Situation Vacant

Cite this article as:
Team DFTB. Situation Vacant, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19567

If you were unable to make it to DFTB19 you might have missed a very exciting announcement.

Come and work at the Royal London Hospital (Major Trauma Centre) as a Senior Clinical Fellow in Paediatric Emergency Medicine and have 20% of your time dedicated to DFTB.

We will take applications for a deferred start date too.

But hurry as applications close at the end of the month!

Mirror Mirror

Cite this article as:
Andrew Tagg. Mirror Mirror, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19303

This blog post complements the talk I gave in the closing session of DFTB19. It has been recorded and will be released as FOAMed later in the year.

As part of my ongoing professional development I decided to volunteer for an experiment the Australasian College for Emergency Medicine were running. As a consultant it is really hard to get feedback on how you are doing, both clinically and professionally. You could ask your colleagues face-to-face but how honest an answer are you really going to get? So I enrolled in a pilot multi-source feedback program. Unlike traditional peer feedback and yearly assessments where you receive one-on-one feedback from the head of department, this was was something different.

I had to nominate 15 colleagues to complete an online survey about my professional behaviours. Anonymized to makes sure that things would not be seen as personal. I chose colleagues from all levels of my work life – from interns, registrars, peers, my immediate bosses and the Chief Medical Officer of the hospital. I chose doctors from specialities that I refer to on a regular basis and I chose non-clinical staff too. And in order to increase the actual worth of the project I included some people that I feel that I don’t get on with as well as I could (yes, they do exist!).

The findings were…interesting. There were the usual comments about drinking less coffee and learning to say no, both of which I fail at miserably on a regular basis. And then there was this one.

Now clearly this says more about the author than it does about me, but it did get me thinking about the impact we have in the workplace.

Emotional contagion

Human beings are social animals. We thrive in groups and, despite having had language for approximately 100,000 years, we rely on non-verbal communications to let members of our tribe know how we are feeling.

Charles Darwin, in his three-quel to The Origin of the Species, wrote that, despite their fleeting nature, our emotions are written large on our faces and this process is far beyond our control. But what is more fascinating is what happens when someone witnesses that unbidden display of emotions. Watch someone smile, genuinely smile, a mirror neurons light up in your brain. In a series of fMRI studies Rizzolatti et al. showed that the same are of the brain fires up when you witness an emotional display as if you had experienced it yourself. This reflexive, sub-thalamic response is emotional contagion.

Whilst our emotions influence our physiological state the reverse is also true. If I smile (more on that later) I feel happier. If I frown I feel more sad. And if I cannot frown – perhaps I have succumbed and finally got some botox to rid me of these troublesome wrinkles – then I will actually feel happier. Well, that is what some scientists have found.

Negative states

The problem is that negative states – fear, anger, boredom – are much more readily transmitted than positive ones – kindness, compassion, calm. Perhaps because they often come unbidden and out-of-control they are more likely to leak out before they can be contained.

This can cause major problems in the workplace as a doctor infects all those around them.

The work we do has a high level of emotional labour, moving from high intensity states such as dealing with life-affecting resuscitations to low intensity states of chronic constipation, without pause.

Some people are more susceptible to emotional contagion than others. Take a look at Docherty’s 15 part emotional contagion susceptibility scale and see where you might fall.

Doherty, R. W. (1997). The Emotional contagion scale: A measure of individual differences. Journal of Nonverbal Behavior, 21, pp. 131-154

And if you are the sort of person that finds themselves crying at the movies then you are not alone. I’ve left a little something for you on our YouTube channel for the next time you want to cut loose.

There are some highly infectious people that we can find in any department.

We’ve all met the MAVERICK – the hot shot doctor that thinks they know everything. They don’t need to follow the guidelines because they know better. They can send home the febrile 28 day old because they look fine to them. They can make the half-baked referrals because it’s the end of their shift and they have to get to their beach volleyball game. Besides the team will sort it out.

They make us fearful, nervous, a little afraid. Their arrogance spreads as they achieve more success, until…. They make a mistake. And they will.

So how can we help them? How can we protect ourselves and the department from their contagion? They need to be reminded, gently, that even Tom Cruise wears a safety harness. Guidelines are there for a reason. It’s okay not to agree with them but you have to be able to defend your actions. If you want to go your own way you need the evidence to back you up. Rather than ignore the MAVERICK and allow the worry to fester it’s important to head them off (whilst allowing them to save face). You set the tone!

What about the MOANER? You only have to go into the staff room of an y department in the hospital to spot one of these creatures. They are the ones drawing everyone into their spiral of doom as they complain about so-and-so from X (insert particular out-group here). Before long the rest of the group has been infected but their particular brand of emotional catharsis and everyone begins to moan.

It’s easier to not become one of them than it is to change their mind. This is the time for herd immunity. The more positive people there are in the room the better. Rather than joining in it is time to point out the dangers of stereotypes and labels. And should the opportunity to moan about your lot at work arise then it is time to take the higher ground. Remember, you set the tone!

And finally there is the MAGNET. Years of bad experience has led to a degree of learned helplessness. The more times they have been crushed by the chaos of the system the more they feel it is pointless to do something about it. At the mention of the Q word – the-word-that-should-not-be-named – they predict an apocalypse worse than any Private Frazer could dream up. Equipment will fail, stock will be missing or fall apart and there will be nobody around to help at the critical juncture – all because you said the word q.u.i.e.t.(shhhhh!)

So what can you do? It is time to role model the desired behaviour. You cannot control what is happening outside of your department but you can claw back a little control from the chaos within. At the beginning of every shift I check the key equipment that I might need to make sure it is working, I make sure that nothing is missing and I make sure roles have been allocated before the inevitable happens. I set the tone!

Manipulation?

All of this behaviour, including the examples I give in my talk, could be seen as manipulative, perhaps even a little sly? Teams that have a happier outlook, with members that embrace positive emotional contagion are safer and more efficient. Whereas when experimental psychologists have planted a MOANER as a confederate they found that teams became much less efficient.

Which sort of team would you rather work in?

Selected References

Doherty, R. W. (1997). The Emotional contagion scale: A measure of individual differences. Journal of Nonverbal Behavior, 21, pp. 131-154.

Don’t Forget The Poetry

Cite this article as:
Team DFTB. Don’t Forget The Poetry, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19547

We wanted to kick off DFTB19 with something just a little different and were blessed to have Erin Bolens, poet, open our London conference.

 

We’ve only just begun…

Cite this article as:
Andrew Tagg. We’ve only just begun…, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19490

As we prepare for the opening of #DFTB19 and meeting friends from all over the world it’s great to see everyone getting stuck into the workshops.

The Compassion Lab

Mary Freer is the Fairy Godmother of the DFTB conferences. Since she spoke at DFTB17 we have been awed at her passion for compassion. This year she ran a boutique Compassion Lab to help bring a little more kindness to our workplace.

In our time poor, resource poor workplaces it can be a challenge to be kind, both to ourselves, each other, and our patients.

If you couldn’t make it over to London then there are still some tickets left for her Compassion Revolution in Melbourne.

Presentation skills 2.0

We like to challenge our speakers to step out from behind the lectern and bring their ‘A’ game. This can be quite confronting when you are used to watching the usual ‘death-by-powerpoint’ type of talk. To make it easier for our speakers Grace Leo and Ross Fisher have, once again, acted as speaker coaches. But we didn’t want only just our speakers to benefit from their wisdom.

Over the course of the day they took delegates from the basics of the P3 methodology to the next level of presenting. We are really looking forward to hearing their pitches for next year.

The Power of POCUS

Ultrasound is the way forward in paediatric imaging and for our two workshops Cian McDermott and Russ Horowitz had an amazing team to help them. With the support of GE Healthcare and Jon Robinson delegates were rotated around a variety of stations to test their ultrasound chops.

They were joined by Resa Lewiss, Mike Griksaitis, Avi Sarfatti and Toni Hargadon-Lowe.

We were lucky to have some very patient paediatric models to tell our ultrascoundrels if they were pushing too hard or putting the probe in the wrong place. We even managed to come up with a new US sign – let’s hope the Toast sign of a full bladder catches on.

Let’s Play Make Believe

A crack team of simulationistas led by Ian Summers ran two sessions on Sunday. Starting with a simulation design workshop and ably abetted by Sandra Viggers, Camille Sorensen, Morten Lindkvist, Damian Roland and LifeCast the group were set the task of designing in situ simulation scenarios with the child in mind.

The afternoon session was led by Walter Eppich who took the delegates through the power of debriefing. He is a man who has spent a lot of time thinking about debriefing.

Bajaj K, Meguerdichian M, Thoma B, Huang S, Eppich W, Cheng A. The PEARLS Healthcare Debriefing Tool. Acad Med. 2018, 93(2), 336.

The day ended with another storytelling evening. Old friends and new gathered at the Sway Bay in central London to share tears and laughter.

What happens at Storytelling stays at Storytelling!

Fixing what once was broken: Ross Fisher at DFTB18

Cite this article as:
Team DFTB. Fixing what once was broken: Ross Fisher at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19345

Spoilers: There are some minor swears at the beginning of this talk so if you are easily offended or are listening with children around then fast-forward 10 seconds or so.

We have all made mistakes. Some are small – like forgetting to get the milk on the way home, some are huge – like forgetting your wedding anniversary. In this closing talk from DFTB18 Ross talks about the ancient Japanese art of Kintsugi. By fixing shards of broken pottery with molten gold artists created something even more beautiful than that which was broken.

 

What if you make a mistake at work? Can you be fixed?

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.

DFTB19 has just a couple of main conference tickets left but there are still spots for some of the pre-conference workshops.

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

Callahan K, Christman G, Maltby L. Battling burnout: strategies for promoting physician wellness. Advances in pediatrics. 2018 May 7.

Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. InMayo Clinic Proceedings 2017 Jan 1 (Vol. 92, No. 1, pp. 129-146). Elsevier.

Bumper Bubble Wrap PLUS – May/June 2019

Cite this article as:
Anke Raaijmakers. Bumper Bubble Wrap PLUS – May/June 2019, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19367

Can’t get enough of Bubble Wrap? The Bubble Wrap Plus is a monthly paediatric journal club reading list  from Anke Raaijmakers working with Professor Jaan Toelen & his team of the University Hospitals in Leuven. This comprehensive list is developed from 34 journals, including major and subspecialty paediatric journals. We suggest this list can help you discover relevant or interesting articles for your local journal club or simply help you to keep an finger on the pulse of paediatric research.

This list features answers to intriguing questions such as: ‘Is it time to stop checking gastric residual volume in neonates?’, ‘Do we need to flush peripheral catheters?’, Is methotrexate a good drug to treat atopic dermatitis?’, ‘How long does the DTP vaccine provide protection?’, ‘Is routine ultrasound for the hip necessary after breech presentation?’, ‘For which children is team sport participation associated with better adult mental health?’,  ‘What is the outcome after a 10-min APGAR score of zero?’ and ‘What is the effect of online health information (Dr Google) on trust in pediatricians’ diagnoses?’.

You will find the list is broken down into four sections:

MAY PAPERS

1.Reviews and opinion articles

Glucocorticoids for Croup in Children.

Gates A, et al. JAMA Pediatr. 2019 Apr 29.

The role of objective tests to support a diagnosis of asthma in children.

Danvers L, et al. Paediatr Respir Rev. 2019 Feb 28.

Invasive group A streptococcal disease: Management and chemoprophylaxis.

Moore DL, et al. Paediatr Child Health. 2019 May;24(2):128-129.

Relaxation training for management of paediatric headache: A rapid review.

Thompson AP, et al. Paediatr Child Health. 2019 May;24(2):103-114.

Necrotizing Enterocolitis, Gut Microbiota, and Brain Development: Role of the Brain-Gut Axis.

Niemarkt HJ, et al. Neonatology. 2019 Apr 11;115(4):423-431.

Newborn screening for cystic fibrosis: Is there benefit for everyone?

Course CW, et al. Paediatr Respir Rev. 2019 Feb 28.

Ethical Issues in Perinatal Clinical Research.

Walsh V, et al. Neonatology. 2019 Apr 4;116(1):52-57.

Machine Learning in Medicine.

Rajkomar A, et al. N Engl J Med. 2019 Apr 4;380(14):1347-1358.

The child with an incessant dry cough.

Galway NC, et al. Paediatr Respir Rev. 2018 Aug 30.

2. Original clinical studies

Association of Rhinovirus C Bronchiolitis and Immunoglobulin E Sensitization During Infancy With Development of Recurrent Wheeze.

Hasegawa K, et al. JAMA Pediatr. 2019 Apr 1.

Respiratory Syncytial Virus, Rhinoviruses, and Recurrent Wheezing: Unraveling the Riddle Opens New Opportunities for Targeted Interventions.

Ramilo O, et al. JAMA Pediatr. 2019 Apr 1.

Effect of Gastric Residual Evaluation on Enteral Intake in Extremely Preterm Infants: A Randomized Clinical Trial.

Parker LA, et al. JAMA Pediatr. 2019 Apr 29.

Lack of Efficacy of Lactobacillus reuteri DSM 17938 for the Treatment of Acute Gastroenteritis: A Randomized Controlled Trial.

Szymański H, et al. Pediatr Infect Dis J. 2019 Apr 25.

Flushing of peripheral intravenous catheters: A pilot, factorial, randomised controlled trial of high versus low frequency and volume in paediatrics.

Kleidon TM, et al. J Paediatr Child Health. 2019 Apr 29.

The association between crowding within households and behavioural problems in children: Longitudinal data from the Southampton Women’s Survey.

Marsh R, et al.  Paediatr Perinat Epidemiol. 2019 Apr 29.

Genetic and Early-Life Environmental Influences on Dental Caries Risk: A Twin Study.

Silva MJ, et al. Pediatrics. 2019 Apr 26.

The Association of Paternal IQ With Autism Spectrum Disorders and its Comorbidities: A Population-Based Cohort Study.

Gardner RM, et al. J Am Acad Child Adolesc Psychiatry. 2019 Apr 23.

Rethinking ADHD intervention trials: feasibility testing of two treatments and a methodology.

Fibert P, et al. Eur J Pediatr. 2019 Apr 24.

Long-term effect of methotrexate for childhood atopic dermatitis.

Purvis D, et al. J Paediatr Child Health. 2019 Apr 23.

Sleep-Related Infant Suffocation Deaths Attributable to Soft Bedding, Overlay, and Wedging.

Erck Lambert AB, et al. Pediatrics. 2019 Apr 22.

Effect of Albuterol Premedication vs Placebo on the Occurrence of Respiratory Adverse Events in Children Undergoing Tonsillectomies: The REACT Randomized Clinical Trial.

von Ungern-Sternberg BS, et al. JAMA Pediatr. 2019 Apr 22.

Duration of Immunity and Effectiveness of Diphtheria-Tetanus-Acellular Pertussis Vaccines in Children.

Domenech de Cellès M, et al. JAMA Pediatr. 2019 Apr 22.

Contribution of Sensory Processing to Chronic Constipation in Preschool Children.

Little LM, et al. J Pediatr. 2019 Apr 12.

Postvaccination Febrile Seizure Severity and Outcome.

Deng L, et al. Pediatrics. 2019 Apr 19.

The effect of pediatric patient temperament on post-operative outcomes.

Uhl K, et al. Paediatr Anaesth. 2019 Apr 18.

Adolescent and Young Adult Cancer Patients’ Experiences With Treatment Decision-making.

Mack JW, et al. Pediatrics. 2019 Apr 18.

Evaluation of referrals for short stature: A retrospective chart review.

Yue D, et al. Paediatr Child Health. 2019 May;24(2):e74-e77.

Respiratory Viruses Frequently Mimic Pertussis in Young Infants.

Damouni Shalabi R, et al. Pediatr Infect Dis J. 2019 May;38(5):e107-e109.

The Clinical Presentation of Pediatric Mycoplasma pneumoniae Infections-A Single Center Cohort.

Gordon O, et al. Pediatr Infect Dis J. 2019 Apr 10.

Paediatric reference intervals are heterogeneous and differ considerably in the classification of healthy paediatric blood samples.

Alnor AB, et al. Eur J Pediatr. 2019 Apr 17.

Investigating the need for routine ultrasound screening to detect developmental dysplasia of the hip in infants born with breech presentation.

D’Alessandro M, et al. Paediatr Child Health. 2019 May;24(2):e88-e93.

High-density Bacterial Nasal Carriage in Children Is Transient and Associated With Respiratory Viral Infections-Implications for Transmission Dynamics.

Thors V, et al. Pediatr Infect Dis J. 2019 May;38(5):533-538.

Children With Noncritical Infections Have Increased Intestinal Permeability, Endotoxemia and Altered Innate Immune Responses.

Sturgeon JP, et al. Pediatr Infect Dis J. 2019 Apr 10.

The Role of Patient and Parental Resilience in Adolescents with Chronic Musculoskeletal Pain.

Gmuca S, et al. J Pediatr. 2019 Apr 10.

Proband and Familial Autoimmune Diseases Are Associated With Proband Diagnosis of Autism Spectrum Disorders.

Spann MN, et al. J Am Acad Child Adolesc Psychiatry. 2019 May;58(5):496-505.

Breastfeeding in Infancy and Lipid Profile in Adolescence.

Hui LL, et al. Pediatrics. 2019 Apr 9. pii: e20183075.

Classic Metaphyseal Lesions among Victims of Abuse.

Adamsbaum C, et al. J Pediatr. 2019 Apr 5.

Postextubation Dysphagia in Pediatric Populations: Incidence, Risk Factors, and Outcomes.

Hoffmeister J, et al. J Pediatr. 2019 Apr 3. pii: S0022-3476(19)30243-4.

Pediatric Septic Arthritis of the Knee: Predictors of Septic Hip Do Not Apply.

Obey MR, et al. J Pediatr Orthop. 2019 Apr 3.

Association between hypotension and serious illness in the emergency department: an observational study.

Hagedoorn NN, et al. Arch Dis Child. 2019 Apr 4.

Association of In Vitro Fertilization With Childhood Cancer in the United States.

Spector LG, et al. JAMA Pediatr. 2019 Apr 1:e190392.

Prenatal Omega-6:Omega-3 Ratio and Attention Deficit and Hyperactivity Disorder Symptoms.

López-Vicente M, et al. J Pediatr. 2019 Mar 22.

Molecular Genetic Anatomy and Risk Profile of Hirschsprung’s Disease.

Tilghman JM, et al. N Engl J Med. 2019 Apr 11;380(15):1421-1432.

4. Case reports

Gaze Palsy: An Important Diagnostic Clue.

Madaan P, et al. J Pediatr. 2019 Apr 24.

When Posture Gives the Clue: “Jug Handle Deformity”.

Banerjee A, et al. J Pediatr. 2019 Apr 17.

A 10-year-old female with unilateral seventh cranial nerve palsy.

Gohal S, et al. Paediatr Child Health. 2019 May;24(2):69-71.

A boy with developmental regression.

MacLellan K, et al. Paediatr Child Health. 2019 May;24(2):67-68.

A Healthy Toddler With Fever and Lethargy.

Suri NA, et al. Pediatrics. 2019 Apr 5. pii: e20180412.

Acute encephalopathy associated with influenza infection: Case report and review of the literature.

Albaker A, et al. Paediatr Child Health. 2019 May;24(2):122-124.

JUNE PAPERS

2. Original clinical studies

Risk of invasive bacterial infections by week of age in infants: prospective national surveillance, England, 2010-2017.

Ladhani SN, et al. Arch Dis Child. 2019 May 30.

Impact of paediatric tonsillectomy perioperative management on pain, nausea and recovery: A prospective cohort study.

Richards J, et al. J Paediatr Child Health. 2019 May 29.

Efficacy and safety of systemic hydrocortisone for the prevention of bronchopulmonary dysplasia in preterm infants: a systematic review and meta-analysis.

Morris IP, et al. Eur J Pediatr. 2019 May 29.

Severe Acute Respiratory Failure in Healthy Adolescents Exposed to Trimethoprim-Sulfamethoxazole.

Miller JO, et al. Pediatrics. 2019 May 29.

Retrospective study of budesonide in children with eosinophilic gastroenteritis.

Fang S, et al.Pediatr Res. 2019 May 29.

Care for children with severe chronic skin diseases.

De Maeseneer H, Van Gysel D, et al. Eur J Pediatr. 2019 May 22.

Association of Team Sports Participation With Long-term Mental Health Outcomes Among Individuals Exposed to Adverse Childhood Experiences.

Easterlin MC, et al. JAMA Pediatr. 2019 May 28.

FEEDMI: A Study Protocol to Determine the Influence of Infant-Feeding on Very-Preterm-Infant’s Gut Microbiota.

Morais J, et al. Neonatology. 2019 May 27:1-6.

Association between early life (prenatal and postnatal) antibiotic administration and coeliac disease: a systematic review.

Kołodziej M, et al. Arch Dis Child. 2019 May 25.

The effect of follow-up after a negative double-blinded placebo-controlled cow’s milk challenge on successful reintroduction.

Schrijvers M, et al. Eur J Pediatr. 2019 May 24.

Prevalence of Gastroesophageal Reflux Disease Symptoms in Infants and Children: A Systematic Review.

Singendonk M, et al. J Pediatr Gastroenterol Nutr. 2019 Jun;68(6):811-817.

What does sleep hygiene have to offer children’s sleep problems?

Hall WA, et al. Paediatr Respir Rev. 2018 Nov 9.

Physiological effects of high-flow nasal cannula therapy in preterm infants.

Liew Z, et al. Arch Dis Child Fetal Neonatal Ed. 2019 May 23.

Treatment failure in children diagnosed with constipation in a paediatric emergency department in relation to Rome III criteria.

Eltorki M, et al. Paediatr Child Health. 2019 Jun;24(3):185-192.

Traffic Crashes, Violations, and Suspensions Among Young Drivers With ADHD.

Curry AE, et al. Pediatrics. 2019 May 20.

Preparing for Discharge From the Neonatal Intensive Care Unit.

Gupta M, et al. Pediatrics. 2019 May 3.

Infant Deaths in Sitting Devices.

Liaw P, et al. Pediatrics. 2019 May 20.

Higher Sun Exposure is Associated With Lower Risk of Pediatric Inflammatory Bowel Disease: A Matched Case-Control Study.

Holmes EA, et al. J Pediatr Gastroenterol Nutr. 2019 May 15.

Genetic Associations Between Executive Functions and a General Factor of Psychopathology.

Harden KP, et al. J Am Acad Child Adolesc Psychiatry. 2019 May 15.

Accuracy of surgeon prediction of appendicitis severity in pediatric patients.

Yu YR, et al. J Pediatr Surg. 2019 Apr 24.

Outcomes related to 10-min Apgar scores of zero in Japan.

Shibasaki J, et al. Arch Dis Child Fetal Neonatal Ed. 2019 May 15.

Topiramate plus Cooling for Hypoxic-Ischemic Encephalopathy: A Randomized, Controlled, Multicenter, Double-Blinded Trial.

Nuñez-Ramiro A, et al. Neonatology. 2019 May 15;116(1):76-84.

Risk factors for development of urinary tract infection in children with nephrolithiasis.

Cetin N, et al. J Paediatr Child Health. 2019 May 14.

LISTERIA MENINGITIS IN DANISH CHILDREN 2000-2017: A Rare Event Even in a Country With High Rates of Invasive Listeriosis.

Vissing NH, et al. Pediatr Infect Dis J. 2019 May 15.

Cerebral oxygenation and blood flow in term infants during postnatal transition: BabyLux project.

De Carli A, et al. Arch Dis Child Fetal Neonatal Ed. 2019 May 13.

Machine Learning at the Clinical Bedside-The Ghost in the Machine.

Zorc JJ, et al. JAMA Pediatr. 2019 May 13.

Comparison of Machine Learning Optimal Classification Trees With the Pediatric Emergency Care Applied Research Network Head Trauma Decision Rules.

Bertsimas D, et al. JAMA Pediatr. 2019 May 13.

Adherence to metformin is reduced during school holidays and weekends in children with type 1 diabetes participating in a randomised controlled trial.

Leggett C, et al. Arch Dis Child. 2019 May 11.

Physicians’ Attitudes on Resuscitation of Extremely Premature Infants: A Systematic Review.

Cavolo A, Dierckx de Casterlé B, Naulaers G, et al. Pediatrics. 2019 May 10. pii: e20183972.

Young people’s experiences of brief inpatient treatment for anorexia nervosa.

Thabrew H, et al. J Paediatr Child Health. 2019 May 6.

Increasing the dose of oral vitamin K prophylaxis and its effect on bleeding risk.

Löwensteyn YN, et al. Eur J Pediatr. 2019 May 6.

Antibiotic Treatment in the First Week of Life Impacts the Growth Trajectory in the First Year of Life in Term Infants.

Kamphorst K, et al. J Pediatr Gastroenterol Nutr. 2019 Apr 15.

Abdominal Wall Pain or Irritable Bowel Syndrome: Validation of a Pediatric Questionnaire.

Siawash M, et al. J Pediatr Gastroenterol Nutr. 2019 May 2.

Virtual Reality for Pediatric Needle Procedural Pain: Two Randomized Clinical Trials.

Chan E, et al. J Pediatr. 2019 Jun;209:160-167.e4.

Paging Dr. Google: The Effect of Online Health Information on Trust in Pediatricians’ Diagnoses.

Sood N, et al. Clin Pediatr (Phila). 2019 May 1:9922819845163.

Nebulised surfactant to reduce severity of respiratory distress: a blinded, parallel, randomised controlled trial.

Minocchieri S, et al. Arch Dis Child Fetal Neonatal Ed. 2019 May;104(3):F313-F319.

Nasal High-Flow Therapy for Newborn Infants in Special Care Nurseries.

Manley BJ, et al. N Engl J Med. 2019 May 23;380(21):2031-2040.

Mometasone or Tiotropium in Mild Asthma with a Low Sputum Eosinophil Level.

Lazarus SC, et al. N Engl J Med. 2019 May 23;380(21):2009-2019.

Association of Gestational Weight Gain With Adverse Maternal and Infant Outcomes.

LifeCycle Project-Maternal Obesity and Childhood Outcomes Study Group, et al. JAMA. 2019 May 7;321(17):1702-1715.

Prepregnancy Body Mass Index, Weight Gain During Pregnancy, and Health Outcomes.

McDermott MM, et al. JAMA. 2019 May 7;321(17):1715.

4. Case reports

Playful Child, Dangerous Intruder: A Case of Silent Foreign Body Aspiration in a 13-Month-Old Boy.

Bradshaw J, et al. Clin Pediatr (Phila). 2019 May 25:9922819851265.

History Matters: A 20-Month-Old Child With Cough and Congestion.

Ellis S, et al. Clin Pediatr (Phila). 2019 May 21:9922819850484.

A Teenager With Painful Oral and Genital Lesions.

DiSantis F, et al. Clin Pediatr (Phila). 2019 May 21:9922819850478.

Hypothermia and Vomiting in a Newborn Without Prenatal Care.

Nichols K, et al. Clin Pediatr (Phila). 2019 May 21:9922819850485.

Vomiting and seizure following circumcision in an infant.

Fleming L, et al. Paediatr Child Health. 2019 Jun;24(3):146-147.

An interlabial mass-like lesion in an otherwise healthy newborn girl.

Navabi B, et al. Paediatr Child Health. 2019 Jun;24(3):143-145.

Blurry Vision and Irregularly Shaped Pupil in a 3-Year-Old Female.

Boye B, et al. Clin Pediatr (Phila). 2019 May 20:9922819850460.

Asymmetric Crying Facies Syndrome.

Ho KY, et al. J Pediatr. 2019 May 3.

Nicolau Syndrome: A Rare Complication following Intramuscular Injection.

Quincer E, et al. J Pediatr. 2019 May 3.

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

Vicarious Trauma : It’s ok to not be ok

Cite this article as:
Jasmine Antoine. Vicarious Trauma : It’s ok to not be ok, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19256

One afternoon my team broke the news to three different families that their children had a non survivable condition. That same week I was involved with a patient transitioning to a palliative pathway focused on comfort. I returned home to utter the words, “She is so sweet, I hope she dies soon.

For many of us, days like these, occur commonly.

Being a doctor is a privilege, an honour, a calling. Our jobs are stressful, diagnostically challenging, involve managing team members, and effectively communicating and engaging with different families whom have different needs. We are reliant on our knowledge and skills. What sets our job apart from other high stress environments is that any given day can involve death and dying. We see distressing conditions. Our day includes the uncommon, the unlucky and the unfortunate events of life. To the public these events occur few and far between, but for us it may be a daily occurrence -a relentless barrage of traumatic events, poor outcomes and sad stories.

The intensive care environment is difficult to navigate. The rates of burnout, mental health issues and self medication are high amongst our peers. 70% of junior doctors feel burnt out following a neonatal rotation. Strikingly, their (our) rates of suicide are twice that of the general population. Most of us have heard the words compassion fatigue. Some of us may even be familiar with vicarious trauma – the negative experience of working directly with traumatised populations. Compassion fatigue and vicarious trauma are on a spectrum. We initially may feel overwhelmed by our interaction but this can develop into symptoms of post traumatic stress.

At DFTB18, I spoke about some of the things we can do to reduce this happening to us, and the events above reinforced that message;

  • Seek the support of those around you.
  • Reflect with your supervisor.
  • Get together with your team to debrief.
  • Seek professional psychological support.
  • Foster a culture in your workplace that is supportive and open, whilst also taking time for yourself.
  • Make a regular appointment to see you GP.

And remember, it’s ok not to be ok

For more on this topic of the difficulties of dealing with death and burn out hit up DFTB at:

Burning out by Mark Garcia

A short story about death by Andy Tagg

Selected References

Boss RD, Geller G, Donohue PK. Conflicts in Learning to Care for Critically Ill Newborns: “It makes me question my own morals”, Bioethical Inquiry. 2015;12:437-448

Hauser N, Natalucci G, Ulrich H, Sabine K, Fauchere JC. Work related burden on physicians and nurses working in neonatal intensive care units: a survey, Journal of Neonatology and Clinical Pediatrics. 2015;2:2:0013.

Nimmo A, Huggard, P. A systematic review of the measurement of compassion fatigue, vicarious trauma and secondary traumatic stress in physicians. Australian Journal of Disaster and Trauma Studies. 2013;1:37-44.

Stress, burnout and vicarious trauma: looking after yourself. RACGP Webinar Series.

DFTB19 – One week to go

Cite this article as:
Team DFTB. DFTB19 – One week to go, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19295

This year the conference is being held at the QE2 Conference Centre in Westminster. With the theme being ‘The Journey” we are thinking about not just distance but time as a group of amazing speakers from all around the world get together.

With just one week left to go before our THIRD conference we asked some of the team what they are most looking forward to. Catching up with friends old and new was at the top of everyone’s list. It is that sense of our global paediatric community that brings a DFTB event alive.

Here are some of their other highlights…

“I’m looking forward to the storytelling evening. A great way to get to know a small group of people, in an intimate evening where people can relax and be entertained before the main conference begins.”

Tessa

Last year we held an intimate social event on the Sunday before the conference proper. Hosted by Mary Freer a group of courageous speakers got to tell us a story – some made us laugh, some made us cry and all made us think. They were unscripted and sans visual aids. It was just a group of friends, sitting down and listening to tales of the human condition. We are doing the same this year if you want to come along.

I’m looking forward to hearing some great talks to improve my practice and re-connecting with a global community of people passionate about delivering excellent paediatric care

Ben

I’m excited about four days of great learning, sharing of ideas and inspiration to improve practice. I’m also looking forward to the break times so that I can meet old/new friends and (spoiler alert!) see delegates take part in some fun DFTB research and design projects!

Grace

I’m looking forward to the third episode of what I consider to be the best conference I have been to, meeting old friends and making some new friends and actually learning about the care of children. And as a speaker coach I shall have that anxious excitement as colleagues deliver some amazing presentations that I have seen them develop over the last few months.

Ross

Ross and Grace have once again acted as speaker coaches, helping our experts give the best talks of their lives. By challenging old dogma they aim to help provide the best educational experience possible.

It is difficult to find a balance between being up-to-date on the evidence underpinning your clinical practice as well as being aware of the impact clinical practice has on your colleagues and you. The DFTB conference series negotiates this tension brilliantly and I’m excited to see how it allows delegate’s to explore the latest research and expert guidance ensuring that both science and story are given equal weight

Damian

I’m looking forward to getting to know dozens of people in real life whom up till now I’ve known only as a Twitter handle

Katie

If you can’t make it then you can still sign on to livestream the event. It will be there online for you to watch it for three days after in case you are at work or asleep.

You have brains in your head: Eric Levi at DFTB18

Cite this article as:
Team DFTB. You have brains in your head: Eric Levi at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19241

In honour of CrazySocks4Docs Day it seems only fitting that today we release Eric’s talk on mental wellbeing.

Outside of his interest in ears, noses and throats Eric is passionate about our wellbeing. No doctor or healthcare provider is immune to the risk of depression. Andrew Tagg spoke about his own personal struggles at our first conference. Perhaps part of the same spectrum of work potentiated illness is burnout. Characterized by emotional exhaustion, low professional efficacy and high levels of cynicism it is rampant amongst our profession.

#CrazySocks4Docs day was started by a Melbourne cardiologist, Geoff Toogood, with a view to ending the stigma surrounding mental health ion physicians. For more details check out the website here.

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.

DFTB19 has just a couple of main conference tickets left but there are still spots for some of the pre-conference workshops.

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.

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Selected references

Callahan K, Christman G, Maltby L. Battling burnout: strategies for promoting physician wellness. Advances in pediatrics. 2018 May 7.

Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. InMayo Clinic Proceedings 2017 Jan 1 (Vol. 92, No. 1, pp. 129-146). Elsevier.

Paediatric blood cultures – We’re doing it wrong

Cite this article as:
Alasdair Munro. Paediatric blood cultures – We’re doing it wrong, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19022

Anne is a 3yr old girl brought in by her father with cellulitis on her arm which has worsened despite oral antibiotics. She needs IV Flucloxacillin, so you put a cannula in (with great difficulty). Since you’re taking bloods anyway, you take 0.5ml to send in a blood culture.

The next day on ward round, she’s much improved, but the lab calls to say she’s grown gram positive cocci in her blood culture. The decision is made to continue on IV’s until the organism is identified.

That night her cannula blows. The night SHO couldn’t get a new one in. The reg couldn’t get a new one in. She gets a dose of IM Ceftriaxone. The next day the lab confirms the bacteria was a coagulase negative Staphylococcus, and a contaminant. She is discharged to complete a course of high dose oral antibiotics.

Blood cultures are one of the most common investigations we perform in children, yet most people receive scant education on how to maximise their yield or what happens once the bottle has disappeared to the lab, and many myths persist surrounding their use. As such, we’re currently doing it wrong. It’s time to set the record straight! Let’s start with the basics…

What happens to a blood culture?

The first step is inoculating the contents of the vial with blood. The vials contain a mix of ingredients, rather deliciously referred to as a “broth” (less deliciously containing things such as “brain heart infusion”, or “tryptic soy broth”), including a rich supply of nutrients for bacteria, and anticoagulants which neutralise immune cells and inhibit the actions of antibiotics. There are different broths for aerobic and anaerobic culture (Paediatric bottles are just aerobic). Notably, the broth is specially balanced to work perfectly with specific volumes of blood.

Once in the lab, the bottle is placed into a machine which incubates it at body temperature. The machine is able to continuously monitor levels of CO2 in the bottle, and an exponential rise signifies metabolic activity of living bacteria. The machine sees this and lights up on the outside to alerts laboratory staff that the culture is positive. Some systems will automatically issue an alert at this point to clinical systems outside the lab too.

Once flagged positive, lab staff will take a sample from the bottle and Gram stain it – this means fixing it to a slide, adding crystal violet dye which will stain gram positive organisms purple, then washing the slide and adding a counter dye (safranin or fuchsin) which will stain gram negative organisms pink. They look under the microscope and classify the bugs as either gram positive (purple) or gram negative (pink), and round (cocci) or long (bacilli), and how they are arranged (in couples, in chains, or in groups).

Lab staff then subculture the bacteria to get its ID and antibiotic sensitivities. Blood from the vial is swabbed onto an agar plate and left to grow overnight. Then solid colonies of bacteria from the plates can be isolated and analysed, using methods such as maldi tof, which utilises mass spectrometry to produce a chemical finger print capable of rapidly identifying the species of bacteria found. Further tests are performed to identify antibiotic susceptibility, using traditional agar plate methods and antibiotic discs, or more advanced machine methods, such as the cool sounding “phoenix”.

What if nothing grows? This is important: as blood cultures are continuously monitored, they are always negative UP UNTIL the point at which they flag positive. Most labs will keep negative bottles on the machine for up to 5 days before removing them and disposing of them.

So now that we are experts in what happens to blood cultures, we’re ready to busy some myths.

Blood culture myth busting

Myth 1 – If you’re putting a cannula in, you might as well send a blood culture

We are always trying to minimise painful procedures in children, so in many ways this seems to make sense. The idea that you would need to stab a child again later for a blood culture is enough to make people send one, “just in case”. This however is bad practice. Let’s explore why.

Firstly, did you know that in some studies the majority of paediatric blood cultures that flag positive are actually contaminants? That’s right – the majority. So, when you get the news that there’s a bug in the blood of the child, it may be more likely to be a bug off their skin (or your skin…) than a true bacteraemia. This is a problem, as these children will either be started on antibiotics they might not need, or have them continued for longer than they required, meaning more time in hospital, more time with a cannula, maybe even having more cannulas, etc.

It is important to consider is the pre-test probability of your patient having a bacteraemia. In the general paediatric hospital population, only about 2% of blood cultures ever grow pathogens, and most of these are in young children or those with complex needs and co-morbidities.

Some conditions have a particularly poor yield for blood cultures, including uncomplicated community acquired pneumonia and uncomplicated skin and soft tissue infections. Sending blood cultures in these instances is highly likely to cause more harm than good to the patient, and is associated with significant increased cost.

Myth 2 – Blood cultures “come back” negative at 48 hours

Let’s go back to earlier when we discussed what happens to blood cultures vials.

Once in the lab, they are added to the blood culture machine and monitored continuously for a rise in CO2. If they remain negative, they will stay there for up to 5 or even 7 days. So, what happens at 48 hours to make people think that at this point they are suddenly negative?

Nothing.

This just happens to be the time point most labs will issue a result on the computer systems stating that the blood culture is still negative. Why have they chosen this time? Arbitrarily it is the time point by which studies show that 99% of all blood cultures that will become positive, are positive. However, this result is 90% by 24hrs and 95% at 36 hours. So, if you had a high suspicion that your patient was bacteraemic, it might make sense to wait 48 hours before deciding whether to change therapy. However, if you had a low suspicion there is no reason to wait that long, and 24 hours should be enough time to wait to see if anything grows. In low incidence settings (1-2%), waiting more than 36 hours picks up one extra positive blood culture for every 1250–2778 you send.

So, try not to say, “the cultures aren’t back yet”. They are never back, because they don’t go anywhere! The cultures are, “negative to date”, and at whatever time point is most appropriate you can decide how to alter therapy.

Myth 3 – Taking blood cultures when febrile increases the chance of a positive result

There is a story that in children with bacteraemia, spiking a fever is related to a septic shower, which in turn means there are more bugs circulating and therefore you are more likely to catch them if you take a blood culture at this time. This is a lovely and bio-plausible explanation.

But let’s be clear:

If your patient has a bacteraemia, the presence of absence of fever has no influence on whether the blood cultures are positive or not, in children or in adults.

Fever is a sign of infection, so is one of many possible signs of bacteraemia. However, you may have a patient who has previously had a fever and now does not, or they may have a purpuric rash with tachycardia and hypotension but no fever. These are also signs of infection, and these patients are no less likely to get a false negative than someone currently febrile.

Do not wait for fever to take blood cultures, and do not take blood cultures on the basis of fever alone. If you suspect bacteraemia, take them NOW, and if you’ve already done it, you don’t need to do it again just because of a fever*.

*a confusing caveat to this is the patient who remains febrile after appropriate therapy, in which case fever might be the only sign of ongoing bacteraemia and infection – but you still don’t have to do it at the time of fever.

Myth 4 – You only need to take 1-2ml of blood

This is where we’re really getting it wrong. If you only take home one message from this blog, let it be this:

The only variable which determines the likelihood of a false negative or positive of a blood culture is the volume of blood inoculated into the bottle.

We do not put enough blood in the majority of paediatric blood culture bottles. In fact, only between 30 and 50% of blood cultures actually have enough blood in them to get a reliable result. This is a problem for several reasons, including:

  1. The likelihood of obtaining a false negative is greatly increased by inoculating an inadequate volume.
  2. The likelihood of growing a contaminant is increased by inoculating an inadequate volume (possibly due to more blood causing more dilution of contaminant bacteria).

Why are we taking so little blood? Likely because we draw similar amounts of blood regardless of the child’s age (usually 1 – 2ml), and because we lack knowledge as to how much is actually required.

How much blood should we take? For comparison, let’s start with the recommendations for adult blood cultures;

Three sets of blood cultures with 20ml per set. Total 60ml per patient.

In children, the optimum amounts are less well prescribed, and recommendations vary between age and weight based. Manufacturer recommendations for paediatrics are:

Neonates less than 2kg: 1ml per child

Child between 2kg and 13kg: two paediatric culture bottles, 1x 4ml and 1x 2ml.  Total 6ml per child.

Child between 13 and 36kg: 1 x set of adult cultures with 10ml in each bottle. Total 20ml per child.

Child >36kg: Adult recommendations. Total 40-60ml per child.

If you are a paediatrician, I imagine your jaw is currently on the floor.

Realistically, we are unlikely to achieve these *gold standard* recommendations for blood culture volume as they are so distant from current practice, but we can certainly do much better (interventions to improve culture volumes do seem to work). Ever thought to yourself why we seem to see so many cases of culture negative sepsis?

As an easy rule of thumb, the minimum volume of blood inoculated into a blood culture should be the child’s age in ml (2ml for a 2yr old, 5ml for a 5yr old etc). For children with central lines, there is no excuse, and we should be aiming to take adult culture bottles from the majority of these cases. A special consideration in very small babies is their total blood volume, and no more than 4% of total blood volume is recommended.

Conclusion

  • Do not take blood cultures just because you’re putting a cannula in. Think about the probability of bacteraemia in that patient (especially in pneumonia and skin/soft tissue infection) and if it’s worth the risk of false positives.
  • You don’t need to wait for 48 hours for all blood cultures to treat them as negative. Make a decision based on the pre-test probability of your patient.
  • There is no correlation between timing blood cultures with fever and likelihood of positivity. If you suspect bacteraemia, the best time to culture is now, regardless of fever.
  • Take much, much more blood to inoculate into your blood culture vials. Aim for at least 1ml per year of the child’s age. It increases your chance of finding the true bug, and decreases the chance of growing a bystander.

Psychological defences in education: Ben Symon at DFTB18

Cite this article as:
Team DFTB. Psychological defences in education: Ben Symon at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19224

The  audience at DFTB18 were privileged to attend a series of sessions from team at Simulcast, the premier podcast for all things sim and debriefing. 

In this second talk of the session Ben Symon interviews Jannie Geertsema about why we become defensive at work and in the educational space education when we could be connecting.

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.

DFTB19 has just a handful of main conference tickets left but there are still spots for some of the pre-conference workshops.

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.

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