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The 26th 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 the 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 feature 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: 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 nine US emergency departments and 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 over 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 two had meningitis.

Why does it matter?

While most children do not have IBI, it is extremely important to filter these kids from the overall well cohort. Most commonly used risk stratification protocols have high sensitivities, but performance in infants under 28 days remains unsatisfactory. The cost-effectiveness of clinical risk stratification tools has to be considered.

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 under 28 days with IBI who were ‘wrongly’ classified as low risk and who did not undergo invasive CSF testing are at risk. This group should be monitored closely by clinicians and informed parents.

Reviewed by: Anke Raaijmakers

Article 2: How can you spot a septic child?

Snelson E, Ramlakhan S. Which observed behaviours may reassure physicians that a child is not septic? An international Delphi study. Arch Disease Child. 2018;103:864-867

What’s it about? 

Everyone wants to detect sepsis as soon as possible. Many diagnostic aids 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 has achieved 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 assessed unwell children and had 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 (though mostly the UK and North America) and included paediatricians, emergency physicians and GPs with an interest in paediatrics.

104 participants responded to the round two questionnaire. This contained fourteen statements based on the themes of responses that came out of 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 drink, and being interactive were moderately reassuring by at least 50% of respondents.

Why does it matter? 

The exclusion of sepsis through wellness is rarely considered in decision aids or guidelines. They 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 like tachycardia are common and have poor specificity. We 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. Thinking about it is the first step in preventing that from happening.

Fortunately, sepsis is relatively rare when compared with other illnesses that can often trigger a sepsis alert, e.g. tonsillitis. This study identifies some factors clinicians use to make decisions on wellness that often aren’t written down in guidelines or decision-making aids.

It also provides helpful data to inform further research. 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

Article 3: How do PEM consultants manage infants with fever and bronchiolitis in Canada vs UK/Ireland?

Simone L, Lyttle MD, Roland D, et al. Canadian and UK/Ireland practice patterns in lumbar puncture performance in febrile neonates with bronchiolitis. Emerg Med J Published Online First: 06 February 2019. doi: 10.1136/emermed-2018-208000

Why does it matter?

In caring for young infants, we strive to give them appropriate treatment and also to avoid any procedures that are not necessary.

A febrile infant under 30 days would usually 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 workup 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 PERUKI and PERC networks.

The survey used a case study of a well-appearing febrile neonate with bronchiolitis. Across six questions, it explored confidence with diagnosis, suspected risk of confection and the estimated probability that they would perform an LP, the latter being the primary outcome of the study.

More from PERC would perform a full sepsis workup (94.4% vs 70.2%). 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 for those not choosing to perform an LP included a low perceived risk of bacterial meningitis, concern about worsening respiratory distress or parental concern, and greater perceived risk of the procedure compared to the risk of meningitis.

There was a greater degree of risk aversion amongst the Canadians, with 11.1% requiring a zero risk of meningitis before foregoing an LP compared to 2.9% amongst the UK/Irish participants. The authors suggested having different healthcare 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, including a lumbar puncture.

Further evaluation could help develop 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 two months get a double hit?

Mahajan P, Browne LR, Levine DA, Cohen DM, Gattu R, Linakis JG, Anders J, Borgialli D, Vitale M, Dayan PS, Casper TC. Risk of Bacterial Coinfections in Febrile Infants 60 Days Old and Younger with Documented Viral Infections. The Journal of Pediatrics. 2018 Sep 6.

What’s it about?

We are in the middle of our viral season in the Northern Hemisphere, 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, 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 of 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 performed a secondary analysis on a prospective observational cohort collected over a 5-year period (2008-2013) across 28 PECARN sites. The inclusion criteria (60 days or younger/temp over 38oC /cultures and 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 meningitisbacteremia, or UTI) are standard.

It was a pretty impressive sample size with 2945 participants. 9% had an SBI, with 40.7% positive for at least one virus. When this was broken down to answer the team 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 significantly associated with SBI, including age 28 days or younger, temperature and absolute neutrophil count (ANC), with the latter two noting an increased risk with increasing temp or ANC.

The bottom line

This paper literally appeared in my inbox as I was managing a clinically viraemic but pyrexial fourteen-day-old. 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 does offer some reassurance that for the majority of these young, viraemic children, withholding antibiotics may be appropriate. However, a not insignificant number had both a viral infection and SBI, meaning covering a proportion 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

Article 5: Bubble bubble, toil and no trouble!

Longobardi, C., Prino, L.E., Fabris, M.A. and Settanni, M., 2019. Soap bubbles as a distraction technique in the management of pain, anxiety, and fear in children at the paediatric emergency room: a pilot study. Child: care, health and development45(2), pp.300-305.

What’s it about?

Blowing bubbles is 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 the 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 metre!) 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. Brief surveys performed by the children with their parents were collected after triage, after soap bubbles (prior to the medical visit) and after the medical visit.

There was no reduction in anxiety, but they found a significant reduction in fear and a trend towards lower pain scores following soap bubbles.

Why does it matter?

A hospital can be a scary place for patients and their families, especially when feeling sick and waiting to be seen. This soap bubble activity is a 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!).

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.


  • 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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