Hey Reader,

Welcome to another edition of Bursting The Bubbles, DTFB's newsletter with some top tips, evidence highlights, and the best dad jokes.

This week we look at COVID and mental health, knee examination, and menstruation.

Let's do it...

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WEEKLY BUBBLE WRAP: COVID + MENTAL HEALTH

What’s It About?

During the COVID-19 pandemic, children and adolescents suffered ongoing disruption to their education and their social life.

Family stress levels grew due to parental depression, unemployment, domestic violence, and increased alcohol consumption.

We continually questioned this impact on children but had no clear data about what was happening during the pandemic.

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This systematic review of the literature and a meta-analysis tried to identify whether attendance to the PED for children presenting with attempted suicide, self-harm, and suicidal ideation changed during the COVID-19 pandemic. This was the first systematic review and meta-analysis looking at this topic.

There was a reduction in total attendance during the COVID-19 pandemic (rate ratio 0.68, 90% CI 0.62- 0.75). The mean age across the study was 11.7 years. There appeared to be an increase in attendance for attempted suicide (1.22, 1.08-1.37) and a modest increase in suicidal ideation (1.08, 0.93- 1.25). There was limited evidence for a change in attendance for self-harm.

Attendances for suicidal ideation or attempt increased more for girls, whereas attendance for self-harm showed no difference between boys and girls. Self-harm increased in older children (16-17 years was most conclusive) and decreased in younger children.

Attendances for suicidal ideation increased in all but the lowest socio-economic group, whereas rates of attendance for self-harm only increased in the higher socio-economic group. There was good evidence for a reduction in all other mental health presentations (e.g. depression, psychosis).

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Why Does It Matter?

The COVID-19 pandemic is, hopefully, a once-in-a-lifetime historic event. It will undoubtedly impact the mental health of our children and young people. We need to be mindful of the long-term effect that the COVID-19 pandemic has had on young people’s mental health and provide care to this vulnerable population.

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Clinically Relevant Bottom Line:

This study revealed increased presentations of attempted suicide among young people during the pandemic. Other mental health presentations such as depression and psychosis reduced in this population during the pandemic.

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Reviewed by: Emma Bagshaw. Read the full Bubble Wrap here.

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TOPIC OF THE WEEK: KNEE EXAMINATION

As popularity and intensity of children’s sports increases, there are increased demands placed on children and adolescents. They can present with knee pain that is traumatic or atraumatic, acute or chronic. Paediatric patients are particularly vulnerable to overuse injuries involving the physes and apophyses due to their inherent weakness (see post, hyperlink article on fractures around the knee).

Along with these, there has also been an increase in soft tissue injuries. These are seen more commonly in older children/adolescents as their bones become stronger and are less likely to fracture with age.

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What Do I Need To Ask In The History?

Important points to note on the history include:

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• If there was clear onset of pain
• Traumatic or atraumatic
• Duration of pain
• Previous injury/surgery
• Site of the pain (try to be as specific as possible)
• Severity of pain
• Nocturnal pain
• Systemic symptoms
• Associated swelling (intermittent or progressive)
• Contralateral injuries (may result in abnormal gait placing additional pressure on knee)
• Hip or back pain

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Umm, What's The Anatomy Of The Knee Again?

Recalling the anatomy of the knee makes evaluating the site of pain easier. The following make up the knee and all can be injured/inflamed and cause pain.

1. Bones around knee – femur ends at lateral and medial condyles which articulates with tibial plateau and anteriorly the patella unsheathed in the patellar tendon.
2. Ligaments – anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial and lateral collateral ligaments.
3. Meniscus – medial and lateral menisci act as shock absorbers and interdigitate into the ACL and PCL for more stability.
4. Bursae – supra-patellar bursa, infra-patellar bursa, pre-patellar bursa, and pes anserine bursa (medial aspect of knee).
5. Tendons – quadriceps tendon (inserts into patella), patellar tendon (inserts into tibial tuberosity)
6. Other – iliotibial band (fibrous support of fascia lata originating at the external lip of iliac crest and inserting into the lateral condyle of the tibia).

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What Should I Be Examining?

Examination in the acute setting is often difficult and may be limited. This is due to swelling, pain and anxiety. Try your best to be as detailed as possible but ensure you note any red flags on examination. These are:

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• Inability to do straight leg raise (extensor mechanism rupture)
• Ligamentous laxity
• Catching, locking or giving away (meniscal injury)
• Inability to fully straighten the knee

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Injured ligaments are considered “sprains” and are graded on a severity scale.

• Grade 1 sprains: The ligament is mildly damaged. It has been slightly stretched, but is still able to help keep the knee joint stable.
• Grade 2 sprains: The ligament has been stretched to the point where it becomes loose. This is often referred to as a partial tear of the ligament.
• Grade 3 sprains: This type of sprain is most commonly referred to as a complete tear of the ligament. The ligament has been split into two pieces, and the knee joint is unstable.

Ligament specific examinations:

• Anterior and posterior drawer tests – asses anterior and posterior cruciate ligament integrity.
• Lachman test – assesses ACL integrity. Most sensitive test for ACL rupture. Non-dominant hand cups and support the knee. Ensure quads and hip flexors are relaxed for it to work. The dominant hand grasps the proximal tibia, knee flexed at 20-30 degrees. Pull sharply. Tibia shouldn’t move much and should have distinct endpoints.

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• Posterior sag test – patient supine, hip flexed at 45 degrees and knee at 90 degrees. Look at the knee from the lateral position. If PCL is damaged you’ll see tibia sagging posteriorly.
• Varus and valgus stresses – assess the integrity of medial and lateral collateral ligaments. Compare both sides for laxity.

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To read more about how to manage there check out our DFTB post.

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HIGHLIGHT: POLIO

There have been several news reports about cases of polio in the United States (New York State), Ukraine, sub-Saharan Africa, and India. In most of these countries, poliomyelitis was thought eradicated, with no cases reported for years, mainly due to successful vaccination campaigns.

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What Are The Signs And Symptoms Of Polio?

95% of infections are either asymptomatic or cause very mild disease. Patients may have influenza-like symptoms, with vomiting, headache, and/or myalgia. This is called abortive poliomyelitis (note: it’s often called poliomyelitis” even if there is no neurological involvement). In a minority of cases, polio can be more severe: this occurs in approximately 1:1000 infants or 1:100 adolescents. Patients may develop meningitis, encephalitis, or paralytic polio.

In most cases, the disease is limited to aseptic meningitis. Patients are sick with a high fever and lethargy and may be nauseated. Patients who have aseptic meningitis do not tend to experience paralytic symptoms.

In some cases, the disease progresses to acute flaccid myelitis. This is a sudden-onset weakness of the muscles without cognitive loss and without sensory changes. Symptoms vary according to the level of paralysis — it may be spinal, bulbar, or both (bulbospinal). Spinal poliomyelitis is, by far, the most common. Patients may have decreased or absent tendon reflexes. They may also develop difficulties in breathing or swallowing. This explains why some children with polio died when respiratory support was not readily available. Paralytic polio is not only more common in older patients but also more severe. Quadriplegia is more common in adults.

Encephalitis is rare. These patients present with a change of mental status and fever. Seizures may also occur, as may paralysis. This is usually of the spastic kind, characterised by hypertonia, unlike classic paralytic polio.

Neurological symptoms (such as muscle pain, new weakness or even paralysis) may return decades after recovery from the initial disease. This is known as post-poliomyelitis syndrome or post-polio syndrome. This occurs in up to 40% of survivors of paralytic disease.

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Read more about Polio here.

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EVENT OF THE WEEK

Last month saw Menstrual Hygiene Day.

Don't avoid this - if we are embarrassed to talk about periods, our patients will be too.

Check out Tara's post about lost tampons here.

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TIP OF THE WEEK

Consider the possibility of non-accidental injury in a child with a non-blanching rash,

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JOKE OF THE WEEK

What do you call a bear with no teeth?

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A gummy bear!

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That's it for this week, Reader.

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Remember, your work makes a difference in the lives of paediatric patients every day.

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Stay tuned for next week's edition of Bursting The Bubble.

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From Tessa (on behalf of Team DFTB)

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