Things We Like This Month – August 2019
As another month of paediatric medical education rolls over, the list of things we have enjoyed reading grows longer and longer. With summer firmly here, the wards finally seem to be getting some breathing room. If you get a second to relax and sit down with a cup of tea, why not have a peruse through August’s edition of TWLTM?
Journal articles we like
A Prediction Model to Identify Febrile Infants <60 Days at Low Risk of Invasive Bacterial Infection
A day may come when the paediatric world no longer argues about antibiotics in children less than 3 months old. But, alas, today is not that day. With vaccinations dropping rates of serious bacterial infections to all-time lows, the “shoot-first, ask questions later” approach of yesteryear is rapidly becoming outdated, especially with rates of antimicrobial resistance rising and rising. There is no doubt that these patients represent a unique challenge to paediatricians, and in the past few years we have seen a number of scoring systems come up looking at risk stratifying the youngest of these children to see which, if any, we can justify judiciously withholding antibiotics initially and waiting to see how the situation pans out.
This latest piece of work comes from the States, looking at validating a recent prediction model for children with fever <60 days. Though there have been a few studies recently into the same populations, including the excellent and popular Step-by-Step paper by Gomez et al. in August 2016, however the use of procalcitonin made the results from Step-by-Step difficult to implement in hospitals where this wasn’t available.
This case-control study found that in patients who were afebrile in the emergency department, with a normal urine dipstick and an absolute neutrophil count of <5.1 were considered low risk for bacteraemia and bacterial meningitis. Bottom line: There will always be great difficulty in designing a scoring system that is both sensitive and specific for these conditions, due to the low overall prevalence of disease in the developed world. However, this paper adds to a growing body of research that suggests that within the population of febrile children <60 days, there are high risk and low risk children, and working out which ones are which is the next big challenge for paediatrics.
Serial C-Reactive Protein Measurements in Newborn Infants without Evidence of Early-Onset Infection
Assessing children at risk of infections in the neonatal period is extremely difficult. Invasive GBS-septicaemia is a horrific condition that can kill a newborn child extremely quickly. However, in children at risk, who have received early antibiotics as per NICE guidelines, how do we risk stratify patients for whom we can safely stop antibiotics quickly, and those we need to continue antibiotics for, in lieu of the pretty low sensitivity of blood cultures in this age group.
Enter CRP. C-reactive protein entered the battle of neonatal sepsis as a knight in shining armour, but unfortunately, as it turns out, CRP is more Don Quixote than it is Sir Lancelot, tilting at a large number of windmills rather than solely slaying dragons. This metaphor has gone on too long now, but I’m sure you get the message.
The NICE Guidelines for Neonatal Early Onset Sepsis set their benchmark out at 10mg/l. A reading above this, and you likely earn yourself an LP, and extended course of antibiotics. Below this, and you stop antibiotics at 36 hours. However, what was not know until recently is what the normal trend of CRP in well children without infection is. How many lumbar punctures and extended courses of antibiotics are we giving to well children?
This paper looked at the trend of CRP in normal, asymptomatic babies without clinical or microbiological evidence of infection. It is a small study, with only 79 children enrolled, and the data was retrospectively acquired, making it difficult to ascertain the clinical picture at the time of screening, however, the results suggest that there is a rise in CRP following delivery that occurs without infective stimulus, and sought to show the centile distribution for these results.
Should this affect a change in our practice? The difficulty comes from locally navigating the NICE Guidelines, which use 10mg/l as a hard cut off, but then somewhat underwhelmingly only suggest “considering an LP” and “continue antibiotics until a reassuring trend of CRP and improvement in clinical condition”. Locally in Norwich, the cut-off for continuing antibiotics and undertaking an LP has moved to 20, and we are seeing an impressive, and safe, reduction of ‘antibiotic babies’ in the trust. As ever, this is not a groundbreaking trial, but certainly is useful at highlighting the unreliability of using biomarkers solely as a means of rational antibiotic use.
Fifteen Minute Consultation: The Limping Child
As a common presentation to the acute children’s services, the limping child is a great representation of Damian Roland’s “evil twin theory” – the vast majority of presentations are benign, self limiting illnesses, however, lurking amongst them is a serious, life-altering disease that we must have a high index of suspicion for if we are to catch it.
Wrapped up neatly in the brilliant Fifteen Minute Consultation series, this article walks you through the specifics of the serious disease processes, red flags, and addresses a key point in acute care – risk management. Although we aim for diagnostic certainty all the time, the reality of the situation is that we cannot be 100% sure 100% of the time. Managing risk, and adequately safety netting is a cornerstone of good emergency-based practice, and this article does an excellent job at addressing that.
**Shameless self-plug – this article is the perfect deep dive from our limping child infographic published earlier this year – check it out here**
#FOAMed content we like
The great day paradox – Simon Carley via StEmlynsBlog
The blog that accompanied a fantastic session at DFTB19, Simon walks us through his own musings on the interesting paradox that, the day that you go home and describe as “great” is likely the worst day of at least one person or family’s lives thus far. When it comes to procedures, generally the people drawn to ED and acute paediatrics as a career are people who like doing things. But are we doing things because the patient needs them, or are we doing things because, deep down, we just really want to do it. In the words of the late Dr John Hinds “Are your intentions honourable?”. This talk generated a lot of discussion at DFTB19, the intricacies of which unfortunately were lost in translation onto Twitter, but it certainly gave me pause for thought on my own great days, and where they fit in from a patient’s perspective.
Right Breathe – an inhaler database
Whilst most kids with asthma are generally kept on inhalers that we see on a daily basis, the sheer number of inhalers in the community is absolutely staggering. This website is a one-stop shop for all inhalers available on the market, including dosing regimes, interactions, spacer information and pathways for asthma management. Respiratory clinic got you sweating? Look no further…
Why Wellness Matters – Carl Van Heyningen via #EM3
Wellness in paediatrics and emergency medicine is, quite rightly, being thrust into the forefront of discussions about the future of these respective careers. With the recent publication of the GMC survey, this issue is clearly becoming more and more of a problem. The problem itself is two-fold: the emphasis is often put on trainees to pursue their own wellbeing at work, however, there is deep seated need for change at an institutional level to help tomorrow’s doctors survive the moral injuries plaguing our profession. Carl neatly summarises the resources from the various colleges available to institute change in workplace wellbeing, both in optimising the culture of wellbeing at work, as well as focussing on personal wellbeing, and the steps we can take to improve there as well.
Podcasts we like
Peripheral Vasoactive Drugs in Kids – Chris Flannigan via Paediatric Emergencies
The old military adage of “Fail to prepare, prepare to fail” runs deeply through resuscitative medicine as well. We simulate, we discuss, we debrief, all to prepare ourselves better for when it goes wrong for real. Most of us are familiar and prepared to give fluid boluses to children with reduced cardiac output, however, what happens when that doesn’t work? Inotropes are usually the remit of the neonatal unit or PICU, but if you are in a DGH, and have a crashing child, who is not fluid responsive with no central line, where do you turn?
Peripherally administered vasoactive drugs can be an extremely useful get-out-of-jail card to have up your sleeve for the severely unwell child that isn’t responding to volume, and Chris Flannigan clearly walks you through the uses and ways to make up these drugs.
**N.B. Don’t forget that drug doses for all vasoactive drugs are available via the CATS website, just click on the calculator or follow this link