Investigations in Bronchiolitis – Help a Brother Out

One of the things that a crisis should do is to bring people together.  As the UK's National Health Service experiences a winter that is bringing  it to it's knees, we should be more aware than ever that Primary and Secondary Care need to work together as a team so that we all come out the other end of this intact.  There are those in each camp that are so entrenched in the us-and-them mentality that this idea of teamwork is against  their very being.  If you think that General (family) Practitioners (GPs) are lazy idiots or you think that hospital doctors are arrogant and lack communication skills, I'm not sure that I've got anything to help you.  (Perhaps a hug?)  If you are willing to believe that we are all part of a team and that any divisions are both understandable and resolvable, read on.

The issues that cause division are (in my experience) usually due to misunderstanding and a lack of insight into the part that we play in creating these disparities.  The irritations that I cause my colleagues, whether in Primary or Secondary Care, tend to be completely unintentional.  Sometimes it can be what seems like the smallest thing and I have no idea of the impact it has on someone else.  That's why it's so important to talk to each other.

Let me describe an example: the seemingly simple act of requesting a chest X-ray for a baby with bronchiolitis.

Bronchiolitis is usually a set piece.  An infant, usually under 12 months old, gets inflammation in their airways during a viral respiratory tract infection.  This leads to a three to five day period of increasing symptoms that usually consist of cough, wheeze, difficulty feeding and increased work of breathing.  In practical terms, that might play out like this:

Monday - A three month old is snotty and coughing but well and feeding nicely.  Breathing will probably be normal at this stage.

Tuesday - The parents have now noticed some noisy breathing and that feeding isn't as good as it normally is.  like many people in these circumstances, they seek a medical opinion and so go to their GP.  They are seen and the diagnosis of bronchiolitis is explained.  The clinician advises frequent small feeds and gives safety-netting advice for what to look out for in case this child becomes one of the very small minority who develop breathing or feeding difficulties that require support as an inpatient.  In keeping with NICE guidelines (1), they do no tests and give no treatments.

Wednesday - The parents have noticed a slight worsening of the feeding and are unsure about whether this is bad enough to need something to be done.  They hold off doing anything during the day but when their baby refuses an evening feed they take their precious bundle to the local emergency department.  There the child gets a thorough assessment.  Clinically the infant is well hydrated and although they have wheeze and mild recession they are looking happy and have oxygen saturations of 95% in air. Despite the earlier feed refusal, they now take 100 mls of milk. The assessing clinician hears a few crackles in the chest and decides to do a chest X-ray, just to be sure that today's worsening symptoms are not due to a bacterial pneumonia developing.

When is it necessary to do a chest X-ray for babies with bronchiolitis?

There are many possible complications of bronchiolitis.  In theory, these should be apparent on a chest X-ray.  There are also conditions that mimic simple bronchiolitis, most notably congestive cardiac failure.  So, a chest X-ray seems a sensible thing to do to add value to the assessment.  Except that it doesn't, for two main reasons.

These are the reasons why a chest X-ray doesn't add value to the assessment of a typical presentation of bronchiolitis:

  • There is always something to be seen on the X-ray.  If you are looking for normal, you are unlikely to find it.
  • If the infant has bronchiolitis, that is enough explanation for their clinical condition.  If they had a complication such as lobar pneumonia as well, you would't be doing the chest X-ray to see if there is a problem, you'd be doing it because the child is seriously unwell.

Coming back to our little one with bronchiolitis, let's assume that the chest X-ray shows what it always shows in bronchiolitis - something of uncertain significance.  There will be a little fluffy shadow somewhere due to the mucous plugging and atelectasis that is part and parcel of bronchiolitis.  Often, there is something to be seen at the right heart border (or as a wise radiologist once redefined for me: "the area of radiological romance") which may or may not be something.  Once seen, it is very difficult not to feel the need to treat for possible bacterial infection.  This brings me on to the next few reasons for not doing a chest X-ray.

Doing a chest X-ray in bronchiolitis is associated with increased antibiotic prescribing rates.  Bacterial superinfection in bronchiolitis is rare and is usually clinically apparent.  Bronchiolitis is reason enough to have respiratory symptoms.  If a baby also develops pneumonia, they are usually quite unwell and have a marked degree of distress.  So, following that logic, for our baby the antibiotics are simply unnecessary, in which case they may do harm.  Since one of the problems that comes with bronchiolitis is feeding and hydration, why give these babies a gastric irritant?

Finally, there is a second victim here: the clinician who saw the baby on Tuesday.  Despite sterling work by the GP, the parents are likely to believe in retrospect that they were given a poor service.
All the evidence is there:

  • The person that they saw in the community did nothing and their child became worse.  
  • The experts in the hospital did a test which showed that their baby needed antibiotics.
  • Antibiotics were given and eventually the bronchiolitis got better. 

Why didn't the GP do something when we went the first time?

Of course both clinicians in this story were trying to do their best for the patient.  Neither of them had anything on their mind other than trying to ensure the best outcome for the child. There was no disrespect intended and no one wanted to cause anyone any problems.  We are all just trying to get through the day and to keep our patients safe and well.

Thankfully, it turns out that in bronchiolitis, keeping your patient safe and well is probably best done without the use of chest x-ray and antibiotics.  So, we in Secondary Care can help our colleagues in Primary Care out by making the assessment that needs to be made: in or out (of hospital)?  That decision is made on clinical grounds and if they need to be admitted, a chest X-ray may be useful.  Maybe.

Edward Snelson
Vice President of the Guild of Doing as Much Nothing as Possible
@sailordoctor

Disclaimer:  I did a chest X-ray for bronchiolitis once.  There was a white patch at the right heart border but it turned out to be tippex on the screen.

Reference

  1. Bronchiolitis in children: diagnosis and management, NICE guideline [NG9] Published date: June 2015



Something Old and Something New – Social Media and Young People’s Mental Health

And now for something completely different...

While we tend to associate winter with infections and respiratory complaints in children and young people, it is also a time of increased mental health problems in young people.  It is often asked, "Is there a genuine rise in mental health problems in young people?  Are we just recognising it better?  Have we simply moved the goalposts so that what was once called normal is now labelled as mental heath problems?"  There has been an apparent increase in mental health problems in young people in the UK according to the best evidence.  Various factors are thought to be contributing, and the rise of social media use is one of these factors.

Allow me a story to give some context to the world in which we now live.  Since we are currently within the centenary of the first world war (WW1), this story I'm going to tell you is one of modern times.

Three months after the outbreak of WW1, a German warship, the SMS Emden, had been causing havoc in the Pacific.  She had captured or sunk ships running into double figures and the captain decided that it was time for the ship to have some repairs and the crew to get some shore leave.  He steamed into the island of Diego Garcia, which was at the time under the control of the British.  Despite being three months into a war between these two countries, not only was there no resistance from the British garrison but the local force welcomed the cruiser, helped with the repairs and presumably made them all tea.  Why?  Because the British Garrison didn't know that they were at war.  No information about the hostilities between the two nations had reached them.  True story.

Fast forward a few generations and think about the world that our young people live in.  Everything is fast, if not immediate.  Everything comes with an expectation (I know what a few dozen people think about the next hotel I'm going to stay in) and gets rated and reviewed.  One of the problems of modern times is that this is happening to our young people, not just to hotels and restaurants.  they are themselves being rated and given instant, sometimes brutal feedback every time they go online.

One of the known risks to mental health is any detrimental effect on self esteem.  If the world tells  a young person that they should be thin and beautiful and rich often enough, this has an effect on their self esteem.

Another problem that comes with social media is that it is a fickle friend.  Young people need to feel accepted or validated as part of a healthy psyche.  When something brings you down, it helps to have a solid person in your life to let you know that you are an OK human being.  Social media has made it possible for young people to be connected to hundreds of others.  The trouble is that what these 'friends' or followers say or don't say can be detrimental. Online interaction can be any degree of unpleasant and all varieties of negativity are seen in various forms.

Social media gives you a value.  How many online friends do you have?  How does that compare to other people?  How many 'likes' did your latest selfie get?  Why so few when someone else in your class got 300 likes?



The online world brings a great deal of opportunities for young people but it also brings risk.  If a young person is vulnerable to mental illness, then the negative effects of social media can be the trigger. (1)

What can be done about the risk?  If a young person is showing signs of mental health problems then we need to be able to offer helpful advice.  The debate about how to intervene is never-ending.  This week, Facebook was in the news for its new under 13 year old version of Messenger, which Facebook is currently testing.  Facebook argue that since 12 year olds simply pretend to be older online, it is preferable to have a safer version of Facebook, specifically designed for this age group.

Most discussions around the issue of social media and the risk to young people's mental heath centre around parental controls and managing the media.  Another way to approach the issue is to concentrate on everything but the social media itself.  Emphasise everything that is likely to have a positive effect on that young person's mental health:

  • Stable relationships
  • Positive family interaction
  • Affirmation
  • Participation in hobbies and sport

Many parents and carers find that it is an impossible or divisive task to police and interfere with a young person's social media use.  Parents need to know that they can intervene positively in their child's social media use.  However, if that seems to be exacerbating any stresses, it may be more constructive to fill the voids in that young person's life with things other than social media.

To return to the original question, mental health problems in young people do appear to be on the rise.  Recognition of mental illness is just one of the challenges that we face.  Prevention and treatment are seemingly unachievable within the resources available, however we need to take the issue of mental health as seriously as we do any other group of  childhood illnesses.

It is probably unnecessary to get caught up in a debate about whether social media is to blame for the rise.  Adolescence is a time of emotional vulnerability and any trigger can be to blame for a mental illness.  The negative effects of social media are one possible trigger.  We need to be aware of this and share this knowledge with families who present with concerns about the mental health or an adolescent.

Edward Snelson
Looking for validation elsewhere thankfully
@sailordoctor

Disclaimer:  Rather than my usual nonsense, I would like to allow myself a serious footnote.  Over the time I have been writing GPpaedsTips, I have noticed what gets the most and the least attention.  If I was to maximise the numbers of shares and clicks, I would never mention mental health ever again.  Although we should indeed be interested in treating asthma and sepsis, suicide remains a leading cause of death in young people (2) and the impact of mental health problems in adolescence is massive.  Although I wouldn't normally ask, please share this post.  How else will I be a valid person if I don't get enough likes?  If I get enough clicks on this post, I promise to write about sepsis next time.
  1. O'Keeffe, G. et al, The Impact of Social Media on Children, Adolescents, and Families - Pediatrics April 2011, Vol 127, Issue 4
  2. Pearson. G et al, Why children die: avoidable factors associated with child deaths, Arch Dis Child (2010). doi:10.1136/adc.2009.177071

    Is Montelukast Too Easy?

    How much does the acceptability of a treatment matter when compared to the efficacy of that treatment?  This is a decision that we all make, consciously or unconsciously when prescribing for children.

    For example, ten to twenty years ago, it was not uncommon for children to be given salbutamol in a liquid preparation.  The decision to give this preparation (rather than via MDI and spacer) probably went something like this:
    1. A very small person is wheezy
    2. A parent wants a treatment for the wheezy small person
    3. It is difficult to give inhaled bronchodilators to small people
    4. There is a liquid preparation of salbutamol available
    At the time, there was probably also an element of inertia which came from the era before the invention of the spacer.  Until spacers came on the market, liquid preparations were the only option for young children.  So despite the change in what was available, it is not surprising that some continued to use what  they had used previously.  Now, I never see children on salbutamol syrup.  Inhaled therapy is the best treatment option and ease of administration is overruled by the superiority of child-friendly spacer devices.

    Ease of administration, acceptability of taste and lack of side effects all make a considerable difference to the effectiveness of medicines in children.  One of the most common examples of this is phenoxymethypenicillin, often used for suspected streptococcal throat infections.  It has a vile taste and is often rejected by the child after the first few doses.  It can't work if the child won't take it.  Fortunately it is often not needed, so it doesn't matter when the child votes with their feet.

    By contrast, montelukast is one of the great success stories of child-friendly medicines of recent times.  It comes in a chewy tablet or sprinkles.  It's like being Dr Willy Wonka when you prescribe montelukast for children.

    Acceptability is not the only factor when it comes to effectiveness.  There has to be a proven clinical efficacy.  Otherwise, montelukast becomes the salbutamol syrup of our generation.  Just because it's a medication for wheezy children doesn't mean it will work in every clinical scenario.  Just because it is easy to administer doesn't mean it should be the first line treatment.

    A recent article in the Archives of Disease in Childhood (1) did an excellent job of exploring the evidence for montelukast as a treatment in the various phenotypes of childhood wheeze.  This was no mean feat considering how many there are and that these phenotypes are variously defined and hotly debated.

    Here is a summary of what they found:

    Bronchiolitis* and montelukast

    Unsurprisingly, montelukast can be added to the list of things that don't work when a child under the age of two has wet, inflamed airways (without bronchospasm).  No doubt we will coninue to look for an effective treatment but so far nothing has worked.  The management of bronchiolitis remains the art of doing as much nothing as possible, while knowing exactly when to do something.

    * Bronchiolitis is defined slightly differently in the UK  to the USA.  In the UK, it is mainly infants under the age of 12 months with wet lungs of viral aetiology who are given the label bronchiolitis.  In the USA, the definition includes young children with viral induced bronchospasm.  This is why the UK guidelines recommend that bronchodilators are not used, while the guidance in the USA is that they an be tried.

    Viral Wheeze (Viral Episodic Wheeze) and montelukast

    There is some conflicting evidence for the use of montelukast both as prevention and as rescue treatment for pre-school children who develop bronchospasm only when they get a viral URTI (i.e. no other triggers and no chronic symptoms).  However, a Cochrane review (2) did not find the evidence needed to support the use of montelukast as rescue therapy or as a preventative treatment for viral wheeze.  So it seems that it's not really useful for these children either.

    Multi-trigger Wheeze (aka asthma in the under 5 year olds) and montelukast

    If you weren't already aware, there is debate about whether children under the age of five should be diagnosed as asthmatic even when they have interval symptoms and wheezy episodes which are not exclusively triggered by viral episodes.  Some are calling this asthma and some call it viral wheeze.  Arguably, it doesn't matter too much what it is called so long as we use evidence based treatment and we avoid mislabelling children who do not fit this phenotype.  For example, it would be a mistake to say that viral episodic wheeze is the same as asthma since the latter benefits from inhaled corticosteroids (ICS) and the former does not.  With multi-trigger wheeze and asthma in the under five year-olds, we essentially have two names for the same clinical scenario.

    The article in ADC notes that the BTS/SIGN guidance recommends leukotrine receptor antagonists (LTRAs) as the next step after low dose inhaled corticosteroids or as first line treatment where the ICS is not tolerated.

    The authors go on to note that while there is good evidence for benefit in this group of children, the effects of montelukast are moderate and clinically inferior to ICS.  Also, there is no evidence to show that montelukast is effective above and beyond the benefit of ICS therapy.  So, if there is a treatment with good evidence for superiority, how badly does a child have to not tolerate that treatment before you reach for the next option?

    Since effect and tolerance are both important factors in the efficacy of a treatment, we need to consider both factors.  Clearly if one factor is the same between two option, then the other is the deciding factor.  In the case of the asthmatic/ MTW three year old, you may be faced with a difficult choice:
    • Inhaled corticosteroids, which their parents are struggling to give
    • Montelukast which is clinically inferior to inhaled corticosteroids but which the child might happily take
    If only we had a formula to help us decide...  So, I made one up.  After all, paediatrics is full of things that were invented by clinicians based on what they believed to be true.
    So let's try this out.  Say that ICS therapy has a 90% likelihood of improving symptoms and that montelukast has a 20% likelihood.  Then say that parents will manage to give the montelukast every day and that they would manage to give the inhaled corticosteroids half of the time.  This gives us a BS cubed number of 0.11 for the steroid inhalers and 0.2 for the montelukast.

    Although the formula is made up, the point is valid.  Efficacy and concordance are the key factors in determining effectiveness.  Since we can't change the efficacy of a treatment, we are only able to influence the concordance.  In the example given above, if we could improve the concordance then this is a complete game changer.  This is where a full team approach comes in.  The prescribing clinician can emphasise the superiority of ICS over other treatments.  The pharmacist can make a huge difference by a good explanation and demonstration.  This can all be reinforced by a practice nurse who reviews technique and encourages the use of the inhaler, giving tips and tricks about how to get the child to take their inhalers.

    Persistence counts for a lot with inhaler therapies.  There are few (if any) children who immediately take to the idea of having a mask put on their face and few parents who find it easy to use the inhaler/ spacer combination well with a moving target to begin with.  In time, children come to accept that the inhalers will be given and parents usually find that giving them becomes easier.

    If the easy treatment was also the most effective, that would be brilliant wouldn't it?  For some reason, that rarely seems to be the case.  Is montelukast too easy?  If it makes us choose it over trying everything possible to get the inhaled therapy to work, then the answer is yes.

    So, choose the treatment with the biggest boom and maximise the sweetness of the delivery.  It that way, the child who will benefit gets the best possible treatment in the most effective way.

    Edward Snelson
    Order of the Philosophers of Mathematics
    @sailordoctor

    Disclaimer - although a made up formula, there is good reason for applying a factor to the concordance.  In very few cases does half the treatment have half the effect.  Small moves away from the centre of the therapeutic window of a drug make a very big difference to the effect that it will have.  I wanted to use a round number for simplicity but I would be willing to bet that the reality for most treatments lies somewhere between squared and cubed.  Wouldn't it be great if the answer was really that the factor was pie?

    References
    1. Haq et al, Should we use montelukast in wheezy children? Archives of Disease in Childhood, October 2017
    2. Brodie M et al, Leukotriene receptor antagonists as maintenance and intermittent therapy for episodic viral wheeze in children Cochrane Database Syst Rev. 2015 Oct 19