With millions of journal articles published yearly, it is impossible to keep up.
What an achievement for the team… Hundred’s of papers wrapped, lots of authors involved and an ongoing community of interested individuals. This is a BIG milestone! And to mark the event this wrap is an extra special treat from the DFTB Executive team.
Catch us all in person at DFTB26 DFTB26 is coming to Glasgow – Don’t Forget the Bubbles
Happy Birthday BubbleWrap love Vicki, Dani. Henry, Tessa and Becki xxx
Happy reading 🙂
If you or your team want to submit a review, please get in touch with Dr Vicki Currie at @DrVickiCurrie1 or vickijanecurrie@gmail.com.
Article 1: Should we still be using 0.9% saline as resuscitation fluid in DKA?
Agarwal A, Jayashree M, Nallasamy K, et al. 0.9% Saline versus Ringer’s lactate as initial fluid in children with diabetic ketoacidosis: a double- blind randomized controlled trial. BMJ Open Diab Res Care 2025;13:e004623. doi:10.1136/ bmjdrc-2024-004623
What’s it about?
Paediatric resuscitation practice has moved away from using 0.9% saline as the first line resus fluid where possible- but DKA guidance had been clinging on to this as first line.
This study compares 0.9% saline with Ringers Lactate (RL) for use in the initial resuscitation fluid in DKA. This was a prospective double blind randomised control trial looking at 67 children between 9months to 12 years with DKA who presented to a large tertiary referral centre in India. Children with cerebral oedema, pre-existing CKD, liver disorders or inborn errors of metabolism were excluded from the study. Patients were allocated in 1:1 ratio to 0.9% saline or Ringer’s Lactate by someone not involved in the study. Bags were wrapped in silver foil so those involved in the trial were blinded.
The primary outcome was DKA resolution (defined as good oral intake- ph >7.3, OR Bicarbonate >15mmol, Ketones <2mmol and closure of anion gap <2. In extreme situations where there was an ongoing hyperchloraemic metabolic acidosis but the other criteria were met- this was counted.
Secondary outcomes were change in bicarbonate level and chloride to baseline, incidence of new onset/ progressive AKI and total amount of fluid received and incidence of AKI in both groups.
The median age was 7 and 28% of the children were malnourished. 2/3RD’s of the children were new onset DKA. 64% presented with severe DKA. The time to DKA resolution was quicker in the RL groups 12.9 +/- 7.9 hours vs 16.8 +/- 9 hours. Those who received 0.9% saline had a higher level of chloride in the initial hours and those in RL group had a quicker rise in bicarbonate.
This was a relatively small sample size and a relatively short time of use of initial fluids as RL was not available with dextrose added.
Why does it matter?
We know that (ab)normal saline contains higher levels of chloride than other fluids. This can lead to a hyperchloraemia and in some cases increased concern with AKI. Previous studies have shown a slight increase in PICU stay length with use of 0.9% saline. We know that in resource limited settings children presenting in DKA may have more haemodynamic compromise and need higher amounts of fluid resuscitation.
For more on fluids in DKA check out Sweet and Salty – fluids in DKA – Don’t Forget the Bubbles
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Clinically Relevant Bottom Line
This study shows improved outcomes for children treated with RL vs 0.9% Saline when treated for DKA.
Reviewed by Vicki Currie
Article 2: Adrenaline for croup: does the device matter?
Novi B, Kahne K, Psihos C, et al. Delivery of L-epinephrine by metered-dose inhaler compared to racemic epinephrine by nebulizer for the treatment of croup. J Emerg Med. 2025;79:C198–205.
What’s it about?
This US single-centre retrospective cohort study compares two ways of giving epinephrine to children with croup: traditional nebulised racemic epinephrine (REN) and l-epinephrine delivered via a metered-dose inhaler (MDI).
A quick translation for UK practice: We don’t routinely use racemic epinephrine; instead, we give nebulised L-adrenaline (1:1000 epinephrine), which is considered clinically equivalent.
The study included 325 children aged 1-10 years presenting to a paediatric ED in New York, of whom 38 received MDI epinephrine. The primary outcome was the need for additional epinephrine doses, with secondary outcomes including admission, 48-hour return to care, and changes in heart rate.
Children treated with MDI epinephrine showed a clinically meaningful improvement in Westley Croup Score (WCS), with a median reduction of 2 points at 30 minutes.
When compared with nebulised treatment, there were no significant differences in: Need for repeat dosing, admission rates, 48 hour reattendance and changes in heart rate.
No adverse events were reported in the MDI group.
Why does it matter?
This study sits in the context of practice changes seen during the COVID-19 pandemic, particularly in the US, where concerns about aerosolisation led to a shift away from nebulisers and towards MDI delivery.
Unlike in some US settings, UK practice did not fully abandon nebulisers. While MDIs became more widely used for wheeze, nebulised adrenaline for croup has remained standard practice.
What this paper does is reopen the question. Not from an infection-control perspective alone, but also from a service-delivery perspective.
MDIs are quicker to administer, portable, and do not require the same equipment or setup as nebulisers. That creates potential beyond the emergency department, particularly in primary care, pre-hospital care or lower-resource settings where nebulisers or oxygen may be less readily available.
There is also a possible system-level impact. If treatment can be delivered safely and effectively earlier, or even outside the ED, there is the potential to reduce hospital attendances. That aligns with broader NHS priorities in the 10-year plan to deliver care closer to home and reduce pressure on urgent and emergency care services.
Cost is also a consideration. In the study setting, an MDI device cost around $32 (approx £25) and was single-patient use. By comparison, nebulised adrenaline in the UK is inexpensive per dose. However, a narrow drug-cost comparison risks missing the bigger picture. Staff time, equipment use, patient flow, and avoided attendances may all shift the balance depending on how and where the treatment is used.
However, this is a small, single-centre study and is underpowered to demonstrate non-inferiority. The authors estimate that around 600 patients would be needed to adequately power such a comparison, so these findings should be interpreted with appropriate caution.
In practice, treating croup is not just about pharmacology. Many of these children are distressed, and attempts to get close or apply a mask can worsen distress and airway obstruction. Nebulisers allow us to deliver treatment at a distance, often with a child sitting on a parent’s lap, which is a significant practical advantage in the acute setting.
For all things croup see Croup – Don’t Forget the Bubbles
Clinically Relevant Bottom Line
MDI-delivered l-epinephrine appears to be as safe and effective as nebulised epinephrine for treating croup, with similar clinical outcomes and improvement in Westley Croup Score.
For UK clinicians, this likely translates to equivalence with nebulised L-adrenaline, which remains the current standard of care.
MDI delivery may offer benefits in pre-hospital or community environments, and in lower-resource settings where nebulisation is not feasible. However, in the emergency department, where minimising distress is central to safe care, the ability to deliver treatment without approaching the child too closely remains an important consideration.
Reviewed by Becky Platt
Article 3: Does prenatal alcohol exposure increase the risk of time spent in youth detention centres?
Kerry, J., Tan, G. K. Y., Panton, K. R., Mutch, R., Freeman, J., Passmore, H., & Pestell, C. F. (2024). Neuropsychological profiles of adolescents sentenced to detention in Western Australia with and without prenatal alcohol exposure. Criminal Behaviour & Mental Health, 34(2), 163–181. https://doi.org/10.1002/cbm.2329
What’s it about?
In 2018, a widely read study of 99 young people (Fetal alcohol spectrum disorder and youth justice: a prevalence study among young people sentenced to detention in Western Australia | BMJ Open) emphasised the high prevalence of adolescents with Foetal Alcohol Spectrum Disorder in the youth detention context.
Three of the authors from the 2018 group, re-ran the data to compare the neuropsychological profiles of adolescents in detention with and without a history of pre-natal alcohol exposure (PAE), with the hypothesis that adolescents with confirmed PAE would score lower on all tests. Adolescents with uncertain PAE status were excluded from the analysis.
There were no statistically significant difference in test scores between groups, and regression was not indicative of any models predictive of PAE-group membership.
Why does it matter?
Foetal Alcohol Spectrum Disorder is a diagnosis that has increasing awareness, and increasing stigma, depending on the context, be that medical, legal, educational or societal. Historically, certain diagnoses were associated with “criminality”, including Turner syndrome, Kleinelter syndrome as well as the work of Lombroso. This study demonstrates a neurodevelopmental profile that is prevalent in young people in youth detention, noting that there is no specific difference for young people with confirmed PAE.
Learn all about Foetal Alcohol Spectrum Disorder at Fetal Alcohol Syndrome – Don’t Forget the Bubbles
Clinically Relevant Bottom Line
Regardless of whether youth in detention have confirmed PAE, it is evident that they possess a complex and compounding risk profile interacting between neuropsychological impairments, offending behaviours, systemic disadvantage and psychosocial adversities.
For adolescents interfacing with youth justice and healthcare, the role of healthcare is not to ask “How can we fix the thing that is broken/sick/wrong?” but rather “What care/environment/resources does this person need to be healthy?”
Reviewed by Henry Goldstein
Article 4: Screen use at bedtime and sleep duration and quality among youths
Brosnan B, Haszard JJ, Meredith-Jones KA, et al. Screen Use at Bedtime and Sleep Duration and Quality Among Youths. JAMA Pediatrics. 2024;178(11):1147-1154. doi:10.1001/jamapediatrics.2024.2914
What’s it about?
How many times have you told a teenager to turn off screens an hour before bed? This study from New Zealand questions that advice.
Researchers recruited 79 healthy young people aged 11 to 14 in Dunedin. They measured screen use over four non-consecutive nights with wearable chest cameras before bed and infrared cameras in the bedroom.
The study looked at two main periods: screen use in the 2 hours before getting into bed and screen use in bed before trying to sleep. Screen use in the 2 hours before bed had no significant effect on total sleep time – any delay in getting to sleep was balanced by a later wake time.
In-bed screen use was a different (bedtime) story. Every additional 10 minutes of screen time in bed linked to 3 fewer minutes of sleep. Interactive use caused even more trouble: gaming in bed related to 17 fewer minutes of sleep for every 10-minute session, and multitasking across devices led to 35 fewer minutes on nights it happened.
Why does it matter?
Current guidelines suggest stopping all screen use 1 to 2 hours before bed. However, this study suggests this may not be the right focus. The main issue seems to be time displacement – screens delay when young people try to sleep, and using screens in bed means that time cannot be recovered.
The sample size was small (n=79) and came from a single city where parents were highly educated. The age range was limited. Manual video coding was time-consuming, and reactions to the cameras can’t be completely ruled out. Causation cannot be proven.
Clinically Relevant Bottom Line
The real issue may not be screens before bed, rather screens in bed, especially for interactive use. It may be more practical and effective to keep devices out of the bedroom or stop using them once under the covers, than to enforce broad pre-bedtime bans.
Reviewed by Tessa Davis
Article 5: Academic pressure and adolescent mental health
What’s it about?
Rates of adolescent depression and self-harm have risen over recent decades, and young people consistently identify academic pressure as a major source of stress. However, most existing studies are cross-sectional, small, or lack adjustment for important confounders.
This UK longitudinal study used data from the Avon Longitudinal Study of Parents and Children (ALSPAC) to examine whether perceived academic pressure at age 15 years predicted later depressive symptoms and self-harm from ages 16 to 24 years.
Academic pressure was measured using three items reflecting worry about schoolwork, pressure from home, and the importance placed on performance in GCSEs, national exams taken aged 16 (total score 0–9). Outcomes were depressive symptoms (Short Mood and Feelings Questionnaire) at five timepoints between ages 16 and 22, and self-harm in the previous year at four timepoints between ages 16 and 24.
The primary outcomes were depressive symptom scores and odds of self-harm. Analyses used multilevel models with multiple imputation and were adjusted for sociodemographic factors, prior mental health, bullying, autistic traits, and school grades.
Among 4714 adolescents (58% female), each 1‑point increase in academic pressure at age 15 was associated with a 0.43‑point increase in depressive symptoms (95% CI 0.36–0.51). The association was strongest at age 16 (0.53 points) but persisted to age 22 (0.35 points).
For self-harm, each 1‑point increase in academic pressure was associated with an 8% higher odds of self-harm (adjusted OR 1.08, 95% CI 1.01–1.16). Associations did not differ by age, sex, social class, or baseline depressive symptoms.
The study is limited by missing data, potential residual confounding, and reliance on self-reported measures. The cohort is predominantly White, which may limit generalisability.
Why does it matter?
We frequently encounter young people whose distress is bound to school expectations, exams and academic stress. This study provides robust longitudinal evidence that the academic environment is not just a background stressor but a measurable contributor to depressive symptoms and self-harm risks.
A reminder on how to do a HEADSSS assessment can be found here The HEADSSS Screen – Don’t Forget the Bubbles
The findings reinforce the importance of asking directly about school workload, parental expectations and exam-related worry during psychosocial assessments and routine health assessments of adolescents. They also highlight opportunities for early intervention – identifying young people under high academic pressure aged 14 to 15 may allow an intervention to mitigate later mental health deterioration.
The study also strengthens the case for advocating at a systems level, working with schools, families, and policymakers to reduce high‑stakes testing and promote healthier academic cultures.
Clinically Relevant Bottom Line
Higher academic pressure at age 15 is associated with increased depressive symptoms up to age 22 and higher odds of self-harm up to age 24. Reducing academic pressure may be a meaningful target for improving adolescent mental health.
Reviewed by Dani Hall
If we missed something useful or you think other articles are worth sharing, please add them in the comments!
That’s it for this month—many thanks to our reviewers for scouring the literature so you don’t have to.
Vicki Currie, DFTB Bubble Wrap Lead, reviewed all articles.
