All paediatricians are complicit in delivering a racist healthcare service

Cite this article as:
Zeshan Qureshi and Anna Rose. All paediatricians are complicit in delivering a racist healthcare service, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.33938

We’re supposed to be the nice ones. The friendly, fun, caring and supportive speciality – right? We’re the ones who have teddies on our stethoscopes and know all the words to Disney songs. In the hospital, we’d like to think we’re the Good Guys – but maybe we’re not when it comes to race. 

The COVID-19 pandemic has been a monumental challenge to the NHS and has, undoubtedly, showcased the everyday heroism of our staff. It has also thrown a sharp light onto the ongoing racial inequalities in our society and healthcare systems. Racial disparities in the pandemic have been widely documented – and make for sobering reading. Analysis of national hospital data suggests that people of black and other minority backgrounds are up to twice as likely to die from the virus, as compared to white Britons – with some groups, such as black African-born men living in Britain, having an even higher risk [1]. Despite this, we have little doubt that the major impetus for the unprecedented emergency measures, national lockdowns, and political obsession was not the deaths of the poor, the ethnic minorities, or those in low and middle-income countries – but the perceived threat to wealthy, predominantly white, Westerners.

In an eerie parallel to the racial inequalities highlighted by the pandemic, the past year has also seen racial tensions in the USA reach boiling point. Following several high-profile incidents of police brutality, there was an eruption of social unrest and protest in America and around the world. The systemic disregard of black lives is not just written in blood on American pavements. It is written into the systems that surround us in our everyday working lives. As a speciality, and in the NHS as a whole, we must confront these engrained systemic inequalities, if we are to provide truly equitable care to all of our patients. 

In this blog series, we will examine how clinical outcomes for common paediatric conditions are worse for children from minority ethnic backgrounds. Stillbirth, low birth weight and preterm birth are all more common in minority groups as compared to white northern European populations [2,3,4 ]. Outcomes for common chronic conditions, such as asthma and type 2 diabetes, are also worse for children within minority groups [5,6]. This could be because care received by children with chronic conditions is worse. Non-white children with renal failure are less likely to pre-emptively receive a renal transplant, for example [7]. There are also complex social and environmental roots to these adverse health outcomes – such as increased poverty in non-White groups [8] — and we will try to investigate these issues in more detail. 

We will also explore how paediatrics has normalized white Northern European genetics, physiology and behaviour, leading to biased clinical decision making. Normalization of one ethnic group has lead to the classification of other normal values (in both the laboratory and social sense) as pathological or inappropriate. In other words – you are only normal if you are white and normal. Neutrophil counts are often lower in black babies [9]. Rather than reporting ethnically normal ranges babies often end up having multiple blood tests due to a lack of awareness of the variation. Parents get told that their neutrophil count is low, but it’s acceptable for a black baby (rather than categorically stating that their count is normal). Worst still, it might be classified as a disease – benign ethnic neutropenia – despite not being associated with increased morbidity or mortality.

Within medical education, we are guilty of peddling irrelevant and outdated racial and religious stereotypes. These hold little educational value, but risk enforcing dangerous bias within our future doctors. Any paediatrician would be able to tell you about the association between Tay-Sachs disease and Ashkenazi heritage, or sickle cell disease and sub-Saharan Black Africans. Such associations are often over-simplified and over-emphasized, to the point of creating a disease-ridden caricature, particularly in exam questions. Most of these stereotyped conditions are very rare, and over-emphasis during medical school risks blinkering us to more common diagnoses. We’ll explore how racial bias is ingrained in medical education in the UK, and try to come up with some ideas on how we can improve MedEd to be more diverse and inclusive in the future. 

There also seems to be a disproportionate concern that those from Muslim backgrounds might be consanguineous, and that we need to ask about this even when it is not relevant to the presenting complaint. Conversely, when genetic testing is being sent off, a detailed family tree needs to be drawn. It should include details of any consanguinity – yet it seems that a white family is less likely to be asked. As first or second cousin marriages are no longer a social norm in the UK, they have become defined by pathological associations with genetic conditions, such as inborn errors of metabolism. And whilst there are, of course, differences in the prevalence of disease alleles in different populations, and an increased risk of recessive disorders in families with intergenerational consanguinity, it does not automatically follow that a child from a Muslim background has a recessive disorder, or that a white British child does not. The same considerations need to be given to other cultural practices that might be different to the social norms of Northern and Western Europe. Putting children on a vegetarian diet is often classed as a ‘restrictive diet’ – despite the fact that it is only restrictive based on traditional Western standards – and might, in fact, hold health benefits [10]. 

Finally, in our series, we will examine how systemic racism within the health service tolerates – and sometimes even facilitates –  the unacceptable behaviours demonstrated by some parents. One thing that sets paediatrics apart from adult medicine is that patients are almost never seen alone, and a parent is often required to deliver care. This can present a dilemma to staff when confronted with a racist parent. Any punishment directed towards the parents might directly harm their child. We will explore how guidelines should be developed to help clinicians handle racist parents, whilst minimizing the effect on the clinical care of our patients. 

It can be painful for us – as individuals and as a speciality – to consider that we might be complicit in a racist system that ultimately leads to poorer health outcomes for some children. Just because something is painful, does not mean we shouldn’t do it. We hope that you’ll join us for this series of short articles, as we try to explore how we can begin to move from a white-centric healthcare system to a child-centred one.

James Baldwin quote on racism

Selected references

1) The IFS Deaton Review. Are some ethnic groups more vulnerable to COVID-19 than others? 

2) Gardosi J, et al. (2013). Maternal and fetal risk factors for stillbirth: population-based study. BMJ 346:f108.

3) Kelly Y, et al. (2008). Why does birthweight vary among ethnic groups in the UK? Findings from the Millenium Cohort Study. Journal of Public Health, 31:131–137.

4) Aveyard P, et al (2002). The risk of preterm delivery in women of different ethnic groups. British Journal of Obstetrics and Gynaecology 109:894-899.

5) Asthma UK (2018) On the Edge: How inequality affects people with asthma. Available at www.asthma.org.uk

6) RCPCH (2020) State of Child Health: Diabetes. Available at www.rcpch.ac.uk

7) Plumb LA et al. (2021) Associations between Deprivation, Geographic Location, and Access to Pediatric Kidney Care in the United Kingdom. CJASN. 16:194-203.

8) Office for National Statistics (2020) Child poverty and education outcomes by ethnicity. Available at www.ons.gov.uk.

9) Haddy TB, Rana SR, Castro O. (1999) Benign ethnic neutropenia: what is a normal absolute neutrophil count? J Lab Clin Med. 133:15-22.

10) Kalhoff H. et al (2021) Vegetarian Diets in Children—Some Thoughts on Restricted Diets and Allergy. International Journal of Clinical Medicine. 12:43-60.

Moral injury HEADER

Psychological distress in healthcare workers

Cite this article as:
Gladymar Perez and Rie Yoshida. Psychological distress in healthcare workers, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32653

We know that healthcare workers are at a greater risk of burnout, however you chose to define it. This study takes a look at the impact of COVID on the psychological distress of those on the frontline.

Roberts T, Daniels J, Hulme W, Hirst R, Horner D, Lyttle MD, Samuel K, Graham B, Reynard C, Barrett MJ, Umana E. Psychological Distress and Trauma in Doctors Providing Frontline Care During the COVID-19 Pandemic in the United Kingdom and Ireland: A Prospective Longitudinal Survey Cohort Study.

Background

This study aimed to assess the prevalence and extent of psychological distress and trauma of doctors working in the UK and Ireland during the first wave of the COVID-19 pandemic.   

Doctors working in Emergency Medicine (EM), Anaesthetics and Intensive Care Medicine (ICM) were asked to complete online surveys at the acceleration, peak and deceleration of the COVID-19 first wave, providing an insight into their psychological well-being at different phases of the pandemic. Exposure to previous infectious disease outbreaks have shown that elevated psychological distress is associated with the development of chronic stress, depression, anxiety, physical health problems, increased sickness rates, emotional exhaustion and impaired performance at work. Given that the COVID-19 pandemic will undoubtedly have a significant impact on the mental health of healthcare workers in the UK and Ireland, this study is important to understand the extent of the pandemic’s impact in these settings. The study also looked at personal and professional factors associated with increased distress in an attempt to identify those who are most at-risk and may benefit from early intervention.  

Methods

The study was carried out using a prospective online three-part longitudinal survey administered at the acceleration, peak and deceleration of the COVID-19 first wave.  Primary outcome measures were psychological distress and trauma, measured using the General Health Questionnaire for distress and the Impact of Event Scale -Revised for trauma.  These tools have been extensively utilised across different settings and cultures. The survey was distributed to doctors working in Emergency Medicine (EM), Anaesthetics and Intensive Care Medicine (ICM) in the UK and Ireland through existing trainee research networks, faculties and Royal Colleges.   Following participation in the first survey, the subsequent surveys were emailed directly to participants.  Survey distribution dates were decided based on public health data on the number of confirmed cases and deaths in the UK and Ireland.   The following dates were used:

  • Acceleration phase UK: 18/03/2020 – 26/03/2020, Ireland: 25/03/2020 – 02/04/2020
  • Peak phase UK: 21/04/2020 – 05/05/2020, Ireland: 28/04/2020 – 12/05/2020
  • Deceleration phase UK: 03/06/2020 – 17/06/2020, Ireland: 10/06/2020 – 24/06/2020

Personal and professional characteristics relating to participants’ current role, and their preparedness and experiences during the pandemic were also collected. 

Results 

Of the estimated 34,188 eligible doctors, the response rate for the initial acceleration survey was 15.9% (n=5440).  Peak and deceleration response rates were 71·6% (n=3896) and 56·6% (n=3079) respectively. (Ed. note- Though you could argue that the peak and deceleration responses were actually 11% and 9% of all eligible doctors). Prevalence of psychological distress was highest during the acceleration phase at 44·7% then declined through peak and deceleration phases of the first wave to a level comparable to pre-pandemic levels, reflecting a degree of natural recovery. The prevalence of trauma was highest at the peak of the pandemic at 23·7%. The figures for both psychological distress and trauma were substantially higher than for the general population.  The most significant personal and professional predictors associated with distress and trauma related to familial safety; personal safety and established mental health conditions.  Whilst ethnicity was not strongly associated with distress, it was a stronger predictor of trauma (R2 = 0·03).   

Strengths

This is a large-scale longitudinal study that prospectively examined the psychological wellbeing of frontline doctors, using GHQ-12 and IES-R, validated self-report measures for assessing  distress and trauma respectively. These outcome measures have been used in previous infectious disease outbreaks. A pre-specified analysis plan was published and is available online. 

This study included responses from 5440 frontline doctors throughout the UK and Ireland, an impressive response rate given that it was undertaken in the midst of a pandemic and was achieved thanks to the collaboration of multiple Emergency Medicine and Intensive Care research networks. (TERN, PERUKI, RAFT, ITERN, TRIC)  

Due to the extent of data collected, findings from this study offer an essential insight into the mental health of frontline doctors in an infectious disease outbreak.  These can be used to inform policy-makers on the development of interventions in the current pandemic and future outbreaks.  The three phase approach means interventions can be targeted in a timely manner.    

The study identifies ethnicity as a novel, key predictor of trauma.  By including the impact of ethnicity in the study the researchers have recognised the important role that ethnicity has played in this pandemic, given the higher rates of reported mortality in ethnic minority groups.  

Limitations

The surveys were distributed in a specific time frame that was based on the number of cases in both countries as a whole without accounting for the regional variation which occurred. 

As such, the researchers recognise that the variation in regional peaks may have influenced accurate capturing of psychological distress and trauma rates. In addition, pre-pandemic levels of distress and trauma in the cohort included in the study, remain unknown. 

There was a considerable drop-out rate in responses throughout the study with a 56.6% response at the final deceleration phase.  The researchers note that there was no significant difference in either the GHQ-12 or IES-R scores between those who dropped out and those who remained in the study.  However, the reason for participants’ lack of response is unknown and these participants may have been experiencing increased distress. Alternatively, a number of those without any concerns may have felt it no longer necessary to complete the survey, therefore, exaggerating the finding of significant trauma in those who did respond.

Conversations about constipation

Cite this article as:
Chris Dadnam. Conversations about constipation, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31554

Like most of you I have to deal with the issues of constipation within the ED or CAU environment and most of the time it’s not the reason the child attends the department! This can then lead to a series of awkward questions and issues that parents may ask that we need to consider in order to provide safe, useful and most of all, worthwhile advice! 

So let’s go through these questions ask issues:

1. My child has a UTI, why are you talking to me about constipation? 

This is something I get asked not only when a UTI is diagnosed but other clinical conditions including; appendicitis, bedwetting, incontinence, urinary retention, obstruction, etc…. it is important that parents understand the implications of constipation, not only from a pain and symptoms point of view but also the complications surrounding it. Indeed, many parents also struggle to understand how their child, who is rolling around in agony, is only suffering from constipation (you can literally feel them questioning your medical acumen). 

During these tough times I always mention two key points. Firstly, the fact that your bowel covers the majority of your abdomen. A build up of wind and solid matter in the bowels can bring about severe griping abdominal pain, when pressing against sensitive nerves. As it covers a lot of your abdomen, when full, it will compress other structures like your child’s bladder leading to urinary infections, incontinence and retention. The second point is that stools are like a toxin your body wants to expel, when it remains in your bowels it can get into small structures like your child’s appendix and cause it to become inflamed and that leads to appendicitis.

Also, the longer the stools sit in the colon the more water is absorbed leading to harder, solid stools. This will cause a blockage and lead to vomiting and obstruction which may require surgery. 

Once parents have a better understanding of these points they’re less likely to roll their eyes at constipation! 

2. How are they constipated, they go every day? 

This in fairness is a good question, one that used to throw me quite a bit in my early paediatric years, but let’s break it down. Constipation is not simply the length of time between going to the toilet, rather it is the build up and insufficient clearance of stools in your bowels. With this in mind, a child can go daily and pass small amounts of stool but still have a backlog of faecal matter in their bowels. Therefore also question the time spent on the toilet, straining and pain during defecation. These are all signs of constipation. If you can, ask your young patients too! 

3. They already drink plenty of fluids

Don’t let this answer fool you, explore the parents’ meaning of fluids. When we are saying it, we mean clear liquids like water and squash (preferably sugar-free), but for the parents, it’s anything from water and tea, to milk and hot chocolates. Now there is a myth that milk makes us constipated but that’s simply not the case….well not entirely. Milk is indeed a liquid and it doesn’t make us constipated but it’s thicker and takes longer to digest (hence why in surgery they stress only clear liquids 4hrs before). Milk fills up the child and so reduces their intake of solid food which will be full of fibre. 

Always remember, parents may say they’ve cut out all the milk, but this may have been substituted for milky teas and hot chocolates, so double check! 

In terms of managing the milk, appreciate the difficulty the family is about to face. Wean the milk down slowly, starting with the bottles in the middle of the day, then the morning bottle and finally the night bottle. Milk shouldn’t be stopped entirely, having a 250-500ml glass of milk daily is perfectly fine. 

4. They eat a really good diet 

Whenever I get this response, I immediately think they haven’t and 99% of the time I’m right……says a lot. 

Again, this is either due to a misconception as to what a good diet is, or they don’t think it’s an important issue so they simply brush it off with this generic statement so that they can get to the medication that will actually help. Another quick way to check is to just ask the child. They normally find it much more difficult to turn a blind eye.

I always try to tackle this in one of two ways:

Tell me what they eat?

– it’s surprising how many children don’t have breakfast or any of the three square meals a day. If they do, just add in tips when you can.

Breakfast; dried fruits in cereal (especially raisins), don’t switch the cereal completely but rather mix in an all bran, so they’re still getting their tasty favourites, but now with added fibre. Toast – if it’s white bread, freeze it; it’ll keep longer and by placing it straight into the toaster means that the strands of carbs, fats and protein are bound together and form fibre.

Lunch; Try to include salad into sandwiches. If the parents say they don’t like salad then how do they expect their children too! Encourage healthy eating in the parents as well, to form positive connotations for their kids.

Dinner; any sauce can hide a multitude of veggies if blended or chopped fine enough – so get them cooking and where possible get them to encourage their kids to join in. If they cook it themselves, they’ll appreciate the food and, for some reason, enjoy it more……probably a labour of love! And it’s a great time to leave out and pick on a bowl of fresh berries or grapes, the more accessible things are the more they get eaten.

Do they eat all their fruit and vegetables?

This again leads to a classic ‘Yes’ response – which falsely reassures a lot of healthcare professionals. In truth, it’s a vague and rather inadequate question to ask. If I told you that my child eats peeled apples and pears, has a glass of orange juice and then eats loads of veggies which I boil until soft… It might make you think twice about the goodness they’re actually getting.  So I always ask – Do they eat the skins of the fruit and vegetables? How do you prepare them? The skin of most fruits and vegetables holds the majority of fibre along with different vitamins and minerals required. In all honesty, if you are peeling apples and pears, all you’re left with is sugar and water, so I tell parents to give their child the peel instead! 

Again with veggies, I tend to suggest for microwaving or steaming as people tend to overcook them when they boil them. They need a crunch as that equals fibre. Root vegetables (potatoes, sweet potatoes, carrots, butternut squash, celeriac, parsnips) – all these lovely fibre rich foods – contain most of the fibre in their skins. I tell parents to roast them, long and slow – they’ll taste better (caramelizes the sugars in the veg/skin) so children will prefer them! 

Be mindful of smoothies and fruit juices. Yes, they can count for 1 of our 5 a day (soon to be 10 a day) but they can have little to no fibre, especially with the models that separate out the pulp. The pulp is fibre!! Try to get them to have whole fruits instead or 1 x 250ml glass of fruit smoothie a day with the pulp. 

5. I have tried all this and it doesn’t work 

Before you dismiss this answer make sure you look over the medical background again (cystic fibrosis, hypothyroid disease, Hirschsprung’s). Ask these all-important questions:

  • When did they have their very first poo? It should be within the first 48 hours. Then double-check it was a good amount – small smears don’t count.
  • Have they had issues with weight gain and prolonged issues with chest problems (in cystic fibrosis, LRTIs tend to happen towards the end of their first year of life).
  • Did they have a Guthrie / heel prick test. Any developmental delay? A large soft spot on their head?

In all of these conditions, the child would have always had an issue with constipation since birth, so don’t miss them. 

Once covered, it’s important to go through what they have tried….. most parents will only have been given a packet of Movicol and told to get on with it. Look at the summary section to see how to structure a constructive management plan.

6. I’m scared they’ll starve so I give them what they want. 

How many of us have been told this with little Jonny sitting there looking larger than life?

In general, throughout the developed world, children are unlikely to starve if their parents are trying to feed them a healthy balanced diet. There are caveats to this:-

  • Autistic children or children with textural issues. 
  • Children with a background of eating disorders (bulimia or anorexia). 

These children will need extra support and input from community and nutritional teams. 

All the other children will always put up a fight (normally a good one!) but then their bodies will give in and want food. This is an important step for parents to understand, especially when the child is too young to go out and get food themselves. Make sure you tell the parents this won’t be a simple task, and the main reason children normally win, is that carers will be busy and won’t have time to tackle this problem. It’s a quick fix to give them something just so that they know they’ve eaten…….then the habit starts. I always tell parents, wait until you have a week off and prepare yourself/ yourselves for a bumpy ride. Have a united front, it’s no good if one parent plays the ‘strict/ bad guy’ whilst the other literally feeds the problem behind their back. Prepare meals and hide away the unhealthy processed snacks (or don’t buy them in the first place) and leave fruit out. Again, get the child involved in cooking, build a healthy connection with food and make it fun. Children will most likely throw tantrums at the start, but remind them that eventually their child’s body will give in and they will come for food, most likely with a grumpy face. 

Just make sure they’re hydrated with clear fluids! And NO milky substitutes. Remind the parents they’re not bad people and this will help fix things in the long run.

7. Movicol doesn’t work and I don’t want it to make their bowels lazy 

This age-old answer…..makes you wonder why we bother using Movicol? More often than not they’ve not prepared it correctly, despite the instructions being on the box. Honestly, the ways parents use Movicol; sprinkle on cereal, mix into snacks or food, add to tea….the list goes on!

Movicol is only effective when it is bound with water. After this, the parent can then mix it with a small amount of any other liquid or flavouring. Make sure they don’t add it to a litre bottle of squash as the child will have to drink the whole lot. Also, this means they don’t need the flavoured versions (which taste vile – remember when they made you try them in medical school!). 

Another myth is that “it’ll make their bowels lazy.” Explain that Movicol is not a stimulant, it is an osmotic diuretic and acts to drive the water you mixed it with into the child’s stool to make them softer and easier to pass. With this in mind, even stimulant laxatives won’t make your bowels lazy. I always say, they can be on it for the rest of their lives, it’ll never make their bowels lazy – that tends to reassure parents.

8. I tried laxatives before and they suddenly had diarrhoea so I stopped using it. 

This answer may again throw you into thinking that the laxative has done a great job in under 72 hours and fixed a months worth of constipation… it sounds too good to be true?? Well, it is. The big problem here is, if clinicians don’t pre-warn the carers what might happen after starting a laxative, it can lead to long term mistrust in both the medication and in our advice.

I always start off by setting the day to start. Aim to start the laxative at the end of the week, a Thursday or Friday, to avoid accidents in the school. They will deter the child from ever trying them again.

Once we know when to take them, always triple check they’re using them correctly… mix with water first, then add to a small volume of any other liquid for taste.

Finally, but most importantly, the change in stool. Referring to the Bristol stool chart (the only card I carry around!), I explain the child will start with Type1-3 stools. Then, they’ll have what looks like diarrhoea, brown watery smelly stools, but, of course, it’s overflow. Take the time to talk about why this happens; the Movicol is slowly moving through the hard stools, like rain trickling down a wall, in their child’s bowel. The Movicol/water mix will initially run over it but over time their stools start to soften. 

The next step, again important due to risk of pain, is the big logs. And big means big! I’ve had parents say they’ve used shears to cut up these stools in the toilet. This is essentially the wall slowly being emptied out. 

Once this is over, they will finally have the soft mushy stools. The laxative story should not end there! It is important to mention this ‘wall of stool’ has caused the bowels to stretch. This will lead to a build-up of stools again as the child won’t know when they need to go. This is reservoir constipation. It can take months to revert back to normal so I always advise to continue on with the laxatives and reduce (but not stop) the maintenance daily dose down if the child is passing clear watery liquid. Usually, treatment should continue for at least three months to treat reservoir constipation (although in some children it can be longer).

9. They don’t like my cooking. They’re vegetarian now, I’m not. 

It doesn’t have to be vegetarian, of course, this is just what an angry mum said to me once about her daughter. Parents will mention the difficulties of preparing food they’re not used to cooking, I always suggest ‘get your child involved‘. This is the perfect time to do something together (bonus points as well in tackling mental health and isolation. It gets the family talking). The child will appreciate their intent and willingness to give their lifestyle a try, which will build confidence in the relationship as well. They can get a cookbook, go online (it’s all free and easily accessible these days) and adapt their cooking style. Again. this will make their child feel more involved and interested in cooking and eating healthy foods. 

10. They don’t like fruit and vegetables. 

I think we’ve all suffered from hating vegetables and fruit at some point in our lives. I remember hating tomatoes and peppers, so I feel for any parent tackling this problem. 

There are several factors to contend with here:

  • Their child not liking the fruit because it’s unknown to them or feels texturally unsatisfactory.
  • Having access to other more ‘enjoyable’ foods such as biscuits, chocolates and crisps around the house which they can graze on and avoid these unwanted bags of goodness. 
  • Watching older siblings and parents, and copying them.

To this, I normally offer a number of solutions but be mindful that parents will have busy lives around their child’s eating habits so it has to be a conscious effort at a convenient time, like over the weekend or annual leave.  

Firstly, hide unhealthy snacks or simply reduce the amount you buy, what they don’t see they don’t know…. out of sight, out of mind technique.

Secondly, I always tell carers that they and older siblings are role models. If you’re not eating it, why should they? There should be a united front by the parents. 

Finally, get cooking and get your child involved. Any child who cooks will appreciate the food they’ve made and the sense of achievement, even if it doesn’t taste nice, they’ll love it. It’s a great time to chat over a bowl of fresh berries…

My own enthusiasm then tends to kick in. I like to say “Get creative in the kitchen!” I’ve mentioned simple things for example: make flapjacks and throw in lots of dried fruits; raisins, dates, apricots, prunes – all-natural sweetness with skinned nuts & oats. Freeze smoothies with the pulp into ice-lollies. Fruit crumbles with honey and oats… With vegetables, always remember to steam or microwave them, they need the crunch. Again if kids don’t like them…. Chop them up/ blend them and throw them into sauces, pies and mixed into other dishes. If it’s the taste they don’t like, again mixed into gravy or a tasty sauce will fix that problem! 

It is important to mention the importance of a healthy balanced diet. Food is your best medicine. This is can be true for managing many conditions; anaemia , skin problems, poor immunity, nail and hair problems..you get my point. A varied diet holds the key to a lot of management plans, and it’s important to mention this even when the child is on supplements. A classic example is the parent says we’ve fixed the iron problem with iron tablets, but they fail to realise, without vitamin C your body can’t absorb the iron through the small intestine. Therefore, they’ll be questioning why their child remains anaemic in months to come. 

11. They’ve gone back into nappies as they’re scared of using the toilet. 

This is an important issue. It’ll mean the child will probably have problems with incontinence which may be affecting their social life such as staying over at a friends houses. Yet another reason why it needs tackling. 

Always start with asking what happened? More often than not it’s a series of bad habits and untimely events that have led to a regression in the family’s good practice. It happens to the best of us. Reassure everyone and give them the positive reinforcement that they’ve identified a problem that needs to be solved. Then offer the advice below. Take your time with these parents, it would have taken a lot for them to come into an acute setting to seek advice, so try to give them some. 

A framework for managing constipation.

This is ultimately an important topic that you have or, no doubt, will see at some point in your paediatric career. Knowing how to manage it is a core skill. 

I always frame my management in 3 steps: 

1. Diet and fluid intake – take the points from the above questions. Ultimately, the parents control the diet and food at home. They, and older siblings, are the child’s role models so what they eat will influence the child’s diet too. Remind them that food is their family’s best medicine so they need to get it right. Cancel out the milky drinks, cook smart & healthy and don’t forget clear fluids.

2. Toileting – our constipation module covers this but key points; get them into a routine (20 to 30mins after dinner – to sit on the toilet). Make the toilet a fun place with all their toys and gadgets and don’t forget to get them to blow the bubbles. Optimise positioning with knees above bums when sitting, using a footstool. 

3. Medication – ensure parents are giving them correctly – mixing with water first then adding to any other liquid for taste. Make sure this isn’t a full bottle, as they’ll have to drink the lot!. Movicol doesn’t make your bowels lazy. If they’re on a disimpaction regime, think about the volume they’ll be drinking each time. It may be better to split it into thrice daily doses instead. Briefly touch on the sequence of stool changes to reduce misconceptions of overflow and diarrhoea. Lastly start Movicol towards the end of the week, Thursday or Friday to avoid accidents at school. 

End with: 

  • Referencing the ERIC constipation website. It’s a great tool for constipation and bedwetting. It talks to the parent and child, so easy to understand and explain.
  • It will take time for things to fall into place. There is no quick fix. There will be tantrums, sleepless nights and days you’ll want to give in. Hang in there and once you’re sorted you’ll wish you’d done it sooner!
Volcano

Managing Gastro-Oesophageal Reflux Disease

Cite this article as:
Sarah Davies. Managing Gastro-Oesophageal Reflux Disease, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.29563

Isobel is a 10 week old, exclusively breast-fed, baby girl. She is brought into the Emergency Department with a history of frequent vomiting and poor weight gain. Her examination is normal, but when you ask Isobel’s exhausted-looking mother to put her to the breast, she becomes fractious and fussy, pulling away, arching her back, and taking very little feed at all.  

What are you going to do? 

At face value, this familiar presentation sounds like gastro-oesophageal reflux disease (GORD), although the differential for a ten-week old with vomiting and weight loss is wide.

Gastro-oesophageal reflux (GOR) is …the effortless retrograde passage of gastric contents into the oesophagus, with or without overt regurgitation. 

It is:

  • Physiological, due to low tone in the immature lower oesophageal sphincter
  • Common, occurring in up to 50% infants under 6m
  • Frequent – can happen up to x6/day

Gastro-oesophageal reflux disease (GORD) can be diagnosed clinically when GOR is accompanied by troublesome symptoms that affect everyday functioning (eg crying, back-arching, food refusal) and may lead to complications (eg failure to thrive).

Alternative diagnoses should be considered when there are additional red flag features (see below) indicative of a different pathology and under these circumstances, investigations should be tailored to rule these in or out.

*Some red flags overlap with symptoms directly related to GORD. The number, duration and severity of these should inform your decision to investigate on a case by case basis

As Isobel has symptoms of GORD with faltering growth you check her head circumference (which is appropriate), dip a urine (which is negative), and send some bloods for a faltering growth screen (although you strongly suspect they will come back as normal). You explain to Isobel’s mother that there is a stepwise approach to the management of GORD starting with non-pharmacological measures.

So, in the absence of red flag symptoms, do I need to prove its GORD?

In short, no. There is no single gold standard test for the diagnosis of GORD, hence the emphasis on clinical diagnosis. 

Invasive testing does have a place, though it is rarely the job of an ED clinician to be considering this. 

Endoscopy is used under the guidance of a Paediatric Gastroenterologist, for infants who fail to respond to optimal medical management. This will diagnose erosions and eosinophilic oesophagitis. 

pH MII (multi-channel intraluminal impedance) monitoring is used in children whose symptoms persist despite optimal medical therapy with normal endoscopy.   For a great explanation of this technique this previous DFTB post on reflux from 2016

Barium is out. Reliable biomarkers don’t yet exist. Scintigraphy, ultrasound and trial of a proton-pump inhibitor (PPI) are not useful in babies. 

OK, so I only need to investigate if I think there may be another cause for the symptom. But what should be my initial approach to treatment?

  • Positional management?
  • Avoiding overfeeding?
  • Thickening feeds?

Positional management – keeping the baby upright after feeds and elevating the head of the cot to sleep – is often advised for reflux. However, a study by Loots and colleagues in 2014 showed that regurgitation was only reduced through the use of side-lying positions which should NEVER be recommended due to the increased risk of SIDS. Head elevation made no difference at all despite some evidence that it can be beneficial in adults. 

And whilst a common-sense approach would support a move to smaller more frequent feedings and keeping a baby upright for 20-30 minutes after a feed, there isn’t any good quality evidence that confirms this. 

Feed thickeners have been shown repeatedly to reduce the frequency of visible regurgitation episodes in babies with reflux and in some studies to decrease cry/fuss behaviour too. They are safe and come highly recommended as a first-line intervention for babies with troublesome reflux. If you are going to advise a thickener for a breastfed infant, it’s important to suggest a carob bean-based product, such as Carobel, because the amylase in breast milk will digest the rice cereal-based thickeners such as Cerelac.  

Acupuncture, probiotics, massage, hypnotherapy have not yet been adequately studied for us to say one way or another if they are of any benefit. And alginates, probably the most familiar to us being Gaviscon? We’ll cover those shortly.

The key thing to remember for any intervention, is to reserve these for your patients with GORD. Happy, thriving, refluxy babies, typically outgrow their symptoms as they transition to solid food and should be left well alone

OK, but what if my patient has tried these already? What should I advise next? 

First, check how long they have persisted with the intervention. 

One of the biggest reasons for the simpler interventions not to help with GORD is that they are not given enough time to make a difference. Having said that, if a tired parent is repeatedly confronted with a grizzly, uncomfortable baby who is refusing to feed, asking them to persevere for two weeks with an intervention they don’t think is helping, may be practically difficult to achieve. 

In the UK, we have a choice of two key guidelines to help us with the next steps in reflux management.  

  1. NICE, last updated 2019

OR

  1. ESPGHAN/NASPGHAN 2018 joint consensus guidelines which are endorsed and recommended by our own BSPGHAN
  • European Society of Paediatric Gastroenterology, Hepatology and Nutrition
  • North American Society of Paediatric Gastroenterology, Hepatology and Nutrition
  • British Society of Paediatric Gastroenterology, Hepatology and Nutrition

Except that these guidelines differ a little on the advice they give for when simple measures don’t help…

NICE recommend a trial of Gaviscon first, and if that doesn’t work 4-8 weeks of a PPI such as omeprazole, and only then suggest a trial of cow’s milk protein exclusion (either through use of a hydrolysed formula or maternal dairy exclusion in breastfed infants) as a last resort, if reflux does not improve after ‘optimal medical management’. 

NASPGHAN/ESPGHAN on the other hand, suggest that ALL infants undergo an initial trial of cow’s milk protein exclusion, and only if this fails do they suggest the use of a PPI or hydrogen receptor antagonist (H2RA) such as Ranitidine. The bottom line is, that no-one has looked at the efficacy of a cow’s milk protein-free diet for symptom relief in babies presenting with reflux as the single symptom of cow’s milk protein intolerance (CMPI).  

The NASPGHAN team argues, that whilst there is no evidence on the topic, there are a number of babies with CMPI manifesting as reflux only who will benefit from this approach. They suggest eliminating cow’s milk protein from an infant’s diet for a minimum of 2 weeks, ideally four. If symptoms resolve and reappear on reintroduction then the diagnosis is clear. 

NASPGHAN then suggest babies who do not respond should be referred to secondary care services and started on a time-limited trial of PPI. 

This is largely so that infants are not left struggling on inadequate therapy for long periods of time, but also because their review found conflicting evidence around the benefit and side effect profile of these medications for young children. 

In six studies looking at PPI versus placebo, four studies showed no difference in regurgitation or other reflux associated symptoms between intervention and control groups. Three studies comparing H2RAs to placebo did show some benefit of the intervention, however, these studies were all in older children with biopsy-proven erosive oesophagitis up to 8 years of age.  Two studies showed endoscopic and histological and clinical features of GORD were reduced with H2RA over placebo, but these were in mixed-age groups including children up to 8 years old.

All studies showed a similar profile of side effects and between drug and placebo arms, however, one study demonstrated an increased rate of infection, in particular lower respiratory tract infection and diarrhoea in the PPI group. 

Given these findings, NASPGHAN cautiously recommends PPI or H2RA therapy in babies who have troublesome reflux despite trying a number of other non-pharmacological management options. 

Their key message is around early referral to secondary care, giving sufficient time for any one intervention to work, and making sure children are appropriately followed up.

So, what should I do? 

Given the somewhat conflicting advice outlined by these two well-respected groups, you could be left feeling unsure how to manage your next case. However, the genuine gap in the evidence market here does mean you are free to exercise your own clinical judgment and tailor your decision making to each individual refluxy baby, whilst empathetically taking on board the thoughts and preferences of the family.  This could, for some babies and parents, be medicine in itself. 

And what about alginates?

Two studies in the large literature review by the NASPGHAN/ESPAGHN group, compare Gavsicon to placebo. They show a reduction in visible regurgitation but no difference in reflux-associated symptoms. Furthermore, infants treated with alginate and then undergoing pH MII for 24 hours, showed no difference in the frequency of regurgitation events between groups. 

Chronic use of alginates causes constipation and poses a theoretical risk of milk-alkali syndrome, which is perhaps why the authors suggest use is limited to short term therapy. NICE do recommend a trial of Gaviscon therapy at an early stage in their pathway, as an alternative to feed thickener, but again on a time-limited basis with a planned review. 

Isobel’s mother had already tried two weeks of feed thickener on recommendation from the GP with no improvement. She was keen to avoid medication if possible so you agreed to a trial of dietary cow’s milk elimination for Mum who would continue to breastfeed and give top-ups with a hydrolysed formula if there was still no weight gain in a week. You gave her a sheet of dietary advice to ensure she maintained her own calcium intake and asked her to see the GP in 2 weeks for a review.  

Take home message

  • The vomiting infant has a wide differential – actively look for red flag features and investigate if you are concerned.
  • Infants with GORD need a management plan; infants with GOR, leave well alone
  • Start simply with an intervention that the family are happy to trial
  • Give time for it to work (up to two weeks)
  • Ensure follow-up for all and onward referral for infants who require acid-suppressive medication 

References

  1. Loots et al. Body positioning and medical therapy for infantile gastroesophageal reflux symptoms. Journal of Pediatric Gastroenterology and Nutrition 2014; 59 (2): 237-243. 
  2. Rosen et al. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition and the European Society of Pediatric Gastroenterology, Hepatology and Nutrition. JPGN 2018; 66(3): 516-554. 
  3. Winter et al. Efficacy and safety of pantoprazole delayed release granules for oral suspension in a placebo-controlled treatment withdrawal study in infants 1-11 months old with symptomatic GERD. JPGN 2010; 50: 609-618.  
  4. Orenstein et al. Multicenter, double-blind, randomized, placebo-controlled trial assessing the efficacy and safety of proton pump inhibitor lansoprazole in infants with symptoms of gastroesophageal reflux disease. Journal of Pediatrics 2009; 154: 514-520e4. 
  5. Davidson et al. Efficacy and safety of once daily omeprazole for the treatment of gastroesophageal reflux disease in neonatal patients. Journal of Pediatrics 2013; 163: 692-698.e1-2. 
  6. Winter et al. Esomeprazole for the treatment of GERD in infants ages 1-11 months. JPGN 2012; 55: 14-20. 
  7. Hussain et al. Safety and efficacy of delayed release rabeprazole in 1-11 month old infants with symptomatic GERD. JPGN 2014; 58: 226-236. 
  8. Moore et al. Double-blind placebo-controlled trial of omeprazole in irritable infants with gastroesophageal reflux. Journal of Pediatrics 2003; 143: 219-223. 
  9. Cucchiara et al. Cimetidine treatment of reflux oesophagitis in children: an Italian multi-centric study. JPGN 1989; 8: 150-156. 
  10. Orenstein et al. Ranitidine, 75mg, over the counter dose: pharmacokinetic and pharmacodynamic effects in children with symptoms of gastro-oesophageal reflux. Alimentary Pharmacology and Therapeutics 2002; 16: 899-907. 
  11. Simeone et al. Treatment of childhood peptic esophagitis: a double-blind placebo-controlled trial of nizatidine. JPGN 1997; 25: 51-55. 
  12. Miller et al. Comparison of the efficacy and safety of a new aluminium free paediatric alginate preparation and placebo in infants with recurrent gastroesophageal reflux. Current Medicines and Research Opinion 1999; 15: 160-168. 
  13.  Ummarino et al. Effect of magnesium alginate plus simethicone on gastro-oesophageal reflux in infants. JPGN 2015; 60: 230-235.
Picture of house

Hospital in the Home

Cite this article as:
Jo Lawrence. Hospital in the Home, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.28959

Elise is about to have her 8th birthday and has planned a small party at home with her family and two best friends.  Elise also has acute lymphoblastic leukaemia and is in the middle of chemotherapy treatment.  Her next dose of methotrexate is due the day after her birthday but requires pre-hydration the day before….

Thomas is in year 3 and loves playing foursquare at lunch with his friends. He also has CF and requires regular tune-ups of 2 weeks IV antibiotics and physiotherapy…..

MaryKate is an 8 month old and the youngest of 5 children.  She has poor oral feeding due to a complex medical background and requires nasogastric top-ups. Her parents have been told that she could wean from the tube if she participated in an intensive multidisciplinary program but are reluctant to attend hospital due to the significant disruption on family routine…..  

Is there a way Elise could enjoy her birthday at home, Thomas stay active at school and MaryKate receive the treatment she needs without significant family disruption?

What is Hospital in the Home?

Hospital in the Home (HITH) refers to hospital level care provided in the home environment. 

As we look at managing our growing population with a fixed number of hospital beds this is one area of healthcare that is set to boom!  

When admitted to HITH, clinicians visit the home and provide the acute care interventions required in 1-2 visits per day.  The advantages of this model of care on hospital flow and access are readily apparent.  Less obvious, although equally critical, are the substantial benefits for the family and patient.  Being treated in a safe place surrounded by familiar faces eases the stress and anxiety experienced by the child. Cost-savings for families obviously include not having to fork out for travel and hospital parking, but the real cost-savings occur for families because both parents no longer have to take carers leave – one for the hospitalized child, the other for the siblings. On average, HITH ends up being one-third of the cost of hospitalization for families1. In addition, HITH avoids disruption to family routines and unwanted separation.

So what can Hospital in the Home do?

Pretty much anything!  As long as the patient is clinically stable (not heading for ICU) and can have their care needs delivered in up to 2 visits per day, then it can be done.  

Traditionally Hospital in the Home models have centred around IV antibiotics and little else, but that has dramatically changed over the past few years. 

Here are some of the common things that paediatric HITHs are currently doing2:

  • Diabetes education
  • Eczema dressings
  • Subcutaneous infusions
  • Chemotherapy
  • Pre and post-hydration for chemotherapy
  • TPN hook ons and hook offs
  • Wound dressings
  • NG feed support
  • Cardiac monitoring
  • CF tunes ups
  • Physiotherapy 
  • IV antibiotics 

Baseline criteria regarding distance from hospital and safety of home environment exist but solutions exist for almost situations.

Although most centres service a certain distance from hospital, care can often be outsourced for children who live more rurally.  The care continues to be managed by the tertiary hospital but provided by local care teams – a superb option.

In cases where a barrier exists for staff to enter the home, creative solutions can be found by meeting children at school, in parks or family member’s homes.  

What has changed with Covid-19?

Whilst paediatric hospitals in general saw a fall in patient presentations, HITH referrals have sky-rocketed.  Doctors and families have experienced renewed interest in moving vulnerable patients out of hospital walls and away from the potential of cross-infection.  Stricter visitor restrictions meant hospitalisation had an even greater impact on family life and the driver to manage care at home wherever possible has grown.

Most of this growth has been through increasing the proportion of eligible children referred rather than creating new pathways.  A couple of children have been admitted for observation of Covid-19 infection, but these cases have been few and far between.

However, as with every area of healthcare delivery, the biggest changes for HITH have been moving with the technology.  Education visits, medical and nursing reviews and physiotherapy have all been converted to telehealth where safe to do so.

Vaccination for influenza was offered to all patients admitted to HITH and was accepted by 70% of eligible patients.  65% of these were being vaccinated for the first time against flu3.  In an environment where routine vaccinations have been falling4, this is a powerful demonstration of the opportunities that exist within HITH.

Infants with bronchiolitis have been managed through HITH before5 but the care pathway has never stuck due to barriers accessing cylinders on the same day and clinician confidence.  A new model has been rolled out overcoming these barriers through utilising oxygen concentrators and remote monitoring.

With time, our use of remote monitoring and ability to feed vital signs directly into the Electronic Medical Record, will allow massive expansion of HITH services.   Predictive modelling from large EMR datasets will allow more accurate prediction of which children are likely to be safely transferred to the home environment.  Realtime data and predictive modelling will enhance clinician and family confidence and enable us to fully realise the benefits of HITH to hospitals and families.  

So what about our friends Elise, Thomas and MaryKate….

Elise is able to receive her pre-hydration at home on her birthday.  She celebrates her birthday in her parent’s bed with her sister beside her, both building her new lego sets.  Her best friends visit and her mother prepares a special meal and bakes a special cake.  She is able to go to bed that night, knowing the HITH nurses will visit every day over the following week to administer her chemotherapy and post-hydration and she has avoided another week in hospital.

The HITH nurses visit Thomas daily before school to connect his longline to a Baxter antibiotic infusion. Before and after school he performs physiotherapy via telehealth.  At school, he wears his antibiotic in a backpack and can continue to play 4 square at lunch.

MaryKate is visited by the HITH dietitian and speech therapy who provide feeding advice and a regime that fits around the family routine. They can see where MaryKate sits for meals and how her meals are prepared first hand and are able to offer some helpful suggestions. The team are also able to visit MaryKate at her daycare and ensure her routine is consistent. In between visits, MaryKate is reviewed via telehealth by the allied health team.  She makes significant oral progress and by the end of 2 weeks, her tube is no longer required.

Time for Telehealth

Cite this article as:
Alison Boast and Allison Hempenstall. Time for Telehealth, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.24401

As the COVID19 pandemic continues to spread and utilize more of our health resources, many clinicians are being asked to minimize in–hospital clinic appointments. While it may seem simple to switch to telehealth for routine clinic appointments, there are a number of factors that need to be considered to make the process as smooth as possible for yourself and your patient and family.

This post will help you make the transition from face–to–face clinic appointments to telehealth. There are even more tips and tricks for assessing children with acute illnesses via telehealth, stay tuned!

 

Is your patient suitable for telehealth review?

If the answer is yes then continue on! There are some factors to consider though.

Need for clinical examination – if a clinical examination plays a key role in decision making telehealth may not be appropriate e.g. features of heart failure in a child requiring correction of a congenital heart defect

Multidisciplinary clinics e.g. cleft palate clinic – it may not be possible for clinics with multiple different providers to be shifted to telehealth

Need for procedures – in some clinics procedures are essential such as dressing changes or immunizations and therefore may not be possible via telehealth or community services

Some of the above barriers may be overcome by collaborating with your patients, their families, local general practitioner, and nurse practitioner; it is worth exploring this as an option.

 

Does your patient and their family have the right technology?

In general, the technology required for telehealth includes:

  • Reliable internet connection (remember that the weather, location and other users online at the time can impact your connection speed)
  • Computer, tablet or smartphone 
  • Web–camera (inbuilt in many computers, tablets, and smartphones)
  • Secure program to communicate through (e.g. Skype, Zoom, FaceTime)

 

Telehealth consultations are inherently different to face to face ones. It’s really important to acknowledge that your consultation has shifted to a two–dimensional format which poses unique challenges.

 

Voice or video – which should I choose?

Voice is more accessible, particularly for the elderly who may not have phones or computers with video capabilities. It requires lower bandwidth and is less susceptible to disruptions. Unfortunately, you can’t see the patient (duh!) which means you can’t use your ‘end–of–the–bed–o–gram’ to see if they are well or unwell.

Video provides visual information on whether your patient appears ‘well’ or ‘unwell’. It is ideal for those patients and families with hearing impairment as non–verbal communication is preserved, as is the option to lip–read. With the increased use of the internet during isolation, quarantine and social distancing,  connectivity can be slow at times. Some governments have been advocating for online streaming services to downgrade from HD format to help preserve bandwidth.

Irrespective of the method chosen it is important to ensure the lighting optimizes illumination of your face, and sound is adequate with minimal background noise.

 

How should I run the consultation?

Before you start make sure you have your information technology support team phone number in case issues arise that you can’t troubleshoot. Check the patient’s identity, sound, and vision (if using video) and consider having a set of earbuds/ headphones handy.

Ensure that your patient and their families are holding the consultation in a private, safe space. Clarify the amount of time available for the consultation. Non-verbal cues that the consult needs to come to an end are more challenging with telehealth.

Limit distractions – if the family has lots of children or pets, it is worth asking at the beginning of the consultation if they can play in another room (safely), or have a quiet activity to get on with. Communication with noisy siblings is even harder via telehealth than in real life

If you need an interpreter before to organize this in advance, either by phone or in-person

At the end of the consultation take a brief moment to ask your patient and their family for feedback about the telehealth consultation

  • Did your patient hear/ see you throughout the consultation?
  • Was your patient happy with the care they received?
  • Would your patient be happy to have another telehealth consultation in the future?

 

But how do I examine the patient?

A major barrier to telehealth is the inability to carry out a physical examination. You can, however, gather more from video telehealth than you realize.

General Inspection – probably the most important part of the paediatric examination :

  • Does the child look well or unwell?
  • Are they active and engaged, or quiet and withdrawn?
  • Do they look well-grown? (remember to review your patients’ growth charts!)
  • Do they look like their parent(s)? Do they have dysmorphic facial features?

Observations – In most teleconsultations you won’t have this information, some patients and their families may have:

  • A  thermometer to take their temperature (although generally not required for a routine clinic appointment unless the child is acutely unwell)
  • A smartwatch or app on their smartphone which can take their heart rate and or oxygen saturation for older children with comorbidities (e.g. chronic lung disease)
  • If a blood pressure is important for decision making (e.g. chronic kidney disease) it is vital that the cuff is fitting correctly; few families have at–home sphygmomanometers, so they may be able to visit the local practice nurse for an accurate measurement

RespiratoryA wise professor once said that most of the respiratory examination only requires your eyes

If the video quality allows – what is the respiratory rate? Are there signs of increased respiratory effort? Is the respiratory cycle normal, or is there a prolonged expiratory phase?

Development – assessment requires some assistance and props from parents, but this in itself gives you information about the parent–infant bond and social skills:

  • Gross motor – stacking blocks, throwing a ball, sitting/walking/cruising/running and jumping
  • Fine motor – picking up raisins, scribbling or drawing
  • Speech and Language – can the child point out pictures in a book? Read you something?
  • Social – difficult to assess via telehealth; it’s easier to obtain from history and parental/teacher questionnaires
  • Questionnaires filled out ahead of time can help gather more objective information on the developmental domains of concern (e.g. Ages and Stages Questionnaires) 

Neurological – this is very challenging to assess via telehealth, only gross assessments of tone and coordination will be possible (see above for gross and fine motor)
 

Financial Considerations

In Australia, many Medicare item numbers have recently become available to bulk-bill telehealth sessions. This includes quarantined/isolated doctors who are still able to provide telehealth from home. It is worth checking with the relevant agency in your area to see what options are available to support telehealth, and what the surrounding rules and regulations are.

 

Medicolegal Considerations

Here are some useful elements to document:

  • Your name, date, time & location of consultation
  • Patient/ carer consent for the telehealth consultation
  • Those present for the consultation
  • Video vs phone consultation
  • Limitations to quality of consultations (e.g. poor connectivity)

We recommend giving your friendly indemnity insurer a call if you have any specific medicolegal questions

 

Check out more resources here

https://www.rch.org.au/telehealth/

https://www.bmj.com/content/bmj/suppl/2020/03/24/bmj.m1182.DC1/gret055914.fi.pdf

https://www.bmj.com/content/bmj/368/bmj.m1182.full.pdf

https://www.racp.edu.au/docs/default-source/advocacy-library/telehealth-guidelines-and-practical-tips.pdf

https://www.racgp.org.au/getmedia/c51931f5-c6ea-4925-b3e8-a684bc64b1d6/Telehealth-video-consultation-guide.pdf.aspx

BRUE v ALTE – have the new guidelines made a difference?

Cite this article as:
Roland D, Davis T. BRUE v ALTE – have the new guidelines made a difference?, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20773

This week sees the publication of a new paper in Pediatrics by the team at the Children’s Hospital of Pittsburgh and the University of Pittsburgh.

Ramgopal SR, Noorbakhsh KA, Callaway CQ, Wilson PM, Pitetti RD. Changes in the management of children with brief unresolved unexplained events (BRUEs). Pediatrics.

Why was this study needed?

In 2016, the American Academy of Pediatrics published a guideline which renamed and redefined ALTEs (acute life-threatening event). The new term was BRUE (brief resolved unexplained event).

ALTE was initially coined in 1986 and the definition was:

an episode that is frightening to the observer and that is characterised by some combination of apnoea (central or occasionally obstructive), colour change…marked change in muscle tone (usually marked limpness), choking, or gagging. In some cases, the observer fears that the infant has died.

This was a broad definition and caused some difficulties for those of us assessing babies in hospitals. Although an ALTE could indicate a serious underlying problem – NAI, infection, seizure – commonly the infant was completely well. ALTEs by definition were subjective and this made the management of them tricky. Often these babies had overnight admissions to hospital for observation.

The new definition for BRUE is:

A BRUE has occurred if the observer reports a sudden, brief, and now resolved, unexplained episode of ≥1 of the following:

  • cyanosis or pallor
  • absent, decreased, or irregular breathing
  • marked change in tone (hyper- or hypotonia)
  • altered level of responsiveness

As well as the new definition, the guideline also stratifies patients and recommends management for those in the low-risk group.

Read our DFTB summary of the change in guidance here.

It has now been three years since the change from ALTE to BRUE. The aim of this study was to see whether the new guidance has affected rates of admission, investigations, or outcomes.

The objectives of the study were cleared stated and relevant to paediatric emergency medicine.

Who were the patients?

Patients were taken from the Pediatric Health Information System, which is a database with all information from presentations and admissions in hospitals across 26 states in the USA.

Patients were included if they were under 1 year old and had a diagnosis coded of either ALTE or BRUE between 2015 and 2017.

Exclusions were if patients had been transferred from another hospital, or had ambulatory surgery.

A control cohort was also used from all ED presentations of children under one year old during the inclusion period with no diagnosis of ALTE and BRUE (same exclusion criteria). The aim of the cohort group was to check whether there were any confounding trends in admissions/investigations during that time period.

This was an appropriate choice of patient group and the use of control cohort was beneficial. Sample size estimates were not stated explicitly but were alluded to.

The limitation here is the reliance on coding. However, additionally the authors were unable to determine if the diagnosis was correct, or if the patient could be classified as a low-risk BRUE as these assessments require a history and examination.

9,501 patients were used for the cohort analysis (5508 patients 0-60 days old, and 3993 who were 60 days to 1 year old). This group was split into a 2015 cohort (i.e. before the new guidelines) and a 2017 cohort (after the introduction of the new guidelines)

A second analysis was an interrupted time series analysis to look at trends in admissions over time. 13,977 patients were included in this group.

1.4 million patients were in the control cohort.

What analysis was carried out on these groups?

The cohort analysis looked at the rate of admissions as the primary outcome. Secondary outcomes included revisits and investigations performed. A comparison was also conducted by using the control cohort.

The interrupted time series analysis looked at whether admission rates changed over time following the introduction of the guideline. Admission rates were analysed in one-week batches throughout the three year time period.

The subjects were all accounted for and appropriate outcomes were considered.

What were the findings?

Admissions: the proportion of admissions in the 61-365 day old group was 86.2% in the 2015 cohort and 68.2% in the 2017 cohort. The admissions were also significantly lower in the 0-60 days group – 89.9% in the 2015 group and 84.1% in the 2017 group.

Investigations: the 2017 group had significantly lower rates of EEG, MRI, CXR, FBC, U+Es, LFT, and urinalysis. Those in the 0-60 day old group (2017) had significantly lower rates of blood gas measurement, blood sugar testing, head CT, metabolic studies, and lumbar puncture.

Revisits: in the 0-60 day old group, revisits within 3 days were significantly lower in the 2017 group (3.7%) than in the 2015 group (5.2%). The rest of the revisit rates were similar.

Analysis of the control cohort here suggested that the decreased rates of these outcomes were independent of other trends over time.

Interrupted time series analysis: in the 0-60 day old group the introduction of the guideline did not affect trends in admissions rates. However, in the 61-365 day old group, the admission rates decreased each week after the guideline was published.

The authors were clear on what was measured and how it was measured. Follow up was for a 30 day period so should have picked up most complications. The measurements were reliable, valid, and the basic data was adequately described.

What did the authors conclude?

Between 2015 and 2017 there has been a significant reduction in the rates of admission and investigations for patients with ALTE/BRUE. This rate decreased steadily following the guideline publication.

The authors note that this reduction is seen in the 0-60 day old group, even though that age group would be stratified as higher risk in the new guidelines. The fact that BRUE is a diagnosis of exclusion, whereas ALTE was all-encompassing may mean that this diagnosis is being applied to a smaller, safer group over time, which might explain the findings. There were less patients diagnosed with ALTE/BRUE in 2017 compared to 2015.

The results are discussed in relation to existing knowledge and the discussion seems balanced and not biased. The conclusions are justified by the data.

Will this paper change my practice?

Changing practice is challenging, changing a definition is a little easier.

This study is a great example of how to review the impact of guideline change and determine whether the outcomes have improved for patients without unintended consequences. At face value the BRUE approach has had beneficial clinical impact. We see an overall decline in admission and investigations with no obvious harm (returns don’t increase).

There are a few caveats that are important to consider though. This study was from a chain of hospitals likely working with similar cultures and convergent working practices. A random selection of children’s hospitals may have interpreted the AAP guideline with a greater degree of variance (and therefore application). With this in mind the relevance of quite a profound change in coding should be highlighted. In a similar timescale 25% of patients with a prior diagnosis of ALTE are no longer coded as such and it appears that these patients are not replaced with a BRUE code (as there was a 25% reduction overall in either code). This means that either the guidance has been successful in making staff think hard about about the underlying reason for the infant’s presentation or that perhaps initial coding was not as precise as it could have been (“I’m not sure what happening here so I’ll just call it an ALTE“). Of note the return rate isn’t supplied for those not coded as BRUE or ALTE so we don’t know if the cohort of patients now coded as something else have actually come to increased harm. It is also interesting to note the significant fall in admissions for those less than 60 days old. This wasn’t the intention of the initial guidance and while this group’s re-admission rates didn’t increase this study wasn’t powered (or designed) to look at whether the re-admission changes would be significant or not. The fact that it appears safer is a statistical construct, not a clinical one. This means a type II error is possible (there is actually a problem but we aren’t seeing it).  

Ultimately, while these risks are real, and do need investigation in future study, it is likely that altering to using BRUE will effectively rationalize your investigation and management pathways without causing additional harm. The challenge for those outside the United States is whether national organizations are happy to formally endorse the BRUE concept as staff may feel uncomfortable applying new rules without official sanction. Locally certainly, we use the BRUE criteria in our risk assessment and this study only further endorses that approach.

Post-publication commentary from one of the authors

This is a really wonderful summary and analysis of the study. The findings do suggest that patients in the low risk cohort identified by the AAP BRUE guidelines are being discharged safely without an increase in return visits. It is important to note that this narrower definition of BRUE has not excluded all high acuity conditions, as patients with high acuity co-diagnoses were identified in both age groups after the practice guideline publication.
 
Overall, I think our findings support continued clinical application of the BRUE definition and guidelines. While not within the scope of our study, the results did make us wonder about the impact of guidelines published by a national medical organization. How much of the change we saw in a three-year period were due to influence by the AAP and how much was because the medical community was ready for a change in ALTE management? Finally, we hope that our findings are able to support further research into management of both low-risk and high-risk BRUE and into understanding what has changed in the management of infants who are now excluded from the BRUE diagnosis.
 
Katie Noorbakhsh (author)

Here’s a printable A4 summary of the paper & our thoughts:

Changes in the management of children with Brief resolved unexplained events (BRUEs)

An approach to obesity: Matt Sabin at DFTB18

Cite this article as:
Team DFTB. An approach to obesity: Matt Sabin at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20580

Associate Professor Matt Sabin is the Chief Medical Officer of the Royal Children’s Hospital in Melbourne. It was not in this role that we asked him to speak but rather in his clinical role as a paediatric endocrinologist running the largest tertiary hospital obesity service in Australia.

Unlucky dip: Rational diagnostic testing for infections

Cite this article as:
Alasdair Munro. Unlucky dip: Rational diagnostic testing for infections, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20311

We see lots of children with suspected infections. Modern microbiology techniques have opened up a huge array of tests: some new and expensive, but we are often still reliant on good old fashion microscopy and culture.

With so many tests so readily available, we need to think hard about diagnostic stewardship. This means testing the right patients for the right reasons. We must be wary of over-diagnosis, preventing confusion, anxiety or unnecessary treatment, and making choices that represent good value. Many tests can be expensive and are often not necessary to make management decisions.

With that in mind, let’s take a look at some of the most common diagnostic tests for infections, and when we should (or shouldn’t!) be deploying them.

 

Urine dips and MC&S

Urinary tract infections (UTIs) are the most common serious bacterial infection in high-income countries. There are many departments where it is routine to set up every febrile child to get a “clean catch” urine as soon as they arrive. This is unwise, because it is VERY EASY to contaminate a urine sample from a clean catch. We have all seen children or parents putting their hands/feet/face in the bowl, and let’s be honest – if the child is sitting on the container, it’s basically directly under the body’s primary waste pipe.

Accepting a decent risk of false positives, we must aim to test only those who need the test. So when should we do it?

Fever without a source

This is the primary indication for doing a urine dip, and it is a sensible one. However, still not every child with fever and no source needs a urine dip. Older children can report urinary symptoms, and the absence of these makes a UTI much less likely. In addition, by school age, UTIs in males with normal renal tracts become very rare, so urine testing also becomes less useful.

As a framework, urine dips should be performed in the following groups with fever and no source (assuming they have no risk factors for UTIs and have no red flags):

Outside of these groups, use your clinical discretion to decide if the pre-test probability justifies the risk of a false positive – take into consideration the child’s age, gender, duration of symptoms, how unwell they appear, and obviously if they have known risk factors such as renal abnormalities or previous UTIs.

Symptoms of UTI

This seems obvious – but it’s worth stating that once urinary symptoms are present (increased frequency, dysuria) you should dip the urine to check for infection, and it may be worth sending samples for MC&S even if they are dip negative in this scenario (you can withhold treatment pending results).

It is worth taking more care for children with non-urinary symptoms, such as abdominal pain or vomiting (which is probably not predictive of UTI). Once at school age (particularly in boys) these symptoms are unlikely to be a symptom of a UTI so a higher threshold for testing should be adopted.

Some people say that all children with rigors require urine testing. Rigors are not evidenced to have any influence on the risk of UTI (or any significant risk of bacterial infection). If there is another source of the fever, urine dip is certainly not indicated on the basis of a rigor alone.

For more information on relative risks for UTIs in younger children, the supplementary materials to the UTI risk calculator study make an interesting read.

What about hot babies with bronchiolitis?

This becomes a slightly more controversial topic, and decisions require risk stratification based on the age of the child. For example, a febrile neonate with bronchiolitis might be lucky to escape the full shebang of a septic screen anyway – and a quick in/out catheter is unlikely to yield a false positive.

The literature on this topic is a bit confusing because of varying definitions of UTI and bronchiolitis (some studies including any child with RSV detected in their nose). The most recent meta-analysis with more stringent criteria for diagnosing UTI found a rate of concomitant UTI with bronchiolitis of 0.8% – low enough that testing is not advised.

Bottom line: if an infant has a fever and a clinical diagnosis of bronchiolitis, then urine dip is not necessary in most instances – however this should be given strong consideration in infants <60d and should be performed in neonates.

 

Blood culture

For a full myth busting exercise in blood cultures, please read the recent DFTB post on this topic. Some things to bear in mind if you’re thinking of taking a blood culture:

  • You are testing for bacteraemia. If you do not suspect bacteraemia, do not send a blood culture.
  • Blood cultures are extremely low yield in uncomplicated skin/soft tissue infection and pneumonia and should be avoided.
  • You do not need to wait for a fever to take a blood culture – it has no influence on the likelihood of obtaining a positive result. If you suspect bacteraemia, take the culture now.
  • If you are going to take a blood culture, aim to inoculate at least 1ml of blood per year of the child’s age. Less than this and you increase the risk of contamination and decrease the sensitivity.

 

Wound swab

When it comes to swabbing for microscopy, culture and sensitivity (MC&S), there is a golden rule*:

Do not swab any non-sterile site that you have not already clinically diagnosed as being infected.

A skin swab, throat swab, eye swab etc. will grow bacteria 100% of the time, because these places are non-sterile. They will often grow pathogens, because many pathogens are quite happy just being colonisers a lot of the time, and actually some of them are more often found as bystanders than as trouble-makers (Pseudomonas aeruginosa is a prime example – it is very rarely pathogenic in non-sterile sites). A positive swab does not diagnose infection.

YOU have to diagnose infection; a swab will just tell you what bacteria is causing it.

I would like to give a special shout out to gastrostomies at this point – just because they are “mucky” is not a good reason to swab. If you do swab it, you will find good old Pseudomonas (it loves playing in wet stuff). Skin and soft tissue infections are red, hot and inflamed +/- a bit of pus. Yellowish clearish greenish stuff is normally just serous fluid, so don’t worry about it and don’t swab it!

The same goes for babies sticky eyes. If you swab it, it will grow bacteria, but this tells you nothing about whether they are infected. Look for inflammation, if you find it then diagnose infection, treat empirically and send a swab if you are concerned about resistant bacteria.

*there are some exceptions to the golden rule, including burns and chronic wounds in immunosuppressed patients.

 

Throat swabs

Before starting – let’s remember that you cannot diagnose a bacterial throat infection with a swab alone. If you are considering swabbing a throat for MC&S, you must have already clinically diagnosed infection.

Guidelines vary quite widely in their recommendations to swab or not swab when diagnosing tonsillitis. It is worth considering that a throat swab has a reasonable sensitivity for group A Strep, if performed correctly. Sadly – we are all dreadful at performing throat swabs in children (who are usually very good at not wanting a throat swab), and often get a good dose of tongue and palate. Not good.

A further thing to consider is that approximately half of all throat swabs positive for group A Strep just indicate carriage – you’ve found the bug, but it’s just a bystander.

This means that if you swab and haven’t found the bacteria, it might be there but you’ve missed it, and if you have found it, there’s a 50% chance it’s not causing the illness anyway…

If it’s extremely important you detect the presence of group A Strep (for example in populations high risk for rheumatic fever) then I would definitely do a swab. If it’s not (and it usually is not), then make your decision to treat or not on clinical grounds alone.

Also, remember that in children <4yrs group A Strep tonsillitis is rare and almost never causes complications, so if you’re thinking of doing a throat swab for a child in this age group you need to have a very good reason.

 

Respiratory virus testing

Respiratory tract infections are extremely common in children. There is a fair amount of controversy and disagreement about the role for respiratory virus testing. It can have several roles:

  1. Local epidemiology. Some big/university hospitals like to keep track of what’s circulating, and will often have guidelines on who and when they want these tests performed.
  2. Cohorting. In bronchiolitis season, some hospitals might fill one bay with RSV and another with Rhinovirus. This is an evidence free zone.
  3. Fever without a source. Influenza in particular can cause horrible febrile illnesses in children without the classic respiratory prodrome. The idea is to detect the flu to prevent unnecessary antibiotics.

A group of children you should not test for respiratory viruses is anyone with cough and coryza. They do not need a test – they can be safely diagnosed clinically, and the presence or absence of a virus on testing does not change anything.

What about in lower respiratory tract infections? We can imagine that the discovery of a virus would prevent unnecessary antibiotics. However, respiratory viruses are common (even among non-hospitalised populations) and co-infection with bacteria is also common in viral infections. The presence of a virus does not preclude a bacterial infection. As such, their use in this context is contentious, and they do not appear to reduce antibiotic use.

For a thorough look at the principles and evidence of respiratory virus testing in children, I would recommend this excellent review paper.

 

Conclusions

  • Not every child with fever and no source needs a urine dip. Do it in infants, young girls and children with fever persisting >48hrs. Otherwise, use clinical discretion.
  • You probably don’t need to urine dip febrile children with clinical bronchiolitis.
  • Only do blood cultures if you suspect bacteraemia, and take lots of blood if you do.
  • Only send a swab for MC&S from a non-sterile site if you’ve already diagnosed infection.
  • Throat swabs are usually not useful. Only do them for high risk groups.
  • Respiratory virus testing is not useful in most circumstances. Only do it if you have a definite plan for how it will change your management.
  • When in doubt – if you can’t explain how the test will change your management, don’t do the test.

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.

Feeding problems in infancy: David Tickell at DFTB18

Cite this article as:
Team DFTB. Feeding problems in infancy: David Tickell at DFTB18, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17426

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