Fever under 60 days of age

Cite this article as:
Alasdair Munro & Damian Roland. Fever under 60 days of age, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.18571

Prompted by Tessa’s Top 5.5 Papers in PEM presentation at RCEM, Alasdair Munro kicked off an exciting twitter debate with the question…Would you do a full septic screen on a baby under 60 days with a fever?

Many of us will be familiar with the mantra that all children under 3 months get a full septic screen and antibiotics. It feels like we are over-treating, but this is a high risk group so is there any other way?

Vaccine hesitancy: Margie Danchin at DFTB18

Cite this article as:
Team DFTB. Vaccine hesitancy: Margie Danchin at DFTB18, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17112

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.

How to draw a Genogram

Cite this article as:
Daniel Bakhsh. How to draw a Genogram, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17132

As a Student Doctor at the University of Queensland, I was offered the opportunity to shadow the Adolescent Team at The Child and Youth Mental Health Service (or CYMHS) at the Queensland Children’s Hospital. This was an amazing opportunity to observe some really important work in two of my special interest areas: Paediatrics and Psychiatry. The attachment really drove home that patients don’t exist in isolation, and how this is particularly true for children. The surrounding family system strongly dictates how well they will fare once they leave the hospital.

As part of this attachment I was asked to prepare and present Genograms for every patient at the weekly Multidisciplinary Team meeting. As I began to interview family members in order to gather the required 3 generations of family history, it became clear to me that a small diagram could represent and quickly convey what would otherwise have taken several pages of text. Genograms provide a wealth of insight at a glance, can help align patients with their most appropriate care, and are relatively easy to draw once you know how. They are a mainstay of Paediatrics for a reason.

When I first came across Genograms as a student, attempting to create one was very confusing and a little overwhelming. There are also surprisingly few reference materials available to aid you along the way. So in order to make this task a little easier for the next student, I put together this little video. I hope you find it useful.

– Daniel Bakhsh, Student Doctor, Doctor of Medicine Program, University of Queensland

Bronchiolitis guidelines

Cite this article as:
Tessa Davis. Bronchiolitis guidelines, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17023

Up to 48% of infants admitted to Australian hospitals with bronchiolitis receive treatment that has no evidence of benefit. Bronchiolitis remains the most common reason for admission to hospitals in Australia and New Zealand for infants, and yet our practice in treating these patients remains variable.  The PREDICT network have conducted a systematic review to produce Australia’s first bronchiolitis guideline based on a robust systematic review. These guidelines broadly agree with the American Academy of Pediatrics and NICE guidelines.

 

O’Brien S, Wilson S, Gill FJ, Cotterell E, Borland ML, Oakley E, Dalziel SR, Paediatric Research in Emergency Departments
International Collaborative (PREDICT) network, Australasia. The management of children with bronchiolitis in the Australasian hospital setting: development of a clinical practice guideline. J Paediatric Child Health, 2018. doi:10.1111/jpc.14104

 

The authors have produced 22 recommendations based on their robust evidence review. Let’s take a look at their key recommendations.

 

What investigations should we do?

  • Routine blood and urine testing is not recommended.
  • Viral swabs are not recommended (although the authors mention that further study needs to be done to determine the benefit of cohorting in wards i.e. when all babies with the same virus are put in the same bay together to avoid spread).
  • The authors note that in infants under 2 months old with bronchiolitis there is an increased risk of a concurrent UTI.

Therefore in babies under 2 months old with pyrexia, likely bronchiolitis but some clinical uncertainty – send a urine for m, c, & s

 

What treatments are effective?

  • Salbutamol – there is no benefit in using salbutamol in infants with bronchiolitis (and some evidence of adverse effects)
  • Nebulised adrenaline – no benefit
  • Nebulised hypertonic saline – there is weak evidence of a reduction in length of stay of 0.45 days. However when two studies were removed, both of which used a different discharge criteria than most hospitals, there was no benefit. This is not recommended routinely, although the authors suggest that it should be used only as part of an RCT
  • Glucocorticoids – no benefit
  • Antibiotics – not recommended

The risk of a secondary bacterial infection is very low, and there is potential harm from giving antibiotics

  • Oxygen – no evidence of benefit in infants with no hypoxia, and low level evidence that maintaining the sats over 91% with oxygen actually prolongs the length of stay. There are no reports of long-term adverse neurodevelopmental outcomes in infants with bronchiolitis, however there is also no data on the safety of targeting sats <92%

Commence oxygen therapy to maintain sats over 91%

  • Sats monitoring – there is moderate evidence suggesting that continuous sats monitoring increases the length of stay in stable infants
  • High flow – there is low to very-low level evidence of benefit with high flow
  • Chest physiotherapy – not recommended
  • Saline drops – routine saline drops are not recommended but a trial with feeds may help
  • Feeds – both NG and IV are acceptable routes for hydration

 

This is the first robust Australasian acute paediatric guideline on bronchiolitis. It provides clear guidance for the management of patients seen in Australasian EDs and general paediatric wards with bronchiolitis and is in line with US and UK recommendations. Our current practice often deviates from this evidence-based, and hopefully these guidelines will start the shift towards unifying evidence-based practice in managing infants with bronchiolitis.

 

 

References

American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics 2006; 118: 1774–93.

Ricci V, Delgado Nunes V, Murphy MS, Cunningham S; on behalf of the Guideline Development Group and Technical Team. Bronchiolitis in children: Summary of NICE guidance. BMJ 2015; 350: h2305.

Bacterial co-infection

Cite this article as:
Andrew Tagg. Bacterial co-infection, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16783

Often we are asked to look at a febrile infant with what appears to be a viral illness. But could there be something else going on? If you believe in Occam’s Razor or the law of parsimony then you might think the simplest solution, the obvious viral illness, is the cause of the fever. But what about Hickam’s Dictum – the patient can have as many diseases as they please?

Finding the needle – without using one

Cite this article as:
Ben Lawton. Finding the needle – without using one, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16714

This week the DFTB team have been invited to run a conference within a conference in Sydney. Resus @ the Harbour is a multidisciplinary resuscitation conference combining powerful patient stories with cutting edge care – just the sort of thing we love at DFTB.

Lyme Disease

Cite this article as:
Emily O'Connor. Lyme Disease, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16210

A nine year old girl, Skye, comes to see you with her parents. She has a two day history of a red, circular and enlarging rash on her right calf, which they describe as looking like a ‘bull’s eye’.  She has also been feeling generally unwell with headaches, muscle aches, fatigue and a fever. They tell you in passing that they came back from holiday, in Scotland, a week ago.

Josh Francis: Paediatrics in East Timor at DFTB17

Cite this article as:
Team DFTB. Josh Francis: Paediatrics in East Timor at DFTB17, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16238

And so we come to the final talk of the final day of DFTB17 in Brisbane.

You can check out any of our other conference talks on our YouTube channel.

Claire Nourse: Tuberculosis at DFTB17

Cite this article as:
Team DFTB. Claire Nourse: Tuberculosis at DFTB17, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.15791

This talk was recorded live on the second day at DFTB17 in Brisbane. If you missed out in 2017 then why not book your leave for 2018 now. Tickets are on sale for the pre-conference workshops as well as the conference itself at www.dftb18.com.

Can Point-of-Care CRP testing identify children with serious infection?

Cite this article as:
Tessa Davis. Can Point-of-Care CRP testing identify children with serious infection?, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.15806

As paediatric emergency clinicians, a large part of our job is identifying the child with a serious infection. The utility of blood tests in helping with diagnosis in this group of children is debatable. Could point-of-care CRP testing help identify children with serious infection?

Antibiotics for all?

Cite this article as:
Andrew Tagg. Antibiotics for all?, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.15679

Sometimes a paper is published that makes you stop dead in your tracks. In this post-truth era we are so used to reading headlines that sound too good to be true that we just skip over them. But this paper was published in the reputable New England Journal of Medicine.

Lumbar Puncture Needle Depth

Cite this article as:
Henry Goldstein. Lumbar Puncture Needle Depth, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.14720

Recently, I prepared up to perform a lumbar puncture for the first time in a few months and a quiet voice at the back of my brain whispered ;

How deep would I need to go?
Which length needle would be the best?

I asked a handful of senior and junior colleagues, both at the time and in the writing of this post, and the response was almost universally “deep enough that the CSF comes out.” Certainly true, but not very pragmatic, and lacking the kind of detail I was hoping for…

Background


I know there’s much discussion about the tip shape of a lumbar puncture needle, and in honesty, I’ve yet not read sufficiently to have strong opinions. However, in the fifteen minutes before the procedure, I had a look at the literature around needle length, and swiftly realized there was much more to this than I’d thought. Procedure finished, I was back to the drawing board.

Essentially, the balance is that a needle that is too short won’t reach the sub-arachnoid space, and a needle too long confers additional technical difficulty and increases the risk of going through.

So first, some basic anatomy; the aim of the exercise for lumbar puncture and CSF examination is to be in the sub-arachnoid space. To reach this space, the needle must pass through (in order) skin, superficial fascia, supraspinous ligament, interspinous ligament, ligamentum flavum, epidural space, dura mater and the arachnoid. I’m no neurosurgeon, but I’m pretty sure that it’s impossible to feel each of these layers on the end of the needle.

Lumbar puncture layers

The anatomical target is either the L3/4 or L4/5 vertebral interspace, which respectively lie one vertebral body above & below the level of Tuffier’s line. Tuffier’s line is the imaginary line running between the superior iliac crests, and is used to demarcate the lower end of the spinal cord (which, in neonates, ends around L3 and moves superiorly with linear growth).

Finding a formula

One of the more widely used formulas is from a 1997 paper where Craig et al. derived an elegant formula that;

 LP needle depth (cm) = 0.03 x height of child (cm).

Easily memorable and from a sample of 107 children receiving an LP with macroscopically clear CSF, the authors’ intention was a formula requiring only one variable that could be obtained in a critically unwell child – height being easily obtained with a measuring tape or Broselow tape.



In my department, the most common single measure recorded is weight; Bilic’s 2003 study of 195 Croatian children (over 3m of age) found the best correlate for LP depth was weight, using the formula

LP depth (cm) = 1.3 + (0.07 x Body weight (kg) )

The above formulae use a single variable and hence are probably more useful and pragmatic in the setting of an unwell child. Several other articles have discussed the most accurate formula for LP depth; all of which are reliant on at least two measured parameters. The following formulae may be more beneficial for elective CSF examination.



Several formulae were derived for LP depth from a cohort of 279 paediatric oncology patients in Malaysia; the best fit for their dataset was

y = 10 (weight (kg)/height (cm)) + 1

For this cohort, the LP depth was measured by perhaps a less reliable method than other datasets described, as the investigators measured the distance from their finger on the needle when pressed to the back at withdrawal. Irrespective, this paper summarizes many of the preceding papers in the discussion section.



Abe and foundation DFTB contributor Loren Yamamoto took a slightly different approach in a 2005 study; they reviewed 175 abdominal CTs to identify spinal canal depth at the iliac crest, deriving the formula of

LP depth (cm) = 1+ 17( weight/height).

Crucially, they went on to compare standard needle sizes to these depths to identify if the needle was too short or too long.

Defining the needle depth in this way has several benefits – firstly, it’s relatively prescriptive and secondly, it draws to attention the risks associated with using a needle that is too short (multiple punctures, anatomically impossible to reach the CSF), which amount to avoidable harm. In this context, it’s pertinent to know your tools. That is, identify which spinal needles are available in your department, their lengths and the type of tip.

LP needles are available in the following lengths (mm), depending on the brand, introducer, tip type: 25, 35, 38, 50, 64, 70, 75, 90, 103, 120, 150. Find the stock in your department  and see what’s there.

What about ultrasound?


The use of ultrasound to identify the depth of the spinal cord has been trialed in a number of papers; the two mentioned here were both produced from Addenbrooke’s Hospital in Cambridge, UK.

Firstly, in a neonatal population (105 neonates), weighing between 500g and 4500g, USS was used to measure median spinal cord depth (MSCD). They subsequently derived a formula of

LP depth (median spinal cord depth in mm) =  2(Weight) + 7 mm (R^2 0.76).

Subsequently, this nomogram was validated (albeit by the same author group and unit) in this study.

A later study by the same group undertook USS on 225 children aged 3m to 17 years presenting for echocardiography. The majority of patients were over 5 years of age. MSCD was identified as above, and a number of prediction models developed. The formula put forward by the group as satisfying the inherent tradeoff between accuracy (R^2 =0.72) and utility is

MSCD (mm)=0.4 W (kg)+20

So, does this change my practice? I will admit that I don’t have any of the above formulas fixed in my head, as yet.  Spinal needles in my hospital don’t have depth markings (it would be interesting to know if these exist). Instead, the above information serves to help in selecting a needle, particularly in those patients somewhere between neonate and adult sized. On this basis, I suspect I’m most likely to utilize formulae with weight as the single variable. I also went and re-read Ben Lawton’s post on champagne taps before the next one.

In summary;

  • Formulae are not yet in regular practice to identify needle depth for lumbar puncture.
  • We advocate increased awareness of the depth of the target structure, particularly when it comes to needle selection.
  • A needle can be too short, but it can’t be too long – it just becomes harder to use.