It’s always nice to come across a paper that makes you pause. A paper that challenges, until you read it, what you know to be “true”.
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.
Therefore in babies under 2 months old with pyrexia, likely bronchiolitis but some clinical uncertainty – send a urine for m, c, & s
The risk of a secondary bacterial infection is very low, and there is potential harm from giving antibiotics
Commence oxygen therapy to maintain sats over 91%
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.
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.
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
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?
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.
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.
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.
When people approach me to ask about writing for DFTB I usually suggest that they write about what they know. That is certainly my approach and why I started to write the Normal Neonate series a year ago. The littlest Tagg has just had her year’s check up with the maternal and child health nurse. She thought that tiny Tagg had uneven buttock creases and wanted her assessed for DDH. But how sensitive is this sign?
Mary had a little taste…
Common non-toxic exposures (and what to expect)
As clinicians, we will occasionally come across someone with a case of Toxicophobia – the fear of being poisoned. In paediatrics, this usually presents in the parents of a little one who has explored their way into something they shouldn’t have. Whilst developmentally normal, it can be hard to tell what to be worried about (and given the last post, there are definitely things to be worried about!). It may seem that something will surely happen (you can blame television for that feeling), but in many cases, a patient is going to be just fine.
Before looking further into the various substances that can cause problems for our young patients, I thought it would be interesting and a bit of fun to talk about some of the non-toxic exposures the Poison Information Centre receives calls about – sometimes on a daily basis. In the instances where patients and their parents find themselves in front of you, it’s useful to know a little about what you needn’t worry about. Or in some cases, only worry about a little…
Topical antiseptics and hand sanitisers
With all this talk about hand hygiene and killing germs, it’s not surprising that someone would worry about someone getting into one of these.
From a Toxicology perspective, there are two ingredients in these products that can be problematic – the first are quaternary ammonium compounds. A prime example is benzalkonium chloride, found in products such as Dettol. The concentrations for most household products are low (less than 7.5%) and likely to cause GI irritation at best with perhaps a vomit and some diarrhoea so supportive treatment will suffice.
Not surprisingly, deliberate overdoses can be clinically more significant with sequelae including corrosive injury, hypotension, renal injury and aspiration. Hand sanitisers containing alcohol, typically ethanol, and can cause intoxication if a large amount is ingested. In scenarios, where a child has had a taste, lick or swallow, significant toxicity is very unlikely
In the end, Paracelsus still holds true – the dose makes the poison and in the vast majority of these cases, it will not be a problem.
Silica gel packets
Containing sodium silicate to prevent excess moisture build-up and food spoilage, these little white packets are everywhere you look in the pantry. It is not surprising people get worried when they read the warning ‘DO NOT EAT’ all over the packet. Fortunately, silica is non-toxic however; it can be a choking hazard so a medical assessment is recommended if there are any signs suggestive of inhalation (e.g. cough, wheeze).
Dish-washing detergents
Dishwashing detergents contain soaps to help get rid of dirt and grease but luckily not people. Like other household products, they only cause mild GI upset, a ‘scratchy’ throat and aspiration if vomiting occurs.
Toilet bowl cleaners
The usual suspects are the toilet discs (see below). Given their job is to help clean yucky organic matter from the inside of a toilet; these are rather pretty in appearance.
As a parent, I do not know what would horrify me more – my child putting his finger into a disc or into the toilet! Maybe the latter…
These discs contain detergent and perfume but the method of exposure is usually a ‘finger dip’ so minimal exposure occurs. If anything, mild GI upset may occur with a larger ingestion. Important advice for parents is that the next poo might be a more psychedelic colour than usual.
Glow sticks
I suspect the majority of calls come around New Year’s or Moomba (if you live in Melbourne). Glow sticks glow thanks to an ester called cyalume, which luminesces when mixed with hydrogen peroxide. Some products have a plastic casing that contains an inner glass capsule that when broken allows the cyalume (in the glass capsule) to mix with the hydrogen peroxide (surrounding the capsule). An accidental chew will lead to a bitter taste, a dry mouth and perhaps a vomit with some nausea, but not much else.
Creams and Lotions
Whilst they keep your skin looking healthy and young, eating these will not do much to your insides apart from a GI upset. Some of these contain small amounts of ethanol but normally not enough to cause clinically significant toxicity.
Perfumes, colognes and after-shaves
Similar to creams and lotions, these products are often in reach of little hands. Little people often do not drink much, if any, due to their strong odour and taste. Small ingestions are irritant in nature but larger ingestions can result in ethanol intoxication. However a lot of these products can be 60-80% ethanol and given the taste, it would be a very rare event for a child to swallow enough to become intoxicated.
As these are volatile products, off gassing of fumes can occur and causes a chemical pneumonitis in larger ingestions but the taste and smell of these is such that this is a rare occurrence.
Pens/Ink
Suddenly I find myself back in high school, swinging from my chair in the back row whilst chatting with friends. The typical patient is a young teenager sucking on a pen. The anticipated adverse effects include discoloration of the tongue, faeces and clothing often with a sense of embarrassment but nothing more.
Bubbles
Whilst we ask you not to forget about the bubbles, I’m happy to add ‘Don’t worry about the bubbles’. These often contain a soap or mild detergent to produce these clear spheres of pure delight so a drink from a container will result only in GI upset and perhaps some irritation if other parts of the body make contact (e.g. eyes). Not to be confused with the champagne variety.
Don’t forget to check out the other posts in this series…
Special thanks to Jeff Robinson for his review and input
Hammond, K., Graybill, T., Spiess, S. E., Lu, J., & Leikin, J. B. (2009). A complicated hospitalization following dilute ammonium chloride ingestion. Journal of Medical Toxicology, 5(4), 218–222. https://doi.org/10.1007/BF03178271 Joseph, M. M., Zeretzke, C., Reader, S., & Sollee, D. R. (2011). Acute ethanol poisoning in a 6-year-old girl following ingestion of alcohol-based hand sanitizer at school. World Journal of Emergency Medicine, 2(3), 232–233. https://doi.org/10.5847/wjem.j.1920-8642.2011.03.014References
Disclaimer: The information published in this post is for medical education only and does not constitute formal Toxicology advice. The information is current at the time of writing and may change with emerging evidence over time. If you have concerns about an individual who may be poisoned, please call your local Poisons Information Centre (13 11 26 for Australia).
A nine year old girl, Skye, comes to see you with her parents. She has a two day history of a red, circular and enlarging rash on her right calf, which they describe as looking like a ‘bull’s eye’. She has also been feeling generally unwell with headaches, muscle aches, fatigue and a fever. They tell you in passing that they came back from holiday, in Scotland, a week ago.
How to draw a Genogram
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