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The 20th 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 PERUKI (Paediatric Emergency Research in UK and Ireland) to point out something that has caught their eye.

Article 1: Out-of-Hospital Arrests

Day E, Hort JR. Out-of-hospital arrests attending an Australian tertiary paediatric emergency department over 13 years: An observational study.Emerg Med Australas. 2018 Jul 18. doi: 10.1111/1742-6723.13127.

What’s it about?

CPR in progress” is never a phrase you want to hear over the red phone. This observational study was undertaken at Westmead Children’s Hospital from 2000-2013 and looked at children with an OHCA presenting to ED with CPR still in progress.

Patients with ROSC en route were excluded, as were patients with a primary respiratory arrest, neither group being the focus of the study question.

For the study cohort, outcomes were universally fatal within 96 hours, irrespective of ROSC.

Why does it matter?

In a nutshell, this study leads us to consider the concept of futility.

With the paper’s opening sentence, the authors reflect on ILCOR’s statement that ’there are no simple guidelines to determine when resuscitative efforts become futile’. Hort and Day have sought to establish variables more closely associated with death, as they may assist in the development of guidelines and inform other approaches to the cessation of cardiopulmonary resuscitation.

Variables for the subgroup analysis included witnessed versus unwitnessed, at home versus elsewhere, length of total CPR, characteristics of CPR delivery included bystander versus paramedic and pre-versus in-hospital, total doses of adrenaline and whether the rhythm was shockable. Additionally, there was no difference in variables between the ROSC and non-ROSC groups.

Clinically Relevant Bottom Line:

Although the variables provided insufficient data due to the 0% survival rate, Hort and Day reasonably suggest the next step in this line of thinking focuses on a national multicentre study. The results also gave me a chance to revisit the literature on zero numerator problems, particularly the classic Hanley and Lippman-Hann 1983 paper on the topic.

I appreciated the epidemiologic component of this paper in particular, as these situations are rare and frequently emotionally charged. The exact details are challenging to ascertain, and it can be challenging to develop a higher level of insight at the time of presentation.

This paper provides some framing for the current situation of patients with CPR in progress due to OHCA and lays some foundations in the Australian context for the development of guidelines around the cessation of CPR.

Reviewed by: Henry Goldstein

Article 2: Childhood Immune Thrombocytopenia: To treat or not to treat?

Heitink-Pollé KMJ et al. Intravenous Immunoglobulin versus observation in childhood immune thrombocytopenia; a randomized controlled trial, Blood. published online June 26, 2018, DOI 10.1182/Blood-2018-02-830844

What’s it about? 

This was a prospective randomised control trial (TIKI) examining whether IVIg treatment of Idiopathic Thrombocytopenic Purpura (ITP) reduces the likelihood of chronic ITP. Patients were between three months and 16 years old with a diagnosis of ITP, platelets ≤ 20 × 109/L and grade 1-3 bleeding on the Buchanan Bleeding Score. Exclusion criteria were severe bleeding, receiving immunomodulatory drugs in the past month or contraindications to IVIg such as renal failure or IgA deficiency.

Between 2009-15, 206 patients from 48 centres were randomly allocated within 72 hours of diagnosis to receive either a single dose of IVIg (at 0.8g/kg, 102 patients) OR no treatment and observation (104 patients). The primary outcome was the development of chronic ITP. Secondary outcomes were the rate of recovery, safety, and efficacy of treatment choices.

The initial study design used a platelet count ≤ 150 × 109/L for chronic ITP; the study was modified to reflect current consensus since 2009 guidelines of ≤ 100 × 109/L platelets where possible.

Essentially,  platelet recovery was significantly higher in the IVIg group at 1-week, one and 3-month intervals. However, there was no significant difference in the presence of chronic ITP at 6 and 12 months (10% in the IVIg group vs 12% without at 12 months)

Regarding adverse events, bleeding (grade 4-5, mostly epistaxis or menorrhagia within the first month) occurred in 9% of the observation group compared to 1% in the IVIg group. One patient from the observation group suffered from a spontaneous intracranial haemorrhage but made a good recovery with treatment. The number needed to treat based on this data was 13: treat 13 children with IVIG to prevent one severe bleeding event.

Why does it matter? 

This is one of the first prospective RCTs looking at IVIg as a treatment for acute ITP in children. In the long term, treatment does not seem to reduce the development of chronic ITP. However, given the IVIg group had higher early complete response rates and fewer bleeding events, the question of whether to treat still remains.

One of the considerations is the expense IVIg and limitations of access. You can find Australian guidelines for administration via the National Blood Authority.

Genetic testing may help identify which children are likely to recover and which children are at risk of serious bleeds, but this is even more expensive than IVIg and not routinely available.

Clinically Relevant Bottom Line:

Acute ITP in children may present to ED with signs of bleeding, but many others are incidentally identified on blood tests after presenting with typical viral symptoms and fevers.

Given the cost, limited availability of IVIg and the low risk of a life-threatening bleed (< 1%), many patients can be safely managed with observation, advice about safety precautions and carer education.

Reviewed by: Tina Abi Abdallah

Article 3: The Prenatal Visit

Yogman, M., Lavin, A., Cohen, G., Lemmon, K.M., Mattson, G., Rafferty, J.R., Wissow, L.S. and Committee on psychosocial aspects of child and family health, 2018. The prenatal visit. Pediatrics142(1).

What’s it about?

This paper is an update of a policy from the American Academy of Pediatrics recommending, advocating the usefulness of and outlining objectives for a pediatric prenatal visit during the third trimester for all expectant families.

It advocates this visit as an important first step in establishing a child’s medical home.  This is especially important for first-time parents or families who are new to the practice; single parents; women with a high-risk pregnancy or who are experiencing pregnancy complications or multiple gestations; and parents whose previous pregnancies had a complication such as preterm delivery, an infant with a congenital anomaly, a prolonged course in the NICU, or a perinatal death.

Why does it matter?

Prenatal visits allow general paediatricians to establish a supportive and trusting relationship with parents, gather basic information from them, offer information and advice regarding the infant and they may identify psychosocial risks early that require special care.

The bottom line

General paediatrics is a big field in America, and the model differs from Australia and the UK. This policy does, however, provide useful tips for engaging with parents-to-be or new parents. It also helps highlight the importance of prenatal, paediatric review for high-risk pregnancies so that postpartum family care is optimized.

Reviewed by: Rachel Wong

Article 4: Could a household remedy help with button battery ingestion?

Anfang RR, Jatana KR, Linn RL, Rhoades K, Fry J, Jacobs IN, pH-Neutralizing Esophageal Irrigations as a Novel Mitigation Strategy for Button Battery Injury. The Laryngoscope. 018 Jun 11. doi: 10.1002/lary.27312. [Epub ahead of print]

What’s it all about?

This animal study explores using several weakly acidic and viscous household solutions as an immediate intervention post-button battery ingestion to help reduce corrosive damage. The theory is that solutions such as apple juice, Powerade, honey and Carafate (anti-ulcer medication) could help to neutralise the oesophageal irritation following button battery ingestion.

The materials were first tested in vitro on cadaveric pig oesophagi (n=18). This was done by irrigating the area with the chosen solution every 10 minutes. The more promising results were then tested on pigs in vivo (n=9).

Honey and Carafate were best at neutralising the pH of the tissue and, in vivo, were found to decrease full-thickness injury and outward injury extension in the deep muscle.

Although the results at microscopic and macroscopic levels are encouraging, it is going to be tricky to give a child 10mls of honey to ingest every 10 minutes. Furthermore, this intervention may well act as a distraction from the primary goal – the removal of the battery.

Additionally, honey should not be given after perforation, with a history of allergy, or if the child is less than one year of age (botulism). One may also need to consider the risk of aspiration-related anaesthetic complications.

Why does it matter?

3000 button battery ingestions occur annually in the US, and this problem is growing. Children under six years are at the highest risk for ingestion. Serious damage from the battery can occur in two hours. Erosion through vital structures can cause serious short-term and long-term consequences, including death. If intermediary interventions could reduce the damage caused by the ingestion of button batteries, that would be of great benefit.

Clinically Relevant Bottom Line:

Button battery ingestion is serious business with potentially lifelong sequelae. This early study suggests liquids like honey may reduce the damage by neutralising the pH of the affected tissue. Perhaps in the future, with further studies, intermediary agents may be developed to reduce damage caused to the oesophagus by button batteries prior to retrieval.

Ultimately, prevention is better than cure, and we should ensure children are kept well away from button batteries.

Reviewed by: Vikram Baicher

If we have missed out on something useful or you think other articles are absolutely worth sharing, please add them in the comments!

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.


  • Grace is a Registrar at Sydney Children's Hospital. She loves innovative medical education and paediatrics. She is on the organising committee for the DFTB18 and SMACC conference. Grace is a former internal director of the AMSJ. She enjoys board games, cooking and graphic design.


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