How to stop the URTI-antibiotic discussion becoming an ordeal this winter

 

The antibiotic debate is a big one for several good reasons.  One of those reasons is that times have changed and change can be challenging.  Antibiotics were used liberally by previous generations of clinicians.  We and our patients now find ourselves in a world where antibiotics are being used less often.  This culture change is a major contributor to the conflict that arises due to the expectation of antibiotics as a treatment for sore throats and painful ears in young children.

 

The good news is that if you are prescribing fewer antibiotics then you are part of a growing trend.  In the UK and many other countries, antibiotics prescribing rates have fallen over the past few years.  This means a lot more children are benefiting from symptomatic treatment without the added side effects of antibiotics.  So far the evidence is that this reduction has not been the cause of a rise in bacterial complications such as peritonsillar abscess and rheumatic fever. (1)

 

If you work in a country with a low incidence of complications of streptococcal infections, that tells you more about the pathogenicity of your local bacteria than about your prescribing rates.  We therefore greatly rely on our Public Health team to facilitate the safety of the no-antibiotic approach to managing URTI/AOM/tonsillitis.  The Public Health team monitors the rates of complications of streptococcal infection and alerts you when there is a more pathological strain of strep and will make recommendations regarding temporary changes in prescribing practices.

 

It’s great to know that Public Health have our backs, but it’s a little complicated to explain to patients and parents in the time restrictions of a consultation.  Explaining the rationale for avoiding antibiotics for sore throats and ears can be tricky.  While many of of us are finding that it is problematic less often than it used to be, it is still one of the most important skills that we should have.  The question is, what can we do to make it likely that this discussion goes well and goes quickly?

 

The first thing to do is make sure that we’re coming at this from the point of view of the best interests of the child.  I understand the need for antibiotic guardianship but quite frankly when it comes to each clinical encounter, I’m always going to choose what will be best for my patient.  If this is what is driving our avoidance of antibiotics then the parents will hopefully sense that we want what they want -their child to be as well as possible as soon as possible.  What this child-centred approach achieves is that we then have the right attitude towards the subject of antibiotics.  We don’t come across as having a hidden agenda.  It’s all about the child and wee hope that parents will respond well to that.

 

When we have the discussion it is important to be considered when choosing our words.  If we talk about “not needing” antibiotics, it might come across as them not having fulfilled the criteria for what they see as the ultimate treatment.  Instead, talk in terms of antibiotics not helping.

 

It is fairly standard at this point to mention the side effects of antibiotics.  I don’t tend to mention allergic reactions, partly because they are not that common and partly because we are trying to get away from parents thinking that everything that happens while taking antibiotics is an allergic reaction.  What I do emphasise is that common side effects are abdominal pain, vomiting and diarrhoea.  I make sure that the parents know that the main reason for wanting to avoid antibiotics is that I don’t want to do that to the child and I don’t want to make life harder for the parents.

 

Because most people don’t seek a medical opinion about what not to do, this is the ideal time to discuss what does work.  Analgesia is key and parents will sometimes need encouragement in this regard.  One thing that causes much confusion is the issue of what the medicine is for.  There has been an unhealthy emphasis on controlling temperature which sometimes means that paracetamol (acetaminophen) and ibuprofen are not used as analgesia when the child is afebrile but refusing to drink.

 

This is all important information and yet at the same time, it is way too much information for a parent.  In many ways, the complexity of the information is part of what perpetuates the overuse of antibiotics.  It is far simpler for the parents and the clinician to simply say, “Your child needs antibiotics.”  Unfortunately, this is the illusion of simplicity.

 

So what we need are strategies to simplify the complicated. A leaflet is a very good way to achieve this.  We know what the questions that most people tend to ask, so why not give them some answers?  Here is a simple leaflet, in a question and answer format:

 

You could even start the process in the waiting room.  A poster that gives a bit of context might soften the ground for the discussion to be allowed to focus on more important things.

 

If you would like access to either the leaflet or the poster then please let me know and I can give you a fully editable copy.  You will need to register a free account at canva.com  When you have done that, either send me a direct message via social media or post a comment at the end of this blog.  (You don’t need to worry about anyone seeing the comment.  I get to review all comments before they are published and if you start your comment with “not for publishing” I will keep it for my eyes only.)  Give me your email address that you used to register the canva.com account and I will share the templates of the leaflets or poster if that is of use to you.  You can then use these to edit and personalise.

 

There are lots of leaflets, posters and websites available.  You should use them both to inform and to simplify.  My view is that they should be basic but contain important information.

 

Finally, make sure that the parents know that they need to be looking out for signs of secondary infection and sepsis.  Complications of URTI are thankfully low where I practice but we should all be thinking of URTI as pre-sepsis.  I think that this safety-netting discussion can actually be used to support the no-antibiotic element of the consultation.  Parents need to know that the clinician realises that their child is genuinely ill.  For that reason, we should avoid the phrase “just a virus”.  It may be meant as reassurance but is often perceived as dismissive.  By completing the consultation with an explanation of signs of complicated URTI and when to re-attend we are helping the parent to see that we have taken the child’s illness seriously.

 

Edward Snelson
Very Serious Doctor
@sailordoctor

 

Disclaimer:  The online content of this blog may have been corrupted by pixies and as such the responsibility for anything that turns out to be wrong sits with the Fairy King.

 

Edward Snelson is a consultant in paediatric emergency medicine at Sheffield Children’s Hospital. He writes gppaedstips.blogsot.co.uk and is the author of The Essential Clinical Handbook of Common Paediatric Cases. This post was originally published on his site and is used with his permission.

 

Did you find this CPD article useful? Why not record your CPD using our revalidation form below? We will email you a copy directly to your email inbox.

 

Write your CPD topic in here. The information will be emailed to you.
*We will use your email to send you the details of your revalidation CPD entry. You can then copy/paste the detail directly into your GPhC record. By adding your email you agree to receive our newsletter via email. We send a daily newsletter. You can unsubscribe at any time. Read our privacy policy on the homepage.

 

Dr Edward Snelson

 

Reference

  1. Sharland M, et al, Antibiotic prescribing in general practice and hospital admissions for peritonsillar abscess, mastoiditis, and rheumatic fever in children: time trend analysis, BMJ 2005;331:328

 

 

Stephen-Andrew Whyte on a career in paediatrics, sexism, what the point of pharmacy is and where we are going

Stephen-Andrew Whyte is an advanced clinical practitioner, has an interest in child health and is an all-around educationalist. We are also extremely proud to have the benefit of Stephen’s insight as a member of the Pharmacy in Practice editorial board.

 

I spoke to Stephen recently about his career in paediatric pharmacy, professional coaching, sexism, bullying, apprenticeships and broadly where the profession of pharmacy in the UK needs to go.

 

 

Stephen will be joining us in Scotland later this year to support the running of the new Pharmacy in Practice support days for pharmacists working in primary care (GP pharmacy and community pharmacy) in Scotland. To register your interest in these days and be alerted when dates are announced click here.

 

If you prefer to never miss an episode you can subscribe on your preferred podcast platform. Just click on the links below to get going.

AnchoriTunesGoogle PodcastsSpotifyBreakerOvercastPocketCastsRadio PublicPodbeanStitcher

We need to talk about codeine

Things have changed a lot with regards to opioids and children and young people over the past few years.  In 2013, the UK Medicines and Healthcare products Regulatory Agency (MRHA) recommended that codeine should no longer be used under the age of 12 years old. (1)

 

To kick off 2019, The American Academy of Paediatrics has published an article regarding the opioid epidemic in young people. (2) These two things actually had nothing to do with each other. The MHRA advice was about side effects and not about addiction.

 

What are we supposed to use instead of codeine?

 

Well, the seemingly contradictory answer that you may or may not have heard is (wait for it…) that we should instead use morphine to provide moderate pain relief to children.  That’s not as crazy at it first sounds but it does require some explanation.  The explanation begins with a bit of pharmacology.  Then by adding a bit of physiology, it all starts to make sense.

 

First the pharmacology:  Codeine is not itself the thing that produces the opiate effect.  Codeine is metabolised to various things, the most important of which is morphine.  Essentially, when you prescribe codeine, you are prescribing morphine via the metabolism of the liver.

 

Secondly the physiology. The codeine-morphine metabolism that occurs in the liver varies in speed and completeness from person to person. It is estimated that about 2% of the population are fast metabolisers.

 

The end result is that when someone takes codeine, there is a variable conversion to morphine. The morphine which results and has a clinical effect is produced in amounts and over a time frame that varies from person to person. While slightly less information exists about Dihydrocodeine, it is similar enough to codeine to make all of the above apply.

 

 

Is this possibility of harm all just speculation?

 

There is some weak evidence that codeine may be to blame for some child deaths, mainly in use as analgesia following tonsillectomy. (3) It was these cases which prompted the ban on the use of codeine under the age of 12 in the UK. Although there are plenty of reasons why the deaths reported here are not generalisable to all children requiring strong analgesia, a recurring theme is that children who died often had a fast metabolism gene.

 

 

Despite concerns and rulings, codeine is still used frequently in children. (4) Now it seems that young people are choosing it themselves more and more. (2)

 

The good news is that opiates are rarely needed in children outside of a hospital setting.  If strong analgesia is required on a temporary basis, oral morphine is often prescribed where codeine would have once been given.  This paradoxical move has come about through a better understanding of how opioids work and the effect they can have in children and certain patient groups.

 

We need to be wary of opiates and opioids in children. These drugs definitely have an important place and we shouldn’t hesitate to use them appropriately when acute analgesia is needed. A good first choice option for oral strong analgesia is oral morphine, while for more rapid onset, intranasal diamorphine works very well.

 

It seems that in the past we were lulled into thinking that codeine, in particular, was a soft and safe option. The evidence of recent years has told us that in terms of prescription use and abuse, this is not the safe drug that it was thought to be.

 

Edward Snelson is a consultant in paediatric emergency medicine at Sheffield Children’s Hospital. He writes gppaedstips.blogsot.co.uk and is the author of The Essential Clinical Handbook of Common Paediatric Cases. This post was originally published on his site and is used with his permission.

 

References

 

  1. April 2015 Monthly Newsletter, Medicines and Healthcare products Regulatory Agency
  2. Sharon Levy, Youth and the Opioid Epidemic, Pediatrics Jan 2019, e20182752; DOI: 10.1542/peds.2018-2752
  3. Kelly, Lauren et al, More Codeine Fatalities After Tonsillectomy in North American Children, Pediatrics May 2012, 129 (5) e1343-e1347; DOI: 10.1542/peds.2011-2538
  4. Chua KP, Shrime MG, Conti RM. Effect of FDA investigation on opioid prescribing to children after tonsillectomy/adenoidectomy. Pediatrics. 2017;140(6):e20171765