As increasing evidence comes out of the countries hit worst by the COVID-19 pandemic, there is growing concern about the number of healthcare workers being affected. A large number of COVID-19 positive tests in Italy (currently about 10%) have been healthcare workers.
It is important to emphasise that these statistics will inevitably have at least some bias. Healthcare workers are much more likely to be tested for COVID-19.
It is a concerning figure nevertheless and it is well known that healthcare environments are inherently risky when it comes to acquiring an infection.
There are three main ways to avoid getting an infection as a healthcare worker. The first is to avoid patient contact where possible. The second is to use appropriate personal protective equipment as per guidance. The third is to minimise the risk of the clinical encounter.
Over the past few weeks, there has been a growing discussion amongst frontline clinicians about a radical cultural change in clinical practice.
We have been asking the following question:
Should I stop examining children’s throats?
Like any such suggestion, the first time the question was asked out loud was probably in a one-to-one conversation in a closed room after checking that the General Medical Council hadn’t bugged the place. Then, as the question was asked more and more, it became quickly apparent that there was a large proportion of frontline clinicians who felt that this was a sensible move in the current situation.
On 25th March 2020, the RCPCH published guidance stating that in the current situation “the oropharynx of children should only be examined if essential.”
Never before in my career have I seen such a change in practice go from whispers between colleagues to official college guidance in such a short period of time. Well done RCPCH! For the first time since the introduction of FAOMed, you’re ahead of us!
While this move is entirely intended to reduce the risk of clinical contact during the COVID-19 pandemic, clinicians will at the very least have questions. When something is part of our routine and then taken away from us it will cause anxieties. As acute clinicians, our intuitive thinking relies on a reasonably consistent approach and in most paediatric encounters, we are used to looking in the throat.
So the question is, is it OK to stop doing that routinely?
Here are a few common questions in response to this radical change.
What if I need to know what the focus of infection is?
Good question.
This has always been a hugely subjective issue. Even before this pandemic, the majority of clinicians and organisations have been trying to encourage self-care for uncomplicated febrile illness in children. If a clinical confirmation of infection focus was essential, health care organisations would be getting the message out.
“Never give your child fever medicines without seeing a doctor to check what the problem is.”
That’s not a thing.
A snotty febrile child has an upper respiratory tract infection (URTI). URTI does not exclude other infections nor does it exclude sepsis so the redness of the throat should not reassure us if we think a child has another probable diagnosis such as UTI, LRTI or sepsis.
The important question has always been, “does this child have signs of serious bacterial infection or sepsis?”
If the answer is no then the throat exam won’t really change things (see below). If the answer is yes, you’re looking for a source and it probably isn’t in the throat.
When might I need to examine the throat?
The necessity for this is probably going to be mainly to look for evidence of a significant pathology such as peri-tonsillar abscess. I would suggest that such a possibility can be all but excluded clinically if a child is well analgesed and is able to eat or drink.
If you do feel that examining the throat is important to do, you must wear eye protection.
Don’t I need to determine if the child has tonsillitis?
Tonsillitis in children can always be treated symptomatically. The NICE guidance for treating sore throats attempts to direct the clinician toward cases where a symptom benefit from antibiotics is more likely but does not mandate the use of antibiotic in any uncomplicated URTI or tonsillitis. The reason there is no mandate is that there is no evidence that in this era in the UK, antibiotics prevent the rare complications of URTI/tonsillitis.
Regardless of clinical findings, the symptom benefit from antibiotics is poor. The lack of evidence for the significant benefit has led the Children’s Hospital Melbourne to recommend no prescription of antibiotics in any case apart from high-risk children or signs of complicated URTI.
So if the child is low risk (99.9% of children) and has no signs of complications from the infection, the visualisation of the tonsils is non-essential.
Should I, therefore, prescribe antibiotics empirically?
In the interests of openness and honesty, I need to say first that the RCPCH does advocate this. There is a reminder that under the age of three years old, FeverPAIN should not be used. Over the age of three, it is proposed that in the current climate we prescribe antibiotics as follows.
“If using the feverpain scoring system to decide if antibiotics are indicated (validated in children 3 years and older), we suggest that a pragmatic approach is adopted, and automatically starting with a score of 2 in lieu of an examination seems reasonable.
Children with a total feverpain score or 4 or 5 should be prescribed antibiotics (we suggest children with a score of 3 or less receive safety netting advice alone)”
I’m going to stick my neck out and suggest that this approach is wrong, for the following reasons:
- First and foremost, it contradicts the public health approach to containing the COVID-19 pandemic. People are being told that if they have a fever without signs of something that looks like a serious illness (difficulty breathing, poorly responsive etc.) they should stay at home, self-medicate and not seek a face to face clinical contact. This is for their benefit, to protect the health service and to reduce the spread of COVID-19. Lowering a threshold for prescribing antibiotics for sore throat at this time goes against that move.
- Secondly, the RCPCH has misquoted the NICE guidance. In their speediness to protect clinicians from unnecessary risk, they have missed a word. Just the one but it the word from the guidance that frequently goes unnoticed. That word is ‘consider’. It doesn’t say ‘give’ antibiotics for a FeverPAIN score above 4. It says consider. I consider that question every time and in most cases the answer is “The likelihood of benefit from antibiotics does not justify the risks.”
I feel (personal opinion) that since there is no mandate to treat low-risk children who have no signs of complications of their URTI or tonsillitis, we should default to not prescribing antibiotics in these cases. To lower our threshold for prescribing instead of raising it at this time of such a high-risk clinical environment feels wrong. It seems contrary to the need to protect children and their carers from the risks of a visit to a GP or hospital and it feels contrary to the drive to reduce the number of people bringing COVID-19 with them to those places.
Again, huge respect to the RCPCH for cutting through the red tape and rapidly producing guidance to protect healthcare workers. Whenever something is done in that sort of timeframe, it is likely that detail gets missed. That’s where we come in. We notice the typos and consider the implications. We ask questions that deserve answers after the fact in lieu of the consultation period that couldn’t happen due to the timescale needed.
Edward Snelson
@sailordoctor
You can view Edward’s excellent blog by clicking here.
