The Right Sort of Confidence – (Easter Egg: Acute abdominal pain in children)

I feel pretty confident that my car has the right amount of oil in the engine and air in the tires.  Why?  because that has been the case every time I check these things.  So why bother checking?

Paediatrics is a dangerous speciality because the usual outcome of any child presenting for assessment is that everything is fine.  Fever?  It's probably an uncomplicated viral infection.  Rash?  Virus.  Lump in the neck?  Virus.  You get the idea.

As a result, any one of us can become so used to the benign outcome that we don't expect the dangerous problems or the unusual causes of childhood symptoms.  This is called availability bias.  The last 50 children with this presenting complaint had a virus and got better, so this patient is likely to be the same.

Of course the statement about the likelihood is true, however people don't bring their children to us just for a probability estimate.  We are there to assess whether there is a significant problem that requires intervention.  To get there, we need to know what to look for.

Abdominal pain in children is a good example.  Children often get abdominal pains.  One of the most common presentations is abdominal pain during a febrile illness.  Most likely cause?  Virus.  I suspect that the significant pathology that is most often considered in this situation is appendicitis.  Appendicitis is relatively rare in younger children but paradoxically more difficult to diagnose, so while the chances of a 3 year old having appendicitis is very low, so are the chances that a 3 year old with appendicitis will get this diagnosed easily.

Appendicitis is at least on our minds and so we're probably not going to miss it through failure to look.  There are plenty of causes of abdominal pain that are easily missed for various reasons.  Lower lobe pneumonia, for example, is easily missed because it isn't in the abdomen.  Testicular torsion is easily missed if it isn't looked for.  You'd think that if a child or young person had a problem with their genitalia they might mention that.  They often don't.  If you don't look for torsion, you won't find it.

Here's a brief overview of some of the easily missed causes of abdominal pain in children:
Here is a more extensive list of possible causes of abdominal pain in children.

Going through these, starting at one o'clock:

Mesenteric Adenitis - Yes, children with viral upper respiratory tract infection can get acute abdominal pains and can even have localised abdominal tenderness.  Children with more significant causes of pain can also have URTI, so if there are red flag signs or symptoms you should still take these seriously.
Non-IgE food allergy - This can cause acute abdominal pain but paradoxically is a diagnosis best not made acutely.  History, a food diary and follow-up are the way forward when food allergy becomes a possibility.
Gastroenteritis - When vomiting precedes abdominal pain then this makes gastroenteritis more likely.  Similarly, diarrhoea is a strong indicator of viral enteritis.  However, there is no such thing as always, so careful abdominal examination is key and signs that suggest a surgical cause should still lead to referral.
Gynaecological - The main thing to say about this is that it is a common pitfall to forget to even consider this possibility in children.  How often do you think ectopic pregnancy is considered in the differential of a 13 year old with acute abdominal pain?  It should always be remembered as a possiblity.  Do a pregnancy test.
Constipation - This is possibly the most common cause of afebrile acute abdominal pain in children.  There are two main pitfalls.  The first is to miss the diagnosis because the child or parent doesn't think the child is constipated.  The second is to think that because the presentation is acute, the problem just needs a brief period of treatment.  If they are constipated enough to present with acute pain, the problem is chronic and should be treated as such as per NICE guidelines.
Urinary Tract Infection - Abdominal pain +/- vomiting without diarrhoea is a common way for children to present with UTI.  There is no absolute rule on when and when not to test a urine but it is fair to say that significant diarrhoea usually precludes it for a couple of reasons.  In all other cases of acute abdominal pain, it is usually a good idea even if interpreting the result is not completely straightforward.
Colic - Truly a diagnosis of exclusion, but this can be a good history and examination. What to do with colic is covered here.
Appendicitis - Uncommon but not so rare that you won't see a case every now and then. Picking them out from the crowd can be difficult.  Good simple analgesia and reassessment after an hour is often a helpful discriminator for the grey cases if you can do that.
Testicular torsion - Inguinal and genital examination is part of the examination of a male presenting with abdominal pain.  Do it, even if the last 100 times were normal.
Intussusception - Rare but deadly.  Episodes of pallor and signs of being significantly unwell are reasons to suspect intussusception.  Bloody and mucousy (recurrent jelly-like) stools make it easier to diagnose but may be a late sign.
Diabetic Ketoacidosis - It is very easy to see how first presentations are initially diagnosed as viral illnesses.  If you've got a child who's a bit more lethargic or subdued than your typical gastroenteritis case, or if there is a report of polyuria, test a glucose.

In most cases, significant causes will be excluded by a thorough history and examination.  Often a urine test is a good idea and sometimes a second opinion will be necessary.  Abdominal X-ray is almost never useful in making a decision about referral.

Paradoxically,  the wrong sort of confidence comes from repeated experience of nothing bad happening.  The right sort of confidence comes from knowing that bad things will happen and knowing that we're ready for that eventuality.  This often happens once you've experienced the sharp end of an unexpected diagnosis.  If that has happened, congratulations!  You're now an expert.

Edward Snelson
Experienced if not Expert

Disclaimer - Experience doesn't always lead to expertise but it's a fairly important element. Bad experience is a good wad to develop great expertise but only if you have all the right elements in place to ensure that you learn without becoming a second victim.  I would like to see more work in that area, especially at the Primary/ Secondary Care interface.

Quick and Easy FOAMed – Fallacies and Facts About Foreskin Problems in Children

In case you hadn't noticed, there is now a guideline for everything.  It is impossible to keep up. FOAMed can be really useful in that respect because it should keep a finger on the pulse for you and give you a condensed version of the important things, allowing you to be selective about when you go into something in more detail.  The way it works is that I read the guideline, just in case you don't get the chance.  (insert cheeky winking emoji here)

Nor can you rely on guidelines, alerts and journals to cover everything, despite the sheer quantity of them.  The nature of FOAMed is that it often covers the things that haven't earned a guideline, are not deemed worthy of an alert and have too little academic value to have a published article.  Some things that are over-represented in practice are under-represented in paper.  By way of example, I give you foreskins in children.  I think that the lack of publications on the subject is surprising considering the number of children attending primary and secondary care with this problem, and considering how much is often misunderstood about foreskins in pre-pubertal children.

At some point in my medical training I remember being taught that uncircumcised penises should easily retract by about 3-4 years old and that they should be kept clean.  Balanitis was seen as evidence of poor hygiene and so we were told that more cleaning was the solution.  Foreskins that were ‘non-retractile’ were considered abnormal and if there was recurrent balanitis or ballooning, the child should be considered for circumcision.  We now believe that all of this is untrue.  It is quite normal for the foreskin to remain adhered to the glans until they hit puberty, whenever that may be.  Ballooning is within normal limits and balanitis is often due to unnecessary attempts to retract or clean under a foreskin.  Recurrent balanitis is usually an indication to leave the foreskin alone, rather than to cut it off.

So I know that I was taught something that later turned out to be untrue and I know that many clinicians in both primary and secondary care haven’t heard the good news.  Why?  Presumably because it isn't seen to be worth a guideline, alert or journal article.  There is stuff out there, but not a lot.  This was the best article that I found. (1)

But the lack of literature is not a problem in the brave new world of FOAMed.  FOAMed comes in many different shapes and sizes.  Often it takes the form of a written piece, but some have embraced the infographics approach.  Most notably there is the excellent library of infographics that has come out of the Derby Emergency Department. (2)  I was inspired by Ian Lewins making infographics sound like a good thing so I'm having a go with it.  Here's the result:

An infographic is, by nature, pithy and lacks detail but hopefully it gets the job done.  I've gone for substance over style. I know that if I had given the job to a medical student, they probably would have been much better with the visual effects.  They would also have made sure there were more pictures.  Somehow, this didn't seem like the best subject with which to take that step.

Edward Snelson
President of the Sir Lancelot Spratt Association
Disclaimer:  Anyone can do this stuff.  If you want to have a go at making infographics and want to find out more about rickrolling, click this link.

  1. Drake T, Foreskin problems in boys, Trends in Urology and Men's Health, March/April 2014

    Time for Child Advocacy – 10 things to keep kids safe

    Don't you love it when someone brands something that you've always been doing?  Advocacy is nothing new, but by making a big deal of it, we are all prompted to think about how we can do more of it and do it better.  Every consultation involving a child or young person will tend to include a bit of advocacy.  I am doing it every time I tell a parent that when their febrile child is refusing to drink, that usually means that they are in pain.  Parents sometimes think that paracetamol and Ibuprofen are just for reducing fever.  Part of my job is to put analgesia on the agenda.  It is the perfect time to do it because this is when the parents want their child to feel as well as possible.

    Similarly, the impact of safety advice is greatest following an injury.  So when a child or young person comes to me with a mishap, I try to work a bit of prevention in alongside the cure.

    Injury is the leading cause of death in children over the age of one in the UK. (1)  So, while we worry about sepsis and meningitis, preventing injury may be the real battleground.  Injury is inherently preventable, as demonstrated by the massive difference between rates in different countries.  It is not just lethal injury that is important.  In fact, to the children themselves it is the debilitating injuries that really matter.  Missing a sporting event or the ability to swim just before a holiday is the end of the world.  Or at least it is when 'the future' is essentially the next month or so.

    What I do is to try to throw in something relevant to the presentation.  Whether injury or ingestion, there are lots of ways that we can make the environments of children and young people safer.  Here are a few that are worth spreading the word about to parents and colleagues:

    1. Warn parents of babies and toddlers about common choking hazards

    Have you ever wondered why pen lids have a hole in the top?  Before that little innovation, these were common choking hazards.  Anything that fits neatly into the windpipe runs the risk of a fatal choking episode.  The list of dangerous things includes many food and playthings that parents readily give to their children.

    I think that any household mishap is a good opportunity to warn parents about choking hazards.  Prevention can include avoidance.  Supervision is also great but only if you know what to do, and with choking, prevention really is better than cure.

    2. Make sure that children can't get hold of button batteries

    If you were not aware of this, button batteries are incredibly dangerous to children.  There is a misunderstanding about these miniature killers.  It is not the contents leaking that are dangerous, it is the electrical current which forms corrosive chemicals outside of the battery.  Button batteries have become more powerful, in order to meet the demands of today's toys and gadgets.  When swallowed, the current may burn a hole in the gut (usually the oesophagus) and bleeding can be fatal.  A swallowed button battery needs to be located as an emergency in case it is stuck, as these carry the highest risk.

    I find that many parents don't know about this, so I often mention it when a child has swallowed something concerning but less harmful, like a diamond ring.

    3. Make sure that liquid gel detergent capsules are kept away from children

    Ask any ophthalmologist what common household item is most dangerous to children's eyes and I am willing to bet that they say liquid gel detergent capsules.  Why?  They are the perfect thing to cause massive damage.  Firstly, they look very appealing to a child.  They are brightly coloured and a bit like something that might be good to eat.  If bitten into, the contents come out under pressure, so the eye has no time to protect itself from the contents.  The contents themselves are a highly concentrated alkali which will burn and dissolve the thin layers of the eyeball.  While the industry has made some moves to warn people to keep these away from children, such messages can be interpreted as a standard bit of advice, which does no justice to the fact that these capsules are far more dangerous than the standard bottles or boxes of detergents.

    So when a child has had a mishap with another item, I like to warn parents about other things that they may not have thought about.

    4. Recommend that all children with a bike wear a bike helmet.

    Heads injuries are the most common cause of fatal injury in children.  Bikes are great fun and a good way for children to keep fit.  Unfortunately, injury is all about physics.  I have yet to see a child run into something and have a significant head injury.  Bicycles however, allow a young person to gain enough momentum to do real damage even if another vehicle is not involved.  While it can be difficult to persuade young people to wear helmets, they are the must have accessory for anyone who likes their brain or their face.  Road rash on the face is not a good look and helmets do a decent job of protecting the face from being badly grazed in a fall from a bike.

    I emphasise the facial injury as much as the head injury prevention as it often means more to the young person involved.

    5. Advise a bit of trampoline safety

    Trampolines are a favourite for all ages.  They are also one of the biggest sources of injuries that come into children's emergency departments.  While I am not suggesting that trampolines should be avoided, the risk of broken bones can be minimised.  One of the common factors in many of the worst trampolining injuries that I have seen is that there has been another person involved.  The worst injuries tend to occur when a small child is on the trampoline with an older child.  I would recommend that younger children in particular should never have someone larger than them on the trampoline.  Ideally, they should be on the trampoline alone, with onlookers cheering them on.

    6. Make sure that parents lock up medicines

    Medication packaging always has on it 'keep out of reach of children.'  What this fails to take into account is the incredible resourcefulness of children who may seem to small to get up to cupboards or high shelves.  I can tell you from experience that nowhere is safe.  The only completely safe place for a medicine is in a locked cupboard or box.  Nor can you rely on 'child proof' containers to prevent accidental poisoning.  Child proof containers seem to be adult proof (It can't be just me that struggles with the tops) while children who have time on their hands always seem to get them open in the end.

    7. Know about the surprise household poison - plug in air fresheners

    Many plug in air fresheners contain essential oils.  These chemicals are potentially incredibly poisonous due to their ability to dissolve into brain tissue.  Parents are frequently surprised by this fact so it is well worth letting people know about this dangerous household item.  People are also surprised by the ability of toddlers to drink the contents of these plug ins if they get hold of them.  I don't know how they do it.  And why won't they eat their vegetables???

    8. Warn parents to beware of the sun

    When the sun comes out and children quite rightly make the most of it, we often end up seeing children with quite severe sunburn.  Babies are especially at risk due to their thin skin and lack of protection from the sun.  Make sure that people know that children can get deep burns from the sun and that prevention is key.  Children are also vulnerable to the dangers of overheating so hydration and sun avoidance are important when the sun is out.

    9.  Remind adolescents to respect water

    It is great that young people use the opportunity of time off school to go and have a bit of an adventure.  One way that this sometimes goes very wrong is when water is involved.  Getting into trouble in water is all too easy.  The simplest way to avoid the danger is to make sure that all swimming is done in appropriate areas.  Tempting though it is to jump into a reservoir or an abandoned quarry full of water, this is very high risk.

    10.  A surprise danger – twilight

    Now for the sciency bit…  Twilight is a very dangerous time for pedestrians and young people are already very much at risk due to their lack of perceived mortality.  Why is it dangerous when the sun rises and sets?  The answer is probably due to a little known chemical (found in the eye) called rhodopsin.  This is the chemical that enables the eye to adjust to lower levels of light.  The trouble is that it takes many minutes to produce the chemical and only seconds for a flash of light to get rid of it completely.  As a result, drivers can have their ability to see reduced very suddenly by a moment of setting or rising sun, allowing a person in the shadows to become almost invisible. (3)

    It is important to teach young people road safety, but also to let them know that at certain times of day, drivers may not see them at all.
    We're already making every consultation matter.  Giving parents a little suggestion every now and then about how to make their child's environment a bit safer is just another way of adding to the difference we already make.  Paediatrics is so rarely about preventative medicine but when a child has a mishap, we have a golden opportunity to discuss ways to avoid the next accident.

    Edward Snelson
    Chronic Avoider

    FOAMed is free.  The clue is in the name.  That said, if anyone would like to celebrate their enjoyment of the free open access education provided by GPpaedsTips by helping children to receive the best possible care, I have set up a donation page where I am raising money for a new Sheffield Children's Hospital Emergency Department.  For more information about this or to donate, click on the link in the Just Giving logo:
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    1. RCPCH, "Why children die: death in infants, children and young people in the UK"
    2. AAP, "Prevention of Choking Among Children", February 2010