COVID-19 and children: what do you need to know?

Cite this article as:
Boast A, Munro A. COVID-19 and children: what do you need to know?, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.23868

In late 2019, a new infectious disease emerged and spread to almost every continent, called COVID-19. As of March 11th 2020 it was declared a global pandemic by the World Health Organisation, meaning that is was being spread among multiple different countries around the world at the same time. It has changed the way we live our lives.

What we understand about SARS-CoV2 and COVID-19 has increased dramatically, with research being done at an extraordinary rate. For those of us whose business is looking after children, what do we need to know?

 

Editor’s note: This post is based on what we know today, Wednesday 15th of April 2020, and will be updated as new information becomes available.

 

What is COVID-19?

  • COVID-19 is the name of the disease caused by a new coronavirus, which has been named SARS-CoV-2. COVID-19 is the disease, and SARS-CoV-2 is the virus.
  • A coronavirus is a type of virus named after its unique appearance – with a ‘crown’ of proteins – when viewed with high power microscopy.
  • Coronaviruses very commonly infects humans (and some animals).
  • In humans, coronaviruses are a frequent cause of the ‘common’ cold – resulting in an upper respiratory tract infection with cough and coryza. There are, however, three types which can cause severe, even life-threatening disease in humans (SARS, MERS, and COVID-19).

 

What is the difference between COVID-19, SARS, and MERS?

Whilst they are all severe illnesses caused by coronaviruses, there are some important differences. Some useful things to consider include the R0 (how many people, on average, one case of the disease will spread to in others) and the Case Fatality Rate (CFR), an estimate of how many people who contract the disease will die from it. Neither of these statistics is hard and fast (and are both highly context-specific), but they provide a rough yardstick with which to compare infectious diseases.

  • SARS: This is an acronym for Severe Acute Respiratory Syndrome, a disease caused by the virus SARS-CoV. In 2002-3 the spread of SARS-CoV resulted in around 8,000 cases, with a CFR of approximately 10%. Similar to COVID-19, SARS-CoV originated in China, before spreading around the world, predominantly Europe, North America, and South America. The R0 from SARS is thought to be 3.
  • MERS: This is an acronym for Middle East Respiratory Syndrome, caused by the virus MERS-CoV . As the name suggested, it originated in the middle east in 2012, transmitted initially from camels to humans. MERS causes the most lethal infection of the coronaviruses, with a CFR of around 35%. The R0 from MERS is thought to be <1.
  • COVID-19:This is an acronym for COronaVIrus Disease 2019, the disease caused by the virus SARS-CoV-2. It is a zoonotic disease (meaning it was transmitted to humans from animals) and although the intermediate host has not yet been identified, it’s thought to most likely have originated in bats. It was initially identified in December 2019 in China, before spreading around the world. The CFR is unclear, as it is still uncertain how many people actually have the virus, and how many who currently are unwell will die from the disease. The overall CFR is thought to be about 1.3%. This is highly dependent on the country (and available health resources) but another significant factor is age, with only a handful of deaths reported in children <12 years who have confirmed COVID-19. The R0 for COVID-19 is still unclear but is thought to be 2-3.

 

What are the symptoms?

  • The symptoms of COVID-19 are similar to other respiratory viral infections. Importantly, in children the symptoms of COVID19 are more likely to be mild, and a significant proportion may be asymptomatic.
  • Infected children who are symptomatic most commonly present with cough and fever.
  • A small proportion of children also present with gastrointestinal symptoms (vomiting or diarrhoea) (~10%)
  • Sore throat and runny nose do not appear to be uncommon features in children (as opposed to adults)

 

How does COVID-19 affect children?

Evidence from across the globe (namely China, Spain, Italy and America), has shown that children are significantly less affected by COVID19 than adults. There are both fewer cases in children, and less children who are severely unwell. Younger infants appear to be most likely to be hospitalised. Overall, there have been only a small number of deaths in children with confirmed COVID-19 reported. A number of epidemiological and clinical papers on COVID-19 in children have been published, summarised on DFTB.

The exact reason why there are so few children with confirmed COVID-19 is unknown. Initially it was thought that due to the high rate of asymptomatic infection children were simply less likely to be swabbed and have confirmed infection. However, recent evidence from Iceland, Japan and Korea shows that children may also be less likely to become infected with SARS-CoV-2 following exposure.

It is yet unknown whether asymptomatic children can pass the infection on to others. In epidemiological studies children have not been found to have a significant role in household transmission. It appears children may continue to excrete the virus through their faeces (poo) for several weeks after the symptoms of infection have passed, but the role of this excretion in viral transmission is not clear (there is some evidence to show it is only viral particles rather than active virus). Regardless, hand hygiene remains of paramount importance in reducing spread.

 

If my child is unwell, can I give them ibuprofen?

There has been considerable social media interest in the use of ibuprofen in suspected or confirmed COVID-19. In the UK, the MHRA has deemed there is no evidence of increased risk of using ibuprofen even in cases of COVID-19.

 

What about neonates?

Neonates without comorbidities do not appear to be at an increased risk. A large number of case series having been published of babies born to mothers with COVID-19. Although some neonates have swabbed positive for SARS-CoV-2, there have been no reports of this being associated significant illness. Evidence about the possibility of transmission from mother to baby in the womb is currently unclear.

In the UK, the RCPCH has published guidelines (with the Royal College of Obstetrics and Gynaecology) recommending pregnant women with COVID-19 who are in labour should deliver their baby in an obstetric unit, however there is no need to separate mother and baby after birth, and the benefits of breast feeding outweigh any theoretical risks. Of note, the American Academy of Pediatrics has released conflicting guidelines, suggesting separation of the mother and baby.

 

What about children with chronic conditions?

There is limited data to guide us currently on how COVID-19 might affect children with underlying health conditions. There are small case studies of children with suppressed immune systems who have not developed severe illness, including children treated for cancer and inflammatory bowel disease. There is some evidence that children with respiratory or cardiovascular comorbidities may be at higher risk of hospitalisation, but it is still unclear. For children currently being treated for cancer, the UK Children’s Cancer and Leukaemia Group have posted guidance for families including which groups are extremely vulnerable and should be “shielding”.

 

Is there any treatment?

There is no proven treatment for COVID-19, however, there are many clinical trials underway for many different therapies. The WHO has clearly stated that experimental therapies should only be used in the context of a clinical trial. Hydroxychloroquine and remdesivir have been studied most extensively, but there remains no clear evidence of benefit. Importantly, hydroxychloroquine has been associated with significant adverse effects, highlighting the importance of its prescription only in the context of a clinical trial.

Notably, there are only a handful of clinical trials for children registered, so it is unlikely that any therapeutics will be widely used in children with COVID-19. As the disease is generally mild in children, it is not likely to often be necessary to provide anything further than supportive care.

Vaccines will hopefully provide protection against future outbreaks of COVID-19, though these are still early in the drug development pipeline and unlikely to be available this year.

 

What can I do to minimize my risk?

Two words – hand hygiene. As with other viruses spread by droplet (e.g. influenza) hand hygiene, particularly when out in public, plays a critical role in preventing transmission. Washing hands with soap and water, for an adequate amount of time, covering all areas of the hands is most effective. Hand sanitizer is effective, but no more so than usual hand washing

It is important to avoid contact with others who are acutely unwell. Wearing surgical masks will not protect you from respiratory viruses. Wearing one if you are unwell may protect others from your respiratory secretions.

Physical distancing is becoming increasingly important, with many countries now mandating various ‘lock-downs’. You should follow advice from your public health authorities, and it would be wise to reduce non essential physical or close personal contact with other people to a minimum 

 

What should I do if someone in my family becomes unwell?

 

Resources for health professionals

Many journals have made their COVID-19 resources open access including NEJMThe LancetBMJ, and JAMA

National professional resources can be found at:

 

Literature

For a comprehensive review of all paediatric English language literature to date which has informed this article please see our separate page for COVID-19 Evidence

Communicating with children with additional needs: Liz Herrieven at DFTB19

Cite this article as:
Team DFTB. Communicating with children with additional needs: Liz Herrieven at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21387

Communication is vitally important in so much we do as clinicians.  Without good communication we can’t hope to get a decent history, properly examine our patient, explain what we think is going on or ensure appropriate management.

Nocturnal enuresis

Cite this article as:
Mary Hardimon. Nocturnal enuresis, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.23446

Kristy is a 5-year old girl; her mother has brought her in due to her having started kindie. She has been invited to have a sleepover at a family friends house however she still wets the bed most nights of the week and is wondering about how to manage this.

 

Attaining continence – both daytime and nighttime – is a developmental milestone with a significant normal variation which is affected by both genetic and environmental factors.

At 5 years of age, approximately 15% of children continue to experience nocturnal enuresis (more commonly known as bedwetting). Every year beyond this, there is spontaneous resolution in ~15% of affected children (although it should be noted that the longer duration of NE, the lower the likelihood of spontaneous resolution).

Boys are more commonly affected than girls (2:1) and there is a strong family predisposition (both parents = 77%, single parent = 43%). Only one-third of those affected will seek medical attention.

 

What is nocturnal enuresis?

Nocturnal enuresis is episodes of urinary incontinence during sleep in children ≥5 years of age. It may be further subdivided into monosymptomatic (aka uncomplicated) and non-monosymptomatic (aka complicated or polysymptomatic).

  • Monosymptomatic: incontinence is present without other symptoms of lower urinary tract/gastrointestinal tract
  • Non-monosymptomatic: incontinence associated with other symptoms including but not limited to
    • Polyuria/oliguria (8/3 times per day respectively)
    • Urgency, hesitancy, intermittency
    • Straining/holding manoeuvres
    • Weak stream, dribbling
    • A feeling of incomplete emptying
    • Pain

When episodes additionally occur during the day, it is more appropriately referred to as diurnal enuresis/incontinence.

Incontinence should be classified as primary or secondary.

  • Primary: the child has never been dry
  • Secondary: the child has been dry for a period of at least 6 months

 

Why does nocturnal enuresis occur?

Nocturnal enuresis is the result of inappropriate emptying of the bladder by the child and is the result of a mismatch between the neurones of the bladder and the conscious state of the child. This may be due to a multitude of factors including:

  • Maturation delay
  • Genetic factors
  • Nocturnal polyuria – this may be due to fluid intake, reduced response to antidiuretic hormone (ADH) and/or reduced production of ADH
  • Disturbed sleep in the child (controversial)
  • Small bladder capacity
  • Detrusor overactivity

These factors may be primary to the child (eg. genetic factors) or secondary to an underlying condition (eg. polyuria secondary to undiagnosed diabetes insipidus)

 

 


How to evaluate a child with nocturnal enuresis?

It’s almost all in the history – search for red flags!

History:

  • Onset
  • Previously dry?
  • Daytime symptoms (non-monosymptomatic NE)
  • Frequency, amount
  • Response to episodes
  • Fluid habits
  • Bowel habits
  • Sleep routines

 

Examination:

  • Height/weight
  • BP
  • Tonsillar hypertrophy/adenoidal facies
  • Abdomen (distended bladder, faecal mass)
  • Spine
  • Lower limb neurology
  • Perianal/vulval inflammation (pinworms)

 

Do you need to do investigations?

Investigations are not necessary for all patients and should be guided by history and examination. Consider:

  • Blood sugar level (fingerprick)
  • Urinalysis (m/c/s, electrolytes)

Imaging and blood tests are not routinely indicated.

 

What are the treatment options?

 

Important things to remember in treatment:

  • Tricyclic medications are not recommended as they are less effective and have a higher risk of adverse effects
  • Intranasal desmopressin is not recommended due to the risk of hyponatraemia
  • There are high rates of relapse when desmopressin is discontinued (60 – 70%) therefore best used as a short term measure (eg. for going to camp) whilst awaiting spontaneous resolution
  • Desmopressin should not be used in those who are unable to adhere to fluid restrictions (due to risk of hyponatraemia)
  • Treatments with weak evidence include elimination diet, hypnosis, retention control (holding urine for progressively longer periods), biofeedback, acupuncture, scheduled awakenings, caffeine restriction

 

Take-home messages

  • It doesn’t require treatment in those under the age of 6
  • It is common  although undertreated despite treatment options (and families potentially being eligible for funding)
  • It is usually a primary disorder rather than secondary to an underlying medical condition (although maybe particularly exacerbated by constipation)
  • Investigations are not routinely required
  • Treatment requires a motivated family, with behavioural measures and bedwetting alarms being the first line of treatment.

 

Selected references

Tu, Baskin, Arnhym et al (2019) “Nocturnal Enuresis in Childre: Etiology and Evaluation”. UpToDate.

Tu, Baskin, FAAP (2019). “Nocturnal Enuresis in Children: Management”. UpToDate.

The Royal Childrens Hospital. (2019). “Enuresis – Bedwetting and Monosymptomatic Enuresis.” Melbourne. Retrieved from: https://www.rch.org.au/clinicalguide/guideline_index/Enuresis_-_Bed_wetting_and_Monosymptomatic_Enuresis/

Thiedke C. “Nocturnal Enuresis”. American Family Physician (2003); April 1; 67(7): 1499 – 1506

Ramakrishnan K. “Evaluation and treatment of enuresis”. American Family Physician (2008); August 15; 78(4): 489 – 496.

Managing cough: Adam Jaffe at DFTB19

Cite this article as:
Team DFTB. Managing cough: Adam Jaffe at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22157

Adam is a respiratory physician at Sydney Children’s Hospital. He spoke about all things wheezy in Melbourne for DFTB18.  In this talk from our London conference, he deals with that bane of parents’ lives – the coughing child.

 

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

iTunes Button
 

Selected references:

Chang AB. Cough, cough receptors, and asthma in children. Pediatric pulmonology. 1999 Jul;28(1):59-70.

Sensational Solids

Cite this article as:
Annabel Smith. Sensational Solids, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22364

You are a paediatric registrar, discharging a 5-month-old boy (Sam) home after an overnight admission with a respiratory illness. When you check if there are any final questions, Sam’s parents want to know whether they should be commencing solids now, and if so, how they should go about it.

This is a great opportunity for some quick education for the family, made a little more efficient on a busy ward with the provision of some written information (see the resources section for my favourite websites). There have been lots of changes to infant feeding advice over the years, and a plethora of ideas about what comprises a healthy infant diet, so families can easily become confused. Some targeted, sensible advice can get most families on track towards safe and healthy eating for their infants, with positive implications for long term health and wellbeing.

 

When to introduce solids?

According to the World Health Organisation, all infants should ideally be exclusively breastfed for the first 6 months of life – no food and no extra water (medicines are, of course, allowed) – as introducing solids too early can interfere with this provision of nature’s perfect nutrition. However, the Australasian Society of Clinical Immunology and Allergy (ASCIA) has advised that food exposures can start occurring from (but not before) 4 months and that this is beneficial for allergy prevention. I encourage this for families in my care, explaining that from 4-6 months, these are to be just exposures, not meals – e.g. a lick of nut butter from a parents’ finger, a taste of bolognaise sauce, a finger play with mushy vegetables, and so forth.

From 6 months, babies particularly need sources of iron (as placental-derived stores will have run out), so regular small meals can commence – all solids should be offered AFTER a breastfeed until around 9-10 months of age when this can usually be reversed. Babies will need to be developmentally ready to start solids, with good head and neck control, ability to sit upright with support, showing an interest in food, and opening their mouth when offered a spoon. If not showing these signs by 7 months, the infant should be seen by their GP.

Infants can be fed purees, and/or soft hand-held foods (including foods they can safely suck on, such as a strip of toast or meat). There are different philosophies around the benefits of each method, but practically, it can work best for families to use a mixture of spoon- and finger-feeding. Finger-feeding provides great sensory and developmental experiences, but is messy and time-consuming, and requires a developmental level equivalent to around 8-9 months of age to reliably consume anything, so purees do have their place. Regardless of the feeding method, all meals must be closely and actively supervised by a competent adult.

 

What foods can be given and what should be avoided?

Infants can and should be exposed to all food groups from as early an age (at least prior to 12 months) as possible, except for honey, due to the risk of botulism (this can be introduced after 12 months if desired). Hard foods pose a choking hazard, so fruit and vegetables should be softened with cooking, and nut butter should be used instead of whole nuts. Home-cooked wholefoods are typically best for health, but there are some healthy commercial preparations. 

To avoid confusion if allergic reactions occur, families should, according to ASCIA, introduce food types one at a time, a couple of days apart. This also gives the infant time to adjust to all the new, exciting textures and flavours.

Water should be offered with all solids from 6 months onwards to encourage good drinking habits. Infants and children shouldn’t drink juice, and cow’s milk shouldn’t be used a drink until after 12 months, although small amounts can be used on cereals or as a component of other meals for dairy exposure. After 12 months, limit cow’s milk to 500ml per day (less or none is fine, especially if still breastfeeding, and/or if having plenty of other calcium sources, such as other dairy products, or green leafy vegetables). ‘Toddler formula’ is almost never needed, and then only on specialist advice.

 

What happens if Sam has a reaction to a food?

Allergic reactions to food can be immediate or delayed and are highly variable and sometimes controversial. Symptoms may include rashes, respiratory difficulty, or gastrointestinal issues. Any suspected reactions require an immediate cessation of the suspected food(s), and medical review (urgency dependant on the severity of the symptoms) should be sought.

 

What if the family follows a special diet, like veganism?

Vegetarian and vegan families, or any other families following a relatively restricted diet for any reason, would benefit from an early assessment by a registered dietician. These diets may lack vitamins and minerals critical for the health of the developing infant, but can usually be safely adhered to with support and planning. Restrictive diets do increase the risk for food allergy and intolerance on later exposures, however, and families must be aware of this.

Ultimately, food should be about fun, togetherness, and good health. Families should be encouraged to keep mealtimes positive and family-centred, with everyone eating together at a table whenever possible (with all devices turned off). Parents should evaluate their own diet and ensure they are setting a good example, and empowering and teaching their children how to fuel their amazing, active bodies with a wide variety of healthy, delicious foods. It’s never too early to start forming good habits and positive food relationships.

 

References and Resources:-

Australasian Society for Clinical Immunology and Allergy (allergy.org.au)

Useful handouts;

  • Information on how to introduce solid foods to infants (
  • Infant feeding and allergy prevention (

Raising Children’s Network (raisingchildren.net.au)

The Royal Children’s Hospital Melbourne (rch.org.au)

Back to School

Cite this article as:
Andrew Tagg. Back to School, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.23086

It’s the first day of school here in Australia and parents and carers are waving their young children off with a kiss for their first day.  When I first saw the size of school bags I was amazed. How can children carry so much? Surely they will just fall over and lie on their backs waving their little legs in the air like distressed turtles? What on earth are they carrying in there that needs the Bag of Holding?*

 

 

What’s the problem?

Barbosa J, Marques MC, Izquierdo M, Neiva HP, Barbosa TM, Ramírez-Vélez R, Alonso-Martínez AM, García-Hermoso A, Aguado-Jimenez R, Marinho DA. Schoolbag weight carriage in Portuguese children and adolescents: a cross-sectional study comparing possible influencing factors. BMC pediatrics. 2019 Dec;19(1):157.

With reduced access to lockers, it seems that children are taking the weight of the world on their shoulders. Surprisingly, this Portuguese group found that Grade 5 children carried more than Grade 9 kids. This trend has been replicated in New Zealand with Grade 3 kids carrying around 7kg (13.2% of their body weight) and Grade 6 leavers bearing only 6.3Kg (10.3% body weight). Most school items have a set weight, no matter what grade you are in, but one might have thought that as the educational load increases over the years so might the weight of the textbooks. Perhaps an increase in the use of personal electronic devices and e-books accounts for some of this difference.

Surely carrying those giant bags can’t be good for the growing body? Neck, back, and shoulder pain are prevalent in adolescents and are closely linked by carrying heavy school bags. These effects take place when the bag weighs more than 10% of their body weight. In nearly every study girls carry more than boys. This makes sense as although they may carry exactly the same things in their rucksacks girls are generally lighter and so the weight of their bag, as a percentage of their total body weight, is higher.

 

Mandrekar S, Chavhan D, Shyam AK, Sancheti PK. Effects of carrying school bags on cervical and shoulder posture in static and dynamic conditions in adolescent students. International journal of adolescent medicine and health. 2019 Oct 30.

This group looked at how they carry their bags. Trying to be cool and swinging your bag over just one shoulder changes one’s static biomechanics.  The head and neck move forward to compensate and the carrying shoulder rises. Then, because the centre of gravity is shifted the subject would tilt their torso away. Could this be the cause of the stereotypical teenage posture? It took just five minutes of bag wearing for any postural changes to become evident. It has also been suggested that a heavier bag weight is associated with an increased incidence of lower back pain in teens and this, in turn, is linked with an increased risk of lower back pain as an adult.

If they are not wearing their back slung over one shoulder they are wearing it slung low, rather than high and tight on their shoulders, and most of the biomechanic data suggests this puts a lower degree of stress on their lumbar spines than letting it ride high. The higher position also lends itself to more forward rotation of the pelvis and greater hip flexion. And, of course, wearing your bag on the front, instead of on the back, causes a whole new range of issues.

Harmless?

Whilst this post is focusing on just one potential downside of heavy school bags, Wierseema et al. found 247 children with injuries related to backpack use between 1999-2000. These were due to tripping over them (28%), getting hit by one (13%) or just trying to put them on (8%). Actually wearing the thing was associated with another 13% of complaints – specifically back pain.

There is also a condition called backpack palsy or, to be more accurate, backpack brachial plexus palsy. It is much more common in military recruits but can occur in children. Often unilateral, the paraesthesia, pain and sensory loss in addition to possible muscle wasting are due to neuropraxia of the brachial plexus.

Losing weight?

Does it make a difference if teenagers take some of the rubbish out of their bags?

Rodríguez-Oviedo P, Santiago-Pérez MI, Pérez-Ríos M, Gómez-Fernández D, Fernández-Alonso A, Carreira-Núñez I, García-Pacios P, Ruano-Ravina A. Backpack weight and back pain reduction: effect of an intervention in adolescents. Pediatric research. 2018 Jul;84(1):34.

This Spanish group targetted teenagers with an educational intervention. This comprised of a one-hour session on posture, the effects of backpack weight and some healthy lifestyle advice. They found that the intervention arm of the trial did indeed have (statistically significant) lighter bags moving forward in the younger cohorts but not in the older ones.

Strapping in?

Mathur H, Desai A, Khan SA. To determine the efficacy of addition of horizontal waist strap to the traditional double shoulder strap school backpack loading on cervical and shoulder posture in Indian school-going children. Int J Phys Med Rehabil. 2017;5(434):2.

If you want to reduce the usual bag-induced postural slump these authors, looking at 60 children, suggest that adding a waist strap to the usual two shoulder straps could make all the difference.

So what does this all mean?

As parents, we need to keep an eye on what our children are actually putting in their bags (compared to what they say they are putting in there). Perhaps we should weigh the bags as often as the children and limit the number of keyrings and Beanie Boos attached to the outside? Perhaps we need to further embrace technology and allow for the increased use of electronic devices coupled with a much, much older technology and let them use bags on wheels, similar to carry on luggage?

There have been a number of initiatives to make the wearing of school backpacks healthier. Sri Lanka introduced a National Healthy Schoolbag Campaign aimed at improving the lives of children. Large textbooks were split into smaller volumes to make it easier to carry just one small book around and a multidisciplinary schoolbag regulatory council was set up to liaise with industry partners to help regulate bags. In the US the “Pack it light, wear it right” initiative focussed on what the individual could do.

 

*If you really want to know what is in their bags you need to look inside. This wonderful paper from Archives suggests that the vast majority (96%) of parents had never checked the weight of their children’s bags and 34% had never even looked inside

Forjuoh SN, Little D, Schuchmann JA, Lane BL. Parental knowledge of school backpack weight and contents. Archives of disease in childhood. 2003 Jan 1;88(1):18-9.

 

Other Selected References:

American Academy of Pediatrics. How not to wear a school backpack. AAP Grand Rounds. 2008 Nov 1;20(5):58-9.

Brackley HM, Stevenson JM. Are children’s backpack weight limits enough?: A critical review of the relevant literature. Spine. 2004 Oct 1;29(19):2184-90.

Kim KE, Kim EJ. Incidence and risk factors for backpack palsy in young Korean soldiers. Journal of the Royal Army Medical Corps. 2016 Feb 1;162(1):35-8.

Goodgold S, Corcoran M, Gamache D, Gillis J, Guerin J, Coyle JQ. Backpack use in children. Pediatric physical therapy: the official publication of the Section on Pediatrics of the American Physical Therapy Association. 2002;14(3):122-31.

Jayaratne K, Jacobs K, Fernando D. Global healthy backpack initiatives. Work. 2012 Jan 1;41(Supplement 1):5553-7.

Maurya S, Singh M, Bhandari PS, Bhatti TS. Backpack brachial plexus palsy. Indian Journal of Neurotrauma. 2009 Dec;6(02):153-4.

Rose K, Davies A, Pitt M, Ratnasinghe D, D’Argenzio L. Backpack palsy: A rare complication of backpack use in children and young adults–A new case report. european journal of paediatric neurology. 2016 Sep 1;20(5):750-3.

Talbott NR, Bhattacharya A, Davis KG, Shukla R, Levin L. School backpacks: it’s more than just a weight problem. Work. 2009 Jan 1;34(4):481-94.

Weir E. Avoiding the back-to-school backache. CMAJ: Canadian Medical Association journal= journal de l’Association medicale canadienne. 2002 Sep;167(6):669-.

Wiersema BM, Wall EJ, Foad SL. Acute backpack injuries in children. Pediatrics. 2003 Jan 1;111(1):163-6.

Human Donor Breastmilk

Cite this article as:
Annabel Smith. Human Donor Breastmilk, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22355

You are a junior doctor working in ED. A 4-month-old girl, Lisa, is brought in by her parents with suspected bronchiolitis. On reviewing her history, her Dads tell you that Lisa is adopted, and is being fed donor breastmilk (and formula when they can’t access sufficient volumes). You’ve never encountered a baby on donor breastmilk, so you aren’t sure of the implications. You ask your friendly paediatric registrar about it…

Given that human milk is vastly superior to formula, it stands to reason that if a baby can’t be fed milk by his or her own mother, donor breastmilk should be the next step. Families wishing to access such milk must utilize either formalized milk banks, wet nurses, or private donor arrangements. The use of wet nurses (direct feeding of an infant by a lactating woman other than the infant’s mother) is very unusual these days, though still occurs in some cultures.

Charles et Henri Beaubrun anciennement attribué à Anonyme France XVIIe siècle Title Français : Louis XIV et la Dame Longuet de La Giraudière

Milk Banks

Formal ‘milk banks’ were quite prevalent a few decades ago, until HIV fears in the 1980s shut many facilities down. With new protocols for screening and techniques for pasteurization available, a resurgence in milk banking is being seen across the globe. Currently, a small handful of milk banks exist across Australia, predominantly to provide donor milk to vulnerable premature and low birth weight infants in Neonatal Intensive Care Units.

Formal milk banks cost a lot of money to set up (AUD$200,000-$250,000) and to run (AUD$150,000-$250,000 per year). Donors are screened in a very similar fashion to blood donors, with questionnaires and blood tests, and the milk is pasteurized to remove bacteria and viruses. Some live components of breastmilk are denatured in this process, but many important immunological and nutritional features remain. NICU infants are prime donor milk recipients, given they require so little compared to their older infant counterparts, and human milk has been shown to reduce rates of necrotizing enterocolitis and sepsis (compared with formula).

 

Private Breastmilk Sharing

For the rest of the Australian community, accessing milk banks is almost impossible, so many families who require a breastmilk alternative are utilizing social media and other community networks to find donors. These are entirely unregulated, although some web pages provide guidelines for collection, handling, ‘home pasteurization’, and storage of breastmilk. Donors will sometimes sell their milk, which is considered highly unethical, although reimbursement of a donor’s costs may be acceptable.

The Australia Breastfeeding Association does not endorse private exchanges of breastmilk supplies, as there can be no guarantees of safety for infants. It does provide web links to sites with guidelines for private milk sharing in case members are interested in this route, so that families (and donors) can be appropriately educated.

 

Conclusion

Ideally, formal human milk banks should be accessible to all families who, for whatever reason, require a safe alternative to maternal breastmilk. However, given the high set-up and running costs, and the fact that most mothers should be able to feed their own infants if given adequate support, perhaps any funds would be better spent for now on improving health sector lactation support, maternity leave financial support and breastfeeding infrastructure. Informal exchange of breastmilk is hard to endorse, given the inherent risks, however, if families are well educated, and guidelines are adhered to, the risks can likely be significantly reduced. Given the myriad health benefits in utilizing human milk over formula, many families will likely consider these risks acceptable and will continue to utilize donor human milk where available. 

In Lisa’s case, her dads explain that they are sourcing the milk from three altruistic donors who are all long-term friends of the family. They are all healthy women, and all have been strictly following the advice provided on the ‘eats on feets’ and ABA websites to ensure the milk is managed safely. The paediatric registrar has discussed this with the parents and reminded them about the risks of viral and bacterial transmission even with all due care, but as Lisa is otherwise a thriving baby, with just a mild case of bronchiolitis, there appears to be no cause for further investigation or cessation of the current feeding regimen.

 

References and Resources:

Commonwealth of Australia. Donor Human Milk Banking in Australia – Issues and Background Paper. 2014. Available from: https://www.health.gov.au/internet/main/Publishing.nsf/Content/D94D40B034E00B29CA257BF0001CAB31/$File/Donor%20Human%20Milk%20Banking%20in%20Australia%20paper%20(D14-1113484).pdf

Australian Breastfeeding Association. Position Statement on Donor Milk. Updated 2014. Available from: https://www.breastfeeding.asn.au/policy/statement-donor-milk

Websites providing advice and networks for private breastmilk sharing;

  • www.hm4hb.net

Hot Garbage: Mythbusting fever in children

Cite this article as:
Alasdair Munro. Hot Garbage: Mythbusting fever in children, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22916

Juniper is a 3yr old girl brought in with her mother, with a 48hr history of fever. Her mum is particularly concerned because her fever was up to 39.8°C, didn’t come down with paracetamol and she describes an episode which sounds like a rigor. On examination, she has a temperature of 39.3°C, a runny nose and bright red tonsils, and looks otherwise well. You go to discharge her, but your colleague asks if you should wait to see if her temperature comes down with ibuprofen before sending her home?

 

Introduction

Febrile illnesses are the most common cause of presentation to acute paediatric medical services. This means that fever is the most common presenting symptom seen by paediatricians, and it is clearly a huge cause of concern for parents. Despite this fact, it is clear that in day-to-day practice that there is a widespread misunderstanding about fever, its purpose, and its clinical interpretation.

Well, no longer! Once you have finished reading, you will be a master of all things related to fevers in children. We will start with some basic understanding of the processes surrounding fever, and finish off with some mega myth-busting!

What is fever?

Fever is an elevated core body temperature, as part of a physiological response to infection regulated by the hypothalamus. This is crucial to understand – your body is in control of your temperature. This is not something an infection is doing to your body; it is something your body is doing to the infection. This is different from pathological hyperthermia, where your temperature is elevated by either hypothalamic dysfunction or external heat. These are extremely rare.

Note: there are other, non-infectious causes of fever, such as cancer, Kawasakis, and autoinflammatory conditions, but these are rare in comparison to infectious fever and are covered elsewhere.

 

What temperature counts as a fever?

At what threshold do we say a child has an elevated body temperature? This is more controversial than one might think, as actually the data from which we derive “normal” body temperature is extremely poor. The most common cut off for defining a fever is 38°C – but it is important to remember that there is nothing magic about 38°C compared to 37.9°C, and temperature is better taken in context or a trend, if possible.

How do we get fevers?

The process of developing fever is extremely complex, and our understanding is still developing. At present, our best explanation is that the process is triggered by the presence of chemicals referred to as pyrogens. Pyrogens can either be exogenous (such as parts of the microbe itself, like the lipopolysaccharide on the outside of bacteria), or endogenous, such as cytokines like IL1, TNF, Prostaglandin E2 and importantly IL6, which are released by immune cells when they detect an invader. These pyrogens act to increase body temperature peripherally, but importantly also trigger receptors in the preoptic nucleus in the brain. This releases PGE2 into the hypothalamus, which then sets a new target temperature. This target is met by many facets designed to increase heat, including:

  • Release of noradrenaline by the sympathetic nervous system, increasing thermogenesis in brown adipose tissue and causing peripheral vasoconstriction and piloerection (reducing heat loss)
  • Acetylcholine release stimulating muscle myocytes to induce shivering
  • Feeling cold”, inducing heat-seeking behaviours (warm clothes and blankets)

It is important to remember that the body is trying to get hotter. If you intervene with non-medicinal efforts to cool it down, it will work even harder to try to heat up.

Why do we get fevers?

The process of having a fever has been conserved across species from lizards to mammals, and even plants! This is because it is a beneficial response to an infection. The mechanisms by which a fever helps protect you from infection include:

  1. Higher temperatures inhibiting growth/replication of pathogens
  2. Higher temperatures promoting the immune response to infection

It is also worth noting that bacteria are killed more easily by antibiotics at higher temperatures, so there is also a potential third mechanism.

 

Summary

Fever is beneficial. When a pathogen causes infection, pyrogens stimulate the hypothalamus to increase the body temperature through several mechanisms, and this increased temperature helps inhibit the growth of the pathogen AND stimulates the immune system to fight it.

That was a lot of science. Don’t worry – it’s time to get clinical! All this science stuff is lovely, but what does this mean for our patients?

Clinical significance of fever

As we have ascertained, fever is beneficial. For this reason, when a child presents with fever, the fever itself is actually of no concern. What we are interested in is the reason for the fever. Is this fever the result of a benign, self-limiting, childhood infection – or is it associated with a serious bacterial infection? Trying to determine this is enough for its own blog article (the most important thing is the end of the bed assessment – see Andy Tagg’s excellent breakdown of the paediatric assessment triangle).

Ignore the fever itself – what’s important is ascertaining its cause.

Now, let’s get on and bust some myths that persist surrounding fever in children!

 

Myth 1 – Higher temperature indicates a serious infection

This is one of the most common concerns amongst parents. The particular height of temperature may be what prompts them to come to hospital, or even what prompts the health care provider to initiate more aggressive management or investigations.

The truth is that the relationship between the height of temperature and risk of serious illness is at best complicated, and at worst a dangerous distraction. There is a very poor correlation, with such woeful sensitivity and specificity that it will both grossly over and under-call serious infections (either if the high temperature is used to rule in, or lower temperature to rule out). The caveat to this is in younger infants (particularly under 60 or 90 days), who have a higher baseline risk of serious infections (and more to the point – once they spike a temperature will be managed aggressively regardless of how high it was). Some studies have shown an extremely weak association in older children, but not enough for it to have any meaningful influence on our management. A fever is a fever – higher temperatures should not be managed any differently than lower ones.

 

Myth 2 – Temperature not relieved by antipyretics indicates a serious infection

Another common misconception also linked to the myth above. Some fevers respond well to antipyretics, and some do not. We do not understand why this is the case, however, studies have not demonstrated that failure to respond to antipyretics is a useful indicator of a more serious infection. It is not very pleasant for the child to remain hot, but it does not mean they are at any higher risk. A child whose temperature does not respond to antipyretics should not be treated any differently to one that does.

Myth 3 – Rigors indicated a serious infection

This has been covered in-depth in a separate blog post – but to summarise; there is extremely weak evidence that rigors are associated with an increased risk of bacterial infection in children, which is irrelevant when factors that are more important are taken into account. There is also evidence of no increased risk. The presence or absence of rigors should not be a deciding factor in the management of febrile children.

Myth 4 – You must wait for a fever to come down before discharge

This may seem common practice for many of you working in acute paediatrics. If a child is febrile on arrival, people often want to wait to see the temperature come down before allowing them to be discharged (this should be differentiated from seeing observations normalize in the absence of fever – which is a more understandable if still slightly questionable practice). As we have seen, a fever merely indicates the presence of an infection. If you have ascertained the cause of the fever, or at least ruled out any red flags for serious causes, the ongoing presence or absence of a fever means nothing for the child. If it comes down before discharge, it will probably just go up again once they are home! There is no need to make them wait around for hours for no reason.

Myth 5 – Fever should be treated with antipyretics

We have established that fever is beneficial. Therefore, there is essentially no reason to treat a fever in and of itself. It will not cause harm, and it is probably helping. Some children tolerate having higher temperatures extremely well, so if they are playing happily or do not seem terribly bothered about their temperature of 39°C then you leave them well alone.

Treat the child, not the fever.

Myth 6 – Fever should not be treated with antipyretics

There is an opposing school of thought, which says that since fevers are beneficial, we should not treat them at all. Given how absolutely dreadful it can feel to have a fever (which many of us adults should be able to vouch for), many of us give medicines to try to bring the temperature down and make the child more comfortable. This is the right thing to do. Despite the potential benefits having a fever confers, there is no evidence of any clinically meaningful harms to treating temperatures in unwell children, or even in adults in ICU. If the child is distressed by the temperature, they should have antipyretics to make them feel more comfortable.

Summary

  • Fever helps your body to fight infection and is not dangerous (no matter how high)
  • The fever itself is not important. The cause of the fever is what matters
  • There is little to no evidence that higher temperatures, temperatures that don’t respond to antipyretics, or rigors indicate an increased risk of serious infection
  • Persisting fever on its own is not a reason to postpone discharge
  • Only treat fevers if they are causing distress. Treat the child, not the fever

 

Postscript: Febrile convulsions

When I posted my initial thread on twitter about fevers, there were many comments asking why I didn’t address febrile convulsions. This was mainly because these are worth a post to themselves (which they have here). In brief, febrile convulsions are extremely distressing for parents to observe, but they are common and they are very benign. We do not advise treating fevers to prevent febrile convulsions, and until recently, this was because there was no evidence that they had any effect in preventing them. A recent study from Japan did demonstrate a decrease in recurrence of febrile convulsions in children who had already had one if given regular PR paracetamol, however, there are major caveats to this study discussed in depth here.

 

For the more visual oriented, the talented Emma Buxton has created an infographic of the key reminders from this blog post:

A better discharge summary

Cite this article as:
Beckie Singer. A better discharge summary, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21995

Discharge summaries, often considered the bane of every junior doctor and ED physician’s existence. But what if we took a step back and considered these as a clinical handover to primary care – similar in nature to the clinical handover that occurs in the transfer of care documents that you would send with a patient you are transferring to another hospital? They suddenly take on a whole other level of importance. Studies from the ‘adult medicine world‘ have shown that roughly 20% of patients experience an adverse event during the hospital-to-home transition, many of which could be mitigated by good handover between the hospital and the primary care provider.

I am Sam

Cite this article as:
Dani Hall. I am Sam, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.21781

This post is based on a talk Dani presented at the Irish Association of Emergency Medicine conference in November 2019. The talk wouldn’t have been possible without the extraordinary help and inspiration from Mike Farqhuar from the Evelina London Children’s Hospital and Mike Healy from the Linn Dara CAMHS Unit.

What’s the formula for formula?

Cite this article as:
Annabel Smith. What’s the formula for formula?, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.21688

Whilst breastfeeding confers myriad benefits for infants and their mothers, there are many reasons why some infants will require formula, at least at some point in their first 12 months of life. Having a basic understanding of the different products available and the way formula should be prepared and administered is important for all doctors and nurses working with young children. The variety of formulas, bottles and teats available, as well as the complexities of preparation, administration, and storage, confuses the best of us, so here’s my attempt to make it a little clearer.

Breastfeeding Basics

Cite this article as:
Annabel Smith. Breastfeeding Basics, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.21681

“If breastfeeding did not already exist, someone who invented it today would deserve a dual Nobel Prize in medicine and economics… Breastfeeding is a child’s first inoculation against death, disease, and poverty, but also their most enduring investment in physical, cognitive, and social capacity.”