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26 Oct 2016

Myths about children’s illnesses

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Another blog on essential paeds tips from consultant paediatrician Edward Snelson.  Including the truth about paediatric observations and myth busting whether or not to give ibuprofen in chickenpox.

I like a good myth as much as the next person.  They tend to be far more exciting than anything that is verifiable, but when it comes to clinical practice myths are outright unhelpful.  I am not talking about conflicting evidence or lack of evidence for one practice or another.  I am talking about misinformation.

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Where does this misinformation come from?  Usually from something that someone said or a bit of research that was not definitive.  ‘Experts’ have to be very careful about what they say and how they say it.  Paediatrics certainly has a fair number of examples of those who had a loud voice and the wrong message.

The best thing for myths and misunderstandings is to unsay them.  Ignoring them certainly doesn’t work!  Often they are perpetuated by how snappy and convenient they are.  The truth is often so much more mundane.  Who wants to hear that Napoleon was 5’ 6” and that Marie Antoinette never said, “Let them eat cake”?

Here are a few medical myths relevant to paediatrics.  I’ll let you decide if you want to burst any bubbles the next time they are quoted.

Myth 1: Babies feeds should be 150ml/kg/day.

This is one of those made-up numbers that has been with us for a very long time.  It actually comes from a convenient Imperial measurement rule of thumb of 1oz per pound per 4 hourly feed.  Anyone who can find me the evidence for it wins a major prize.

In practice, it is actually a good rule of thumb when trying to work out if a baby is being greatly overfed or underfed.  I don’t know what the 95th centile is for normal feeds though and neither does anyone that I know of.  You have to put the number in context of the clinical scenario and not stick too rigidly to made-up numbers.

Myth 2: We know what the normal heart rate and respiratory rate of children should be at different ages.

For a long time, there have been three ‘normal ranges’ circulated around books and guidelines in the UK.  Each is slightly different and each is made up, based on the consensus of experts.  Pooled research data shows that they are close but flawed.  The academics point out that there is no such thing as normal in children anyway since parameters are hugely affected by pain, fear, fever, activity etc.

How does this help you in practice?  Well, it means that you can listen to your gut instinct with children when trying to decide if they are unwell.  What is more reassuring: a child with normal physiological parameters or a child who is running off to catch a Pokémon?

Myth 3: Foreskins should be retracted and cleaned by the age of three.

This is an old way of thinking, but there is surprisingly little done to let anyone know what the current thinking is.  The reality is that much balanitis that we see is not due to poor hygiene but too much of it.  Pre-pubertal foreskins are naturally adherent to a glans, itself a mucous membrane.  Retraction and soap cause trauma and inflammation.

When seeing a pre-pubertal child with balanitis, ask if anyone is trying to pull the foreskin back or clean it.  Then tell them to stop.  Often, the foreskin is inflamed and not infected.  A barrier cream can be very effective until healing takes place.

Myth 4: Salbutamol doesn’t work in children under the age of 12 months

This is one of the most persistent myths in paediatrics.  It is true that initial research suggested that infants below a year old have not developed β-receptors in the lungs.  Later this was found to be untrue and has been refuted on many occasions.  Confirmation bias is probably to blame for the way that this myth is still with us.  It is true that most wheezy babies do not respond to salbutamol, but that is because they have bronchiolitis, which is not ever going to respond to a β-agonist (or any other medication).  Some of the wheezers of this age do have viral induced wheeze (VIW), for which the mechanism is bronchospasm (in bronchiolitis, it is really just wet lungs not tight tubes) and VIW does respond to salbutamol.  Telling the difference between the two is challenging but important in order to ensure the right children get the right treatment and others are not treated unnecessarily.  (See previous post on Network Locum (now Lantum)s Blog – “Pertussiolitis and Other Animals”)

Myth 5: Ibuprofen causes necrotising fasciitis in children with chickenpox

A few years ago there was a case series published which noted an association with ibuprofen use in a group of children who developed necrotising fasciitis while unwell with chickenpox.   The study was riddled with bias and no causation has ever been established.  Despite this it is often stated that the one causes the other.  I feel it would be better if we used our energy to spread the word about the real danger: that childhood deaths from invasive streptococcal sepsis during varicella infection are all too common.  Beware of the child with chickenpox who are more unwell or becomes worse late in the illness.

What other medical myths about children do you know?  Post them in the comments below so that we can burst a few more bubbles!

Edward Snelson
Paediatrician
@sailordoctor

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