The 40th Bubble Wrap

Cite this article as:
DFTB, T. The 40th Bubble Wrap, Don't Forget the Bubbles, 2020. Available at:
https://dontforgetthebubbles.com/the-40th-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.

Bubble Wrap Plus – May 2020

Cite this article as:
Anke Raaijmakers. Bubble Wrap Plus – May 2020, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.25719

Here is a new Bubble Wrap Plus, our monthly paediatric Journal Club List provided by 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. For a summary on COVID-19, we refer to our collection of COVID resources and in particular, our weekly updated literature summary.

This month’s list features answers to intriguing questions such as: ‘What are atypical presentations of Covid-19 in children?’, ‘Can cycled phototherapy substantially reduce total treatment time?’, ‘Is saline nasal irrigation useful for acute upper respiratory tract infections?’, ‘What is the clinical value of Factor XIII in HSP?’ and ‘ Is iron supplementation useful for breath holding spells?’.

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

 

1.Reviews and opinion articles

Anorexia Nervosa.

Mitchell JE, et al. N Engl J Med. 2020 Apr 2;382(14):1343-1351.

Reflexes that impact spontaneous breathing of preterm infants at birth: a narrative review.

Kuypers K, et al. Arch Dis Child Fetal Neonatal Ed. 2020 Apr 29.

Nickel Allergic Contact Dermatitis: Identification, Treatment, and Prevention.

Silverberg NB, et al. Pediatrics. 2020 Apr 27.

Prevention of iron-deficiency anemia in infants and toddlers.

Sundararajan S, et al. Pediatr Res. 2020 Apr 24.

Peanut Allergy: New Advances and Ongoing Controversies.

Abrams EM, et al. Pediatrics. 2020 Apr 17.

The medical evaluation of prepubertal children with suspected sexual abuse.

Smith T, et al. Paediatr Child Health. 2020 Apr;25(3):180-194.

Bronchopulmonary dysplasia: A review of the pulmonary sequelae in the post-surfactant era.

Haggie S, et al. J Paediatr Child Health. 2020 Apr 8.

Possible causes for decreased susceptibility of children to coronavirus.

Zhu L, et al. Pediatr Res. 2020 Apr 8.

Tuberculosis treatment in children: The changing landscape.

Huynh J, et al. Paediatr Respir Rev. 2020 Feb 26.

State-of-the-Art Renal Imaging in Children.

Viteri B, et al. Pediatrics. 2020 Feb;145(2).

Vesicoureteral reflux is it important to find?

Hewitt I, et al. Pediatr Nephrol. 2020 Apr 22.

2. Original clinical studies

Atypical presentation of COVID-19 in young infants.

Nathan N, et al. Lancet. 2020 Apr 27.

Vulnerable Youth and the COVID-19 Pandemic.

Silliman Cohen RI, et al. Pediatrics. 2020 Apr 28.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in Children and Adolescents: A Systematic Review.

Castagnoli R, et al. JAMA Pediatr. 2020 Apr 22.

Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young.

Oxley TJ, et al. N Engl J Med. 2020 Apr 28

Lung biopsy in children: when is it useful?

Chan CD, et al. Arch Dis Child. 2020 Apr 29.

Migraine in children under 6 years of age: A long-term follow-up study.

Marchese F, et al. Eur J Paediatr Neurol. 2020 Apr 17.

Prevalence of Continuous Pulse Oximetry Monitoring in Hospitalized Children With Bronchiolitis Not Requiring Supplemental Oxygen.

Bonafide CP, et al. JAMA. 2020 Apr 21;323(15):1467-1477.

Is Carbon Dioxide Insufflation During Endoscopy in Children as Safe and as Effective as we Think?

Dike CR, et al. J Pediatr Gastroenterol Nutr. 2020 Apr 14.

Antibiotic prophylaxis for prevention of urinary tract infections in the first year of life in children with vesicoureteral reflux diagnosed in the workup of antenatal hydronephrosis: a systematic review.

Leigh J, et al. Pediatr Nephrol. 2020 Apr 30.

Application of PECARN rules would significantly decrease CT rates in a Dutch cohort of children with minor traumatic head injuries.

Niele N, et al. Eur J Pediatr. 2020 Apr 28.

Hospitalizations and Deaths Associated with EVALI.

Werner AK, et al. N Engl J Med. 2020 Apr 23;382(17):1589-1598.

E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI) Without Respiratory Symptoms.

Matta P, et al. Pediatrics. 2020 Apr 21.

E-cigarette Product Characteristics and Subsequent Frequency of Cigarette Smoking.

Barrington-Trimis JL, et al. Pediatrics. 2020 Apr 6. pii: e20191652.

Cardiopulmonary resuscitation in pediatric pectus excavatum patients – where is the heart?

Jang YE, et al. Paediatr Anaesth. 2020 Apr 16.

Cycled Phototherapy Dose-Finding Study for Extremely Low-Birth-Weight Infants: A Randomized Clinical Trial.

Arnold C, et al. JAMA Pediatr. 2020 Apr 27.

Delayed menarche in girls with chronic kidney disease and the association with short stature.

Kim HS, et al. Pediatr Nephrol. 2020 Apr 27.

Oral Paracetamol vs Oral Ibuprofen in Patent Ductus Arteriosus: A Randomized, Controlled, Noninferiority Trial.

Kumar A, et al. J Pediatr. 2020 Apr 23.

Effect of blue LED phototherapy centered at 478 nm versus 459 nm in hyperbilirubinemic neonates: a randomized study.

Ebbesen F, et al. Pediatr Res. 2020 Apr 26.

Blue LED phototherapy in preterm infants: effects on an oxidative marker of DNA damage.

van der Schoor LWE, et al. Arch Dis Child Fetal Neonatal Ed. 2020 Apr 8.

Reduced Antibiotic Exposure by Serial Physical Examinations in Term Neonates at Risk of Early-onset Sepsis.

Vatne A, et al. Pediatr Infect Dis J. 2020 May;39(5):438-443.

BMI changes through childhood: the impact on puberty, linear growth and hormonal regulation.

Tryggestad JB, et al. Pediatr Res. 2020 Apr 16.

Factor XIII as a potential predictor of severe gastrointestinal involvement in Henoch Schoenlein purpura: A case study research.

d’Angelo DM, et al. J Paediatr Child Health. 2020 Apr 15.

Trimethoprim-Sulfamethoxazole Associated Drug-Induced Liver Injury in Pediatrics: A Systematic Review.

Burgos RM, et al. Pediatr Infect Dis J. 2020 Apr 8.

Iron Supplementation for the Treatment of Breath-Holding Spells: A Systematic Review and Meta-Analysis.

Hecht EM, et al. Clin Pediatr (Phila). 2020 Apr 13:9922820915893.

Respiratory pathogens and acute chest syndrome in children with sickle cell disease.

Ploton MC, et al. Arch Dis Child. 2020 Apr 8.

High flow nasal cannula as respiratory support in treating infant bronchiolitis: a systematic review.

Moreel L, et al. Eur J Pediatr. 2020 May;179(5):711-718

4. Case Reports

Teenager With Abdominal Pain and Decreased Appetite.

Clore J, et al. Pediatrics. 2020 Apr 29.

A Case of a Mediastinal Mass in a Teenager Causing Chest Pain, Difficulty Breathing, and Emesis: A Rare Complication of a Relatively Common Disease.

Chang TF, et al. Clin Pediatr (Phila). 2020 Apr 26:9922820915888.

A 6-week-old male infant with persistent leukocytosis.

Matthews R, et al. Paediatr Child Health. 2020 Apr;25(3):131-133.

Thyroid Storm in a Toddler Presenting as a Febrile Seizure.

Ladd JM, et al. Pediatrics. 2020 Feb;145(2).

Self-Limiting Sternal Tumor of Childhood: A “Do Not Touch” Lesion.

Moreira BL, et al. J Pediatr. 2020 Apr 17.

 

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

The 39th Bubble Wrap

Cite this article as:
Leo, G. The 39th Bubble Wrap, Don't Forget the Bubbles, 2020. Available at:
https://dontforgetthebubbles.com/the-39th-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 the UK and Ireland) to point out something that has caught their eye.

Genomic Testing 101

Cite this article as:
Sarah Josephi-Taylor. Genomic Testing 101, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.25467

A question from the paediatric intensivist reaches me via the registrar. ‘Does this normal array result exclude 22q11.2 deletion?’ “Yes!” I say emphatically, delighted to finally have a definitive answer to a genetic question. Genetic investigations are so full of caveats and uncertainty, and very rarely able to exclude anything, that I relish standing on a small island of certainty.

That our esteemed colleagues are wrapping their heads around chromosome microarray results a decade after arrays became mainstream makes a lesson on genomic testing all the more pressing. Why? Because, despite being in the midst of a devastating global pandemic caused by a maleficent 29,844 base pairs of RNA, the genomic revolution has arrived and our patients stand to benefit.

 

Who Can Order Genomic Sequencing?

For the Australians in the audience, a Medicare item for genomic sequencing has been released on 1st May 2020. Whole exome sequencing, known as WES (think Wes Anderson), and whole-genome sequencing (WGS), are now government funded for children 10 and under with:

  • non-familial facial features and a major congenital anomaly OR
  • moderate global developmental delay
  • AND a non-informative chromosome microarray result.

Genomic sequencing can now be ordered by a paediatrician in conjunction with a clinical geneticist. What this ‘in conjunction’ will look like will vary depending on service, but the goal is to usher in a safe adoption of this powerful diagnostic technology.

Not to stoke inter-hemispheric rivalry, but the Australian approach lags behind the UK, who for years have had a co-ordinated and mainstreamed approach to genomic testing, first through the Deciphering Developmental Disorders study and now the 100,000 genomes project. The NHS has implemented an excellent genomics education program for clinicians and patients alike.

 

The Burden of Genetic Disorders

Whilst individually rare, the combined incidence of rare diseases is common, estimated to affect approximately 8% of the Australian and UK populations, with the vast majority being genetic in origin. These numbers are similar to the proportion of people living with diabetes or asthma. Children with rare diseases have disproportionate representation in the emergency department, NICU, PICU, general and developmental paediatrics clinics, often with the input of many paediatric subspecialists. In years past, many of these individuals were thoroughly reviewed by clinical geneticists, occasionally received a diagnosis, often after many years, but the majority remained undiagnosed, occasionally adopting the moniker of a syndrome without a name (SWAN).

 

Enter the genomic revolution

Our genome, the instructions that make us who we are, is in almost every cell in our body (enucleated red blood cells are a notable exception). These instructions, coded via 3 billion base pairs of DNA, are tightly packaged into chromosomes. Typically, a person has 46 chromosomes, 1 to 22 (longest to shortest, in theory, but not quite) and the sex chromosomes, XX or XY. Genes, the individual recipes for proteins and enzymes, are spaced out irregularly along the chromosomes, akin to legible sentences in a sea of lorum ipsum.

Adapted from University of Washington

 

Remarkably, the approximately 20,000 genes that humans have make up only 2% of the whole genome. WES sequences only the 2% slice of the apple, whereas WGS sequences the whole darned apple. Sequencing the whole apple achieves better coverage of the 2%, detects structural rearrangements, and has a 5 to 10% higher diagnostic yield than WES. Irrespective of what is sequenced, the bulk of the analysis remains focused on the 2%. Whilst tempting to order WGS as a first-line test, in Australia at least, there are very limited places that have access to WGS through public laboratories.

Only 1 out of 4 of all human genes are currently known to be associated with health conditions. The remaining 3 out of 4 genes may have pathophysiological associations yet to be discovered, or be the genetic equivalent of a gastrointestinal appendix. Genes can be disrupted in many ways, making them inactive, overactive, or just a general nuisance by interfering with normal functioning proteins. These disruptions can happen at different levels.

At the level of the chromosome, whole genes can be deleted or duplicated. Systematically arranged photographs of chromosomes taken under a microscope were revolutionary when they arrived over 50 years ago. Known as karyotypes, this was the first test able to detect imbalances in chromosomal material. Generally, these imbalances contained dozens, if not hundreds, of genes.  Current day equivalents, chromosome microarrays, offer much of what a karyotype does, but at a far higher resolution (think several orders of magnitude), often being able to detect single gene deletions or duplications. Chromosome microarrays have approximately a 10 to 15% diagnostic yield as a first pass test for multiple congenital anomalies or developmental delay and should always be the first test ordered for these presentations. Fragile X testing should also always be ordered for children of either sex presenting with developmental delay, as it remains the most common inherited form of intellectual disability.

What microarrays do not do, is get down to the level of reading every single letter of every single gene, looking for a spelling mistake. That is what genomic sequencing does. Diagnostic yield of WES varies from paper to paper, but is somewhere between 35 and 60%, depending on a multitude of factors, slightly higher for WGS.

 

Whole exome sequencing, half exome sequencing? Genomes? What do I tell my patients?

Beyond one vial of blood in an EDTA tube, and lots of waiting, what’s involved? Consent. Consent. Consent. And then some. Educational videos on genomic consent can be found here and here. A large focus of consent is on managing patient expectations about potential outcomes, raising the possibility of identifying non-familial relationships (think non-paternity), incidental genetic findings, and an exploration of implications for life and income protection insurance. A thorough consent means that a proportion of families will elect not to go ahead with testing.

 

Ok. So, you either find the diagnosis, or you don’t, right? Not entirely.

Due to natural variation, on average, each of us has 3 million base pairs that vary from the reference genome. Which of these 3 million variants is the culprit? Bioinformatics filtering removes the bulk of variants, but at the end of the residual list of variants is a very human curation effort, with scientists and genetic pathologist intently scrutinising, often for hours, variants for their pathogenicity.

Parents frequently view a genetic diagnosis as precise and unequivocal and can be perplexed by vague and uncertain interpretations of results. Imagine, for example, if all our genes were cake recipes. Our task is to compare them to a giant Martha Stewart reference compendium. WES is able to identify each time a recipe varies from the Martha Stewart original but does not have the capability to bake that cake, to see what the effect of the new recipe is. Some changes are obvious. If the new recipe stops at ‘preheat the oven’, substitutes sugar with salt, or asks for vibranium, clearly there is no cake to be had. But what about subtle changes? Can sugar be substituted by honey? Can you double the chocolate (umm…yes!)? The latter constitute a group of variants known as variants of uncertain significance (VUS) and need to be considered with caution.

Genomic testing can be either singleton or trio.  Singleton sequences only the child’s DNA. Trio sequencing achieves a higher diagnostic yield by analyzing the child’s and parental DNA together. This ability to segregate variants in real-time substantially reduces the number of red herrings or the risk of throwing the proverbial baby out with the bioinformatic bathwater.

So the potential outcomes are:

  • A molecular diagnosis is made, and the family has an answer
  • No significant variants are identified. This does not exclude it being genetic in origin. A variant may be outside current technical or bioinformatic capabilities to detect, or in a gene whose function is yet to be discovered. Reanalysis of previously captured genomic data can be requested through most laboratories, with a recommended interval of 2 years minimum.
  • A variant of uncertain significance (VUS).
  • Importantly, although rare, approximately 1% to 2% of the time, an incidental finding is identified. It is difficult to explain to a family that the cause of their child’s intractable epilepsy has not been identified, but that the child and mother carry a change in the BRCA1 gene, putting them at increased risk of breast cancer. The disclosure of incidental findings is ethically fraught, with some laboratories offering an ‘opt-out’ service.

 

Is it worth it?

Information is a vital tool for empowering patients and the value of a molecular diagnosis is hard to quantify. An early genetic diagnosis demonstrably reduces the burden of costly and often invasive investigations a child typically undergoes during their diagnostic odyssey. Some tertiary institutes may be able to offer ultra-rapid genomic testing, with turnaround times of days, for children in acute care settings, such as the NICU or PICU. Direct changes in management are rare, but when they do occur, can be transformative: such as novel therapies for achondroplasia or life-prolonging antisense oligonucleotides for spinal muscular atrophy (admittedly two genetic conditions which are diagnosed on clinical grounds, not genomic testing). Even without a disease-specific change in management, families perceive significantly reduced barriers to coordinated care and funding once a diagnosis is made. Disease-specific patient organizations, often hosted on social media platforms, can be a vital source of support and information for families already at risk of significant social isolation.

For couples considering further children, the phenomenon of reproductive stoppage, whereby couples elect to have no further children to avoid possible recurrence, is very real. Being able to provide an accurate estimate of the likelihood of recurrence, as well as family planning options, restores reproductive confidence.

However, a diagnosis is no panacea. With the majority of families pursuing testing in a desire to anticipate a child’s future potential complications and life expectancy, thanks to an increasing number of ultra-rare conditions, this effort at prognostication often fall short. One parent eloquently describes it as finally receiving the last piece of the puzzle, yet the picture on the puzzle remains blank. If your child is the 7th in the world with a condition, there is little that can be gleaned with certainty from the other n=6. Even for well-characterized conditions, there is an increasing awareness of phenotypic expansion, as children at the milder end of the spectrum are diagnosed through genetic tests rather than the prototypic collection of features previously required to secure a diagnosis. Yet thanks to this space of uncertainty, there is room for genuine hope, with the very real possibility that a child proves the textbooks wrong and exceeds all expectations.

For those that remain undiagnosed, there are more tests on the horizon. In the meantime, be bold, be brave, and know that there is a more powerful test to offer your patients and that clinical geneticists have your back. And that patient who didn’t have 22q11.2 deletion? His WES is in progress.

 

Further resources

https://www.genomicseducation.hee.nhs.uk/

https://learn-genomics.org.au

Genomic Testing Consent Resources for Medical Specialists: https://www.genetics.edu.au/health-professionals/genomic-videos

RACP: Clinical genomics for physicians: https://elearning.racp.edu.au/login/index.php

Explaining a VUS: https://vimeo.com/336811697

Chromosome microarray analysis: A soothing guide https://onlinelibrary.wiley.com/doi/full/10.1111/jpc.13869 

Genetic disorders UK: https://www.geneticdisordersuk.org/

Why obtaining a diagnosis is important: https://swanaus.org.au/information/diagnosis/diagnosis/#1468139158856-daf34e3b-8b25

The Voice of Rare Disease Patients in Europe: https://www.eurordis.org/

A recent publication about limitations of WES: https://pubmed.ncbi.nlm.nih.gov/32190976/

Neonatal ventilation basics

Cite this article as:
Jasmine Antoine. Neonatal ventilation basics, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.19875

A term infant is admitted to the intensive care nursery with severe respiratory distress. They are currently on CPAP 8cm H2O and FiO2 0.50  with no signs of improvement. You begin preparing for intubation. The nurse looking after the baby is setting up the ventilator. “What ventilator setting would you like, doctor”?

 

Before listing off some ventilator settings, there are several decisions that we need to make. What type of ventilation should we be using for this baby? What settings will we start them on? What do we need to do post ventilation? This post will begin to answer some of these questions, but as always, it is advisable to be guided by your unit policies and senior staff members.

 

Ventilation modes

This post will discuss the basics of conventional ventilation. High-frequency oscillatory ventilation (HFOV) is also commonly used in the nursery, particularly for extremely preterm infants or those with persistent pulmonary hypertension. Stay tuned for an upcoming post on HFOV.

Synchronized intermittent mandatory ventilation (SIMV)

This type of ventilation administers a set amount of mechanical breaths that are synchronized with the patient’s own inspiration. When the infant breaths above the set ventilator respiratory rate, these additional breaths do not receive a ventilator breath. This mode can be useful when weaning ventilation.

Synchronized intermittent positive pressure ventilation (SIPPV) or patient triggered ventilation (PTV) or Assist Control (AC)

This form of ventilation confusingly has many different names. It supports every breath the infant makes. The set ventilator respiratory rate is the backup number of breaths that will be mechanically administered if the infant makes no spontaneous breaths. Each mechanical breath is synchronized with the patient’s own inspiration.

Pressure support ventilation (PSV)

Similar to SIPPV in that every breath is supported with mechanical ventilation. However, the inspiratory time is limited depending on the infant’s own inflation. The infant sets their own mechanical breath rate and inspiratory time.

Volume controlled (VC) or volume guarantee

This mode of ventilation can be used with SIMV or SIPPV. The ventilator aims to deliver tidal volumes (VT) set by the clinician. A maximum peak inspiratory pressure (PIP) is set, the ventilator’s PIP will vary to reach the target volume.

 

So, which is better for our infant?

There have been no large prospective trials that have determined if SIMV or SIPPV is the superior format of ventilation. The choice of ventilation will largely depend on unit preference. Studies have illustrated that volume-controlled ventilation reduces the duration of ventilation, risk of pneumothorax, grade 3/4 intraventricular haemorrhage, and chronic neonatal lung disease.

 

So what’s on your ventilator screen?

Peak end expiratory pressure (PEEP):

The maximum pressure that provides continuous distension of the lungs. Usually between 6-8cmH20

Peak inspiratory pressure (PIP):

Maximum pressure used during inspiration. Consider the tidal volumes achieved to determine a suitable PIP. VT are usually around 4-5ml/kg.

Respiratory rate (RR):

Set number of mechanical breaths administered in a minute. Usually between 40-60. In SIMV the set RR is both the maximum and minimum rate while in SIPPV the RR is the minimum but not the maximum rate.

Inspiratory time (Ti):

Set time for inspiration during a breath. Usually between 0.3-0.5s

Patient Circuit Flow Rate or Rise Time or Rise Slope:

Depending on the manufacturer or the unit policy, one of these options will be available. If only the patient circuit flow rate is available then this is set 6 – 10 L/min. If rise time or slope is available then this is set to 30 – 50% of the Ti.

Pmax:

In the volume-controlled mode this is the maximum peak inspiratory pressure you wish the ventilator to administer to reach target tidal volumes. Usually set 5 cmH2O higher than the average PIP used to achieve the set tidal volume.

FiO2:

The amount of supplementary oxygen. Target saturations will depend on the gestational age and the underlying condition affecting the infant. Your unit’s policy on SpO2 targets should guide the FiO2 setting.

Many other ventilators exist

 

What are the ventilator measurements we should be aware of?

Minute volume (MV):

Amount of gaseous exchange in one minute. MV= VT x RR

Tidal volume (VT):

The amount of gas in an expiration. Usually around 4-5ml/kg.

Leak:

Traditionally in neonates, uncuffed tubes are used for intubation due to concerns regarding subglottic stenosis and pressure necrosis. As a result, most infants will have a percentage of leak. It will change during an infant’s respiratory cycle, it is usually greater in inspiration.

 

What do we need to do next?

After attaching our infant to the ventilator, clinical checks should once again be undertaken to ensure adequate ventilation. Review the infant, is there misting of ETT, equal air entry by auscultation, symmetrical chest rise, stable observations and adequate tidal volumes being achieved.

A post-intubation chest x-ray should be taken as early as possible to check the placement of the endotracheal tube. The ideal placement is between T1-3,  just above the carina.

An arterial gas should be undertaken post-intubation to check adequate ventilation, within an hour. The timing of the next gas will depend on the results, clinical condition and how old the patient is. Your boss will be able to give you some guidance.

 

Take-home messages

  • Avoiding mechanical ventilation using early continuous positive airway pressure (CPAP) with, or without, surfactant administration is the most effective way to reduce the risk of lung injury.
  • Using volume-controlled ventilation reduces the risk of chronic neonatal lung disease.
  • If you’re not sure where to start or how to alter ventilation, ask for your boss’ help.

 

Resources

Keszler M. State of the art in conventional mechanical ventilation. Journal of Perinatology. 2009 Apr;29(4):262.

Mechanical ventilation of the premature neonate. Respir Care. 2011 Sep;56(9):1298-311; discussion 1311-3. doi: 10.4187/respcare.01429

Bumper Bubble Wrap PLUS – March/April 2020

Cite this article as:
Anke Raaijmakers. Bumper Bubble Wrap PLUS – March/April 2020, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.25289

Here is a Bumper Bubble Wrap Plus, our paediatric Journal Club List provided by Professor Jaan Toelen & his team of the University Hospitals in Leuven (Belgium). Including some Paediatric COVID articles, but for a summary on COVID-19, we refer to our collection of COVID resources and in particular, our weekly updated literature summary. Our comprehensive Bubble Wrap Plus 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.

This Bumper List features answers to intriguing questions such as: ‘Do children with ADHD have a slower growth?’, ‘Which respiratory viruses can be found in children with FUO?’, ‘ Do parents prefer shorter waiting times and do they want to avoid painful procedures in the A&E department? (now it is EBM!)’, ‘What is pentoxifyllin and why would neonatologists start to use it?’  and ‘Is pyelonephritis possible in children who display neither pyuria nor bacteriuria?’.

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

  1. COVID-19

Vertical Transmission of Coronavirus Disease 19 (COVID-19) from Infected Pregnant Mothers to Neonates: A Review. Karimi-Zarchi M, et al. Fet Ped Path. 2020 Apr 2:1-5 (39 cases, no transmission)

Clinical characteristics of novel coronavirus disease 2019 (COVID-19) in newborns, infants and children. Hong H, et al. Pediatr Neonatol. 2020 Mar 10. (9 newborn cases > no/mild disease)

Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records.

Chen H, et al. Lancet. 2020 Mar 7;395(10226):809-815.  (9 cases > no vertical transmission)

Neonatal Early-Onset Infection With SARS-CoV-2 in 33 Neonates Born to Mothers With COVID-19 in Wuhan, China. Zeng L, et al. JAMA Pediatr. 2020 Mar 26. (33 neonates > 3 symptomatic, mild disease)

Proposal for prevention and control of the 2019 novel coronavirus disease in newborn infants.

Li F, et al. Arch Dis Child Fetal Neonatal Ed. 2020 Mar 4 (letter to the editor > very short guideline)

Novel 2019 coronavirus SARS-CoV-2 (COVID-19): An updated overview for emergency clinicians

Giwa AL, et al. Emerg Med Pract. 2020 May 1;22(5):1-28

COVID-19 in Children: Initial Characterization of the Pediatric Disease.

Pediatrics. 2020 Mar 16.

COVID-19 epidemic: disease characteristics in children.

Jiatong S, et al. J Med Virol. 2020 Mar 31.

COVID-19 infection in children.

Sinha IP, et al. Lancet Respir Med. 2020 Mar 27.

Why is COVID-19 so mild in children?

Brodin P. Acta Paediatr. 2020 Mar 25

Review article: gastrointestinal features in COVID-19 and the possibility of faecal transmission.

Tian Y, et al. Aliment Pharmacol Ther. 2020 Mar 29.

Clinical and epidemiological features of 36 children with coronavirus disease 2019 (COVID-19) in Zhejiang, China: an observational cohort study. Qiu H, et al. Lancet Infect Dis. 2020 Mar 25

Systematic review of COVID-19 in children shows milder cases and a better prognosis than adults.

Ludvigsson JF. Acta Paediatr. 2020 Mar 23

Chest computed tomography in children with COVID-19 respiratory infection.

Li W, et al. Pediatr Radiol. 2020 Mar 11.

High-Resolution Computed Tomography Manifestations of 5 Pediatric Patients With 2019 Novel Coronavirus. Liu M, et al. J Comput Assist Tomogr. 2020 Mar 25.

Epidemiological Characteristics of 2143 Pediatric Patients With 2019 Coronavirus Disease in China.

Dong Y, et al. Pediatrics. 2020 Mar 16

Mitigate the effects of home confinement on children during the COVID-19 outbreak.

Wang G, et al. Lancet. 2020 Mar 21;395(10228):945-947.

What Does the Coronavirus Disease 2019 (COVID-19) Mean for Families?

Thompson LA, et al. JAMA Pediatr. 2020 Mar 13.

Parenting in a time of COVID-19.

Cluver L, et al. Lancet. 2020 Mar 25

2.Reviews and opinion articles

The Effects of Nicotine on Development.

McGrath-Morrow SA, et al.  Pediatrics. 2020 Feb 11.

Is sharing really caring? Viewpoints on shared decision-making in paediatrics.

Jordan Z, et al.  J Paediatr Child Health. 2020 Feb 11.

Beta-lactam allergy in the paediatric population.

Wong T, et al.  Paediatr Child Health. 2020 Feb;25(1):62-63.

Dietary intake of sodium by children: Why it matters.

Gowrishankar M, et al.  Paediatr Child Health. 2020 Feb;25(1):47-61.

Update on acute flaccid myelitis: recognition, reporting, aetiology and outcomes.

Hardy D, et al.  Arch Dis Child. 2020 Feb 10

Sex effects in pyelonephritis.

Albracht CD, et al.  Pediatr Nephrol. 2020 Feb 10.

Computer-Assisted Psychiatric Diagnosis.

Kobak K, et al.  J Am Acad Child Adolesc Psychiatry. 2020 Feb;59(2):213-215.

Assessment for Learning: How to Assess Your Learners’ Performance in the Clinical Environment.

Hanson JL, et al.  Pediatrics. 2020 Feb 6.

Children With Minor Blunt Head Trauma Presenting to the Emergency Department.

Nigrovic LE, et al.  Pediatrics. 2019 Dec;144(6).

Fertility Preservation for Pediatric and Adolescent Patients With Cancer: Medical and Ethical Considerations.

Klipstein S, et al.  Pediatrics. 2020 Feb 18.

Abusive Head Trauma in Infants and Children.

Narang SK, et al. Pediatrics. 2020 Apr;145(4). pii: e20200203.

Obesity Treatment Among Adolescents: A Review of Current Evidence and Future Directions.

Cardel MI, et al. JAMA Pediatr. 2020 Mar 23.

Neonatal sepsis: need for consensus definition, collaboration and core outcomes.

Molloy EJ, et al. Pediatr Res. 2020 Mar 19.

Radiographic timelines for pediatric healing fractures: a systematic review.

Messer DL, et al. Pediatr Radiol. 2020 Mar 10.

Necrotizing Enterocolitis: The Future.

Neu J. Neonatology. 2020 Mar 10:1-5.

Functional abdominal pain: what clinicians need to know.

Andrews ET, et al. Arch Dis Child. 2020 Mar 9.

Primary immunodeficiencies and their associated risk of malignancies in children: an overview.

Renzi S, et al. Eur J Pediatr. 2020 Mar 11.

2. Original clinical studies

What matters when managing childhood fever in the emergency department? A discrete-choice experiment comparing the preferences of parents and healthcare professionals in the UK.

Leigh S, et al.  Arch Dis Child. 2020 Feb 27

Epidemiology and Etiology of Severe Childhood Encephalitis in The Netherlands.

de Blauw D, et al.  Pediatr Infect Dis J. 2020 Feb 21.

Associations of Assisted Reproductive Technology and Twin Pregnancy With Risk of Congenital Heart Defects.

Wen SW, et al.  JAMA Pediatr. 2020 Feb 24.

Assessment of the Urinary Microbiome in Children Younger Than 48 Months.

Kinneman L, et al.  Pediatr Infect Dis J. 2020 Feb 20.

Detection of Respiratory Viruses in the Clinical Outcome of Children With Fever and Neutropenia.

Cerdeira Barreiro N, et al.  Pediatr Infect Dis J. 2020 Feb 20.

A pilot study exploring interventions for physician distress in pediatric subspecialists.

Kase SM, et al.  Pediatr Res. 2020 Feb 12.

Efficacy, Safety, and Acceptability of Pharmacologic Treatments for Pediatric Migraine Prophylaxis: A Systematic Review and Network Meta-analysis.

Locher C, et al.  JAMA Pediatr. 2020 Feb 10.

Parental Concerns on Short Stature: A 15-Year Follow-Up.

Murano MC, et al.  J Pediatr. 2020 Feb 6.

Factors Associated With Choice of Infant Sleep Location.

Kellams A, et al.  Pediatrics. 2020 Feb 7.

Impact of outpatient appointments on school attendance.

Chingono J, et al.  Arch Dis Child. 2020 Feb 7.

Low Apgar score in term newborns and long-term infectious morbidity: a population-based cohort study with up to 18 years of follow-up.

Gutbir Y, et al.  Eur J Pediatr. 2020 Feb 3.

Lower versus Traditional Treatment Threshold for Neonatal Hypoglycemia.

van Kempen AAMW, et al.  N Engl J Med. 2020 Feb 6;382(6):534-544.

Microbiome of the first stool after birth and infantile colic.

Korpela K, et al.  Pediatr Res. 2020 Feb 13.

Six-Year Follow-up of a Trial of Antenatal Vitamin D for Asthma Reduction.

Litonjua AA, et al.  N Engl J Med. 2020 Feb 6;382(6):525-533.

Association Between Neurological Disorders and Death by Suicide in Denmark.

Erlangsen A, et al.  JAMA. 2020 Feb 4;323(5):444-454.

Improving Influenza Vaccination in Hospitalized Children With Asthma.

Foradori DM, et al.  Pediatrics. 2020 Feb 27.

Recurrent Kawasaki disease and cardiac complications: nationwide surveys in Japan.

Sudo D, et al.  Arch Dis Child. 2020 Feb 27.

Risk factors of parenteral nutrition-associated cholestasis in very-low-birthweight infants.

Wang N, et al.  J Paediatr Child Health. 2020 Feb 26.

Variable persistence of serum testosterone in infants and children exposed to topical testosterone.

Sanderson E, et al.  J Paediatr Child Health. 2020 Feb 26

Solitary Rectal Ulcer Syndrome in Children: A Report of 140 cases.

Poddar U, et al.  J Pediatr Gastroenterol Nutr. 2020 Feb 24.

Maternal Alcohol-Use Disorder and Child Outcomes.

O’Leary C, et al.  Pediatrics. 2020 Feb 24.

Maternal Drinking and Child Emotional and Behavior Problems.

Lund IO, et al.  Pediatrics. 2020 Feb 24.

Gestational Age, Perinatal Characteristics, and Autism Spectrum Disorder: A Birth Cohort Study.

Brumbaugh JE, et al.  J Pediatr. 2020 Feb 21.

Language functions deserve more attention in follow-up of children born very preterm.

Stipdonk LW, et al.  Eur J Paediatr Neurol. 2020 Feb 14.

Rumination Syndrome in Children Presenting With Refractory Gastroesophageal Reflux Symptoms.

Nikaki K, et al.  J Pediatr Gastroenterol Nutr. 2020 Mar;70(3):330-335.

Analysis of Multiple Factors Involved in Pertussis-Like Coughing.

Cao J, et al.  Clin Pediatr (Phila). 2020 Feb 19:9922820905871.

Sleep and Adiposity in Children From 2 to 6 Years of Age.

Xiu L, et al.  Pediatrics. 2020 Feb 18.

Stillbirth in Greece during the years of economic crisis: a population-based study.

Siahanidou T, et al.  Eur J Pediatr. 2020 Feb 15.

Body Mass Index Trajectories in Early Life Is Predictive of Cardiometabolic Risk.

Yuan Y, et al.  J Pediatr. 2020 Feb 12.

Hepatitis C Testing Among Perinatally Exposed Infants.

Lopata SM, et al.  Pediatrics. 2020 Feb 14.

Is Mother’s Own Milk Lactoferrin Intake Associated with Reduced Neonatal Sepsis, Necrotizing Enterocolitis, and Death?

Ochoa TJ, et al.  Neonatology. 2020 Feb 13:1-8.

Child-related and parental predictors for thelarche in a general population of girls: the PANIC study.

Savinainen SE, et al.  Pediatr Res. 2020 Feb 12.

Acute Kidney Injury During Treatment with Intravenous Acyclovir for Suspected or Confirmed Neonatal Herpes Simplex Virus Infection.

Downes KJ, et al.  J Pediatr. 2020 Feb 6.

Randomized Controlled Trial of Bovine Lactoferrin for Prevention of Sepsis and Neurodevelopment Impairment in Infants Weighing Less Than 2000 Grams.

Ochoa TJ, et al.  J Pediatr. 2020 Feb 6.

The Cerebrospinal Fluid Interleukin-6/Interleukin-10 Ratio Differentiates Pediatric Tick-borne Infections.

Ygberg S, et al.  Pediatr Infect Dis J. 2020 Mar;39(3):239-243

Vitamin B12, Folate, and Cognition in 6- to 9-Year-Olds: A Randomized Controlled Trial.

Kvestad I, et al.  Pediatrics. 2020 Feb 4.

Early Hyperbilirubinemia in Neonates with Down Syndrome.

Bahr TM, et al.  J Pediatr. 2020 Jan 31.

Assessment of C-Reactive Protein Diagnostic Test Accuracy for Late-Onset Infection in Newborn Infants: A Systematic Review and Meta-analysis.

Brown JVE, et al.  JAMA Pediatr. 2020 Feb 3.

Children With Attention-Deficit/Hyperactivity Disorder Are at Increased Risk for Slowed Growth and Short Stature in Early Childhood.

Davallow Ghajar L, et al.  Clin Pediatr (Phila). 2020 Feb 1:9922820902437.

Dose-escalation trial of budesonide in surfactant for prevention of bronchopulmonary dysplasia in extremely low gestational age high-risk newborns (SASSIE).

McEvoy CT, et al.  Pediatr Res. 2020 Feb 1.

Maturation of Esophageal Motility and Esophagogastric Junction in Preterm Infants.

Rayyan M, et al. Neonatology. 2020 Mar 24:1-9.

Trends in incidence and outcomes of necrotizing enterocolitis over the last 12 years: A multicenter cohort analysis. Han SM, et al. J Pediatr Surg. 2020 Feb 29.

Intravenous pentoxifylline is well tolerated in critically ill preterm infants with sepsis or necrotizing enterocolitis. Schüller SS, et al. Eur J Pediatr. 2020 Mar 16

“How can a drug to treat claudication in adults save preterm newborns?”

Kurul S, et al. Eur J Pediatr. 2020 Mar 16

Low risk of necrotising enterocolitis in enterally fed neonates with critical heart disease: an observational study. Nordenström K, et al. Arch Dis Child Fetal Neonatal Ed. 2020 Mar 13.

Culture-proven Bloodstream Infections at a Specialist Pediatric Hospital.

Al Yazidi LS, et al. Pediatr Infect Dis J. 2020 Mar 20

Efficacy of Melatonin in Children With Postconcussive Symptoms: A Randomized Clinical Trial.

Barlow KM, et al. Pediatrics. 2020 Apr;145(4).

Melatonin is useful alternative for sedation in children undergoing auditory brainstem responses testing. Hajjij A, et al. Eur J Pediatr. 2020 Mar 16

Born with a solitary kidney: at risk of hypertension.

La Scola C, et al. Pediatr Nephrol. 2020 Mar 24.

Dietary Fats and Atherosclerosis From Childhood to Adulthood.

Laitinen TT, et al. Pediatrics. 2020 Apr;145(4).

Non-HDL Cholesterol Levels in Childhood and Carotid Intima-Media Thickness in Adulthood.

Juonala M, et al. Pediatrics. 2020 Apr;145(4).

Paediatric empyema: worsening disease severity and challenges identifying patients at increased risk of repeat intervention. Haggie S, et al. Arch Dis Child. 2020 Mar 24

Clinical Implementation of a Parent Questionnaire to Identify Seizures in High-Risk Children.

Greenlaw C, et al. J Child Neurol. 2020 Mar 24:883073820911505.

Manifestation of migraine in adolescents: Does it change in puberty?

Böttcher B, et al. Eur J Paediatr Neurol. 2020 Feb 20

Challenging the view that lack of fibre causes childhood constipation.

Tappin D, et al. Arch Dis Child. 2020 Mar 10.

Excessive screen time is associated with maternal rejection behaviours in pre-school children.

Erat Nergiz M, et al. J Paediatr Child Health. 2020 Mar 20.

Clinical Characteristics of Pediatric Pyelonephritis Without Pyuria or Bacteriuria.

Yokoyama T, et al. Pediatr Infect Dis J. 2020 Mar 13.

Short-course antibiotics for chemotherapy-induced febrile neutropaenia: retrospective cohort study.

Seneviratne N, et al.. Arch Dis Child. 2020 Mar 17.

Antibiotic Use and Outcomes in Children in the Emergency Department With Suspected Pneumonia.

Lipshaw MJ, et al. Pediatrics. 2020 Apr;145(4).

Antibiotic Prescribing for Viral Respiratory Infections in the Pediatric Emergency Department and Urgent Care. Desai NM, et al. Pediatr Infect Dis J. 2020 Mar 5.

Association Between Proton Pump Inhibitor Use and Risk of Fracture in Children.

Wang YH, et al. JAMA Pediatr. 2020 Mar 16.

Acute Cerebellitis or Postinfectious Cerebellar Ataxia? Clinical and Imaging Features in Acute Cerebellitis. Yildirim M, et al. J Child Neurol. 2020 Mar 12:883073820901407

Unique Features of Hospitalized Children with Alveolar Pneumonia Suggest Frequent Viral-Bacterial Coinfections. Gavrieli H, et al. Pediatr Infect Dis J. 2020 Mar 5.

Reducing unnecessary neonatal testing in infants of mothers with thyroid disease.

Churcher LM, et al. J Paediatr Child Health. 2020 Mar 16

Longitudinal neurodevelopmental outcomes in preterm twins.

Christensen R, et al. Pediatr Res. 2020 Mar 14.

Maternal Autoimmune Disorders and Risk of Kawasaki Disease in Offspring.

Belkaibech S, et al. J Pediatr. 2020 Mar 11

Acute kidney injury in critically ill children and 5-year hypertension.

Hessey E, et al. Pediatr Nephrol. 2020 Mar 11.

The Infantile Hemangioma Referral Score: A Validated Tool for Physicians.

Léauté-Labrèze C, et al. Pediatrics. 2020 Apr;145(4).

Efficacy and Effectiveness of the PCV-10 and PCV-13 Vaccines Against Invasive Pneumococcal Disease.

Berman-Rosa M, et al. Pediatrics. 2020 Apr;145(4).

Infant sleep and child mental health: a longitudinal investigation.

Cook F, et al. Arch Dis Child. 2020 Mar 9.

Maternal age at delivery and fertility of the next generation.

Reynolds TS, et al. Paediatr Perinat Epidemiol. 2020 Mar 9.

Association Between Rotavirus Vaccination and Type 1 Diabetes in Children.

Glanz JM, et al. JAMA Pediatr. 2020 Mar 9

A Longitudinal Investigation of Symptom Recovery following Concussion in Youth Soccer.

Kirkwood MW, et al. J Pediatr. 2020 Mar 5.

Assessment of anti-infective medication adherence in pediatric outpatients.

Warembourg M, et al. Eur J Pediatr. 2020 Mar 5.

Mycoplasma pneumoniae in Children With and Without Community-acquired Pneumonia. What do PCR and Serology Say? Copete AR, et al. Pediatr Infect Dis J. 2020 Feb 28.

Consequences of Undervaccination – Measles Outbreak, New York City, 2018-2019.

Zucker JR, et al. N Engl J Med. 2020 Mar 12;382(11):1009-1017

5. Case Reports

Case 5-2020: A 32-Day-Old Male Infant with a Fall.

Newton AW, et al.  N Engl J Med. 2020 Feb 13;382(7):656-664.

Transient Ischemic Attack in a Five-Year-Old Girl.

Kalawi AZ, et al.  Pediatr Infect Dis J. 2020 Feb 14.

A Case of a 15-Month-Old With Periorbital Edema and Severe Anemia.

Kamzan AD, et al.  Pediatrics. 2020 Feb 20. pii: e20190391.

Sudden visual loss: A not so simplex case.

Sampson MCR, et al. J Paediatr Child Health. 2020 Mar;56(3):484

Weakness, Anemia, and Neutropenia in a 9-Year-Old Girl With Influenza.

Cohen A, et al. Pediatrics. 2020 Apr;145(4

 

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

The child with a limp

Cite this article as:
Andrew Tagg. The child with a limp, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.23509

This post is based on the talk Andrew Tagg was invited to give at BadEMFest20 in Capetown. Unfortunately, world events made that a little challenging.

Humans evolved from Homo erectus to Homo sapiens around 500,000 years ago. Fossils dug up from by the Leakeys in Olduvai Gorge, Tanzania, revealed how we moved from shuffling knucklewalkers to the upright hominids we recognize today. Walking on two legs allowed us the freedom to use our hands – to communicate, to use tools, and to keep ourselves safe.

 

How do we walk?

The normal human gait is comprised of three distinct phases:

  • The contact phase – from heel strike to flat foot
  • The stance phase – from flat foot to heel off the ground
  • The swing phase – the propulsion phase as weight transfers from the toes

The swing phase normally comprises 40% of the gait cycle.

 

 

Like Sherlock Holmes or his progenitor, Joseph Bell, if you watch your patient walk you can get a lot of clues as to the potential underlying pathology before you even exchange a word with them or their parents.

Antalgic gait

This hobbling gait has a normal contact phase and normal propulsion with a decreased stance phase. In essence, the patient is trying to decrease the amount of time spent bearing weight through the hip joint itself.

Trendelenburg gait

In this gait disturbance, the hip muscles are too weak and so the unaffected side drops towards the floor. It suggests a biomechanical issue such as ass avascular necrosis, or a slipped capital femoral epiphysis.

Circumduction gait

The patient swings their leg out and around to clear the floor. This is often due to a leg-length discrepancy in the delayed diagnosis of developmental dysplasia of the hip (DDH).

Equinus gait

Toe walking, though normal up to the age of three may suggest that the child is unwilling or uncomfortable engaging their gastrocnemius muscles in walking. This can occur in many conditions.

 

The rate of presentation to the emergency department with an atraumatic limp is approximately 1.4 per 1000 in children under the age of 14. It occurs more often in boys than in girls (1.7:1) and the median age is 4.4 years. When we consider the potential causes the list is massive. In this post, we are going to concentrate on both the more common conditions and those diagnoses that we really shouldn’t miss. Whilst any part of the limb might be the cause (from the toes to the hip) this post is going to focus on causes centred around the hip joint. They account for about 60% of cases of limp. That doesn’t mean you shouldn’t look in their shoes for pebbles or look at their toes though!

Let’s break it down to some age-specific diagnoses and those that can occur at any age


Late presentation of developmental dysplasia of the hip (DDH)

It is just possible that routine screening with Ortolani’s and Barlows test might have missed a case of hip dysplasia. The limb resultant limb shortening can be hard to detect if it is bilateral but this is one time to get out the tape measure and look for a leg length discrepancy as you measure from anterior superior iliac spine (ASIS) to medial malleolus.

If you don’t have a tape measure to hand then look for a positive Galeazzi sign, suggesting a shorter hip segment on the affected side.

Original by Walt Shumway

 

Transient synovitis

This diagnosis accounts for the majority of cases of atraumatic limp and may follow an upper respiratory tract infection though the evidence for causation is poor. It is most common in young boys, aged 4 to 8 years of age and is self-limiting in nature. It’s a diagnosis of exclusion rather than anything else made easier by the well-appearing, afebrile child. It should respond to simple NSAIDs though is recurrent in 20% of cases.

Dr. Sathya Subramaniam, Pediatric EM Fellow – Kings County/SUNY Downstate and The POCUS Atlas

According to Viera and Levy, bedside sonography has a sensitivity of 90% and specificity of 100% to detect an effusion. Unfortunately, it doesn’t help with determining the cause.

Occult trauma

It’s beyond the scope of this post to talk about NAI and long bone injuries in children (especially as Nikki Abela did such a great job at DFTB18) so instead, it’s worth thinking about toddlers’ fractures. These occur due to torsional force on the tibia, accompanied by a fall, and may only be picked up as tenderness over the distal third of the tibia. That first set of x-rays performed in the emergency room may not show any obvious pathology with signs only becoming obvious after a couple of weeks. This is one of those occasions where ultrasound may be much more helpful though if clinical suspicion remains it should be treated with immobilization and close follow-up. Repeat imaging may then show the beginnings of some callus formation or a radionuclide bone scan may be needed. If they are not toddling and waddling it is not going to be a toddler’s fracture.

 

Case courtesy of Dr. Jeremy Jones, Radiopaedia.org. From the case rID: 9317

Neuromuscular

Although unlikely to present as an isolated limp, cerebrovascular events may present as hemiparesis; It’s beyond the scope of this post to go into them in more detail. Watch this space.

 

Perthes disease

This is idiopathic avascular necrosis of the growing femoral head and typically presents in boys at the younger end of the scale (4 to 8 years old). Because of this, these children are often shorter than their peers and there is a possible association with hyperactivity. The classical findings on a plain AP x-ray of the pelvis include sclerosis leading to destruction and the eventual collapse and flattening of the femoral head.  As this is a biomechanical problem, they might present with a slow onset antalgic gait with pain on internal rotation and ABduction. Around 20% of cases are bilateral.

Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org. From the case rID: 7980

 

Both MRI and bone scan are equally sensitive if the plain films are equivocal. Treatment may be surgical or conservative depending on the degree of bone destruction and the age of the child. Left unchecked neovascularization occurs with the destruction of the femoral head.

Though first described in 1897, it was not until 1910 that it was found to be unrelated to tuberculosis. Arthur Legg, Jacques Calvé and Georg Perthes are guilty of its eponymous name.

Transient synovitis

I think we’ve said enough about transient synovitis already.

Neuromuscular

As well as a stroke a limp might be the initial feature of an ascending paralysis in Guillain-Barré. We’ll talk about that and ADEM another time.

 

Slipped Capital Femoral Epiphysis

A slipped capital femoral epiphysis or slipped upper femoral epiphysis is more common on older, overweight boys, over the age of 10 years of age. There is often a structural weakness of the physis itself so it is more common in cases of endocrine dysregulation (such as hypothyroidism) and metabolic conditions (such as renal osteodystrophy). The proximal epiphysis displaces anteriorly and laterally relative the metaphysis. Involvement of the medial obturator nerve may mean that they present as knee pain rather than hip pain. Early fixation and we mean in less than 24 hours in unstable cases, can ward off the threat of life-long pain and deformity. Plain AP films may not be enough in the case of subtle slippage. So if you are suspicious then you should go ahead and order a lateral film as well.  A lot of other hip pathology is made easier to spot in a frog-leg lateral. Don’t do this if you are suspicious of a SCFE, you might make things much, much worse.

Look for Klein’s line. A line along the superior aspect of the femoral neck should intercept with the epiphysis. Imagine it as an ice cream slipping off the cone on a hot summer day.

Adapted from case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org. From the case rID: 2715

Case courtesy of Dr. Hani Salam, Radiopaedia.org. From the case rID: 9298

 

 

Some things need to be in our differential no matter the age of the child.

Septic arthritis

The hip is the most commonly infected joint with the haemategenous spread of organisms grown dependent on the local flora. Young children (under the age of 2), those who are immunosuppressed or asplenic are at higher risk. In Australia, for instance, the commonest organisms grown are Staphylococcus aureus and Group B Streptococcus (especially now that Haemophilus influenzae b infections have been almost wiped out by immunization). In the youngest, patients consider the weirder organisms like Kingella kingae and Salmonella (in patients with sickle cell disease).

The juvenile physis does not prevent the spread from a remote source from entering the epiphysis and so haematogenous spread (rather than direct local invasion) is often the culprit. The hip is classically held in a position of external rotation, ABduction and, flexion, perhaps in an effort to maximize the joint space and minimize the pain.

It would be great if there was a way we could differentiate the serious diagnosis of septic arthritis from something less serious, such as transient synovitis. Step forward Meninder Kocher et al. and their seminal paper.

Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. JBJS. 1999 Dec 1;81(12):1662-70.

They looked at 17 years of data for patients that presented to a single tertiary hospital with an acutely irritable hip. This amounted to 282 cases in all of which only 168 had their hip joint aspirated.  Of this 168,  only 26 had true septic arthritis as confirmed by a positive culture of joint aspirate or 50,000 WCC in the aspirate with a positive culture, 9 had a positive joint culture and negative blood cultures and 3 had only positive blood cultures.  By performing a multivariate analysis they then looked for key indicators that differentiated cases of septic arthritis from the more benign irritable hip. Four key factors cropped up. They were a history of fever, inability to bear weight, a WBC greater than 12 x 109/l and an ESR ≥ 40mm/hr. If you had none of these then the probability of having septic arthritis is 0.1%. But if you have all four it jumps to 99.8%.

Of course, this is all the primary literature that most people read but when Kocher tried to validate the study having all four markers gave the chance of having septic arthritis as 93% and when Luhmann et al. tried to externally validate the criteria it dropped to 59%. Caird et al. must have realized that not many of us use ESR any more and so appended the more common C-reactive protein (CRP). Having all 5 gave a 97.5% positive predictive value though there were only 14 cases of transient synovitis, and 5 of septic arthritis.

 


 

Osteomyelitis

An indolent course and a non-specific physical examination make this a difficult diagnosis to pick up at first glance. Around 1.5-2% of all children presenting with an atraumatic limp will have osteomyelitis.  Plain films may be unremarkable early in the course of the illness and only show periosteal changes after a week to 10 days. An MRI scan is more sensitive and if the diagnosis is still a challenge then radionuclide scanning might pinpoint the infection. The hip is one of the more common joints affected (25%) followed by the tibia/fibula (25%) then the humerus (13%). Osteomyelitis and septic arthritis can coexist as infection from the bone spreads to the joint capsule.

 

One case series suggests that 40% of cases are due to transient synovitis, chronic muscle sprain or trauma accounted for 16% and no diagnosis was made in 30%. All those diagnoses we have to learn for exams are much less common (Perthes’ disease 2%, osteomyelitis 1.5%, toddlers’ fractures 1%, and SCFE 1%). What has not been mentioned, as the incidence is incredibly low is the thing that many parents worry about – cancer.

 

Malignancy

Whilst parents may not have heard of a slipped capital femoral epiphysis or Kocher’s criteria but they have heard of cancer and so we need to address it. Primary benign tumours (unicameral bone cysts, for example, as well as malignant ones can present as bony hip pain.  Hip pain can also be a presenting feature in haematological malignancies such as acute lymphoblastic leukaemia. The most common malignant bone tumours in infants are osteogenic sarcoma and Ewing’s sarcoma. Both of these are most common in the second decade of life.

Persistent pain, coupled with constitutional symptoms such as night sweats, weight loss and night pain are highly suspicious and should prompt imaging and blood tests.

 

 

 

Selected references

Please, Just STOP LIMPING from Tim Horeczko and the PEM Playbook

Septic arthritis from PEM Morsels

 

Adamson J, Waterfield T. Fifteen-minute consultation: The limping child. Archives of Disease in Childhood-Education and Practice. 2019 Jun 29:edpract-2018.

Caird MS, Flynn JM, Leung YL, Millman JE, Joann GD, Dormans JP. Factors distinguishing septic arthritis from transient synovitis of the hip in children: a prospective study. JBJS. 2006 Jun 1;88(6):1251-7.

Fischer SU, Beattie TF. The limping child: epidemiology, assessment and outcome. The Journal of bone and joint surgery. British volume. 1999 Nov;81(6):1029-34.

Flynn JM, Widmann RF. The limping child: evaluation and diagnosis. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2001 Mar 1;9(2):89-98.

Herman MJ, Martinek M. The limping child. Pediatrics in review. 2015 May;36(5):184-95.

Hill D, Whiteside J. Limp in children: Differentiating benign from dire causes. Journal of Family Practice. 2011 Apr 1;60(4):193.

Hussain M, Gholipour B, Owen N. A pictorial review of the radiological presentations of the child presenting with an acute limp in the emergency department. Clinical Radiology. 2019 Oct 1;74:e14.

Kocher MS et al. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am. 1999 Dec;81(12):1662-70.

Leet AI, Skaggs DL. Evaluation of the acutely limping child. American Family Physician. 2000 Feb 15;61(4):1011-8.

Lewis D, Logan P. Sonographic diagnosis of toddler’s fracture in the emergency department. Journal of Clinical Ultrasound. 2006 May;34(4):190-4.

Long B, Koyfman A, Gottlieb M. Evaluation and Management of Septic Arthritis and its Mimics in the Emergency Department. Western Journal of Emergency Medicine. 2019 Mar;20(2):331.

McCarville MB. The child with bone pain: malignancies and mimickers. Cancer Imaging. 2009;9(Special issue A):S115.

Mooney III JF, Murphy RF. Septic arthritis of the pediatric hip: update on diagnosis and treatment. Current opinion in pediatrics. 2019 Feb 1;31(1):79-85.

Perry DC, Bruce C. Evaluating the child who presents with an acute limp. BMJ. 2010 Aug 20;341:c4250.

Ryan DD. Differentiating Transient Synovitis of the Hip from More Urgent Conditions. Pediatric annals. 2016 Jun 15;45(6):e209-13.

Sawyer JR, Kapoor M. The limping child: a systematic approach to diagnosis. American family physician. 2009 Feb 1;79(3):215.

Singhal R, Perry DC, Khan FN, Cohen D, Stevenson HL, James LA, Sampath JS, Bruce CE. The use of CRP within a clinical prediction algorithm for the differentiation of septic arthritis and transient synovitis in children. The Journal of bone and joint surgery. British volume. 2011 Nov;93(11):1556-61.

Vieira RL, Levy JA. Bedside ultrasonography to identify hip effusions in pediatric patients. Ann Emerg Med. 2010;55(3) :284-9

Wainwright, AM; Catterall, A (2010). “Chapter 27: Legg–Calvé–Perthes disease: Its name”. In Benson, M; Fixsen, J; MacNicol, M; Parsch, K (eds.). Children’s orthopaedics and fractures (3rd ed.). London: Springer. p. 465

Forget the Bubbles!

Cite this article as:
Andrew Tagg. Forget the Bubbles!, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.23585

It’s time for hospital accreditation week and you have taken the posters off of the walls, had all of the computers PAT tested and the team have even completed their mandatory competencies. The Infection Control team do a final sweep of the department and make sure the alcohol hand rub dispensers are in a perfect position. As you lead them out you hear a giggle from one of the cubicles followed by a slow drifting stream of iridescent bubbles.

“Bubbles? Bubbles! Get them out of here! They are harbouring all sorts of germs!”

Is this political correctness gone mad or is there something in it?

 

How do bubbles form?

K. Herman Schwartz proposed that a bubble is the minimal surface area way of enclosing a given volume of air back in 1888. This surface is made up of a thin layer of water molecules sandwiched between two layers of soap molecules. When two bubbles meet they merge walls in order to maintain their minimal surface area.

When they pop, according to researchers at MIT, water evaporates from the cap of the bubble cooling its surface temperature when compared to the base (imagine a bubble on a flat plate).  There is then a difference in surface tension at the base and the cap driving water upwards to the cap. This is known as Marangoni flow. If this occurs on the surface of water the bubble may only last seconds. High-speed cameras capturing the event reveal they pop into 10-15 droplets. But if it takes place on not-so-clean a surface the bubbles can last much longer and explode into 250 or more tiny droplets.

 

Can you grow bacteria on bubbles?

Absolutely! Though you might think that soap helps get rid of bacteria consider what soap solution is made of. If contaminated water is used then it is certainly possible to grow bacteria on a bubble. The commonest organism grown is Pseudomonas aeruginosa followed by Escherichia coli.

The formation of a biofilm on the surface of a bubble extends its life and as we saw earlier these bubbles explode creating 10 times as many droplets as sterile bubbles. They also expulsed 10 times faster from bacteria-laden bubbles than clean ones – up to 15 m/s. Does this make a bubble the ultimate bacterial dispersal system?

 

A bubble contaminated with bacteria (shown in the bottom panel) lasts much longer than a clean bubble. (Image: © Image courtesy Lydia Bourouiba and Stephane Poulain, Massachusetts Institute of Technology.)

 

So, can they actually cause harm?

McGarrity and Coriell showed, experimentally, that if you blew bubbles using a contaminated sample then bacterial isolates could be collected from the face and hands of the bubble artiste, and that they remained on non-porous for up to 30 minutes. The question then becomes, just how many products are contaminated?

An enterprising nurse epidemiologist, back in 2005, found that 38 out of 75 (50.6%) of solutions were contaminated in the Children’s Hospital in Denver. This lead to wholesale removal of them from the paediatricians’ repertoire whilst a safer alternative was found. It seems that pinwheels and party blowers just don’t cut it with the kids and so it was back to soap and water.

This also proved to be a problem in 2o12 when three children developed sepsis when playing with a contaminated bubble-blowing toy.  They had been playing happily in the morning and by the evening had developed a sore throat, limb pain, and a fever. The soap solution was the most likely culprit and an Italian team of investigators traced the soap products back to a couple of particular manufacturing zones in China.

 

Are bubbles really that bad?

Bubbles have been a source of wonderment for over 400 years. Paintings by Flemish artists such as Adriaen Hanneman and Jean-Etienne Liotard show children blowing bubbles with smiles on their faces.

Children Blowing Bubbles by Jean-Etienne Liotard © Ali Meyer/CORBIS

In the emergency room, they are routinely used as a distraction from potentially painful procedures or as a means to assess a pre-verbal child. If they can track and follow, reach out to grab and smile then they are on the right track.

But in this time of full PPE for aerosol generating procedures perhaps it is best to leave your bubble blowing exploits for home.

The best bubble mix?

Here are your basic ingredients:

  • 1 cup of liquid dish soap
  • 6 cups of distilled water
  • 1 tablespoon of glycerin

Pour the dish soap into the water and gently mix it (try not to make any bubbles!). Then add in the glycerin and stir. Put the lid on the container and leave it overnight before use.

 

Selected references

Amoruso I, Bertoncello C, Caravello G, Giaccone V, Baldovin T. Child toy safety: An interdisciplinary approach to unravel the microbiological hazard posed by soap bubbles. Journal of public health policy. 2015 Nov 1;36(4):390-407.

Caprilli S, Vagnoli L, Bastiani C, Messeri A. Pain and distress in children undergoing blood sampling: effectiveness of distraction with soap bubbles: A randomized controlled study. Children’s Nurses: Italian Journal of Pediatric Nursing Science/Infermieri dei Bambini: Giornale Italiano di Scienze Infermieristiche Pediatriche. 2012 Mar 1;4(1).

Dolan SA, Eberhart T, James JF. Ask the Expert: Bubbles to Wubbles™: An Investigation Involving the Contamination of Soap Bubble Products at a Pediatric Hospital. Journal for Specialists in Pediatric Nursing. 2006 Jul;11(3):189-95.

Helmenstine, Anne Marie, Ph.D. “What’s the Science Behind Bubbles?” ThoughtCo, Feb. 11, 2020, thoughtco.com/bubble-science-603925.

H. Lhuissier, E. Villermaux, “Bursting bubble aerosols,” J. Fluid Mech. 696, 5 (2012)

Maghsoudi S, Sajjadi Z, Behnam Vashani H, Asghari Nekah SM, Manzari ZS. Comparison of the effects of play dough and bubble making distraction techniques on venepuncture pain intensity in children. Evidence Based Care. 2016;5(4):25-32.

McGarrity GJ, Coriell LL. Bacterial contamination of children’s soap bubbles. American Journal of Diseases of Children. 1973 Feb 1;125(2):224-6.

Oliveira NC, Linhares MB. Nonpharmacological interventions for pain relief in children: A systematic review. Psychology & Neuroscience. 2015 Mar;8(1):28.

Poulain S, Bourouiba L. Disease transmission via drops and bubbles. Physics Today. 2019 May 1;72(5):70-1.

Sartor, C. (2000) Nosocomial Serratia marcescens infections associated with extrinsic contamination of a liquid nonmedicated soap. Infection Control and Hospital Epidemiology 21 (3): 196–199.

Time for Telehealth

Cite this article as:
Alison Boast and Allison Hempenstall. Time for Telehealth, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.24401

As the COVID19 pandemic continues to spread and utilize more of our health resources, many clinicians are being asked to minimize in–hospital clinic appointments. While it may seem simple to switch to telehealth for routine clinic appointments, there are a number of factors that need to be considered to make the process as smooth as possible for yourself and your patient and family.

This post will help you make the transition from face–to–face clinic appointments to telehealth. There are even more tips and tricks for assessing children with acute illnesses via telehealth, stay tuned!

 

Is your patient suitable for telehealth review?

If the answer is yes then continue on! There are some factors to consider though.

Need for clinical examination – if a clinical examination plays a key role in decision making telehealth may not be appropriate e.g. features of heart failure in a child requiring correction of a congenital heart defect

Multidisciplinary clinics e.g. cleft palate clinic – it may not be possible for clinics with multiple different providers to be shifted to telehealth

Need for procedures – in some clinics procedures are essential such as dressing changes or immunizations and therefore may not be possible via telehealth or community services

Some of the above barriers may be overcome by collaborating with your patients, their families, local general practitioner, and nurse practitioner; it is worth exploring this as an option.

 

Does your patient and their family have the right technology?

In general, the technology required for telehealth includes:

  • Reliable internet connection (remember that the weather, location and other users online at the time can impact your connection speed)
  • Computer, tablet or smartphone 
  • Web–camera (inbuilt in many computers, tablets, and smartphones)
  • Secure program to communicate through (e.g. Skype, Zoom, FaceTime)

 

Telehealth consultations are inherently different to face to face ones. It’s really important to acknowledge that your consultation has shifted to a two–dimensional format which poses unique challenges.

 

Voice or video – which should I choose?

Voice is more accessible, particularly for the elderly who may not have phones or computers with video capabilities. It requires lower bandwidth and is less susceptible to disruptions. Unfortunately, you can’t see the patient (duh!) which means you can’t use your ‘end–of–the–bed–o–gram’ to see if they are well or unwell.

Video provides visual information on whether your patient appears ‘well’ or ‘unwell’. It is ideal for those patients and families with hearing impairment as non–verbal communication is preserved, as is the option to lip–read. With the increased use of the internet during isolation, quarantine and social distancing,  connectivity can be slow at times. Some governments have been advocating for online streaming services to downgrade from HD format to help preserve bandwidth.

Irrespective of the method chosen it is important to ensure the lighting optimizes illumination of your face, and sound is adequate with minimal background noise.

 

How should I run the consultation?

Before you start make sure you have your information technology support team phone number in case issues arise that you can’t troubleshoot. Check the patient’s identity, sound, and vision (if using video) and consider having a set of earbuds/ headphones handy.

Ensure that your patient and their families are holding the consultation in a private, safe space. Clarify the amount of time available for the consultation. Non-verbal cues that the consult needs to come to an end are more challenging with telehealth.

Limit distractions – if the family has lots of children or pets, it is worth asking at the beginning of the consultation if they can play in another room (safely), or have a quiet activity to get on with. Communication with noisy siblings is even harder via telehealth than in real life

If you need an interpreter before to organize this in advance, either by phone or in-person

At the end of the consultation take a brief moment to ask your patient and their family for feedback about the telehealth consultation

  • Did your patient hear/ see you throughout the consultation?
  • Was your patient happy with the care they received?
  • Would your patient be happy to have another telehealth consultation in the future?

 

But how do I examine the patient?

A major barrier to telehealth is the inability to carry out a physical examination. You can, however, gather more from video telehealth than you realize.

General Inspection – probably the most important part of the paediatric examination :

  • Does the child look well or unwell?
  • Are they active and engaged, or quiet and withdrawn?
  • Do they look well-grown? (remember to review your patients’ growth charts!)
  • Do they look like their parent(s)? Do they have dysmorphic facial features?

Observations – In most teleconsultations you won’t have this information, some patients and their families may have:

  • A  thermometer to take their temperature (although generally not required for a routine clinic appointment unless the child is acutely unwell)
  • A smartwatch or app on their smartphone which can take their heart rate and or oxygen saturation for older children with comorbidities (e.g. chronic lung disease)
  • If a blood pressure is important for decision making (e.g. chronic kidney disease) it is vital that the cuff is fitting correctly; few families have at–home sphygmomanometers, so they may be able to visit the local practice nurse for an accurate measurement

RespiratoryA wise professor once said that most of the respiratory examination only requires your eyes

If the video quality allows – what is the respiratory rate? Are there signs of increased respiratory effort? Is the respiratory cycle normal, or is there a prolonged expiratory phase?

Development – assessment requires some assistance and props from parents, but this in itself gives you information about the parent–infant bond and social skills:

  • Gross motor – stacking blocks, throwing a ball, sitting/walking/cruising/running and jumping
  • Fine motor – picking up raisins, scribbling or drawing
  • Speech and Language – can the child point out pictures in a book? Read you something?
  • Social – difficult to assess via telehealth; it’s easier to obtain from history and parental/teacher questionnaires
  • Questionnaires filled out ahead of time can help gather more objective information on the developmental domains of concern (e.g. Ages and Stages Questionnaires) 

Neurological – this is very challenging to assess via telehealth, only gross assessments of tone and coordination will be possible (see above for gross and fine motor)
 

Financial Considerations

In Australia, many Medicare item numbers have recently become available to bulk-bill telehealth sessions. This includes quarantined/isolated doctors who are still able to provide telehealth from home. It is worth checking with the relevant agency in your area to see what options are available to support telehealth, and what the surrounding rules and regulations are.

 

Medicolegal Considerations

Here are some useful elements to document:

  • Your name, date, time & location of consultation
  • Patient/ carer consent for the telehealth consultation
  • Those present for the consultation
  • Video vs phone consultation
  • Limitations to quality of consultations (e.g. poor connectivity)

We recommend giving your friendly indemnity insurer a call if you have any specific medicolegal questions

 

Check out more resources here

https://www.rch.org.au/telehealth/

https://www.bmj.com/content/bmj/suppl/2020/03/24/bmj.m1182.DC1/gret055914.fi.pdf

https://www.bmj.com/content/bmj/368/bmj.m1182.full.pdf

https://www.racp.edu.au/docs/default-source/advocacy-library/telehealth-guidelines-and-practical-tips.pdf

https://www.racgp.org.au/getmedia/c51931f5-c6ea-4925-b3e8-a684bc64b1d6/Telehealth-video-consultation-guide.pdf.aspx

Communicating with children with additional needs: Liz Herrieven at DFTB19

Cite this article as:
Team DFTB. Communicating with children with additional needs: Liz Herrieven at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21387

Communication is vitally important in so much we do as clinicians.  Without good communication we can’t hope to get a decent history, properly examine our patient, explain what we think is going on or ensure appropriate management.

Nocturnal enuresis

Cite this article as:
Mary Hardimon. Nocturnal enuresis, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.23446

Kristy is a 5-year old girl; her mother has brought her in due to her having started kindie. She has been invited to have a sleepover at a family friends house however she still wets the bed most nights of the week and is wondering about how to manage this.

 

Attaining continence – both daytime and nighttime – is a developmental milestone with a significant normal variation which is affected by both genetic and environmental factors.

At 5 years of age, approximately 15% of children continue to experience nocturnal enuresis (more commonly known as bedwetting). Every year beyond this, there is spontaneous resolution in ~15% of affected children (although it should be noted that the longer duration of NE, the lower the likelihood of spontaneous resolution).

Boys are more commonly affected than girls (2:1) and there is a strong family predisposition (both parents = 77%, single parent = 43%). Only one-third of those affected will seek medical attention.

 

What is nocturnal enuresis?

Nocturnal enuresis is episodes of urinary incontinence during sleep in children ≥5 years of age. It may be further subdivided into monosymptomatic (aka uncomplicated) and non-monosymptomatic (aka complicated or polysymptomatic).

  • Monosymptomatic: incontinence is present without other symptoms of lower urinary tract/gastrointestinal tract
  • Non-monosymptomatic: incontinence associated with other symptoms including but not limited to
    • Polyuria/oliguria (8/3 times per day respectively)
    • Urgency, hesitancy, intermittency
    • Straining/holding manoeuvres
    • Weak stream, dribbling
    • A feeling of incomplete emptying
    • Pain

When episodes additionally occur during the day, it is more appropriately referred to as diurnal enuresis/incontinence.

Incontinence should be classified as primary or secondary.

  • Primary: the child has never been dry
  • Secondary: the child has been dry for a period of at least 6 months

 

Why does nocturnal enuresis occur?

Nocturnal enuresis is the result of inappropriate emptying of the bladder by the child and is the result of a mismatch between the neurones of the bladder and the conscious state of the child. This may be due to a multitude of factors including:

  • Maturation delay
  • Genetic factors
  • Nocturnal polyuria – this may be due to fluid intake, reduced response to antidiuretic hormone (ADH) and/or reduced production of ADH
  • Disturbed sleep in the child (controversial)
  • Small bladder capacity
  • Detrusor overactivity

These factors may be primary to the child (eg. genetic factors) or secondary to an underlying condition (eg. polyuria secondary to undiagnosed diabetes insipidus)

 

 


How to evaluate a child with nocturnal enuresis?

It’s almost all in the history – search for red flags!

History:

  • Onset
  • Previously dry?
  • Daytime symptoms (non-monosymptomatic NE)
  • Frequency, amount
  • Response to episodes
  • Fluid habits
  • Bowel habits
  • Sleep routines

 

Examination:

  • Height/weight
  • BP
  • Tonsillar hypertrophy/adenoidal facies
  • Abdomen (distended bladder, faecal mass)
  • Spine
  • Lower limb neurology
  • Perianal/vulval inflammation (pinworms)

 

Do you need to do investigations?

Investigations are not necessary for all patients and should be guided by history and examination. Consider:

  • Blood sugar level (fingerprick)
  • Urinalysis (m/c/s, electrolytes)

Imaging and blood tests are not routinely indicated.

 

What are the treatment options?

 

Important things to remember in treatment:

  • Tricyclic medications are not recommended as they are less effective and have a higher risk of adverse effects
  • Intranasal desmopressin is not recommended due to the risk of hyponatraemia
  • There are high rates of relapse when desmopressin is discontinued (60 – 70%) therefore best used as a short term measure (eg. for going to camp) whilst awaiting spontaneous resolution
  • Desmopressin should not be used in those who are unable to adhere to fluid restrictions (due to risk of hyponatraemia)
  • Treatments with weak evidence include elimination diet, hypnosis, retention control (holding urine for progressively longer periods), biofeedback, acupuncture, scheduled awakenings, caffeine restriction

 

Take-home messages

  • It doesn’t require treatment in those under the age of 6
  • It is common  although undertreated despite treatment options (and families potentially being eligible for funding)
  • It is usually a primary disorder rather than secondary to an underlying medical condition (although maybe particularly exacerbated by constipation)
  • Investigations are not routinely required
  • Treatment requires a motivated family, with behavioural measures and bedwetting alarms being the first line of treatment.

 

Selected references

Tu, Baskin, Arnhym et al (2019) “Nocturnal Enuresis in Childre: Etiology and Evaluation”. UpToDate.

Tu, Baskin, FAAP (2019). “Nocturnal Enuresis in Children: Management”. UpToDate.

The Royal Childrens Hospital. (2019). “Enuresis – Bedwetting and Monosymptomatic Enuresis.” Melbourne. Retrieved from: https://www.rch.org.au/clinicalguide/guideline_index/Enuresis_-_Bed_wetting_and_Monosymptomatic_Enuresis/

Thiedke C. “Nocturnal Enuresis”. American Family Physician (2003); April 1; 67(7): 1499 – 1506

Ramakrishnan K. “Evaluation and treatment of enuresis”. American Family Physician (2008); August 15; 78(4): 489 – 496.