Poop Patrol

Cite this article as:
Andrew Tagg. Poop Patrol, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.10986

It’s the one question that all parents seem to ask about their newborn – “Is this normal? How can such a small thing create such a lot of mess?” One of the things that stood out to me from Ross Fisher’s presentation on “What every Paediatric Surgeon wished you knew” was the line “There is no such thing as a normal bowel habit“. In an effort to avoid changing yet another nappy (diaper to some of you) I thought I would take a closer look.

Or Not…

Cite this article as:
Andrew Tagg. Or Not…, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.10499

With an impending new arrival I was excited about the educational opportunities that would arise.  I’d read up my fetal physiology and was eagerly awaiting the chance to write a series of posts on what normal babies do.  I had planned to take pictures of meconium filled nappies and film normal neonatal reflexes. I’d made a little list of the things I really wanted to capture. But things don’t always turn out the way you expect them to.

Transition from Fetal Physiology

Cite this article as:
Andrew Tagg. Transition from Fetal Physiology, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.10360

The imminent arrival of another Tagglet (not to be confused with aglet*) has prompted me to go back to my textbooks and refresh my knowledge of what to expect.  One of the problems of being a medical parent is being expected to know the answers to the most random of medical questions that are thrown out there. Is it supposed to look like that? Why are her hands that colour? And the question that is really being asked is, “Are they normal?” So here begins a series of posts on what is “normal” in neonates.

Coffee culture

Cite this article as:
Andrew Tagg. Coffee culture, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.10045

Melbourne is the coffee capital of the world (according to me at least). It’s the city that is home of the deconstructed latte and coffee bars can be found on most street corners. Every morning I am woken at 5-ish by one of my children calling out to me.  After the yell of “Daaaaaddy“, the second word she utters is “Coffee“.  Perhaps she is a little too young for her first espresso shot?

Lessons from Bankstown

Cite this article as:
Tessa Davis. Lessons from Bankstown, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.9723

A report has been released by the Chief Medical Officer, NSW, outlining the finding of the recent events in Bankstown-Lidcombe Hospital, where a baby died following a neonatal resuscitation. There are lessons to be learned for all of us from this tragic case. Here, we summarise the findings. The full report can be read here.

 

What happened?

In June 2016, a neonate (Baby 1) was resuscitated in the operating theatres. The baby survived, but there was an unexpected poor outcome and so a RCA (Root Cause Analysis investigation) was initiated. A few weeks later, in July 2016, a second baby (Baby 2) was resuscitated in the same operating theatre. The baby tragically died. This case was referred to the coroner and consequently the police became involved.

The day after the death of Baby 2, a paediatrician requested testing of the gas outlets in this operating theatre. It was tested one week later and it was found that the oxygen outlet was emitting nitrous oxide.

 

When were the outlets initially installed?

18 months earlier, the hospital was using oxygen cylinders for neonatal resuscitation. On one occasion, a baby required resuscitation in the birthing suite using the oxygen cylinders, but the oxygen tank ran out. The baby had to be transferred to Special Care where they had more oxygen available. An RCA was instigated in this case, and consequently it was decided to install piped oxygen to the birthing suite and also to the neonatal resuscitation area in theatres.

This was installed in July 2015.

 

How many babies were resuscitated in this theatre?

Although the gas outlet was installed in July 2015, the outlet was not used in this theatre (one of 8 theatres) until June 2016 when Baby 1 was born. After checking records retrospectively, only Baby 1 and Baby 2 were resuscitated with gas in this theatre.

 

How was nitrous oxide connected to the oxygen outlet?

The report indicates two areas where mistakes occurred: the procedure for installing the gas; and the procedure for verifying the gas post-installation.

The gas was installed by an independent company. I am not an engineer, but my understanding of the process is as follows:

  • when installing a new gas outlet, the engineer is required to isolate only the gas required
  • the pipe for this gas is then drained of pressure
  • when the pipe is then cut to make a new connection there will be no pressurised gas in that pipe
  • if there is any pressure detected, then that indicates that the wrong gas is being attached to the new connection

In this case, rather than isolating just the oxygen gas, the engineer isolated all the gases, including nitrous oxide. Therefore, when cutting the pipe, there would be no indication that the wrong pipe had been cut.

Secondly, after installation the gas should have been verified as being oxygen. This verification should have been witnessed by a member of clinical staff who is experienced in delivering medical gases. The engineer has noted twice on the forms that the oxygen was tested and was 100% oxygen. This cannot have been the case as the actual reading would have been 0% oxygen. No clinical staff verified or witnessed this testing.

 

What are the report findings and recommendations?

The report identifies issues with the engineering process and also the governance within the hospital.

The RCA made a recommendation for submission to the Australian Resuscitation Council to review the existing neonatal resus algorithm. It recommends that a section be added about unexpected hypoxia which includes consideration of the gas outlets.

 

This is a tragic case and must be very stressful for all those involved. As clinicians who are frequently involved in neonatal resus, we have a process for reviewing equipment when faced with unexpected hypoxia during neonatal resuscitation. From now on, we should consider gas outlets as part of this trouble-shooting process and this may need to include a final step of disconnecting the baby from the piped gases and trialling on a self-inflating bag in room air.

A new approach to febrile infants

Cite this article as:
Henry Goldstein. A new approach to febrile infants, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.9565

The fortnight has seen two hot off the press articles by a group from the Basque Country. They are challenging the existing paradigm in the investigation and management of febrile infants with their “Step by step” approach. The approach questions the relative supremacy of the Rochester criteria as a basis for investigating and managing infants under 90 days with fevers and controversially considers managing a subset of “low risk” infants on the outpatient basis without lumbar puncture or antibiotics.

“Step by Step” – the new kid on the block – aims to risk stratify this group to both reduce the number of unnecessary investigations and treatments in this group as well as predict those patients at risk of serious bacterial infections (SBI). The Step by Step approach was first suggested by the same group in 2014. The algorithm is thus;

step by step algorithm

There are clear parameters for each of the components of the algorithm. To be considered “low risk” an infant with fever without source must be:

  • Well appearing
  • Aged >21 days
  • No leukocytes in urine
  • Procalcitonin <0.5 ng/mL
  • Absolute Neutrophil Count <10,000/mm3
  • CRP < 20 mg/L

 

Firstly, the larger of the two papers is a validation study for the “step by step” method. The algorithm was applied retrospectively to 2185 infants presenting to 11 European Paediatric emergency departments over a 24 month period, with the aim of comparing the Step by step algorithm to the Rochester Criteria and Lab-score.

Gomez B, Mintegi S, Bressan S, et al. Validation of the “Step-by-Step” Approach in the Management of Young Febrile Infants. Pediatrics. 2016;138(2):e20154381

 

Population: A prospective study of 2185 infants aged <90 days presenting with a fever without source.

Intervention: Risk stratification via the “Step by step” approach to identify the level of risk for invasive bacterial infection.

Comparator: Rochester criteria and Lab-score for same.

Outcome: For Step by Step an overall Sensitivity of 92% and NPV 99.3%, vs Rochester 81.6% and 98.3% for IBI or non-IBI in the “low risk” group. This compares favourably v Rochester. 

Patients were excluded if there was any of 1) a clear source of fever on history & examination, 2) no fever at arrival and subjective/tactile ‘fever’ identified by the parents , 3) absence of 1+ of the mandatory ancillary tests, or 4) parents refused participation.

The authors define fever without source, serious bacterial infections, invasive bacterial infections, occult bacteraemia, sepsis and possible bacterial infections individually. Of note, all growths of Staphylococcus epidermidis, Propionibacterium acnes, Streptococcus viridans, or Diphtheroides were considered contaminants.

The real meat of this algorithm is in the number of patients identified in the “low risk” group with any significant, treatable infection. In this validation study, ~45% of infants made it to the “low risk” group, and of these 991, there were 7 invasive bacterial infections (IBI) and 4 Non-invasive bacterial infections (Non-IBI).

The paper presents findings separately between IBI & Non-IBI. The multiple definitions of bacterial infections seem very reasonable in theory, but in practice we’re probably concerned about “missing” a serious bacterial infection. Hence, I’ve reworked the calculations analysing IBI and Non-IBI together. Practically, this means that the Negative Predictive Value of “low risk” is 97.8%, with a miss rate of 11 per 1000. Here’s my working, based on the data provided in figure 3.

validation of step by Step

The other article from the same group published this week put the “step by step” approach into practice over a 7 year period at a single paediatric emergency department in the Basque Country. Infants in the “low risk” group were offered the no LP, no antibiotics and up to 24hours observation (with a view to discharge); there was planned follow-up and support for representation.

Mintegi S, Gomez B, Martinez-Virumbrales L, et al. Outpatient management of selected young febrile infants without antibiotics. Arch Dis Child. 2016 Jul 28. pii: archdischild-2016-310600. doi: 10.1136/archdischild-2016-310600. [Epub ahead of print]

 

Population: A dataset of 1472 infants of fever without source is presented, however the analysis focuses on 767 at “low risk” of SBI as per the step by step criteria.

Intervention: This subgroup of patients were managed without lumbar puncture, antibiotics, 48hr admission.

Comparator: There was no control group for the trial

Outcome: 2 of 586 infants had a serious bacterial infection. 29 of 586 had a UTI (culture positive, leuks negative) and 51 returned for review due to persistent fever or irritability. 

Additionally, assessment was done by a Paeds trained attending or resident. Safety mechanisms for the low risk group included a follow-up phone call or primary care practitioner review; 10 patients were entirely lost to follow-up. There were no differences in rates of return in patients observed for <6hrs or >6hrs in the short stay unit.

Within the “low risk” group, as per the step by step algorithm, a significant number received CSF examination (for persistent fever, irritability or poor feeding), or deteriorated. None of these infants had SBIs, although almost half receiving lumbar puncture had viral meningitis.

The study is an impressive example of putting your money where your mouth is, and an excellent example of a theoretical construct applied in the real world. I suspect it probably overstates the success of the no LP, no antibiotics, outpatient management group. Using the initial patients in the “low risk” group as an intention to (not) treat analysis from the 767 “low risk” as per the “Step by step” group gives a miss rate of 52 SBI per 1000;

trial of step by step

The authors also state … in our series, no infant was finally diagnosed with bacterial meningitis and no infant had a clinical deterioration compatible with bacterial meningitis.

The title of the paper focusses on those infants as “low risk” who are do not receive a lumbar puncture and are then managed as outpatients without antibiotics. A reasonable point of focus, but in the context of the group’s overall goal – rolling out the step by step as a tool for risk stratification – I think they have identified the algorithm’s weaknesses.

Commentary:

This is an exciting development. There is more nuance than meets the eye in a febrile infant and whilst our current Australian standard of care is a “full septic screen”, the potential to reduce iatrogenic complications and overtreatment in this population whilst keeping these patients safe has some promise.

As the authors of these studies note, the actual rate of SBI in this population is low, but we likely also overestimate the risk of SBI; deVos-Kerkhof and colleagues attempt to illustrate this in their 2015 European Journal of Paediatrics article.

What are we actually comparing?

The stakes for a “rule out” algorithm – rather than a “rule-in” algorithm – are high. Considering that standard practice in this group is about reducing the risk, and I suspect an individual tendency to default to the safest option, the numbers and pragmatics of the algorithm would have to be breathtakingly good to modify practice.

I think the comparison against the Rochester criteria is ultimately flawed; the numbers need to stand alone with respect to having an acceptable miss rate. Additionally, the epidemiology of bacterial infections, vaccination and population health as a whole has changed markedly since the Rochester criteria was published in 1985.

It’s also worth noting that the “step by step” approach also attempts to reach towards an earlier age; previous criteria have treated and investigate all infants <28 days, whereas the “step by step” approach only takes this approach with infants <21 days.

The nuances of infection

Both studies describe a number of infants with urinary tract infections (UTI) (and normal leukocyte counts) with a significant pure bacterial growth; these patients are managed as “low risk” via the algorithm. In practice, it would be not uncommon for an infant with a “fever without source” to receive their UTI diagnosis during admission, with subsequent management for same. Most other studies I’ve seen in this area consider a UTI as a serious bacterial infection.

With respect to other infections, 44 of the 91 infants in the second paper had viral meningitis. Although not amenable to antibiotic treatment, there’s no mention of the rate of Herpes simplex encephalitis. More so, in many departments the initiation of acyclovir goes hand in hand with antibiotics in the management of this population until the HSV CSF PCR shows no virus. Additionally, symptoms and signs of viremia may warrant inpatient management or observation, and it’s my impression that “step by step” is vulnerable in this area.

Finally on this, I think it is relevant to bundle the SBI into a single outcome at the “low risk” stage. The IBI vs Non-IBI dichotomy is, I think, useful and relevant for unwell and very unwell infants (“high risk”), as it may be predictive of other metrics including outcomes, place of management and other clinical trajectories. Additionally, at the intermediate and high risk strata, the ratio of IBI:Non-IBI will likely be different to the low risk group. Alternatively, with a planned management of no treatment with antibiotics and discharge, I have sought to conceive all missed SBIs as just that.

Which test is best?

 It would be interesting to see an analysis for the independence of each of the variables in this sample. Without a comprehensive review of the literature for each of the constituent parts of the step by step approach, I can’t honestly say that “no one test” can predict the likelihood of a serious bacterial infection in infants, although it’s what I’ve been taught for a long time. I welcome any robust evidence that contradicts this dogma.

On that front, although procalcitonin isn’t yet widely ordered in Australian laboratories, there is a growing weight of evidence that there it has some utility in this area. A paper from JAMA Paediatrics earlier this year suggests PCT is equivocal to CRP for SBI but more accurate for IBI.

Certainly, “Step by step” shows promise – the Rochester criteria and other American predecessors have had a profound influence on paediatric practice since their inception. There remains significant ground to cover to find the a safe medium of both an acceptable level of risk for missed SBI and the likelihood of over-treatment in this population.

 

References

Mintegi S, Bressan S, Gomez B et al. Accuracy of a sequential approach to identify young febrile infants at lowrisk for invasive bacterial infection. Emerg Med J. 2014 Oct;31(e1):e19-24. doi: 10.1136/emermed-2013-202449. Epub 2013 Jul 14.

Gomez B, Mintegi S, Bressan S, et al. Validation of the “Step-by-Step” Approach in the Management of Young Febrile Infants. Pediatrics. 2016;138(2):e20154381

Mintegi S, Gomez B, Martinez-Virumbrales L, et al. Outpatient management of selected young febrile infants without antibiotics. Arch Dis Child. 2016 Jul 28. pii: archdischild-2016-310600. doi: 10.1136/archdischild-2016-310600. [Epub ahead of print]

Dagan R, Powell KR, Hall CB, Menegus MA. Identification of infants unlikely to have serious bacterial infection although hospitalized for suspected sepsis. J Pediatr. 1985 Dec;107(6):855-60.

deVos-Kerkhof E, Roland D, de Bekker-Grob E, et al. Clinicians’ overestimation of febrile child risk assessment. Eur J Pediatr. 2016 Apr;175(4):563-72. doi: 10.1007/s00431-015-2667-5. Epub 2015 Dec 4.

Probiotics in review

Cite this article as:
Henry Goldstein. Probiotics in review, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.9304

Like almost every other human entering a pharmacy in the ten last years, I was offered some probiotics when I collected a prescription recently. On my walk back to the car I mused about the evidence behind the shop assistants attempted up-sale. I reminded myself of the use of probiotics to prevent necrotising enterocolitis, and was starting to think of some other indications. Some days later, this review by Hania Szajewska in the Archives of Disease in Childhood popped up; here’s a precis of an excellent paper:

Szajewska, H.What are the indications for using probiotics in children? Arch Dis Child. Published Online First: 7 September 2015

Probiotics are “live microorganisms that, when administered in adequate amounts, confer a health benefit on that host.” The most common strains used therapeutically are the lactobacillus strains L. reamnosus GG (LGG) and L. reuteri DSM 17938 as well as bifidobacterium and saccharomyces. There are also some novel probiotics in development.

Probiotic preparations differ to standard medications as the dose, viability and even agent (organism) are harder to control. There is significant industry influence and, in my opinion, therapeutic development has likely suffered at the expense of populist marketing. Research into probiotics is strain specific; with that comes the challenges of extrapolating the findings to any over-the-counter product. Specifically, probiotics are not regulated as drugs, hence significant concerns exist with respect to labelling and quality.

In this paper, Szajewska reviews the evidence for a number of paediatric indications for probiotics. I’ve simplified and summarised the findings here;

What do we think works?

Necrotising enterocolitis – Multiple RCTs and a Cochrane review, mostly using L. reuteri DSM 17938 show a reduction in NEC in preterm infants. Additionally, there was a reduced time to full feeds, reduced admission length and reduced rates of late-onset sepsis.

Antibiotic associated diarrhoea – Szajewska references her own meta analysis – albeit primarily an adult population – which identified a NNT of 13 for antibiotic associated diarrhoea; the database is predominantly adults. Most effective probiotic agents for this indication are saccharomyces boulardii and LGG.

Infantile colicL. reuteri DSM 17938 was assessed in 4 RCTs; their combined results showed that the use of reduced crying times in breastfed infants with infantile colic. In one analysis (3 trials), L. reuteri DSM 17938 vs placebo reduced crying times at 21 days of life by an average of 43 minutes/day. Probiotics appear more helpful in breastfed by comparison to formula fed infants.

Functional abdominal pain – A meta analysis of LGG for a range of abdominal pain-related functional gastrointestinal disorders (FGDs) showed that LGG was significantly better than placebo in this population, with a NNT = 7. Szajewska doesn’t appear to have much faith in these results with respect to FGDs as a whole, but notes that patients with Irritable bowel syndrome showed the most benefit (NNT = 4).

Acute gastroenteritis – ESPGHAN (the European Society for Paediatric Gastroenterology, Hepatology & Nutrition) recommend consideration of probiotics (LGG > S. boulardii > L. reuteri DSM 17938) for children with acute gastroenteritis, in addition to hydration therapy.

What might work?

Nosocomial infection – The review considers a number of nosocomial infections, and briefly mentions the importance of rotavirus immunisation, where available. A handful of trials showed that probiotics (LGG) vs placebo had no significant differences for risk of post-admission diarrhoea in children under 2 years old; the results contradict some earlier trials in this area, which showed promise.

Prevention of allergy – This is controversial – two studies published by opposing peak bodies disagree. This includes maternal probiotics to reduce long-term outcomes.

H.Pylori – May improve eradication rate, but limited evidence in children.

IBD – Some evidence for inducing remission of Ulcerative colitis; insufficient evidence in Crohn’s disease. 

What doesn’t work?


Functional constipation – no evidence of benefit; not recommended via ESPGHAN 

Within the review, two positive studies jumped out at me, so I went back to the primary literature for a deeper dive.

Firstly, I was fascinated by the idea of preventing infections in daycare centres – Szajewska’s overall verdict was that there was not currently sufficient evidence, but that LGG and L. reuteri DSM 17938 may have some effect on community-acquired infections. Particularly, the review describes this study;

Gutierrez-Castrellon, P., Lopez-Velazquez, G., Diaz-Garcia, L. et al. Diarrhea in Preschool Children and Lactobacillus reuteri: A Randomized Controlled Trial. Pediatrics Mar 2014, peds.2013-0652; DOI: 10.1542/peds.2013-0652

P: 336 children born at term aged 6-36 months attending a daycare in Mexico
I: 5 drops L. reuteri DSM 17938 for 12 weeks
C: placebo drops
O: The primary outcome was the number of days with diarrhoea per child, which was defined as days when 3 or more loose or watery stools were passed within a 24-hour period with or without vomiting, both during the intervention and for 12 weeks afterwards.

  • About ¼ of families offered enrolment decline; which means we should question the (?social) acceptability of the intervention in this population.
  • Semi blinded – one of the authors was overseeing the block-randomisation.
  • Interesting exclusion criteria including birth weight < 2500 g, chronic disease, failure to thrive, allergy or atopic disease, recent (previous 4 weeks) exposure to probiotics, prebiotics, or antibiotics, or were participating in other clinical trials.
  • A reasonably well defined list of secondary outcomes.
  • Parents were educated about stool descriptors using the Bristol stool scale, and upon a loose motion had to contact the study centre, and then report for assessment. I wonder if this call-presentation process lent itself to underreporting (in both groups.)
  • All four primary outcomes: Number of diarrhea episodes, Episodes of diarrhea per child, Mean duration of diarrhea episodes and Days with diarrhea per child were significantly better in the treatment arm, both during the intervention and afterwards. With p values ranging from 0.03 to 0.01.


Secondly, the idea that probiotics could reduce infantile colic seemed immensely appealing; it’s an area that has had a myriad of debunked therapies over the last several millenia. T

Indrio F.,Di Mauro A., Riezzo G., et al..Prophylactic use of a probiotic in the prevention of colic, regurgitation, and functional constipation: a randomized clinical trial. JAMA Pediatr. 2014 Mar;168(3):228-33.

P: 589 term infants aged less than one week, in 9 centres across Italy.
I: 5 drops of L reuteri DSM 17938 (1×10^8 cfu) for 90 days
C: placebo
O: Primary outcomes were daily crying time, regurgitation, and constipation during the first 3 months of life. Cost-benefit analysis of the probiotic supplementation.

  • Infants receiving antibiotics in the first week of life were excluded; (in Australian maternity units, this would account for a significant number.)
  • Trial was independently randomized and double blinded.
  • Around ⅙ patients were lost to follow-up; a significant number were withdrawn from the treatment arm for protocol violations by the investigator.
  • Parents recorded data in a structured diary and sought advice as required via usual channels.
  • At both one and 3 months of life, the infants in the treatment arm cried for significantly shorter periods of time and stooled more frequently. At three months, there were fewer episodes of regurgitation in the treatment arm.
  • Although this is a single study, there are a number along similar lines; Szajewska’ paper mentions 4 in total. The results are most striking in this paper, hence my curiosity.

The organism of the hour, L. reuteri DSM 17938 was first cultured from breast milk of a Peruvian mother; it is patented by BioGaia whom provided the study drug and placebo for both trials above.

Conclusions


There’s a growing body of evidence for the potential benefits of probiotics in a number of paediatric conditions.

There is a bias in this review (and pretty much all of academic medicine) towards positive trials. That being said, I haven’t given the details of every study mentioned; Szajewska’s review does so nicely and I also recommend a read of the primary literature.

Most importantly, communicating with parents about the uncertainties about over-the-counter probiotics with respect to labelling, quality, dose and organism remain central to this discussion.

Key points:

  • Probiotics are “live microorgnaisms that, when administered in adequate amounts, confer a health benefit on that host.”
  • There are many vested interests & popular marketing with issues around labelling and quality in this area.
  • Research is strain specific.
  • Main strains researched are; Lactobacillus reuteri DSM 17938, Lactobacillus reamnosus GG (LGG), Bifidobacterium and Saccharomyces
  • Presently, benefit has been demonstrated in NEC, Antibiotic associated diarrhoea, infantile colic, functional abdominal pain and acute gastroenteritis.

References:

Szajewska, H.What are the indications for using probiotics in children? Arch Dis Child archdischild-2015-308656 Published Online First: 7 September 2015

Gutierrez-Castrellon, P., Lopez-Velazquez, G., Diaz-Garcia, L. et al. Diarrhea in Preschool Children and Lactobacillus reuteri: A Randomized Controlled Trial. 

Breast milk freezing – baby, it’s cold outside

Cite this article as:
Tessa Davis. Breast milk freezing – baby, it’s cold outside, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.9295

Freezing breast milk – whether you’ve seen it done during your NICU time, or done it yourself as a parent, it’s probably something that we’ve all had to consider. General advice is that it’s ok to freeze your breast milk for 6-9 months. But is that really true, or does freezing damage breast milk?

Passing the TORCH

Cite this article as:
Andrew Tagg. Passing the TORCH, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.8541

6 year old Ella has been sent home from school as she has been itching all day.  When her mum, Val, picked her up she noticed a few spots and thought she better get them checked out.  You see the classical rash of chickenpox and reassure of the relatively benign nature of the illness and discourage her from holding any ‘chickenpox parties’.  As you explain that it would be wise to keep her away from babies, the immunocompromised and pregnant women, Val pauses, looks up at you and says, “I’m 15 weeks pregnant!”.

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.

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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.