ADC/DFTB Journal Club #1 – November – when is a child not septic?

Cite this article as:
Tessa Davis. ADC/DFTB Journal Club #1 – November – when is a child not septic?, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17297

Sepsis is a word we hear many many times a day. As clinicians treating children, it is one of our main concerns. Amongst all the unwell children we see, how do we work out who is septic and who is not?

This month, for our inaugural #DFTB_JC, we discussed this paper by Snelson and Ramlakhan and we were lucky enough to be joined by the authors themselves.

Snelson E, Ramlakhan S. Which observed behaviours may reassure physicians that a child is not septic? An international Delphi study, Archives of Disease in Childhood, 2018, 103:864-967.

We all have experience of using a sepsis guideline or a sepsis decision aid:


There were a few examples of individual centres and their sepsis tool:


However, most people mainly use a combination of clinical judgement, physiological observation, and gestalt – essentially a combination of factors that nobody could quite put their finger on.

 

The evidence shows that none of these guides are very sensitive or specific. This means that we tend to over-treat for fear (not unreasonably) of missing sepsis. The authors highlight that all these guidelines rely on quantifiable measures (pyrexia, tachycardia, tachypnoea) or subjective negative features (withdrawn, flat). In real life, we frequently use features of wellness to reassure us that a child does not have sepsis. In this study, the authors tried to identify reassuring features of wellness, that help clinicians decide to exclude sepsis.

 

Who was included in the study?

The inclusion criteria were ‘clinicians who routinely assessed undifferentiated children in their practice and had done so from the majority of their career”.

The authors approached professional societies of paediatricians, emergency physicians, and general practitioners with an interest in paediatrics. They also asked these respondents to recommend other respondents.

This was a two round questionnaire. They had 195 respondents in the first round, and 104 in the second round (the same group was asked each time).

The group consisted of 188 physicians, two nurse practitioners, two paramedics, and one physician associate.

50% were from North America, 36.6% from the UK, and the others were from a range of other countries.

The group felt that this was a reasonable way to recruit participants but discussed reasons for there being many more US respondents than UK ones.


What was studied?

The author used a modified Delphi technique.

The Delphi method is a structured communication technique which uses a panel of experts being asked questions in one or more round. After each round, the experts receive a summary of the results from the previous round, along with reasoning. The idea is for them to consider revising their view in light of the previous answers from the expert panel. The Delphi method is usually carried out face-to-face, but a modified Delphi can be carried out via email or online communication.

In the first round, participants were asked ‘What activities or behaviours do you feel are reassuring and significantly reduce the likelihood that a febrile child has possible sepsis?”

There were 856 responses – duplicates and illogical responses were removed, and similar responses were grouped together in themes. The authors were able to narrow the results down to 14 statements describing observed behaviour.

These 14 statements were circulated to participants for round two. They were asked to grade the degree of reassurance each statement offered on a 4-point Likert scale.

A Likert scale is where respondents mark their agreement/disagreement with a statement on a scale. The scale is usually symmetrical and balanced.

 

What were the results?

The most reassuring behaviour was ‘actively energetic’ – 99% of respondents found this very or moderately reassuring. The least reassuring behaviour was ‘showing fear of the examining clinician’ – 45% of respondents felt this was not at all reassuring.

Using an electronic device and being consolable were both only seen as slightly reassuring. All the others were moderately reassuring, with being energetic, smiling or laughing, and chatting/babbling/being talkative were seen as very reassuring.

There was no mention of the famous ‘positive Quaver test’*

We had lots of discussion on twitter about whether or not a child playing on an iPhone in the waiting room was a reassuring sign.


And then we had a stark reminder from a parent of how easy it can be to miss sepsis:

 

What were the authors’ conclusions?

We have worked very hard over the last few years in paediatrics to use and develop tools to help us rule in sepsis. But in spite of the vast bodies of work, we have failed to standardise sepsis tools and really only have guidelines with poor sensitivity and specificity. Consequently we over-diagnose and over-treat this group of patients.

Much of our daily practice encompasses looking for reassuring signs in these patients, and utilising those signs to rule out sepsis. This is the first paper to identify a consensus on which features reduce the probability of sepsis. The next step is to validate the negative predictive value of each of these behaviours.

 

 

*other brands of crisps do exist

The 24th Bubble Wrap

Cite this article as:
Leo, G. The 24th Bubble Wrap, Don't Forget the Bubbles, 2018. Available at:
https://dontforgetthebubbles.com/24th-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 UK and Ireland) to point out something that has caught their eye.

Tell me your story: Michelle Johnston at DFTB18

Cite this article as:
Team DFTB. Tell me your story: Michelle Johnston at DFTB18, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17125

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.

Stabbings in adolescents

Cite this article as:
Tessa Davis. Stabbings in adolescents, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17337

It’s a regular day in your Paeds ED. You’ve just pulled a piece of lego out of a child left nostril; there are two wheezy kids waiting for review to see if they can stretch to two hours; and there is a 2 month old with a rash that you’re currently seeing  – everyone is waiting for you to come up with a clever diagnosis. As you stare at the spots and wait for some inspiration, you hear one of your nursing colleagues call…

Don’t Forget The Lego

Cite this article as:
Team DFTB. Don’t Forget The Lego, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17375

It might have escaped your notice but the team at DFTB recently had a paper published by the Journal of Paediatrics and Child Health that has garnered a lot of interest.

Tagg, A. , Roland, D. , Leo, G. S.Y., Knight, K. , Goldstein, H. , Davis, T. , DFTB, (2018), Everything is awesome: Don’t forget the Lego. J Paediatr Child Health. doi:10.1111/jpc.14309

We are sure you have questions. Lots of questions. So we thought we should answer them for you in the best way we know how.

What pressing scientific question did you ask?

We know that coins are the most commonly swallowed foreign object in the paediatric population and there is a lot of data surrounding transit time. The second most commonly swallowed objects are small toys but there is very little data out there. We wanted to know how long it would take for a small piece of plastic toy, in this case a Lego head, to pass through.

How on earth did you come up with the idea?

In one of our regular editorial meetings we were discussing some of our upcoming publications and musing how we could do something a little lighter, akin to the great Peppa Pig paper in last years Christmas BMJ. And then Andy Tagg said, “I’ve got this idea but you might think it a bit strange.” Within a short space of time we had an international team of researchers literally chomping at the bit to undertake the study.

Did you really swallow those poor heads?

Of course we did! Do you want proof?

Then what happened?

We waited to see what would happen. We all know corn kernels can whip through the colon in seemingly no time at all, but what about a little yellow piece of plastic? There was really only one way to find out.

And you searched through your own poo to find them? How?

As with any piece of research it is important to have a robust search strategy in place prior to commencement. A variety of techniques were tried – using a bag and squashing, tongue depressors and gloves, chopsticks – no turd was left unturned. And although we only used a very small sample size the fact that one of our heads went missing suggest that you really shouldn’t worry if you can’t find it.

What happened to the missing head?

Who knows? Perhaps one day many years from now, a gastroenterologist performing a colonoscopy will find it staring back at him.

But what about Ben Lawton? Where was he when all this was going on?

Don’t Forget the Bubbles was founded by four curious doctors – Tessa Davis, Andy Tagg, Henry Goldstein and Ben Lawton. Unfortunately Ben was travelling at the time we undertook the study and we didn’t think searching through his colonic contents in an aeroplane toilet was exactly fair.

And then you kept it quiet, right?

It can take an average of 17 years for science to go from benchside to bedside. Leveraging social media we managed to go from online publication on a Thursday evening to global saturation by Saturday evening.

By Saturday morning Damian Roland was speaking on Canadian radio and the DFTB group made Forbes, ars technica, and the BBC World Service by the afternoon.

But surely this isn’t hard science?

Of course it’s not, it’s a bit of fun in the run up to Xmas.

With such a small sample size it is important that you don’t extrapolate the data to the entire population of Lego swallowers. Anecdata from Twitter suggests that a large number of people accidentally ingested bits of Lego throughout their life with no adverse effects*.

It is also worth noting that most people who swallow Lego are children, not fully grown adults. Data that is applicable to the adult population may well not be applicable to children.

For a more scientific approach to ingested foreign bodies in children then take a look at these two papers.

Yeh HY, Chao HC, Chen SY, Chen CC, Lai MW. Analysis of Radiopaque Gastrointestinal Foreign Bodies Expelled by Spontaneous Passage in Children: A 15-Year Single-Center Study. Frontiers in pediatrics. 2018;6:172.

Macgregor D, Ferguson J. Foreign body ingestion in children: an audit of transit time. Emergency Medicine Journal. 1998 Nov 1;15(6):371-3.

You may also enjoy exploring the following posts about foreign bodies on DFTB:

Andy’s blog post on Foreign Body Ingestion

Chantal McGrath’s DFTB17 talk Batteries Not Included on button battery ingestion

A case study by Loren on ‘the magic coin’ 

What’s next for the group?

Whilst this may be the pinnacle of our publishing careers we hope we have not peaked too early. Next up is finalizing all the details for our upcoming conference in London – www.dftb19.com, and then? Who knows?

*Please do not try this at home.

DFTB in the papers

Ars Technica

Forbes

BBC World Service

CBC Radio Canada – As it happens

10 Daily

Herald Sun

Vaccine hesitancy: Margie Danchin at DFTB18

Cite this article as:
Team DFTB. Vaccine hesitancy: Margie Danchin at DFTB18, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17112

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.

Bubble Wrap PLUS – Nov 2018

Cite this article as:
Anke Raaijmakers. Bubble Wrap PLUS – Nov 2018, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17272

For those that can’t get enough of Bubble Wrap – enjoy this month’s Bubble Wrap Plus – a monthly paediatric journal club list provided by Anke Raaijmakers working with the creator of the list, Professor Jaan Toelen & his team of the University Hospitals in Leuven (Belgium). This comprehensive list of ‘articles to read’ comes from 34 journals, including Pediatrics, The Journal of Pediatrics, Archives of Disease in Childhood, JAMA pediatrics, Journal of Paediatrics and Child Health, NEJM, and many more. 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 month’s list features answers to intriguing questions such as: ‘How can we clinically suspect endocarditis?’, ‘Are there cardiovascular comorbidities in IVF babies?’, ‘Is maternal education good or bad for vaccination rates?’.

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

1.Reviews and opinion articles

The Clinical COACH: How to Enable Your Learners to Own Their Learning.

Bannister SL, et al.  Pediatrics. 2018 Oct 16.

Tics and Tourette syndrome.

Efron D, et al.  J Paediatr Child Health. 2018 Oct;54(10):1148-1153.

Aetiology of childhood apraxia of speech: A clinical practice update for paediatricians.

Morgan AT, et al.  J Paediatr Child Health. 2018 Oct;54(10):1090-1095.

Investigating the child with intellectual disability.

Amor DJ. J Paediatr Child Health. 2018 Oct;54(10):1154-1158.

Attention deficit hyperactivity disorder: Some challenging clinical scenarios.

Efron D. J Paediatr Child Health. 2018 Oct;54(10):1065-1067.

Children who soil: A review of the assessment and management of faecal incontinence.

Trajanovska M, et al.  J Paediatr Child Health. 2018 Oct;54(10):1136-1141.

Child with multiple problems: Clinical complexity and uncertainty.

McDowell M. J Paediatr Child Health. 2018 Oct;54(10):1084-1089.

Motor impairments in children: More than just the clumsy child.

Spittle AJ, et al.  J Paediatr Child Health. 2018 Oct;54(10):1131-1135.

Anxiety-related disorders: An overview.

Riordan DM, et al.  J Paediatr Child Health. 2018 Oct;54(10):1104-1109.

Sleep in children with neurodevelopmental difficulties.

Heussler HS, et al.  J Paediatr Child Health. 2018 Oct;54(10):1142-1147.

The aggressive child.

Scott JG, et al.  J Paediatr Child Health. 2018 Oct;54(10):1165-1169.

Hypertensive crisis in children and adolescents.

Seeman T, et al.  Pediatr Nephrol. 2018 Oct 1.

2. Original clinical studies

Clinical Characteristics of Infective Endocarditis in Children.

Kelchtermans J, et al.  Pediatr Infect Dis J. 2018 Oct 19.

Respiratory syncytial virus hospitalization and incurred morbidities the season after prophylaxis.

Butt ML, et al.  Paediatr Child Health. 2018 Nov;23(7):441-446.

Frequency of medication error in pediatric anesthesia: A systematic review and meta-analytic estimate.

Feinstein MM, et al.  Paediatr Anaesth. 2018 Oct 30.

Central nervous system-active drug abused and overdose in children: a worldwide exploratory study using the WHO pharmacovigilance database.

Carnovale C, et al.  Eur J Pediatr. 2018 Oct 29.

Long-term mortality and functional outcome after prolonged paediatric intensive care unit stay.

Matsumoto N, et al.  Eur J Pediatr. 2018 Oct 27.

Early Antibiotics and Childhood Obesity: Do Future Risks Matter to Parents and Physicians?

Lipstein EA, et al.  Clin Pediatr (Phila). 2018 Oct 26:9922818809534.

Ultrasound Guidance for Pediatric Central Venous Catheterization: A Meta-analysis.

de Souza TH, et al.  Pediatrics. 2018 Oct 25. pii: e20181719.

Assessment of neonatal heart rate immediately after birth using digital stethoscope, handheld ultrasound and electrocardiography: an observational cohort study.

Treston BP, et al.  Arch Dis Child Fetal Neonatal Ed. 2018 Oct 24.

Cost-effectiveness analysis of pulse oximetry screening for critical congenital heart defects following homebirth and early discharge.

Narayen IC, et al.  Eur J Pediatr. 2018 Oct 17.

Income Disparities and Cardiovascular Risk Factors Among Adolescents.

Jackson SL, et al.  Pediatrics. 2018 Oct 17.

International, multicentre, observational study of fluid bolus therapy in neonates.

Keir AK, et al.  J Paediatr Child Health. 2018 Oct 16.

Risk Factors for Delayed Antimicrobial Treatment in Febrile Children with Urinary Tract Infections.

Hum SW, et al.  J Pediatr. 2018 Oct 16.

Maternal Education Is Inversely Related to Vaccination Delay among Infants and Toddlers.

Hazan G, et al.  J Pediatr. 2018 Oct 16.

Iron as a model nutrient for understanding the nutritional origins of neuropsychiatric disease.

Barks A, et al.  Pediatr Res. 2018 Oct 16.

Weaning of Moderately Preterm Infants from the Incubator to the Crib: A Randomized Clinical Trial.

Shankaran S, et al.  J Pediatr. 2018 Oct 15.

Persistent Postconcussion Symptoms After Injury.

Ewing-Cobbs L, et al.  Pediatrics. 2018 Oct 15.

Lessons learned from a hospital-wide review of blood stream infections for paediatric central line-associated blood stream infection prevention.

Campbell AJ, et al.  J Paediatr Child Health. 2018 Oct 13.

Diagnostic Accuracy, Prescription Behavior, and Watchful Waiting Efficacy for Pediatric Acute Otitis Media.

Brinker DL Jr, et al.  Clin Pediatr (Phila). 2018 Oct 12:9922818806312.

Closure of the anterior and posterior fontanelle in the New Zealand population: A computed tomography study.

Kirkpatrick J, et al.  J Paediatr Child Health. 2018 Oct 12.

Food Protein-Induced Enterocolitis Syndrome: Data from a Multicenter Retrospective Study in Spain.

Díaz JJ, et al.  J Pediatr Gastroenterol Nutr. 2018 Oct 12.

Algorithm to Predict Which Children With Chronic Abdominal Pain Are Low Suspicion for Significant Endoscopic Findings.

Mark JA, et al.  Clin Pediatr (Phila). 2018 Oct 11:9922818806317.

Risk of Serious Infections Associated with Biologic Agents in Juvenile Idiopathic Arthritis: A Systematic Review and Meta-Analyses.

Aeschlimann FA, et al.  J Pediatr. 2018 Oct 11.

Timing of puberty in boys and girls: A population-based study.

Brix N, et al.  Paediatr Perinat Epidemiol. 2018 Oct 11.

Shortened IV Antibiotic Course for Uncomplicated, Late-Onset Group B Streptococcal Bacteremia.

Coon ER, et al.  Pediatrics. 2018 Oct 11.

Association Between Third-Trimester Tdap Immunization and Neonatal Pertussis Antibody Concentration.

Healy CM, et al.  JAMA. 2018 Oct 9;320(14):1464-1470

Prediction of school outcome after preterm birth: a cohort study.

Odd D, et al.  Arch Dis Child. 2018 Oct 8.

Effectiveness of a Hand Hygiene Program at Child Care Centers: A Cluster Randomized Trial.

Azor-Martinez E, et al.  Pediatrics. 2018 Oct 8.

Acetaminophen and Febrile Seizure Recurrences During the Same Fever Episode.

Murata S, et al.  Pediatrics. 2018 Oct 8.

Predicting Maintenance of Any Breastfeeding from Exclusive Breastfeeding Duration: A Replication Study.

Dozier AM, et al.  J Pediatr. 2018 Oct 5.

Diagnostic yield of head CT in pediatric emergency department patients with acute psychosis or hallucinations.

Cunqueiro A, et al.  Pediatr Radiol. 2018 Oct 5.

Antecedents of Obesity Among Children Born Extremely Preterm.

Wood CT, et al.  Pediatrics. 2018 Oct 5.

Risk of Developmental Disorders in Children of Immigrant Mothers: A Population-Based Data Linkage Evaluation.

Abdullahi I, et al.  J Pediatr. 2018 Oct 4.

Parental Factors in Pediatric Functional Abdominal Pain Disorders: A Cross-Sectional Cohort Study.

Zeevenhooven J, et al.  J Pediatr Gastroenterol Nutr. 2018 Oct 4.

Acceleration of BMI in Early Childhood and Risk of Sustained Obesity.

Geserick M, et al.  N Engl J Med. 2018 Oct 4;379(14):1303-1312.

Long-Term Cardiovascular Morbidity in Children Born Following Fertility Treatment.

Shiloh SR, et al.  J Pediatr. 2018 Oct 2.

Prevalence and characteristics of positional plagiocephaly in healthy full-term infants at 8-12 weeks of life.

Ballardini E, et al.  Eur J Pediatr. 2018 Oct;177(10):1547-1554.

Experiences, expectations, and fears of adolescents with epilepsy or bronchial asthma.

Fisch SM, et al.  Eur J Pediatr. 2018 Oct;177(10):1451-1457.

Ultrasound-guided peripheral intravenous access placement for children in the emergency department.

Otani T, et al.  Eur J Pediatr. 2018 Oct;177(10):1443-1449.

Lung Ultrasound for the Differential Diagnosis of Respiratory Distress in Neonates.

Corsini I, et al.  Neonatology. 2018 Oct 10;115(1):77-84.

4. Case reports

A Preterm Infant with Abdominal Distension and Bloody Stools.

ElHassan NO, et al.  J Pediatr. 2018 Oct 12.

Recurrent Vulvar Ulcers and “Cradle Cap” in a 2-Year-Old.

Teran VA, et al.  J Pediatr. 2018 Oct 12.

Unilateral Withdrawal of Life-sustaining Therapy in a Severely Impaired Child.

Miller KE, et al.  Pediatrics. 2018 Oct 12.

A 17-Year-Old Girl With Weight Loss and Elevated Inflammatory Markers.

Toner K, et al.   Pediatrics. 2018 Oct 4. pii: e20172959.

 

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

Neonatal jaundice – the basics

Cite this article as:
Shalome Kanagaratnam. Neonatal jaundice – the basics, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17047

Most newborns are jaundiced. Indeed, 60% of term infants, 80% of premies and 33% of breastfed babies are jaundiced in early life. Fortunately, the majority of these self-resolve and have no sinister underlying cause. But how do we identify those who require urgent management? How can we effectively and confidently reassure anxious patients whilst ensuring we don’t miss a significant diagnosis?

The Value of Storytelling: Mariam Issa at DFTB18

Cite this article as:
Team DFTB. The Value of Storytelling: Mariam Issa at DFTB18, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17104

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.

How to draw a Genogram

Cite this article as:
Daniel Bakhsh. How to draw a Genogram, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17132

As a Student Doctor at the University of Queensland, I was offered the opportunity to shadow the Adolescent Team at The Child and Youth Mental Health Service (or CYMHS) at the Queensland Children’s Hospital. This was an amazing opportunity to observe some really important work in two of my special interest areas: Paediatrics and Psychiatry. The attachment really drove home that patients don’t exist in isolation, and how this is particularly true for children. The surrounding family system strongly dictates how well they will fare once they leave the hospital.

As part of this attachment I was asked to prepare and present Genograms for every patient at the weekly Multidisciplinary Team meeting. As I began to interview family members in order to gather the required 3 generations of family history, it became clear to me that a small diagram could represent and quickly convey what would otherwise have taken several pages of text. Genograms provide a wealth of insight at a glance, can help align patients with their most appropriate care, and are relatively easy to draw once you know how. They are a mainstay of Paediatrics for a reason.

When I first came across Genograms as a student, attempting to create one was very confusing and a little overwhelming. There are also surprisingly few reference materials available to aid you along the way. So in order to make this task a little easier for the next student, I put together this little video. I hope you find it useful.

– Daniel Bakhsh, Student Doctor, Doctor of Medicine Program, University of Queensland

Growing up with Down Syndrome: Robyn Brady and Tara Coughlan

Cite this article as:
Team DFTB. Growing up with Down Syndrome: Robyn Brady and Tara Coughlan, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17062

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.

Stabbings in kids – when and where?

Cite this article as:
Tessa Davis. Stabbings in kids – when and where?, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17240

You cannot have missed the UK media stories about the increase in stabbings in young people; and the data from hospitals in London supports this. This week saw the publication of an article in BMJ Open sharing data from stabbing presentations to a major trauma centre in London.