Healthcare for refugees

Cite this article as:
Rachel Austin and Emily Cadman. Healthcare for refugees, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31802

You are a doctor working in an inner-city paediatric emergency department in Europe.

Waleed, a 2 year old boy, is brought to A&E by his mother as he is coryzal and ‘feels hot’. History, examination and observations are all unremarkable. You plan to discharge home with safety netting.

As you explain your plan, Waleed’s mother becomes tearful. She has recently arrived from Syria and the family are seeking asylum in your country. They are not registered with a GP and Waleed is unvaccinated. They have little social support. Mum is concerned about Waleed’s nutrition both in refugee camps prior to their arrival and regarding the food she is currently able to provide for him on governmental asylum support.

You retreat to the doctor’s office to devise a plan to help this family.

A keen medical student overhears you discussing the case with your consultant. They ask you, “What is an asylum seeker?

Some definitions

Asylum seeker: a person who has left their country of origin and applied for asylum in another country but whose application has not yet been concluded.

Refugee: someone whose asylum application has been successful. The government recognizes they are unable to return to their country of origin owing to a well-founded fear of being persecuted for the reasons provided for in the United Nations Refugee Convention or European Convention on Human Rights (such as persecution due to race, sexuality, political opinions or religion).

Refused asylum seeker: a person whose asylum application has been unsuccessful. Nearly half of UK asylum applications are rejected – yet ~40% of appeals are successful.

Undocumented migrant: someone who enters or stays in a country without the documents required under immigration regulations. They usually have no recourse to public funds or governmental support.

Globally, around 80 million people are displaced from their homes. Around 50 million are internally displaced within their own country; around 13 million are hosted in countries neighbouring their own, predominantly in the developing world. In 2019, two thirds of refugees came from just five countries: Syria, Afghanistan, South Sudan, Myanmar and Somalia. 40% of refugees worldwide are children, many unaccompanied.

It’s so stressful, I don’t know what to do, I don’t know where I’m going to live…. (child refugee)

“The experience that I have is killing me every day” – talking about seeking asylum in the UK

“Being scared was a permanent state of mind. I was always scared. When I went to bed, I always wondered if I would wake up the next morning.”  Now they must wait to register for asylum, a process that takes up to two weeks. During those two weeks the family must wait outside the registration centre every day for their number to be called. There are no facilities or shelter from the rain. “I am tired of waiting here all day. We just stand in the rain. But I will tell you something: after everything we have been through, a bit of rain can’t hurt me.”

How do refugee children present to the emergency department?

Evidence suggests that migrant populations use health services less than the native population. Some common challenges include communicable disease, mental illness (such as depression, isolation, PTSD, FGM and domestic/gender-based violence) and untreated chronic health problems. They may have suffered from a period without medical treatment in their country of origin or during the journey to your country. Imagine a child with epilepsy or type 1 diabetes mellitus; medication is crucial for their condition but may have been impossible for parents to obtain. They may be suffering from complications of their untreated illness. They may also have injuries sustained at home or en route.

A recent survey was carried out across Europe with 147 respondents from 23 countries. The authors found that the most common presentations of refugee children to an emergency department were skin and soft tissue infections, safeguarding concerns, mental health problems, weight loss and being generally unwell. Respiratory and gastrointestinal complaints were also common. It appeared that the type and severity of illness were comparable to non-refugee populations. More training may be required, however, for less common presentations such as PTSD or malaria. Cases of Hepatitis B, tuberculosis and incomplete vaccination schedules were also reported. Other studies have suggested sexually-transmitted infection and sexual abuse are common. It appeared that few countries have robust guidelines to aid clinicians in treating refugee children.

Most migrants do not experience mental illness though they are at greater risk due to traumas experienced and lack of social support. People from certain cultural backgrounds may be more likely to somaticize mental trauma in the form of physical symptoms. This requires a sensitive approach. Building trust with those who have experienced persecution can be challenging. They may be deeply distrustful of those in positions of authority. Sourcing appropriate interpreting services to overcome a language barrier is important for all presentations but is crucial when discussing sensitive matters. A useful mental health screening tool for children is the Strength and Difficulties questionnaire, which is available in 89 languages.

You can feel good in your body even though inside you feel poorly. Refugee child

They bring their trauma with them, that that usually manifests itself as PTSD symptoms, mild, moderate and severe. And that’s from past experiences. And in addition to that, I think what happens when they arrive [here] is that they face two main problems. One is the social isolation that comes with being removed from your usual community and not being able to work. The right to work is removed and therefore they don’t have an awful lot to do to occupy themselves. So social isolation is a big factor that affects their health. And the other one I would say was the uncertainty and the hostile environment created by the Home Office around housing stability and the uncertainty around their asylum. Those two factors obviously factor into their mental health but also their physical health so we see a lot of gastric upsets, a lot of physical manifestations of stress. From having those two issues some people don’t eat well or sufficiently so we see people who are underweight or who have gastric problems from becoming quite hungry, many asylum seekers struggle with sleep so don’t always turn up on time to their appointment. HCW discussing refugee patients

How can I assess malnutrition in the ED?

You can consult the RCPCH guidelines. Height, weight and head circumference should be measured as you would do routinely. If malnutrition is then suspected, mid-upper arm circumference should also be measured and compared with age-related norms. The child should be examined for evidence of anaemia and vitamin deficiency (including scurvy, thiamine and Vitamin D deficiency).

Take a good dietary history. Ask about past diet (at home, in transit and in refugee camps) and current diet. Governmental asylum support can be meagre and families may be dependent on food banks. Available foods in your country may differ greatly from that which the family is used to. Many families are placed in hotels and hostels with limited cooking facilities.

If you have concerns about a child’s nutrition, follow-up should be arranged with the GP +/- the health visitor.

I don’t have even have enough money to eat and provide essential things for my family, and I have to spend most of this money on travel going in and out of the hospital with my wife.

Waleed’s mother is particularly concerned about tuberculosis. You wonder whether Waleed requires routine screening for any diseases, considering his country of origin, lack of vaccinations and tumultuous journey to your country.

Does Waleed need screening for diseases such as tuberculosis?

Fortunately, there is online guidance available for specific communicable and non-communicable diseases. This includes guidance for common diseases such as tuberculosis, vitamin D deficiency, anaemia and HIV.

You can also search by country to determine which screening is advised for which country of origin. For example, asymptomatic tuberculosis screening is not required for Syrians. However, Syria is an intermediate prevalence area for Hepatitis B. Anaemia is common (20-40% preschool children) and cases of polio have recently been detected in the country. Due to this, routine screening for Hepatitis B and anaemia should be considered as well as vaccination against polio. Vitamin A and D deficiency is also common.

Routine TB screening is recommended for those arriving from high prevalence areas (incidence of >40/100,000 people): these countries include Afghanistan, Eritrea and Somalia. Children from these countries should automatically be referred to a paediatric TB clinic.

Is there any guidance for catch-up immunisations?

Many refugee children will have uncertain or incomplete vaccination status. Unless there is a reliable history of vaccination, Public Health England (PHE) recommends treating the child as if they were unvaccinated. It is also recommended to plan a catch-up schedule in the minimal amount of time and appointments in order to confer swift protection. The PHE guidance is a useful resource as is the Australian Immunisation Handbook.

Is Waleed entitled to free A&E services?

This is highly dependent on the country in which you work.

United Kigdom

Groups entitled to all NHS services free of charge (including free prescriptions and dental/optometry care) include:

  • Refugees (those who have been granted asylum)
  • Asylum seekers (including those who have mounted appeals)
  • Victims of slavery/trafficking and their families
  • Recipients of section 95 or section 4(2) support for ‘destitute families’
  • Children in care

The following NHS services are free to all regardless of immigration status or country of origin:

  • A&E
  • Urgent care centres and GPs
  • Services for the diagnosis and treatment of certain communicable diseases such as tuberculosis, HIV, sexually transmitted diseases and Covid-19
  • Family planning services (termination of pregnancy not included)
  • Treatment for a mental or physical condition caused by torture, domestic violence, female genital mutilation or sexual violence

Secondary care, such as inpatient admission and outpatient appointments, is billable for non-UK residents (aside from those specified above). This includes maternity, paediatric and oncology services. Undocumented migrants and refused asylum seekers are charged 150% of the cost to the NHS and charges must be paid before treatment. The exception to this is ‘urgent and immediately necessary care’ which is billed after treatment (this includes all maternity services). What constitutes ‘immediately necessary care’ is the judgement of the clinician, taking into account pain, disability and risk of delaying treatment.

Australia

Most refugees and asylum seekers in the community should have a Medicare card which provides them with publicly-funded free or subsidised healthcare. Through Medicare, the Medical Benefits Scheme (MBS) provides full payment for GP services and 75% costs for secondary care. It does not include dental care or ambulance cover. There is a possibility that a service will charge more than the MBS will cover, in which case the patient would have to cover the extra cost. For example, the MBS will pay $37.05 for a GP consultation; however, if the GP charges $65 for an appointment, the remaining costs would be incurred by the patient. Medicare cards may be linked to visas and often expire, leaving their owners vulnerable to healthcare costs. Undocumented migrants do not have access to Medicare support.

Many refugees, and people seeking asylum in Australia, are held in detention facilities, some offshore in Nauru and Papua New Guinea. For these people, healthcare is provided by the state.

I went to the health centre and it was like an interrogation… “When did you come to Sweden? Why did you come here?” … It was the same as they asked me at the migration authority. … if they find something, how will that affect my chance to obtain asylum, and if they find a disease, will they help or what will happen? (Jonzon et al., 2015)

When you speak to Waleed’s mother and inform her that she is entitled to all NHS care free of charge due to her status as an asylum seeker, she informs you that she attempted to register with a GP but was refused as she had no proof of address.

What barriers are there for refugees, asylum seekers and undocumented migrants accessing healthcare?

There are many barriers to accessing adequate healthcare. Examples include:

  • Language barrier
  • Lack of knowledge in how to access services
  • Administrative difficulties such as lack of identification or proof of address
    • In the UK, NHS guidance clearly states that ID/proof of address are not grounds for refusal for registration in primary care. This is a common problem: when volunteers from the charity Doctors of the World approached GP practices, they found that 2 in 5 wrongly refused registration. This leaflet may be a helpful resource for those in the UK.
  • Healthcare debts can be reported to the government and affect asylum applications
  • During transit through a country, aversion to official registration is not uncommon. Documentation of presence in a ‘safe’ country passed through can harm later asylum applications in the desired destination country; a European regulation allows the UK to return an adult asylum seeker to the first European country reached
  • Even if healthcare is free, costs associated with attending appointments may be prohibitive. For those on a low income, costs such as childcare and bus fares to facilitate attendance may be unaffordable

“The language barrier is the tip of the problem. Quite often there’s a language barrier which is massive, so they’re not sure where to go, who to speak to. They’re vulnerable because that’s why they’re seeking asylum in the first place, so there might have been lots of trauma. And then all these other vulnerabilities, in my case if they’re pregnant, they’re homeless, they’re scared, they might be fleeing domestic violence, honour-based violence, FGM. All these vulnerabilities makes them even more vulnerable and then they’re just frightened to access healthcare ‘cause they don’t know where to go.” HCW discussing refugee access to healthcare

“If I had an emergency I couldn’t call 999, how would I speak to them, they wouldn’t understand me in Arabic. I would have to speak to them in English, which I can’t and that’s not good.”

“Resources are limited – I think they are being given £20 per week and they are not allowed to work so I don’t know how a person can survive on that kind of money in this day and age. So there’s these kind of stresses as well. This money is so limited they find it difficult to come to my clinic when coming by bus. Continuity of care is also a problem with this group of people, the Home Office may move them to another city….it’s a multitude of issues which are concerning.” Mr Singh’s story (an asylum seeker), as told by a psychiatrist

What other considerations are there for refugees and asylum seekers?

Torture

33-44% of those seeking asylum have experienced torture. This is a strong predictor of a range of mental and physical health conditions. Those who have experienced torture are 4.5x more likely to suffer from PTSD and 2.5x as likely to suffer from depression. Other sequelae include chronic pain, insomnia and headaches. There are many specialist organisations for torture survivors. These include Freedom from Torture (UK), The Center for Victims of Torture (USA) and FASSTT (Forum of Australian Services for Survivors of Torture and Trauma).

Female genital mutilation

Female genital mutilation (FGM) is the partial or total excision of the external female genitalia for non-medical purposes. It is perpetrated mainly against children in Africa and Asia – the highest prevalence countries include Egypt, Sudan, Somalia, Mali, Sierra Leone and Indonesia – and it is estimated that 200 million women worldwide have undergone FGM. FGM is illegal in the majority of the developed world (including UK, Australia, Canada and New Zealand).

Initial complications include severe pain, haemorrhage, infection, shock and death. Delayed complications include difficulty with urination, menstruation, intercourse, childbirth (including increased neonatal mortality) and mental health (such as depression and PTSD).

                There are specialist services available for those whom have undergone FGM. In the UK, there are specialist adult, maternity and paediatric clinics. There are also many charities worldwide offering support: Forward UK, the Dahlia Project (UK) and NETFA (Australia). If you are concerned a child may be at risk for FGM, follow local safeguarding procedures. An eLearning module about FGM can be found here.

I have one family who have been through an extremely high level of torture and both adults, and I’ve been trying and trying to get them into the mental health services…The GP said there’s no point referring to primary mental health because they wouldn’t have a clue how to deal with this kind of thing. And there was a period where the psychiatrist kept passing the referral back to primary mental health. Primary mental health were saying we wouldn’t know how to work with them and passed it back to the psychiatrist. This went on for a long period. And just recently the hospital said, oh, I feel they should improve their English before we can see them. HCW

Selected references

Nijman, R.G., Krone, J., Mintegi, S., Bidlingmaier, C., Maconochie, I.K., Lyttle, M.D. and von Both, U., 2020. Emergency care provided to refugee children in Europe: RefuNET: a cross-sectional survey study. Emergency Medicine Journal38(1), pp.5-13.

How to interpret Rinne and Weber’s tests

Cite this article as:
Chiadika Uzor. How to interpret Rinne and Weber’s tests, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.30856

Hearing loss in children may be due to a broad range of pathology. Early detection and management are essential for proper language and psychosocial development of children. Clinicians need to be able to to identify potential reversible causes and rule out more sinister conditions.

There are three main types of hearing loss: sensorineural, conductive and mixed. The former, sensorineural, although generally uncommon in children, is the main cause of permanent hearing loss in the paediatric setting. It results from a disturbance of the auditory pathway involving the cochlea of the inner ear, through to the brainstem. Conductive hearing loss typically occurs due to a disruption in the transmission of sound at the level of the external or middle ear. The most common cause of conductive hearing loss in children is otitis media with effusion, otherwise known as glue ear.

This article provides a clinical approach to assessing a child with hearing difficulty using Weber’s and Rinne’s tests and a guide to interpreting the examination findings.

But first, Sarah’s Story….

Sarah is 9-year-old girl who has just begun Grade 4. She is very excited to be back at school after many months of limited contact with friends amid the pandemic. Over the summer, her mum, Michelle, notices that Sarah has become more ‘absent’ and doesn’t seem to be hearing anything she tells her. This is concerning and out of the norm for Sarah who is usually very witty and quick to respond. Mum has noticed that the volume of the TV is higher and many times she has ignored the doorbell ringing (according to mum it’s impossible to miss the doorbell!). Following her attendance at the Parent-Teacher’s meeting where complaints are made about Sarah’s inattentiveness in class, consequently leading to her grades dropping,she decides she has to do something. Sarah has undergone numerous treatments for ear infections in the past with oral antibiotics and topical treatments as well. Michelle and Sarah got to their GP the following day. Otoscopy shows a very narrow external auditory canal, dermatitis and a milky discolouration of the external ear. The GP is concerned and feels that he has exhausted every treatment option and decides to refer for review in the Emergency Department. Sarah is generally well and has no other past medical or drug history. There is no known family history of deafness and Sarah does not swim.

Anatomy of the ear as it relates to hearing tests

The history and physical exam

The presentation of hearing loss differs depending on the age of the child. Auditory anomalies, in newborns, are exclusively picked up via universal screening programmes. In older children, the presentation is usually similar to Sarah’s story. They may have behavioural changes, delayed language skills or listen to the TV at a louder volume than everyone else. These are often picked up by their teachers. It is important to ascertain whether there are other associated otological symptoms including otalgia, otorrhoea, vertigo or tinnitus. A thorough history should be obtained. This includes asking about other neurological symptoms, background medical history (including a thorough medication history), and possible precipitating events such as recent viral infection, trauma, or commencement of a new medication.

The tuning fork tests

Weber and Rinne tests are reliable and useful tools for assessing hearing loss in older, verbal children. They help distinguish between conductive and sensorineural hearing loss and so are more useful in patients with unilateral hearing difficulty. Children with mixed, or bilateral hearing loss, should be referred to an ENT specialist for a more formal pure tone audiometry assessment. It doesn’t matter which test you perform first. These tests should, however, be performed with a full cranial nerve and neurological exam.

How do I do Rinne’s test?

Before you begin the exam, it is important to explain to the child what you are about to do to in way they can understand. Try to put them at ease and make sure they are sitting comfortably, ideally in a silent room. Ask about pain especially over the mastoid.

Rinne’s test aims to compare air conduction with bone conduction. In a normal situation, air conduction is greater than bone conduction.

  • Begin by striking a 512 Hz tuning fork against your knee or elbow.
  • Place the base against the patient’s mastoid process (for those who like to watch it on a video, check one out here)
  • Allow it to stay there for 2-3 seconds to allow them to appreciate the intensity of the sound then promptly raise the fork off the mastoid process and place the vibrating tips about 1cm from their external auditory meatus
  • Leave it there for a few seconds before taking the tuning fork away from their ear
  • Ask the child whether the sound was louder at the beginning (when it was held against their mastoid) or whether it became louder (when it was held in front of their ear).

How do I interpret Rinne’s test?

In a normal ear, air conduction is greater than bone conduction. Air transmits sound to the cochlea more efficiently than bone. A patient who hears the tuning fork loudest when it is placed 1cm from the external auditory meatus has a positive Rinne’s test and a person who hears loudest when placed over the mastoid process has a negative Rinne’s test. The challenge in making these interpretations is in the case of a false positive Rinne’s test where there is unilateral sensorineural hearing loss. This is where Weber’s test is most useful in providing further clues.

How do I do Weber’s test?

  • As in Rinne’s test, begin by striking the 512 Hz tuning fork against your knee or elbow
  • Then, place the base of the fork in the midline, high on the patient’s forehead
  • Ask whether they hear the sound in the midline or if the sound lateralises to either the affected or good ear.
  • If the child is unclear, then ask if they hear the sound everywhere – be careful not to ask in a leading manner.
How to interpret Weber's and Rinne's test

How do I interpret Weber’s?

If a patient has a unilateral sensorineural hearing loss, the sound will lateralise – move to the good ear. If a patient has unilateral conductive hearing loss, the tuning fork sound would be heard loudest in the affected ear. Where hearing loss is bilateral and symmetrical of either type, Weber’s test would be normal. 

The table below summarises the outcomes of Rinne’s and Weber tests

How to interpret Weber and Rinne's test
AC = air conduction; BC = bone conduction

Differential diagnosis

Sarah presents to the Emergency Department and mum narrates the story to the attending doctor. Her right ear appears to be the troubling ear and she is experiencing mild pain on that side. The doctor proceeds to perform a focused ENT exam. He begins with otoscopy and notes that there is unilateral, right-sided narrowing of the external auditory canal secondary to oedema The overlying skin is milk coloured, resembling candida infection. Her left ear is impacted with cerumen but otherwise looks normal. Using a 512 Hz tuning fork, he performs Weber and Rinne’s tests. Rinne’s test demonstrated unilateral right-sided negative result i.e. bone conduction is greater than air conduction in the right ear. There is lateralisation of the tuning fork sound to the left ear on Weber’s: Sarah has reduced hearing in her right ear due to conductive hearing loss likely secondary to fungal otitis externa. The rest of her ENT exam is normal, and she is neurologically intact. The doctor explains to mum that Sarah most likely has a fungal infection of her outer ear and will require a trial of anti-fungal ear drop for 2 weeks. He also prescribes a short course of topical steroid ear drops to reduce the swelling and recommends oil drops for the impacted left ear, telling Michelle to return to her GP if Sarah has further issues with her hearing in the future. He reassures mum that a formal auditory test is not required at this time until the treatment is completed.

Selected references on interpreting Weber’s and Rinne’s

Dimitrov L, Gossman WG. Pediatric Hearing Loss. [Updated 2020 Nov 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538285/

http://www.oxfordmedicaleducation.com/clinical-examinations/tuning-fork-rinnes-webers-test/

https://www.rch.org.au/clinicalguide/guideline_index/Acute_otitis_media/

https://www.youtube.com/watch?v=cZYJL9Jg-3k

https://www.uptodate.com/contents/image/print?imageKey=PC%2F74212&topicKey=PC%2F15359&source=see_link


 [dh1]Andy, I don’t think this image has a Creative Commons license. Do you want to create a new one? Or use a wiki one? There are some free to use ones without labels if you want to use Montserrat here https://www.google.com/search?q=ear%20anatomy&tbm=isch&tbs=il:cl&hl=en&sa=X&ved=0CAAQ1vwEahcKEwiY2fWm4s3sAhUAAAAAHQAAAAAQAg&biw=1190&bih=714#imgrc=HraZbFesh1dWIM

 [dh2]This is definitely not free to use. Do you want to make a new one Andy?

The 47th Bubble Wrap

Cite this article as:
Currie, V. The 47th Bubble Wrap, Don't Forget the Bubbles, 2021. Available at:
https://dontforgetthebubbles.com/the-47th-bubble-wrap/

With millions upon millions of journal articles being published every year it is impossible to keep up.  Every month we ask some of our friends from PERUKI (Paediatric Emergency Research in UK and Ireland) to point out something that has caught their eye.

Article 1: The safety profile of ceftriaxone

Zeng, L., Wang, C., et al., (2020) Safety of ceftriaxone in paediatrics: a systematic review. Archives of Disease in Childhood. Oct;105(10):981-985. doi: 10.1136/archdischild-2019-317950

What’s it about? 

Ceftriaxone is one of the most commonly prescribed antibiotics for children. It is a broad spectrum third generation cephalosporin, used as a first line empirical agent for meningitis, sepsis and useful against many bacterial infections. It has an elimination half-life of 8 hours and can be given once every 24 hours IV or IM, giving us options when that cannula is particularly tricky! Whilst it is well known that using ceftriaxone in the newborn is contraindicated due to biliary sludging, the authors of this paper delved into the literature to identify other adverse reactions (ADRs) to ceftriaxone.

What did they do?

The authors performed systematic searches across several databases looking for studies to evaluate the type of ADR, the incidence of ADRs in patients aged 0 – 18 years old and to identify any potential risk factors for serious ADRs. A total of 112 studies were identified (22 RCTs, 61 case reports, 19 prospective studies, 7 retrospective studies, 2 case series and 1 case control study) which reported on ADRs of ceftriaxone use (although it was not a primary outcome measurement in any of the studies).

Looking at the RCTs, prospective and retrospective studies, gastrointestinal side effects were the most common ADR (specifically, diarrhoea). The second most common ADR identified amongst these studies was hepatobiliary (biliary sludging and cholelithiasis). These ADRs were all transient, and usually self-resolved after cessation of ceftriaxone. The case reports and case studies identified the more serious ADR of immune haemolytic anaemia, which carries a risk of death, especially for patients with an underlying diagnosis of sickle cell disease.

Clinically Relevant Bottom Line:

Transient gastrointestinal side effects are generally tolerable, and we should closely monitor patients for evolving symptoms of gallstones. Most importantly, we should be mindful and cautious when prescribing ceftriaxone in patients with underlying haematological conditions such as sickle cell anaemia, due to the uncommon but significant risk of immune haemolytic anaemia. Ceftriaxone is really a great antibiotic, and as long as we remember the clinical spectrum of ADRs, we will not cause significant patient harm.

Reviewed by: Tina Abi Abdallah

Article 2: Kawasaki Disease vs Septic Shock: Early Differentiating Features Despite Overlapping Clinical Profiles

Power A, Runeckles K, Manlhiot C, Dragulescu A, Guerguerian AM, McCrindle BW. Kawasaki Disease Shock Syndrome Versus Septic Shock: Early Differentiating Features Despite Overlapping Clinical Profiles. J Pediatr. 2020 Dec 5:S0022-3476(20)31482-7. doi: 10.1016/j.jpeds.2020.12.002. Epub ahead of print. PMID: 33290811.

What’s it about? 

According to literature around 6-7% *of patients with Kawasaki disease present with shock and this can provide a challenge in differentiating Kawasaki disease from septic shock. This paper looks to compare clinical features, resuscitative measures and haemodynamic response to treatment between those presenting with Kawasaki disease shock syndrome and children with septic shock.

*Kanegaye JT, Wilder MS, Molkara D, Frazer JR, Pancheri J, Tremoulet AH, et al. Recognition of a Kawasaki Disease Shock Syndrome. Pediatrics 2009;123:e783-9.

What did they do?

This was a retrospective chart review of patients under the age of 18 over a 10-year period admitted to a tertiary centre in the USA. The charts of children who met the criteria for Kawasaki disease shock syndrome (as defined by the American Heart Association) were analysed and children meeting the criteria for septic shock were used as controls. Over the 10-year period >1000 children were admitted to the centre with Kawasaki disease. Of these 9 met the criteria for Kawasaki disease shock syndrome. They were case matched with 18 controls who were admitted with septic shock.

The study found that children with Kawasaki disease shock syndrome were less likely (1 in 9) to have an underlying significant medical illness than the septic shock group (11 in 18). All the patients in the Kawasaki group had at least one of the five classic features of Kawasaki disease at presentation (rash, conjunctivitis, mucous membrane changes, cervical lymphadenopathy and extremity changes). With rash found in 7 of 9 of the patients either at presentation or during the admission. 5 in 9 of the Kawasaki disease cohort had cardiac involvement with zero of the control group with any cardiac involvement.

The length of stay for children in the Kawasaki disease shock syndrome group was a median of 9 days vs 28 days in the septic shock group, with no difference found in ICU length of stay. Biochemical markers were compared, and this study found a lower platelet count (median 140 vs 258) in the Kawasaki group. Interestingly in children with Kawasaki disease shock syndrome the duration of illness prior to admission was much longer (9 days vs 3 days) than the control group.

There have been no studies that directly compare children with Kawasaki disease shock syndrome and septic shock, so this acts as a starting point. However, it is a very small cohort (only 9 patients out of >1000 presentations of Kawasaki disease with Kawasaki shock syndrome); perhaps a multi- centre trial within a network could be done to increase the numbers.

Clinically Relevant Bottom Line:

This study has found that when compared to children with septic shock children with Kawasaki disease shock syndrome are more likely to have a lower platelet count on admission, a longer duration of illness prior to admission, cardiac involvement if an echo is performed and have a longer stay in hospital. All the patients in this study had at least one of the classic features of Kawasaki disease with rash being the most common here. As clinicians who review these children at the front door perhaps a child with a rash and low platelets fever >5 days will continue to make us think about Kawasaki disease.

Reviewed by: Vicki Currie

Article 3: Is it necessary to evaluate urinary tract infection in children with lower respiratory tract infection?

Kim JM, Koo JW, Kim H-B. Is it necessary to evaluate urinary tract infection in children with lower respiratory tract infection? Journal of Paediatrics and Child Health. 2020 Dec;56(12):1924-1928

What’s it all about?

Lower respiratory tract infections (LRTIs) and urinary tract infections (UTIs) are common childhood infections that previous literature has reported to have a concomitance rate of 3 to 10 per 100 children. While LRTIs are often self-limiting viral infections, UTIs are often caused by a bacterial source that can have long term implications if not adequately treated.

What did they do?

This was a retrospective review of 1574 patients’ medical records under 36 months of age who were hospitalised for a LRTI over a 2 year period in a South Korean hospital. 278 of patients had a fever and underwent a subsequent urine evaluation performed either by catheterisation (<24mo) or voided urine (24-36mo).

Patients with a congenital airway or kidney disease, absence of fever at presentation or whose parents refused or failed to undergo a urinalysis were excluded from the analysis.

The overall prevalence rate of a concomitant UTI with LRTI in this population was 1 in 10 in children <36mo and 13 in 100 in children <24mo. Mean age was significantly younger in the UTI group 7 months vs 12 months in the non UTI group. There was a greater prevalence rate of UTIs in boys (n=23) compared to girls (n=7). The most common organism cultured in the UTI group was Escherichia coli which were all treated with a third-generation cephalosporin. The positive rate of virus detection was 93.3% in the UTI group, and 89.9% in the non-UTI group. Most frequently detected co-infections were adenovirus, rhinovirus, and RSV.

The Bottom Line:

LRTIs and UTIs are common childhood infections that have up to a 1 in 10 concomitance rate.  A child presenting with a LRTI and concomitant UTI may present to ED with early respiratory and non-specific symptoms of a UTI (fever, lethargy and irritability), which may lead clinicians to presume a respiratory source of infection and not perform or delay a urinalysis. Hence a diagnosis of an underlying UTI may be missed. Failure to diagnose and promptly treat an underlying UTI can lead to renal morbidity including renal scars, hypertension and chronic kidney disease. Considering the ease of diagnosing and treating a UTI, this study further reiterates the importance of excluding a UTI in children with LRTIs under 36 months of age, especially of male gender. However, given the nature of this single centre study in South Korea, these findings cannot be generalised to a global population and must be taken in context to the population you encounter in clinical practice.

Reviewed by: Emma Chan

Article 4: Why don’t kids get sick with COVID-19?

Zimmermann P, Curtis N., Why is COVID-19 less severe in children? A review of the proposed mechanisms underlying the age-related difference in severity of SARS-CoV-2 infections Arch Dis Child 2020;0 1-11

What’s it about?

A review article analyzing the possible mechanisms for reduced severity of COVID-19 in paediatric patients. The debate about if children have a lower rate of COVID-19 infection continues but it is known that children are less severely affected (in contrast to other respiratory viruses). This appears to be true even in paediatric patients with immune suppression or preexisting conditions e.g. IDDM. What we don’t know is why. The authors look at the evidence for multiple hypotheses but the two they favor are:

1)     Age related endothelial damage and increased coagulability. This fits the clinical profile of COVID-19 which features endotheliitis, micro thrombi, thrombotic complications and vasculitic skin manifestations. It could also explain COVID-19 being more severe in conditions which damage the endothelium e.g. hypertension and diabetes.

2)     Age related changes to the immune system. There is a decline in innate and adaptive immunity in the elderly compared with children who have not gone through this decline. The chronic proinflammatory state (which predisposes to the cytokine storm seen in severe COVID-19) increases with age. Additionally the authors hypothesize that the effect of chronic CMV infection on T-cells may explain the worsening of COVID-19 with age.

The authors concluded that these were the only two hypotheses which fit with the age-gradient in COVID-19 with mortality and morbidity rising steeply after 60-70.

The bottom line

If we could figure the ‘magic formula’ protecting children against severe COVID-19 we could use this to target treatment in adults. However, this paper is very much exploring theories and cannot yet be extended to clinical treatments.

The interplay between a lack of endothelial damage, lack of propensity to hyper-coagulation and their not yet declined immune system are most likely to protect children from severe COVID-19 infection.

Reviewed by: Sarah Reynolds

Article 5: A Gut Feeling: Abdominal Symptoms as an Initial Presentation of EVALI

Christel Wekon-Kemeni, MD, Prathipa Santhanam, MD, Pallav Halani, MD, Lauren Bradford, MD, Ceila E. Loughlin, MD.A Gut Feeling: Abdominal Symptoms as an initial presentation of EVALI, Paediatrics Volume 147, number 1, January 2021.

What’s it about?

 

Vaping or electronic cigarette use associated lung injury (EVALI) is a syndrome resulting from electronic cigarette use which causes predominantly respiratory symptoms, such as shortness of breath.

This case report describes an American 13-year-old male presenting, on two occasions primarily with abdominal symptoms of pain, nausea and vomiting. Initially, he was managed as a case of gastroenteritis, and had been noted to have borderline saturations. Initial abdominal CT report described bilateral lung pathology (lower lobe consolidation and atelectasis) in addition to mild jejunal loop thickening. However, after a second admission with similar symptoms plus raised inflammatory markers and fever, further workup was commenced. 

Repeat abdominal CT excluded appendicitis and evidence of inflammatory bowel disease. CXR revealed bilateral changes and a Thoracic CT identified multifocal ground-glass changes and infiltrates bilaterally with scattered septal thickening and dependent bibasal opacities.

Following a review of the patient by the respiratory team, a year long history of e -cigarette use preceding this patient’s symptoms was discovered, identifying EVALI as the potential diagnosis.

The patient was started on intravenous methylprednisolone which, following an improvement in all symptoms, was converted to a  course of oral corticosteroids. Repeat thoracic CT one month following discharge showed almost complete resolution of the initial changes. 

Why does it matter?

EVALI is a relatively new syndrome, mostly documented in North America, with the potential to increase in prevalence as we see the popularity of e-cigarette use continuing to rise.

Given this patient’s initial symptoms of nausea and vomiting, detailed smoking history to include e-cigarette use may not have been taken. Thus, a workup for abdominal pathology was justifiably completed. However, considering published case reports of EVALI describing nausea and vomiting as common symptoms, this diagnosis should still be considered in patients presenting without respiratory involvement initially. The data available describing EVALI in the paediatric population is sparse, nevertheless in adult’s progression to respiratory failure requiring invasive ventilatory support is reported.

Clinically Relevant Bottom Line:

 Although challenging, obtaining an accurate smoking history to include e-cigarette use in young people is important for the consideration of EVALI as a diagnosis. We still don’t completely understand the pathophysiology of e-cigarettes, or how much damage they are causing to the young people we see who smoke them, but remembering to ask about this as part of your history is a step we can take to improve knowledge and understanding.

Reviewed by: Joshua Tulley

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

That’s it for this month. Many thanks to all of our reviewers who have taken the time to scour the literature so you don’t have to.

Emergency Contraception for teenagers

Cite this article as:
Tara George. Emergency Contraception for teenagers, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31958

Olivia presents to the children’s emergency department at 3:40 one Monday afternoon still in her school uniform and with her friend Annabel. Annabel does all the talking to start with and tells the receptionist her friend has “a gynae problem”. She is somewhat assertive with the triage nurse arguing that Olivia needs to be seen by a doctor, in a private room and not in a cubicle with curtains.  They disclose that they are both 15 years old.  When you arrive in the room, Olivia tells you she’s come to A&E to get “the morning after pill”.

Requests for emergency contraception (EC) are a common reason for presentating to GPs, sexual health services and the emergency department. As a children’s doctor it can be a bit of a shock to the system to recognise that adolescents are just as likely as adults to need emergency contraception. There is often a learning gap in the paediatric medicine curriculum. In the UK, around 7% of all women of childbearing age have used emergency contraception in the past 12 months. 10-20% of sexually active teenagers acknowledge they do not always use condoms when having sex.  A request for emergency contraception in a teenager signals that contraceptive and sexual health needs are not being met.

What do you need to cover in the history?

  • Why does she think she needs emergency contraception?
  • When did the unprotected sex (UPSI) occur? (i.e. how long ago)
  • Where is she in her cycle? (i.e when was her last menstrual period (LMP)?)
  • Is her cycle regular and predictable?
  • How many other episodes of UPSI have there been this cycle?
  • Who did she have sex with?
  • Was it consensual? Do you need to consider Sexual Assault Referral Centre (SARC) or forensic medicine input? STI risk? Childhood Sexual Exploitation risk.
  • Was he a regular partner? (STI risk especially)
  • Remember she is 15 – the Fraser Guidelines apply here – does she have capacity to consent to sex? And to the treatment she is seeking? The NSPCC have a brilliant summary of Gillick Competence and Fraser Guidelines.
  • What contraception, if any, does she normally use?
  • Does she have a preference for the form of emergency contraception?
  • What is her weight? And BMI?
  • Is she on any regular medication which might affect the efficacy of oral emergency contraception?
  • What plans has she got for ongoing contraception?

Olivia tells you she had sex on Saturday night at around 2am.  She was staying over at her boyfriend’s house  Her boyfriend, Jack, and she have been in a relationship for about a year. He told her this morning that he thinks the condom might have split.  Olivia says she is normally careful to use condoms so feels pretty embarrassed about this situation. You ask a bit more about Jack.  Annabel tells you Jack is her twin brother. They are all in the same year at school and have known each other for years.  Olivia says her LMP was 10 days ago, her periods are really regular – every 28 days.  This is the only time since her LMP that she has had sex.  Jack is her only sexual partner ever and she is pretty sure he is hers too. Her BMI is 19 and she has no past medical history and is on no medication.

Now it’s time for a revision session on menstrual physiology*

*and on the life span of eggs and sperm without a good understanding of which, providing emergency contraception is really confusing

In a 28 day cycle the first day of the period is always referred to as day 1.  Ovulation then occurs around day 14 of a 28/7 cycle.  If the ovum is not fertilised within 12-24 hours, menstruation will occur 14 days later. The first part of the cycle is called the follicular phase and the second part the luteal phase.  The luteal phase is fixed in length in all women, if the cycle length varies the follicular phase may be longer or shorter than 14 days but following ovulation, if the ovum does not meet a sperm and implant, menstruation will always follow 14 days later

Sperm released into the female genital tract can live for upto 120 hours meaning if unprotected sexual intercourse (UPSI) has occurred any time from 6 days before the earliest possible calculated ovulation to 24 hours after ovulation there is a risk of pregnancy. If an ovum is fertilized by a sperm, implantation will occur 5-6 days after ovulation.

There’s a brilliant diagram in the BJFM article linked in the references section which shows dates, phases, risks and times of action really effectively.

These dates and timelines are crucial in establishing pregnancy risk and in supplying emergency contraception.  If ovulation has already occurred, a method which acts by postponing ovulation will be ineffective.  A method which works by preventing implantation cannot be used after the earliest possible implantation because it is unlikely to be effective but more importantly because it could be considered to be providing a termination of pregnancy which is only legal in specific situations.

What are the options for emergency contraception for Olivia?

There are 3 options licensed for emergency contraception in the UK.  The Copper IUCD, oral levonorgestrel (Levonelle) and Ulipristal (Ella-One)

The flowcharts and decision-making algorithms from the RCOG FFPRHC provide a really clear guide to prescribing.

The Copper IUCD is considered the gold ctandard first choice for EC because it:

  • Is the only method which is effective post-ovulation.
  • Is unaffected by body weight.
  • Is unaffected by enzyme-inducing drugs.
  • Provides ongoing contraception if required.
  • Has a failure rate of only 0.09% when used for emergency contraception.
  • Can cover multiple episodes of UPSI provided early in cycle.

Any copper IUCD can be used for emergency contraception though the “gold standard” for ongoing use is a device with a minimum of 375mm of copper, for example the T-safe 380a.  It is probably worth emphasizing here that this is not a Mirena IUS which cannot be used for emergency contraception.  A copper IUCD for emergency contraception can be fitted any time up to 5 days after the earliest possible ovulation in a cycle (so up to day 19 in a 28 day cycle). Fitting a copper IUCD for emergency contraception can cover several episodes of unprotected sex earlier in the cycle provided it is now before day 19 of a 28 day regular cycle. If a patient has had a single episode of unprotected sex after day 19 a copper IUCD can still be fitted.

It is unlikely there is a service within your emergency department for fitting copper IUCDs. This means that if a copper IUCD is the chosen option you are going to have to arrange for Olivia to attend a contraception and sexual health clinic or her GP if they have a coil fitting enhanced service. She’s on day 10 of her cycle so this is possible as she doesn’t “need” it until day 19 but are you sure she will go there? Not having had children is NOT a contraindication to having a copper IUCD fitted but it can be extremely uncomfortable and she may need a cervical block or gas and air to tolerate the procedure.

Oral EC  in the form of Levonorgestrel and Ulipristal both work by delaying ovulation. This is an important piece of information to bear in mind because if your patient has already ovulated oral emergency contraception is not going to work. It is also worth being aware of for those patients who believe life begins at fertilisation and who may be ethically or religiously opposed to preventing implantation via the use of a copper IUCD but who would find the postponement of ovulation (as per other hormonal contraceptive measures also) acceptable.  The flowchart in the FFPRHC guidelines is really useful to consult every time you have a case of this sort.  

Ulipristal (Ella-One) is second-line after a copper IUCD for the majority of situations when emergency contraception is needed. It does have a number of interactions, most importantly with enzyme inducers and progestogens. It is contraindicated in asthma if the patient is taking oral steroids.  It is important to note that if a patient has taken a progestogen within the preceding 5 days ulipristal will not work. It is not suitable in the case of “missed pills” requiring emergency contraception and it is not possible to “quickstart” POP/COCP/depo progestogen/Nexplanon if you give ulipristal.

Levnorgestrel is the only emergency contraception available both over-the-counter from pharmacies and on prescription in the UK.  It should really only be used if the risk of pregnancy is low and copper IUCD and Ella-One are both not suitable/not available. It is given as a 1.5g stat dose (though this should be doubled to 3g if she weighs over 70kg or has a BMI over 26 and cannot have Ella-One). If levonorgestrel is given the clinician can (and if reviewing the FFPRHC gold standard and NICE CKS advice, should) “quickstart” alternative contraception immediately with condoms until the next period.  The patient should do a pregnancy test three weeks after use if she has not had a normal period.  If your patient is on an enzyme inducer and declines IUCD, levonorgestrel is unlicensed but is the only other option as she cannot use ulipristal.

What else do I need to consider?

Any teenager who has had unprotected sex is at risk of STIs as well as pregnancy. There is no role for doing swabs urgently as they will not pick up STIs contracted as a result of this episode of unprotected sex.  Your patient should be signposted to a Contraception and Sexual Health (CASH) Clinic or her GP surgery for swabs in 3 weeks. You may want to write some free-text on your discharge letter to ensure the surgery are aware of this, and if the department isn’t too busy you might even want to ring her GP surgery and book her in for an appointment with the practice nurse for swabs.

Every teenager presenting needing emergency contraception has unmet ongoing contraceptive needs.  Whilst provision of such contraception may well be outside the scope of your role in the Emergency Department, basic counselling about ongoing contraception with signposting to CASH/GP and some relevant patient information leaflets such as those from www.fpa.org.uk should be within the scope of all clinicians.

If you have any concerns about a young person’s sexual activity and think there is any risk of sexual exploitation, abuse or inability to consent to treatment or to the sexual activity they have disclosed you need to raise this with the safeguarding lead in your department before you let her leave

You supply Olivia with ullipristal and some written counselling information about reliable contraception. You phone her GP surgery and get her booked in for a telephone appointment with a GP to discuss contraception a few days later and an appointment with the practice nurse for triple swabs for an STI screen in three weeks. Olivia rings her mum whilst in A&E and tells her what has happened. Her mum comes to pick her up and is engaged with the suggestion for ongoing follow up and contraception.

References

https://cks.nice.org.uk/topics/contraception-emergency/

https://www.fsrh.org/standards-and-guidance/documents/ceu-clinical-guidance-emergency-contraception-march-2017/

https://www.bjfm.co.uk/emergency-contraception-which-option-when-part-1

https://learning.nspcc.org.uk/child-protection-system/gillick-competence-fraser-guidelines#heading-top

Burack, R., 1999. Teenage sexual behaviour: attitudes towards and declared sexual activity. The British journal of family planning24(4), pp.145-148.

Bubble Wrap PLUS – February

Cite this article as:
Anke Raaijmakers. Bubble Wrap PLUS – February, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32178

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

This month’s list features answers to intriguing questions such as: ‘How well do we perform paediatric procedural sedation and analgesia in A&E?’, ‘Is home phototherapy feasible for term neonates?’, ‘What are the vestibular disorders in congenital CMV infection?’, ‘Are lower HbA1c targets associated with better metabolic control?’ and ‘Why parents don’t refuse Covid-19 vaccination?’.

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

REVIEWS AND OPINION ARTICLES

Global Ethical Considerations regarding Mandatory Vaccination in Children.

Savulescu J, et al. J Pediatr. 2021 Jan 20:S0022-3476(21)00028-7. 

The Ethics of Predicting Autism Spectrum Disorder in Infancy.

MacDuffie KE, et al. J Am Acad Child Adolesc Psychiatry. 2021 Jan 19:S0890-8567(21)00018-6

Contemporary Management of Urinary Tract Infection in Children.

Mattoo TK, et al. Pediatrics. 2021 Jan 21:e2020012138. 

Overview of nontuberculous mycobacterial disease in children.

Ford TJ, et al. J Paediatr Child Health. 2021 Jan;57(1):15-18. 

Paediatric chemical burns: a clinical review.

Nguyen ATM, et al. Eur J Pediatr. 2021 Jan 6

Should children be vaccinated against COVID-19 now?

Wong BLH, et al. Arch Dis Child. 2021 Jan 5:archdischild-2020-321225. 

Identification and Management of Eating Disorders in Children and Adolescents.

Hornberger LL, et al. Pediatrics. 2021 Jan;147(1):e2020040279

ORIGINAL CLINICAL STUDIES

Maternal Education and Academic Achievement in Schoolchildren: The Role of Cardiorespiratory Fitness.

Reina-Gutiérrez S, et al. J Pediatr. 2021 Jan 27:S0022-3476(21)00081-0

Early Versus Late Brain Magnetic Resonance Imaging after Neonatal Hypoxic Ischemic Encephalopathy Treated with Therapeutic Hypothermia.

O’Kane A, et al. J Pediatr. 2021 Jan 27:S0022-3476(21)00084-6

Pediatric procedural sedation and analgesia in the emergency department: surveying the current European practice.

Sahyoun C, et al. Eur J Pediatr. 2021 Jan 28. 

Early Motor Function of Children With Autism Spectrum Disorder: A Systematic Review.

Lim YH, et al. Pediatrics. 2021 Jan 28:e2020011270

Discharge Age and Weight for Very Preterm Infants: 2005-2018.

Edwards EM, et al. Pediatrics. 2021 Jan 28:e2020016006

Evaluation of COVID-19 Vaccine Refusal in Parents.

Yigit M, et al..Pediatr Infect Dis J. 2021 Jan 4;

Migraine and Tension-Type Headache Among Children and Adolescents: Application of International Headache Society Criteria in a Clinical Setting.

Genizi J, et al..J Child Neurol. 2021 Jan 28:883073820988417

Surgery as a Viable Option in Neutropenic Appendicitis.

Williams K, et al. Pediatrics. 2021 Jan 27:e2020035279. 

Appendectomy Versus Observation for Appendicitis in Neutropenic Children With Cancer.

Many BT, et al. Pediatrics. 2021 Jan 27:e2020027797

No change in neurodevelopment at 11 years after extremely preterm birth.

Marlow N, et al. Arch Dis Child Fetal Neonatal Ed. 2021 Jan 27:fetalneonatal-2020-320650. 

Viral co-infections among SARS-CoV-2-infected children and infected adult household contacts.

Pigny F, et al. Eur J Pediatr. 2021 Jan 27:1-5. 

A matter of taste: Results of antibiotic suspension tasting among paediatric doctors.

Abbotsford J, et al. J Paediatr Child Health. 2021 Jan;57(1):161-162. 

Effect of a Family Media Use Plan on Media Rule Engagement Among Adolescents: A Randomized Clinical Trial.

Moreno MA, et al. JAMA Pediatr. 2021 Jan 25. 

Predictors and outcomes of extubation failure in extremely preterm infants.

Kidman AM, et al. J Paediatr Child Health. 2021 Jan 23. 

The perfusion index histograms predict patent ductus arteriosus requiring treatment in preterm infants.

Osman AA, et al. Eur J Pediatr. 2021 Jan 24. 

Diagnostic Accuracy of the Panbio SARS-CoV-2 Antigen Rapid Test Compared with Rt-Pcr Testing of Nasopharyngeal Samples in the Pediatric Population.

Villaverde S, et al. J Pediatr. 2021 Jan 20:S0022-3476(21)00034-2

Gestational age at birth and child special educational needs: a UK representative birth cohort study.

Alterman N, et al. Arch Dis Child. 2021 Jan 22:archdischild-2020-320213. 

Body composition monitoring in children and adolescents: reproducibility and reference values.

Van Eyck A, et al. Eur J Pediatr. 2021 Jan 22

Comparison of Manual and Automated Sepsis Screening Tools in a Pediatric Emergency Department.

Eisenberg M, et al. Pediatrics. 2021 Jan 20:e2020022590. 

Home phototherapy for hyperbilirubinemia in term neonates-an unblinded multicentre randomized controlled trial.

Pettersson M, et al. Eur J Pediatr. 2021 Jan 19

Romantic Relationships in Transgender Adolescents: A Qualitative Study.

Araya AC, et al. Pediatrics. 2021 Jan 19:e2020007906. 

Maternal caffeine intake during pregnancy and risk of food allergy in young Japanese children.

Tanaka K, et al. J Paediatr Child Health. 2021 Jan 19. 

More Evidence Linking Autoimmune Diseases to Attention-Deficit/Hyperactivity Disorder.

Dalsgaard S. JAMA Pediatr. 2021 Jan 19:e205502

Association of Maternal Autoimmune Disease With Attention-Deficit/Hyperactivity Disorder in Children.

Nielsen TC, et al. JAMA Pediatr. 2021 Jan 19:e205487

Do children with solitary or hypofunctioning kidney have the same prevalence for masked hypertension?

Yel S, et al. Pediatr Nephrol. 2021 Jan 18

Association of Bacteremia with Vaccination Status in Children Aged 2 to 36 Months.

Dunnick J, et al. J Pediatr. 2021 Jan 13:S0022-3476(21)00009-3

CONservative TReatment of Appendicitis in Children: a randomised controlled feasibility Trial (CONTRACT).

Hall NJ, et al. Arch Dis Child. 2021 Jan 13:archdischild-2020-320746

Use of E-cigarettes and Other Tobacco Products and Progression to Daily Cigarette Smoking.

Pierce JP, et al. Pediatrics. 2021 Jan 11:e2020025122. 

Oropharyngeal Carriage of Kingella kingae and Transient Synovitis of the Hip in Young Children: A Case-Control Study.

Gravel J, et al. Pediatr Infect Dis J. 2021 Jan 7;Publish Ahead of Print

Caesarean delivery is associated with an absolute increase in the prevalence of overweight in the offspring: The SENDO project.

Moreno-Galarraga L, et al. J Paediatr Child Health. 2021 Jan 11. doi: 10.1111/jpc.15328. 

Vestibular, Gaze, and Balance Disorders in Asymptomatic Congenital Cytomegalovirus Infection.

Pinninti S, et al. Pediatrics. 2021 Jan 8:e20193945

Vestibular Disorders in Congenital Cytomegalovirus: A Balancing Act.

Demmler-Harrison GJ. Pediatrics. 2021 Jan 8:e2020043778. 

What is the risk of missing orbital cellulitis in children?

Ibrahim LF, et al. Arch Dis Child. 2021 Jan 8:archdischild-2020-320590. 

Rectal Biopsy Technique for the Diagnosis of Hirschsprung Disease in Children: A Systematic Review and Meta-Analysis.

Comes GT, et al. J Pediatr Gastroenterol Nutr. 2021 Jan 6;Publish Ahead of Print

Lower HbA1c targets are associated with better metabolic control.

Van Loocke M, et al. Eur J Pediatr. 2021 Jan 7

The impact of COVID-19 on a tertiary care pediatric emergency department.

Liguoro I, et al. Eur J Pediatr. 2021 Jan 7:1-8. 

Mental Health Disorders in Children With Congenital Heart Disease.

Gonzalez VJ, et al. Pediatrics. 2021 Jan 4:e20201693

Translation of a Host Blood RNA Signature Distinguishing Bacterial From Viral Infection Into a Platform Suitable for Development as a Point-of-Care Test.

Pennisi I, et al. JAMA Pediatr. 2021 Jan 4:e205227

Neutropenia in Children Treated With Ketogenic Diet Therapy.

Munro K, et al. J Child Neurol. 2021 Jan 4:883073820984067

From rigid to flexible bronchoscopy: a tertiary center experience in removal of inhaled foreign bodies in children.

Golan-Tripto I, et al. Eur J Pediatr. 2021 Jan 3

‘Lip-to-Tip’ study: comparison of three methods to determine optimal insertion length of endotracheal tube in neonates.

Priyadarshi M, et al. Eur J Pediatr. 2021 Jan 3. 

Improving Toddlers’ Healthy Eating Habits and Self-regulation: A Randomized Controlled Trial.

Nix RL, et al. Pediatrics. 2021 Jan;147(1):e20193326

Association of Cesarean Delivery with Childhood Hospitalization for Infections Before 13 Years of Age.

Auger N, et al. J Pediatr. 2021 Jan 6:S0022-3476(20)31546-8. 

Early Physical Abuse and Adult Outcomes.

Lansford JE, et al. Pediatrics. 2021 Jan;147(1):e20200873

Child Maltreatment and Mortality in Young Adults.

Segal L, et al. Pediatrics. 2021 Jan;147(1):e2020023416. 

Risk of Electrolyte Disorders in Acutely Ill Children Receiving Commercially Available Plasmalike Isotonic Fluids: A Randomized Clinical Trial.

Lehtiranta S, et al. JAMA Pediatr. 2021 Jan 1;175(1):28-35

Vaginal Transmission of Cancer from Mothers with Cervical Cancer to Infants.

Arakawa A, et al. N Engl J Med. 2021 Jan 7;384(1):42-50

Stillbirths During the COVID-19 Pandemic in England, April-June 2020.

Stowe J, et al. JAMA. 2021 Jan 5;325(1):86-87

Changes in Preterm Birth Phenotypes and Stillbirth at 2 Philadelphia Hospitals During the SARS-CoV-2 Pandemic, March-June 2020.

Handley SC, et al. JAMA. 2021 Jan 5;325(1):87-89

GUIDELINES AND BEST EVIDENCE

The use of diagnostic tools for pediatric AKI: applying the current evidence to the bedside.

Fuhrman D. Pediatr Nephrol. 2021 Jan 25. 

Is ultrasonography mandatory in all children at their first febrile urinary tract infection?

Pennesi M, et al. Pediatr Nephrol. 2021 Jan 22. 

Morphine or hydromorphone: which should be preferred? A systematic review.

Spénard S, et al. Arch Dis Child. 2021 Jan 18:archdischild-2020-319059. 

Fetal alcohol spectrum disorders: an overview of current evidence and activities in the UK.

Schölin L, et al. Arch Dis Child. 2021 Jan 13:archdischild-2020-320435. 

Systematic review with meta-analysis: Probiotics for treating acute diarrhoea in children with dehydration.

Wu HL, et al. J Paediatr Child Health. 2021 Jan 7

Machine Learning for Child and Adolescent Health: A Systematic Review.

Hoodbhoy Z, et al. Pediatrics. 2021 Jan;147(1):e2020011833. 

CASE REPORTS

When Pneumonia Is Not Resolved with Antibiotics: The Incomplete Border Sign.

Pérez-Torres Lobato MR, et al. J Pediatr. 2021 Jan 22:S0022-3476(21)00076-7

Isolated forehead swelling.

Nistico D, et al. J Pediatr. 2021 Jan 11:S0022-3476(21)00004-4

Case 2-2021: A 26-Year-Old Pregnant Woman with Ventricular Tachycardia and Shock.

Scott NS, et al. N Engl J Med. 2021 Jan 21;384(3):272-282. 

Why the Maternal Medication List Matters: Neonatal Toxicity From Combined Serotonergic Exposures.

Brajcich MR, et al. Pediatrics. 2021 Jan 27:e20192250. 

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

Breaking bad news

Cite this article as:
Sarah Kapur. Breaking bad news, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31906

You are admitting a 13-year-old girl, Fatima with a history of easy bleeding and bruising, a full blood count has been performed and shows pancytopenia with blasts cells seen on blood film.  The parents had been waiting in ED for 7 hours and the nursing staff tell you they are very angry at being admitted as no one has explained why they have to stay.  They have a 3-month-old baby who Mum is breastfeeding.  The family are asylum seekers from Libya and mum speaks some English, but the dad doesn’t speak any English.

When on rotation in haematology 2 years later, you meet the same family in the outpatient clinic for review, unfortunately, Fatima’s leukaemia has relapsed and the team looking after her have told them that a cure is not possible.  

This case highlights communication when breaking bad news about a new oncological diagnosis, however the skills and themes discussed are relevant to many specialities and scenarios.

Bad news has been defined as any information that negatively alters a patients view of their future (Buckmann, 1984).   All bad news has serious consequence for a family.  As paediatricians, we must explain many life-changing diagnoses to children and their parents; from a new diagnosis of diabetes, a neuromuscular condition or an autistic spectrum disorder.  Changes in management can also be bad news for that child or family, for example, a neonate who may require a tracheostomy or a child diagnosed with an unsafe swallow who cannot be fed by mouth.

We have to skillfully navigate the triangular relationship between healthcare professional, parent and child.  Timely, open and honest communication is key and families report that this is especially important for conditions with extremely poor prognosis. 

Bad news is always bad news for the family, however, how we deliver it can make a drastic difference to the family and the therapeutic relationship they have developed with the healthcare professionals caring for them and their child.  That bad news may be the start of the doctor-patient relationship, making it important to be honest, in order to build a trusting relationship.  Being honest whilst maintaining hope requires delicate balance.  

The SPIKES model

The SPIKES model has been proposed to give us a framework for discussing bad news with families. (The oncologist, 2000). This framework can help us to structure the conversation and think about issues that may arise.

It begins by setting up the interview.  The need for preparation is paramount, gathering as much information as possible and ensuring that the conversation will not be interrupted.  Many parents stress that diagnostic uncertainty shouldn’t delay important conversations and that we should be honest about what we do not know. 

Think about what you want to say in advance. Think about how you can explain medical terminology in simple terms or whether there are any diagrams or pictures that might help. If any scan pictures are available, these also can be helpful in explaining a diagnosis, although be mindful that some families may not want to see these early on.

If a family need to come up to an outpatient clinic for review, try to be flexible to ensure that both parents can be there. Stressful events can strain already tricky family dynamics so consider this with parents who are separated or who have limited support. They may have jobs that are difficult to get time off from, other children to arrange childcare for, other caring commitments or difficulty with travel. Other family members such as grandparents, aunties or uncles may provide invaluable support.

These conversations can take time and in busy clinical environments this can be tricky.  Whilst it is important not to unnecessarily delay difficult conversations it is also essential that you allow enough time so that the child and family do not feel rushed.  Choosing the right environment would involve a place that allows privacy, has enough chairs and ensuring that you are not carrying any bleeps or expecting important phone calls.  When to involve the child in the discussion is difficult and very age dependent.  It is often appropriate to have a relative or member of staff sit with the child initially and then have subsequent conversations with the child.  These conversations are obviously very difficult but for older children it is important that they understand what is happening in an age appropriate manner.  Charities particular to the condition being discussed often have excellent resources to explain complex diagnoses, or provide story books for children or their siblings.

Open the conversation with introductions, including names and roles, bearing in mind that names are easily forgotten, so an easily visible name badge is helpful.  Kindness and empathy are 2 key principles in developing rapport with the family.  Asking the parents their names and using their names and the child’s name can also help build rapport with the family.

Begin with open-ended questions, to assess the family’s understanding and perceptions of what might be going on.  This can be very different to what you may expect and may help in your explanations of the situation.

The next step in the SPIKE model is obtaining patients invitation i.e. getting an understanding of what they want to know.  This is slightly controversial, as we must also ensure that families are informed about all aspects of care.  However, for initial conversations it could be best not to overload with information.  Giving a warning such as ‘we wish we didn’t have to tell you’ before breaking the news is advised.

After the news has been broken, do not be afraid of silence, you must give the patient time to process what they have heard.  After the initial news has been broken, give more information on the condition and explanations of what will happen next and reassurance of ongoing support.  Be open about uncertainties if the diagnosis is not your area of speciality but be clear about how questions can be answered.  Give further information in chunks checking understanding of complex medical terminology to help develop family’s understanding of complex scenarios.  If news is related to life limiting conditions statements such as ‘we are unable to cure your child (use name) but we will always care for them can be helpful.  

Listening to what the family is saying and do not make assumptions about how they are going to feel.  Be careful to really observe and validate their emotions, using empathetic language to respond to emotion rather than facts. No response from the family is wrong.  Taking conversations at the individuals pace, bearing in mind 2 parents understanding may differ drastically.  

Understanding their previous experiences and understanding of the condition can be very insightful, for example the grandmothers diagnosis of breast cancer is different to his child’s diagnosis of leukaemia.

Think about other family members and what to do when the consultation has ended, some parents report not feeling safe to drive after hearing bad news.  Offering a few minutes in a quiet room after the conversation may be appropriate.  Ask about other siblings and close family members.  Offer support and advice about telling siblings, the child themselves or grandparents. Charitable organisations related to the condition often have excellent resources around this.

Finish by summarising  the information that has been given, provide written information and website links and importantly follow up plans.

A lot of families will do internet searches on the condition, and whilst this can be helpful, it sometimes isn’t.  It is helpful to acknowledge this and encourage families to discuss any information they find to be confusing or contradictory to medical advice.

Encourage families to write down questions for meetings.  Explain that it is normal not to remember a lot of what has been said and that it is important to ask questions to develop their understanding.  

Reassurance of ongoing support is paramount, this support may be from medical, nursing or allied health care professionals.  Parent groups and charities often have excellent information leaflets and support groups. Ensure families know they are not alone and how to access support.

As clinicians we must recognising that doing this well is emotionally and physically draining and be sure to look after our own wellbeing and take time to debrief with the team after if appropriate.

Selected references 

1. Brouwer, M.A., Maeckelberghe, E.L., van der Heide, A., Hein, I.M. and Verhagen, E.A., 2020. Breaking bad news: what parents would like you to know. Archives of Disease in Childhood.

2. Baile, W.F., Buckman, R., Lenzi, R., Glober, G., Beale, E.A. and Kudelka, A.P., 2000. SPIKES—a six‐step protocol for delivering bad news: application to the patient with cancer. The oncologist5(4), pp.302-311.

3. Together for short lives. Core Care pathway. https://www.togetherforshortlives.org.uk/resource/core-care-pathway/

4. Children’s Cancer and Leukaemia group.  https://www.cclg.org.uk