The 4th Bubble Wrap


With millions upon millions of journal articles being published every year it is impossible to keep up.  Every month we ask some of our friends from the world of paediatrics to point out something that has caught their eye.

Article 1 – Is humidified high-flow oxygen useful in bronchiolitis?

E Kepreotes, B Whitehead, J Attia et al. High-flow warm humidified oxygen versus standard low-flow nasal cannula oxygen for moderate bronchiolitis (HFWHO RCT): an open, phase 4, randomised controlled trial. The Lancet, In Press, Available online 2 February 2017

What’s it about? This is the first ever RCT looking at high flow warmed humidified oxygen (HFWHO) – aka high flow nasal cannula oxygen – HFNCO) versus standard nasal cannula oxygen for infants with bronchiolitis. Kepreotes and colleagues carried out a single site open label RCT over 3 years at an Australian children’s hospital, recruiting 202 children <24 months old with moderate bronchiolitis. Of note, 181 children were retrospectively identified as suitable for inclusion, but were not recruited due to staff or ED pressures – a hazard of research in acute settings unfortunately!

The mean baseline SpO2 for included children was 96%, which appears high compared with both the AAP recommendation of 90% and NICE’s level of 92% for supplemental oxygen.

Their primary outcome was time to weaning off oxygen, but they also looked at treatment failure and ICU admission.

Why it matters? HFNCO is being used more widely – based on mostly theoretical benefits, however as with many fancy novel therapies, it is a bit costlier and there is much variability in its clinical use. This study aimed to provide high quality evidence of the effectiveness of HFNCO.

There was no difference in the time to weaning off oxygen, ICU transfer or length of stay. A tight, standardised weaning procedure probably had a significant impact on weaning time, independent of the oxygen delivery method.

Only one child’s treatment failure was due to persistent SpO2<90%, suggesting that the ability of HFNCO to deliver higher concentrations of oxygen is not its primary beneficial effect. It may in fact be due to positive pressures, humidity or other unknown factors.

Importantly, more children failed treatment in the standard nasal cannula group, though two-thirds of these then responded to HFNCO, and avoided escalation to ICU. All children who failed HFNCO required ICU treatment. HFNCO looks like a reasonable option as a rescue therapy to avoid escalation to ICU respiratory support in children who have not responded to standard treatment on the ward or ED.

Reviewed by: Shammi Ramlakhan


Article 2 – Can intervening in the ED change behaviour in drunk adolescents?

Arnaud N, Diestelkamp S et al. Short- to midterm effectiveness o fa brief motivational intervention to reduce alcohol use and related problems for alcohol intoxicated children and adolescents in pediatric emergency departments: a randomised controlled trial. Acad Emerg Med 2017;24:186-200.

What’s it about? Anyone working a Friday or Saturday night in an ED, particularly around holiday or post-exam time has encountered the drunk teenager, surprised friends (“she must have been spiked”) and resigned or horrified parents. This team in Germany wondered whether the ED attendance could be a teachable moment in terms of reducing hazardous drinking behaviour in teenagers. They used a cluster randomised design (with each weekend as a cluster) to assess a targeted brief intervention versus standard care (a leaflet and contact numbers) in reducing binge-drinking and alcohol-related problems.

Why does it matter?  As the parent of a nearly-teenage daughter with a slightly blurry recollection of my own teenage years I’m keen to reduce the harm alcohol can cause our kids. It is intuitively appealing that ending up in hospital could be a teachable moment. The definition of “brief intervention” in this field always makes me laugh a little – in this case it was a 45 minute session of motivational intervention and directive counselling with the adolescent, a brief session with the caregiver and a follow-up reinforcement phone call six weeks later. This is clearly not an intervention that can be introduced unresourced (“maybe you can just ask at triage”). However, if it reduces alcohol related attendances, injuries and harm, potentially worth it.

The team enrolled 320 patients in 6 PEDs over 29 months. Another 71 presented with alcohol intoxication but were discharged before the time when the study counsellors were available. 40 others were “not interested” or “not feeling well”(!). 144 received the intervention and 176 standard care, with pretty good follow-up rates at 3 and 6 months of above 80%.

Sadly, however, the intervention made no difference in any of the outcomes studied (binge drinking frequency, number of alcoholic drinks on a typical occasion, or alcohol-related problems). I suspect this might be due to the change from baseline in the control group: 49% reduction in binge drinking frequency; 26% reduction in number of alcoholic drinks on a typical occasion; 58% reduction in alcohol-related problems (all at 3 months, with minimal change from this at 6 months).

Maybe the teachable point is simply made by ending up in the ED?

For more on this subject come and listen to Diana Egerton-Warburton at DFTB17

Reviewed by: Kirsty Challen


Article 3 – Managing children after reduction of intussusception

Kwon H, Lee JH, Jeong JH, Yang HR, Kwak YH, Kim DK, Kim K. A Practice Guideline for Postreduction Management of Intussusception of Children in the Emergency Department. Pediatric Emergency Care. 2017 Feb 18.

What’s it about? One of the most important roles of research should be to get people thinking about their own practice. I’d like to think a backbone of my approach to the distressed infant is to think intussusception. If confirmed, and effectively treated, then it would be an admission to the surgical wards for convalescence. This study in a small children’s ED (24000 visits annually) aimed to introduce a practice guideline that would mean patients with intussusception could be discharged directly from the ED when treated.

Why does it matter? Having been drawn in by a concept I’d not even considered could be a possibility, I found myself more surprised by the rate of intussusception at the study institution (a tertiary centre in Seoul). Over 2 years there were 111 children with a radiologically confirmed diagnosis. This must be a regular occurrence as the power calculation of 61 patients in each arm allowed the study to proceed. Essentially management pre-implementation (one year) of a guideline allowing ED observation and discharge was compared with post implementation (one year). The authors were a little obsessed with the trend of the length of stay over the study period. I think the different medians 532 minutes (pre) vs 289 minutes (post) speaks for itself.

The recurrence rates were not significantly different between the groups but there was a longer time to recurrence in the post implementation group (15-50 hours n=5) than the pre-implementation group (7-9 hours n=3).

Working in the confines of 4 hours I would be very uncomfortable sending a child home from the ED post-reduction, if only just for the parents sanity. However while I worry that the incidence of intussusception in this institution puts a question mark over external validity, it clearly asks an important improvement and patient experience question that needs addressing.

Reviewed by: Damian Roland


Article 4 – When to scan in head injury: is soft tissue swelling an indication for head CT in infants?

Zaman S, Logan PH, Landes C, Harave S. Soft tissue evidence of head injury in infants and young children: is CT head examination justified? Clinical Radiology. 2017 Jan 21: doi: 10.1016/j.crad.2016.12.012

What’s it about? Advice from the NICE head injury guideline is to get a head CT on all infants <1 year old who have a swelling, bruising or laceration >5 cm in size following a head injury. Does this seem a bit excessive?

The PEM physicians at Alderhey Children’s Hospital (Liverpool, UK) collected data on all children under 3 years of who had a head CT following a head injury over a 3.5 year period. This was further narrowed to cases where the terms ‘bruise, swelling, bump, haematoma, laceration or abrasion’ were used in the CT request. They found notes for 85 cases. In 44 of these, the head CT demonstrated a skull fracture, and in 4 there was an intracranial haemorrhage. One child required neurosurgical intervention.

Of the 85 cases, in 38 of these soft tissue evidence was the sole indication for head CT. 22 of these 38 had a skull fracture and one had an intracranial haemorrhage. In the under 1 year age group, 27 head CTs were performed solely because of soft tissue evidence – 20 of these demonstrated a skull fracture and one had an intracranial haemorrhage.

Why does it matter? We don’t need to feel guilty about performing head CTs on under 1s with large swellings or lacerations. In fact, the pick up rate of skull fractures when doing this is quite good – 57.9% had an underlying skull fracture (although I guess that depends on whether or not you think picking up skull fractures is a good reason for doing a head CT). Having a 5 cm cut-off may be a bit stringent though, because 11 skull fractures in this cohort would have been missed. This 5 cm cut-off originally came from CHALICE, but it is unclear as to why it was chosen by the CHALICE team in the first place.

Reviewed by: Tessa Davis


Article 5 – Invasive infections in critically ill Indigenous children

Ostrowski JA, MacLaren G, Alexander J, Stewart P, Gune S, Francis JR, Ganu S, Festa M, Erickson SJ, Straney L, Schlapbach LJ. The burden of invasive infections in critically ill Indigenous children in Australia. Med J Aust. 2017 Feb 6;206(2):78-84. PubMed PMID: 28152345.

What’s it about? The group looked at all paediatric ICU admissions in Australia over  an 11 year period (2002-2013). They then pulled all the data on the 3150 Indigenous children who were admitted and found that severe invasive infections accounted for 23% of Indigenous children admitted and only 17.3% of non-Indigenous children. These severe infections included pneumonia (54.3%), meningitis (12.3%) and osteomyelitis (3%). Staphylococcus aureus was identified as the causative organism in 22% of cases and Neisseria meningiditis in 11%. Through fancy statistical analysis they found the Staph. aureus sepsis admission rate was 4.42 per 100,000 Indigenous children per year and only 0.57 per 100,ooo non-Indigenous children per year, an eight-fold difference.

Why does it matter? Those of us that work in our white brick temples to Aesclepius need to be more aware of the burden of disease in this supposedly developed country. Indigenous children are twice as likely to die in childhood and are much more likely to contract bacterial illness with severe consequences such as otitis media, pneumonia and bronchiectasis. It is very easy to be blasé about illness in children but most of us need to consider what me can do close the gap.

If you want to know more you could come to DFTB17 and hear from one of the authors of this study.

Reviewed by: Andy Tagg



That’s it for this month.  Many thanks to all of our reviewers who have taken the time to scour the literature so you don’t have to.  If you think they have missed something amazing then let us know.

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Grace is an SRMO at Sydney Children's Hospital. She loves innovative medical education and paediatrics. She is on the organising committee for the DFTB17 and SMACC conference. Grace is a former internal director of the AMSJ. She enjoys board games, cooking and cheesy jokes.