Guidlines-keep them simple otherwise we won't remember them! The example of weight estimation.

One of the most important variables in paediatrics is development, and one important measure of physical development is weight.  This is used for all sorts of things, including drug doses, fluid calculations and body surface area estimation.  Normally of course we can weigh children, so this should be pretty accurate.

Unfortunately, sometimes we can’t do this, most notably in emergency situations; and in such cases it is necessary to estimate the child’s weight.  While this is never going to be as accurate as weighing the child, a good estimate is the best that can often be achieved.  However, this obviously requires two things: 

1. A formula for estimating weight
2. That the person using it can remember it and use it correctly.

A number of methods for estimating weight exist, however a recent letter published in Archives of Disease in Childhood describing a survey among 25 paediatric trainees suggest that this may be a cause of some confusion.   The authors start by reviewing the current Advanced Paediatric Life Support (APLS) Guidelines, which contain three methods of estimating weight:

·         Infants from 1-12 months (0.5 x age in months +4)

·         Children aged 1-5 years (2 x age in years +8)

·         Children aged 6-12 years (3 x age in years +7)

These replace the previous Guidelines which had one formula for children aged 1-10 years, and which still used in some Guidelines.

The study found that only 2 of the participants (8%) were able to correctly apply the new formulae to examples that they were given, and that around half used the old formula.  The extent to which this matters is debatable, but clearly someone thought it was worth changing the guidance on this, and this is what is now taught, so one would expect that paediatric trainees at least would know them.

The lesson from this is that Guidelines should always be as simple as possible if we expect people to remember them.  For parents, it might be worth knowing roughly how much your child weighs!

Challenging the paediatric ward discharge status-quo

One of the unwritten rules of paediatric medicine is that once a child is admitted to a ward they will stay over-night; and if they are ok they will bed and breakfast and probably go home the next morning.  That is one of the reasons that assessment and observation units were set up.  A recent paper in JAMA Pediatrics by Stephanie Iantorno and Evan Fieldston challenges this assumption, and in particular the idea that morning discharges are necessarily a measure of good practice.  One quote in particular seemed pertinent..."accommodating evening discharges can enhance the patient centeredness of care; families have obligations and barriers, including employment and transportation, that make morning discharges difficult and undesirable."

This seems to be one of the biggest challenges for health systems around the world - not just providing high quality care; but also care that fits in with today's lifestyles and expectations that things should happen when we want them to happen or when we need them to happen.  This is an American paper, and of course the health system there is very different to the UK; but the same challenges exist.  Some of this can be seen in the case of general practice hours - which often don't fit in with the hours of those who work in the day.  Another surprisingly important issue in London is avoiding the rush-hour; 07.00-10.00 and 16.00-19.00 are not good discharge times, particularly if one is relying on public transport!