This case is a complex one because it involves not just medical matters, but working with patients and parents. Increasingly patients have access to other sources of information beyond their doctor and will access this, not always in their own interests.
Growth in children is a key priority for parents, with a focus on regular weighing for infants. Many parents feel subconsciously that they have failed as parents if their child is not growing properly. Also, many mothers have strong views about breastfeeding, even feeling their own role as a mother is undermined if they are not able to breast feed their children. Whatever the rights and wrongs of this, these are strong emotions and can alter medical consultations.
With this background, Davina presents with several reasons she is small at different ages. She is growth restricted at birth because of placental insufficiency, she then grows poorly because of a breastfeeding technical problem. Later she develops coeliac disease.
At each stage, good management requires sensible use of appropriate advice and investigations, as well as appropriate use of team members.
Stage 1 – Timidity, ignorance, fixation
Those looking after infants will need to be aware of the basics of breast feeding. While it is established that doctors should know why breast milk offers significant health advantages over bottled milk, there is often ignorance of the features in the history suggesting that Davina is not latching on properly. Her lack of posseting also suggest that she has a fairly empty stomach at the end of feeds. This will lead to the recommendation of formula feeding and consideration of investigations.
Many doctors will be keen to do some tests to rule out other diagnoses. This is useful when the ‘other diagnoses’ need urgent treatment. However the need to do this should be weighed against the impact on the child and family. Timidity is shown in this case when tests are ordered – really a good history will demonstrate that the feeding should be addressed first, and if the child is still not growing, investigate at that stage.
Fixation can also be seen at this stage. Many doctors look for a medical (disease) explanation for all presentations, and use investigations to confirm their beliefs. Of course, there are many non-medical explanations for a wide variety of symptoms, ranging from ‘normal variant’, to behavioural, to social and cultural. These also need to be properly evaluated and addressed, but not necessarily using the history-examination-investigations-treatment model.
Stage 2 – poor teamworking, system error, timidity, ignorance
At stage 2, Davina has returned with poor growth again. She has a different problem medically, but her parents remember the earlier encounter, and this colours their interactions with the player.
The history is suggestive of an energy-deficit (as opposed to a constitutional or hormonal cause) of poor growth. This can be identified from the fairly recent drop-off in weight gain, moving away from her normal centile. At the same time length and head circumference are not affected. The change in stool also suggests a gastrointestinal cause. At this age, coeliac disease is the commonest cause, although a differential might include cystic fibrosis, cow’s milk protein intolerance, and in older children Crohn disease. Hypothyroidism is an important cause of poor growth, but is not likely with this presentation.
For players to successfully manage Davina at this stage blood tests are needed to determine her coeliac antibodies status, then an endoscopy before starting a gluten free diet. The endoscopy, although not well received by parents, is important so that there is certainty about a life long diet.
It is clear that this is what is needed after the initial results, and wanting either further tests or a dietician at this stage is a suggestion of timidity or ignorance. The thyroid function test result is not available, and although we cannot know why in this case, this system error means that the player must decide whether a test should be repeated or not. Although the test was possibly useful initially, once the test results are back with anaemia and positive anti-coeliac antibodies, a repeat is unnecessary – these findings are incompatible with hypo or hyperthyroidism.
Lastly, when unable to manage a case alone, specialists are needed. They are needed for their experience, knowledge, skills and for their status. When a situation is getting out of control, this is when a specialist is useful. Not doing this is poor teamwork. One of the bigger challenges experienced in clinical medicine is knowing when to call for help and when to manage a situation alone. Errors either side are bravado and timidity.
Map: TAME Case 4 - Davina (Tutorial 2) (497)
Review your pathway