Big Picture Paediatrics : Adverse Childhood Experiences

Cite this article as:
Henry Goldstein. Big Picture Paediatrics : Adverse Childhood Experiences, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.10082

So much of paediatrics, and medicine in general, is focussed on small experimental or observational studies. This series of posts takes the wider view; we’re talking here about some of the biggest and longest running studies that help us frame, measure and understand childhood through time and across the world.

Who & what was studied?

Kaiser Permanente is a large Medical Insurer in the USA; they collected data in two waves in the primary care setting with a view to describing the long-term relationship of childhood experiences to important medical and public health problems. The study initially rolled out in 1996 & 1997.

Felitti, VJ, Anda RF, Nordenberg D et al. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults : The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine. 1998:14, 245–258.

The study aimed to assess – both retrospectively and prospectively – the long-term impact of abuse and household dysfunction during childhood on disease risk factors and incidence, quality of life, health care utilization, and mortality for adults.

Here is the actual questionnaire:

Answer yes or no; all ACE questions refer to the respondent’s first 18 years of life.

Abuse

  • Emotional abuse: A parent, stepparent, or adult living in your home swore at you, insulted you, put you down, or acted in a way that made you afraid that you might be physically hurt.
  • Physical abuse: A parent, stepparent, or adult living in your home pushed, grabbed, slapped, threw something at you, or hit you so hard that you had marks or were injured.
  • Sexual abuse: An adult, relative, family friend, or stranger who was at least 5 years older than you ever touched or fondled your body in a sexual way, made you touch his/her body in a sexual way, attempted to have any type of sexual intercourse with you.

Household Challenges

  • Mother treated violently: Your mother or stepmother was pushed, grabbed, slapped, had something thrown at her, kicked, bitten, hit with a fist, hit with something hard, repeatedly hit for over at least a few minutes, or ever threatened or hurt by a knife or gun by your father (or stepfather) or mother’s boyfriend.
  • Household substance abuse: A household member was a problem drinker or alcoholic or a household member used street drugs.
  • Mental illness in household: A household member was depressed or mentally ill or a household member attempted suicide.
  • Parental separation or divorce: Your parents were ever separated or divorced.
  • Criminal household member: A household member went to prison.

Neglect

  • Emotional neglect: Someone in your family helped you feel important or special, you felt loved, people in your family looked out for each other and felt close to each other, and your family was a source of strength and support.
  • Physical neglect: There was someone to take care of you, protect you, and take you to the doctor if you needed it, you didn’t have enough to eat, your parents were too drunk or too high to take care of you, and you had to wear dirty clothes.

What does this mean?

The ACEs questionnaire accumulates a score from zero to seven based on yes/no responses to the above questions. These results in conjunction with a “Health Appraisal Clinic’s questionnaire” allowed correlation with risk factors such as smoking, severe obesity, physical inactivity, depressed mood, suicide attempts, alcoholism, any drug abuse, sexually transmitted diseases, parental drug abuse and a high lifetime number of sexual partners (>50), as well as the big swingers; mortality and overall morbidity.

The ACE score has been utilised to demonstrate a graded dose-response with more than 40 outcomes. You can see the entire list of publications here.

How good is this dataset?

Although there are almost all of the expected threats to validity from a questionnaire administered to people obtaining health insurance in the USA in the 1990s, the dataset is very good.

Of the 13,494 surveys, there was a 70.5% (9508) response rate, sent a week after standardised medical review. Respondents who did not respond to all questions were excluded from the final analysis. After non-responders and exclusions, a total dataset of 8056 responders was analysed. Alarmingly, more than half of the exclusions were for not answering the question about childhood sexual abuse. This certainly raises some concern for a risk of underreporting, particularly if this was the only question omitted! 

What meaning can be drawn from the results (so far)?

The dataset has lent itself to the associations between adverse childhood experiences and a veritable laundry list of medical, psychiatric pathology as well as social and public health problems.

This is data reports that 1 in 5 were sexually abused, nearly 1 in 4 lived with a “problem drinker or alcoholic” and that around 1 in 6 had a household member who was depressed or mentally ill.

It’s worth remembering that this study paints a picture of the adverse childhood experiences of the older generations in the USA – the mean age of respondents was 56.1 (19-92) years – in a study undertaken just over 20 years ago.

Rather than provide a snapshot of what childhood is like today, this data informs us about the childhood of parents of our patients. This gives us some understanding and frameworks by which to consider expectations of childhood from the parental & societal viewpoint – that most parents hope for a rosier childhood with fewer adverse experiences than their own.

With this in mind, and with a critical eye to some of the correlating outcomes, behaviours such as alcohol & drug abuse, smoking, over-eating, and sexual behaviours might alternatively be viewed as both coping strategies and symptoms of the anxiety, anger and depression that is likely co-morbid with high levels of adverse childhood experiences.

Primary prevention of adverse childhood experiences necessitates change at the societal level; with a focus on improving the quality of family and household environments through the childhood years.

Funding for the original study was combined between Kaiser Permanente (San Diego) and the US Center for Disease Control.

Where next?

The Centre for Disease in Childhood has taken over the study and, since 2009, transformed it into a national program across 32 states of the USA, called “Behavioral Risk Factor Surveillance System” (BRFSS). Data from the 2010 BRFSS has been published and includes more than 50,000 respondents. You can see more about the participating states, future timeline and previous data via the CDC website, here.

References:
Felitti, VJ, Anda RF, Nordenberg D et al. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults : The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine. 1998:14, 245–258. 

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention Adverse Childhood Experiences (ACEs)”.U.S. Department of Health & Human Services, Atlanta, USA. Accessed 27 September 2016. https://www.cdc.gov/violenceprevention/acestudy

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention. “About Behavioral Risk Factor Surveillance System ACE Data”.U.S. Department of Health & Human Services, Atlanta, USA. Accessed 5 October 2016. https://www.cdc.gov/violenceprevention/acestudy/ace_brfss.html

The space between…

Cite this article as:
Andrew Tagg. The space between…, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.9926

The readers of Don’t Forget the Bubbles are clearly well educated and try their best to keep up to date with the literature.  We do what we can to help bring the latest research to you to help reduce the knowledge translation window (and have a new project on the horizon to help even more). Those of us who are involved in FOAMed scour the literature to see what is bubbling to the surface but unfortunately, the general public does not. Whilst  I might peruse 40-50 medical journals a month the layperson may only have one source of medical information.  

Key trials in developing countries – 2015-2016

Cite this article as:
Andrew Tagg. Key trials in developing countries – 2015-2016, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.7460

Here is a recently published booklet which summarises much of the latest research on child health in developing countries. It consists of evidence derived from all the randomised trials published over the last year.

Professor Trevor Duke, Intensivist at the Royal Children’s Hospital in Melbourne has put together this excellent summary of some of the key findings, and has kindly allowed us to share it with our DFTB readers.

This year there were 187 publications from randomised or controlled trials. We have high-lighted just a few of the trials.  It is well worth perusing the booklet, if only to realise how lucky those of us are that practice in the developed world when it comes to resources.

Pneumonia

Pneumonia is a leading cause of mortality in children under 5 years old worldwide.

In a trial of over 1000 Indian children with clinical signs of pneumonia with tachypneoa, and chest indrawing out-patient treatment with oral amoxicillin was similar, in regard to treatment failure, as in-hospital treatment, at 7 days.

In a trial of hospitalized children with community acquired pneumonia in Thailand, switching to oral antibiotics within 24 hours of cessation of fever and symptom improvement, was as effective as conventional intravenous therapy.

Use of bubble-CPAP in children with severe pneumonia in Bangladesh was associated with lower risk of death than standard oxygen therapy.

Inotropes

In the setting of fluid refractory shock, in Brazil, early peripheral adrenaline was associated with decreased mortality when compared with dobutamine.

Diarrhoeal illness

A single dose of oral ondansetron reduced the risk of treatment failure with oral rehydration solution and reduced the need for IV therapy in India.

Whilst medical interventions do work, cultural interventions are more useful.

In a large meta-analysis of over 14,000 cases in low and middle income countries hand-washing promotion reduced community diarrhoea rates by about 30%.

Improving water quality in communities in Ghana by drilling bores reduced diarrhoea prevalence in children by 11%. This is in contrast to efforts in rural India to improve sanitation and reduce open defecation which were only partially successful in reducing faecal bacterial loads and cases of diarrhoea.

Neonates

When treating hyperbilirubinemia in term and late-preterm neonates in Nigeria, filtered sunlight was effective in controlling bilirubin levels on 93% of days, and conventional phototherapy was effective in 90% of days. It appeared safe with temperatures higher than 38.0°C occurringin 5% of infants receiving filtered sunlight and in 1% of those receiving conventional phototherapy.

Like most studies in low and middle income countries sample sizes are small and so it is hard to generalize but among preterm Indian neonates with a patent ductus arteriosus, enteral paracetamol was as effective as intravenous indomethacin in closing the PDA: 100% (36/36) versus 94.6% (35/37) respectively.

This is the 14th edition of this booklet.  Previous editions, which summarise 2182 trial publications from 2002-2015 are available at www.ichrc.org.

DFTB in Dublin – the Workshops

Cite this article as:
Tagg, A. DFTB in Dublin – the Workshops, Don't Forget the Bubbles, 2016. Available at:
https://dontforgetthebubbles.com/dftb-in-dublin-the-workshops/

Having braved international flights half of the team from DFTB (Andy and Henry) have made it to SMACCDub. For those of you not in the know the Social Media And Critical Care conference is in it’s fourth year now and partly inspired us to start Don’t Forget The Bubbles.  Although the editors regularly chat online this was the first time Henry and I have met in person.

In order to make the most of our time abroad we had both booked into the #SMACCmini paediatric workshop.

SMACCMini

With a line of speakers encompassing the best and brightest from the world of paediatrics (apart from us) we were excited to see what they had to offer. With a variety of lightning 10 minute talks over the course of the morning topics ranged from communication to caring for the critically ill child.

Resuscitation update

Natalie May was our leatherette clad hostess and kicked off the proceedings with an update on the 2015 ILCOR guidelines.  Whilst little has changed in resuscitation of the infant it is the rare resuscitation of the newborn that scares us the most.  Whilst a precipitous delivery in the department may be a rare event, it does happen.  Babies may be born in less than ideal circumstances – on the leather back seat of their husband’s new car, in the toilet (literally) or in the lift up to the birthing suite – but thankfully the need to perform complex interventions is rare. We need to know what to do before help arrives. This short video may help those who are paralysed by fear.

PEM literature update

Tim Horeczko took to the stage next, disguised as an event organizer. Despite technical issues that were out of his control he took us on a whirlwind tour of some paediatric literature that most of us in the room were not aware of.

Approaches to spotting the sick child

The Wonder Woman of Leicester, Rachel Rowlands, then took to the stage (along with her constant companion, Norman the dinosaur) to remind us of the importance of gestalt in spotting the sick child, a theme that would echoed by many speakers throughout the morning.  She took us on a choose-your-own adventure style quest, not to find the treasure, but to save the life of a young boy that had swallowed a button battery.  If you want to know more about the dangers of these deadly discs then take a look at her video.

Spotting sepsis early

Adrian Plunkett talked eloquently on the the use of the NICE traffic light system and other early warning scores to predict sepsis. But really he gave us two key take home points to lock onto:-

  • Be worried if there is a change of state – they are not the same as they were yesterday
  • Be worried if this illness is like no other illness they have ever had

By using these two key questions in the history we might become more alert to the risk of potential deterioration and look for ways to validate our fears – order the extra blood tests, keep the child in for a period of further observation.

Sick neonates are simple

Trish Woods, a neonatologist from WA, reminded us that all neonates want is to be protected.  When they are threatened, be that in the form of imminent airway or breathing difficulty, their physiology wants to return to the womb.  By understanding the transition from safe, warm and comforting intra-uterine life to the harsh outside world we can guide our resuscitation.

Mistakes and pitfalls in critical care

Phil Hyde, who gave an excellent talk about the use of real children during simulation at last years conference urged us to use our fear, not because it leads to the dark side, but to help us step towards the stressful.  We have all been in a resuscitation when there is a palpable sense of half-repressed panic.  Voices are raised and critical instructions missed, mistakes are made. But just as the emotions of the team leader can have a negative impact on the team they can also act to stop the sweating.  By being the slow, smooth voice of calm the team leader can imbue all of the group with the same feeling.

This can be a challenge so there are things we can do to mitigate the internal stress. Cliff  Reid talks of using the high fidelity simulator that is our brain to visualize these high stress scenarios, before they happen.  That is all when and good if you are experienced and have seen a lot of sick kids. But what do you do if you haven’t.  Phil suggests visiting your local PICU and asking questions of doctors and families, stepping towards the fear.  He also suggested using www.spottingthesickchild.com, a free online resource (though you need to register) to make you more comfortable in your assessment of deteriorating infants.

Paediatric ultrasound

The southern hemispheres Wizard of the Wand, Giant of the Gel, Prince of Probes, himself – Casey Parker – demonstrated how easy it is for us all to perform lung ultrasound on children.  In just 8 minutes he reminded us that our clinical exam counts for very nought and that a normal appearing chest x-ray can be deceptive in a child that you think has pneumonia from the history.  Waving the magic wand is easy and can be taught in just four minutes.  It is certainly a skill that I am going to take home to my place of practice.(Ed. I’d just like to give a huge thanks to Casey for encouraging me to write after the first SMACC in Sydney and publishing my very first blog post.)

What paediatric surgeons wished you knew

The esteemed paediatric surgeon, Mr Ross Fisher of p cubed presentations, then took us through some of personal bugbears.  After learning that there is no such thing as a normal bowel habit in a child, a fact that most parents can attest to, to decrying the lack of  proper physical examination prior to imaging he put us in his shoes.  Surgeons have no special ability to rule out appendicitis, but often have the benefit of experience to help determine what else may be going on.

Paediatric toxicology

As we came towards the end of the first half of the morning Nat Thurtle reminded us that children like to put things in their mouths that no normal person would.  Eschewing the usual list of one pill kills she talked about some newer toxins that most of us would not find palatable – e-liquids, laundry detergent pods and synthetic cannabinoids’s. By using the powerful Resus RSI DEAD mnemonic we can have a framework with which to risk stratify and deal with any potential toxic ingestion.

Paediatric trauma

As we were getting ready for our morning coffee Nat May reminded us that paediatric trauma often presents to non-paediatric centres and that we should all be able to recognize and deal with it.  Mechanisms of trauma vary with age from the drunken horse riding antics of teenagers, to younger children who skateboard in front of cars.  Paediatric trauma can be very confronting and how we approach our parents and their families can have a great impact on their long-term outcomes.

The SMACCmini superheroes

Appropriately caffeinated we headed back to the hall for another round of talks.

Excellence in critical care

Adrian Plunkett started off the session on a positive note.  Whilst it is easy to criticise bad practice it is much harder to praise the good.  He urged us to learn from the things we do well.  By actively promoting best practice within your network a culture of positivity and a ‘can-do’ attitude arises.  If you visit the Learning from Excellence website you can learn from others peer-reported episodes of excellence in practice.    Similar to the ‘Awesome and Amazing’ antithesis to the monthly M&M conference we need to let others in the team know they are doing a great job.

Communication: Kids and families

We all have had occasions when we think we have done a great job with our young patients and their families. Roisin McNamara brought us down to earth with a tale of when things that she thought had gone well had been perceived very differently by the family involved.  When harsh words are spoken it is important to have the emotional intelligence not to snap back, not to get angry. Often parents are not angry at you but at the situation but the doctor in front of them is the visible face of a systemic problem.  Parents may feel they are being dismissed as time wasters if time is not spent taking a thorough history and appropriate physical exam before pronouncing that their darling daughter has no medical cause for their symptoms.

Communication: Adolescents

Most of us know how to talk to children but, via the power of video, Thom O’Neill, spoke passionately about an issue we should all know more about- dealing with LGBT adolescents and youths.

Most traditional textbooks of paediatrics have yet to cover the subject and Thom gave us a useful framework to hang a conversation on, starting with recognising the child or youths right to be called what they want and to identify themselves how they want.  We hope to get Thom to write more on this subject for Don’t Forget The Bubbles. 

Resource poor settings

Nat Thurtle returned to the limelight to talk about her time working in resource poor settings.  Those of us that work in the developed world are incredibly lucky to have access to the resources we have. As she told her moving story of almost insurmountable challenges we al stopped and reflected on how lucky we truly are.

Complex kids

After hearing about children that don’t have access to even supplemental oxygen when it is needed Tim Horeczko talked about technology dependent children and their complex needs.  Whilst we are unlikely to encounter a child with a ventricular assist device outside of a quaternary centre we may well be exposed to children with a VP shunt, or a child that suffers from an incurable neuromuscular or mitochondrial defect.  As is nearly always the case in paediatrics – the parents know best, so listen.

Surgical surprises

Ross Fisher then urged us to “Keep Calm and Carry On” when confronted with potential paediatric surgical nightmares. He reminded us time and again that we know how to do the basics – analgesia, fluid resuscitation, investigate – and that there is nothing that we should be afraid of.

Neonatal procedure tips

Having previous told us that looking after sick neonates was easy-peasy, Trish Woods then went n to teach us how. By focusing on the ABC’s of resuscitation she walked us through the neonatal airway and breathing before showing some great slides and giving us all the tools we need to insert an umbilical line. At the time of neonatal resuscitation early vascular access as a means of giving fluids and adrenaline can save a life.  

Intubation tips

This great procedural talk was followed by Tim Horeczko on his top three tips for intubating infants.  We know that critical procedures are rarely performed by paediatricians let alone general emergency physicians but by adding these three things to ones repertoire we should increase our chance of first pass success.

  • Use the shoulder bump
  • Use the jaw thrust
  • Change your position and look high

Ventilation tips

Once we have successfully intubated (and confirmed tube placement with waveform capnography) Phil Hyde talked about ventilation strategies. By using PEEP and low tidal volume breaths (6-8mls/kg) we can adequately ventilate most children titrating to a pH>7.2 and and an SpO2 >92%. Attention to the simple things such as sedation, paralysis and monitoring can make all the difference.

Phil Hyde on the basics of neonatal ventilation

Patient experience

The final session of the day brought home to all of us in the room why we do what we do.  We heard from Emer, a brave 11 year old girl, who had spent 5 days in ICU with tracheitis, of her experience, both in the emergency room and in the unit.  Her clinical care was excellent and could not be faulted but if there was one thing she wanted us all to take away it was ‘Don’t use long medical words’. We doctors assume a common tongue and use medical terminology as a technical shorthand with our colleagues.  We occasionally slip into this mode of talking with patients and their relatives. Emer reminded us to think before we speak.

The organizing committee and all of the faculty did an amazing job of fitting such a wide array of topics in such a short time frame. Never did the audience feel overwhelmed with knowledge and most of us just stopped tweeting and just listened, quietly reflected and were inspired to do better. If you came along to the workshop and took away something that will change the way you treat children (or their parents) then please feel free to comment below.

pablo

 

Fetal Alcohol Syndrome

Cite this article as:
Andrew Tagg. Fetal Alcohol Syndrome, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.8725

Alcohol use is common in Australian women with surveys suggesting that around 90% of 18-45 year olds have had a drink in the last year and that around 39% of these are unaware of the health implications of drinking on the developing fetus. Fetal Alcohol Syndrome is a leading cause of preventable intellectual disability. An Australian diagnostic guide has recently been developed by the Telethon Kids Institute to help clinicians make the diagnosis of Fetal Alcohol Syndrome Disorders. In this post we cover some of the basics of Fetal Alcohol Syndrome and provide some resources for those who want to learn more.

DFTB in EMA #4 – Spoonful of sugar: Improving the palatability of emergency department visits for children and their families

Cite this article as:
Andrew Tagg. DFTB in EMA #4 – Spoonful of sugar: Improving the palatability of emergency department visits for children and their families, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.8049

Whilst it has been available online for some time now the fourth EMA article from the DFTB team has just hit doormats across Australia.

“Pain, fever, fatigue and fear can all add to anxiety and distress for unwell children and their families, as well as making assessment of their clinical state even more difficult. This article aims to describe some ways of helping the medicine go down for your paediatric emergency patients.”

Click here for the link to the full article – ‘Spoonful of sugar’

Reference:

Lawton, B., Davis, T., Goldstein, H., and Tagg, A. (2015) Spoonful of sugar: Improving the palatability of emergency department visits for children and their families. Emergency Medicine Australasia, 27:504506. doi: 10.1111/1742-6723.12506.