School Time Safety Netting

Safety netting is one of the most important interventions in acute paediatrics, whether you work in Primary or Secondary Care.  When we give safety netting advice, it is usually in the context of a medical problem that we expect to run a benign course and then resolve.  This is plan A.  Safety netting advice allows us to inform the patient (or responsible carer) when to activate plan B.

Plan B might be needed for a number of reasons:

The principles behind good safety netting are simple.


All of these factors are key to the success of the safety netting process.  Leaflets can be a very useful supplement to explanation and discussion.  The opportunity to ask questions is also essential.  Most importantly the parent should feel empowered to make an assessment and to return without feeling that they will be seen as over-anxious.

Recently, there was a lively discussion online (sparked by Damian Roland's writings about safety netting) about this subject, including some great tips about how to do it well and ways that it can go wrong.  One of the pitfalls that were mentioned was the possibility that discussion about the appropriateness of the attendance might get in the way of the touchy-feely aspect of the safety netting.  The gist was that if you discussed when not to come, this would be a barrier to appropriate attendance.  While I agree that this can happen, I don't believe that by discouraging attendance we are running this risk, as long as it is all done in a positive way.

The idea that discussing appropriate attendance is inherently negative is based on a false assumption: namely that the parent wants to come to the doctor.  Even where healthcare is free at the point of delivery there are many, many reasons why people do not want to see a doctor, with inconvenience being one of the most common.

Another issue is that the anxiety associated with the perceived need for a medical assessment is itself an unpleasant experience.  I think that doctors under-appreciate this because we are made to feel like the hero of the hour.  Someone was worried about a symptom and now we are the person to tell them that everything is almost certainly going to be fine.  Go us!

Probably the most common example that I can think of is the way that parents often think that a cough and fever equals a chest infection.  This is sometimes compounded by the belief that chest infection is often fatal - a rare outcome in a healthy child who is given appropriate treatment.

When I hear someone say that they have come to see me because they believe that their child has a chest infection and the child promptly runs off to play with the toys, I could be forgiven for having a 'why me?' moment.  I could use this opportunity to explain why this is an inappropriate attendance since the child is so very well.  That would be a tad self indulgent since I'm not the one with the worry.  Instead, I should make sure that my consultation finishes on a positive note, with good safety netting advice that encourages re-attendance, right?

Well, I think that the two things (good safety netting and discouraging unnecessary attendances) are far from mutually exclusive.

If anything, the two things work together in beautiful harmony and create the opportunity to take safety netting to a platinum standard.
What might this look like in practice?  For the child with the not-a-chest-infection, my school time safety netting might go like this:


It is absolutely important that parents do not feel criticised.  If fear of criticism leads to a child not being brought for assessment when needed, that is of course a bad thing.  So, we have to have the best of intentions when we talk about when and when not to seek medical advice.

I have no interest in doing myself out of a job by reducing attendances.  If anything, reducing avoidable attendances.   It takes me 2 minutes and zero stress to assess the child who has had a minor bump to the head.  If the parents who bring their child to see me when all that's happened is that they fell over and cried for a few seconds stop coming "because it's always best to get checked isn't it doctor?" then I'll just have to see more patients that take time and challenge my thought processes.  So why do I take the time to explain to every single parent the things that would constitute a reason to seek assessment for the next bumped head?

The answer is that it is in the best interests of the parent and child, so why wouldn't I?

Edward Snelson
Founder of MediLeaks
@sailordoctor

Disclaimer:  Exploring health beliefs can be hazardous.  Always wear a helmet.


I would love it if you would post the things that you educate parents about (in a positive way).  You could do that here, on Twitter or on Facebook.  If you post a comment here, don't worry if it doesn't appear straight away.  I have to check all comments before they are published.  (There are a lot of spammers out there!)

It’s Not Easy Being Wheezy – about antibiotics and wheezy kids

In my formative postgaduate years as a doctor, I was told by more than one mentor that antibiotics were a good treatment for children who were wheezing. This advice was given bay various people at different times and whether this was bronchiolitis, viral wheeze* or an exacerbation of asthma, the principles seemed to be the same. The logic is sound - we know that infection triggers all three, and we can never be certain of the infection being a straightforward viral episode.  That was how it was put to me anyway.
*If you are unsure about the difference between viral wheeze and bronchilitis, follow this link for an explanation.

I no longer believe in this strategy as a treatment option for wheezy kids, and this is why:

It's not easy being wheezy.  Children with tight lower airways are up against it but often cope extremely well with their bronchospasm or their bronchiolitis.  I am constantly delighted by the ability of these children to be cheerful despite quite significant breathing difficulty.


It's even worse to have a bacterial lower respiratory tract infection.  As well as the breathing difficulty that comes from the loss of functioning lung, there is the tiring effect of the illness.  Having pneumonia is unpleasant and often exhausting.  It would be unusual to see a child who was cheerful and well despite a bacterial lower respiratory tract infection.




Now imagine combining the two.  Doesn't look good does it?  Children with bronchiolitis and viral wheeze cope with the difficulties of wet or constricted airways because they are systemically well.  Add the lethargy of bacterial infection to this and you go from a child who can compensate to one who cannot.  In short, you won't think "maybe there's a bacterial LRTI as well as the bronchiolitis or viral wheeze."  You'll know it.

Evidence from research backs this up.  The Cochrane review of antibiotics for bronchiolitis concluded that there was no benefit from antibiotics. (1)

You could say, what's the harm in trying antibiotics?  There are many reasons why unnecessary antibiotics might be harmful and none of these are to do with drug resistance.

So, it's time to do away with the idea that antibiotics have a role in treating well children with bronchiolitis or viral wheeze.  I believe that you'll know the children who need antibiotics because they will be properly unwell.

Edward Snelson
Antibiotic Guardian of the Galaxy
@sailordoctor

Disclaimer:  Secretly we all know that antibiotics do treat viruses, but if you tell anyone, you'll be removed from the Magic Circle.

Reference
  1. Farley R et al, Antibiotics for bronchiolitis in children under two years of age, Cochrane database of systematic reviews. 2010

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The Cheater’s Guide to Complex Paediatric Problems


If ill children worry clinicians, then the child with a complex medical background must be terrifying.  Paediatrics is full of syndromes, most of which are so rare that you will probably never encounter them, but these syndromes number so many that the total number ends up being significant.  The end result is that if you work in General Practice or an Emergency Department, you are guaranteed to see a child with an underlying syndrome every so often.

These syndromes are not the only reasons for children to have complex medical histories.  Sometimes a single disease is enough to dramatically change how a child presents and responds to illness.  Intuitively, these children make all of us anxious, and I include paediatricians in that collective of worriers.

So what should you do when faced with a child who comes to you and has a complex medical history?  Most of us would like to practice medicine well within our area of expertise and this scenario is going to be way outside of that?  Well, it doesn't have to be a case of complete panic and run.  No, when faced with unfair odds, if you choose to engage, you just need to know how to balance the playing field.  My approach is simple.  I cheat.

Here's a clinical scenario to illustrate what I am talking about:

A three year old girl presents with a history of pulling her ear. She has had a raised temperature but this has responded well to antipyretic medicine.  Examination is normal apart from a runny nose and a left sided inflamed tympanic membrane.

You see from the child's medical records that she has Aicardi syndrome and has regular followup with a paediatrician for this.


I'm guessing that this all felt safe for the first bit.  There is something particularly unnerving however about finding that a child has a thing that you've never even heard of.  This is a protective instinct that clinicians have (quite rightly) to let them know that they are outside of their area of expertise.

However, you do have options here.

You should of course look at the child's medical records.  This will often give you the diagnosis but not the detail about what the specifics of the thing, how the thing affects this child, or what the plan is for a child with the thing when they become unwell.

You could ask the internet for information about Aicardi syndrome.  Clinicians often feel that this would make them look foolish or lacking in knowledge.  The truth is that the parents do not expect you to have the first clue about their child's rare condition.  If you ask for two minutes to get a bit of information about the thing, they are most likely just relieved that you are not planning to ignore the fact that their child is different.  If anything, they will be pleased that you are taking the time.

The next option is to ask the parents what the deal is with their child's condition.  This approach works really well, assuming that the parents are reasonably in the know.  While the internet can give you an overview of a syndrome, no disorder ever affects two individuals in the same way.  For this reason, I find it useful to ask the following questions:


Note that this is cheating at the highest level.  You can't just expect to be this good straight away, but it's something I feel everyone should be aiming for.

What I've done there is to find out about the underlying medical problem, exactly how it affects this child in front of me and to find out what is expected of me.  This immediately gets me past a few of the most common barriers:
  • Possible gaps in knowledge of the condition
  • The way that a disease/ syndrome manifests is variable
  • There may be specific requirements or expectations when a child with this underlying problem becomes unwell
  • It is very difficult to spot an unwell child if you don't know how they look and behave when they are well.
  • The gut feel that we use when assessing children is less reliable if a child has a complex medical problem.
The reason for going to all of this is all of this trouble is to do with the way that children with complex underlying medical problems develop and respond to illness.


These children may or may not have good immune systems.  What they all have in common is that they will not respond to illness in the same way that a child who has no underlying medical problems would.  The reasons for this may be physiological, neurological or even due to human factors.  These children with complex medical backgrounds experience a normalisation of illness that other children do not.  As a result, they do not necessarily even know how sick they are themselves.

Putting a little bit of extra work into the assessment of these children does make a big difference.  It maximises the chances that the will get seen by the right person, in the right place, at the right time.  Sometimes there are specific things that can be done early on, which will help the child to get better.

Sometimes, being admitted or referred is not the best thing for the child or the parent. I the case of the child above, it turns out that Aicardi Syndrome doesn't affect immunity and that this child is not one of those severely affected.  The end result is that Mum is confident that she can recognise when her child is seriously unwell.  Today she feels that the problem is pain rather than concern about being dangerously ill.

More importantly, Mum has a physiotherapy appointment in an hour, so a referral 'just in case' is going to make her miss that.  After applying the full list of cheats, you decide to manage the child's illness yourself.

Epilogue:  The following week, you find a card and a box of chocolates on your desk.  They are thanking you for taking the time to manage this girl's illness rather than refer to the local hospital, which is what often happens to her.

Edward Snelson
Finding the easy way since 1996
@sailordoctor

Disclaimer: Cheating is only wrong if you get caught.


If you have your own tips and tricks for looking after children with complex medical problems, please post something in the comments box below.


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