doctors we are better programmed to cope with lacerations of the flesh than of the mind. One part of understanding this, that is also a component of the therapeutic relationship, is the “Dynamic theory” (to which I will profess general ignorance past this brief explainer).

Essentially, the interview is treated like an operating room.

  • Outside the room is the rest of life.
  • In the room is you and the patient.
  • The only way we can understand the patient is through their words and actions (and metacommunication)
  • But, not everything the patient thinks or feels is in the room.
  • Equally, not everything you think or feel makes it into the room.

Every interaction arouses thoughts and feelings that remind you of your real (outside the room) life. The challenge here is to work out what is your ‘stuff’, and what is the patient’s ‘stuff’.

The additional layer to understanding this is that even when people talk, they can bring forward any number of ‘voices’. By this I mean that we all have an inner child (c) and an inner parent (P). The goal of the interview is to talk to the Adult/adolescent (A/a) as the clinician (*). You need to quiet your inner parent, and take the position of being bigger, wiser, strong and kind.

 

Bigger, wiser, stronger and kind?

The key, of course, is not to ignore the patient’s ‘inner child’ or ‘inner parent’, because the presence of those ‘voices’ in the room is exquisitely powerful. The metacommunication allows you to feel the golden egg/sacred cow/holy grail of Mental Health, counter-transference.

That is, patients will arouse in you feelings. When you talk to people, you feel sad or angry or aggressive or hopeless or miserable or agitated or confused. This is counter-transference – the unconsciously activated reactions to the client – which may often simply mirror that of the patient. By seeking to understand these feelings, you begin to understand what it is to “be” the patient, and therein lies a key route to understanding the child’s predicament. I’ve heard it described that the best way to “see” these feelings is as if you are a third person watching the interview. At least that’s the theory.

Of note, understanding a patient’s words and feelings as they occur both in the interview and afterwards leads to an interesting paradox; if (in this setting) you feel the urge to act, first take no action and secondly consider Why is it that I feel like I need to act?

 

Defenses

No post on psychiatry would be complete without at least one mention of Sigmund Freud, the Ego, SuperEgo and Id. The concept is, of course, generally relevant to understanding psychiatry, but more specifically and pragmatically helpful in understanding the Ego Defenses. These were first described by Anna Freud, and are part of a personality irrespective of mental health or unhealth.

Although an extensive explanation about the individual styles of personality defence are beyond the scope of this post, their particular characteristics are that they usually operate unconsciously (outside of awareness), that they operate to protect self-esteem by keeping unacceptable thoughts, impulses and wishes out of awareness, that they function to protect the person from experiencing excessive anxiety, they are part of normal personality functioning, they can lead to pathology if one or more is used excessively and that they are distinguishable from one another. Examples include projection, passive aggression, reaction formation, dissociation among others.

The key message here is to consider how a particular defensive style might deal with a difficult day, and an impossible day, and how these coping strategies can make things better or worse for the young person.

Further, the relationship between reality testing and personality defenses is important. Essentially, psychosis is impaired reality testing, and depending on a person’s ego defences, this reality testing can become more or less vulnerable to compromise. Often, rather than a sudden, abrupt impairment of reality testing, this decline may occur more gradually as psychotic thought processes emerge then supervene those grounded in reality.

 

Theories

The theories and philosophies I encountered in my time in adolescent psychiatry were also based on some of the work by three prominent psychoanalysts, John Bowlby (Attachment Theory), Donald Winnicott (being a “good enough” parent and the Transitional object) and Melanie Klein (understanding what “Borderline” means). Rather than oversimplify and undersell their work, I’ll let The School of Life explain in three short (and fascinating!) videos.



 

*In Psychiatry, there is no such thing as “a chat”. A good psychiatric interview might feel – for the patient – like “a chat”, but any interaction where the doctor-patient relationship is in place remains clinical. The clinician remains alert and mindful of their words and can either in situ or retrospectively make an assessment of the patient’s mental state; hence the interaction, irrespective of perceived formality, is essentially a psychiatric interview.

Many thanks for the guidance and mentorship of Dr Jannie Geertsema, Child & Adolescent Psychiatrist in this series.

References:

Alyami H, Sundram F, Hill AG, Alyami M, Cheung G.Visualizing psychiatric formulation.Australas Psychiatry. 2015 Oct;23(5):575-80.

Mace, C & Binyon, S. Teaching psychodynamic formulation to psychiatric trainees Part 1: Basics of formulation. Advances in Psychiatric Treatment (2005), vol. 11, 416–423

Mace, C & Binyon, S. Teaching psychodynamic formulation to psychiatric trainees Part  2: Teaching methods. Advances in Psychiatric Treatment (2006), vol. 12, 92–99

Skynner, R & Cleese, J. Families and How to Survive Them. Vermillion Press, United Kingdom. 1993.

Felluga, Dino. “Modules on Freud: On Psychosexual Development.” Introductory Guide to Critical Theory. Jan 2011. Purdue U. 22/02/2017

Playing with dolls

Cite this article as:
Andrew Tagg. Playing with dolls, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.10427

With a new baby in the house parents can look forward to sleepless nights and sleepless days, beholden to a creature whose whims they have very little control over.  Life revolves around sleeping, eating and changing nappies with seemingly no respite.  As you queue up in the supermarket to buy another packet of newborn nappies, your eyes meet with another new parent and you wonder if you look as tired as they do. Do you have the same posset stains on your crumpled t-shirt? A nod recognizing the shared suffering and you both shuffle out – the living dead – into the car park.

DFTB in Dublin – the Workshops

Cite this article as:
Tagg, A. DFTB in Dublin – the Workshops, Don't Forget the Bubbles, 2016. Available at:
https://dontforgetthebubbles.com/dftb-in-dublin-the-workshops/

Having braved international flights half of the team from DFTB (Andy and Henry) have made it to SMACCDub. For those of you not in the know the Social Media And Critical Care conference is in it’s fourth year now and partly inspired us to start Don’t Forget The Bubbles.  Although the editors regularly chat online this was the first time Henry and I have met in person.

In order to make the most of our time abroad we had both booked into the #SMACCmini paediatric workshop.

SMACCMini

With a line of speakers encompassing the best and brightest from the world of paediatrics (apart from us) we were excited to see what they had to offer. With a variety of lightning 10 minute talks over the course of the morning topics ranged from communication to caring for the critically ill child.

Resuscitation update

Natalie May was our leatherette clad hostess and kicked off the proceedings with an update on the 2015 ILCOR guidelines.  Whilst little has changed in resuscitation of the infant it is the rare resuscitation of the newborn that scares us the most.  Whilst a precipitous delivery in the department may be a rare event, it does happen.  Babies may be born in less than ideal circumstances – on the leather back seat of their husband’s new car, in the toilet (literally) or in the lift up to the birthing suite – but thankfully the need to perform complex interventions is rare. We need to know what to do before help arrives. This short video may help those who are paralysed by fear.

PEM literature update

Tim Horeczko took to the stage next, disguised as an event organizer. Despite technical issues that were out of his control he took us on a whirlwind tour of some paediatric literature that most of us in the room were not aware of.

Approaches to spotting the sick child

The Wonder Woman of Leicester, Rachel Rowlands, then took to the stage (along with her constant companion, Norman the dinosaur) to remind us of the importance of gestalt in spotting the sick child, a theme that would echoed by many speakers throughout the morning.  She took us on a choose-your-own adventure style quest, not to find the treasure, but to save the life of a young boy that had swallowed a button battery.  If you want to know more about the dangers of these deadly discs then take a look at her video.

Spotting sepsis early

Adrian Plunkett talked eloquently on the the use of the NICE traffic light system and other early warning scores to predict sepsis. But really he gave us two key take home points to lock onto:-

  • Be worried if there is a change of state – they are not the same as they were yesterday
  • Be worried if this illness is like no other illness they have ever had

By using these two key questions in the history we might become more alert to the risk of potential deterioration and look for ways to validate our fears – order the extra blood tests, keep the child in for a period of further observation.

Sick neonates are simple

Trish Woods, a neonatologist from WA, reminded us that all neonates want is to be protected.  When they are threatened, be that in the form of imminent airway or breathing difficulty, their physiology wants to return to the womb.  By understanding the transition from safe, warm and comforting intra-uterine life to the harsh outside world we can guide our resuscitation.

Mistakes and pitfalls in critical care

Phil Hyde, who gave an excellent talk about the use of real children during simulation at last years conference urged us to use our fear, not because it leads to the dark side, but to help us step towards the stressful.  We have all been in a resuscitation when there is a palpable sense of half-repressed panic.  Voices are raised and critical instructions missed, mistakes are made. But just as the emotions of the team leader can have a negative impact on the team they can also act to stop the sweating.  By being the slow, smooth voice of calm the team leader can imbue all of the group with the same feeling.

This can be a challenge so there are things we can do to mitigate the internal stress. Cliff  Reid talks of using the high fidelity simulator that is our brain to visualize these high stress scenarios, before they happen.  That is all when and good if you are experienced and have seen a lot of sick kids. But what do you do if you haven’t.  Phil suggests visiting your local PICU and asking questions of doctors and families, stepping towards the fear.  He also suggested using www.spottingthesickchild.com, a free online resource (though you need to register) to make you more comfortable in your assessment of deteriorating infants.

Paediatric ultrasound

The southern hemispheres Wizard of the Wand, Giant of the Gel, Prince of Probes, himself – Casey Parker – demonstrated how easy it is for us all to perform lung ultrasound on children.  In just 8 minutes he reminded us that our clinical exam counts for very nought and that a normal appearing chest x-ray can be deceptive in a child that you think has pneumonia from the history.  Waving the magic wand is easy and can be taught in just four minutes.  It is certainly a skill that I am going to take home to my place of practice.(Ed. I’d just like to give a huge thanks to Casey for encouraging me to write after the first SMACC in Sydney and publishing my very first blog post.)

What paediatric surgeons wished you knew

The esteemed paediatric surgeon, Mr Ross Fisher of p cubed presentations, then took us through some of personal bugbears.  After learning that there is no such thing as a normal bowel habit in a child, a fact that most parents can attest to, to decrying the lack of  proper physical examination prior to imaging he put us in his shoes.  Surgeons have no special ability to rule out appendicitis, but often have the benefit of experience to help determine what else may be going on.

Paediatric toxicology

As we came towards the end of the first half of the morning Nat Thurtle reminded us that children like to put things in their mouths that no normal person would.  Eschewing the usual list of one pill kills she talked about some newer toxins that most of us would not find palatable – e-liquids, laundry detergent pods and synthetic cannabinoids’s. By using the powerful Resus RSI DEAD mnemonic we can have a framework with which to risk stratify and deal with any potential toxic ingestion.

Paediatric trauma

As we were getting ready for our morning coffee Nat May reminded us that paediatric trauma often presents to non-paediatric centres and that we should all be able to recognize and deal with it.  Mechanisms of trauma vary with age from the drunken horse riding antics of teenagers, to younger children who skateboard in front of cars.  Paediatric trauma can be very confronting and how we approach our parents and their families can have a great impact on their long-term outcomes.

The SMACCmini superheroes

Appropriately caffeinated we headed back to the hall for another round of talks.

Excellence in critical care

Adrian Plunkett started off the session on a positive note.  Whilst it is easy to criticise bad practice it is much harder to praise the good.  He urged us to learn from the things we do well.  By actively promoting best practice within your network a culture of positivity and a ‘can-do’ attitude arises.  If you visit the Learning from Excellence website you can learn from others peer-reported episodes of excellence in practice.    Similar to the ‘Awesome and Amazing’ antithesis to the monthly M&M conference we need to let others in the team know they are doing a great job.

Communication: Kids and families

We all have had occasions when we think we have done a great job with our young patients and their families. Roisin McNamara brought us down to earth with a tale of when things that she thought had gone well had been perceived very differently by the family involved.  When harsh words are spoken it is important to have the emotional intelligence not to snap back, not to get angry. Often parents are not angry at you but at the situation but the doctor in front of them is the visible face of a systemic problem.  Parents may feel they are being dismissed as time wasters if time is not spent taking a thorough history and appropriate physical exam before pronouncing that their darling daughter has no medical cause for their symptoms.

Communication: Adolescents

Most of us know how to talk to children but, via the power of video, Thom O’Neill, spoke passionately about an issue we should all know more about- dealing with LGBT adolescents and youths.

Most traditional textbooks of paediatrics have yet to cover the subject and Thom gave us a useful framework to hang a conversation on, starting with recognising the child or youths right to be called what they want and to identify themselves how they want.  We hope to get Thom to write more on this subject for Don’t Forget The Bubbles. 

Resource poor settings

Nat Thurtle returned to the limelight to talk about her time working in resource poor settings.  Those of us that work in the developed world are incredibly lucky to have access to the resources we have. As she told her moving story of almost insurmountable challenges we al stopped and reflected on how lucky we truly are.

Complex kids

After hearing about children that don’t have access to even supplemental oxygen when it is needed Tim Horeczko talked about technology dependent children and their complex needs.  Whilst we are unlikely to encounter a child with a ventricular assist device outside of a quaternary centre we may well be exposed to children with a VP shunt, or a child that suffers from an incurable neuromuscular or mitochondrial defect.  As is nearly always the case in paediatrics – the parents know best, so listen.

Surgical surprises

Ross Fisher then urged us to “Keep Calm and Carry On” when confronted with potential paediatric surgical nightmares. He reminded us time and again that we know how to do the basics – analgesia, fluid resuscitation, investigate – and that there is nothing that we should be afraid of.

Neonatal procedure tips

Having previous told us that looking after sick neonates was easy-peasy, Trish Woods then went n to teach us how. By focusing on the ABC’s of resuscitation she walked us through the neonatal airway and breathing before showing some great slides and giving us all the tools we need to insert an umbilical line. At the time of neonatal resuscitation early vascular access as a means of giving fluids and adrenaline can save a life.  

Intubation tips

This great procedural talk was followed by Tim Horeczko on his top three tips for intubating infants.  We know that critical procedures are rarely performed by paediatricians let alone general emergency physicians but by adding these three things to ones repertoire we should increase our chance of first pass success.

  • Use the shoulder bump
  • Use the jaw thrust
  • Change your position and look high

Ventilation tips

Once we have successfully intubated (and confirmed tube placement with waveform capnography) Phil Hyde talked about ventilation strategies. By using PEEP and low tidal volume breaths (6-8mls/kg) we can adequately ventilate most children titrating to a pH>7.2 and and an SpO2 >92%. Attention to the simple things such as sedation, paralysis and monitoring can make all the difference.

Phil Hyde on the basics of neonatal ventilation

Patient experience

The final session of the day brought home to all of us in the room why we do what we do.  We heard from Emer, a brave 11 year old girl, who had spent 5 days in ICU with tracheitis, of her experience, both in the emergency room and in the unit.  Her clinical care was excellent and could not be faulted but if there was one thing she wanted us all to take away it was ‘Don’t use long medical words’. We doctors assume a common tongue and use medical terminology as a technical shorthand with our colleagues.  We occasionally slip into this mode of talking with patients and their relatives. Emer reminded us to think before we speak.

The organizing committee and all of the faculty did an amazing job of fitting such a wide array of topics in such a short time frame. Never did the audience feel overwhelmed with knowledge and most of us just stopped tweeting and just listened, quietly reflected and were inspired to do better. If you came along to the workshop and took away something that will change the way you treat children (or their parents) then please feel free to comment below.

pablo

 

Screen Queens

Cite this article as:
Andrew Tagg. Screen Queens, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.8492

Life as a parent can be tough – early mornings, convincing your child to eat, having time for yourself. Sometimes you just need five minutes to think.  So what do you do – thrust your mobile device in front of your 3 year old?  Today we explore some of the good, bad and ugly concerns around electronic media.

PAC Conference 2015 – Morris on the difficult adolescent patient

Cite this article as:
Davis, T. PAC Conference 2015 – Morris on the difficult adolescent patient, Don't Forget the Bubbles, 2016. Available at:
https://dontforgetthebubbles.com/pac-conference-2015-morris-on-the-difficult-adolescent-patient/

We have teamed up with APLS to share the videos from their Paediatric Acute Care Conferences. These videos have never been open access before, so if you weren’t able to attend the conferences, then now’s your chance to catch up.

The PAC Conference is run each year by APLS and consists of presentations on a range of topics relevant to paediatric acute and critical care.

How good are apps for preventing paediatric obesity?

Cite this article as:
Tessa Davis. How good are apps for preventing paediatric obesity?, Don't Forget the Bubbles, 2014. Available at:
https://doi.org/10.31440/DFTB.5461

We all know that obesity is a serious problem for the paediatric population (Ogden et al, 2014). And we also know that kids love using iPhones (Chiong et al, 2014). So it’s not surprising that there are lots of apps on the app store aiming to help children tackle their obesity.

In fact, there are lots of apps for pretty much any medical problem you can think of. But how useful are these apps? Do they follow accepted medical practice or public health strategies?

A study published in Childhood Obesity this month looked at this question.

The authors scoured the App store for iPhone apps aimed at reducing paediatric obesity which were for children to use. They found 62 apps.  And they compared them against the American Academy of Paediatrics’ Strategy for the Prevention of Childhood Obesity

Strategies from the American Academy of Paediatrics.

Recommended behaviors

  1. Eat five fruits and vegetables per day
  2. Get 1 hour of physical activity per day
  3. Limit screen time to less than 2 hours per day
  4. Limit consumption of sugar-sweetened beverages
  5. Eat breakfast daily
  6. Switch to low-fat dairy products as part of a diet rich in calcium
  7. Regularly eat family meals together
  8. Limit fast food, take-out, and eating out
  9. Prepare foods at home as a family
  10. Eat a high-fiber diet

Recommended strategies

  1. Goal setting: Children should set clear goals that reflect progress toward target behavior(s).
  2. Positive reinforcement: Children should be encouraged for effort and achievements related to target behavior(s).
  3. Self-monitoring: Children should be encouraged to record their relevant behaviors, efforts, and progress.
  4. Cognitive restructuring: Negative cognitive patterns should be discouraged and successes, including partial successes, should be highlighted.

They found that apps poorly adhered to the whole guideline, but did tend to focus on specific behaviours. For example, most apps targeted exercise or a particular element of food intake but didn’t focus on the others. In general while the apps were quite good in dealing with the recommended behaviours, they were poor at implementing or suggesting the correct strategies. The most common strategy used was self-monitoring.

As an interesting side note there was no correlation between the cost of the apps and how medically appropriate it was – the most expensive app was in fact one of the poorest performing. And strangely, the reviews left on the app store did seem to tally with AAP guidelines adherance.  Perhaps user reviews on the App Store aren’t as irrelevant as we might think….

So whilst there is a future for encouraging your patients to use apps to tackle chronic medical issues, we have no good regulation yet of apps like this on the app store. Check out any apps yourself before recommending them to your patients as there’s a lot of dross out there.

References

Chiong C, Shuler C, Learning: is there an app for that? The Joan Ganz Cooney Center at Sesame Workshop, New York, 2012.

Davis MM, Gance-Cleveland B, Hassink S, Johnson R, Paradis G, Resnicow K, Recommendations for prevention of childhood obesity. Pediatrics. 2007 Dec;120 Suppl 4:S229-53.

Ogden CL, Carroll MD, Kit BK, Flegal KM, Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014 Feb 26;311(8):806-14.

Wearing JR, Nollen N, Befort C, Davis AM, Agemy CK, iPhone App Adherence to Expert-Recommended Guidelines for Pediatric Obesity Prevention. Childhood Obesity, 2014, 10(2):1-13.

 

Obesity

Cite this article as:
Jasmine Antoine. Obesity, Don't Forget the Bubbles, 2014. Available at:
https://doi.org/10.31440/DFTB.3921

 A 10 year old girl, Gemma, has been admitted to the general paediatric unit with an acute exacerbation of asthma. She weighs 70kg and is 1.4m tall. Her symptoms have improved and discharge planning has begun. At the end of your round the consultant asks you to go and discuss Gemma’s weight with her family.