DFTB/ADC Journal Club – The Rules

Cite this article as:
Andrew Tagg. DFTB/ADC Journal Club – The Rules, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16905

We all know that it can take up to 17 years for knowledge to go from benchside to bedside. One of the things we pride ourselves on at DFTB is our ability to cut down this knowledge translation window. We do this in the form of our monthly Bubble Wrap, critical appraisals of key literature and engagement with key thought leaders via Twitter.

Now we are going to try something new – a monthly twitter journal club as a collaboration with Archives of Disease in Childhood.

Want to come to DFTB19?

Cite this article as:
Team DFTB. Want to come to DFTB19?, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17079

After two years in Australia it is time for the Don’t Forget the Bubbles team to take a journey. Whilst it might be just an underground away for some it is a bit further for some of us. With over 70 pitches from speakers from around the world we have taken our time to curate an amazing program for you all.

You can now head over to www.dftb19.com and take a look!

We are also excited to announce some new workshops.

Join Mary Freer as she brings her Compassion Revolution to England, or sit in with Ross Fisher and Grace Leo and get better at presenting. Or, if they don’t take your fancy then why not join Ian Summers and friends and learn how to take your sim and debriefing to the next level.

Tickets for all of the workshops and the conference itself are now available at www.dftb19.com

If you can’t make it, don’t worry, we’ve got you covered. All the talks will be recorded and put out as podcasts after the event.

 

 

Bronchiolitis guidelines

Cite this article as:
Tessa Davis. Bronchiolitis guidelines, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17023

Up to 48% of infants admitted to Australian hospitals with bronchiolitis receive treatment that has no evidence of benefit. Bronchiolitis remains the most common reason for admission to hospitals in Australia and New Zealand for infants, and yet our practice in treating these patients remains variable.  The PREDICT network have conducted a systematic review to produce Australia’s first bronchiolitis guideline based on a robust systematic review. These guidelines broadly agree with the American Academy of Pediatrics and NICE guidelines.

 

O’Brien S, Wilson S, Gill FJ, Cotterell E, Borland ML, Oakley E, Dalziel SR, Paediatric Research in Emergency Departments
International Collaborative (PREDICT) network, Australasia. The management of children with bronchiolitis in the Australasian hospital setting: development of a clinical practice guideline. J Paediatric Child Health, 2018. doi:10.1111/jpc.14104

 

The authors have produced 22 recommendations based on their robust evidence review. Let’s take a look at their key recommendations.

 

What investigations should we do?

  • Routine blood and urine testing is not recommended.
  • Viral swabs are not recommended (although the authors mention that further study needs to be done to determine the benefit of cohorting in wards i.e. when all babies with the same virus are put in the same bay together to avoid spread).
  • The authors note that in infants under 2 months old with bronchiolitis there is an increased risk of a concurrent UTI.

Therefore in babies under 2 months old with pyrexia, likely bronchiolitis but some clinical uncertainty – send a urine for m, c, & s

 

What treatments are effective?

  • Salbutamol – there is no benefit in using salbutamol in infants with bronchiolitis (and some evidence of adverse effects)
  • Nebulised adrenaline – no benefit
  • Nebulised hypertonic saline – there is weak evidence of a reduction in length of stay of 0.45 days. However when two studies were removed, both of which used a different discharge criteria than most hospitals, there was no benefit. This is not recommended routinely, although the authors suggest that it should be used only as part of an RCT
  • Glucocorticoids – no benefit
  • Antibiotics – not recommended

The risk of a secondary bacterial infection is very low, and there is potential harm from giving antibiotics

  • Oxygen – no evidence of benefit in infants with no hypoxia, and low level evidence that maintaining the sats over 91% with oxygen actually prolongs the length of stay. There are no reports of long-term adverse neurodevelopmental outcomes in infants with bronchiolitis, however there is also no data on the safety of targeting sats <92%

Commence oxygen therapy to maintain sats over 91%

  • Sats monitoring – there is moderate evidence suggesting that continuous sats monitoring increases the length of stay in stable infants
  • High flow – there is low to very-low level evidence of benefit with high flow
  • Chest physiotherapy – not recommended
  • Saline drops – routine saline drops are not recommended but a trial with feeds may help
  • Feeds – both NG and IV are acceptable routes for hydration

 

This is the first robust Australasian acute paediatric guideline on bronchiolitis. It provides clear guidance for the management of patients seen in Australasian EDs and general paediatric wards with bronchiolitis and is in line with US and UK recommendations. Our current practice often deviates from this evidence-based, and hopefully these guidelines will start the shift towards unifying evidence-based practice in managing infants with bronchiolitis.

 

 

References

American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics 2006; 118: 1774–93.

Ricci V, Delgado Nunes V, Murphy MS, Cunningham S; on behalf of the Guideline Development Group and Technical Team. Bronchiolitis in children: Summary of NICE guidance. BMJ 2015; 350: h2305.

DFTB go to New York

Cite this article as:
Andrew Tagg. DFTB go to New York, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17016

I first heard of the FemInEM crew in Dublin. Dara Kass, Jenny Beck-Esmay and Stacey Poznanski took to the stage to talk about the birth of FemInEM, first as a blog then as a resource to effect change in the conversation around gender and equity in emergency medicine. Since then they have grown to be a leading voice in this area.

Their first sell out conference, FIX17, in New York brought together a unique set of voices and when the call came out for pitches to speak at FIX18 I thought it would be the perfect place for me to tell a story. This blog post isn’t about my tale – you can read A short story about deathand life here – but about something else.

I consider myself well-travelled, having spent almost 5 years of my life working as a doctor on board cruise ships, but hearing the talks at FIX18 made me realise I a still living in my own little bubble. Everything I hear via Twitter or other forms of social media comes pre-filtered by the source. So if I only follow white hetero-males they inform my worldview. The conference reminded me that there are other voices and other realities.

 

Sex and gender

In a conference where I was clearly in the minority, I was constantly reminded of things I have just taken for granted. Nick Gorton, a transman,  really opened my eyes when he told the audience that life had been like playing a video game on hard mode then, when he became a man, everything just switched over to easy. Look out for his great talk when it comes out…

 

Race

You only have to read the newspaper headlines on any given day to see how race plays a role in the public perception of a person. To hear Arabia Mollette say that she will never be seen as a woman first when she walks into a room because she is a person of colour made me feel uncomfortable. I’d like to think that I don’t see the world that way, but we all have our implicit biases. Don’t think you are biased? Then try out one of the Harvard Implicit Bias tests over at Project Implicit.

 

Privilege

A lot of medics come from a place of privilege, parents with degree level education and jobs that pay well. Many have parents that are, or were, doctors.  Regina Royan spoke of a different type of upbringing, of families struggling to make ends meet, and of the hidden challenges this brings from the start of medical training – not just in the shockingly high costs to apply to medical school in the US but also on things like electives and placements away from your home base.

 

I have lived, comfortably, within my own little bubble of existence. FemInEM has challenged me to expand my worldview, to listen to dissenting voices, and ask more questions.

 

For more accounts of FIX18 then read these accounts…

Penny Wilson – Getting my feminist FIX in New York

Shannon MacNamara – Telling stories to FIX things

Annie Slater – We support, We Amplify, We Promote

 

A short story about death…

Cite this article as:
Andrew Tagg. A short story about death…, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16636

This is the first of a two-part post based on my talk for FIX18 entitled A short story about death and life… We’ll publish the second part tomorrow.

 

“Someone will be along in a minute to explain what is going on”

Then a minute became two, three, five, until fifteen silent minutes had passed, each one seemingly longer than the last. Then footsteps…

It must have taken her an hour to cross the floor, or maybe just 30 seconds, I don’t know. I was no longer there.

I’m sorry, Mr. Tagg, I’ve got some bad news for you….Despite our best efforts, we were unable….

Her words disappeared and floated away with our dreams and I was lost.

That was how I had found out that my daughter had died. It was a tragic accident, the result of an unexpected antepartum haemorrhage and  an unsuccessful neonatal resuscitation. Something happened that day that fundamentally changed me, not just as a person, but as a doctor.

Flashbulb memories

Memory is imprecise – even in times of extreme emotion when it feels like every frame is burnt into your retina like the after image of photograph. These flashbulb memories have been heavily studied by psychologists and Malcolm Gladwell gives an easy to understand rundown in this episode of Revisionist History. What is most fascinating to me is that they are not always correct. So what does that mean of my recollection of the events that August?

The rarity of neonatal resuscitation

According to the Australian Bureau of Statistics a baby is born every 1 minute 42 seconds. That equates to around 8000 babies a day. Unfortunately, 7.2 per 1000 babies are stillborn and there are 2.4 neonatal deaths per 1000 live births. So in the whole of Australia, there are up to 19 neonatal deaths every single day.*

Most of us attend a delivery and never expect to resuscitate an infant. When we do a waft of oxygen is often all that is required. A Dutch study showed that around 2.6% of all births via elective caesarean required supplemental oxygen, around 1% require bag-valve-mask ventilation of some sort and only 0.1% require any more intensive resuscitation. The rates are much higher in lower/middle income countries.

Because they are such a rare event most doctors never expect to have to deal with a fatal outcome. Just as most emergency physicians obsess over the rarest of events, the surgical airway, perhaps those of us that may potentially be present at birth should be prepared to do what is necessary?

*A neonatal death is one that occurs within 28 days of birth

 

Absence does not make the heart grow fonder

A lot has already been written about the benefits and challenges of parental presence during the management of a critically ill child. To get you up to speed then read this post from Natalie May over on St Emlyns. The Resuscitation Council (UK) seems to think it is a good idea and most literature focuses on parental presence in either the ICU or ED setting and in an older cohort.

An exploratory interview study by Harvey and Pattison identified four key concerns surrounding the presence of the father during neonatal resuscitation in the delivery suite.

  • Whose job is it to support them?
  • What should they say or do?
  • The importance of teamwork
  • Impact on the healthcare practitioner

Think about the last time you did any neonatal life support training? No doubt you focussed on the core clinical skills – airway, breathing, circulation – with very little if no mention of dealing with the parents.

Medicine has moved on from beneficient paternalism to a more patient/parent-centred approach. It can be a hard decision to make – stay or go – but it doesn’t have to be the clinician’s choice.

Being present at a neonatal resuscitation can also be distressing for the staff involved and so one can understand how medical teams might want to shield parents from the hurt. There is concern that caregivers might interfere or get in the way with treatment. A skilled guide, such as a social worker or trained nurse, can help explain what is going on and translate the complex medical into plain English.

 

‘They’ll always remember how you made them feel”

In a time when infant death was a common occurrence, the prevailing thought was that grief could be avoided by preventing mothers from seeing their stillborn children. Psychologists would later theorize that an attachment bond had not been formed and so whisking the baby away without ceremony would cause no harm. By the 1970s this theory had been thrown out the window and grieving parents were offered the opportunity to see their children. Perhaps now the attachment bond is formed even earlier, through the use of antenatal screening, regular ultrasound scans and midwife visits making grief even more palpable.

 

The traditional (if flawed) Kubler-Ross model of grief

There will always be questions after an unexpected death – some can be answered and some can never be. But is important for parents to have the opportunity to ask. A qualitative study by Bakhbahki and colleagues in the South West of England identified a number of parental concerns centred around the framework of transparency, flexibility, inclusivity, and positivity.

We want to know that there is a perinatal mortality review process and how it works. As one of the interviewed stated, they wanted to know “this is how your child died and this is how we investigate it“. Parents wanted to know that this process was multidisciplinary involving not just neonatologists or paediatricians but also the obstetricians in order to identify any factors that may future tragic events.

We want our children to be treated like any child should be treated – with respect – regardless of whether they are alive or dead.

“The most distressing thing for me was knowing that she had been stripped of her blanket and photographed before I even had the chance to hold her.”

E.T. – a bereaved mother

There is a stigma attached to the death of a child. Society, whether it means to or not, sees the death of a child as a failure on the part of the mother. She must have done something wrong in pregnancy, she must have broken the rules. Then, these women are isolated from other newborns and their parents to the extent that they may even receive sub-optimal care.

An alternate view

It has been 8 years now and I have progressed far enough in my career to be the one bearing bad news. As an emergency physician who deals with a lot of sick and critically unwell adults, I have gone out of my way to seek formal training on breaking bad news. Specialties, such as obstetrics and paediatrics, are not exposed to death and dying on such a routine basis and very few have received formal training.

So what could be done better?

Whilst being an emotionally distant automaton may afford some protection for the clinician it is important that those breaking bad news are humans first, doctors second. I’ve written before about the power of kindness and this is one of those moments when we need to stop, look, listen and think. The death of a child, any child, is a devastating event and should be acknowledged as such.

 

With thanks to Tess (for letting me share our story) and my big-hearted cheer squad (Tessa, Ben, Henry, Tanya, Genevieve, Ian, and Ross)

Selected References

The rarity of neonatal resuscitation

*De Luca R, Boulvain M, Irion O, Berner M, Pfister RE. Incidence of early neonatal mortality and morbidity after late-preterm and term cesarean delivery. Pediatrics. 2009 Jun 1;123(6):e1064-71.

Kerber KJ, Mathai M, Lewis G, Flenady V, Erwich JJ, Segun T, Aliganyira P, Abdelmegeid A, Allanson E, Roos N, Rhoda N. Counting every stillbirth and neonatal death through mortality audit to improve quality of care for every pregnant woman and her baby. BMC pregnancy and childbirth. 2015 Dec;15(2):S9.

Knight M, Draper ES, Kurinczuk JJ. Key messages from the UK Perinatal Confidential Enquiry into term, singleton, intrapartum stillbirth and intrapartum-related neonatal death 2017.

Lawn JE, Lee AC, Kinney M, Sibley L, Carlo WA, Paul VK, Pattinson R, Darmstadt GL. Two million intrapartum‐related stillbirths and neonatal deaths: where, why, and what can be done?. International Journal of Gynecology & Obstetrics. 2009 Oct 1;107(Supplement):S5-19.

Lee AC, Cousens S, Wall SN, Niermeyer S, Darmstadt GL, Carlo WA, Keenan WJ, Bhutta ZA, Gill C, Lawn JE. Neonatal resuscitation and immediate newborn assessment and stimulation for the prevention of neonatal deaths: a systematic review, meta-analysis and Delphi estimation of mortality effect. BMC public health. 2011 Dec;11(3):S12.

Richmond S, Wyllie J. European resuscitation council guidelines for resuscitation 2010 section 7. Resuscitation of babies at birth. Resuscitation. 2010 Oct 1;81(10):1389-99.

Wilmink FA, Hukkelhoven CW, Lunshof S, Mol BW, van der Post JA, Papatsonis DN. Neonatal outcome following elective cesarean section beyond 37 weeks of gestation: a 7-year retrospective analysis of a national registry. American journal of obstetrics and gynecology. 2010 Mar 1;202(3):250-e1.

Wyllie J, Bruinenberg J, Roehr CC, Rüdiger M, Trevisanuto D, Urlesberger B. European Resuscitation Council Guidelines for Resuscitation 2015: Section 7. Resuscitation and support of transition of babies at birth. Resuscitation. 2015 Oct 1;95:249-63.

 

Absence does not make the heart grow fonder

Boie ET, Moore GP, Brummett C, Nelson DR. Do parents want to be present during invasive procedures performed on their children in the emergency department? A survey of 400 parents. Annals of emergency medicine. 1999 Jul 1;34(1):70-4.

Cacciatore J, Rådestad I, Frederik Frøen J. Effects of contact with stillborn babies on maternal anxiety and depression. Birth. 2008 Dec;35(4):313-20.

Fulbrook P, Latour JM, Albarran JW. Paediatric critical care nurses’ attitudes and experiences of parental presence during cardiopulmonary resuscitation: a European survey. International journal of nursing studies. 2007 Sep 1;44(7):1238-49.

Harvey ME, Pattison HM. The impact of a father’s presence during newborn resuscitation: a qualitative interview study with healthcare professionals. BMJ open. 2013 Jan 1;3(3):e002547.

Nederstigt I, Van Tol D. Parental presence during resuscitation. Resuscitation. 2008 May 1;77:S61.

Offord RJ. Should relatives of patients with cardiac arrest be invited to be present during cardiopulmonary resuscitation?. Intensive and Critical Care Nursing. 1998 Dec 1;14(6):288-93.

Sawyer A, Ayers S, Bertullies S, Thomas M, Weeks AD, Yoxall CW, Duley L. Providing immediate neonatal care and resuscitation at birth beside the mother: parents’ views, a qualitative study. BMJ open. 2015 Sep 1;5(9):e008495.

Tripon C, Defossez G, Ragot S, Ghazali A, Boureau-Voultoury A, Scépi M, Oriot D. Parental presence during cardiopulmonary resuscitation of children: the experience, opinions and moral positions of emergency teams in France. Archives of disease in childhood. 2014 Jan 6:archdischild-2013.

 

‘They’ll always remember how you made them feel”

Badenhorst W, Riches S, Turton P, Hughes P. The psychological effects of stillbirth and neonatal death on fathers: Systematic review. Journal of Psychosomatic Obstetrics & Gynecology. 2006 Jan 1;27(4):245-56.

Bakhbakhi D, Siassakos D, Burden C, Jones F, Yoward F, Redshaw M, Murphy S, Storey C. Learning from deaths: Parents’ Active Role and ENgagement in The review of their Stillbirth/perinatal death (the PARENTS 1 study). BMC pregnancy and childbirth. 2017 Dec;17(1):333.

Bonanno GA, Kaltman S. The varieties of grief experience. Clinical psychology review. 2001 Jul 1;21(5):705-34.

Boyle FM, Vance JC, Najman JM, Thearle MJ. The mental health impact of stillbirth, neonatal death or SIDS: prevalence and patterns of distress among mothers. Social science & medicine. 1996 Oct 1;43(8):1273-82.

Flenady V, Boyle F, Koopmans L, Wilson T, Stones W, Cacciatore J. Meeting the needs of parents after a stillbirth or neonatal death. BJOG: An International Journal of Obstetrics & Gynaecology. 2014 Sep;121:137-40.

Flenady V, King J, Charles A, Gardener G, Ellwood D, Day K, et al.PSANZ Clinical practice guideline for perinatal mortality. Perinatal Mortality Group https:// www.psanzpnmsig.org.au. Perinatal Society of Australia and New Zealand, April 2009; Vol. Version 2.2.

Koopmans L, Wilson T, Cacciatore J, Flenady V. Support for mothers, fathers and families after perinatal death. Cochrane database of systematic reviews. 2013(6).

Mills TA, Ricklesford C, Cooke A, Heazell AE, Whitworth M, Lavender T. Parents’ experiences and expectations of care in pregnancy after stillbirth or neonatal death: a metasynthesis. BJOG: An International Journal of Obstetrics & Gynaecology. 2014 Jul 1;121(8):943-50.

Nuzum D, Meaney S, O’donoghue K. The impact of stillbirth on consultant obstetrician gynaecologists: a qualitative study. BJOG: An International Journal of Obstetrics & Gynaecology. 2014 Jul 1;121(8):1020-8.

 

Moderator guide for #DFTB_JC

Cite this article as:
Tessa Davis. Moderator guide for #DFTB_JC, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16966

The #DFTB_JC is a collaboration between Archives of Disease and Childhood and DFTB to encourage online discussion and critical appraisal of recent research.

We have put this guide together to answer any questions you might have on what you should be doing and how to run the JC.

 

1. Choose an ADC paper for your month – week before the month starts.

The paper will be made open access on the first of the month, so you need to choose it the week before (i.e. for March you need to tell us your paper choice in the last week of Feb so we can release the paper on 1st March). You can choose any ADC paper that you think is worthy of a one hour twitter discussion. Email tessardavis@me.com with you choice of paper.

 

2. Choose a date for your journal club –  by the 1st of the month

This should be in the third week of the month (roughly).

The journal club should run at 8pm UTC (this is to include as many time zones as possible)

 

3. Think of key people to invite

If the authors of your paper are on twitter then it would be great to invite them along to the chat. Similarly if you know any key people who are interested in the topic of the paper then invite them too.

 

4. Do a critical appraisal of your paper – by the journal club date

This is really for yourself as it will help you run the discussion on twitter i.e. so you have already done the analysis

The BestBets checklists are a great way to structure this.

 

5. Think of your four questions – by the journal club date (but would be nice to share them earlier)

There should be four questions (Q1, Q2, Q3, and Q4) which will form the main structure to your journal club. These questions will depend on what you found in your critical appraisal. Once we have run the first JC we will add the questions used there as an example.

 

6. Run the twitter chat – well, this is the date of the journal club

The key focus of each JC will be a one hour twitter chat which you will moderate from the @dftbubbles account at 8pm UTC on your chosen date. Tweets should use the hashtag #DFTB_JC.

Use your four questions as a structure for the hour to generate discussion around a critical appraisal of the paper. Your aim is to facilitate and encourage others to join in and share their views.

Make sure you start and end on time. Nobody likes a JC that runs late.

 

7. Write a summary for DFTB – last week of the month

In the week following your JC you should write a summary of the chat and the paper for DFTB. This is also where your original critical appraisal will come in handy and you can likely use it as a framework for the post and add in other twitter comments and discussion where relevant.

 

Thanks for being part of the DFTB team – we really appreciate it

Bubble Wrap Plus – Oct 2018

Cite this article as:
Anke Raaijmakers. Bubble Wrap Plus – Oct 2018, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16997

Can’t get enough of Bubble Wrap? The Bubble Wrap Plus is a mid-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.

Are there too few women presenting at paediatric conferences?

Cite this article as:
Davis, T. et al. Are there too few women presenting at paediatric conferences?, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16879

Sometimes we have a great idea for a paper but try as we might we cannot get it published in the traditional way. So what better means of disseminating knowledge than publishing it right here, on the Don’t Forget the Bubbles website? Given that this is the week of FIX18, the Feminem Idea eXchange, it seems like there is no better time like the present to discuss female presenters at paediatric conferences.

The burden of trauma

Cite this article as:
Andrew Tagg. The burden of trauma, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16924

In our effort to live just a little longer we are trying to spot sepsis sooner, choose exactly the right antibiotics, give the right amount of fluids – not too little and not too much – but there is something else we can do. We can do out best to try and get our children to wash their hands, cover their noses when they sneeze, but what about that other cause of childhood morbidity and mortality? What about trauma?