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.
This month to ease us into the new clinical year; this bubble wrap will featuring a couple of new papers but also a few flashback reviews of some papers we’ve explored in other posts in case you missed them the first time around!
Article 1: The magic bullet: do infants need an LP to rule out invasive bacterial infection?
Aronson PL, et al. Risk Stratification of Febrile Infants ≤60 Days Old Without Routine Lumbar Puncture. Pediatrics. 2018 Nov 13.
What’s it about?
The Rochester and modified Philadelphia criteria were used in a case-control design to stratify well appearing infants at risk for invasive bacterial infection (IBI). The study was conducted in America in 9 emergency departments who included febrile infants <60 days of age. They included 135 cases and 249 controls. Interestingly, the sensitivity of the modified Philadelphia criteria was higher than that of the Rochester criteria (91.9% vs 81.5%; P = .01), but the specificity was lower (34.5% vs 59.8%; P < .001). None of the low-risk infants >28 days old had IBI, but of 68 infants ≤28 days old with IBI, 14 (20.6%) were low risk per the Rochester criteria, and 2 had meningitis.
Why does it matter?
Whereas most children do not have IBI, it is extremely important to filter IBI children from the overall well children. Most commonly used risk stratification protocols have high sensitivities, but performance in infants <28 days remain unsatisfactory. Moreover, the cost effectiveness of clinical risk stratification tools has to be weighted too.
What’s the Bottom Line?
The modified Philadelphia criteria, which do not include routine CSF testing, classify most febrile infants with IBI as high risk. However, the few infants <28 days with IBI that were ‘wrongly’ classified as low risk and who did not undergo invasive CSF testing, are at risk. This group especially should be monitored closely by both clinicians as well as informed parents.
Reviewed by: Anke Raaijmakers
Article 2: How do we pick out a septic child?
What’s it about?
Everyone wants to detect sepsis as early as possible. Many diagnostic aids are used to prompt one to think about sepsis early. However, not every child that triggers a sepsis alert will be septic and none of these decision aids have yet achieved sufficiently high enough
specificity and sensitivity to avoid the significant risk of overdiagnosis and overtreatment. The authors undertook a modified two round international Delphi study where clinicians were asked for features they believed were indicators of wellness in an ill child.
Participants were 195 clinicians (mostly physicians) who routinely assess unwell children and have done so for most of their careers (50% had been doing so for >10 years, 80% > 5 years). This group was felt to be more likely to participate in all rounds of the Delphi as they
would have an interest in the outcomes. The physicians came from all over the world (mostly UK 98 and North America 71) and included paediatricians, emergency physicians and GP’s with an interest in paediatrics.
104 participants responded to the round two questionnaire which contained 14 statements based on the themes of responses that came out the the open ended question in round one. The respondents rated how reassuring they found each statement on a 4-point Likert
scale. 80% of respondents thought an actively energetic child (e.g. running, jumping) was very reassuring. Moving well (baby) or walking, eating, wanting to eat or drinking, being spontaneously interactive were felt to be moderately reassuring by at least 50% of respondents in each case.
Why does it matter?
The exclusion of sepsis through wellness is rarely considered in decision aids or guidelines which tend to focus on quantifiable measures (e.g. heart rate) and subjective negative features (e.g. subdued). Understanding what clinicians rely on to rule out sepsis is important because features such as tachycardia are common to illness and sepsis and have poor specificity. Therefore we also need to identify which clinical findings are consistent with wellness and/or absence of sepsis.
Clinically Relevant Bottom Line:
No one wants to miss a septic child and thinking about it is the first step in preventing that from happening. Fortunately sepsis is relatively rare when compared with other illness that can often trigger a sepsis alert e.g. tonsillitis. This study is helpful
in identifying some of the factors that clinicians use to make decisions on wellness that often aren’t written down in guidelines or decision making aids. It also provides helpful data which can inform further research in this area. Unfortunately, due to the nature of sepsis it is something that can change very quickly and one should always be mindful of this.
Reviewed by: Vikram Baicher
If you liked this bubble wrap, explore more at: DFTB/ADC November
Article 3: Canada vs. UK/Ireland – How do PEM consultants manage infants with both fever and bronchiolitis?
Why does it matter?
In caring for young infants, we strive to give them both appropriate treatment but also to hopefully avoid any procedures that are not necessary. A febrile infant under 30 days would usually be expected to have a lumbar puncture performed as part of a septic workup. However, the estimated risk of concurrent serious bacterial infection with bronchiolitis is less than 2%. Therefore, if a febrile infant under 30 days appears well and has findings consistent with bronchiolitis; should we still proceed to put the infant through a septic work up and lumbar puncture?
What’s it all about?
To find out how emergency physicians currently investigate infants with fever and bronchiolitis, the authors collated 332 surveys from PEM consultants in the UK/Ireland and Canada belonging to the the PERUKI and PERC networks respectively. The survey utilised a case study of a well appearing febrile neonate with bronchiolitis and across 6 questions explored confidence with diagnosis, suspected risk of confection and estimated probability that they would perform an LP; the later being the primary outcome of the study. Comparing PERC and PERUKI participants, more from PERC would perform a full sepsis workup(94.4% vs 70.2%) and they were also significantly “more likely” or “very likely” to perform an LP on the child described in the case (62% vs 8.6%). Common reasons from those not choosing to perform an LP included low perceived risk of bacterial meningitis, concern about worsening respiratory distress or parental concern, and greater perceived risk of procedure compared to risk of meningitis. The difference in decision making between the groups is contributed to by a greater degree of risk aversion amongst the Canadians; with 11.1% requiring a 0% risk of meningitis before foregoing an LP compared to 2.9% amongst the UK/Irish participants. The authors suggested having different health care models may be a contributor to the results.
Clinically Relevant Bottom Line:
The risk of bacterial meningitis concurrent with bronchiolitis in a <30 day old infant is low; but there is practice variation between Canada and the UK/Ireland in their approach to investigations. The Canadians appear to have a lower threshold for investigating an otherwise well looking, febrile infant with bronchiolitis with a sepsis workup as well as for lumbar puncture. For the future, further evaluation could help with the development of practice guidelines but for now, the decision in this grey area remains yours to make.
Reviewed by: Grace Leo
Article 4: Bacterial AND Viral Infections – How often do infants under 2 months get a double hit?
What’s it about?
In the Northern hemisphere, we are in the middle of our “viral season” and it is not uncommon to see an infant 60 days or younger with a presumed viral illness and temperature. These cases can be difficult to navigate, pitting two fundamental pillars of paediatric emergency medicine against one another; the low threshold of a full septic screen and antibiotics versus the first do no harm principle in managing simple viral infections. The concern for the clinician is always the possibility of missing a serious bacterial infection (SBI) and the morbidity and mortality associated with it.
Why does it matter?
The research team proformed a secondary analysis on a prospective observational cohort collected over a 5-year period (2008-2013) in 28 PECARN sites. The inclusion criteria (60 days or younger/temp over 38oC /cultures + viral screen performed), exclusion criteria (clear focal bacterial infection/significant past medical history/septic), and the definitions they use for SBI (defined as the presence of bacterial meningitis, bacteremia, or UTI) are standard and what we would use in PEM.
The total population number was 2945, so a pretty impressive sample size. Overall, 9% had an SBI with 40.7% positive for at least one virus. When this was broken down to answer the teams research question, there was almost a four-fold increase in SBI for virus negative compared to virus positive (12.7% vs 3.7% respectively).
They also teased out other variables that were significantly associated with SBI, including age 28 days or younger, temperature and absolute neutrophil count (ANC), with the latter two noting an increase risk with increasing temp or ANC.
The bottom line
This paper literally appeared in my inbox as I was managing a clinically viraemic but pyrexic 14 days old and having the ‘do we cover or not’ with the general paediatric team- so it is a clinically very relevant paper. It is important to note, that the paper looked at patients who were laboratory confirmed viral positive and not those who clinically appeared viraemic, so do interpret with caution.
It offers some reassurance that for the majority of these young, viraemic children, withholding antibiotics may be an appropriate action. However, a not insignificant number had both a viral infection and SBI, meaning for a proportion covering with antibiotics is appropriate. Although it does not provide us with a definite solution to this clinical predicament, it does allow us additional information to make a more informed decision for each individual case.
Reviewed by: Stephen Mullen
If you liked this bubble wrap, explore more at: One Way or Another? Bacterial Co-infection
Article 5: Bubble bubble, toil and no trouble!
What’s it about?
Blowing bubbles is a tool often used to distract and entertain children whilst assessing or examining them in hospital. However whilst there have been a few studies looking at the efficacy of bubbles for reducing perception of pain in children having venipuncture, port access and DPT injections; a group of psychologists from Turin, Italy have taken things a step further and looked at how successfully a 15 minute activity using large soap bubbles (50cm up to a meter!) which children can watch, pop or make, could be used in ED waiting rooms to help improve fear, anxiety and pain amongst children whilst waiting to be seen following triage.
The group performed a pilot study using 74 children aged between 7 and 10 divided into an experimental and control arm. Brief surveys performed by the children with their parents were collected after triage, after soap bubbles (prior to the medical visit) and following the medical visit. They found no reduction in anxiety, but they found a significant reduction in fear and a trend towards lower pain scores following soap bubble application. As might be suspected, there was no difference for children in the experimental vs the control after their medical visit.
Why does it matter?
Hospital can be a scary place for patients and their families, especially when this is exacerbated by feeling sick and the uncertainty of waiting to be seen. The soap bubble activity studied in this paper is distraction tool which is inexpensive, achievable and appears to be effective in helping reduce fear and pain for children whilst they are in waiting rooms.
Clinically Relevant Bottom Line:
Bubble blowing to distract children from pain and fear is not just for infants and toddlers. Large bubble activities can be effective in school age children (and I suspect for some adults too!).
Reviewed by: Grace Leo, Recommended by Katie Knight
Things will be kicking off on Twitter for the next DFTB/ADC journal club at UTC 2000hrs, 21/02/2019. with this paper…
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. Please keep an eye out for our upcoming DFTB/ADC Journal Club 3.
