In 2021, we welcomed our first cohort of doctors, nurses, and paramedics from across the world onto the PEM MSc.
This online MSc is undertaken over three years and covers the full range of PEM presentations. In the final year, students use the skills they have learned in knowledge translation and evidence appraisal to undertake their own study for their dissertation. Below is a snapshot of some of the wonderful work produced this year.
Calcium levels on admission and their association with haemodynamic instability in paediatric major trauma: a retrospective single-centre pilot study.
Why?
When we think about trauma resuscitation, we often focus on blood loss and the need for transfusion. But what if a critical imbalance is already at play before the first drop of blood is given?
Ionised hypocalcaemia (iHypoCa) – a drop in calcium levels – is known to cause serious complications in adults, yet we don’t fully understand its impact on children. This pilot study set out to explore whether iHypoCa on admission is linked to low blood pressure in young trauma patients. It also looked at how common the condition is and whether it influences treatment needs and outcomes. Could this often-overlooked electrolyte disturbance be a key player in paediatric trauma care?
How?
This single-centre retrospective pilot study focused on paediatric major trauma patients who had their ionised calcium levels checked before receiving any blood products. Using multivariable logistic regression, the researchers explored whether iHypoCa was linked to hypotension on arrival. But they didn’t stop there—they also investigated whether low calcium levels influenced the need for critical interventions like vasoactive medications, blood transfusions, interventional radiology, or surgery. Beyond the immediate resuscitation phase, the study examined how iHypoCa related to longer hospital stays, morbidity (measured by the Glasgow Outcome Scale), and even mortality. Could this hidden electrolyte imbalance be shaping outcomes more than we realise?
What?
Around one in six paediatric major trauma patients arrived at hospital with ionised hypocalcaemia—before they’d even received a blood transfusion.
While this pilot study wasn’t designed to reach statistical significance, it provided valuable insights for future research. The findings suggested that children with iHypoCa were nearly three times more likely to present with hypotension. There was also a notable link between low calcium levels and the need for more invasive interventions, such as interventional radiology or surgery, within the first 24 hours.
Could correcting calcium levels early make a difference in paediatric trauma care?
These findings set the stage for larger studies to answer that very question.
This study has received an RCEM grant and has been adopted by PERUKI for multicentre expansion.
Owen Hibberd
The use and utility of the paediatric oral fluid challenge in a single tertiary paediatric emergency department
Why?
The paediatric oral fluid challenge (OFC) has been a staple in emergency departments for years, helping to determine which children struggling with oral intake truly need IV fluids. But how well does it actually work? Despite its widespread use, there’s little evidence to support the traditional approach of giving 5ml every 5 minutes for an hour. In fact, research suggests that a more meaningful test would involve much larger volumes—somewhere between 9–20ml/kg over the same time period. This study set out to examine whether the current OFC method is fit for purpose and whether it could be refined to better guide rehydration decisions. Are we setting the bar too low for success?
How?
In a busy tertiary paediatric emergency department, researchers set out to put the oral fluid challenge (OFC) to the test. Over two months, they prospectively collected data on all children with concerns about fluid intake. To keep the focus clear, they excluded those likely to need different IV rehydration thresholds. The study then analysed which children required IV fluids and whether they ended up being admitted. Could the OFC be a more reliable tool with a few adjustments, or is it time to rethink our approach?
What?
Around half of 148 children in the study underwent an oral fluid challenge. But did it help? The results suggest otherwise—there was no difference in IV cannulation rates or hospital admissions between those who had an OFC and those who didn’t. What did change, however, was the length of stay. Children who had an OFC, whether initiated at triage or by a clinician, spent significantly longer in the emergency department. These findings raise an important question: if the OFC, in its current form, doesn’t meaningfully impact outcomes but does extend ED stays, is it time to rethink how (or if) we use it?
Patrick Joe Mullaly
Respiratory support in paediatric patients with Bronchiolitis: A Systematic Review and Meta-analysis
Why?
Bronchiolitis is one of the most common respiratory infections in infants and a leading cause of hospital and PICU admissions. While most cases are mild, some children will require respiratory support—and when they do, clinicians have a range of options. From low-flow nasal cannula (LFNC) to high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), biphasic positive airway pressure (BiPAP), and mechanical ventilation, the challenge lies in knowing which therapy to use and when. But with so many modalities available, are we making the right choices for these young patients?
How?
To better understand the best approach to respiratory support in infants with bronchiolitis, we conducted a systematic review comparing the clinical effectiveness and safety of different modalities in children ≤24 months. We assessed available direct comparisons between treatments using pairwise meta-analyses, applying random-effects models to account for variability. By analysing the evidence, we aimed to determine which strategies offer the best balance of efficacy and safety—helping clinicians make more informed decisions for their youngest patients.
What?
Our study found that high-flow nasal cannula (HFNC) outperformed low-flow nasal cannula (LFNC) in key areas—it significantly reduced treatment failure rates, shortened PICU stays, and decreased the overall duration of oxygen therapy. Interestingly, when comparing HFNC to CPAP, there were no significant differences in primary or secondary outcomes. Given these findings, HFNC could be considered the first-line respiratory support modality for infants with bronchiolitis who require escalation from LFNC. Could this be the sweet spot between efficacy and ease of use in managing these young patients?
Spyridon Karageorgos
Exploring the perceptions and psychological impact to Emergency Medical Services or community healthcare responders following exposure to neonatal or paediatric life-threatening emergencies: A Systematic Analysis and Meta-Ethnography
Why?
Neonatal and paediatric life-threatening emergencies are rare in the out-of-hospital setting—making up just 0.5–1% and 4–8% of all cases, respectively. This scarcity means that EMS clinicians have limited real-world exposure to critically ill infants and children, yet when these cases do arise, the stakes are high.
For those working in EMS and community healthcare, ongoing education and professional development in paediatric emergency care are often insufficient. Limited manpower, ill-fitting equipment, and the dual challenge of managing both the child’s clinical needs and the family’s emotional distress further complicate care delivery.
This study explored the global perspective of EMS providers who have attended these critical events. By examining existing support mechanisms and identifying common themes, it aims to highlight gaps in training and resources—paving the way for improvements in paediatric emergency care beyond the hospital walls.
How?
To gain deeper insight into the experiences of pre-hospital practitioners managing neonatal and paediatric emergencies, a detailed systematic analysis and meta-ethnography were conducted. This approach allowed for synthesising all available qualitative data related to the psychological responses of EMS providers in these high-stakes situations. Through this process, key themes emerged, shedding light on clinicians’ emotional and cognitive challenges. By understanding these responses, we can identify gaps in training, support, and resilience-building strategies for those delivering emergency care to the most vulnerable patients.
What?
Neonatal and paediatric life-threatening emergencies leave a lasting psychological impact on EMS and community healthcare responders. The emotional toll of managing critically ill infants and children—often with limited exposure, resources, and support—can affect confidence, decision-making, and long-term well-being.
For organisations delivering care to these vulnerable populations, clinical preparedness isn’t just about protocols and equipment but also psychological safety. Investing in enhanced training, structured debriefing, and ongoing professional development is essential. Beyond existing measures, we need to build a culture that acknowledges the emotional burden of paediatric emergencies and provides the proper support for those working in these high-pressure environments.
Susan Rhind
Red flags for headaches in the paediatric emergency department: a single-centre retrospective study evaluating the association with severe intracranial conditions.
Why?
Headache is among the most common neurological complaints in paediatric emergency departments, but distinguishing between benign and serious causes remains challenging. Clinicians rely on red flags to identify high-risk cases, yet recent research has questioned their effectiveness—particularly in the fast-paced ED setting. As a result, some children may undergo unnecessary neuroimaging, adding stress, cost, and potential risks without clear benefits.
This study aimed to determine which red flags, if any, truly indicate a higher likelihood of severe underlying pathology. By refining our approach, could we reduce unnecessary scans while ensuring we catch the cases that matter most?
How?
This single-centre retrospective study examined 274 children who presented with headaches to a tertiary paediatric emergency department over two years. Researchers analysed the presence of red flags and compared them between cases with severe and non-severe underlying conditions. Using a chi-square test and multivariate analysis, the study aimed to identify which red flags—if any—were truly predictive of serious pathology. Could refining our criteria help reduce unnecessary neuroimaging while still ensuring we don’t miss critical diagnoses?
What?
Red flags were almost ubiquitous—documented in 95% of children presenting with headaches—yet they weren’t always a sign of something serious. Only 14% of patients with red flags were found to have a life-threatening condition. However, not all red flags were created equal. Statistically significant predictors of severe pathology included an abnormal physical exam, isolated vomiting, papilloedema, and progressive headaches.
Importantly, having three or more red flags significantly increased the likelihood of an underlying serious condition. These findings highlight the need to refine our reliance on red flags in the ED. Could a more selective approach help us strike the right balance between early detection and avoiding unnecessary investigations?
Roberto Segura Retana
Comparative Analysis of Medication Administration Timeliness in Initial Assessment to Paediatric Emergency Department Patients with Injuries: Nurse Patient Group Directions (PGD) Administration vs. Independent Prescribing (IP)
Why?
Paediatric pain management continues to fall short, with significant gaps in research and practice leaving many children undertreated. This study bridges that gap by examining current pain management strategies and identifying evidence-based best practices. The focus? Ensuring that children receive timely and effective analgesia when they need it most. By analysing existing protocols and real-world practices, the study aimed to highlight areas for improvement and pave the way for better, faster pain relief in paediatric emergency care. Are we doing enough to prioritise pain management, or is there still work to be done?
How?
This retrospective, observational case-control study analysed over 4,000 paediatric emergency department (PED) records to investigate the timeliness of pain relief in children with injuries. The study compared two key approaches to analgesia administration: nurse-led Patient Group Directive (PGD) prescribing versus Independent Practitioner (IP) prescribing. By examining the time from Initial Assessment (IA) to the administration of paracetamol and/or ibuprofen in children aged 1–17 years, the study aimed to identify which system delivers faster, more effective pain management. Could streamlining pain relief protocols ensure children get the care they need without unnecessary delays?
What?
The study revealed a clear advantage in the speed of pain relief: children receiving analgesia via nurse-led Patient Group Directives (PGDs) were given medication significantly faster than those relying on Independent Practitioner (IP) prescribing. In fact, paediatric emergency department (PED) patients who received PGD-prescribed analgesia were far more likely to receive pain relief within 20 minutes of their initial assessment.
These findings highlight an important opportunity for improving paediatric pain management. Implementing nurse-led PGD analgesia nationwide within PED initial assessments could streamline medication administration, reduce delays, and ensure children receive timely pain relief when they need it most. Should this become the standard approach across all emergency departments? The evidence certainly makes a strong case for it.
Holly Wakefield
The variation in management of acute asthma and wheeze in children across London
Why?
Asthma is the most common chronic condition in children, and London has the highest asthma rates of any European city. Acute exacerbations of asthma and wheeze are among the leading reasons for paediatric emergency department (PED) visits, yet how these cases are managed can vary significantly between hospitals.
This study explored the similarities and differences in acute asthma and wheeze management across London, comparing real-world practice with national guidelines and the latest evidence. Are all children receiving the best possible care, or does variation in treatment mean some are missing out on optimal management? This research aims to help standardise and improve paediatric asthma care across the capital by identifying gaps and inconsistencies.
How?
This study took a prospective, qualitative approach, using a survey-based design to capture real-world asthma management practices across London. Consultant Paediatricians and Emergency Medicine Consultants from all 26 London hospitals were invited to participate, providing insight into how acute exacerbations are treated step by step—from inhaled bronchodilators to first- and second-line intravenous therapies.
Descriptive statistics highlighted variations in practice, while Fisher exact tests were used to assess differences between hospitals with a reasonable response rate. By mapping these variations, the study aimed to determine whether paediatric asthma care aligns with national guidelines and whether standardisation could help improve outcomes for children across the city.
What?
A total of 74 responses were collected, with 13 hospitals providing enough data for meaningful variability analysis. While there was strong consistency in the use of salbutamol across trusts, notable differences emerged in other aspects of asthma management.
One key area of variation was ipratropium nebulisation, particularly in severe exacerbations, where usage differed significantly between hospitals. When it came to oral corticosteroids, prednisolone was the preferred choice over dexamethasone, but there was a statistically significant variation in dosing practices.
In contrast, intravenous therapy showed greater alignment with national guidance. Magnesium sulphate was almost unanimously chosen as the first-line IV agent, while aminophylline was the preferred second-line option.
These findings highlight areas where paediatric asthma management in London is consistent—and where significant variability remains. Could greater standardisation of treatment protocols help ensure that all children receive the most effective care, regardless of their hospital?
Helena Wilcox
The effect of early analgesia for pain crises on hospital length of stay and acute chest syndrome in children with sickle cell disease
Why?
Pain episodes, or vaso-occlusive crises (VOC), are a hallmark of sickle cell disease, often leading to prolonged hospital stays and serious complications like acute chest syndrome (ACS). While small studies suggest that early pain relief can shorten hospitalisation, the evidence remains limited. International guidelines recommend rapid analgesia within one hour of registration, but the question remains: who benefits the most, and can early intervention also reduce the risk of ACS?
This study set out to explore these critical questions by examining the impact of early analgesia on hospital length of stay and the development of ACS in children with VOC in Trinidad. Could timely pain management be the key to improving both short- and long-term outcomes for paediatric sickle cell patients?
How?
This single-centre, retrospective chart review focused on paediatric patients presenting with vaso-occlusive crises (VOC) as their primary diagnosis. Researchers recorded the arrival time and time to the first dose of pain medication, regardless of the analgesic type or route of administration. To gain deeper insight, additional factors were analysed, including sickle cell genotype, history of asthma or acute chest syndrome (ACS), pain location, and Hydroxyurea use.
Patients were then divided into two groups: those who received analgesia within one hour of registration and those who received it later. The study compared these groups to assess differences in hospital length of stay (HLOS) as the primary outcome and the development of ACS as a secondary outcome. Could faster pain relief reduce hospital stays and prevent life-threatening complications in children with sickle cell disease? This study aimed to find out.
What?
Fifty-five visits, corresponding to 32 unique patients were analysed: almost 80% had severe disease. Twenty-nine visits received analgesia within 1 hour of registration; less than half required hospitalisation, and the remainder had shortened admission (<3 days). The most important and clinically relevant result demonstrated that every minute delay in analgesia corresponded to 30 minutes of additional hospital stay.
Shenelle Soyer
We love learning and sharing our knowledge. Keep an eye out, as some of these will soon be published!
