Team DFTB. The Travelling Doctors Suitcase: Fiona Reilly at DFTB19, Don't Forget the Bubbles, 2020. Available at:
Are you involved in the care of paediatric hickmans, port or picc lines in paediatric patients? Lines, particularly those for oncology patients can sometimes leave nursing and medical staff all tangled up. Thanks to the Royal London Hospital Paediatric Oncology team, Ana Waddington and Amanda Ullman we are happy to share some handy top tips to improve line care:
For your convenience, the top tips are summarised in an A4 poster format (infographic by Grace Leo):
Here is a new Bubble Wrap Plus, our monthly paediatric Journal Club List provided by Professor Jaan Toelen & his team of the University Hospitals in Leuven (Belgium). This comprehensive list of ‘articles to read’ comes from 34 journals, including Pediatrics, The Journal of Pediatrics, Archives of Disease in Childhood, JAMA Pediatrics, Journal of Paediatrics and Child Health, NEJM, and many more.
This month’s list features answers to intriguing questions such as: ‘What is the effect of longer resuscitations at birth on neurodevelopment?’, ‘Is it necessary to evaluate urinary tract infection in children with lower respiratory tract infection?’, ‘What is the effect of social distancing on ‘regular’ URTIs?’, ‘Does maternal pertussis vaccination interfere with neonatal vaccination?’ and ‘Is migraine a common cause for nystagmus in the emergency department?’.
Skellern C J Paediatr Child Health. 2020 Aug 11.
Friedrich AB. Pediatrics. 2020 Aug;146(Suppl 1):S66-S69.
Ghastine L, et al . Pediatrics. 2020 Aug 4:e20193327.
Butters C, et al. J Paediatr Child Health. 2020 Aug 8.
Tsoukas P, et al. Paediatr Child Health. 2020 Aug;25(5):279-285.
Mennini M, et al . J Pediatr Gastroenterol Nutr. 2020 Jul 30.
Lacaille F, et al . J Pediatr Gastroenterol Nutr. 2020 Jul 30.
El-Dib M, et al . J Pediatr. 2020 Jul 30:S0022-3476(20)30978-1.
Singh-Grewal D, et al . J Paediatr Child Health. 2020 Jul 31.
Ledder O, et al. Pediatrics. 2020 Aug 12:e20201149.
Hamilton-Shield J, et al. Pediatrics. 2020 Aug 12:e2020007211.
Foglia EE, et al. Pediatrics. 2020 Aug 12:e20201449.
Kim JM, et al. J Paediatr Child Health. 2020 Aug 8.
Galway NC, et al. Arch Dis Child. 2020 Aug 11:archdischild-2019-318559.
Yonker LM, et al . J Pediatr. 2020 Aug 18:S0022-3476(20)31023-4.
Kuitunen I, et al. Pediatr Infect Dis J. 2020 Jul 28.
Shack AR, et al. J Paediatr Child Health. 2020 Aug 8.
Kim J, et al. Arch Dis Child. 2020 Aug 7:archdischild-2020-319910.
Sola AM, et al . JAMA Pediatr. 2020 Aug 25.
Lee-Archer P, et al . J Paediatr Child Health. 2020 Aug;56(8):1313-1314.
Capecchi E, et al . Pediatr Infect Dis J. 2020 Jul 21.
Parikh RV, et al. Pediatrics. 2020 Aug 11:e20192821.
De Wolf D, et al. Eur J Pediatr. 2020 Aug 11.
von Heideken J, et al. J Paediatr Child Health. 2020 Aug 11.
Goldman RD, et al. Eur J Pediatr. 2020 Aug 10.
Oulego-Erroz I, et al. J Pediatr. 2020 Aug 6:S0022-3476(20)30993-8.
Velasco Rodríguez-Belvís M, et al. Paediatr Child Health. 2020 Aug;25(5):286-292.
Horne RSC.Pediatrics. 2020 Aug 26:e2020014407.
Howarth C, et al .Pediatrics. 2020 Aug 26:e20200337.
Modak MB, et al . J Paediatr Child Health. 2020 Aug 26.
Hasan B, et al . J Child Neurol. 2020 Aug 24:883073820948679.
Dowse G, et al . J Pediatr. 2020 Aug 19:S0022-3476(20)31029-5.
Bush NR, et al . J Pediatr. 2020 Aug 19:S0022-3476(20)31027-1.
Breton MD, et al . N Engl J Med. 2020 Aug 27;383(9):836-845.
Forno E, et al . JAMA. 2020 Aug 25;324(8):752-760.
Abu-Raya B, et al . Pediatrics. 2020 Aug 4:e20193579.
Rossi S, et al . Eur J Pediatr. 2020 Aug 3.
Hickey L, et al . Arch Dis Child. 2020 Aug 3:archdischild-2019-318139.
López EL, et al . Pediatr Infect Dis J. 2020 Jul 17.
Shankaran S, et al . J Pediatr. 2020 Jul 30:S0022-3476(20)30979-3.
Schinckel NF, et al . Arch Dis Child Fetal Neonatal Ed. 2020 Jul 30:fetalneonatal-2020-319136.
Hollebrandse NL, et al . Arch Dis Child Fetal Neonatal Ed. 2020 Jul 30:fetalneonatal-2020-318989.
Garone G, et al . Pediatrics. 2020 Aug;146(2):e20200484.
Salverda HH, et al . Arch Dis Child Fetal Neonatal Ed. 2020 Jul 30:fetalneonatal-2020-318918.
Loe IM, et al. JAMA Pediatr. 2020 Aug 10.
McMullan BJ, et al. Pediatrics. 2020 Aug 5:e20200134.
Cavicchiolo ME, et al. Eur J Pediatr. 2020 Aug 7:1-7.
Tasker RC. Arch Dis Child. 2020 Aug 26:archdischild-2020-320164.
Mintegi S, et al . Pediatrics. 2020 Aug 25:e20201126.
Kronman MP, et al . Pediatrics. 2020 Aug 3:e20200038.
Viner RM, et al . Arch Dis Child. 2020 Aug 3:archdischild-2020-319963.
Merritt RJ, et al . J Pediatr Gastroenterol Nutr. 2020 Aug;71(2):276-281.
Klompas M, et al . JAMA. 2020 Aug 4;324(5):441-442.
Anderson KR, et al. Pediatrics. 2020 Aug 12:e2020008235.
Golomb MR, et al. J Pediatr. 2020 Aug 7:S0022-3476(20)30992-6.
Miyamoto M, et al. J Pediatr. 2020 Aug 6:S0022-3476(20)30991-4.
Geljic A, et al. J Paediatr Child Health. 2020 Aug 7.
Rajvanshi N, et al . J Paediatr Child Health. 2020 Aug 5.
Ho DK, et al . J Pediatr. 2020 Jul 30:S0022-3476(20)30980-X.
Rustogi D, et al. J Paediatr Child Health. 2020 Aug 7.
If we have missed out on something useful or you think other articles are absolutely worth sharing, please add them in the comments!
Abigail is a 10 month-old female presenting to the Emergency Department with a history of profound lethargy, pallor and a mildly distended abdomen over the last few hours. She has no past medical history, her immunisations are up to date, and she has no known allergies. Her parents report that she is usually well, however they have noticed recent swelling of her hands and feet over the last month. Her parents are originally from Nigeria. In the Emergency Department she is pale and flat.
She is tachycardic with a heart rate of 180bpm and afebrile. On examination she has a prolonged capillary refill time of 5 seconds and cool peripheries. She has a soft systolic murmur. Her spleen measures 7cm below the costal margin and she squirms on abdominal palpation. There is no history or evidence of trauma.
Intravenous (IV) access is obtained and bloods are sent including a venous blood gas, blood culture, FBE, blood group and cross match, LFT and UEC.
Abigail is given a 10ml/kg fluid bolus of 0.9% sodium chloride and commenced on broad-spectrum antibiotics. After a second 10ml/kg bolus her capillary refill time and heart rate improve but she remains very lethargic.
You are notified by pathology that Abigail’s formal haemoglobin is 64 g/L and she is thrombocytopaenic with a platelet count of 80 x 109/L. The white cell count is within normal limits.
You send for an urgent blood transfusion and arrange a PICU review.
The treating team is contacted by the haematologist who has reviewed her blood film and noted the presence of target cells, Howell-Jolly bodies and sickle cells.
What is the diagnosis? Abigail has presented in hypovolaemic shock secondary to splenic sequestration as a first presentation of sickle cell disease.
Sickle cell disease (SCD) is a genetic disorder of haemoglobin synthesis.
Haemoglobin is a tetramer comprised of four polypeptide globin chains, each containing a haem molecule (which reversibly binds oxygen). Beyond infancy, adult haemoglobin (HbA) replaces foetal haemoglobin (HbF) as the predominant haemoglobin molecule. HbA consists of two alpha and two beta globin chains.
SCD is caused by a point mutation in the beta globin gene resulting in a structurally abnormal haemoglobin molecule, HbS.
The primary event in sickle cell pathology is polymerisation of HbS, distorting the red cell shape and leading to the characteristic sickle appearance. Polymerisation can occur in the setting of deoxygenation, acidosis, pyrexia and dehydration. Recurrent episodes of sickling cause red blood cell (RBC) membrane damage and an irreversibly sickled cell.
Sickled RBCs adhere to the vascular endothelium and circulating RBCs causing occlusion of the microvascular circulation (vaso-occlusion). Sickled RBCs also undergo haemolysis, with an average RBC lifespan of only 17 days.
The physiological changes in RBCs result in a multisystem disease with the following key features:
Sickle cell anaemia is inherited in an autosomal recessive pattern.
It is one of the most common, severe monogenic disorders worldwide. The prevalence of the disease is high among individuals of sub-Saharan African, Indian, Saudi Arabian and Mediterranean descent.
It is estimated that 312 000 neonates are born with sickle cell anaemia globally each year, over 75% of whom are born in sub-Saharan Africa.
SCD refers to a group of disorders characterised by the presence of at least one HbS allele in addition to a second beta globin gene mutation.
In sickle cell anaemia, individuals are homozygous for HbS (HbSS). This is the most frequent and severe form of the disease. Other variants of SCD include sickle β thalassaemia (HbSβ0 or HbSβ+ thalassaemia) and haemoglobin SC disease (HbSC)
Individuals with sickle cell trait are benign carriers for the condition, inheriting HbS and a normal beta globin gene (HbAS). Sickle cell trait confers a survival advantage in malaria endemic areas.
Universal newborn screening for SCD has been implemented in the United States and United Kingdom. SCD is not part of the newborn screening program in Australia.
SCD can be diagnosed through the identification of haemoglobin variants using haemoglobin electrophoresis, high-performance liquid chromatography (HPLC) or isoelectric focusing.
Symptom onset usually occurs within the first year of life, often at around 5 months. The delay in clinical signs and symptoms is due to the higher levels of HbF in infancy preventing the polymerisation of HbS.
Clinical manifestations include:
There is limited data on the relationship between SCD and COVID-19. Children with sickle cell disease, thalassaemia and rare anaemias without other risk factors do not seem to be at increased risk of having severe disease.
Blood transfusions are used to treat and prevent the complications of SCD. Types of transfusions include simple, manual partial exchange and automated red cell exchange (erythrocytapheresis).
Hydroxyurea is a myelosuppressive agent used in the management of individuals with SCD, which has been shown to reduce the vaso-occlusive complications.
A life-long cure for SCD is only available through haematopoietic stem cell transplantation.
Individuals with SCD have reduced overall life expectancy. In high-income countries, the survival of individuals with SCD is improving steadily through measures such as newborn screening, early initiation of antibiotic prophylaxis, immunisations and screening for children at high risk of stroke.
This is not the case worldwide. The majority of countries where SCD is a major public health concern lack national programs and key public health interventions. As a result, sickle cell anaemia-related childhood mortality in Africa is as high as 50-90%, with less than half of affected children reaching the age of five. The World Health Organization (WHO) estimates that 70% of sickle cell anaemia deaths are preventable with simple, cost-effective interventions.
SCD is a multisystem disease characterised by haemolytic anemia, painful vaso-occlusive episodes and multi-organ damage from micro-infarcts.
Early diagnosis, simple prophylactic measures and parental education improves the morbidity and mortality of SCD.
Always discuss with the on-call hematologist prior to transfusing a sickle cell patient due to the risk of hyperviscosity.
Arlet JB, de Luna G, Khimoud D, et al. Prognosis of patients with sickle cell disease and COVID-19: a French experience [published online ahead of print, 2020 Jun 18]. Lancet Haematol. 2020;S2352-3026(20)30204-0. doi:10.1016/S2352-3026(20)30204-0
Bainbridge R, Higgs DR, Maude GH, Serjeant GR. Clinical presentation of homozygous sickle cell disease. J Pediatr. 1985;106(6):881-885. doi:10.1016/s0022-3476(85)80230-4
Brousse V, Buffet P, Rees D. The spleen and sickle cell disease: the sick(led) spleen. Br J Haematol. 2014;166(2):165-176. doi:10.1111/bjh.12950
Dick M, Rees D. Sickle Cell Disease in Childhood: Standards and Recommendations for Clinical Care (3rd edition, 2019). Available at https://www.sicklecellsociety.org/wp-content/uploads/2019/11/SCD-in-Childhood_Final-version-1.pdf [accessed 24 June 2020]
Grosse SD, Odame I, Atrash HK, Amendah DD, Piel FB, Williams TN. Sickle cell disease in Africa: a neglected cause of early childhood mortality. Am J Prev Med. 2011;41(6 Suppl 4):S398-S405. doi:10.1016/j.amepre.2011.09.013
Meier ER, Miller JL. Sickle cell disease in children. Drugs. 2012;72(7):895-906. doi:10.2165/11632890-000000000-00000
Odunvbun ME, Okolo AA, Rahimy CM. Newborn screening for sickle cell disease in a Nigerian hospital. Public Health. 2008;122(10):1111-1116. doi:10.1016/j.puhe.2008.01.008
Pace BS, Goodman SR. Sickle cell disease severity: an introduction. Exp Biol Med (Maywood). 2016;241(7):677-678. doi:10.1177/1535370216641880
Piel FB, Patil AP, Howes RE, et al. Global epidemiology of sickle haemoglobin in neonates: a contemporary geostatistical model-based map and population estimates. Lancet. 2013;381(9861):142-151. doi:10.1016/S0140-6736(12)61229-X
Therrell BL Jr, Lloyd-Puryear MA, Eckman JR, Mann MY. Newborn screening for sickle cell diseases in the United States: A review of data spanning 2 decades. Semin Perinatol. 2015;39(3):238-251. doi:10.1053/j.semperi.2015.03.008
World Health Organization. Geneva. World Health Organization – 59th World Health Assembly resolutions; 2006. Sickle-cell anaemia. https://apps.who.int/gb/archive/pdf_files/WHA59/A59_9-en.pdf [Accessed on 30th June 2020]
I’ve always had an affinity for John Carter, as played by Noah Wyle, from the TV series ER. The night ER premiered on UK television happened to be my very first ED shift as a medical student at the Chelsea and Westminster Hospital. I remember sneaking away to the lounge to watch it. My first ED experience was nothing like Carters but I was hooked.
I went to Chicago to do my elective and saw them filming in the snow in between shifts at Northwestern and when I returned to England to prepare for finals we would gather around the TV trying to make the diagnosis before the medicos on the television. We called it revising, but really it was escaping from the textbooks for a short time.
My interest wained nearer the end of the run. Carter had been through many trials, as had I, but one thing has stuck with me more than anything else. It was something passed down from David Morgenstern (William H. Macy) to Mark Greene (Anthony Edwards), and then more importantly from Greene to Carter. That is the basis for this talk. You can read the background here.
This talk was recorded live at DFTB19 in London, England. With the theme of “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal.
If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.
Safety netting is a cornerstone of paediatric practice.
Children are a vulnerable group. Their condition can deteriorate and improve rapidly. Uncertainty is inherent in paediatric emergency medicine. From the child with a fever to the infant with vomiting, it is up to us to safeguard children from harm.
Of course, we can’t admit every child to the hospital. Nor should we. The vast majority of patients in A&E return home with reassurance. Easy right? Reassure. Give advice. Send home. Simple?
You’re at the end of a busy shift and you have a train to catch. You’ve put in blood, sweat, and tears and feel happy your last patient has a simple throat infection. You advise fluids, paracetamol for symptoms of headache and neck pain and to come back if worried. The mother is anxious, you give them a leaflet on fever and rush out the door.
Typically, our focus is on the front door of care not the exit. Discharge care is often overlooked. Even in the best of circumstances, we are under pressure to maintain patient flow especially as our emergency departments begin to become busy again.
The next morning, coffee in hand, you walk in the department and hear the words that strike fear into the hearts of all that hear them…
“Do you remember that child you saw yesterday? They’re being admitted to intensive care, it looks like meningitis.”
What could you have done differently? More tests? Not necessarily needed, no? More time? They had been observed and appeared well for several hours. Senior review? You’d seen them with the Consultant and agreed on the diagnosis. Then what?
Acute illness remains one of the most important causes of childhood mortality in the UK. Early illness is notoriously non-specific. Take meningitis. In only half of cases, diagnosis is made at the first presentation. So what do we do? We must educate parents about uncertainty. Discuss the potential for deterioration. Explain the importance of seeking further help if necessary. We must safety net.
The term was first formally described in 1987. Today, it has come to mean “advice about what to do and what to look out for to empower parents and carers to seek help if the child’s condition deteriorates further or if they need more support.”
In addition to the above, it is critical to cover how they should seek help, what they should expect ahead (the disease course) and when to become worried.
Whilst verbal and written formats exemplify current practice, ranging from information leaflets to printed discharge letters, audiovisual and online resources are growing in abundance. Families report wanting this varied range of approaches.
Let’s consider the options.
Face to Face – individualized, personal but highly variable and time-dependent
TOP TIP – be adaptable (don’t just simply recite the same information each time)
Social, educational, and cultural differences may all necessitate adapting your usual spiel in order to truly achieve understanding. Remember, the parents are in an unfamiliar, often noisy, and stressful environment in addition to feeling worried about their child. Expect them to be distracted a little.
Leaflets – standardised, quality assured but not necessarily up to date and potentially bland and uninteresting.
TOP TIP – use leaflets to re-enforce verbal information
When taken home written materials can often act as an aide memoire.
Audio-visual – engaging and memorable with the potential to overcome literacy and language barriers if well designed, though resource intensive and expensive upfront
Internet, social media, websites, apps – there are many innovative methods of connecting families with health information. Our responsibility is thus to navigate the clutter, signpost reliable resources, dispel myths and thus champion true evidence based materials.
TOP TIP – keep the message simple, it can be easy to overwhelm parents with information.
Remember, many parents may not wish to go on the internet. A few may even not have access to it.
As ever, before talking we must first listen. For example, one interview based study found a mother worrying about “their child with cough dying at night through choking on phlegm.” If we do not listen to such fears how can we expect our own advice to be heard.
Emotional distress (addressing this)
Physical symptoms (addressing these)
Information (providing this, particularly reassurance, diagnosis and explanation)
Care (basic care, including food drink and friendliness)
Closure (finding out what’s wrong and, where possible, going home)
An awareness of these priorities can inform our conversations, helping us to better look after our patients from their perspective.
“You don’t actually know how much of that leaflet they’re gonna actually understand, take in, comprehend… going through things step by step, listening, understanding and explaining, I think is more beneficial” (Paediatric ED doctor).
“It’s very difficult to know ‘cause often they’ll nod their heads and say “yes I understand everything you say” and walk off and they might have no idea what we’ve just said” (ED staff nurse).
“If you’ve got a sick child at home and they’re moaning at you, you haven’t got the time to go on the internet… you’ve got a child hanging off your leg going, “Mummy I feel poorly, mummy I want this, mummy I want that”” (Mother).
“My doctor did give like an information leaflet… and I did read through it, because when you’ve got a sheet at least you can find time to do that” (Mother).
After reviewing the literature and FOAMed (see further resources) here are my top tips for giving the very best safety netting advice, enjoy!
And as with all good communication, ensure a quiet, private area and avoid using jargon.
Finally, directly ask if parents understand and are happy. Don’t assume they are.
Here is one good example to get you started…
“…your little guy is likely to continue to have vomiting and diarrhoea. If he remains well in himself, is drinking the amount of fluid we have discussed and is having wet nappies then he is unlikely to become dehydrated. If, however, he becomes drowsy, develops a fever or fails to stay hydrated please call this number and come back to us.”
We must stop thinking of reattendance as a failure – patients do get worse and some need to return.
Good quality safety netting means both you and your patients can get a better nights sleep.
Gill P, Goldacre M, Mannt D, Heneghan C, Thomson A, Seagroatt V and Harnden A (2013) ‘Increase in emergency admissions to hospital for children aged under 15 in England, 1999–2010: national database analysis’, Archives of Disease in Childhood 98, 328–34.
Wolfe I, Cass H, Thompson MJ, Craft A, Peile E, Wiegersma PA, Janson S, Chambers T, McKee M: Improving child health services in the UK: insights from Europe and their implications for the NHS reforms. Bmj 2011, 342:d1277.2.
Thompson MJ, Ninis N, Perera R, Mayon-White R, Phillips C, Bailey L, Harnden A, Mant D, Levin M: Clinical recognition of meningococcal disease in children and adolescents. Lancet 2006, 367(9508):397–403.3.
Neighbour R. The inner consultation. Lancaster: MTP Press, 1987.
NICE guideline [NG143], Fever in under 5s: assessment and initial management, November 2019
Available at https://www.nice.org.uk/Guidance/Ng143/evidence
Almond S, Mant D, Thompson M: Diagnostic safety-netting. The British journal of general practice: the journal of the Royal College of General Practitioners 2009, 59(568):872–874
Jones CH, Neill S, Lakhanpaul M, et al. Information needs of parents for acute childhood illness: determining what, how, where and when of safety netting using a qualitative exploration with parents and clinicians. BMJ Open 2014;4:e003874.
Neill SJ, Jones CH, Lakhanpaul M, et al. Parent’s information seeking in acute childhood illness: what helps and what hinders decision making? Health Expect 2015;18:3044–56.
Austin PE, Matlack R, Dunn KA, et al. Discharge instructions: do illustrations help our patients understand them? Ann Emerg Med 1995;25:317–20.
Scullard P, Peacock C, Davies P. Googling children’s health: reliability of medical advice on the internet. Arch Dis Child 2010;95:580–2.
Mackert M, Kahlor L, Tyler D, et al. Designing e-health interventions for low-health-literate culturally diverse parents: addressing the obesity epidemic. Telemed J E Health 2009;15:672–7.
Knight K, van Leeuwen DM, Roland D, et al. YouTube: are parent-uploaded videos of their unwell children a useful source of medical information for other parents? Arch Dis Child 2017;102:910–4.
CS Cornford, M Morgan, L Risdale, Why do Mothers Consult when their Children Cough?, Family Practice, Volume 10, Issue 2, July 1993, Pages 193–196
Body R, Kaide E, Kendal S, et al. Not all suffering is pain: sources of patients’ suffering in the emergency department call for improvements in communication from practitioners, Emergency Medicine Journal 2015;32:15-20.
(15) Jones, C.H., Neill, S., Lakhanpaul, M. et al. The safety netting behaviour of first contact clinicians: a qualitative study. BMC Fam Pract 14, 140 (2013)
Jones, C.H.D., Neill, S., Lakhanpaul, M., Roland, D., Singlehurst-Mooney, H. and Thompson, M., (2014) Information needs of parents for acute childhood illness: determining ‘what, how, where and when’ of safety netting using a qualitative exploration with parents and clinicians. BMJ Open 4 (1).
RCPCH (2015) Facing the Future: Standards for acute general paediatric services. RCPCH.
RCPCH Safe System Framework, resources accessed 19th November 2019, https://www.rcpch.ac.uk/resources/safe-system-framework-children-risk-deterioration
Dr. Natalie May, MBChB, MPHe, MSc, PGCert Medical Education, FRCEM, FACEM, #CommunicatED 1: Discharge & Safety Netting in ED, available at https://www.stemlynsblog.org/communicated-discharge-safety-netting/
Bruera, Eduardo & Palmer, J Lynn & Pace, Ellen & Zhang, Karen & Willey, Jie & Strasser, Florian & Bennett, Michael. (2007). A randomized, controlled trial of physician posture when breaking bad news to cancer patients. Palliative medicine. 21. 501-5.
Sarah Jarvis, Medico-legal adviser
BSc MBBS MRCGP, Playing it safe – safety netting advice, available at https://mdujournal.themdu.com/issue-archive/issue-4/playing-it-safe—safety-netting-advice
Damian Roland, BMedSci (Hons) MBBS MRCPCH, PhD, TIGHTEN UP YOUR SAFETY NET #WILTW, available at
Safety netting – a guide for professionals and parents of sick kids from GP Paedtips
Shame. How it affects patients and their relationships with health care professionals. https://abetternhs.wordpress.com/2012/11/16/shame/