Non-Accidental Long Bone Injuries: Nikki Abela at DFTB18

Cite this article as:
Team DFTB. Non-Accidental Long Bone Injuries: Nikki Abela at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17833

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families. Tickets for DFTB19, which will be held in London, UK, are now on sale from www.dftb19.com.

Cognitive Biases: Kevin McCaffrey at DFTB18

Cite this article as:
Team DFTB. Cognitive Biases: Kevin McCaffrey at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17768

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families. Tickets for DFTB19, which will be held in London, UK, are now on sale from www.dftb19.com.

Delayed presentation of head injuries – should we be worried?

Cite this article as:
Tessa Davis. Delayed presentation of head injuries – should we be worried?, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17874

We have a clear algorithm for when to CT children who present with head injuries immediately after the injury. But, when children present more than 24 hours after an injury, we aren’t really sure what is best practice. This paper, by the PREDICT group, look at the rates of traumatic brain injury in this patient group.

Borland M,  Dalziel SR, Phillips N, Lyttle M, Bressan S, Oakley E, Hearps SJC, Kochar A, Furyk J, Cheek J, Neutze J, Gilhotra Y, Dalton S, Babl F. Delayed Presentations to Emergency Departments of Children With Head Injury: A PREDICT Study, Annals of Emergency Medicine, DOI: https://doi.org/10.1016/j.annemergmed.2018.11.035

Why is this study needed?

We have a range of decision rules to help guide us for children presenting immediately after a head injury. PECARN and CATCH clinical decision rules specifically exclude children who present with a head injury more than 24 hours after the injury. CHALICE doesn’t specifically exclude this group, but there is no published data on this group of patients.

What we worry about is missing a traumatic brain injury, and in particular one that will need surgical intervention. If a child presents after the initial 24 hours, are they more likely to have a traumatic brain injury and should we therefore have a lower threshold to CT scan these patients?

This is a really common dilemma in Paediatric Emergency, and in my own experience, most people have a lower threshold for scanning children presenting late with head injury concerns because of the lack of guidance and evidence in this group.

The authors’ aim is to look at the prevalence of traumatic brain injury in this group, and to identify any factors in these patients that would make a traumatic brain injury more likely.

Who were the patients?

This was a secondary analysis of an existing cohort – the Australian Paediatric Head Injury Study cohort. This was children with a head injury who presented to one of ten paediatric EDs in Australia/New Zealand over a 3.5 year period.

For this secondary analysis, the cohort was split into those presenting within 24 hours, and those presenting later than 24 hours after the head injury. 5% of the cohort presented >24 hours after the injury.

Children were excluded if they had GCS<14, and were also excluded for representations of the same injury.

The original APHIRST cohort included 20,137 head injury presentations.

352 were excluded due to GSC<14 and 20 were excluded due to unknown time to presentation.

Of the 19,765 left, 981 children presented >24 hours after the injury.

Definitions

Traumatic brain injury on CT (TBI) – intracranial haemorrhage or contusion, cerebral oedema, traumatic infarction, diffuse axonal injury, shearing injury, sigmoid sinus thrombosis, signs of brain herniation, midline shift, diastasis of the skull, pneumocephalus, and depressed skull fracture.

Clinically important traumatic brain injury (cTBI) – death, intubation >24 hours, neurosurgery, or a traumatic brain injury-related admission to hospital of two or more nights.

What were the authors looking at?

The paper examined any associations between a delay in presentation and the mechanism of injury.

It also looked at the injury characteristics and demographics for patients presenting within and after 24 hours of the injury.

Who presented more than 24 hours after a head injury?

Those presenting >24 hours after the injury were significantly more likely to have had a non-frontal scalp haematoma, headache, vomiting, and assault with non-accidental injury concerns.

Loss of consciousness and amnesia were more likely to present within 24 hours of the injury.

Were the late presentations more likely to have a head CT and a brain injury than those presenting within 24 hours?

203 of the 981 patients had a head CT in the late group. This is 20.6% compared to 7.9% in the early presentations.

37 of these children had a TBI on head CT. This is 3.8% compared to 1.2% in the early presentations group. The most common injuries were a depressed skull fracture, intracranial haemorrhage, or contusions.

Eight children had a cTBI (0.8% – which is the same as in the early group) and two required neurosurgical intervention (also not significantly higher than in the early group).

Who were the eight children with clinically important traumatic brain injuries?

The children ranged from six months to 15 years.

  • Five of them had a low-level fall (<1 m) – one of these required neurosurgical intervention
  • One was struck by a high speed object
  • One sustained a blunt injury with a bat during sport – required neurosurgical intervention
  • One fell out of bed more than two days earlier

Of note in the late group…

No children with amnesia had a traumatic brain injury on head CT

Suspicion of a depressed skull fracture and a non-frontal scalp haematoma were significantly associated with a cTBI

No children with loss of consciousness had a cTBI

What can we take from this?

There may be many reasons why our scanning rate in delayed head injury presentations is so much higher – including the lack of previously existing evidence, and our clinical concern that a TBI is more likely if the symptoms are persisting.

The authors conclude that presenting >24 hours after the injury (with a GSC>14), significantly increases the risk of a TBI. Suspicion of depressed skull fracture or a non-frontal scalp haematoma increase the risk of TBI and cTBI in this group.

Commentary from Damian Roland:

This is a useful sub-analysis of a very good research data set prepared by the PREDICT group which has good face validity and is likely to be externally reproducible in other developed nations.

The question I ask myself when reviewing head injury patients with a ‘delayed’ presentation is ‘why are you delayed?’. The sheer size of this data set is testament to the fact that lots of children present to Emergency Departments because of parental concern following a fall or blunt trauma. If a parent chooses not to present initially it’s usually because they thought the injury was not that significant (not a very high bar to reach usually!) and symptoms have evolved or perhaps the initial circumstances weren’t clear or un-witnessed. For the former case this ‘evolution’ of disease is (not surprisingly) significant. The ‘delayed’ group more likely to demonstrate relevant pathology because the symptoms that pathology were producing were becoming more apparent. For the latter “historical’ muddying is either sinister (note the relationship with non-accidental injury concerns) or perhaps critical information which may have resulted in earlier attendance has been missed.

It is important to note that while the post 24 hour group demonstrated increased risks for many features and outcomes, the absolute numbers are still low. Just because you present 24 hours down the line doesn’t mean do a CT. Just think that bit more carefully than if the child had presented straight after the injury. As this same group have also recently shown, our individual decision making capacity is probably just as good as any rule so we can still trust our own clinical judgement

.

Steroids in Wheeze: Meredith Borland at DFTB18

Cite this article as:
Team DFTB. Steroids in Wheeze: Meredith Borland at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17716

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families. Tickets for DFTB19, which will be held in London, UK, are now on sale from www.dftb19.com.

Bubble Wrap PLUS – Dec 18 / Jan 19

Cite this article as:
Anke Raaijmakers. Bubble Wrap PLUS – Dec 18 / Jan 19, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17802

Can’t get enough of Bubble Wrap? The Bubble Wrap Plus is a monthly paediatric journal club reading list from Anke Raaijmakers working with Professor Jaan Toelen & his team of the University Hospitals in Leuven. This comprehensive list is developed from 34 journals, including major and subspecialty paediatric journals. We suggest this list can help you discover relevant or interesting articles for your local journal club or simply help you to keep an finger on the pulse of paediatric research.

This bumper edition of Bubble Wrap Plus heralds the end of 2018 and a fresh start with 2019 to explore answers to intriguing questions such as: ‘Should children rest after mild traumatic brain injury?’, ‘Is US guided LP superior to standard technique?’, ‘Do we prescribe acid-suppression too often?’, ‘Does e-cigarette use lead to or prevent smoking in adolescents?’ and ‘Should we institute elective replacement of IV cannulas in neonates?’.

You will find the list is broken down into four sections:

1.Reviews and opinion articles

Refeeding in anorexia nervosa.

Bargiacchi A, et al. Eur J Pediatr. 2018 Nov 27.

End-stage kidney disease in infancy: an educational review.

Sanderson KR, et al. Pediatr Nephrol. 2018 Nov 21.

Renal aspects of metabolic acid-base disorders in neonates.

Iacobelli S, et al. Pediatr Nephrol. 2018 Nov 19.

Pain Relief in the Palm of Your Hand: Harnessing Mobile Health to Manage Pediatric Pain.

Hunter JF, et al. Paediatr Anaesth. 2018 Nov 16.

Cerebral palsy: not always what it seems.

Appleton RE, et al. Arch Dis Child. 2018 Nov 9.

Utility of lung ultrasound scanning in neonatology.

Woods PL. Arch Dis Child. 2018 Nov 9.

Early warning scores in paediatrics: an overview.

Chapman SM, et al. Arch Dis Child. 2018 Nov 9.

A narrative review of proteinuria and albuminuria as clinical biomarkers in children.

Larkins NG, et al. J Paediatr Child Health. 2018 Nov 9.

A review of feeding intolerance in critically ill children.

Tume LN, et al. Eur J Pediatr. 2018 Nov;177(11):1675-1683.

Practical Wisdom, Rules, and the Parent-Pediatrician Conversation.

Brudney D. Pediatrics. 2018 Nov;142(Suppl 3):S193-S198.

Understanding and Improving Diagnostic Tests: The Clinician Perspective.

Ng PC. Neonatology. 2018 Dec 21;115(3):189-196

Developmental Dysplasia of the Hip.

Yang S, et al. Pediatrics. 2018 Dec 26.

An approach to the child with a wet cough.

Gilchrist FJ. Paediatr Respir Rev. 2018 Nov 23.

What’s new in autoinflammation?

Ozen S. Pediatr Nephrol. 2018 Dec 14

Antiemetic Drug Use in Children: What the Clinician Needs to Know.

Romano C, et al. J Pediatr Gastroenterol Nutr. 2018 Dec 11

The neuroimaging mimics of abusive head trauma.

Mankad K, et al. Eur J Paediatr Neurol. 2018 Nov 22.

How to give a better lecture.

Isaacs D, et al. J Paediatr Child Health. 2018 Dec;54(12):1290-1291

Circumcision in the Paediatric Patient: A Review of Indications, Technique and Complications.

Sebaratnam DF. J Paediatr Child Health. 2018 Dec;54(12):1404.

Magnetic resonance imaging of the pediatric mediastinum.

Bardo DME, et al. Pediatr Radiol. 2018 Aug;48(9):1209-1222

Whole-body magnetic resonance imaging: techniques and non-oncologic indications.

Greer MC. Pediatr Radiol. 2018 Aug;48(9):1348-1363.

Neuropathological Developments in Sudden Infant Death Syndrome.

Bright FM, et al. Pediatr Dev Pathol. 2018 Nov-Dec;21(6):515-521.

Hypersensitivity reactions to intravenous antibiotics in cystic fibrosis.

Wright MFA, et al. Paediatr Respir Rev. 2018 Jun;27:9-12.

Understanding cardiac shunts.

Joffe DC, et al. Paediatr Anaesth. 2018 Apr;28(4):316-325.

Vaccination in Pregnancy-Recent Developments.

Jones CE, et al. Pediatr Infect Dis J. 2018 Feb;37(2):191-193.

2. Original clinical studies

Risk Stratification of Febrile Infants ≤60 Days Old Without Routine Lumbar Puncture.

Aronson PL, et al. Pediatrics. 2018 Nov 13.

Omission of Lumbar Puncture From Evaluation of Source of Fever in Young Infants.

Baker MD. Pediatrics. 2018 Nov 13.

Drowsy Driving, Sleep Duration, and Chronotype in Adolescents.

Owens JA, et al. J Pediatr. 2018 Nov 2.

The mediating role of sleep in the relationship between Indigenous status and body mass index in Australian school-aged children.

Deacon-Crouch M, et al. J Paediatr Child Health. 2018 Nov 24.

Cardiovascular Autonomic Control Is Altered in Children Born Preterm with Sleep Disordered Breathing.

Thomas B, et al. J Pediatr. 2018 Nov 13.

Abnormalities in autonomic function in obese boys at-risk for insulin resistance and obstructive sleep apnea.

Oliveira FMS, et al. Pediatr Res. 2018 Nov 12.

Does Sleep Matter? Impact on Development and Functioning in Infants.

Mindell JA, et al. Pediatrics. 2018 Nov 12.

Uninterrupted Infant Sleep, Development, and Maternal Mood.

Pennestri MH, et al. Pediatrics. 2018 Nov 12.

Development of sleep patterns in children with obese and normal-weight parents.

Xiu L, et al. J Paediatr Child Health. 2018 Nov 10.

Digital Screen Time and Pediatric Sleep: Evidence from a Preregistered Cohort Study.

Przybylski AK. J Pediatr. 2018 Oct 30.

Non-indicated acid-suppression prescribing in a tertiary paediatric hospital: An audit and costing study.

Riess S, et al. J Paediatr Child Health. 2018 Nov 28.

Screening for Iron Deficiency in Early Childhood Using Serum Ferritin in the Primary Care Setting.

Oatley H, et al. Pediatrics. 2018 Nov 28.

Staff matter too: pilot staff support intervention to reduce stress and burn-out on a neonatal intensive care unit.

D’Urso A, et al. Arch Dis Child Fetal Neonatal Ed. 2018 Nov 26.

Being Overweight or Obese and the Development of Asthma.

Lang JE, et al. Pediatrics. 2018 Nov 26.

Language in 2-year-old children born preterm and term: a cohort study.

Sanchez K, et al. Arch Dis Child. 2018 Nov 23.

Association between exposure to macrolides and the development of infantile hypertrophic pyloric stenosis: a systematic review and meta-analysis.

Abdellatif M, et al. Eur J Pediatr. 2018 Nov 23.

Towards an individual screening strategy for first-degree relatives of celiac patients.

Wessels MMS, et al. Eur J Pediatr. 2018 Nov;177(11):1585-1592.

Randomised cross-over study of automated oxygen control for preterm infants receiving nasal high flow.

Reynolds PR, et al. Arch Dis Child Fetal Neonatal Ed. 2018 Nov 21.

Comparison of a Smartphone Otoscope and Conventional Otoscope in the Diagnosis and Management of Acute Otitis Media.

Chan KN, et al. Clin Pediatr (Phila). 2018 Nov 21:

Association of Prenatal Exposure to Air Pollution With Autism Spectrum Disorder.

Pagalan L, et al. JAMA Pediatr. 2018 Nov 19.

Efficacy of Lactobacillus-supplemented triple therapy for Helicobacter pylori infection in children: a meta-analysis of randomized controlled trials.

Fang HR, et al. Eur J Pediatr. 2018 Nov 16.

Trends and Predictors of Clostridium difficile Infection among Children: A Canadian Population-Based Study.

El-Matary W, et al. J Pediatr. 2018 Nov 15.

A comparison between the feeding practices of parents and grandparents.

Metbulut AP, et al. Eur J Pediatr. 2018 Dec;177(12):1785-1794.

Assessment of clinical outcome of children with sepsis outside the intensive care unit.

Zallocco F, et al. Eur J Pediatr. 2018 Dec;177(12):1775-1783.

Pediatric residents’ simulation-based training in patient safety during sedation.

Friedman N, et al. Eur J Pediatr. 2018 Dec;177(12):1863-1867.

Association Between Obesity/Overweight and Functional Gastrointestinal Disorders in Children.

Tambucci R, et al. J Pediatr Gastroenterol Nutr. 2018 Nov 15.

Exposure to and use of mobile devices in children aged 1-60 months.

Kılıç AO, et al. Eur J Pediatr. 2018 Nov 6.

Adenovirus-Associated Central Nervous System Disease in Children.

Schwartz KL, et al. J Pediatr. 2018 Nov 6.

Intellectual Disability in Children Conceived Using Assisted Reproductive Technology.

Hansen M, et al. Pediatrics. 2018 Nov 15.

Physiological Effect of Prone Position in Children with Severe Bronchiolitis: A Randomized Cross-Over Study (BRONCHIO-DV).

Baudin F, et al. J Pediatr. 2018 Nov 14.

Influence of Fathers’ Early Parenting on the Development of Children Born Very Preterm and Full Term.

McMahon GE, et al. J Pediatr. 2018 Nov 14.

Clinical recovery in children with uncomplicated appendicitis undergoing non-operative treatment: secondary analysis of a prospective cohort study.

Knaapen M, et al. vEur J Pediatr. 2018 Nov 12.

Maternal obesity and offspring cognition: the role of inflammation.

Monthé-Drèze C, et al. Pediatr Res. 2018 Nov 12.

Child BMI Over Time and Parent-Perceived Overweight.

Wake M, et al. Pediatrics. 2018 Nov 8.

Geographic and socioeconomic predictors of perforated appendicitis: A national Canadian cohort study.

Akhtar-Danesh GG, et al. J Pediatr Surg. 2018 Nov 7.

E-cigarette Use and Subsequent Smoking Frequency Among Adolescents.

Barrington-Trimis JL, et al. Pediatrics. 2018 Nov 5.

Elective replacement of intravenous cannula in neonates-a randomised trial.

Chin LY, et al. Eur J Pediatr. 2018 Nov;177(11):1719-1726.

Are adolescents really being sedentary or inactive when at school? An analysis of sedentary behaviour and physical activity bouts.

da Costa BGG, et al. Eur J Pediatr. 2018 Nov;177(11):1705-1710.

Delivery Room Management of Meconium-Stained Newborns and Respiratory Support.

Chiruvolu A, et al. Pediatrics. 2018 Nov 1.

Appropriate Management of the Nonvigorous Meconium-Stained Neonate: An Unanswered Question.

Wiswell TE. Pediatrics. 2018 Nov 1.

Gestational Age, Health, and Educational Outcomes in Adolescents.

Berry MJ, et al. Pediatrics. 2018 Nov;142(5).

PEG 3350 Versus Lactulose for Treatment of Functional Constipation in Children: Randomized Study.

Jarzębicka D, et al. J Pediatr Gastroenterol Nutr. 2018 Oct 31.

Nuchal Rigidity in Infantile Bacterial Meningitis.

Iio K, et al. J Pediatr. 2018 Oct 30.

Effect of synbiotic supplementation on children with atopic dermatitis: an observational prospective study.

Ibáñez MD, et al. Eur J Pediatr. 2018 Dec;177(12):1851-1858.

Mealtime insulin bolus adherence and glycemic control in adolescents on insulin pump therapy.

Spaans E, et al. Eur J Pediatr. 2018 Dec;177(12):1831-1836.

Performance of Tuberculin Skin Tests and Interferon-γ Release Assays in Children Younger Than 5 Years.

Velasco-Arnaiz E, et al. Pediatr Infect Dis J. 2018 Dec;37(12):1235-1241.

Viral Acute Respiratory Illnesses in Young Infants Increase the Risk of Respiratory Readmission.

Toizumi M, et al. Pediatr Infect Dis J. 2018 Dec;37(12):1217-1222.

Psychosocial functioning of parents of children with heart disease-describing the landscape.

Wray J, et al. Eur J Pediatr. 2018 Dec;177(12):1811-1821.

Changes in bilirubin in infants with hypoxic-ischemic encephalopathy.

Dani C, et al. Eur J Pediatr. 2018 Dec;177(12):1795-1801.

Needle-related pain and distress management during needle-related procedures in children with and without intellectual disability.

Pascolo P, et al. Eur J Pediatr. 2018 Dec;177(12):1753-1760.

Parent experience in the resuscitation room: how do they feel?

Parra C, et al. Eur J Pediatr. 2018 Dec;177(12):1859-1862.

Renal Replacement Therapy in children with severe developmental disability: guiding questions for decision-making.

Willem L, et al. Eur J Pediatr. 2018 Dec;177(12):1735-1743.

Human Parechovirus 1, 3 and 4 Neutralizing Antibodies in Dutch Mothers and Infants and Their Role in Protection Against Disease.

Karelehto E, et al. Pediatr Infect Dis J. 2018 Dec;37(12):1304-1308.

Predictors of grade 3-5 vesicoureteral reflux in infants ≤ 2 months of age with pyelonephritis.

Bahat H, et al. Pediatr Nephrol. 2018 Dec 26.

Prospective associations between television in the preschool bedroom and later bio-psycho-social risks.

Pagani LS, et al. Pediatr Res. 2018 Dec 26.

Trends, Safety, and Recommendations for Caffeine Use in Children and Adolescents.

Temple JL. J Am Acad Child Adolesc Psychiatry. 2019 Jan;58(1):36-45

Efficacy and Safety of EMLA Cream for Pain Control Due to Venipuncture in Infants: A Meta-analysis.

Shahid S, et al. Pediatrics. 2018 Dec 26.

Age-Related Changes in Inferior Vena Cava Dimensions among Children and Adolescent with Syncope.

Shivaram P, et al. J Pediatr. 2018 Dec 21.

Tracing Effects of Parental Discipline on Child Psychopathology: The Devil’s in the Detail.

Wertz J. J Am Acad Child Adolesc Psychiatry. 2019 Jan;58(1):20-21

Disciplinary Parenting Practice and Child Mental Health: Evidence From the UK MillenniumCohort Study.

Rajyaguru P, et al. J Am Acad Child Adolesc Psychiatry. 2019 Jan;58(1):108-116.e2

Clinical Manifestations, Management, and Outcomes of Osteitis/Osteomyelitis Caused by Mycobacterium bovis Bacillus Calmette-Guérin in Children: Comparison by Site(s) of Affected Bones.

Huang CY, et al. J Pediatr. 2018 Dec 18.

Eating disorder or disordered eating: undiagnosed inflammatory bowel disease mimicking eating disorder.

Harris RE, et al. Arch Dis Child. 2018 Dec 19

Cofactors of Pediatric Tinnitus: A Look at the Whole Picture.

Levi J, Basa K, et al. Clin Pediatr (Phila). 2018 Dec 3:9922818816426.

Probing the Irritability-Suicidality Nexus.

Stringaris A, et al. J Am Acad Child Adolesc Psychiatry. 2019 Jan;58(1):18-19.

Pathways of Association Between Childhood Irritability and Adolescent Suicidality.

Orri M, et al. J Am Acad Child Adolesc Psychiatry. 2019 Jan;58(1):99-107.e3.

Non-urgent paediatric emergency department presentation: A systematic review.

Alele FO, et al. J Paediatr Child Health. 2018 Dec 20.

Reverse-Transcriptase Inhibitors in the Aicardi–Goutières Syndrome

Rice GI, et al. N Engl J Med. 2018 Dec 6;379(23):2275-7.

Everything is awesome: Don’t forget the Lego.

Tagg A, et al. J Paediatr Child Health. 2018 Nov 22.

Oral dextrose gel to treat neonatal hypoglycaemia: Clinician survey.

Alsweiler JM, et al. J Paediatr Child Health. 2018 Nov 22.

Symptoms of Feeding Problems in Preterm-born Children at 6 Months to 7 years Old.

Park J, et al. J Pediatr Gastroenterol Nutr. 2018 Dec 14

Physical activity after mild traumatic brain injury: What are the relationships with fatigue and sleep quality?

van Markus-Doornbosch F, et al. Eur J Paediatr Neurol. 2018 Nov 14

Decreased Fecal Bacterial Diversity and Altered Microbiome in Children Colonized With Clostridium difficile.

Chen LA, et al. J Pediatr Gastroenterol Nutr. 2018 Dec 11.

Comparison of Antibiotic Prescribing for Pediatric Community-Acquired Pneumonia in Children’s and Non-Children’s Hospitals.

Tribble AC, et al. JAMA Pediatr. 2018 Dec 10

Severe Respiratory Syncytial Virus Infection in Hospitalized Children Less Than 3 Years of Age in a Temperate and Tropical Climate.

Butler J, et al. Pediatr Infect Dis J. 2019 Jan;38(1):6-11.

Safety of Lactobacillus reuteri DSM 17938 in Healthy Children 2 to 5 Years of Age.

Kosek MN, et al. Pediatr Infect Dis J. 2018 Dec 10.

Antibiotics for urethral catheterization in children undergoing cystography: retrospective evaluation of a single-center cohort of pediatric non-toilet-trained patients.

Marzuillo P, et al. Eur J Pediatr. 2018 Dec 1.

Yield of brain imaging among neurologically normal children with headache on wakening or headache waking the patient from sleep.

Ahmed MAS, et al. Eur J Paediatr Neurol. 2018 Sep;22(5):797-802.

Paediatricians’ attitudes to and management of functional seizures in children.

Nielsen ES, et al. Eur J Paediatr Neurol. 2018 Sep;22(5):774-781.

Ultrasound-guided lumbar puncture in pediatric patients: technical success and safety.

Pierce DB, et al. Pediatr Radiol. 2018 Jun;48(6):875-881.

Does vitamin E prevent asthma or wheeze in children: A systematic review and meta-analysis.

Wu H, et al. Paediatr Respir Rev. 2018 Jun;27:60-68.

Evaluation of the Clinical Utility of a Real-time PCR Assay for the Diagnosis of Streptococcus pneumoniae Bacteremia in Children: A Retrospective Diagnostic Accuracy Study.

Murphy J, et al. Pediatr Infect Dis J. 2018 Feb;37(2):153-156.

Urinary Tract Infection in Children With Nephrotic Syndrome.

Narain U, et al. Pediatr Infect Dis J. 2018 Feb;37(2):144-146.

Safety of Outpatient Parenteral Antimicrobial Therapy in Children.

Fernandes P, et al. Pediatr Infect Dis J. 2018 Feb;37(2):157-163.

Epidemiology of Sepsis-like Illness in Young Infants: Major Role of Enterovirus and Human Parechovirus.

de Jong EP, et al. Pediatr Infect Dis J. 2018 Feb;37(2):113-118.

3. Guidelines and best evidence

Clinical Practice Guideline: Maintenance Intravenous Fluids in Children.

Feld LG, et al. Pediatrics. 2018 Nov 26.

Management of severe bronchiolitis: impact of NICE guidelines.

Griffiths B, et al. Arch Dis Child. 2018 Nov 24.

Which vasoactive drug should be first choice in paediatric septic shock?

McVea S, et al. Arch Dis Child. 2018 Nov 9.

Effective Discipline to Raise Healthy Children.

Sege RD, et al. Pediatrics. 2018 Nov 5.

Clinical Practice Guideline for the Management of Infantile Hemangiomas.

Krowchuk DP, et al. Pediatrics. 2018 Dec 24

Initial Oxygen Use for Preterm Newborn Resuscitation: A Systematic Review With Meta-analysis.

Welsford M, et al. Pediatrics. 2018 Dec 21

Room Air for Initiating Term Newborn Resuscitation: A Systematic Review With Meta-analysis.

Welsford M, et al. Pediatrics. 2018 Dec 21

Pediatric Eosinophilic Esophagitis: Results of the European Retrospective Pediatric Eosinophilic Esophagitis Registry (RetroPEER).

Hoofien A, et al. J Pediatr Gastroenterol Nutr. 2018 Dec 11.

Question 3: Can we diagnose asthma in children under the age of 5 years?

Yang CL, et al. Paediatr Respir Rev. 2018 Oct 24.

Why should we screen for arterial hypertension in children and adolescents?

Litwin M. Pediatr Nephrol. 2018 Jan;33(1):83-92.

Screening children for hypertension: the case against.

Ide N, et al. Pediatr Nephrol. 2018 Jan;33(1):93-100.

To screen or not to screen: for high blood pressure.

Tullus K. Pediatr Nephrol. 2018 Jan;33(1):81-82.

Interventions to Improve Medication Adherence: A Review.

Kini V, et al. JAMA. 2018 Dec 18;320(23):2461-2473.

4. Case reports

Rare and striking complication of Henoch-Schönlein purpura.

Moussaoui D, et al. Arch Dis Child. 2018 Nov 23.

Young girl with bruising: Finding the X factor.

Chan DW, et al. J Paediatr Child Health. 2018 Nov 13.

Case 19-2018: A 15-Year-Old Girl with Acute Kidney Injury.

Grisaru S, et al. N Engl J Med. 2018 Nov 1;379(18):e34.

Dissociative state: Returned traveller with a high fever and low heart rate.

Freeth P, et al. J Paediatr Child Health. 2018 Dec;54(12):1395-1396.

Acute Knee Swelling and Limp in a 10-year-old Child.

Islam S, et al. Pediatr Infect Dis J. 2018 Feb;37(2):194-195.

 

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

Please join us for our next #DFTB_JC on twitter…The DFTB/ADC Journal Club is a monthly collaboration between @DFTBubbles and @ADC_BMJ featuring a FREE access article from the latest issues of Archives of Disease of Childhood. January’s pick  is ‘ Can we use POCUS to Diagnose Pneumonia?’ Read the article here: bit.ly/2TMDf2M The chat will happen on twitter at Tue 22/1/19 at UTC2000hrs (That’s Wednesday 0700 23/1 AEST), just search the hashtag #DFTB_JC

ADC/DFTB Journal Club #2 – December – How well do we manage suspected meningitis in ED?

Cite this article as:
Grace Leo. ADC/DFTB Journal Club #2 – December – How well do we manage suspected meningitis in ED?, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17786

Vaccines have been instrumental in reducing rates of bacterial meningitis. However bacterial meningitis still represents 4-19% (1) of cases of meningitis and has been estimated to be cause 2% of all child deaths (2). Timely administration of antibiotics helps save lives with adult research suggesting that every hour of delayed treatment increases the risk of death or permanent disability by 10-30% (3). So how swiftly do we investigate and treat children with suspected meningitis? The paper from Archives of Disease of Childhood featured in our second #DFTB_JC sought to answer this question:

 

What’s it about?

This was a prospective cohort study of 388 children who attended three UK paediatric tertiary centres between 2011-2. They had been either hospitalised with suspected meningitis or underwent lumbar puncture (LP) during sepsis evaluation.

Of the 388 children, 18% (70) were given a diagnosis of meningitis but only 13 were documented as bacterial and 26 as viral with and 31 patients having no known or identified cause. Just over half the children (57%) had seen a doctor in the same illness prior to ED presentation.

The median time from initial hospital assessment to antibiotic administration was 3.1 hours.  The time to LP was even longer at 4.8 hours, but once discounting intentional postponement for reasons including convulsions, concern regarding raised intracranial pressure, coagulopathy or shock, this time reduced to 3 hours. Over half of the children (62%) had their LP following antibiotics.

In further discussion with the corresponding author @manishs_  the mean was chosen due to skewing of the data and the time from initial hospital assessment was equivalent to arrival in ED. The time between initial assessment and LP ranged from 0-183 hours whilst the time between initial assessment and antibiotics ranged from 0 to 136 hours. For the 221 patients who they had data in hours available; only 31 received antibiotics in the first hour. However 131 of the 221 patients did receive antibiotics in the first 4 hours.

 

 

The general sentiment from the twitter discussion was  that the median time of 3.1hours to antibiotic administration was longer than expected, and suboptimal. Whilst the actual time point may have been somewhat surprising; many could identify common reasons for antibiotic delay and in particular, discussion about the difficulties that lumbar puncture can pose in different age groups and its contribution towards delay of antibiotics.

“It surprised me. Think we generally give abx before LP in children and LP before abx in babies… probably because of less anxiety around the procedure in babies. But no excuse for 3 hour delay in any age group really.” – @DrRoseM

 

 

 

We then delved deeper into the importance of LP before or after antibiotics and factors affecting unintentional LP delay. Paediatrician from Ontario, Tom Lacroix shared concern that with improved vaccines, he has seen skill attrition.

“…I wonder how much of delay is bc we have become unaccustomed to doing LPs. I have seen a fall in LPs 90%+ since intro of pneumococcal conjugate vaccine” – @drtom_lacroix

Across in the UK, the perceived anxiety surrounding performing an LP in older children was raised including staffing challenges, concerns about pain and procedural sedation.

“In neonates we rush to get the LP done within an hour, but in older children it always seems to take a lot longer. Do we have misplaced anxiety in this age group?” – @TessaRDavis

“…It takes one NICU nurse to flex a 6 day old up for an LP, but a play specialist, at least two nurses and one parent to get an older child in position for an LP” – @edd_broad

Differences in practice in terms of performing a FBC and Coags screen prior to LP were also highlighted.

“Not sure about mandatory, but I’ve been taught (and continue to practice) confirming PLT > 50×10^9/L prior to LP. ” – @henrygoldstein

“…Unless evidence of coagulopathy ie purpura. Do LP and then give abx” – @DocAnthonyT

 

 

 

In the supplementary tables from the paper, of all children in the study, just under a quarter (24.7%) had bacterial and/or viral CSF PCR performed. Of the 70 children who had meningitis, CSF PCR was performed on only 9 (13%). The rate was slightly higher for meningitis of cause unknown (6 of 29 patients, 21%). The authors commented that this represents a significant underutilisation, particularly as CSF PCR is recommended in the current UK guidelines. The suspected cause of this was a long turnaround time to PCR.

However the benefits of positive viral CSF PCR results would include reducing length of treatment and inpatient stay as well as building a more accurate understanding of true disease rates.

The results of this paper contrast with experiences of our journal club participants where CSF PCR appeared to be a more common order, particularly in the neonatal setting:

“Might depend on the CSF WCC for the bacterial PCR? If zero, I wouldn’t necessarily send bacterial PCR (but will still frequently send viral PCR)…Parechovirus PCR is automatically sent for our neonates. #DFTB_JC ” – @DrSarahMcNab

“NICU where I work send viral PCRs as standard with turnaround in 24 hours. Think you still need to request in paeds. ” – @DavidKing83

 

Paediatric Registrar Rose provided a good summary of what she learned from the article and the #DFTB_JC chat:

take home- give the abx as soon as possible and definitely within 1 hour. If unable to do LP pre abx due to delays etc then do LP ASAP after abx. Consider PCR as a valuable tool to aid decision re duration of treatment” – @DrRoseM

From the DFTB team, the discussion has made us rethink how each step in assessment and management of suspected meningitis may delay optimal care. In particular we’ll be thinking about how strong the evidence is behind ‘the golden hour’ of antibiotic administration, the anxiety surrounding LPs in older children and evidence behind performing coagulation studies prior to LP…now that sounds like a potential post for the future.

Thanks again to everyone who participated in our #DFTB_JC and we hope you will join us again later this month for our next paper.

 

Please join us for our next ADC/DFTB Journal Club on twitter at Tue 22/1/19 at UTC2000hrs (That’s Wednesday 0700 23/1 AEST) January’s featured FREE access article from @ADC_BMJ featuring a FREE access article from the latest issues of Archives of Disease of Childhood. January’s pick  is ‘ Can we use POCUS to Diagnose Pneumonia?’ Read the article here: bit.ly/2TMDf2M The chat will happen on twitter, hosted by @DFTB_Bubbles. Remember to use the hashtag #DFTB_JC for all related posts.

Five go on an adventure: hosted by Deb Shellshear at DFTB18

Cite this article as:
Team DFTB. Five go on an adventure: hosted by Deb Shellshear at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17621

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families.

Thoracolumbar spine x-rays

Cite this article as:
Tessa Davis. Thoracolumbar spine x-rays, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17581

Read our step-by-step guide to interpreting thoracic and lumbar spine x-rays.

Thoracolumbar spine x-ray involves two views – AP and lateral.

 

  1. Check it’s an adequate view

For a lumbar spine view

  • you should be able to see L1-L5 but also the full T12 vertebral body, T11/12, and the sacrum on the AP view
  • the vertebral bodies, facet joints, and pedicles should be clearly visible on the lateral view
  • the transverse processes should also be visible (and are often obscured by gas)

For the thoracic spine view

  • make sure the whole thoracic spine is visible
  • you should be able to see the pedicles, spinous processes, and vertebral bodies
  • the ribs can cause difficulty seeing the thoracic spine on a lateral view

 

2. Know your anatomy

  • Clavicle is at T3
  • Tracheal bifurcation is T4/5
  • 12th rib is at T12
  • In the lumbar spine, the disc spaces also increase in size, although note that the L5/sacral space is narrower than the L4/L5 space

From https://www.wikiradiography.net/

3. Check the alignment

On the AP check that the vertebral bodies and spinous processes are aligned. On the lateral, check the alignment of the vertebral bodies.

 

 

4. Look for loss of vertebral height

In the thoracic spine, the vertebral bodies (and the disc spaces) should gradually increase in size as you get further down the spine.

Check all the vertebral bodies looking specifically for loss of height. This indicates a compression fracture.

 

 

 

5. Look for widened inter-spinous or inter-pedicle distance and check the processes

In the lumbar spine check that all the pedicles, spinal, and transverse processes are intact.

See below (under burst fracture) for an example of widened inter-pedicle distance and (under Chance fracture) widened spinous process process distance.

Transverse process fracture From https://www.imageinterpretation.co.uk/thoracolumbar.php

 

6. Check for translation/rotation or distraction

Translation or rotation is displacement in horizontal plane; and distraction is displacement in the vertical plane.

Translation/rotation is due to a side-to-side motion (can be left-to-right or front-to-back). It is a serious injury and always involves the posterior ligamentous complex.

Distraction is where the vertebrae are pulled apart and carries a high risk of cord injury. Often there is compression at the other side (see Chance fracture below).

 

7. Know the common types of fractures

Compression fracture

This is the most common type of fracture and is identified through loss of vertebral height (see number 4 above). It involves one column only and is a stable fracture.

 

Burst fracture

On x-ray alone 25% of burst fractures are misdiagnosed as vertebral compression fractures. A burst fracture is where there is a compression, but part of the vertebral body has been projected out anteriorly.

On AP view there will be an increased interpedicular distance in 80% of burst fractures.

On lateral view there will be reduced vertebral height and disrupted anterior alignment.

A burst fracture involves two columns and is usually considered to be unstable.

 

Chance fracture

Usually from a seatbelts injury and is commonly at L2/L3

This is a flexion-distraction injury where there is horizontal splitting of the vertebral body with ligament rupture. This is an unstable fracture and involves all three columns

Sometimes there is increased distance between the spinous processed on the lateral view (but not always).

On the AP view there can be increased distance between the spinous processes at the level of the Chance fracture.

 

Jumper’s/lover’s fracture

So-called because it’s usually from people jumping out of windows to escape the police or angry partners. This is severe axial loading leading to compression/burst fractures alongside a calcaneus fracture.

https://radiopaedia.org/articles/lovers-fracture-2?lang=us

References

Radiopaedia

Radiology Assistant

Norwich Image Interpretation Course

Radiology Masterclass

Abnormal Treatment Behaviour: Jannie Geertsema at DFTB18

Cite this article as:
Team DFTB. Abnormal Treatment Behaviour: Jannie Geertsema at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17711

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families. Tickets for DFT19, which will be held in London, UK, are now on sale from www.dftb19.com.

Jannie Geertsema is a Child and Adolescent Psychiatrist at the Queensland Children’s Hospital. In this talk he reminds us of one of the challenges that faces all doctors – who are we actually treating? Is it the child in front of us, is it their mother, is it the family dynamic?

I fought the law…

Cite this article as:
David McDonald. I fought the law…, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17508

I recently attended my forty-year post-graduation reunion – I graduated from Sydney University in September 1978. It was a cheerful night and great to see old friends.  I am still recovering from the humiliating ritual of dancing the Village People YMCA number. (I was the cowboy).

There has been a lot of awareness about medico-legal matters among junior doctors since the Bawa-Garba case. I thought I would share a retrospective view on some aspects of my personal experience interacting with the legal profession over a long career. The medico legal area is so complicated that I will not comment upon specifics other than saying that joining a Medical Defence Organisation (MDO) is essential for any practicing doctor. MDOs know stuff that you will never know.

 

Choosing a Medical Defence Organisation

Choosing a MDO that suits your needs is one of the most important decisions you will make during your career. The decision should be considered carefully as not all insurance companies are the same. I recommend a Mutual Defence Organisation (MDO) that is not necessarily a part of a large commercial insurance company.  I have remained with the same company very successfully with all the ups and downs for over forty years.  A good Mutual Defence Organisation has the commitment to care about the doctor’s personal welfare as well as the other legal matters. The good ones have experienced and sympathetic medical advisors, and you will need their emotional support as well as expertise if things get sticky.

A public hospital has its own insurance to cover claims for financial compensation made by patients against it. Legally, the employer hospital is liable for its employees, so the cover extends to resident staff. But such staff may be the subject of other, personal, types of legal situations such as HCCC complaints and coronial inquiries and whatever help the hospital may provide is discretionary. You cannot assume that the hospital will provide representation for you personally. A colleague of mine had assistance denied only a short time before an inquest where his management was a focus of attention. An MDO will provide assistance in these other legal situations.

 

How do you manage if you hear that you are being involved in a legal matter?

 This is one of the most stressful things that can occur for a doctor so be prepared in advance. Step 1 is to find a good experienced mentor that suits your personal style as early as possible in your career and before bad stuff has happened. There are differences between a supervisor and a mentor. A supervisor is appointed by the hospital administration, whereas you can choose your own mentor. Accordingly, a mentor is a better fit for your personality and aspirations. Sensible mentors recognise that being asked to mentor a junior colleague is a compliment in the Hippocratic tradition, and don’t mind helping when approached. You don’t have to propose formally.

If you do hear that you are being involved or sued, contact your MDO immediately. You will need emotional support from understanding contacts like your mentor or peer colleagues. This support may come from your partner; however non-medical partners may not understand the paradigm completely. It is difficult when you “put yourself out there” doing what you hope is the very best for your patients, usually because have a great deal of internal self-drive, and then have the whole thing turn into a mess. Also, you may reasonably wish to quarantine work stuff and home stuff, especially if you have a young family.

Friends and colleagues that have been sued often say it is the reassurance and support of their colleagues who remind them that “you really are a good doctor” that is most helpful. In addition to your mentor and colleagues, consider professional support from your organisations Employee Assistance Program. Most of all, do not personalise it excessively nor let it affect your sense of self or enjoyment of your profession. Many people that have been through the difficult journey find that they emerge with a greater sense of destiny and fulfilment and greater skill and knowledge.  It takes some effort and luck to get to that point.

If you do have to attend court get specific orientation and support from your MDO. Be prepared – you may be permitted to carry your notes into the witness stand and read from them, for example. Know what type of proceedings that you are giving evidence -is it Criminal or civil? At all times, with or without a lawyer’s help, you must tell the truth about the facts and not be evasive (e.g. if you did tell a superior about something), even if the truth may not help others.

 

How is medical conduct adjudicated?

The Bawa-Garba case showed that doctor’s performance is judged “on the facts of that specific case”. That principle was a factor in why the Bawa-Garba case judgement appeared so unreasonably harsh. Despite the sadness of the whole affair, the court took the view based on the bare facts of the case that the management of the patient was well below reasonable professional standards. Mitigation for prolonged shift length/personal situation was not a consideration.

It means that if you are in a situation where you believe that workplace practices impair your ability to practice safely, consider raising a paper trail or at least initiate a discussion that objectively states your concerns with your supervisor. Situations could include excessive clinical workload or roster lengths, systematically poor communication, unavailable supervision, or being directed to provide care or undertake a procedure that is outside your level of expertise.

 

Workplace matters

Workplace matters are another area that MDOs can be very worthwhile. There is the potential for an enormous range of conflicts or difficulties. I was once threatened with substantial legal action for defamation by another clinician following a complaint I made to a teaching hospital about the medical care that was provided to one of my patients. It was a difficult time. I was able to deter the threatened defamation action with the assistance of my MDO. My painful teaching lesson was that “You can express an opinion and relate facts about what happened but don’t be malicious, and tell the truth”.

Your MDO can assist with workplace disputes such as bullying and harassment from staff or patients, or if you are accused of that. There are processes in place for this and many other workplace scenarios of which you may not be aware. An example could be if you feel the need to withdraw from providing medical care to a patient if they are harassing you. That needs a number of carefully calibrated steps including making satisfactory to the patient alternative arrangements for care.

Medical insurance does not substitute for a professional organisation such as ASMOF or the AMA and all doctors should belong to one of these.

 

Root cause analyses

NSW Health does have a process for misadventure called Root Cause Analysis (RCA), and most Public Health Organisations have similar processes. They are supposed to look at systems rather than individuals. They have legal privilege and confidential recommendations, although the information can leak out. RCAs can be a useful means of improving patient care. Even if it is difficult I advise honest engagement with this process. RCAs are humbling and stressful. If there is senior medical staff engagement and diligent exploration of the facts, clinically useful outcomes are possible.

 

Expert certificates and reports

There are some differences between an “Expert Certificate” and an “Expert Report”. An Expert Certificate is prepared for the court by doctors involved in a case, such as for the Coroner. Any grade of doctor can be approached. Senior doctors are much more likely to be approached to write expert reports, which may seek review of a case that they did not personally manage. In both areas, sticking carefully to the facts of the case is crucial, and not being tempted to step outside your area of expertise or to conjecture. A skilful barrister can make even the most caring doctor look pretty stupid in the witness stand. In both circumstances look at them as an objective means of assisting the court, and not representing or supporting any individual. Don’t run the risk of appearing biased (or excessively sympathetic to a colleague).

 

If you are asked to provide a mandated expert certificate I would advise that is done with the assistance of your MDO. Expert reports are generally a request rather than a directive. Although agreeing to write an expert report is “doing the right thing”, it exposes the doctor to what may not be a nice experience. You need to ask what it will involve for you e.g. being subpoenaed to court, maybe having to attend joint conferences with other experts. Enquire about fees and a timeline for “when you will be paid”. I personally accept those expert report requests with my eyes wide open, and agree to cooperate if the matter is of sufficient merit, the request is put reasonably and originates from a reputable source (such as a MDO).

 

Dealing with legal profession is stressful but it is also a crucial part of our professional responsibility. An important lesson from the Bawa-Garba case is that it is essential for any doctor of any grade to be a member of a good Medical Defence Organisation. Ask your senior colleagues about their experience. Choose your MDO carefully – you could be married to them for life.