Being a NICU parent: Joanne and Scott Beedie at DFTB18

Cite this article as:
Team DFTB. Being a NICU parent: Joanne and Scott Beedie at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.18131

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 DFTB19, which will be held in London, UK, are now on sale from www.dftb19.com.

Challenging Communication: Damian Roland at DFTB18

Cite this article as:
Team DFTB. Challenging Communication: Damian Roland at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.18059

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 DFTB19, which will be held in London, UK, are now on sale from www.dftb19.com.

Transient hypogammaglobulinaemia of infancy

Cite this article as:
Clementine David. Transient hypogammaglobulinaemia of infancy, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17301

A 14-month-old boy is brought to your GP clinic by his mother with recurrent upper respiratory tract infections. His mother reports that he attends full time day care and he is ‘constantly sick.’ You note that one of your colleagues has seen him twice for acute otitis media this year.

Eczema

Cite this article as:
Davis, T. Eczema, Don't Forget the Bubbles, 2019. Available at:
https://dontforgetthebubbles.com/eczema-2/

This post is based on teaching by Jean Robinson, Clinical Nurse Specialist in Paediatric Dermatology at the Royal London Hospital; and notes by Joe Piper.

The broad principles are of eczema are:

Emollients are to put moisture into the skin

Steroids are to reduce inflammation

Note: a skin flare up is always itchy – if it’s not, then question the diagnosis.

 

Can we cure it?

Atopic eczema is seen in 15-20% of children. There is no cure, and so treatment aims to control rather than cure the eczema. The aim is to get it under control. 80% will improve by puberty/teenage years with topical treatments. There will be remits and relapses, and children and families require education and support.

50% will resolve by age 7, but be careful with the figures you share with parents, as they may be disappointed when it does not improve. 85% of eczema sufferers have mild eczema, and most start with symptoms after one year of age.

 

Bad disease is usually due to poor management from the practitioner, or being on the right treatment but having poor compliance.

Poor adherence is the number one reason for a flare. There are often lots of psychological issues: embarrassment; bullying; confusion around treatment. Well-meaning relatives/friends can give contradictory advice and suggests alternative therapies.

Families will present with a mixture of frustration, stress, reduced quality of life, and are often miserable, with sleep disturbance. Eczema needs to be taken seriously and managed well. There is a similar reduction in quality of life to families of other chronic disease patients – partly due to sleep disturbance, but also a because it is a very visible disease.

 

Management principle 1 – Bathing

Bathing was previously advised for 15 minutes daily, in lukewarm water, with added oil.

The recent publication of the BATHE trial has turned this advice on its head. The Southampton-based trial randomised 483 children with atopic dermatitis to either have emollient added to the bath for 12 months or no emollient added to the bath for 12 months. Outcomes were eczema control and eczema severity. The BATHE trial showed no benefit in adding emollients to the bath.

However, there is ongoing debate amongst dermatologists as to whether this study is applicable to those being treated by specialist dermatology teams.

  1. The BATHE trial was conducted in patients being managed in primary care.
  2. No benefit was shown in the group who bathe 4 times or less per week; however, when looking at those who bathed more frequently, a clinically meaningful benefit was demonstraed (although it was small).

So for now, our hospital-based dermatology team at my own hospital in London, still recommends emollients in bath oils.

For bath oil, use Oilatum Junior or Hydromol. Use one capful for one baby bath. If a normal bath is being used, then use two to three capfuls and make sure it is mixed in well.

Oilatum Plus has antiseptic in it, and hence can cause bad dermatitis if not mixed in water well. Many centres do not recommend this version any more.

When washing with water – use a soap-free cleanser when washing as the water on its own will dry out the skin. The most infected use Dermol 500 as a soap substitute, and it can be used on the face. Consider applying this after washing hands, at nursery (this can be hard to do at school).

These are all prescribable: we should encourage GPs and us to prescribe it, so that parents do not have to buy it (to improve compliance)

Reactions to aqueous cream in children are so common that it should only be used as a soap substitute, and not as a leave-on emollient.

 

Management principle 2 – Steroids

There are four different strengths:

Mild: 1% hydrocortisone, (Fucidin H: Fucidin & Hydrocortisone)

Moderate: Eumovate (clobetasone butyrate 0.05%) – this is the strongest you should use on the face, Betnovate RD (reduced dilution 0.025%). These can be used for those over one year (if repeated courses are needed despite the eczema not improving then the patient should be refered to dermatology)

Potent: Betamethasone 0.1%, Fucibet (fucidin & betamethasone) –  microbial resistance is high in the UK, so only use for 14 days),  Elocon (mometasone furoate). These are the strongest for the body. They can be used for short term treatment i.e. one to two weeks, but you probably need a dermatology opinion if there is no response to the initial course.

Super-potent: Dermovate (clobetasol propionate), Clobaderm. These are dermatology recommended only.

 

Know the generic names as well as the brand names and check the percentage.

Hydrocortisone cream vs ointment – ointment is oilier and better.

The cream has more water and more additives. Only give the cream if the patient doesn’t  like ointments.

Note: If very very infected and ointment will slide off, then cream has better application, but this is very rare, even within dermatology (<2%).

 

How do you apply steroids?

As a rough guide – one finger tip unit (i.e. squeezed over adult finger) should be enough to cover two adult palm-sized areas.

It is much easier to say ‘apply enough so it looks shiny’. Do all the application with a finger, not with the hand, otherwise the majority will be absorbed before it reaches the child.

Make sure steroids are applied to inflamed areas, including open areas. But don’t apply it on surgical wounds or ulcers.

Skin thinning is rarely an issue (we hardly ever see skin thinning from topical steroid use, but we see loads of under treated children) – so avoid saying ‘apply a thin layer’.

The advice should be:

  • Start with pea-sized lump
  • Apply to all of the active area, including lichenified areas, hyperpigmented areas
  • Leave the healthy bits
  • For papular areas – anything that is thickened is inflamed and needs treating with steroids

Apply steroids twice a day in general, but there is a move to use them once a day (Mometasone is once a day)

 

Which steroids to choose?

Start with hydrocortisone on the face. If the eczema is severe, you can go up to a moderately potent steroid (e.g. Eumovate) on the face and potent on the body, but often this should be discussed with dermatology, and should certainly be discussed if it is not improving after two weeks. However, be more cautious in babies – from four months of age, you can use Eumovate (moderately potent) on the body.

Do not use potent steroids without specialist advice.

Only apply the steroids to active eczema. Use the steroids for seven days, and you can stop if it has completely cleared with no inflammation. There may be a need for longer steroid use e.g. for 14 days, 28 days, or 33 days for small, persistent parts.

Chronic relapse is very common and people struggle on for long time with too weak steroids. Often it is better to then try short dose of stronger steroids. Moderate or potent steroids for short periods only can be used in the axillae and groin – it can be difficult with skin folds to get to the active area. Generally, do not use potent steroid in children (e.g. Betnovate) without specialist advice. You can go up to potent/moderately potent on scalp.

Make sure you show people how to use the steroids i.e. consider it the same as checking inhaler technique.

 

Management principle 3 – Emollients

Use the greasiest the family are happy to use. If the child has very sore skin, then 50/50 is the greasiest.

With paraffin, beware of smoking, and open fires.

Lotions are acceptable, but not as greasy, so should be used only if the family are finding a greasy emollient too difficult.

The rough estimate is using one pot every two weeks (250g-500g), and use it four times a day if it’s bad enough for hospital presentation, otherwise they can step it down to twice a day

Pump dispensers are cleaner, but you cannot use emollients in a pump dispenser. From a tub, use a clean spoon at home, ideally with a saucer. Apply the emollient in the direction of hairs, so that it does not upset hairs and potentially lead to folliculitis. After a bath, the skin is very moist and so there is better absorption.

Put the steroid on first and then wait for 20-30 minutes and then put the emollient on top.

Keep going with emollients even when the eczema is clear. If the child is still scratching, use emollients.

 

 

If you want to dive a little deeper then read these previous posts…

The basics by Dilshad Marikar

Living with eczema by Andrea Coe

Complications by Andrea Coe

When nothing works: Greg Kelly at DFTB18

Cite this article as:
Team DFTB. When nothing works: Greg Kelly at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.18046

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 DFTB19, which will be held in London, UK, are now on sale from www.dftb19.com.

Bubble Wrap PLUS – February

Cite this article as:
Anke Raaijmakers. Bubble Wrap PLUS – February, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.18007

Welcome to February’s Bubble Wrap Plus, our monthly paediatric journal club provided by Professor Jaan Toelen & his team of the University Hospitals in Leuven (Belgium). This comprehensive list of ‘articles to read’ comes from 34 journals, including Pediatrics, The Journal of Pediatrics, Archives of Disease in Childhood, JAMA Pediatrics, Journal of Paediatrics and Child Health, NEJM, and many more.

This month’s list features answers to intriguing questions (and maybe answers) such as: ‘Is inattention the main cause of medication errors in hospitalized newborns?’, ‘Which children have trouble falling asleep after concussion?’, ‘What are the determinants of low measles vaccination coverage in children?’, ‘Is new media usage associated with poorer sleep in toddlers?’ and ‘Is early fish introduction associated with a lower risk of asthma?’.

You will find the list broken down into four sections:

1.Reviews and opinion articles

New therapies for acute RSV infections: where are we?

Xing Y, Proesmans M. Eur J Pediatr. 2019 Feb;178(2):131-138.

ADHD in children and youth: Part 1-Etiology, diagnosis, and comorbidity.

Bélanger SA, et al. Paediatr Child Health. 2018 Nov;23(7):447-453.

ADHD in children and youth: Part 2-Treatment.

Feldman ME, et al. Paediatr Child Health. 2018 Nov;23(7):462-472.

Imaging of diseases of the vagina and external genitalia in children.

Matos J, et al. Pediatr Radiol. 2019 Jan 5.

Supporting breathing of preterm infants at birth: a narrative review.

Martherus T, et al. Arch Dis Child Fetal Neonatal Ed. 2019 Jan;104(1):F102-F107.

2. Original clinical studies

Incident reports versus direct observation to identify medication errors and risk factors in hospitalised newborns.

Palmero D, et al. Eur J Pediatr. 2019 Feb;178(2):259-266.

Risk prediction of severe reaction to oral challenge test of cow’s milk.

Kawahara T, et al. Eur J Pediatr. 2019 Feb;178(2):181-188.

Association Between Screen Time and Children’s Performance on a Developmental Screening Test.

Madigan S, et al. JAMA Pediatr. 2019 Jan 28.

Presentation and outcomes in hypertrophic pyloric stenosis: An 11-year review.

Vinycomb TI, et al. J Paediatr Child Health. 2019 Jan 24.

Trouble Falling Asleep After Concussion Is Associated With Higher Symptom Burden Among Children and Adolescents.

Howell DR, et al. J Child Neurol. 2019 Jan 22:883073818824000.

Effect of a Low Free Sugar Diet vs Usual Diet on Nonalcoholic Fatty Liver Disease in Adolescent Boys: A Randomized Clinical Trial.

Schwimmer JB, et al. JAMA. 2019 Jan 22;321(3):256-265.

Association of Rotavirus Vaccination With the Incidence of Type 1 Diabetes in Children.

Perrett KP, et al. JAMA Pediatr. 2019 Jan 22.

Questions and Concerns About HPV Vaccine: A Communication Experiment.

Shah PD, et al. Pediatrics. 2019 Jan 22.

Three Important Findings From a Study on HPV “Real World” Effectiveness.

Dempsey AF. Pediatrics. 2019 Jan 22.

Human Papillomavirus Vaccine Effectiveness and Herd Protection in Young Women.

Spinner C, et al. Pediatrics. 2019 Jan 22.

High-flow nasal cannula therapy for children with bronchiolitis: a systematic review and meta-analysis.

Lin J, et al. Arch Dis Child. 2019 Jan 17.

Determinants of low measles vaccination coverage in children living in an endemic area.

Lo Vecchio A, et al. Eur J Pediatr. 2019 Feb;178(2):243-251.

Factors Associated With Rotavirus Vaccine Coverage.

Aliabadi N, et al. Pediatrics. 2019 Jan 17.

Recognizing critically ill children with a modified pediatric early warning score at the emergency department, a feasibility study.

Vredebregt SJ, et al. Eur J Pediatr. 2019 Feb;178(2):229-234.

Calprotectin instability may lead to undertreatment in children with IBD.

Haisma SM, et al. Arch Dis Child. 2019 Jan 17.

Psychogenic movement disorders in children and adolescents: an update.

Harris SR. Eur J Pediatr. 2019 Jan 11.

Sleep and new media usage in toddlers.

Chindamo S, et al. Eur J Pediatr. 2019 Jan 16.

Preventing Neonatal Group B Streptococcus Disease: The Limits of Success.

Mukhopadhyay S, et al. JAMA Pediatr. 2019 Jan 14.

Epidemiology of Invasive Early-Onset and Late-Onset Group B Streptococcal Disease in the United States, 2006 to 2015: Multistate Laboratory and Population-Based Surveillance.

Nanduri SA, et al. JAMA Pediatr. 2019 Jan 14.

Complications and risk factors for severe outcome in children with measles.

Lo Vecchio A, et al. Arch Dis Child. 2019 Jan 12.

RSV hospitalization in infancy increases the risk of current wheeze at age 6 in late preterm born children without atopic predisposition.

Korsten K, et al. Eur J Pediatr. 2019 Jan 12.

Cognitive Outcomes and Positional Plagiocephaly.

Collett BR, et al. Pediatrics. 2019 Jan 11.

Retinal Findings in Young Children With Increased Intracranial Pressure From Nontraumatic Causes.

Shi A, et al. Pediatrics. 2019 Jan 10.

Introduction of fish and other foods during infancy and risk of asthma in the All Babies In Southeast Sweden cohort study.

Klingberg S, et al. Eur J Pediatr. 2019 Jan 7.

Nebulised hypertonic saline in children with bronchiolitis admitted to the paediatric intensive care unit: A retrospective study.

Stobbelaar K, et al. J Paediatr Child Health. 2019 Jan 6.

Black Race Is Associated with a Lower Risk of Bronchopulmonary Dysplasia.

Ryan RM, et al. J Pediatr. 2019 Jan 4.

Exposure to and use of mobile devices in children aged 1-60 months.

Kılıç AO, et al. Eur J Pediatr. 2019 Feb;178(2):221-227.

Patterns of Prenatal Alcohol Use That Predict Infant Growth and Development.

Bandoli G, et al. Pediatrics. 2019 Jan 4.

Wide variation in severe neonatal morbidity among very preterm infants in European regions.

Edstedt Bonamy AK, et al. Arch Dis Child Fetal Neonatal Ed. 2019 Jan;104(1):F36-F45.

Follow-up and outcome of symptomatic partial or absolute IgA deficiency in children.

Moschese V, et al. Eur J Pediatr. 2019 Jan;178(1):51-60.

The problem of defecation disorders in children is underestimated and easily goes unrecognized: a cross-sectional study.

Timmerman MEW, et al. Eur J Pediatr. 2019 Jan;178(1):33-39.

Meningococcal Disease Among College-Aged Young Adults: 2014-2016.

Mbaeyi SA, et al. Pediatrics. 2019 Jan;143(1).

3. Guidelines and best evidence

Diagnosis and Management of Kawasaki Disease.

Sosa T, et al. JAMA Pediatr. 2019 Jan 22.

Pharmacologic Treatments for Sleep Disorders in Children: A Systematic Review.

McDonagh MS, et al. J Child Neurol. 2019 Jan 23:883073818821030.

Development and Validation of a Cellulitis Risk Score: The Melbourne ASSET Score.

Ibrahim LF, et al. Pediatrics. 2019 Jan 3.

Nasal high flow therapy for neonates: Current evidence and future directions.

Hodgson KA, et al. J Paediatr Child Health. 2019 Jan 7.

Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum: US Preventive Services Task Force Reaffirmation Recommendation Statement.

US Preventive Services Task Force, Curry SJ, et al. JAMA. 2019 Jan 29;321(4):394-398.

4. Case reports

A Devil of a Case: Chest Pain in an Adolescent.

Bruehl MJ, et al. Clin Pediatr (Phila). 2019 Jan 28:9922819826102

 

If we have missed out on something useful or you think other articles are absolutely worth sharing, please add them in the comments!

Please join us for our next #DFTB_JC on twitter…The DFTB/ADC Journal Club is a monthly collaboration between @DFTBubbles and @ADC_BMJ featuring a FREE access article from the latest issues of Archives of Disease of Childhood. January’s pick  is ‘ Can we use POCUS to Diagnose Pneumonia?’ Read the article here: bit.ly/2TMDf2M The chat will happen on twitter at Tue 22/1/19 at UTC2000hrs (That’s Wednesday 0700 23/1 AEST), just search the hashtag #DFTB_JC

The 26th Bubble Wrap

Cite this article as:
Leo, G. The 26th Bubble Wrap, Don't Forget the Bubbles, 2019. Available at:
https://dontforgetthebubbles.com/26th-bubble-wrap/

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 PERUKI (Paediatric Emergency Research in UK and Ireland) to point out something that has caught their eye.

This month to ease us into the new clinical year; this bubble wrap will featuring a couple of new papers but also a few flashback reviews of some papers we’ve explored in other posts in case you missed them the first time around!

ADC/DFTB Journal Club #3 – January – POCUS vs Pneumonia?

Cite this article as:
Henry Goldstein. ADC/DFTB Journal Club #3 – January – POCUS vs Pneumonia?, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17878

Diagnosing pneumonia can be tricky. Each year, 1.2 million children under five years of age die from pneumonia. In developed countries, the incidence is 0.05 per person-year. Pneumonia can imply both bacterial or viral, and there is a distinct challenge in differentiating between these given similar clinical and investigative pictures, or even the presence of pneumonia at all.

What about some POCUS? Can we utilise this investigative modality to spot a child with pneumonia?  The paper from Archives of Disease of Childhood featured in our third #DFTB_JC sought to answer this question.

What’s it about?

 

The general sentiment from the Twitter discussion was that making a diagnosis of pneumonia is challenging. More specifically, there’s no reliable way of differentiating between viral and bacterial pneumonia, nor any particularly strong evidence for whom should or should not receive antibiotic therapy.

Most of those actively contributing (including Sarah McNab, Edd B, Damian Roland & Ding online identified the use of clinical skills; with an emphasis on history (of fever, cough) and examination features (pallor, focal chest findings), with the use of chest radiograph (or roentgenogram if you’re feeling formal), to augment or refute this diagnosis.

Blake (@cobra6blake) suggested a 2017 JAMA review article by Shah et al. as a good summary.

 

The authors methodology made sense with respect to answering the stated question regarding the diagnostic accuracy of LUS vs CXR for diagnosing pneumonia, using this approach:

Although there are well established pros and cons for each modality there was a distinct lack of congruity about which modality was the more accurate, including the rates of agreement between both operators. Jessica Wong (@jessicawswong) also identified Dominguez et al.’s related 2018 article in the Journal of Paediatrics and Child Health.

 

Sonia Twigg and Damian Roland identified the intricacies of anatomic pathology, citing the difference between the clinical entity of pneumonia and the pathologic entity of hepatisation (grey vs red); I recommend Robbins’ pathology for a refresher.

 

Both Sonia & Edd B have identified the key challenge with the paper (and frankly acknowledged the next step, nicely summarised by Lassi et al in this Cochrane Review (emphasis mine).

“Pneumonia is an infection of the lungs. In children it is one of the leading causes of childhood deaths across the globe. Pneumonia can be classified based on the World Health Organization (WHO) guidelines. This classification involves assessment of certain clinical signs and symptoms and the severity of disease. The treatment is then tailored according to the classification. For non-severe pneumonia, the WHO recommends the use of oral antibiotics for treatment. However, pneumonia is caused more commonly by viruses that do not require antibiotic management but rather supportive care. On the other hand, pneumonia caused by bacteria needs management with antibiotics to avoid complications. Since there is no clear way to distinguish quickly which organism actually caused pneumonia, it is considered safe to give antibiotics. However, it may lead to the development of antibiotic resistance and thus limit their use in future infections. Thus the question arises as to whether the use of antibiotics is justified in non-severe pneumonia.” – Lassi et al.

 

For me personally, this paper has sought to highlight an emerging utilisation of POCUS; whilst it contributes to – rather than definitively answering – the evidence and understanding around both paediatric pneumonia and the availability and utility of USS & CXR.

So, a short summary of what we’ve discussed;

– CXR is the “Gold standard” Ix, but the clinical diagnosis of pneumonia remains the most accepted, with occasional augmentation via CXR

– LUS vs CXR are roughly comparable, both with flaws regarding isolated accuracy & predictability

– This study hasn’t been designed to inform whom should receive treatment, but it’s what we’d all like to know

– POCUS is an emerging skill set for emergency +/- paediatric providers to consider

Thanks again to everyone who participated in our #DFTB_JC and we hope you will join us again later this month for our next paper, thanks to #ADC_BMJ.

“Drug preparation and administration errors during simulated paediatric resuscitations”

Things will be kicking off on Twitter at UTC 2000hrs, 21/02/2019. with this paper…

Murugan S, Parris P, Wells M. Drug preparation and administration errors during simulated paediatric resuscitations. Archives of disease in childhood. 2018 Nov 9:archdischild-2018.

 

 

If you want to level up your POCUS skills then why not sign up to one of our point of care ultrasound workshops. They are going to take place on the Sunday before DFTB19. Check out the website for more details.

Making the Call in NAI: Bindu Bali at DFTB18

Cite this article as:
Team DFTB. Making the Call in NAI: Bindu Bali at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17854

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 DFTB19, which will be held in London, UK, are now on sale from www.dftb19.com.

Skeletal survey for NAI

Cite this article as:
Katie Mckinnon. Skeletal survey for NAI, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17911

In November 2018 the revised edition of “The radiological investigation of suspected physical abuse in children” was released in the UK. This was written by the Royal College of Radiologists and the Society and College of Radiographers, and endorsed by the Royal College of Paediatrics and Child Health. It produced guidance on the process of skeletal surveys and how and when to perform them.

The management of non-accidental injury is an area of fear for many paediatricians. The increasing guidance in this area helps to take some of the variation in practice out of the process.

Rubella

Cite this article as:
Andrew Tagg. Rubella, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17280

In November of 2018 the healthcare press celebrated the eradication of a disease that had been the scourge of pregnant mothers – the third disease, otherwise known as rubella. One of the challenges of paediatrics in this era of near global vaccine coverage is maintaining a degree of awareness in those of us that have never seen the illness. So with that in mind, let’s refresh your knowledge of German Measles.