The 7th Bubble Wrap

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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 PERUKI (Paediatric Emergency Research in UK and Ireland) to point out something that has caught their eye.

Article 1: Concomitant Acute Bacterial Meningitis in Neonates with Febrile UTI

Wallace SS, Brown DN, Cruz AT. Prevalence of concomitant acute bacterial meningitis in neonates with febrile urinary tract infection: a retrospective cross-sectional study. J Pediatr. 2017 May;184:199-203. doi: 10.1016/j.jpeds.2017.01.022.

What’s it about?

The work up for infants under 3-months with temperatures has changed during my time as a paediatrician with some of my colleagues deferring a LP based on recent literature. The neonatal patient (<28 days) with a temp however, evokes a ‘you shall not pass’ attitude and gets a full septic screen including CSF.

In my practice this holds true even if a urine dip is suggestive of a UTI, driven by previous experiences and the knowledge that a positive CSF result will impact the duration of antibiotics. What if this was not the case? The authors of this article aim to answer this question. They performed a single centred retrospective analysis over an 8-year period reviewing patients under 30 days with a lab confirmed UTI and who also had a LP.

Why does it matter?

The team identified 342 infants who presented to ED and met the inclusion criteria.106 infants were excluded. Urine sample was obtained by SPA or catheterisation. Five infants (2.1%) had signs of shock at the time of ED evaluation. Fourteen infants (5.9%) had been pre-treated with antibiotics before LP. Of these 14 infants, 6 received lumbar puncture within 1 hour and 3 within 2 hours of antibiotic pre-treatment. No mention is made of the remaining 5 patients.

Urinalyses were positive in 94.1% (222/236) of neonates. Of those with a positive urinalysis, urine dip was positive in 98.6% (219/222) for leukocyte esterase. Bacteremia was identified in 23 (9.7%) of the cohort. In 20/23 (86.9%) of cases, the same bacteria was isolated from the urine and bloodstream. None of the 5 patients presenting with shock had a positive culture.

No infant met criteria for definite acute bacterial meningitis. Two infants (0.8%) met criteria for probable meningitis. Both were pre-treated with antibiotics, and had bloody CSF. Three infants had viral meningitis/meningoencephalitis.

Clinical Bottom Line:

The bottom line always has to be will this change my practice – and I would have to answer no, but it does provide food for thought and the need for further research into this area.

The retrospective nature of the study, the definition of neonate being under 30 days (as opposed to the more widespread 28 days) and the large number of cases excluded (half of which were due to missing data) dents the impact of the results. I am also a little dubious about labelling any form of positive leukocyte esterase as a UTI at presentation.

Yet this study is not supporting the withholding of antibiotics in these cases, but to potentially defer a LP while we await a urine culture. Given the median number of lumbar puncture attempts was 2 (range 0-8 attempts) with nine (4.8%) infants received >3 lumbar puncture attempts this piece of research challenges us to look deeper at these cases. A well-designed prospective (ideally RCT) study would allow more meaningful conclusion that may change practice.

On an interesting side note, the results support the difficult in diagnosing ‘septic’ children clinically. The 5 patients presenting with shock had clear cultures with the almost 10% who had bacteraemia potentially appearing well.

Reviewed by: Stephen Mullen (@smullen001)

 

Article 2: Medical Clowns and cortisol levels in children

Rimon A et al. Medical clowns and cortisol levels in children undergoing venipuncture in the emergency department: a pilot study. Isr Med Assoc J. 2016 Nov;18(11):680-683.

What’s it about? 

A core issue in Paediatric Emergency Medicine practice is the management of pain. We have been debating pain scales, analgesic methodologies and implementation strategies for years. There is a bibliographic analysis waiting for anyone brave enough to do it to see if we have actually made any real progress in this area (happy to collaborate on this venture!) In the meantime a team from Israel looked at the impact of Medical Clowns in the Emergency Department on pain reduction during venipuncture.

Why does it matter?

I reviewed this paper because I struggled with the underlying assumption made and wanted to understand it a little more. The study group undertook a prospective randomized controlled trial with a not unreasonable allocation process. However the recruitment only occurred on days when the medical clown was present, which may have caused unintentional bias as prior to the study the medical clown had not been routinely present. In the control arm the “regular distraction and comfort techniques that parents provide” were allowed. In the medical clown arm, to quote a small extract from the paper:

To minimize the effect of other behavioral factors, parents were not given any instructions regarding how to aid their child, nor did ED nurses utilize any guided imagery or distraction techniques, even though many were knowledgeable about distraction techniques. For the same reason, topical anesthetic was not used, although it is a well-established treatment in reducing pain.”

The above to me is a little challenging; as I don’t understand why both groups couldn’t have had anesthetic [sic] cream. I also struggle with not aiding the parents at all and wondered what a parent representative may have said about this study.

But the main hypothesis that intrigued me was the use of both a subjective and objective measure of pain. The team employed a FACES (younger children) and a visual analogue scale (older children) to measure pain reduction as well as measuring serum cortisol levels (taken from the blood sample at the time of venipuncture). The team noted in their introduction that only major injury or severe trauma can increase ACTH and cortisol. While cortisol is a stress hormone its acute rise and fall is not always predictable and I struggled to find similar or relevant studies looking at acute blood cortisol levels in children.

No power calculations were attempted so we are left pondering what a reduction in pain scores in study group (n=29) versus the control group (n=24) actually meant. There was no difference in cortisol levels which given the physiological processes at work is probably not surprising.

Clinical Bottom Line:

As you probably always have continue to brief your family, appropriately distract your child and use local anaesthetic agents when clinically relevant to do so.

Reviewed by: Damian Roland (@Damian_Roland)

 

Article 3: Blood cultures in children with pneumonia

Davis TR, Evans HR, Murtas, J, Weisman A, Francis JL & Khan A. (2017), Utility of blood cultures in children admitted to hospital with community-acquired pneumonia. J Paediatr Child Health, 53: 232–236. doi:10.1111/jpc.13376

What’s it about? 

Obtaining blood cultures in a child unwell enough to be admitted to hospital with a likely diagnosis of pneumonia are currently standard practice; this retrospective study begins to challenge the utility of this investigation. The authors (including DFTB’s Tessa Davis), reviewed 215 admissions to the paediatric ward of a regional Australian hospital with a diagnosis of pneumonia. Of these, 177 patients had blood cultures taken. The results are impressive; either the cultures had no growth, or were false positives in 98.9% of cases. Only 2 of 177 blood cultures were positive, both grew Strep pneumoniae, an organism covered by empirical treatment.

Why does it matter?
This is a beautiful example of “because we’ve always done it” being questioned. Essentially, in the cohort studied, there was no material difference in the collection of blood cultures. That is, there was no change to the child’s clinical management as a result of blood culture results.

My reading of the paper is that patients with a primary diagnosis of septicaemia would be excluded, but those with viral pneumonia would be included; this can be a hard call to make in the first few hours of a child’s presentation.
There are several other interesting statistics to consider. firstly, the two children with positive blood cultures also had CRP > 250mg/L; a test that would return results much faster than blood cultures, albeit without any of the specificity. Additionally, only ¼ of the study population had received any antibiotics prior to presentation. 97.7% of patients received a chest radiograph, with just less than half having lobar changes; one of the children with positive blood cultures did not receive a chest radiograph.

Clinical Bottom Line:
Blood cultures have a very low yield in identifying an organism in children admitted with moderate to severe CAP. The positive blood culture result, when present, did not appear to affect the management of the patients. The sickest patients (those requiring transfer to tertiary units for further investigation or management) all had negative blood cultures.”Collection of blood cultures is remains universal practice; this study identifies a low diagnostic yield and the overstated clinical priority of this test in a patient with pneumonia.

Reviewed by: Henry Goldstein (@henrygoldstein)

 

Article 4: Missed fractures in infants presenting to ED with fussiness

Kondis JS, Muenzer J, Luhmann J. Missed Fractures in Infants Presenting to the Emergency Department With Fussiness. Pediatr Emerg Care, March 2017, 2017. doi: 10.1097/PEC.0000000000001106

What’s it about? 

The study investigated a link between prior presentation to a Paediatric Emergency Department (PED) with fussiness or crying and subsequent diagnosis of fracture on re-presentation in the future. It assessed both fractures suggestive of Non-accidental injury (NAI) and accidental fractures.

The overall aim of the study was to assess the incidence of prior fussiness in infants subsequently diagnosed with fractures suggestive of NAI. Given that “fussiness” and unexplained excessive crying are common presentations to PED, the study posed the question whether clinicians should have a higher suspicion for NAI when assessing infants under the age of six months with unexplained “fussiness” and broaden the use of skeletal surveys within this population. The researchers performed a retrospective review of infants younger than six months presenting to PED over a 6 year period (2006-2011) with a diagnosis of a fracture, break, trauma, child abuse or a complaint of “fussiness” or crying. Medical records were reviewed for terms including ” fussiness” &/or “crying” with no additional coding identifiers. All records were reviewed by a single reviewer (main author of the paper with a MD qualification) and a standardised data collection form was used.

In total 3732 infants’ cases were reviewed, 279 were confirmed as having a diagnosis of a fracture, 35% (n=99) of whom had a fracture considered concerning for NAI. In addition, there were a total of 2005 attendances of infants with “fussiness” or crying, 0.9% (n=18) were diagnosed with a fracture at a later presentation and of these 18; 16 infants had a fracture suspicious of NAI. Therefore of the total 99 fractures suggestive of NAI, 16% (n=16) had a previous presentation of “fussiness” with a further 69% (n=11) demonstrating healing fractures on skeletal survey from the time of initial “fussiness”. The timeframe between the initial episode of fussiness and fracture with a mean of 27 days (median time = 20 days).

Of the children identified with ” fussiness” and/or “crying” at first presentation: 28% had a diagnosis of reflux/vomiting; 22% unexplained fussiness; 11% feeding problem; 11% corneal abrasion; 11% respiratory illness; 11% query sepsis and 6% fall. The authors conclude that fractures concerning for NAI are an important cause of unexplained “fussiness” in infants presenting to PED and so a high index of suspicion is needed within this infant population.

Why does it matter?

We are already know non-specific “fussiness” and unexplained crying are very common presenting complaints to PED. Furthermore, young infants with injuries caused by NAI often present with vague symptoms and provides a diagnostic challenge for the clinician. This is the first study to describe a population of infants who presented to the PED with fractures, who had previously attended for “fussiness” in which their fracture may have been missed.

This study suggests that clinicians should have a high suspicion for NAI when evaluating infants with “fussiness” (but this should already to be the case) and the retrospective nature of the study and lack of case-control probably does not support a recommendation of broader use of skeletal survey within this population.

Clinical Bottom Line:

This study is further evidence of the need for a high index of suspicion for NAI in infants, especially under the age of six, in order to prevent further harm to the child.

Reviewed by: Kate O’Loughlin (@KateOLoughlin5)

 

Article 5: Ethics in decision making for resuscitation of premature infants in the “grey zone”

Gillam L, Wilkinson D, Xafix V, Isaacs, D. Decision-making at the borderline of viability: Who should decide and on what basis? J Paediatr Child Health, 53(2) 2017 p105-111. DOI: 10.1111/jpc.13423

What’s it about and why does it matter? 

In this article, three ethicists discuss a case of threatened labour at 23 weeks gestation. They provide frameworks of thinking around whether active resuscitation and invasive interventions should be offered and whether clinicians should be able to over-rule parental decisions if parents decline medical intervention.

This is a complex issue which needs care and attention from clinicians involved in the care of bother parents and baby. The choice for parents of whether to choose active resuscitation and intervention over palliation in severely pre-term babies at the border of viability is a difficult one which will depend greatly on individual values.

Wilkinson’s (@NeonatalEthics) thoughts hone in on  the boundaries of the “grey zone”. He advocates from a move away from only gestational-age-based guidelines (generally considered between 23 weeks and 24 weeks and 6 days) towards use of a prognosis based framework.

Gillam asks if parental choice is causing harm to the baby, considering intervention which may possibly involve high burden of care and uncertainty of a meaningful life compared to palliative care. Both she and Xafis agree that where there is doubt about prognosis it is difficult to justify clinicians over-riding parental decisions to forego treatment. Xafis notes that the choice of parents will impact on their individual and family make up for the rest of their lives.

Clinical Bottom Line:

Clinicians should be wary of overruling parental decision making in this area of great uncertainty. It is important for clinicians to consider not just gestational age but also prognostic features in decision making or advocating for intervention.

Reviewed by: Grace Leo (@gracie_leo)

 

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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About 

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.