I read Davison et al’s paper with great interest. Congratulation for this summary of how, fortunately and/or probably, most experienced paediatricians routinely communicate with children and their families: the strength of their paper is that it describes in simple words good communicating skills which most paediatricians consider as obvious although without having themselves the capability to describe them so well. One of their suggestions deserves some discussion though: In Box 1, Davison et al recommend to ask the children permission to ask them or their parents a few questions. Involving patients is a requisite in a shared decision making model. Children’s views must be respected, as stated in the article 12 of the 1989 Convention on the rights of the child 1. However, given a child’s capacity of discernment, parental views may be necessary. If the child denies the permission, how will then the paediatrician seek parental views? Will the child consider his/her paediatrician as a trustful “friend” if he/she doesn’t respect his/her objection to question his/her parents? Will the child still trust his/her paediatrician if he/she tries and convince him/her to change his mind? It is a fair to give a choice to a child as long as the choice can be respected.
I read Davison et al’s paper with great interest. Congratulation for this summary of how, fortunately and/or probably, most experienced paediatricians routinely communicate with children and their families: the strength of their paper is that it describes in simple words good communicating skills which most paediatricians consider as obvious although without having themselves the capability to describe them so well. One of their suggestions deserves some discussion though: In Box 1, Davison et al recommend to ask the children permission to ask them or their parents a few questions. Involving patients is a requisite in a shared decision making model. Children’s views must be respected, as stated in the article 12 of the 1989 Convention on the rights of the child 1. However, given a child’s capacity of discernment, parental views may be necessary. If the child denies the permission, how will then the paediatrician seek parental views? Will the child consider his/her paediatrician as a trustful “friend” if he/she doesn’t respect his/her objection to question his/her parents? Will the child still trust his/her paediatrician if he/she tries and convince him/her to change his mind? It is a fair to give a choice to a child as long as the choice can be respected.
Dear Sir, Mulholland et al. make some very important points but I think understate the importance of bedside teaching. The only learning that ever stuck with me as a junior doctor was when it took place in relation to a clinical scenario involving a patient. Nothing has hurt training more than the reduction in exposure to patients either as in-patients or in the out-patient setting. It is an unavoidable consequence of the reduction in working hours but the feedback trainers give to trainees when reviewing patients is still the most important part of their learning. The only problem now is that the trainee is probably not rostered on for the next week. The importance of this patient interaction is highlighted by the fact that undergraduates are now learning their basic anatomy, physiology etc. in the context of clinical scenarios and meeting real patients. This is a major step forward for undergraduate training and something I am very pleased to be involved in. Unfortunately, in my opinion, post graduate training has gone in the opposite direction and there is not a lot we can do about it other than increasing the length of training programs. The way we now work means that trainees see fewer patients and therefore learn more slowly. We can organise as many study days as we like but it does not compensate for that loss.
In order to avoid repetition of the mistakes that have been made in the ascertainment of asymptomatic status in adults who might have COVID-19 infection(1) healthcare practitioners in paediatrics must ascertain the full currently known range of COVID-19 symptoms before a child is declared to be asymptomatic. In the event of an oligosymptomatic or monosymptomatic clinical presentation each of those children with sparse or atypical symptoms should be fully followed up to ascertain if the "stand alone" symptoms are "joined" by new symptoms or whether the oligosymptomatic status persists throughout the course of that child's illness. Finally, in conformity with the principles of Bayes' Theorem, frontline healthcare workers should be issued with a nomogram spelling out the post test probability of COVID-19 infection(2) in the event of a negative RT-PCR test result. The nomogram should be the subject of regular re-evaluation and updating, on the basis of new information about the authenticity of new symptoms reportedly associated with COVID-19. I have no funding and no conflict of interest References (1) Saurabh S., Vohra S What should be the criteria for determining asymptomatic status in COVID-19 QJMed 2020;doi.org/10.1093/qjmed/hcab002 Article in Press (2) Chan GM Bayes theorem, Covid-19, and screening tests Amer J Emerg Med 2020;38:2011-2013
Paediatric Anaesthetic Training During COVID-19: The UK National Paediatric Anaesthesia Trainee Research Network (PATRN) Swift Survey
The Paediatric Anaesthesia Trainee Research Network (PATRN) Committee read with great interest the findings of the national survey of paediatric trainee experiences during the Covid-19 pandemic from Harmer et al. The re-deployment of anaesthetic trainees to support the surge in demand from adult intensive care, postponement of elective surgery and pauses to trainee rotations1 all affected access to sub-specialty training in anaesthesia. Thus, PATRN conducted an equivalent national survey evaluating the impact of the pandemic on training in paediatric anaesthesia from March to August 2020.
A survey questionnaire consisting of Sixteen questions focussed on trainee experience of paediatric anaesthesia during the first wave of Covid-19 infections, from March to August 2020. Paediatric anaesthesia experience in the UK occurs at all stages of training, with the option for an additional ‘advanced’ module. The survey was reviewed by members of the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) Scientific Committee. Distribution was via email to all UK-based trainees by College Tutors and the Anaesthetists in Training Representative Group (ATRG) through The Royal College of Anaesthetists (RCoA) and APAGBI trainee members from December 2020 to March 2021.
Paediatric Anaesthetic Training During COVID-19: The UK National Paediatric Anaesthesia Trainee Research Network (PATRN) Swift Survey
The Paediatric Anaesthesia Trainee Research Network (PATRN) Committee read with great interest the findings of the national survey of paediatric trainee experiences during the Covid-19 pandemic from Harmer et al. The re-deployment of anaesthetic trainees to support the surge in demand from adult intensive care, postponement of elective surgery and pauses to trainee rotations1 all affected access to sub-specialty training in anaesthesia. Thus, PATRN conducted an equivalent national survey evaluating the impact of the pandemic on training in paediatric anaesthesia from March to August 2020.
A survey questionnaire consisting of Sixteen questions focussed on trainee experience of paediatric anaesthesia during the first wave of Covid-19 infections, from March to August 2020. Paediatric anaesthesia experience in the UK occurs at all stages of training, with the option for an additional ‘advanced’ module. The survey was reviewed by members of the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) Scientific Committee. Distribution was via email to all UK-based trainees by College Tutors and the Anaesthetists in Training Representative Group (ATRG) through The Royal College of Anaesthetists (RCoA) and APAGBI trainee members from December 2020 to March 2021.
The findings were reflective of those identified by Harmer et al, with changes to work schedule being commonplace. 90/170 (53%) of respondents, representing all stages of training, were due to complete a paediatric training module during the specified timeframe. Only 23% remained working in paediatric anaesthesia, almost all of whom were undertaking ‘higher’ or ‘advanced’ modules (n=19). The majority of trainees who experienced disruption with re-deployment was to support adult intensive care (33/69; 48%). Many trainees did not have sufficient paediatric cases to achieve module sign off (32/66; 48%), due to re-deployment or a lack of elective training lists. Most trainees felt they had insufficient paediatric experience for progression of training (37/69; 54%).
In addition, teaching sessions were reduced; 52% (90/170) of respondents reported fewer sessions compared to pre-COVID, despite delivery of virtual sessions. 84/170 (49%) of respondents were able to undertake extracurricular activities for personal development, including training other staff, writing COVID protocols, quality improvement projects and COVID research.
Training in paediatric anaesthesia relies upon ‘hands-on’ experience to develop confidence. Our findings reflect the RCoA’s efforts to minimise disruption to trainees at a critical stage of progression, however, the qualitative impact of COVID-19 is difficult to assess and relates to individual confidence. New ARCP outcomes2 have been created to identify the impact of COVID-19 on training and allow remediation. Following the acute phase of the pandemic, the authors feel access to training should be prioritised. This is of particular importance for junior trainees who have been unable to achieve sign-off or gain experience to feel well-equipped for progression. The survey findings support the requirement for ongoing open discussions at a national level on how to address these issues.
In the UK we are presently in the middle of a significant heatwave with July 2006 declared the UK's hottest month on record (1). Both the Department ofHealth and NHS direct have been quick to disseminate health advice (2) particularly to parents and healthcare workers responsible for the care ofchildren, about the dangers of heat exposure and dehydration. This advice has emphasised the need for...
In the UK we are presently in the middle of a significant heatwave with July 2006 declared the UK's hottest month on record (1). Both the Department ofHealth and NHS direct have been quick to disseminate health advice (2) particularly to parents and healthcare workers responsible for the care ofchildren, about the dangers of heat exposure and dehydration. This advice has emphasised the need for adequate fluid intake, particularly that of water. Notably parents have been encouraged to ‘give babies plenty of cooled boiled water throughout the day’ (3)Although we believe this to be sound advice to parents in the majority of situations, we believe it is important for clinicians to be aware of the risks of water intoxication, especially in infants. Water intoxication in children has previously been well described (4) and as being on the increase, if not reaching epidemic proportions in the United States (5). It can cause significant morbidity and mortality from hyponatraemia, brain swelling and seizures. Primarily associated with inappropriate dilution of formula feeds, bottled water has previously beendescribed as a significant cause (6,7). Children are at particular risk asit is thought that as well as renal function being immature, infants have a powerful thirst drive which may impede their ability to curb intake.Bhalla et al reported 4 cases in the UK of hyponatreamic seizures that were secondary to excessive solute ingestion in 1999 (8). As a paediatric intensive care retrieval service we have recently dealt with a previously normal hyponatraemic child presenting with abnormal neurology and seizures. A one-year-old child presented in status epilepticus following a 2 day history of vomiting during which time hypotonic fluids where administered. The child required iv lorazepam and one dose of rectal paraldehyde to terminate the seizure and was intubated, ventilated and transferred to a regional paediatric intensive care unit. Serum sodium on attendance was 116 mmol/L. The child was subsequently fluid restricted for 48 hours.Although we have insufficient evidence at present to implicate water intoxication in their pathogenesis we feel it is an issue that has not been addressed in the current DOH literature. This situation also emphasises the importance of parental education to the potential risks of this conditon.
Dr R M Kayani Retrieval FellowDr P Ramnarayan Consultant Paediatric IntensivistChildren’s Acute Transport Service, Great Ormond Street Hospital, London
2. ‘ Heatwave’ -A guide to looking after yourself and others during hot weather. Department of Health http://www.dh.gov.uk/assetRoot/04/13/53/04/04135304.pdf
3. Department of Health Website - http://www.nhsdirect.nhs.uk/articles/article.aspx?ArticleId=1955
4. Dugan S, Holliday MA. Water intoxication in two infants following the voluntary ingestion of excessive fluids. Pediatrics 1967;39:418-20.
5. Keating JP,Schears GJ, Dodge PR. Oral water intoxication in infants. AnAmerican epidemic.Am J Dis Child. 1991 Sep;145(9):985-90.
6. Bruce RC , Kliegman RM Hyponatremic seizures secondary to oral water intoxication in infancy: association with commercial bottled drinking water.Pediatrics. 1997 Dec;100(6):E4. Review
7. From the Centers for Disease Control and Prevention-Hyponatremic Seizures Among Infants Fed With Commercial Bottled Drinking Water--Wisconsin, 1993. JAMA 272(13),October 1994, pp 996-997
8. P Bhalla, F E Eaton, J B S Coulter, F L Amegavie, J A Sills and L J Abernethy
Lesson of the week: Hyponatraemic seizures and excessive intake of hypotonic fluids in young children 1999;319;1554-1557 BMJ
In his extensive guideline review of the glucocorticoid treatment in croup, in agreement with the conclusions of the Cochrane review (1), Baumer HJ (2) states that “in the absence of further evidence, the use of a single oral dose of dexamethasone, probably 600 µg/kg, should be preferred because of its safety, efficacy and cost-effectiveness”.
In his extensive guideline review of the glucocorticoid treatment in croup, in agreement with the conclusions of the Cochrane review (1), Baumer HJ (2) states that “in the absence of further evidence, the use of a single oral dose of dexamethasone, probably 600 µg/kg, should be preferred because of its safety, efficacy and cost-effectiveness”.
We believe this statement is not correct because a difference should be made between cases of mild-moderate and severe croup. In fact, before high doses of dexamethasone are used extensively in children with mild-moderate croup, some relevant questions need to be addressed.
Russel K (1) and Griffin S and colleagues (3) reviewed the data from several double-blind randomised clinical studies of inhaled budesonide in croup and found it to be significantly more effective than placebo. Several studies also show that nebulised budesonide, the effect of which starts within 30 minutes, and oral dexamethasone are equally effective (1,3). Given the evidence, it seems more cautious to choose inhaled ratherthan oral/injectable corticosteroids for mild-moderate croup treatment.Secondly it has been shown that a single low oral dose of dexamethasone (150 µg/kg), as suggested by the BNF for children (4), is equally effective in treating croup (5). This issue needs to be further addressed,given the potential adverse effects of high-dose dexamethasone in children.
Other than the need for further randomised controlled trials comparing different dexamethasone doses, as suggest by Baumer JH (2), we think that it could be more relevant to conduct studies comparing inhaled versus oral corticosteroids for the treatment of mild-moderate croup, withregard to their clinical onset of action and security profile.
References:
1.Russell K, Wiebe N, Saenz A, et al. Glucocorticoids for croup. Cochrane Database Syst Rev 2004; Issue 1:CD001955
2.Baumer HJ. Glucocorticoid treatment in croup. Arch Dis Child Educ Pract Ed 2006;91:ep58-ep60
3.Griffin S, Ellis S, Fitzgerald-Baroon A, Rose J, Egger M. Nebulised steroid in the treatment of croup: a systematic review of randomised controlled trials. Br J Gen Pract 2000;50:135-41
4.British National Formulary. BNF for children. London: BMJ Publishing, 2005:158
5.Sparrow A, Geelhoed G. Prednisolone versus dexamethasone in croup:a randomised equivalence trial. Arch Dis Child 2006;91:580-83
With interest we read the paper by Tighe et al about the use of pH-monitoring in childhood.(1) However, we believe that the authors overestimate the role of this technique and their omission of a detailed discussion of the utility of pH-impedance monitoring renders this review incomplete.
The term ‘gold standard’ can no longer be applied to 24-hour pH-monitoring because pH-probes only d...
With interest we read the paper by Tighe et al about the use of pH-monitoring in childhood.(1) However, we believe that the authors overestimate the role of this technique and their omission of a detailed discussion of the utility of pH-impedance monitoring renders this review incomplete.
The term ‘gold standard’ can no longer be applied to 24-hour pH-monitoring because pH-probes only detect a minority of gastro-oesophagealreflux (GOR) episodes.(2) Combined pH-impedance monitoring allows for the detection of all reflux (liquid, mixed, gas, acidic, weakly acidic, weaklyalkaline). With an increasing body of evidence showing a role for weakly acidic bolus GOR in symptom generation, the measurement of acidity alone provides an incomplete picture of the degree of bolus reflux and the relationship of bolus reflux to symptom episodes. Therefore, symptomatic reflux cannot always be excluded when a pH-study (acid exposure) is normal. The ability to detect bolus reflux, independently of acidity, allows symptomatic reflux to be more accurately detected. Not mentioned inthis article, is that there are statistical measures of association between GOR episodes and symptoms (e.g. symptom association probability score). By detecting all bolus reflux, pH-impedance monitoring markedly increases the yield of positive symptom association in infants and children.(3)
In addition, infants with GORD present differently from older children and, as other tests such as upper GI endoscopy are more difficultto perform in infants, the case for invasive functional testing may be greater for infants than older children. In infants, conservative management before any testing or pharmacological therapy is proven effective(4). However, with PPI therapy recently being shown to be ineffective in infants who fail such conservative therapy (5), pH-studies may in fact be justifiable on the basis of establishing acid-related disease when endoscopy is not possible. A recent study in such infants shows that the degree of symptom improvement on esomeprazole correlates with the level of acid exposure off therapy.(6) Nevertheless, the big issue with pH-monitoring is the cut off value of the reflux index used to diagnose pathological acid exposure. The fact remains that no outcome studies testing the value of the reflux index criteria are available. Until they are, clinicians need to be very conservative in interpreting these findings.
We contend that pH-impedance monitoring has greater clinical utility than pH monitoring alone, since it allows for a more complete investigation of reflux and the association of reflux with symptoms.
Sincerely yours,
Michiel P. van Wijk, Clara M. Loots, Taher I. Omari, and Marc A. Benninga
1.Tighe M, Cullen M, Beattie R. How to use: a pH study. Arch Dis Child Educ Pract Ed. 2009 Feb;94(1):18-23.
2.Wenzl TG. Esophageal pH monitoring and impedance measurements: a comparison of two diagnostic tests for gastroesophageal reflux. J Pediatr Gastroenterol Nutr. 2002;34(5):519-23.
3.Loots C, Benninga M, Davidson G, Omari T. Addition of pH-impedance monitoring to standard pH monitoring increases the yield of symptom association analysis in infants and children with gastroesophageal reflux.J Pediatr. 2009;154(2):248-52.
4.Orenstein SR, McGowan JD. Efficacy of conservative therapy as taught in the primary care setting for symptoms suggesting infant gastroesophageal reflux. J Pediatr. 2008;152(3):310-4.
5.Orenstein SR, Hassall E, Furmaga-Jablonska W, Atkinson S, Raanan M.Multicenter, Double-Blind, Randomized, Placebo-Controlled Trial Assessing the Efficacy and Safety of Proton Pump Inhibitor Lansoprazole in Infants with Symptoms of Gastroesophageal Reflux Disease. J Pediatr. 2008; Epub ahead of print.
6.Omari T, Lundborg P, Sandström M, Bondarov P, Fjellman M, Haslam R, et al. Pharmacodynamics and systemic exposure of esomeprazole in preterm infants and term neonates with gastroesophageal reflux disease. J Pediatr. 2009;In Press.
Whilst we greatly enjoyed Mary C J Rudolph’s “Best Practice” article on “The Obese Child” [1], we cannot agree with her conclusion that obesity fulfils most of the criteria for a condition that justifies screening. Our own local experience in Solihull, West Midlands, might illustrate thispoint.
Using a grant from the Children’s Fund, (www.cypu.gov.uk/corporate/childrenstrust/index,cfm)...
Whilst we greatly enjoyed Mary C J Rudolph’s “Best Practice” article on “The Obese Child” [1], we cannot agree with her conclusion that obesity fulfils most of the criteria for a condition that justifies screening. Our own local experience in Solihull, West Midlands, might illustrate thispoint.
Using a grant from the Children’s Fund, (www.cypu.gov.uk/corporate/childrenstrust/index,cfm) we aimed to set up a “Fit Club” serving children aged 7-11 in 7 wards in Solihull, with DETRI deprivation indices ranging from 7.53 to 54.49. All 7 wards contain enumeration districts with deprivation indices in the worse 15% of the country.
We attempted to recruit 20 children, for an initial consultation phase, in which they and their families would be able to discuss with our multi disciplinary team the kinds of services they would like to tackle the child’s weight. They would be able to try out various exercise programmes if they wished, as well as receiving dietetic advice, and as anincentive we also offered £10.00 worth of fresh fruit and vegetables. Theonly criterion for recruitment was that the child should be perceived to have a weight problem both by their family and professionals.
We attempted to recruit children via contact with school nurses, recommendation from General Practitioners, and an advertisement in the local paper. To our disappointment, we found that we were able to recruitonly 4 children. GPs had forwarded 7 names, of whom one actually made contact with the service, whilst the school nurses informally fed back that families felt that their child’s weight was not an issue upon which they needed to take action. A final attempt at recruitment, based on one large primary school with support of teaching staff, was similarly completely unsuccessful. It would seem likely that a difference in perception of the seriousness of overweight and the need for action between parents and professionals explained our disappointing outcomes. [2]
Our experience thus leads us to believe that detecting obese or overweight children by screening will not substantially alter the scale ofthese problems on a population basis, although services for those that do request them are clearly justified.
References
(1). Mary C J Rudolph. The Obese Child. Arch Dis Child Educ Pract Ed 2004;89:ep 57-ep 62
(2). A N Jeffery, L D Voss, B S Metcalf, S Alba, T J Wilkin. Parents’ Awareness of Overweight in Themselves and Their Child: Cross Sectional Study Within a Cohort (EarlyBird21), BMJ 2005;330:23-24
We read this paper with great interest. We have been investigating the use of skeletal surveys in our hospital and have come to an entirely different conclusion due to very different results. We have collected data over 13 years during which time 117 skeletal surveys were undertaken as part of the investigation into possible non accidental injury (NAI). We only detected additional fractures in 4 cases each of which presented with significant risk factors -E.g. multiple injuries, very young age, rib fractures. We have been concerned that the number of SS undertaken with a negative result suggests that we have been overusing this investigation.
Our results reflect a fairly liberal interpretation of the RCPCH guidance that 'when physical abuse is suspected, thorough investigation to exclude occult injury is required' 1. In practice most children under 2 presenting with any unexplained injury will have a skeletal survey.
As with every investigation we need to decide what levels of sensitivity and specificity are realistically obtainable, if every skeletal survey that we do shows additional fractures we are clearly not doing enough, but if they are only detected occasionally we are probably doing too many.
It is likely that the use of SS is variable across the country, and perhaps a national review of practice and outcomes would allow us to to produce more clear instructions - as highlighted in this paper to determine which children need a s...
We read this paper with great interest. We have been investigating the use of skeletal surveys in our hospital and have come to an entirely different conclusion due to very different results. We have collected data over 13 years during which time 117 skeletal surveys were undertaken as part of the investigation into possible non accidental injury (NAI). We only detected additional fractures in 4 cases each of which presented with significant risk factors -E.g. multiple injuries, very young age, rib fractures. We have been concerned that the number of SS undertaken with a negative result suggests that we have been overusing this investigation.
Our results reflect a fairly liberal interpretation of the RCPCH guidance that 'when physical abuse is suspected, thorough investigation to exclude occult injury is required' 1. In practice most children under 2 presenting with any unexplained injury will have a skeletal survey.
As with every investigation we need to decide what levels of sensitivity and specificity are realistically obtainable, if every skeletal survey that we do shows additional fractures we are clearly not doing enough, but if they are only detected occasionally we are probably doing too many.
It is likely that the use of SS is variable across the country, and perhaps a national review of practice and outcomes would allow us to to produce more clear instructions - as highlighted in this paper to determine which children need a skeletal survey and then trying to ensure that they get one.
A medical student perspective on history-taking for a child presenting with a limp: doing it for the first time
Ravi Patel & Matthew Knights
A child presenting with a limp, is a common presentation in primary and secondary care in the UK. It can be due to a number of different aetiologies with varying degrees of severity. A concise history offers the opportunity to identify key risk factors, mechanisms of injury, duration of symptoms and a collateral history from family members, thus is an important skill for all healthcare professionals irrespective of speciality. [1,2] However, many medical students and newly graduated junior doctors feel-ill prepared to take one. [3] Missing key red-flags, delaying diagnosis and referral for appropriate management. We present our own experiences of history taking and discuss how improvements can be made within the medical school curriculum.
Key factors in making history taking a challenge for children presenting with a limp for medical students or clinicians include; quantifying duration and pain the child is experiencing, the precise location of pain, establishing the true mechanism of injury, weather a non-accidental injury is questionable, cultural differences when taking a collateral history and the birth and developmental history. This applies even more so to those with inadequate training. A recent survey conducted by the University of Newcastle medical school found average duration of the T&O attachm...
A medical student perspective on history-taking for a child presenting with a limp: doing it for the first time
Ravi Patel & Matthew Knights
A child presenting with a limp, is a common presentation in primary and secondary care in the UK. It can be due to a number of different aetiologies with varying degrees of severity. A concise history offers the opportunity to identify key risk factors, mechanisms of injury, duration of symptoms and a collateral history from family members, thus is an important skill for all healthcare professionals irrespective of speciality. [1,2] However, many medical students and newly graduated junior doctors feel-ill prepared to take one. [3] Missing key red-flags, delaying diagnosis and referral for appropriate management. We present our own experiences of history taking and discuss how improvements can be made within the medical school curriculum.
Key factors in making history taking a challenge for children presenting with a limp for medical students or clinicians include; quantifying duration and pain the child is experiencing, the precise location of pain, establishing the true mechanism of injury, weather a non-accidental injury is questionable, cultural differences when taking a collateral history and the birth and developmental history. This applies even more so to those with inadequate training. A recent survey conducted by the University of Newcastle medical school found average duration of the T&O attachment being 5 weeks in all 23 UK medical schools.[4] With such short exposure to a large subject may encourage superficial learning which medical education is specifically trying to avoid. It is estimated that 30% of all GP consultations in the UK are Musculoskeletal, of which a quarter who visit their GP are <18 years old. [5,6,7] This is fundamentally important as 50% of all medical graduates in the UK will be training to become GPs.[8] We believe from our clinical experience in numerous primary care and secondary care sites that observation of clinicians alone may be an ineffective method in acquiring the key skills to conduct a concise consultation.
When asked to take our first history for a child presenting with a limp in new patient clinic, we found difficulty phrasing sensitive questions about non-accidental injury, asking about childhood obesity as well as establishing a clear contralateral history from family members. This uncertainty sometimes led us to neglect certain parts of the history entirely. One case, when observing a FY2 led to a partial delay in diagnosis of an acute on chronic slipped capital femoral epiphysis (SCFE). As the plain anteroposterior radiographs of the pelvis were unremarkable as the slip was subtle and the child was not overweight, nor was there any endocrinal abnormalities such as hypothyroidism and growth hormone deficiency from the patient history. When reflecting, we feel additional techniques should be implemented in other aspects of clinical education alongside history taking under supervision in order to prevent pit-falls in core principles as a clinician. For example, practicing with simulated patients has given us a greater degree of confidence when handling difficult discussions, having an index of suspicion for abuse cases and identifying good clinical practice when communicating with children and parents. The removal of the fear factor in a safe environment prior to seeing patients additionally helped. When examining the literature further, it shows simulated patients are as effective learning resource in the orthopaedic training of undergraduate medical students as real patients. [9] Driving changes by Royal College of surgeons Ireland to implement more SP training as part of the undergraduate syllabus.
From Student Feedback across 5 hospital sites across the Yorkshire and Humber region, our medical school is now adopting a multi-modal approach. In which simulated orthopaedic patients has now been adopted as part of the curriculum, alongside sexual health and ABCDE masterclass SP teaching sessions. We hope our efforts provide the foundations for a more competent and confident medical students in identifying issue in relation to with a child presenting with a limp.
References [1] Perry D C, Bruce C. Evaluating the child who presents with an acute limp BMJ 2010; 341: c4250 doi:10.1136/bmj.c4250 [2] 1. Al-Nammari SS, Pengas I, Asopa V, Jawad A, Rafferty M, et al. (2015) The inadequacy of musculoskeletal knowledge in graduating medical students in the United Kingdom. J Bone Joint Surg Am 97: e36. [3] 2. Pinney SJ, Regan WD (2001) Educating medical students about musculoskeletal problems. Are community needs reflected in the curricula of Canadian medical schools? J Bone Joint Surg Am 83: 1317-1320. [4] J.R. Williams. A review of undergraduate teaching in orthopaedic surgery in the United Kingdom. Orthopaedic Proceedings Vol. 85-B, No. SUPP_I. British Orthopaedic Association/Japanese Orthopaedic Association Combined Congress. 21 Feb 2018 [5] de Inocencio J. Musculoskeletal pain in primary paediatric care: analysis of 1000 consecutive general paediatric clinic visits. Paediatrics. 1998 Dec;102(6):E63. doi: 10.1542/peds.102.6.e63. PMID: 9832591 [6] De Inocencio J. Epidemiology of musculoskeletal pain in primary care. Arch Dis Child. 2004;89(5):431-434. doi:10.1136/adc.2003.028860 [7] Hassan Raja, Shehzaad A Khan, Abdul Waheed. The limping child — when to worry and when to refer: a GP’s guide. British Journal of General Practice 2020; 70 (698): 467. DOI: 10.3399/bjgp20X712565 [8] Deakin N. Where will the GPs of the future come from? BMJ 2013; 346 :f2558 doi:10.1136/bmj.f2558 [9] Gardiner S, Coffey F, O’Byrne J, et al. 0209 Simulated Patients Versus Real Patients As Learning Resources In The Clinical Skill Training Of Medical Students – A Randomised Crossover Trial Of Their Effectiveness. BMJ Simulation and Technology Enhanced Learning 2014;1:A23.
I read Davison et al’s paper with great interest.
Congratulation for this summary of how, fortunately and/or probably, most experienced paediatricians routinely communicate with children and their families: the strength of their paper is that it describes in simple words good communicating skills which most paediatricians consider as obvious although without having themselves the capability to describe them so well.
One of their suggestions deserves some discussion though: In Box 1, Davison et al recommend to ask the children permission to ask them or their parents a few questions. Involving patients is a requisite in a shared decision making model. Children’s views must be respected, as stated in the article 12 of the 1989 Convention on the rights of the child 1. However, given a child’s capacity of discernment, parental views may be necessary. If the child denies the permission, how will then the paediatrician seek parental views? Will the child consider his/her paediatrician as a trustful “friend” if he/she doesn’t respect his/her objection to question his/her parents? Will the child still trust his/her paediatrician if he/she tries and convince him/her to change his mind?
It is a fair to give a choice to a child as long as the choice can be respected.
1 United Nations, Human Rights. Convention on the rights of the child.https://www.ohchr.org/en/professionalinterest/pages/c...
Show MoreI read Davison et al’s paper with great interest.
Congratulation for this summary of how, fortunately and/or probably, most experienced paediatricians routinely communicate with children and their families: the strength of their paper is that it describes in simple words good communicating skills which most paediatricians consider as obvious although without having themselves the capability to describe them so well.
One of their suggestions deserves some discussion though: In Box 1, Davison et al recommend to ask the children permission to ask them or their parents a few questions. Involving patients is a requisite in a shared decision making model. Children’s views must be respected, as stated in the article 12 of the 1989 Convention on the rights of the child 1. However, given a child’s capacity of discernment, parental views may be necessary. If the child denies the permission, how will then the paediatrician seek parental views? Will the child consider his/her paediatrician as a trustful “friend” if he/she doesn’t respect his/her objection to question his/her parents? Will the child still trust his/her paediatrician if he/she tries and convince him/her to change his mind?
It is a fair to give a choice to a child as long as the choice can be respected.
1 United Nations, Human Rights. Convention on the rights of the child.https://www.ohchr.org/en/professionalinterest/pages/crc.aspx. Accessed 17.12.2021.
Show LessDear Sir,
Mulholland et al. make some very important points but I think understate the importance of bedside teaching. The only learning that ever stuck with me as a junior doctor was when it took place in relation to a clinical scenario involving a patient. Nothing has hurt training more than the reduction in exposure to patients either as in-patients or in the out-patient setting. It is an unavoidable consequence of the reduction in working hours but the feedback trainers give to trainees when reviewing patients is still the most important part of their learning. The only problem now is that the trainee is probably not rostered on for the next week.
The importance of this patient interaction is highlighted by the fact that undergraduates are now learning their basic anatomy, physiology etc. in the context of clinical scenarios and meeting real patients. This is a major step forward for undergraduate training and something I am very pleased to be involved in. Unfortunately, in my opinion, post graduate training has gone in the opposite direction and there is not a lot we can do about it other than increasing the length of training programs. The way we now work means that trainees see fewer patients and therefore learn more slowly. We can organise as many study days as we like but it does not compensate for that loss.
In order to avoid repetition of the mistakes that have been made in the ascertainment of asymptomatic status in adults who might have COVID-19 infection(1) healthcare practitioners in paediatrics must ascertain the full currently known range of COVID-19 symptoms before a child is declared to be asymptomatic. In the event of an oligosymptomatic or monosymptomatic clinical presentation each of those children with sparse or atypical symptoms should be fully followed up to ascertain if the "stand alone" symptoms are "joined" by new symptoms or whether the oligosymptomatic status persists throughout the course of that child's illness.
Finally, in conformity with the principles of Bayes' Theorem, frontline healthcare workers should be issued with a nomogram spelling out the post test probability of COVID-19 infection(2) in the event of a negative RT-PCR test result. The nomogram should be the subject of regular re-evaluation and updating, on the basis of new information about the authenticity of new symptoms reportedly associated with COVID-19.
I have no funding and no conflict of interest
References
(1) Saurabh S., Vohra S
What should be the criteria for determining asymptomatic status in COVID-19
QJMed 2020;doi.org/10.1093/qjmed/hcab002 Article in Press
(2) Chan GM
Bayes theorem, Covid-19, and screening tests
Amer J Emerg Med 2020;38:2011-2013
Paediatric Anaesthetic Training During COVID-19:
The UK National Paediatric Anaesthesia Trainee Research Network (PATRN) Swift Survey
The Paediatric Anaesthesia Trainee Research Network (PATRN) Committee read with great interest the findings of the national survey of paediatric trainee experiences during the Covid-19 pandemic from Harmer et al. The re-deployment of anaesthetic trainees to support the surge in demand from adult intensive care, postponement of elective surgery and pauses to trainee rotations1 all affected access to sub-specialty training in anaesthesia. Thus, PATRN conducted an equivalent national survey evaluating the impact of the pandemic on training in paediatric anaesthesia from March to August 2020.
A survey questionnaire consisting of Sixteen questions focussed on trainee experience of paediatric anaesthesia during the first wave of Covid-19 infections, from March to August 2020. Paediatric anaesthesia experience in the UK occurs at all stages of training, with the option for an additional ‘advanced’ module. The survey was reviewed by members of the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) Scientific Committee. Distribution was via email to all UK-based trainees by College Tutors and the Anaesthetists in Training Representative Group (ATRG) through The Royal College of Anaesthetists (RCoA) and APAGBI trainee members from December 2020 to March 2021.
The findings were reflective of thos...
Show MorePaediatric Anaesthetic Training During COVID-19:
The UK National Paediatric Anaesthesia Trainee Research Network (PATRN) Swift Survey
The Paediatric Anaesthesia Trainee Research Network (PATRN) Committee read with great interest the findings of the national survey of paediatric trainee experiences during the Covid-19 pandemic from Harmer et al. The re-deployment of anaesthetic trainees to support the surge in demand from adult intensive care, postponement of elective surgery and pauses to trainee rotations1 all affected access to sub-specialty training in anaesthesia. Thus, PATRN conducted an equivalent national survey evaluating the impact of the pandemic on training in paediatric anaesthesia from March to August 2020.
A survey questionnaire consisting of Sixteen questions focussed on trainee experience of paediatric anaesthesia during the first wave of Covid-19 infections, from March to August 2020. Paediatric anaesthesia experience in the UK occurs at all stages of training, with the option for an additional ‘advanced’ module. The survey was reviewed by members of the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) Scientific Committee. Distribution was via email to all UK-based trainees by College Tutors and the Anaesthetists in Training Representative Group (ATRG) through The Royal College of Anaesthetists (RCoA) and APAGBI trainee members from December 2020 to March 2021.
The findings were reflective of those identified by Harmer et al, with changes to work schedule being commonplace. 90/170 (53%) of respondents, representing all stages of training, were due to complete a paediatric training module during the specified timeframe. Only 23% remained working in paediatric anaesthesia, almost all of whom were undertaking ‘higher’ or ‘advanced’ modules (n=19). The majority of trainees who experienced disruption with re-deployment was to support adult intensive care (33/69; 48%). Many trainees did not have sufficient paediatric cases to achieve module sign off (32/66; 48%), due to re-deployment or a lack of elective training lists. Most trainees felt they had insufficient paediatric experience for progression of training (37/69; 54%).
In addition, teaching sessions were reduced; 52% (90/170) of respondents reported fewer sessions compared to pre-COVID, despite delivery of virtual sessions. 84/170 (49%) of respondents were able to undertake extracurricular activities for personal development, including training other staff, writing COVID protocols, quality improvement projects and COVID research.
Training in paediatric anaesthesia relies upon ‘hands-on’ experience to develop confidence. Our findings reflect the RCoA’s efforts to minimise disruption to trainees at a critical stage of progression, however, the qualitative impact of COVID-19 is difficult to assess and relates to individual confidence. New ARCP outcomes2 have been created to identify the impact of COVID-19 on training and allow remediation. Following the acute phase of the pandemic, the authors feel access to training should be prioritised. This is of particular importance for junior trainees who have been unable to achieve sign-off or gain experience to feel well-equipped for progression. The survey findings support the requirement for ongoing open discussions at a national level on how to address these issues.
References
Rimmer A. COVID-19: trainees will not move jobs in April. BMJ 2020;368:m1088
Show LessRCOA. Anaesthetics ARCP decision guidance COVID – 19. RCOA. Anaesthetics ARCP decision guidance COVID – 19.https://www.rcoa.ac.uk/sites/default/files/documents/2020-05/Anaesthetic... (last accessed 29th March 2021).
Dear Editor,
In the UK we are presently in the middle of a significant heatwave with July 2006 declared the UK's hottest month on record (1). Both the Department ofHealth and NHS direct have been quick to disseminate health advice (2) particularly to parents and healthcare workers responsible for the care ofchildren, about the dangers of heat exposure and dehydration. This advice has emphasised the need for...
Dear Editor,
In the UK we are presently in the middle of a significant heatwave with July 2006 declared the UK's hottest month on record (1). Both the Department ofHealth and NHS direct have been quick to disseminate health advice (2) particularly to parents and healthcare workers responsible for the care ofchildren, about the dangers of heat exposure and dehydration. This advice has emphasised the need for adequate fluid intake, particularly that of water. Notably parents have been encouraged to ‘give babies plenty of cooled boiled water throughout the day’ (3)Although we believe this to be sound advice to parents in the majority of situations, we believe it is important for clinicians to be aware of the risks of water intoxication, especially in infants. Water intoxication in children has previously been well described (4) and as being on the increase, if not reaching epidemic proportions in the United States (5). It can cause significant morbidity and mortality from hyponatraemia, brain swelling and seizures. Primarily associated with inappropriate dilution of formula feeds, bottled water has previously beendescribed as a significant cause (6,7). Children are at particular risk asit is thought that as well as renal function being immature, infants have a powerful thirst drive which may impede their ability to curb intake.Bhalla et al reported 4 cases in the UK of hyponatreamic seizures that were secondary to excessive solute ingestion in 1999 (8). As a paediatric intensive care retrieval service we have recently dealt with a previously normal hyponatraemic child presenting with abnormal neurology and seizures. A one-year-old child presented in status epilepticus following a 2 day history of vomiting during which time hypotonic fluids where administered. The child required iv lorazepam and one dose of rectal paraldehyde to terminate the seizure and was intubated, ventilated and transferred to a regional paediatric intensive care unit. Serum sodium on attendance was 116 mmol/L. The child was subsequently fluid restricted for 48 hours.Although we have insufficient evidence at present to implicate water intoxication in their pathogenesis we feel it is an issue that has not been addressed in the current DOH literature. This situation also emphasises the importance of parental education to the potential risks of this conditon.
Dr R M Kayani Retrieval FellowDr P Ramnarayan Consultant Paediatric IntensivistChildren’s Acute Transport Service, Great Ormond Street Hospital, London
References:
1. Meteorological Office Press Release http://www.meto.gov.uk/corporate/pressoffice/2006/pr20060801.html
2. ‘ Heatwave’ -A guide to looking after yourself and others during hot weather. Department of Health http://www.dh.gov.uk/assetRoot/04/13/53/04/04135304.pdf
3. Department of Health Website - http://www.nhsdirect.nhs.uk/articles/article.aspx?ArticleId=1955
4. Dugan S, Holliday MA. Water intoxication in two infants following the voluntary ingestion of excessive fluids. Pediatrics 1967;39:418-20.
5. Keating JP,Schears GJ, Dodge PR. Oral water intoxication in infants. AnAmerican epidemic.Am J Dis Child. 1991 Sep;145(9):985-90.
6. Bruce RC , Kliegman RM Hyponatremic seizures secondary to oral water intoxication in infancy: association with commercial bottled drinking water.Pediatrics. 1997 Dec;100(6):E4. Review
7. From the Centers for Disease Control and Prevention-Hyponatremic Seizures Among Infants Fed With Commercial Bottled Drinking Water--Wisconsin, 1993. JAMA 272(13),October 1994, pp 996-997
8. P Bhalla, F E Eaton, J B S Coulter, F L Amegavie, J A Sills and L J Abernethy
Lesson of the week: Hyponatraemic seizures and excessive intake of hypotonic fluids in young children 1999;319;1554-1557 BMJ
Dear Editor,
In his extensive guideline review of the glucocorticoid treatment in croup, in agreement with the conclusions of the Cochrane review (1), Baumer HJ (2) states that “in the absence of further evidence, the use of a single oral dose of dexamethasone, probably 600 µg/kg, should be preferred because of its safety, efficacy and cost-effectiveness”.
We believe this statement is not correct becau...
Dear Editor,
In his extensive guideline review of the glucocorticoid treatment in croup, in agreement with the conclusions of the Cochrane review (1), Baumer HJ (2) states that “in the absence of further evidence, the use of a single oral dose of dexamethasone, probably 600 µg/kg, should be preferred because of its safety, efficacy and cost-effectiveness”.
We believe this statement is not correct because a difference should be made between cases of mild-moderate and severe croup. In fact, before high doses of dexamethasone are used extensively in children with mild-moderate croup, some relevant questions need to be addressed.
Russel K (1) and Griffin S and colleagues (3) reviewed the data from several double-blind randomised clinical studies of inhaled budesonide in croup and found it to be significantly more effective than placebo. Several studies also show that nebulised budesonide, the effect of which starts within 30 minutes, and oral dexamethasone are equally effective (1,3). Given the evidence, it seems more cautious to choose inhaled ratherthan oral/injectable corticosteroids for mild-moderate croup treatment.Secondly it has been shown that a single low oral dose of dexamethasone (150 µg/kg), as suggested by the BNF for children (4), is equally effective in treating croup (5). This issue needs to be further addressed,given the potential adverse effects of high-dose dexamethasone in children.
Other than the need for further randomised controlled trials comparing different dexamethasone doses, as suggest by Baumer JH (2), we think that it could be more relevant to conduct studies comparing inhaled versus oral corticosteroids for the treatment of mild-moderate croup, withregard to their clinical onset of action and security profile.
References:
1.Russell K, Wiebe N, Saenz A, et al. Glucocorticoids for croup. Cochrane Database Syst Rev 2004; Issue 1:CD001955
2.Baumer HJ. Glucocorticoid treatment in croup. Arch Dis Child Educ Pract Ed 2006;91:ep58-ep60
3.Griffin S, Ellis S, Fitzgerald-Baroon A, Rose J, Egger M. Nebulised steroid in the treatment of croup: a systematic review of randomised controlled trials. Br J Gen Pract 2000;50:135-41
4.British National Formulary. BNF for children. London: BMJ Publishing, 2005:158
5.Sparrow A, Geelhoed G. Prednisolone versus dexamethasone in croup:a randomised equivalence trial. Arch Dis Child 2006;91:580-83
Federico Marchetti, clinical paediatrician, fedemarche@tin.it
Jenny Bua, senior house officer in paediatrics
Marzia Lazzerini, clinical paediatrician
Department of Paediatrics
Institute of Child Health
Burlo Garofolo
Trieste
Via dell'Istria 65/1-34100 Trieste, Italy
Competing interests: None declared
Correspondence to:Federico Marchetti
Tel: 39-040-3785.454
Fax: 39-040-3785452
E mail: fedemarche@tin.it
Dear Sir,
With interest we read the paper by Tighe et al about the use of pH-monitoring in childhood.(1) However, we believe that the authors overestimate the role of this technique and their omission of a detailed discussion of the utility of pH-impedance monitoring renders this review incomplete.
The term ‘gold standard’ can no longer be applied to 24-hour pH-monitoring because pH-probes only d...
Dear Sir,
With interest we read the paper by Tighe et al about the use of pH-monitoring in childhood.(1) However, we believe that the authors overestimate the role of this technique and their omission of a detailed discussion of the utility of pH-impedance monitoring renders this review incomplete.
The term ‘gold standard’ can no longer be applied to 24-hour pH-monitoring because pH-probes only detect a minority of gastro-oesophagealreflux (GOR) episodes.(2) Combined pH-impedance monitoring allows for the detection of all reflux (liquid, mixed, gas, acidic, weakly acidic, weaklyalkaline). With an increasing body of evidence showing a role for weakly acidic bolus GOR in symptom generation, the measurement of acidity alone provides an incomplete picture of the degree of bolus reflux and the relationship of bolus reflux to symptom episodes. Therefore, symptomatic reflux cannot always be excluded when a pH-study (acid exposure) is normal. The ability to detect bolus reflux, independently of acidity, allows symptomatic reflux to be more accurately detected. Not mentioned inthis article, is that there are statistical measures of association between GOR episodes and symptoms (e.g. symptom association probability score). By detecting all bolus reflux, pH-impedance monitoring markedly increases the yield of positive symptom association in infants and children.(3)
In addition, infants with GORD present differently from older children and, as other tests such as upper GI endoscopy are more difficultto perform in infants, the case for invasive functional testing may be greater for infants than older children. In infants, conservative management before any testing or pharmacological therapy is proven effective(4). However, with PPI therapy recently being shown to be ineffective in infants who fail such conservative therapy (5), pH-studies may in fact be justifiable on the basis of establishing acid-related disease when endoscopy is not possible. A recent study in such infants shows that the degree of symptom improvement on esomeprazole correlates with the level of acid exposure off therapy.(6) Nevertheless, the big issue with pH-monitoring is the cut off value of the reflux index used to diagnose pathological acid exposure. The fact remains that no outcome studies testing the value of the reflux index criteria are available. Until they are, clinicians need to be very conservative in interpreting these findings.
We contend that pH-impedance monitoring has greater clinical utility than pH monitoring alone, since it allows for a more complete investigation of reflux and the association of reflux with symptoms.
Sincerely yours,
Michiel P. van Wijk, Clara M. Loots, Taher I. Omari, and Marc A. Benninga
1.Tighe M, Cullen M, Beattie R. How to use: a pH study. Arch Dis Child Educ Pract Ed. 2009 Feb;94(1):18-23.
2.Wenzl TG. Esophageal pH monitoring and impedance measurements: a comparison of two diagnostic tests for gastroesophageal reflux. J Pediatr Gastroenterol Nutr. 2002;34(5):519-23.
3.Loots C, Benninga M, Davidson G, Omari T. Addition of pH-impedance monitoring to standard pH monitoring increases the yield of symptom association analysis in infants and children with gastroesophageal reflux.J Pediatr. 2009;154(2):248-52.
4.Orenstein SR, McGowan JD. Efficacy of conservative therapy as taught in the primary care setting for symptoms suggesting infant gastroesophageal reflux. J Pediatr. 2008;152(3):310-4.
5.Orenstein SR, Hassall E, Furmaga-Jablonska W, Atkinson S, Raanan M.Multicenter, Double-Blind, Randomized, Placebo-Controlled Trial Assessing the Efficacy and Safety of Proton Pump Inhibitor Lansoprazole in Infants with Symptoms of Gastroesophageal Reflux Disease. J Pediatr. 2008; Epub ahead of print.
6.Omari T, Lundborg P, Sandström M, Bondarov P, Fjellman M, Haslam R, et al. Pharmacodynamics and systemic exposure of esomeprazole in preterm infants and term neonates with gastroesophageal reflux disease. J Pediatr. 2009;In Press.
Dear Editor,
Whilst we greatly enjoyed Mary C J Rudolph’s “Best Practice” article on “The Obese Child” [1], we cannot agree with her conclusion that obesity fulfils most of the criteria for a condition that justifies screening. Our own local experience in Solihull, West Midlands, might illustrate thispoint.
Using a grant from the Children’s Fund, (www.cypu.gov.uk/corporate/childrenstrust/index,cfm)...
Dear Editor,
Whilst we greatly enjoyed Mary C J Rudolph’s “Best Practice” article on “The Obese Child” [1], we cannot agree with her conclusion that obesity fulfils most of the criteria for a condition that justifies screening. Our own local experience in Solihull, West Midlands, might illustrate thispoint.
Using a grant from the Children’s Fund, (www.cypu.gov.uk/corporate/childrenstrust/index,cfm) we aimed to set up a “Fit Club” serving children aged 7-11 in 7 wards in Solihull, with DETRI deprivation indices ranging from 7.53 to 54.49. All 7 wards contain enumeration districts with deprivation indices in the worse 15% of the country.
We attempted to recruit 20 children, for an initial consultation phase, in which they and their families would be able to discuss with our multi disciplinary team the kinds of services they would like to tackle the child’s weight. They would be able to try out various exercise programmes if they wished, as well as receiving dietetic advice, and as anincentive we also offered £10.00 worth of fresh fruit and vegetables. Theonly criterion for recruitment was that the child should be perceived to have a weight problem both by their family and professionals.
We attempted to recruit children via contact with school nurses, recommendation from General Practitioners, and an advertisement in the local paper. To our disappointment, we found that we were able to recruitonly 4 children. GPs had forwarded 7 names, of whom one actually made contact with the service, whilst the school nurses informally fed back that families felt that their child’s weight was not an issue upon which they needed to take action. A final attempt at recruitment, based on one large primary school with support of teaching staff, was similarly completely unsuccessful. It would seem likely that a difference in perception of the seriousness of overweight and the need for action between parents and professionals explained our disappointing outcomes. [2]
Our experience thus leads us to believe that detecting obese or overweight children by screening will not substantially alter the scale ofthese problems on a population basis, although services for those that do request them are clearly justified.
References
(1). Mary C J Rudolph. The Obese Child. Arch Dis Child Educ Pract Ed 2004;89:ep 57-ep 62
(2). A N Jeffery, L D Voss, B S Metcalf, S Alba, T J Wilkin. Parents’ Awareness of Overweight in Themselves and Their Child: Cross Sectional Study Within a Cohort (EarlyBird21), BMJ 2005;330:23-24
We read this paper with great interest. We have been investigating the use of skeletal surveys in our hospital and have come to an entirely different conclusion due to very different results. We have collected data over 13 years during which time 117 skeletal surveys were undertaken as part of the investigation into possible non accidental injury (NAI). We only detected additional fractures in 4 cases each of which presented with significant risk factors -E.g. multiple injuries, very young age, rib fractures. We have been concerned that the number of SS undertaken with a negative result suggests that we have been overusing this investigation.
Our results reflect a fairly liberal interpretation of the RCPCH guidance that 'when physical abuse is suspected, thorough investigation to exclude occult injury is required' 1. In practice most children under 2 presenting with any unexplained injury will have a skeletal survey.
As with every investigation we need to decide what levels of sensitivity and specificity are realistically obtainable, if every skeletal survey that we do shows additional fractures we are clearly not doing enough, but if they are only detected occasionally we are probably doing too many.
It is likely that the use of SS is variable across the country, and perhaps a national review of practice and outcomes would allow us to to produce more clear instructions - as highlighted in this paper to determine which children need a s...
Show MoreWe read this paper with great interest. We have been investigating the use of skeletal surveys in our hospital and have come to an entirely different conclusion due to very different results. We have collected data over 13 years during which time 117 skeletal surveys were undertaken as part of the investigation into possible non accidental injury (NAI). We only detected additional fractures in 4 cases each of which presented with significant risk factors -E.g. multiple injuries, very young age, rib fractures. We have been concerned that the number of SS undertaken with a negative result suggests that we have been overusing this investigation.
Our results reflect a fairly liberal interpretation of the RCPCH guidance that 'when physical abuse is suspected, thorough investigation to exclude occult injury is required' 1. In practice most children under 2 presenting with any unexplained injury will have a skeletal survey.
As with every investigation we need to decide what levels of sensitivity and specificity are realistically obtainable, if every skeletal survey that we do shows additional fractures we are clearly not doing enough, but if they are only detected occasionally we are probably doing too many.
It is likely that the use of SS is variable across the country, and perhaps a national review of practice and outcomes would allow us to to produce more clear instructions - as highlighted in this paper to determine which children need a skeletal survey and then trying to ensure that they get one.
Show LessA medical student perspective on history-taking for a child presenting with a limp: doing it for the first time
Ravi Patel & Matthew Knights
A child presenting with a limp, is a common presentation in primary and secondary care in the UK. It can be due to a number of different aetiologies with varying degrees of severity. A concise history offers the opportunity to identify key risk factors, mechanisms of injury, duration of symptoms and a collateral history from family members, thus is an important skill for all healthcare professionals irrespective of speciality. [1,2] However, many medical students and newly graduated junior doctors feel-ill prepared to take one. [3] Missing key red-flags, delaying diagnosis and referral for appropriate management. We present our own experiences of history taking and discuss how improvements can be made within the medical school curriculum.
Key factors in making history taking a challenge for children presenting with a limp for medical students or clinicians include; quantifying duration and pain the child is experiencing, the precise location of pain, establishing the true mechanism of injury, weather a non-accidental injury is questionable, cultural differences when taking a collateral history and the birth and developmental history. This applies even more so to those with inadequate training. A recent survey conducted by the University of Newcastle medical school found average duration of the T&O attachm...
Show MoreA medical student perspective on history-taking for a child presenting with a limp: doing it for the first time
Ravi Patel & Matthew Knights
A child presenting with a limp, is a common presentation in primary and secondary care in the UK. It can be due to a number of different aetiologies with varying degrees of severity. A concise history offers the opportunity to identify key risk factors, mechanisms of injury, duration of symptoms and a collateral history from family members, thus is an important skill for all healthcare professionals irrespective of speciality. [1,2] However, many medical students and newly graduated junior doctors feel-ill prepared to take one. [3] Missing key red-flags, delaying diagnosis and referral for appropriate management. We present our own experiences of history taking and discuss how improvements can be made within the medical school curriculum.
Key factors in making history taking a challenge for children presenting with a limp for medical students or clinicians include; quantifying duration and pain the child is experiencing, the precise location of pain, establishing the true mechanism of injury, weather a non-accidental injury is questionable, cultural differences when taking a collateral history and the birth and developmental history. This applies even more so to those with inadequate training. A recent survey conducted by the University of Newcastle medical school found average duration of the T&O attachment being 5 weeks in all 23 UK medical schools.[4] With such short exposure to a large subject may encourage superficial learning which medical education is specifically trying to avoid. It is estimated that 30% of all GP consultations in the UK are Musculoskeletal, of which a quarter who visit their GP are <18 years old. [5,6,7] This is fundamentally important as 50% of all medical graduates in the UK will be training to become GPs.[8] We believe from our clinical experience in numerous primary care and secondary care sites that observation of clinicians alone may be an ineffective method in acquiring the key skills to conduct a concise consultation.
When asked to take our first history for a child presenting with a limp in new patient clinic, we found difficulty phrasing sensitive questions about non-accidental injury, asking about childhood obesity as well as establishing a clear contralateral history from family members. This uncertainty sometimes led us to neglect certain parts of the history entirely. One case, when observing a FY2 led to a partial delay in diagnosis of an acute on chronic slipped capital femoral epiphysis (SCFE). As the plain anteroposterior radiographs of the pelvis were unremarkable as the slip was subtle and the child was not overweight, nor was there any endocrinal abnormalities such as hypothyroidism and growth hormone deficiency from the patient history. When reflecting, we feel additional techniques should be implemented in other aspects of clinical education alongside history taking under supervision in order to prevent pit-falls in core principles as a clinician. For example, practicing with simulated patients has given us a greater degree of confidence when handling difficult discussions, having an index of suspicion for abuse cases and identifying good clinical practice when communicating with children and parents. The removal of the fear factor in a safe environment prior to seeing patients additionally helped. When examining the literature further, it shows simulated patients are as effective learning resource in the orthopaedic training of undergraduate medical students as real patients. [9] Driving changes by Royal College of surgeons Ireland to implement more SP training as part of the undergraduate syllabus.
From Student Feedback across 5 hospital sites across the Yorkshire and Humber region, our medical school is now adopting a multi-modal approach. In which simulated orthopaedic patients has now been adopted as part of the curriculum, alongside sexual health and ABCDE masterclass SP teaching sessions. We hope our efforts provide the foundations for a more competent and confident medical students in identifying issue in relation to with a child presenting with a limp.
References
Show Less[1] Perry D C, Bruce C. Evaluating the child who presents with an acute limp BMJ 2010; 341: c4250 doi:10.1136/bmj.c4250
[2] 1. Al-Nammari SS, Pengas I, Asopa V, Jawad A, Rafferty M, et al. (2015) The inadequacy of musculoskeletal knowledge in graduating medical students in the United Kingdom. J Bone Joint Surg Am 97: e36.
[3] 2. Pinney SJ, Regan WD (2001) Educating medical students about musculoskeletal problems. Are community needs reflected in the curricula of Canadian medical schools? J Bone Joint Surg Am 83: 1317-1320.
[4] J.R. Williams. A review of undergraduate teaching in orthopaedic surgery in the United Kingdom. Orthopaedic Proceedings Vol. 85-B, No. SUPP_I. British Orthopaedic Association/Japanese Orthopaedic Association Combined Congress. 21 Feb 2018
[5] de Inocencio J. Musculoskeletal pain in primary paediatric care: analysis of 1000 consecutive general paediatric clinic visits. Paediatrics. 1998 Dec;102(6):E63. doi: 10.1542/peds.102.6.e63. PMID: 9832591
[6] De Inocencio J. Epidemiology of musculoskeletal pain in primary care. Arch Dis Child. 2004;89(5):431-434. doi:10.1136/adc.2003.028860
[7] Hassan Raja, Shehzaad A Khan, Abdul Waheed. The limping child — when to worry and when to refer: a GP’s guide. British Journal of General Practice 2020; 70 (698): 467. DOI: 10.3399/bjgp20X712565
[8] Deakin N. Where will the GPs of the future come from? BMJ 2013; 346 :f2558 doi:10.1136/bmj.f2558
[9] Gardiner S, Coffey F, O’Byrne J, et al. 0209 Simulated Patients Versus Real Patients As Learning Resources In The Clinical Skill Training Of Medical Students – A Randomised Crossover Trial Of Their Effectiveness. BMJ Simulation and Technology Enhanced Learning 2014;1:A23.
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