The high yield respiratory examination: David Krieser at DFTB19

Cite this article as:
Team DFTB. The high yield respiratory examination: David Krieser at DFTB19, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.21344

One of the challenges of paediatrics is how to distill a life of experience down to something more tangible. When you are asked “How did you know s/he was sick?” you need to be able to give a better answer than “I just know”. In this session from DFTB19  we challenged three clinicians to explain just why they think the way they do.

Wheeze. It’s all in the timing…

Cite this article as:
Patrick Aldridge. Wheeze. It’s all in the timing…, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.21378
You’ve just treated a 5 year old with their second episode of wheeze this year. They’ve had burst therapy,  and are now one hourr post treatment with no work of breathing, scattered wheeze on auscultation and oxygen saturations of 95%. You contemplate giving them steroids and decide against it.

The Medicines Handbook: Simon Craig at DFTB18

Cite this article as:
Team DFTB. The Medicines Handbook: Simon Craig at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20590

Ask any paediatrician what the hardest, tricksiest procedure that you might ever have to perform and they would all be in agreement – calculating drug doses in the middle of a paediatric resuscitation. In this talk Simon Craig, from Monash, takes us through the how we can do better than scratching out rough calculations on the whiteboard at 6am. He asked the key question…

 

 

 

 

 

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

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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*Lori was once one of Andy Tagg’s trainees but he is quick to point out that none of the situations depicted are about him.

 

Exercise induced wheeze: Rob Roseby at DFTB18

Cite this article as:
Team DFTB. Exercise induced wheeze: Rob Roseby at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20582

Associate Professor Rob Roseby is a respiratory physician. You might see many adults huffing and puffing around the local park every Sunday, bright red in the face, gasping for breath. This shouldn’t be the case for the children in their charge. In this talk Rob reminds the reluctant athletes in the audience that exercise and sport is good for children – both in terms of mental health and physical health. 

 

So, should we prescribe sport for our younger patients? Does it actually make a difference? And if they can’t play the sport that they love how can we get them back to it? Listen to this talk from Rob to find out how we can make that all important difference

 

 

 

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

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

iTunes Button
 

 

*Lori was once one of Andy Tagg’s trainees but he is quick to point out that none of the situations depicted are about him.

 

Mentoring in Medicine: Melanie Rule at DFTB18

Cite this article as:
Team DFTB. Mentoring in Medicine: Melanie Rule at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20557

Mel Rule is one of the founding members of the extraordinary WRaPEM group. They are a group of passionate educators and clinicians waim to bring back Wellness, Resilience and Performance coaching for the everyday doctor.

Giving Feedback: Lori Chait at DFTB18

Cite this article as:
Team DFTB. Giving Feedback: Lori Chait at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20517

When we learn about feedback it is often from the side of the wise expert, the person giving it. Whilst they might be very good at what they do it is worth considering how the person on the receiving end feels. In this talk from 2018 Lori Chait, a paediatric trainee*, reflects on what it is like to be on the receiving end and how we might do a better job.

 

 

 

 

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

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

iTunes Button
 

 

*Lori was once one of Andy Tagg’s trainees but he is quick to point out that none of the situations depicted are about him.

 

What is the evidence for high flow in bronchiolitis?

Cite this article as:
Tessa Davis. What is the evidence for high flow in bronchiolitis?, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20191

Over recent years, the use of high flow nasal cannula in the treatment of bronchiolitis in infants has increased. Whilst it used to be mainly used in PICU, it is now widely used in EDs and on the wards. The recent PARIS trial examined whether delaying starting high flow in infants with bronchiolitis led to a worse outcome (it didn’t). See Alasdair Munro’s excellent analysis here.

But is high flow actually useful in these patients, and if so when? Should we be using it in our Emergency Departments at all?

The PREDICT research group published an updated systematic review this month in the Journal of Paediatrics and Child Health.

High flowing controversy: A return ticket to PARIS

Cite this article as:
Alasdair Munro. High flowing controversy: A return ticket to PARIS, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20129

Today we are all familiar with high flow nasal cannula (HFNC) as respiratory support. We see it in our emergency departments, on our wards and in the PICU. People rave about it, and people rant about it. People talk about it so much that there must be some high-quality evidence about it, right?

There certainly wasn’t until last year, when the much-anticipated Paediatric Acute Respiratory Intervention Study (PARIS) was published in the prestigious New England Journal of Medicine (if you haven’t read about the trial, most of this will make little to no sense to you. Have a quick read of the DFTB run down here, or read the article itself in full here).

This RCT of HFNC in bronchiolitis has stirred up strong opinions in some, and a few pretty convincing and controversial myths have arisen from it over the past year.

This take on HFNC and the PARIS trial may be a little controversial, so buckle your seatbelts (and please comment if you disagree).

 

Myth 1 – PARIS was a badly conducted study

If you hate HFNC and are looking for a take-down of the PARIS trial, I’m afraid this isn’t it. PARIS was a fantastically well-conducted trail, with an impressive write up. It was performed to the highest standards of clinical research and it has been clearly analysed. Most importantly, it finally provided the first attempt at high-quality evidence about an intervention which has already become a standard of care, despite having no evidence to support its use. The authors should be congratulated.

If PARIS was so well conducted, where have these myths come from? Almost all stem from a misunderstanding of myth number 2…

 

Myth 2 – Paris was a trial of HFNC vs standard oxygen therapy

This is a confusing myth, as the publication of the study states this is the case in the methods section and throughout the article. If this is what the authors say it is, how can this be untrue?

It can be argued that PARIS cannot be a trial of HFNC vs standard oxygen therapy, for two reasons:

  • In both groups, 100% of escalated children get HFNC at some point (you cannot compare HFNC vs something else if everyone gets HFNC).
  • The primary outcome for the two arms, despite being called the same thing, are actually different. For both arms the outcomes are called “escalation of care”, but for the HFNC group this means escalation to PICU, whereas for the standard O2 group this means escalation to…you’ve got it – HFNC.

You don’t have to be a research wizard to realise that having two different outcomes for your groups is a no-no. It means you cannot compare outcomes between the two groups, as you are not comparing like with like. The HFNC group has apples, and the standard O2 therapy group has oranges.

 

So, what is PARIS a trial of?

PARIS is a trial of a strategy of immediate HFNC for hypoxaemia in bronchiolitis, vs a strategy of rescue HFNC for hypoxaemia when standard oxygen therapy fails.

If we are not comparing the original primary outcomes, what should we compare?

In PARIS we should compare treatment escalation to PICU, as this is an equal outcome for both arms.

If we assess the study this way, we can see quite clearly that when comparing these two strategies, there is no difference in outcome of escalation to PICU (9% of standard therapy, 12% of HFNC, p=0.08). In fact, when we discount the original primary outcome definition, there is no difference in any other outcome between the two groups (except that the HFNC group were sicker when they got escalated).

The PARIS trial was an amazing piece of clinical research, but the write up has asked a strange question of the data and described the groups in a confusing way.

 

Myth 3 – PARIS demonstrated immediate HFNC is superior

Based on a misunderstanding of the above, plus a frequently stated statistic from the trial that:

The NNT of HFNC vs standard oxygen therapy to prevent one episode of escalation of care is 9

Some people have taken home the message that a strategy of immediate HFNC is superior to standard oxygen, as it prevents treatment failure. However, as we have already discussed, treatment escalation for the standard oxygen therapy group consists of being started on HFNC. All this means then, is using HFNC is superior for preventing you from later putting the patient on HFNC. Obviously, this makes no sense at all.

If we are discounting this mind-bending interpretation, and (as above) we see that an immediate strategy of HFNC changed no outcomes compared to a strategy of rescue HFNC, how do we decide which is better?

This is simple: when faced with two interventions which provide equivalent outcomes, you always pick the one which is cheapest and least invasive. Here, a strategy of standard oxygen therapy with rescue HFNC is the winner.

 

Myth 4 – PARIS tells us HFNC is effective in bronchiolitis

Sadly, PARIS cannot tell us anything about HFNC in and of itself, because we did not compare HFNC to no HFNC. Everyone got HFNC in the end, so there is no true control group. Although we can try and guess what would have happened in the standard oxygen therapy arm if there was no HFNC available, we can’t say this for sure as it didn’t happen.

Many people certainly believe that HFNC works and prevents PICU admission (which it may well do), but unfortunately PARIS cannot answer that question for us, and as yet no trial has done so.

What PARIS CAN tell us about HFNC is that it is safe. There were very few adverse events, of which it is unlikely any were related to HFNC.

 

If PARIS cannot tell us if HFNC is effective, how do we find out?

We want to design a study to tell us if HFNC is useful in bronchiolitis. First, we need to decide what we actually want HFNC to do. We are not expecting it to save lives, as children rarely die of bronchiolitis, and if they look like they might die then we have an effective intervention, which is to send them to PICU and intubate them. We also don’t expect HFNC to get children home any quicker, as it doesn’t treat the underlying disease process.

So, what do we want from HFNC? I would argue it is to keep children out of PICU, and on the ward. This is cheaper, nicer and less invasive. A win all around.

So how could we tell if HFNC keeps children out of PICU? We need a trial which compares rescue HFNC (which PARIS has demonstrated is preferable to immediate HFNC, as there’s no difference between the two), to standard care – basically normal treatment of bronchiolitis without using HFNC at all (hard to remember a time when this was the norm…). You then see if there is any difference between how many children go to PICU, or how long they stay there. Let’s put our dream study in a PICO:

P – Infants with bronchiolitis with hypoxaemia

I – Standard care + HFNC as treatment escalation

C – Standard care (no HFNC)

O – Admission to PICU/ PICU LOS

If the above looks strange to you, it’s worth remembering that not too long ago there was no HFNC, and there is certainly no way that the same number of children we currently put on HFNC all used to go to PICU instead.

 

Why hasn’t this trial happened?

If that’s the dream trial, where is it?

Unfortunately, because medical devices are not regulated in the same way as drugs, there is no requirement to prove their efficacy or added value prior to them being approved for any indication. HFNC made its way into every paediatric unit faster than a bronchiolitic baby can sneeze, and quickly became the standard of care without ever having any evidence it was effective. The horse has now left the stable, and there is no way of convincing people to run a trial in which half of the children do not get HFNC.

In the absence of any evidence, the world has now been split into a group of “HFNC believers” and “HFNC non-believers”, neither of which have any evidence that they are right (but many getting confused about the PARIS trial and sometimes misusing it to confirm their opinions).

 

Myth 5 – But I’ve SEEN HFNC work

Some people may read all this, and think,

“Yes, but who cares. I use HFNC and I have seen it help children and stop them go to PICU. We don’t need a trial, because we can SEE it works”.

Sadly, we have learnt from previous experience that even when people believe they have seen interventions work, sometimes when the evidence is finally produced it turns out we were wrong all along. This is particularly a problem for medical devices, due to the way they are regulated. Just look at the recent NEJM study for IVC filters to prevent pulmonary emboli, or the mind blowing ORBITA trial last year for coronary stenting for chronic angina. This is why randomised controlled trials are so vital. They have demonstrated millions of pounds have been wasted on ineffective procedures and devices in these scenarios, even when health professionals truly believed that they had seen them work. Time has proven again and again that we will often just see what we want to see.

 

Conclusion

  • PARIS was a fantastically well conducted trial
  • PARIS was NOT a trial of HFNC vs standard care. It was a trial of immediate HFNC vs rescue HFNC, and no differences between the two were demonstrated.
  • When two interventions provide the same outcome, you always pick the cheapest and least invasive option, which in this case is rescue
  • PARIS cannot answer questions about HFNC efficacy, but did demonstrate its safety
  • To demonstrate efficacy, we require a trial of rescue HFNC vs standard care (without HFNC), with an outcome of PICU admission/LOS
  • Current problems with device regulation mean they can be instituted without evidence of efficacy, and following widespread implementation it becomes very difficult to test their effects. We owe our patients better than that.

Additional reading

A recent meta-analysis of HFNC in bronchiolitis, including (and heavily weighted by) the PARIS trial, was recently published in the Journal of Paediatrics and Child Health. You can read our analysis here.

Top 5 Papers in PEM

Cite this article as:
Tessa Davis. Top 5 Papers in PEM, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.18476

This post is based on a talk I presented at the RCEM Spring Conference in April 2019 – Top 5 papers in PEM.

Kylie and Jason are enjoying their time at home with their first baby. The highs of being new parents is at its peak and true sleep deprivation is yet to set in. Jayden is two weeks old and is simply perfect. They spend hours staring at him each day marvelling at the perfect human they have created. 

As we follow Jayden through his journey to adulthood, we’ll encounter some common paediatric problems. The 5.5 papers I have chosen were selected because: they cover common presentations; they use large patients groups; and they were conducted by well-respected and highly regarded research groups. But back to our story…

 One night Jayden seems a bit more unsettled than normal. When they check his temperature it’s 38.4. They get in the car and bring Jayden to ED

 Febrile neonates are a huge source of concern – we know that they can deteriorate quickly and we usually err on the side of caution by doing a full septic screen, IV antibiotics, and admission. Actually many of these babies don’t have a serious bacterial infection. Is there a way to tell which ones do?

When you see Jayden in your ED, you ask yourself is…should I do a full septic screen?

Paper 1 - Kupperman et al, 2019, A clinical prediction rule to identify febrile infants 60 days and younger at low risk for serious bacterial infections, JAMA Pediatrics


This paper aimed to derive and validate a highly accurate prediction rule to identify infant at low risk of SBI. The patients were febrile infants 60 days and younger (who had a rectal temp of >38 in the ED or a fever at home within the preceding 24 hours)

They excluded those who were critically ill, who had antibiotics in the preceding 48 hours, those born premature, and those with other medical conditions.

There were 1821 febrile infants included.

The authors considered clinical suspicion of SBI. They then look at various markers: blood culture; urine culture and urinalysis; CSF; FBC; and procalcitonin levels. The outcomes  considered were serious bacterial infection – that is bacterial meningitis, bacteraemia, or urinary tract infection.

Overall, the rates of SBI in this group was 9%. The authors formulated a rule with a very high sensitivity (97.7%) for identifying those at low risk of serious bacterial infection. They were low risk if they fulfilled three criteria:

  • negative urinalysis
  • neutrophil count of less than 4/mm3 
  • procalcitonin of less than 0.5ng/ml

61.3% of their patient group were low risk.

Interestingly their low risk rule does not include use of  lumbar puncture67.4% of the low risk group had a lumbar puncture that would not have been necessary.

Key take away: There may be some febrile neonates that are low risk, and therefore we could avoid a lumbar puncture and full work up. In practical terms, this is unlikely to change our practice at the moment. Many of us cannot send a procalcitonin in the ED, and we might have to wait several hours to get a neutrophil count back. However this does bode well for the future in identifying which of these well febrile neonates are low risk.

Jayden does get a full septic screen. He has IV antibiotics for 48 hours and remains well. His blood cultures are negative so his antibiotics are stopped and he is discharged.

FLASH FORWARD…

 

 

Jayden is growing well. At 7 months of age, he is looking great and developmentally normal. Dad, Jason, smokes, but reassures you that he never does so in the house. Jayden develops a cough and two days later starts breathing very quickly and noisily. They head to the emergency department.

Jayden has bronchiolitis. This is very common and your departments and wards have no doubt been filled with these children over the winter. We know that little works with these children. So you force yourself to hold back the ‘trial of salbutamol’ because it won’t make any difference.. But high flow does seem to be the one thing (along with oxygen) that might make a difference.

You ask yourself the question...should I start high flow?

Paper 2 - Franklin et al, A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis. NEJM. 2018. 378(12):1121-1131

This study looks at infants under 12 months old with a clinical diagnosis of bronchiolitis and a need for supplemental oxygen. 1472 were included (after exclusions). Patients were excluded if: they had an alternative diagnosis; they had cyanotic heart disease; or they were on home oxygen.

Patients were randomised to either high flow or low flow. The high flow group were given heated humidified high flow oxygen – 2L/kg/min via Optiflow. The oxygen was then weaned to achieve target saturations, and they were taken off high flow once they had been on air for four hours. The low flow group were given wall oxygen via nasal cannulae at 2L/min max.

The outcome  was escalation of care. This meant who in the low flow group was escalated to high flow, and who in the high flow group was escalated to BiPAP or was intubated. Treatment failure was based on: an increase in heart rate; if the respiratory rate increased or didn’t drop; if they were needing oxygen in >2L/min of flow or >0.4 FiO2 to maintain their saturations; or if they achieve a high early warning score. Clinicians could also escalate care themselves (34% were escalated in this way).

Escalation of care occurred much more commonly in the low flow group – with 12% being escalated in the high flow group and 23% in the low flow group.

 

Interestingly there was no difference in the length of stay between the two groups.

Key take away: High flow does reduce the need for escalation. Escalation itself is significant – it requires increased nursing attention for low flow patients while they are transferred onto Optiflow.  There may be less medical staffing on the wards if the child deteriorates on high flow overnight. Although they aren’t comparing like with like, escalation itself is an important clinical event. They also demonstrated that high flow does not increase the number of adverse events (for example there was no difference in the number of pneumothoraces between the groups). High flow is safe to use and we should consider starting it early in ED.

You start Jayden on high flow in ED and he stabilises. 12 hours later he is weaned off on the ward and is discharged the following day.

FLASH FORWARD…

Jayden is now a healthy 3 year old boy. He loves Paw Patrol.  He hates vegetables and won’t eat any food that is the colour green or yellow. Kylie and Jason are expecting their next child, and Jason has finally quit smoking. Unfortunately Jayden is prone to wheezy episodes and now has his very own inhaler which he hates using. The change in weather in London, from quite cold to…colder, seems to have triggered something and he’s now pretty wheezy and short of breath. They head into their favourite emergency department.

 Jayden is now firmly in the realm of viral-induced wheeze. Yes, it’s all on a spectrum, but he’s now 3 years old with an inhaler. You asses him and think he should have a salbutamol burst.

As you are writing the salbutamol up, your SHO asks  you – should I give him steroids?

Paper 3 - Foster SJ, Cooper MN, Oosterhof S, Borland ML. Oral prednisolone in preschool children with virus-associated wheeze: a prospective, randomised, double-blind, placebo-controlled trial. The Lancet Respiratory Medicine. 2018 Jan 17.

 This paper aimed to assess the efficacy of oral prednisolone in children presenting to an ED with viral wheeze.

The patients included were 2-6 years old. They were excluded if: saturations were less than 92% in air; they had a silent chest; they had sepsis; there was a previous PICU admission for wheeze; they had prematurity; or they had recently had steroids.

605 patients were included and they were randomised to receive either prednisolone or placebo. The prednisolone group received 1mg/kg prednisolone once a day for three days. The placebo group received a placebo medication (matched for volume and taste to prednisolone) once a day for three days.

Patients were assessed for their wheeze severity using a validated pulmonary score.

The outcome measures were length of stay (until clinically fit for discharge). They also considered re-attendance, readmission, salbutamol usage, and residual symptoms.

The results are tricky to interpret. Those who were discharged from ED within four hours did not benefit from prednisolone. However there may be some benefit in the mild to moderate wheeze group, and some in those who used salbutamol at home prior to presenting to ED. Interestingly this paper did not support our previously held belief that those children with atopy respond better to prednisolone.

 Key take homes: Some pre-schoolers are steroid responsive, but identifying which ones is a challenge. As Damian Roland discusses here, it is likely that we are seeing lots of children presenting with the same symptoms (wheeze) but with different pathology behind it. Once we can identify the pathology we can start to target specific groups of patients with management that works.

You decided not to give Jayden prednisolone and after his salbutamol burst he stretches to 4 hours and is discharged home.

FLASH FORWARD…

Jayden is 5 years old and in his excitement of building the new Hogwarts Lego castle he accidentally swallows a Lego head. Kylie and Jason aren’t sure whether to worry or not? So they take him into ED.

Children ingesting random objects is a common presentation to ED.

When you see Jayden in the department, his parents ask you…should I search through his poo?

Paper 3.5 - Tagg, A. , Roland, D. , Leo, G. S.Y., Knight, K. , Goldstein, H. , Davis, T. , DFTB, (2018), Everything is awesome: Don’t forget the Lego. J Paediatr Child Health. doi:10.1111/jpc.14309

Myself and 5 of my fearless, and brave, paediatric colleagues swallowed a Lego head each to see how quickly it passed. The paper was generously published in the Journal of Paediatrics and Child Health.

To ensure serious scientific rigour, we put together some scoring systems.

The Stool Hardness and Transit time (the SHAT score) took into account how hard our stools were, and whether that impacted (no pun intended) on the time to retrieve the Lego head.

And out main outcome was the Found And Retrieved Time (the FART score). This was the time to get our Lego heads back, and the average FART score was 1.71 days.

Unfortunately one of the six of us didn’t find his Lego head. After valiantly searching through his own faeces for two weeks, he gave up. And it may still be up there.

Key take home: Don’t search through poo, it’s gross.

Jayden heads home happily to finish building his Lego Castle.

FLASH FORWARD.

Jayden is 6 years old. He thinks Paw Patrol is for losers. Fortunately he still loves Lego and Harry Potter. He also enjoys climbing. Unfortunately, two days ago he fell off the ladder coming down from his bunk bed. He seemed okay at the time, and Kylie and Jason had other plans that evening, so they decided to keep him at home. Now, two days later, he has a massive egg on his head and has been complaining of a headache. He also vomited yesterday. They bring him to ED.

 

We have fabulous head injury guidance for kids thanks to PECARN, CHALICE, and CATCH. But actually PECARN and CATCH specifically exclude injuries more than 24 hours old, and CHALICE doesn’t publish data on this group. So, for Jayden you need to put the NICE guideline away because it doesn’t apply. This is a common grey area.

The question you ask is….should I scan his head?

Paper 4 - Borland M, Dalziel SR, Phillips N, Lyttle M, Bressan S, Oakley E, Hearps SJC, Kochar A, Furyk J, Cheek J, Neutze J, Gilhotra Y, Dalton S, Babl F. Delayed Presentations to Emergency Departments of Children With Head Injury: A PREDICT Study, Annals of Emergency Medicine, DOI: https://doi.org/10.1016/j.annemergmed.2018.11.035

This paper aimed to establish the prevalence of traumatic brain injuries in children presenting more than 24 hours after the head injury.

Traumatic brain injury (TBI) was defined as: intracranial haemorrhage; contusion; cerebral oedema; diffuse axonal injury; traumatic infarction; shearing injury; or a sigmoid sinus thrombosis.

The also looked a clinically significant traumatic brain injury (cTBI) – this included death, intubation for more than 24 hours, neurosurgery, or admission for 2 or more nights to hospital.

The patients were from the Australian Paediatric Head Injury Study Cohort which was 20,137 patients. 5% of these presented over 24 hours after the injury. 981 children were included in this study.

The authors considered the injury characteristics and demographics, trying to find an association between mechanism and delay in presentation. Those presenting were more likely to have: a non-frontal scalp haematoma; headache; vomiting; and assault with NAI concern. Those with loss of consciousness and amnesia were more likely to have presented within the first 24 hours.

The CT rates were much higher in the late presentation group – 20.6% being scanned in the delayed group and only 7.9% in the early group. This probably reflects the lack of evidence in this area, and therefore we feel safer doing more scans.

But the rates of TBI also varied. 3.8% in the delayed presentation group had a TBI, whereas only 1.2% in the early presentation group did.

The rates cTBI were the same between the groups at 0.8%

Key take homes: There is an increased risk of TBI when presenting more than 24 hours after a head injury injury. The authors found that risk is increased if the patient has a non-frontal scalp haematoma or a suspicion of a depressed skull fracture.

You decide to scan Jayden’s head, but it turns out to be normal and he is discharged home.

FLASH FORWARD… 

Jayden is 8. He’s been drinking a LOT of water over the last few weeks and seems to be weeing constantly. His clothes seem a bit big for him too. He looks so bad one day (and has vomiting and abdominal pain) that Jason finally reneges and takes him into ED.

Jayden has DKA. The debate about over-zealous fluid administrations and its relationship to the dreaded cerebral oedema is long-standing. Previous research suggested a link but only by association, not causality.

You ask yourself…how fast should I give IV fluids?

Paper 5 - Kupperman et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis NEJM 2018 vol 378 (24) pp 2275-2287

The study examines the causal effect between fluid resuscitation and cerebral oedema.

They included 1389 episodes of DKA. Exclusions were mainly due to too much management prior to contact with the study team, as well as children with a GCS<12. The median age was 11. It should be noted that the very young and the very sick are probably lost in this cohort.

Patients were randomised to received either fast or slow rehydration, and then were split again into received either 0.9% NaCl or 0.45% NaCl.

The fast rehydration group received 20ml/kg bolus and then replacement of 10% deficit, half over 12 hours and rest over next 24 hours. The slow rehydration group received a 10ml/kg bolus and then replacement of 5% deficit over 48 hours. Maintenance fluids and insulin were given in addition.

The outcomes looked at were deterioration of neurological status within first 24 hours of treatment. They also assessed short term memory during treatment, and IQ 2-6 months after the episode of DKA.

In short, they found no difference between the groups. There was a 0.9% rate of brain injury overall and it didn’t matter which type of fluids or how fast. Patients were more likely to get hyperchloraemic acidosis in the 0.9% NaCl group but this is of debatable clinical significance.

Key take homes: The evidence does not support our traditionally cautious approach to DKA. The speed of IV fluids does not seem to be the cause of brain injury in DKA.

You resuscitate Jayden and send him off to the ward. He is discharged a few days later with good support from the Endocrine team for management of his diabetes.

FLASH FORWARD…

Jayden is now 16 years old and next time he comes to ED, he’ll be in the harsh world of Adult ED. We have navigated him through his common childhood presentations to ED and answered the key questions we ask ourselves every day in the Paeds ED.

 

Should I do a full septic screen on this hot baby?

Should I start high flow on this infant with bronchiolitis?

Should I give prednisolone to this 2 year old with wheeze?

Should I scan this child with a head injury?

How fast should I give fluids to my DKA?

And most importantly, do I ever need to sift through my child’s poo, or my own ever again?

Steroids in Wheeze: Meredith Borland at DFTB18

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

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

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.