1. 49 shades of grey…… and irritable Sarah Martin LCCH ED

5. Why a talk about them? An approach to them …

6. What proportion of kids that present to EDs in Australia are irritable at some time during the presentation? A. 110% (+10% for parents of the kids) B. 100% C. 75% D. that’s what ketamine is for

7. The problem in a nutshell ….

8. “Irritability on examination”

16. “irritability” stats for LCCH Jan-March 2016

17. “Irritable” Children @ LCCH March 2016 145 irritable children 24 (17%) SSU 81 (55%) Discharged

18. Top 5 Discharge Diagnoses Feeding problems in a newborn “No injury found” Febrile illnesses – Bronchiolitis – Gastroenteritis – URTI – Otitis media – Pharyngotonsillitis Minor head injury Rash

19. But there was also … Meningitis Kawasaki disease VP shunt dysfunction Intussusception “Child at risk” Appendicitis

20. On an average day MOST children we see in ED will be irritable at some point … Most will not have serious pathology causing the irritability BUT some will so we need a solid approach

21. Which of the following has not been described as a cause of irritability in a neonate? …..

23. Beware of the Child with Developmental Delay ….

24. Irritability in older children ….

25. A case …

26. The context … 2330 in Purple Zone “the place where dreams go to die..” Hungry, tired, keen to go home but still to do a SSU ward round Almost time to shut the zone

27. Triage note 9/52 baby boy “Unsettled & irritable; passing wind ++; treated for reflux with Losec. Mother feels it isn’t working. Fussy with feeds. Poor sleeping.”

28. “I can’t find anything wrong but the mother & grandmother are sure there is something wrong & they’ve driven from Caboolture Heights so we can sort it out”. Triaged at 2023 Seen at 2220 Now 2330 Everyone likely to be irritable!

29. What I found A baby sound asleep Normal obs Exhausted teary mother Angry grandmother who wanted some “tests”

30. Further history 1 st babe Difficult delivery Discharged day 2 Breastfeeding since Partner works away

31. Had consulted… GP who started a trial of omeprazole but “didn’t think it was reflux” Chiropractor (3 times) who manipulated babe’s spine “& this improved the baby’s head movements but didn’t improve irritability” Child health clinic who reassured her Day stay feeding clinic Referred to Ellen Barron but on waiting list Caboolture ED “they just said he was ok”

32. My thinking in this case : I just need to use my “healthy baby, tired mother” spiel BUT I have cognitive degradation AND am at risk of experiential bias AND I know don’t LIKE chiropractors who crack babies necks

33. History

36. All babies cry, this is how they communicate Average amount of crying at 8 weeks = 3 hours/day Peak crying time = 3pm – 11pm Going red in the face, pulling legs up, passing wind while crying is normal, not pathological Generally improves by 3-4 months of age

45. Examine …..

59. In the case of RG Completely reassuring examination No red flags in babe’s history ? Mood disturbance in mother The Grandmother…

60. Assuming normal examination & normal obs who would investigate with ….? A. No tests B. Urine C. “Bloods” & Urine D. The full shebang

61. “The Crying Infant : Diagnostic Testing & Frequency of Underlying Serious Disease” Retrospective review Afebrile patients < 1 year – Irritability – Screaming – Excessive crying 237 infants 12 (5.1%) serious underlying causes 2 (0.8%) - investigations in the absence of a suggestive clinical picture contributed – Both < 4 mths & had UTIs Freedman et al 2009 Pediatrics, 123:841-848

62. “History & physical examination remain the cornerstone of the evaluation of the crying infant & should drive investigation selection”

63. Aim not to medicalise a normal situation Can’t “just do some bloods” or “just check a urine”

64. The power of listening & HEARING

65. If all normal … Referral for early (within days) ongoing support is essential. Maternal and child health nurse/clinic Lactation consultants GP or general paediatrician Mother-baby day unit or Ellen Barron unit Social worker Admission to hospital - if child considered at risk of non-accidental injury or parental exhaustion

66. Babe RG Admitted under the care of the general paediatricians No investigations Lactation consultant & social worker Discharged to Ellen Barron Family Centre

67. Resource Folder in ED Brochures for local child health clinics Referral forms for Ellen Barron centre Lactation consultant details

68. Beware of…. When not to use type 1 thinking (times of cognitive degradation) “Dangerous” patients Your particular cognitive biases (eg experiential bias)

69. And diagnostic momentum …

70. So … “Irritable” is a common label applied to children Most times the underlying problem is benign & self-limited Sometimes the underlying problem is very serious Needs a confident approach