Don’t Forget The Lego

Community paediatrics / Gastrointestinal / General paediatrics
Cite this article as:
Team DFTB. Don’t Forget The Lego, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17375

It might have escaped your notice but the team at DFTB recently had a paper published by the Journal of Paediatrics and Child Health that has garnered a lot of interest.

Tagg, A. , Roland, D. , Leo, G. S.Y., Knight, K. , Goldstein, H. , Davis, T. , DFTB, (2018), Everything is awesome: Don’t forget the Lego. J Paediatr Child Health. doi:10.1111/jpc.14309

We are sure you have questions. Lots of questions. So we thought we should answer them for you in the best way we know how.

What pressing scientific question did you ask?

We know that coins are the most commonly swallowed foreign object in the paediatric population and there is a lot of data surrounding transit time. The second most commonly swallowed objects are small toys but there is very little data out there. We wanted to know how long it would take for a small piece of plastic toy, in this case a Lego head, to pass through.

How on earth did you come up with the idea?

In one of our regular editorial meetings we were discussing some of our upcoming publications and musing how we could do something a little lighter, akin to the great Peppa Pig paper in last years Christmas BMJ. And then Andy Tagg said, “I’ve got this idea but you might think it a bit strange.” Within a short space of time we had an international team of researchers literally chomping at the bit to undertake the study.

Did you really swallow those poor heads?

Of course we did! Do you want proof?

Then what happened?

We waited to see what would happen. We all know corn kernels can whip through the colon in seemingly no time at all, but what about a little yellow piece of plastic? There was really only one way to find out.

And you searched through your own poo to find them? How?

As with any piece of research it is important to have a robust search strategy in place prior to commencement. A variety of techniques were tried – using a bag and squashing, tongue depressors and gloves, chopsticks – no turd was left unturned. And although we only used a very small sample size the fact that one of our heads went missing suggest that you really shouldn’t worry if you can’t find it.

What happened to the missing head?

Who knows? Perhaps one day many years from now, a gastroenterologist performing a colonoscopy will find it staring back at him.

But what about Ben Lawton? Where was he when all this was going on?

Don’t Forget the Bubbles was founded by four curious doctors – Tessa Davis, Andy Tagg, Henry Goldstein and Ben Lawton. Unfortunately Ben was travelling at the time we undertook the study and we didn’t think searching through his colonic contents in an aeroplane toilet was exactly fair.

And then you kept it quiet, right?

It can take an average of 17 years for science to go from benchside to bedside. Leveraging social media we managed to go from online publication on a Thursday evening to global saturation by Saturday evening.

By Saturday morning Damian Roland was speaking on Canadian radio and the DFTB group made Forbes, ars technica, and the BBC World Service by the afternoon.

But surely this isn’t hard science?

Of course it’s not, it’s a bit of fun in the run up to Xmas.

With such a small sample size it is important that you don’t extrapolate the data to the entire population of Lego swallowers. Anecdata from Twitter suggests that a large number of people accidentally ingested bits of Lego throughout their life with no adverse effects*.

It is also worth noting that most people who swallow Lego are children, not fully grown adults. Data that is applicable to the adult population may well not be applicable to children.

For a more scientific approach to ingested foreign bodies in children then take a look at these two papers.

Yeh HY, Chao HC, Chen SY, Chen CC, Lai MW. Analysis of Radiopaque Gastrointestinal Foreign Bodies Expelled by Spontaneous Passage in Children: A 15-Year Single-Center Study. Frontiers in pediatrics. 2018;6:172.

Macgregor D, Ferguson J. Foreign body ingestion in children: an audit of transit time. Emergency Medicine Journal. 1998 Nov 1;15(6):371-3.

You may also enjoy exploring the following posts about foreign bodies on DFTB:

Andy’s blog post on Foreign Body Ingestion

Chantal McGrath’s DFTB17 talk Batteries Not Included on button battery ingestion

A case study by Loren on ‘the magic coin’ 

What’s next for the group?

Whilst this may be the pinnacle of our publishing careers we hope we have not peaked too early. Next up is finalizing all the details for our upcoming conference in London – www.dftb19.com, and then? Who knows?

*Please do not try this at home.

DFTB in the papers

Ars Technica

Forbes

BBC World Service

CBC Radio Canada – As it happens

10 Daily

Herald Sun

November 26, 2018 0

Vaccine hesitancy: Margie Danchin at DFTB18

Communication / Community paediatrics / DFTB18 / General paediatrics / Health / Infectious Diseases / Podcast / Portfolio
Cite this article as:
Team DFTB. Vaccine hesitancy: Margie Danchin at DFTB18, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17112

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families. Tickets for DFT19, which will be held in London, UK, are now on sale from www.dftb19.com.

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November 23, 2018 0

Neonatal jaundice – the basics

Community paediatrics / Emergency / General paediatrics / Neonatology
Cite this article as:
Shalome Kanagaratnam. Neonatal jaundice – the basics, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17047

Most newborns are jaundiced. Indeed, 60% of term infants, 80% of premies and 33% of breastfed babies are jaundiced in early life. Fortunately, the majority of these self-resolve and have no sinister underlying cause. But how do we identify those who require urgent management? How can we effectively and confidently reassure anxious patients whilst ensuring we don’t miss a significant diagnosis?

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November 19, 2018 1

How to draw a Genogram

Adolescent medicine / Communication / Community paediatrics / Education / Emergency / General paediatrics / Health / Infectious Diseases
Cite this article as:
Daniel Bakhsh. How to draw a Genogram, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17132

As a Student Doctor at the University of Queensland, I was offered the opportunity to shadow the Adolescent Team at The Child and Youth Mental Health Service (or CYMHS) at the Queensland Children’s Hospital. This was an amazing opportunity to observe some really important work in two of my special interest areas: Paediatrics and Psychiatry. The attachment really drove home that patients don’t exist in isolation, and how this is particularly true for children. The surrounding family system strongly dictates how well they will fare once they leave the hospital.

As part of this attachment I was asked to prepare and present Genograms for every patient at the weekly Multidisciplinary Team meeting. As I began to interview family members in order to gather the required 3 generations of family history, it became clear to me that a small diagram could represent and quickly convey what would otherwise have taken several pages of text. Genograms provide a wealth of insight at a glance, can help align patients with their most appropriate care, and are relatively easy to draw once you know how. They are a mainstay of Paediatrics for a reason.

When I first came across Genograms as a student, attempting to create one was very confusing and a little overwhelming. There are also surprisingly few reference materials available to aid you along the way. So in order to make this task a little easier for the next student, I put together this little video. I hope you find it useful.

– Daniel Bakhsh, Student Doctor, Doctor of Medicine Program, University of Queensland

November 12, 2018 0

Bronchiolitis guidelines

Community paediatrics / General paediatrics / Infectious Diseases / Neonatology / Respiratory
Cite this article as:
Tessa Davis. Bronchiolitis guidelines, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17023

Up to 48% of infants admitted to Australian hospitals with bronchiolitis receive treatment that has no evidence of benefit. Bronchiolitis remains the most common reason for admission to hospitals in Australia and New Zealand for infants, and yet our practice in treating these patients remains variable.  The PREDICT network have conducted a systematic review to produce Australia’s first bronchiolitis guideline based on a robust systematic review. These guidelines broadly agree with the American Academy of Pediatrics and NICE guidelines.

 

O’Brien S, Wilson S, Gill FJ, Cotterell E, Borland ML, Oakley E, Dalziel SR, Paediatric Research in Emergency Departments
International Collaborative (PREDICT) network, Australasia. The management of children with bronchiolitis in the Australasian hospital setting: development of a clinical practice guideline. J Paediatric Child Health, 2018. doi:10.1111/jpc.14104

 

The authors have produced 22 recommendations based on their robust evidence review. Let’s take a look at their key recommendations.

 

What investigations should we do?

  • Routine blood and urine testing is not recommended.
  • Viral swabs are not recommended (although the authors mention that further study needs to be done to determine the benefit of cohorting in wards i.e. when all babies with the same virus are put in the same bay together to avoid spread).
  • The authors note that in infants under 2 months old with bronchiolitis there is an increased risk of a concurrent UTI.

Therefore in babies under 2 months old with pyrexia, likely bronchiolitis but some clinical uncertainty – send a urine for m, c, & s

 

What treatments are effective?

  • Salbutamol – there is no benefit in using salbutamol in infants with bronchiolitis (and some evidence of adverse effects)
  • Nebulised adrenaline – no benefit
  • Nebulised hypertonic saline – there is weak evidence of a reduction in length of stay of 0.45 days. However when two studies were removed, both of which used a different discharge criteria than most hospitals, there was no benefit. This is not recommended routinely, although the authors suggest that it should be used only as part of an RCT
  • Glucocorticoids – no benefit
  • Antibiotics – not recommended

The risk of a secondary bacterial infection is very low, and there is potential harm from giving antibiotics

  • Oxygen – no evidence of benefit in infants with no hypoxia, and low level evidence that maintaining the sats over 91% with oxygen actually prolongs the length of stay. There are no reports of long-term adverse neurodevelopmental outcomes in infants with bronchiolitis, however there is also no data on the safety of targeting sats <92%

Commence oxygen therapy to maintain sats over 91%

  • Sats monitoring – there is moderate evidence suggesting that continuous sats monitoring increases the length of stay in stable infants
  • High flow – there is low to very-low level evidence of benefit with high flow
  • Chest physiotherapy – not recommended
  • Saline drops – routine saline drops are not recommended but a trial with feeds may help
  • Feeds – both NG and IV are acceptable routes for hydration

 

This is the first robust Australasian acute paediatric guideline on bronchiolitis. It provides clear guidance for the management of patients seen in Australasian EDs and general paediatric wards with bronchiolitis and is in line with US and UK recommendations. Our current practice often deviates from this evidence-based, and hopefully these guidelines will start the shift towards unifying evidence-based practice in managing infants with bronchiolitis.

 

 

References

American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics 2006; 118: 1774–93.

Ricci V, Delgado Nunes V, Murphy MS, Cunningham S; on behalf of the Guideline Development Group and Technical Team. Bronchiolitis in children: Summary of NICE guidance. BMJ 2015; 350: h2305.

October 26, 2018 4

DFTB go to New York

Communication / Community paediatrics / Education / General paediatrics / Health / Leadership
Cite this article as:
Andrew Tagg. DFTB go to New York, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17016

I first heard of the FemInEM crew in Dublin. Dara Kass, Jenny Beck-Esmay and Stacey Poznanski took to the stage to talk about the birth of FemInEM, first as a blog then as a resource to effect change in the conversation around gender and equity in emergency medicine. Since then they have grown to be a leading voice in this area.

Their first sell out conference, FIX17, in New York brought together a unique set of voices and when the call came out for pitches to speak at FIX18 I thought it would be the perfect place for me to tell a story. This blog post isn’t about my tale – you can read A short story about death… and life here – but about something else.

I consider myself well-travelled, having spent almost 5 years of my life working as a doctor on board cruise ships, but hearing the talks at FIX18 made me realise I a still living in my own little bubble. Everything I hear via Twitter or other forms of social media comes pre-filtered by the source. So if I only follow white hetero-males they inform my worldview. The conference reminded me that there are other voices and other realities.

 

Sex and gender

In a conference where I was clearly in the minority, I was constantly reminded of things I have just taken for granted. Nick Gorton, a transman,  really opened my eyes when he told the audience that life had been like playing a video game on hard mode then, when he became a man, everything just switched over to easy. Look out for his great talk when it comes out…

 

Race

You only have to read the newspaper headlines on any given day to see how race plays a role in the public perception of a person. To hear Arabia Mollette say that she will never be seen as a woman first when she walks into a room because she is a person of colour made me feel uncomfortable. I’d like to think that I don’t see the world that way, but we all have our implicit biases. Don’t think you are biased? Then try out one of the Harvard Implicit Bias tests over at Project Implicit.

 

Privilege

A lot of medics come from a place of privilege, parents with degree level education and jobs that pay well. Many have parents that are, or were, doctors.  Regina Royan spoke of a different type of upbringing, of families struggling to make ends meet, and of the hidden challenges this brings from the start of medical training – not just in the shockingly high costs to apply to medical school in the US but also on things like electives and placements away from your home base.

 

I have lived, comfortably, within my own little bubble of existence. FemInEM has challenged me to expand my worldview, to listen to dissenting voices, and ask more questions.

 

For more accounts of FIX18 then read these accounts…

Penny Wilson – Getting my feminist FIX in New York

Shannon MacNamara – Telling stories to FIX things

Annie Slater – We support, We Amplify, We Promote

 

October 25, 2018 0

Bacterial co-infection

Community paediatrics / General paediatrics / Infectious Diseases
Cite this article as:
Andrew Tagg. Bacterial co-infection, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16783

Often we are asked to look at a febrile infant with what appears to be a viral illness. But could there be something else going on? If you believe in Occam’s Razor or the law of parsimony then you might think the simplest solution, the obvious viral illness, is the cause of the fever. But what about Hickam’s Dictum – the patient can have as many diseases as they please?

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September 24, 2018 0

DFTB go to the Harbour

Community paediatrics / Emergency / General paediatrics
Cite this article as:
Andrew Tagg. DFTB go to the Harbour, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16727

This week the DFTB team have been invited to run a conference within a conference in Sydney. Resus @ the Harbour is a multidisciplinary resuscitation conference combining powerful patient stories with cutting edge care – just the sort of thing we love at DFTB.

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September 21, 2018 0

Finding the needle – without using one

Community paediatrics / Emergency / General paediatrics / Infectious Diseases
Cite this article as:
Ben Lawton. Finding the needle – without using one, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16714

This week the DFTB team have been invited to run a conference within a conference in Sydney. Resus @ the Harbour is a multidisciplinary resuscitation conference combining powerful patient stories with cutting edge care – just the sort of thing we love at DFTB.

Read more
September 17, 2018 2

FPIES

Community paediatrics / Gastrointestinal / General paediatrics
Cite this article as:
Clementine David. FPIES, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16444

A 6-month-old male is brought to ED by his mother with multiple episodes of profuse vomiting after eating lunch. No diarrhoea, fevers or unwell contacts. He is usually a well child and had a normal neonatal period.

He is immunised and otherwise thriving from a growth and developmental perspective. The mother, a nurse, reports that the infant was mottled, pale and lethargic at home but began to pick up whilst being triaged in ED.

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September 10, 2018 0