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...
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.
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...
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.
Rimmer A. COVID-19: trainees will not move jobs in April. BMJ 2020;368:m1088
RCOA. 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).
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.  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...
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. 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. 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.  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.
 Perry D C, Bruce C. Evaluating the child who presents with an acute limp BMJ 2010; 341: c4250 doi:10.1136/bmj.c4250
 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.
 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.
 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
 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
 De Inocencio J. Epidemiology of musculoskeletal pain in primary care. Arch Dis Child. 2004;89(5):431-434. doi:10.1136/adc.2003.028860
 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
 Deakin N. Where will the GPs of the future come from? BMJ 2013; 346 :f2558 doi:10.1136/bmj.f2558
 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.
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
(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
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.
There is a section on short-term management in the original article and I think it needs correcting. Currently the opening statment is: "Following initial fluid resuscitation, maintenance fluid was continued as normal saline with 5% dextrose infusion at a rate of 100 mL/kg/day." This will lead to too rapid a correction of serum sodium concentration and I would recommend starting with 0.45% saline following the bolus normal saline that will have appropriately been given as resuscitation fluid. The composition of the maintenance fluid can then be adjusted based on urine sodium results. It is improtant to impress on the laboratory that the results are needed urgently.
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...
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.
Thank you for highlighting the recommendation for avoiding too rapid correction of hyponatraemia and the need for close monitoring of urinary electrolytes. The focus of the article (problem solving in clinical practice) was the differential diagnosis rather than the nuances of management but we agree that regular assessment of urinary electrolytes will help to guide fluid management in the sick hyponatraemic baby. The importance of focusing on urine content as well as blood electrolytes has been an important component of clinical practice in our unit for many years (1).
In our experience infants recover very quickly after the initial resuscitation and can frequently be fed enterally within a matter of hours. Osmotic demyelination syndrome is very uncommon in paediatric practice (an interesting story in itself) and one wonders whether there are more subtle differences in outcome that can be linked to initial management. The reality (we suspect) is that many hyponatraemic babies are managed without close, detailed regular scrutiny of urinary electrolytes and perhaps this is a topic for further study.
Dr Smith and Maderazo rightly states that ‘Healthy kidneys can cut urinary sodium losses to almost zero’ however please note that babies with adrenal disorders such as 21-hydroxylase deficiency often require relatively high doses of mineralocorticoid as well as sodium supplements for several months.
1. Coulthard MG. Will changing maintenance intravenous f...
1. Coulthard MG. Will changing maintenance intravenous fluid from 0.18% to 0.45% saline do more harm than good? Arch Dis Child. 2008 Apr;93(4):335-40
I appreciate as ever the careful encouragement of Helen Bedford and David Elliman about ways to engage with parents hesitant about having their children vaccinated. Implicit throughout the article, but I think worth making explicit, is the importance of building trust between professional and parent(s) around this issue. With this in mind, it is clearer why telling stories, and discussing feelings (for example parents' fears of hurting or harming their children, and professionals' frustration at apparent conflicts of interests that advocates of anti-MMR or anti-vaccine stances may have), can work so well. Those engaging in these conversations may do well to make relationship, feelings and trust the centre points of respectful dialogue with parents who are feeling hesitant about vaccines.
We read with interest the problem solving article by Tse et al. looking at the management of infants presenting with hyponatraemia plus hyperkalaemia1. They recommend the administration of intravenous 0.9% NaCl to correct hyponatraemia until oral feeds can be given. We are concerned that this protocol will produce a rise in serum [Na+] faster than recommended. The guidance is that once any acute symptoms have been addressed the rise in serum [Na+] should not exceed 8 mmol/L/day in order to minimise the risk of developing Osmotic Demyelination Syndrome (ODS). Certainly the rise should be less than 10-12 mmol/L in any 24-hour period or 18 mmol/L in any 48-hour period2.
No specific comment is made about the speed of correction of the serum sodium concentration in case 1 other than that there was "gradual resolution of both the hyponatraemia and hypokalaemia". However in case 2 the serum sodium concentration is said to have normalised within 48 hours. The starting sodium concentration was 108 mmol/L and the normal quoted as 133-146 mmol/L so the minimum rate of rise was 12.5 mmol/L/day, exceeding the recommended rate of rise.
As illustrated by the two cases, these patients usually present with extracellular fluid (ECF) contraction and require replacement of the ECF volume deficit. This should be with a fluid that matches the electrolyte composition of the ECF but we tend to only cater for a normal ECF [Na+] and use 0.9% NaCl. However i...
As illustrated by the two cases, these patients usually present with extracellular fluid (ECF) contraction and require replacement of the ECF volume deficit. This should be with a fluid that matches the electrolyte composition of the ECF but we tend to only cater for a normal ECF [Na+] and use 0.9% NaCl. However in patients with hyponatraemia, 0.9% NaCl is hypertonic and tends to lead to a rise in serum sodium concentration in excess of that which is desired. In an acute situation this is usually unavoidable but must be taken into consideration when prescribing further fluids if too rapid a rise in serum [Na+] is to be avoided.
Once euvolaemia has been established a gradual correction of serum [Na+] is best effected by administering a fluid which contains a slightly higher [Na+] than that in the fluids being lost from the body. The main fluid loss, in the absence of diarrhoea or vomiting, is urine. Greater control of the rise in serum sodium concentration is obtained by measuring the [Na+] of the urine and adjusting the [Na+] of the intravenous fluid accordingly. Once the underlying pathology has been corrected, in these two case, by steroid replacement and treatment of urine infection and urinary obstruction, the kidneys will start to hold onto sodium, particularly while hyponatraemic. Fluids containing relatively low concentrations of sodium will then be sufficient to raise the serum sodium concentration.
A more appropriate management scheme is highlighted by a recent case we had:
A 4 month old boy presented with poor feeding. He had been born at 38 weeks gestation and remained well, and growing appropriately for the first few months of life. Antenatal scans had demonstrated hydronephrosis but he had not attended for a post natal scan. A good urinary stream had been observed. Prior to presentation he had been unwell for one week with an URTI and slightly loose stools. He was noted to normally take 6-7 ounces of milk every 3-4 hours.
On admission, he was alert and active, warm and well perfused. Observations: Weight 5.89 kg, Temperature 35.2°C; Pulse 134 bpm; Respiration 36 bpm; O2 saturation 100% in air; Blood pressure 80/47
Examination was unremarkable.
He was initially started on oral Dioralyte and blood sent for routine investigations:
Hb 143 g/L, WCC 19.9x109/L, Na+ 113 mmol/L, K+ 8.1 mmol/L, Urea 24.4 mmol/L, Creatinine 93 µmol/L, CRP 5 mg/L. A venous blood gas revealed a metabolic acidosis: pH 7.25, pCO2 3.0 kPa, BE -17.1, HCO3- 10.1 mmol/L. Urine was positive for leucocytes on dipstick testing. A renal ultrasound was carried out. It showed moderate bilateral hydronephrosis and both ureters were significantly dilated down to the vesicoureteric junction. There was layering of echogenic material in the distal left ureter.
The hyperkalaemia was managed with salbutamol nebulizers, calcium gluconate and sodium bicarbonate (half correction with 28 mmol). A bolus of 10 ml/kg 0.9% NaCl was also given. These equated to a total of 37 mmol of sodium which is already a significant proportion (47%) of the calculated sodium deficit (0.6 × Wt (kg) × (desired serum [Na+] - current serum [Na+]) of approximately 78 mmol.
Antibiotics were started for a presumed urinary tract infection and a urinary catheter passed in case of urethral obstruction.
On consultation with the regional paediatric nephrology team a plan was put in place to achieve a gradual correction of the hyponatraemia over a minimum period of 72 hours. A presumptive diagnosis of type 4 renal tubular acidosis was made while blood was sent to exclude congenital adrenal hyperplasia. The initial urine [Na+] was 54 mmol/L in keeping with an inability to hold on to sodium despite hyponatraemia. As already mentioned, 37 mmol of sodium had already been prescribed so it was important to slow down sodium administration if too rapid a rise in serum [Na+] was to be avoided and to allow the intracellular compartment to adapt to the rise that had already taken place. The intravenous fluid prescribed was therefore 0.45% NaCl + 5% Dextrose at a rate equivalent to urine output + 4 ml/h to cover insensible losses. Four hourly biochemistry was carried out. Six hours into the management the urine [Na+] had dropped to 25 mmol/L and in order to maintain the gradual correction the intravenous fluid was changed to a mixture of 0.45% NaCl and 5% dextrose in a ratio of 2:1, giving a solution containing 50 mmol/L of sodium. This still contained an excess of sodium compared to the fluid being lost from the body, to facilitate correction of the hyponatraemia. After 24 hours the serum [Na+] had risen to 126 mmol/L (still above the ideal) but the curve had flattened with most of that rise taking place in the first 12 hours (reaching 124 mmol/L) due to the initial fluid boluses.
On day 2 oral feeds were started, initially at 10 ml/h and gradually increased as tolerated. The sodium content of formula milk is around 1 mmol/100ml so an intake of 100ml/kg/d gives 1 mmol/kg/d. This was therefore supplemented with an additional 1 mmol/100ml of sodium chloride. By day 3 he was on full feeds and the sodium supplements were stopped on day 4 when the serum [Na+] had reached 131 mmol/L.
It is important to recognise that in the two cases described by Tse et al.1, when the underlying problem is addressed, the kidneys ability to retain sodium will start to recover and continued administration of 0.9% NaCl will produce too rapid a rise in serum [Na+] and risk causing ODS. Healthy kidneys can cut urinary sodium losses to almost zero. Initial resuscitation often gives a significant amount of sodium over a short period of time and it is important therefore to rein back on replacement in order to allow the adaptive mechanisms that the body has put in place, to correct. I would urge clinicians faced with such cases to measure urinary [Na+] and adjust intravenous replacement fluids accordingly.
1. Tse Y, et al. Problem solving in clinical practice: the sick infant with low sodium and high potassium. Arch Dis Child Educ Pract Ed 2020; 0: 1–5.
2. Verbalis JG, et al. Diagnosis, evaluation, and treatment of hyponatremia: expert panel recommendations. Am J Med. 2013; 126 (10 suppl 1): S1–S42.