Defining Learning Disability

Cite this article as:
Liz Herrieven. Defining Learning Disability, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.33287

In all areas of paediatric practice (and beyond), we come into contact with children with a learning disability, learning difficulties or autism. Terminology is important, not only for making sure we understand a child’s diagnosis properly, but also for providing the best possible care. Getting it right can also help gain the trust of parents and carers who will often know far more about appropriate language use than we clinicians. This guide aims to describe the key points to remember – some of them easier to grasp than others.

Learning Disability

Let’s start with learning disability or LD. 2.5% of the children in the UK have a learning disability, yet it’s one of the most commonly confused terms. Probably the most pragmatic and descriptive definition is that used by Mencap, a UK charity supporting people with LD: “A learning disability is a reduced intellectual ability and difficulty with everyday activities – for example household tasks, socialising or managing money – which affects someone for their whole life.” The World Health Organisation keeps it short, although open to discussion and interpretation. For them it’s “a state of arrested or incomplete development of mind.”

Having a learning disability means an individual will not only find learning difficult but also face challenges with retaining, processing, reasoning and deducing information. Some people will find different areas of learning more challenging than others. Children with Down syndrome have a relative strength in visual learning and find learning or remembering auditory information more difficult. Building on strengths can help to balance out some of the more challenging areas. Some people with LD may be able to communicate very well, even if they struggle to understand all of what is communicated to them but many will have an associated speech and language problem.

The term intellectual disability, or ID, is used rather than LD, to signify that the condition affects intellect and is lifelong. This fact is important – the individual will need support, depending on their level of disability, for the whole of their life. There are many causes of LD, all involve the developing brain – genetic or chromosomal conditions, intrauterine infections, perinatal hypoxic brain injury to name but a few. After the brain has developed, such an insult is described as an acquired brain injury.

The level of disability may be mild, moderate or severe, depending on IQ, although this is rarely formally calculated and actually doesn’t really add much. Support and care should be tailored to an individual’s needs rather than their IQ.

The term PMLD is used to describe individuals with Profound and Multiple Learning Disability. These patients may have fairly complex comorbidities alongside severe learning disabilities. They can affect not only their ability to learn and process information, but also their ability to communicate and to be independent.

Learning Difficulty

A learning difficulty is very different to a learning disability, and is far more common. Things like ADHD, dyspraxia or dyslexia are all examples of a learning difficulty. They all make learning more difficult, but don’t affect overall intellect or IQ.

Autism

Autism, or an autistic spectrum condition (ASC), is not itself a learning disability, although about one-third of people with ASC will also have LD. The National Autistic Society (UK) describes autism as “a lifelong developmental disability which affects how people communicate and interact with the world”. There are lots of different elements, each of which may be present to a greater or lesser extent within one individual, so each autistic person is different from the next. The autistic spectrum is not a linear thing, with someone being more or less autistic. “High functioning” or “low functioning” are not particularly appropriate terms either. It’s more helpful to think about how someone’s autistic features affect them. The most common features include social communication difficulties, sensory processing disorder and restrictive or repetitive movements.

Social communication difficulties include challenges in interpreting body language or facial expression, and reading hidden meaning into words or phrases, particularly when metaphors are used. Sensory processing difficulties involve the body misinterpreting sensations. A light touch may be perceived as very painful whilst a deeper touch may be more comforting. Bright lights or certain noises could be very distressing. Restrictive or repetitive movements are often comforting, or theymay distract from upsetting or uncomfortable situations.

ASC was more commonly known as ASD, or autistic spectrum disorder. The move to calling it a condition, instead, is an attempt to remove unnecessary negativity. ASC encompasses many other conditions such as that previously known as Asperger syndrome. This name is no longer preferred – Hans Asperger has a troubling history. It was used to describe people with normal or even high intelligence, coupled with autistic features. Other conditions included under the ASC umbrella include PDD (pervasive developmental disorder) and PDA (pathological demand avoidance).

Person First vs Identity First Language

We use person-first language for many conditions. Someone with asthma is not defined by their asthma but has a whole identity of their own, so they are described as someone with asthma. Someone with Down syndrome may share certain physical features with someone else with Down syndrome, but they have their own identity and character which is very different from that of others with Down syndrome, so they are described as a person with Down syndrome, not a Down’s person or, even worse, a Downs.

Child with learning disability

Many autistic people feel that their autistic features form part of their identity – that they would be a very different person if they did not have autism, so they describe themselves as autistic, rather than a person with autism. You can read more about person first vs identity first language here.

And if you can’t remember what to say when?

Ask! It’s always better to ask someone how they would prefer to be described than to guess. All people. whether they have LD, a learning difficulty or ASC are individuals and will have their own preferences, likes and dislikes. Getting the language right can be a great start, but being honest and open when you’re not sure is a very close second.

Mother Ship by Francesca Segal

Cite this article as:
Mahima Chandrasekhar and Tara George. Mother Ship by Francesca Segal, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32838

A mother’s experience of the Neonatal Unit

Mother Ship by Francesca Segal chronicles the first 56 days, from birth to discharge, that the author’s twin, 30 week, premature babies spent in the NICU. She describes a journey that is far from smooth sailing; rocky and filled with turbulence from the start. At the same time, it is one filled with hope, longing and joy, which ultimately steers this ship to its destination: home. 

Book cover for Mother Ship

Segal describes how she expected her pregnancy to progress, and how divergent from reality it became. At times, her words are soaked in guilt and come through to the reader in waves: “we are encouraged to believe that a mother’s body is mad and clever… though mine was not quite mad and clever enough to sustain a pregnancy.” It is soothed, in part, by her well-timed jabs of humour, expressed through the rose-tinted glasses of nostalgia. She celebrates bonds forged through shared experiences between the mothers of the ‘milking shed’, makes us appreciate the enduring presence of her husband and prioritises hygiene in a way that would make every Infection Control team proud. 

Importantly, Segal highlights many areas for improvement in the way care is provided. Her observations of the NICU bring attention to the lightning-fast and disorientating ward rounds, the constant use of medical jargon, frighteningly alien words second only to the name of that town in Wales (you all know where I am speaking about), and reluctance in having to involve yet another ‘Mum’ in decision making. Despite this, she showers gratitude upon the healthcare professionals with whom she shares a complicated but respectful relationship.

The book evokes a cocktail of emotions, prompts you to give your mother a call, and makes you ever so fond of little ‘A-lette’ and ‘B-lette’. Mother or not, clinician or not, a treat for all who read.

Why I am recommending this book

Tara George (GP)

Mother Ship provides a window into a world that may be familiar to many of us in a work context but seen here through the eyes of a mother. Disorientating, frightening, a liminal place where babies born too small, too soon may live or may die. What really struck me was the camaraderie of “the milking shed”, the irreverent humour, the ability ultimately to be human when that was all she had left. It left me expanding the horizons of what the word “mother” really is.  There are important lessons for those of us who look after whole families as well as for paediatricians – leaving your newborn (safely?) in the hospital and being at home, a mother with no mothering to do. As a GP with some interest in perinatal mental health, it is clear how much mothers in the scenario need support but it is also made strikingly obvious how little time she has for anything other than sleep, travel, endless expressing of milk and being in the hospital.  The moment of absolute compassion and wisdom when the nurses send her and her husband out for dinner one night reaffirms for me how truly amazing NHS staff are at both the high tech bits of medicine and at the human side.  

Mahima Chandrasekhar (FY2)

Medical school has always highlighted the merits of clear communication, empathy and a multidisciplinary approach to decision making. We practiced a lot of these skills in simulated environments and attempted to apply our learning into the clinical environment, to varying degrees of success. Reading Mothership has provided me with the perspective of the mother. Apart from being an enjoyable and moving story, it has provided some constructive feedback on our communication as a health profession. This book has given me several points to reflect on:

‘Mum’ has a name!

It is often hard to remember all the names of all the children and parents. However, making that effort to ask for her name in the ward round will improve the quality of your rapport. It will also make the mother of your patient feel more like she is part of the team making decisions about the child: which she is.

The mother of your patient might be a patient too

Sometimes, the child is born via emergency C-Section, and the mother standing opposite you, less than a day after the operation, is on a cocktail of drugs to allow her to achieve basic functionality through the haze of pain. The information you are giving may not be absorbed in the way you intend, and something as small as offering her a chair to sit on, can make the world of a difference.

Avoid jargon

I often have to Google certain terms and abbreviations, especially when moving on to a new job. If it is confusing for a medical junior, I can imagine it being downright disorientating for a non-medical parent. Explaining the plan and developments in detail without jargon can help avoid unnecessary anxiety and misunderstandings.  

Involve parents in the decision making

Inevitably, parents will need to care for their children when discharged from hospital. Ensuring they are aware of the ongoing medical issues, red flags, NG tube training, basic life support, emergency numbers to call, is paramount for a safe discharge. Involve parents early, to avoid information dump at the end.

Being at the start of my medical career, everything is a learning point, and I could go on. You will make your own reflections, both personal and professional, when you pick up this book.

Mother Ship is an enjoyable learning experience on communication. A case-based discussion that is riveting and heart-warming, right in the comfort of your own home, with a warm cup of tea in hand and a rich environment for reflection. 

If you want to go deeper then please watch this heartfelt talk from neonatologist, Jasmine Antoine, about being the parent, not the practitioner in NICU.

Supraglottic airway devices

Cite this article as:
Jessica Rogers. Supraglottic airway devices, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32780

Endotracheal intubation (ETI) in children is thankfully rare and our first pass success rate could definitely do with some improvement.

It is difficult to compare the efficacy of various advanced airway techniques in children. There are ethical implications, of course, but also marked differences in ages and in the potential aetiology of the arrest. There is often time to talk with the intensive care team and make a plan based on the best airway for that given situation. Similarly, the operating theatre, home of many an airway trial, is a very different environment. We’ll look at advanced airways in cases of cardiac/respiratory arrest. Be mindful there will always be a difference in timing and skill set between out-of-hospital cardiac arrest (OHCA) to in-hospital cardiac arrest (IHCA).

There are few actual studies comparing the advanced airway treatments used during cardiac arrest management in children. There are even fewer studies surrounding the use of supraglottic airways (SGAs) in children. Most of these are observational studies.

ILCOR currently recommends endotracheal intubation (ETI) as the ideal way to manage an airway during resuscitation. They also state that supraglottic airways are an acceptable alternative to the standard bag-valve-mask ventilation (BVM). There are very few clinical trials in children on which these recommendations are based (and certainly none of rigorous design in the last 20 years). Due to this lack of evidence, they commissioned a study as part of the Paediatric Life Support Task Force.

Lavonas EJ, Ohshimo S, Nation K, Van de Voorde P, Nuthall G, Maconochie I, Torabi N, Morrison LJ, DeCaen A, Atkins D, Bingham R. Advanced airway interventions for paediatric cardiac arrest: a systematic review and meta-analysis. Resuscitation. 2019 May 1;138:114-28.


Lavonas et al. (2018) carried out a systematic review and meta-analysis on the use of advanced airway interventions (ETI vs SGA), compared to BVM alone, for resuscitation of children in cardiac arrest. Only 14 studies were identified. 12 of these were suitable for inclusion in the meta-analysis. They were mostly focused on OHCA. There was a high risk of bias and so the overall quality of evidence was in the low to very low range. The key outcome measure was survival to hospital discharge with a good neurological outcome. The analysis suggested that both ETI and SGA were not superior to BVM.

So now, let’s cover some of the literature on the use of supraglottic airway devices. These are mostly based on studies in adults.

The ideal ventilatory device

  • …is easy to set up and insert by anyone so it doesn’t matter what the make-up of the team is
  • …is quick to set up and quick to insert. This reduces the time taken away from other important tasks and allowing that all-important ‘bandwidth’
  • …allows for minimal risk of aspiration
  • …provides a tight seal to allow for high airway pressures if needed
  • …is sturdy enough that the patient cannot bite through it and cut off their own oxygen supply
  • …provides an option to decompress the stomach via the same device
  • …has minimal risk of accidental misplacement or loss of airway once inserted

If this sounds too good to be true, it is. No one device combines all of these essential features. This leaves us deciding which is most suited to the patient in front of us.

sizing chart for supraglottic airway devices
Rather than tape the i-gel to the cheek it is often easier to use traditional tube ties to secure the airway

It is very difficult to compare SGAs with endotracheal tubes (ETT). An ETT is a ‘definitive airway’ that provides protection against aspiration. This does not mean that SGAs are a ‘lesser’ option. An SGA is still an ‘advanced airway’ and more effective than using a bag-valve-mask technique. It is important to remember that advanced airways have their pros and cons. Whilst they may improve a patients’ likelihood of survival with good neurological recovery, there can be associated complications.

Table showing advantages and challenges of bag-valve mask compared to supraglottic airway devices

The science behind supraglottic airways

So what does the science say? There are few trials in children but there have been several seminal papers released on advanced airway techniques in adults. Whilst not directly related to children, they do raise some interesting points of comparison between devices.

Benger JR, Kirby K, Black S, Brett SJ, Clout M, Lazaroo MJ, Nolan JP, Reeves BC, Robinson M, Scott LJ, Smartt H. Effect of a strategy of a supraglottic airway device vs tracheal intubation during out-of-hospital cardiac arrest on functional outcome: the AIRWAYS-2 randomized clinical trial. Jama. 2018 Aug 28;320(8):779-91.

This multicentre, cluster randomised trial, was conducted by paramedics across four ambulance services in England. It compared supraglottic devices to tracheal intubation in adult patients with OHCA looking at their effect on functional neurological outcome. This study only included patients over the age of 18. They found no statistically significant difference in 30-day outcome (the primary outcome measure) or in survival status, rate of regurgitation, aspiration or ROSC (secondary outcomes). There was a statistically significant difference when it came to initial ventilation success. Supraglottic airways required less attempts, but their use also lead to an increased likelihood of the loss of an established airway

So what does this mean? The main concern that gets bandied around when discussing SGAs is the higher risk of aspiration. If there was no difference in risk, would that change your mind?

Jabre P, Penaloza A, Pinero D, Duchateau FX, Borron SW, Javaudin F, Richard O, De Longueville D, Bouilleau G, Devaud ML, Heidet M. Effect of bag-mask ventilation vs endotracheal intubation during cardiopulmonary resuscitation on neurological outcome after out-of-hospital cardiorespiratory arrest: a randomized clinical trial. Jama. 2018 Feb 27;319(8):779-87.

This was a multicentre, randomised clinical trial in France and Belgium looking at OHCA over a 2-year period. Again this study enrolled adults over 18 years old. They looked at the non-inferiority of BVM vs ETI with regard to survival with favourable neurological outcome at 28 days. Responding teams consisted of an ambulance driver, a nurse and an emergency physician. The rate of ROSC was significantly greater in the ETI group but there was no difference in survival to discharge. Overall, the study results were inconclusive either way.

If survival to discharge is unaffected, should we all be spending time training and maintaining competency or should endotracheal intubation be kept only for those who practice it regularly in their day job?

Wang HE, Schmicker RH, Daya MR, Stephens SW, Idris AH, Carlson JN, Colella MR, Herren H, Hansen M, Richmond NJ, Puyana JC. Effect of a strategy of initial laryngeal tube insertion vs endotracheal intubation on 72-hour survival in adults with out-of-hospital cardiac arrest: a randomized clinical trial. Jama. 2018 Aug 28;320(8):769-78.


This cluster-randomised, multiple crossover design was carried out by paramedics/EMS across 27 agencies. It looked at adult patients receiving either laryngeal tube or endotracheal intubation and survival at 72 hours. Again, they only included adults over 18 with non-traumatic cardiac arrest. They found a ‘modest but significant’ improved survival rate in the LMA group and this correlated with a higher rate of ROSC. Unfortunately, this trial included a lot of potential bias and the study design may not be robust enough to back up the level of difference.

Could the survival rate be explained by first-pass success and less time spent ‘off the chest’ during initial resuscitation? No study is perfect. Always critically appraise for yourself and check if study results are applicable to your local population and own practice before changing anything.

More questions than answers

After reading the science (and please do go take a deeper dive into those papers and appraise them for yourselves), let’s tackle some common queries.

SGAs are so easy you can just whack it in and done!

No. Getting the SGA in is only the first step. Even then, you need to be sure you have picked the appropriate size and assessed for leaks. SGAs are much more likely to become dislodged and lead to an unexpected loss of airway. Generally, we are not as meticulous about securing them as we should be. Ideally, use a tube tie to secure it in place and monitor the position (in relation to the teeth). Some SGAs have a black line on the shaft that should line up with the incisors (beware this may only be present in the larger sizes). Just like ETTs, they require you to check for adequate ventilation via auscultation, ETCO2 and listening for an obvious leak.


It’s okay if there is a leak at the start as the gel will mould as it heats up

No. There is no evidence to suggest the shape of i-gels (this is usually the model clinicians are referring to in this instance) will mould to the inside of the larynx. Researchers have tried heating up the material and there is no statistical change in the leak. If you do have a significant leak, consider re-positioning, swapping out for a different size or using a different model. You may find a small leak that disappears over time. Over time, the airway jiggles around and sits better.


You should always decompress the stomach when you put in an LMA

Possibly. This is not routinely found in guidelines as it is seen as more of a fine-tuning procedure. It can take time and resources away from other critical tasks (such as chest compressions, IV access, optimal ventilation) but if you have the resources to do so, without affecting the basics of good resuscitation care, then it is a good option if ventilation is not as optimal as it could be. This is particularly important in children. We know that they are at higher risk of diaphragmatic splinting from overzealous ventilation so the early insertion of a nasogastric tube can really improve things.

Laryngoscopy should be used before every SGA insertion

Possibly. Some places have started to mandate laryngoscopy because they have missed obstruction by a foreign body, or to allow better suctioning and improve the passage for insertion. There is an argument that the SGA may sit better if inserted with the aid of a laryngoscope as, in a number of cases, it hasn’t been inserted deeply enough. Laryngoscopy is a complex skill, that takes regular practice and comes with its own challenges (damage to mouth/teeth, additional time taken, higher skill set needed).

Once inserted, SGAs can be used alongside continuous chest compressions

Possibly. This really needs to be considered on a case-by-case basis. SGAs are an advanced airway and can be used with continuous chest compressions to increase cerebral perfusion pressures. It is up to the individual clinician to monitor and decide if the ventilatory support they are giving is adequate during active compressions. In cases where the arrest is secondary to hypoxia (as in many paediatric arrests) it may be easier, and more useful, to continue with a 30:2 or 15:2 ratio to ensure good tidal volumes are reaching the lung. Some studies have shown little difference comparing the 30:2 approach to continuous ventilation.

Troubleshooting

This is the same in both SGAs and ETTs.

  • Patient issues – vomit, secretions, bronchospasm, position, change in intrathoracic / intrabdominal pressures, and in SGAs there is a risk the epiglottis has moved and is covering the opening of the device
  • Device issues – position, size, biting/kinking of an ETT
  • Equipment issues – ventilator settings, connections, oxygen supply

Remember, if you are really struggling, take a second to consider if you might be in a “can’t intubate, can’t ventilate” type of situation. Check out this article, which takes a closer look at this rare scenario.

The bottom line is, we just do not know what is best in our paediatric population. Due to lack of scientific evidence, we often have to rely more on operator skill, available equipment and previous experience.

Selected resources on supraglottic airways

Check out the ‘Roadside to Resus: Supraglottic airways’ podcast from The Resus Room

PHEMcast also have podcasts on ‘The LMA’ and ‘The collapsed infant’

Nasal injuries

Cite this article as:
Ragavan Navaratnam. Nasal injuries, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.33108

13-year-old Freya (she/her) has been tackled in rugby and fell onto her nose. It bled initially and her mother has brought her as it is really swollen and looks wonky. “Is it broken, doctor?”

Nasal injuries in children are frequently encountered in paediatric emergency departments. One third of all nasal fractures occur in children, accounting for 60% of all facial fractures seen in the emergency department. The nose is the second most commonly injured site on a child and is more commonly seen in males. The most common locations of injury to the nose are: the nasal tip, the dorsum, and nasal root region with only 32% of injuries involving the nasal skeleton.

Nasal fractures are more common after three years of age, and unlikely below the first year of life, as the nasal bones are hardly ossified. But the bones aren’t the only thing you need to look out for; nasal obstruction and septal haematomas are important to identify and treat urgently.

History

Nasal trauma in children commonly arises following: falls, contact sports and automobile crashes, typically involving bicyclists or pedestrians. Non accidental injury also must be considered as a potential mechanism.

Important aspects of history should include:

  • mechanism
  • if there was any deformity immediately
  • new-onset nasal obstruction.
  • bleeding
  • anosmia

It is also important to note any previous nasal injury or pre-existing deformity.

Examination

Children with facial trauma are usually apprehensive, so any examination may be limited due lack of cooperation.  Pain relief and play therapy will go a long way. Bleeding and swelling often accompany injuries and can limit a thorough examination. Applying local pressure may be necessary prior to starting a formal examination.

Inspection

The examination should start with inspection of the nose and the surrounding facial structures.  It is important to note:

  • Periorbital bruising in the absence of other orbital findings is suggestive of a nasal fracture.
  • External nasal deformity, epistaxis, oedema, and bruising is highly suggestive of a septal injury. Any deformity more be masked by swelling.
  • A flattened, broad nose with an increase of the inner canthal distance and associated with vertical orbital displacement is suggestive of a naso-orbito-ethmoid fracture. The normal mean inner canthal distance is 16 mm at birth and increases to 25 to 27 mm in the mature female and male face, respectively, although there is ethnic variation.

The intranasal cavity should be assessed with a nasal speculum to exclude a septal injury. A septal haematoma can arise without the presence of any external signs. The septum should be examined for the presence of fractures, displacement, lacerations, discoloration, and abnormal swelling. Don’t forget that the nasal septum may be acutely or chronically deviated so you may need to ask about this in the history. Sometimes looking at an old photo helps.

The key findings suggestive of septal hematoma include:

  • An asymmetrical septum with a blue/red discolouration
  • Swelling of the nasal mucosa that obstructs the nasal passage
  • The size of the mass does not change with the application of topical vasoconstricting agents.

Most times a septal haematoma looks like a blueberry up the nostril.

Palpation

After inspection, the nasal bones should be palpated for tenderness, deformity, mobility and  crepitus, although realistically poking a bruised nose may be too painful to tolerate. It is important to note:

  • Tenderness over the frontal sinus may indicate frontal sinus fractures.
  • Tenderness to palpation of the tip of the nose may be suggestive of a septal hematoma
  • Tenderness and instability on palpation of the anterior nasal spine from beneath the upper lip may indicate a significant septal injury.
  • Malocclusion is suggestive of a midfacial Le Fort fracture.

It is important to exclude an associated skull fracture which may be indicated by the presence of clear fluid in the nasal cavity. A fracture through the cribriform plate can result in a CSF leak. In an ideal world you can test for beta-2-transferrin (present only in CSF, perilymph, and aqueous humor), but I have yet to hear of EDs which offer this.

The signs and symptoms of nasal septal injury may evolve during the 24 to 72 hours after injury. Children with nasal trauma should be safety-netted to return if anything changes after they go home.

Investigations

A history and clinical examination should more than suffice in guiding the management of children with nasal injuries. In simple nasal injuries, imaging adds very little. Plain radiographs are of very limited benefit as the majority of the nose in children in cartilaginous and therefore poorly visualised on x-rays.

In injuries associated with more worrying features i.e. CSF leak or malocclusion, CT imaging is the modality of choice due to the risk of a Le Fort fracture or a base of skull injury.

Classification

A number of classifications systems have been proposed for nasal injuries. The first and most widely quoted was based on the pattern of injury sustained and the direction of force applied. More recently, a classification system based on pathological findings was proposed. This second classification system has been adapted, to incorporate clinical findings as opposed to the  pathologic patterning of injury.

Table showing 6 types of nasal injury
Classification of nasal injuries

A complicated fracture is classified as a Type II to Type IV  fracture with CSF rhinorrhea, airway obstruction, septal haematoma, crush injury, numbness, severe displacement or midface involvement.

Treatment

The management of nasal trauma in infants and children depends upon their age, the degree of nasal obstruction, and associated injuries. Children with nasal trauma should maintain upright posture to prevent the formation and facilitate the resolution of any associated oedema and hematoma. Patients who have no symptoms, minimal swelling, and no septal deviation or hematoma do not need specific follow-up.  Ensure adequate analgesia is given and appropriate advice when to return (on-going bleeding, evolving nasal obstruction, worsening pain).

Epistaxis – Most acute nasal bleeds respond to direct pressure over the anterior nose. Encourage the child to pinch their own nose but if they are unable, asking a parent to perform this has the added benefit of helping reduce the patient’s anxiety. During simple compression, position the child upright and sit them forward. This will help avoid possible aspiration of blood. Distraction and play therapy during compression are useful. In the majority, bleeding is controlled within 5 – 10 minutes.

If direct pressure fails to control bleeding, a number of management options are available but are rarely needed in the emergency department. These include:

  • Nasal packing. Tamponading the bleeding point can be very effective but can be very distressing to children. Sedation is often required to facilitate the procedure. It is advisable to seek an ENT opinion before packing a child’s nose, especially if this is traumatic.
  • Topical vasoconstrictors. These can be very effective but are not without risks. They are most commonly used in the theatres by the ENT surgeons. Options include topical phenylephrine or oxymetazoline. After application of a vasoconstrictor, direct pressure should be applied for at least 5 minutes before reassessing for further bleeding.
  • Tranexamic acid.
  • Cautery. In the emergency department, chemical cautery is commonly used, predominately in the adult population. Typically 75% silver nitrate is used to arrest bleeding. Cauterisation is undertaken around the bleeding point. Cautery works most effectively on dry areas so direct cautery of a bleeding point is often unsuccessful until the surrounding area has been treated. Care must be taken to avoid the skin and it is paramount the child is calm and cooperative, which may necessitate sedation. Make sure you don’t cauterise both sides of the septum.

Children presenting with possible fractures or obvious deformity should be reviewed by an ENT specialist; generally this can wait a few days. In the very young, injuries resulting in nasal obstruction should be referred urgently as young children are obligate nasal breathers.

As mentioned previously, swelling and oedema can make an accurate assessment difficult. As such, an immediate referral of a child with a broken nose but no features of airway compromise may not be needed. Children can be referred to an outpatient clinic for review but should be seen within in five to seven days. Short delays in definitive management of up to a week have been shown to have little impact on long term outcome. However, delays over seven days can make reduction of fractures more challenging, largely due to the active growth centres in a child’s nasal bones promote rapid healing.

Potential complications of nasal injuries

A number of potential complications can arise as a result of nasal trauma, particularly if there is a fracture. The most common complication is obstruction. This is often due to either soft tissue swelling or a deviation of the septum following an injury. Persistent obstruction following an injury is more likely due to septal deviation and therefore requires assessment by an ENT surgeon.   

Poor cosmesis following healing is a common problem reported by patients and is a valid concern for many parents. Recent work has shown that those sustaining fractures at a younger age compared to those that had none, had no differences in functional outcomes but were likely to suffer with deviations of the septum, bumps or humps in the nasal bridge and saddle formation.  Ensuring a timely referral to a surgeon may help reduce the incidence of a poor aesthetic result for the patient.

A septal haematoma that is not promptly dealt with can result in a septal abscess or necrosis (and a future flat nose). Though infection can remain localised, cases of intracranial infection via tracking through the cavernous sinus have been reported. Cavernous sinus thrombosis is also a recognised complication of septal haematomas. Damage to the cribiform plate with a resulting CSF leak is also a potential avenue for intra-cranial infection.

Rarer complications but still clinically important include:

  • Lacrimal duct obstruction
  • Maxillary hypoplasia
  • Naso-oral fistula
  • Anosmia. If this occurs following trauma, it very rarely returns.

Take homes

A clever history and examination are key.

Ensure you examine the inside of the nose especially for a septal haematoma

Adequate analgesia and distraction will make examination much easier

Radiological investigations have little use in simple injuries.

Direct pressure for at least 10 minutes should stop most cases of epistaxis.

Make sure, if referring to clinic, the child is seen within a week.

You have examined Freya and she has no signs of obstruction, no septal haematoma and her bleeding as stopped. She does seem to have a deviated septum however, so you discharge her with advice for simple analgesia, safety-netted and referred her for rapid access ENT clinic within seven days.

References

Baek HJ, Kim DW, Ryu JH, Lee YJ. Identification of Nasal Bone Fractures on Conventional Radiography and Facial CT: Comparison of the Diagnostic Accuracy in Different Imaging Modalities and Analysis of Interobserver Reliability. Iran J Radio. 2013 Sep; 10(3): 140–147.

Beck R, Sorge M, Schneider A, Dietz A. Current approaches to epistaxis treatment in primary and secondary care. Dtsch Arztebl Int. 2018 Jan; 115(1-2): 12–22

Béquignon E, Teissier N, Gauthier A, Brugel L, De Kermadec H, Coste A, Prulière-Escabasse V. Emergency Department care of childhood epistaxis. Emerg Med J. 2017;34(8):543

Burnius M, Perlin D Pediatric ear, nose, and throat emergencies. Pediatr Clin North Am. 2006;53(2):195

Caglar B, Serin S, Akay S, Yilmaz G, Torun A, Adibelli ZH, Parlak I. The accuracy of bedside USG in the diagnosis of nasal fractures. Am J Emerg Med 2017 Nov;35(11):1653-1656.

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The 50th Bubble Wrap

Cite this article as:
Currie, V. The 50th Bubble Wrap, Don't Forget the Bubbles, 2021. Available at:
https://dontforgetthebubbles.com/the-50th-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.

Article 1: Are steroids of any use in pre-school wheeze?

Wallace A, Sinclair O, Shepherd M, et alImpact of oral corticosteroids on respiratory outcomes in acute preschool wheeze: a randomised clinical trialArchives of Disease in Childhood 2021;106:339-344

What’s it about? 

This paper looks at a common problem and one where there is huge variation in practice; should we give oral steroids to pre-school children who present to the emergency department with wheeze?

This was a double-blinded, randomised, placebo-controlled trial based in three hospitals in New Zealand. Children were either allocated 3 days of oral prednisolone or a placebo of similar colour, taste and viscosity (yuk!).  The primary outcome was measured by a change in Preschool Respiratory Assessment Measure (PRAM) score at 24 hours, although several interesting secondary outcomes were also measured.  The authors looked at 24–59 month-olds in order to exclude bronchiolitis cases. 3247 children were identified as being eligible with 477 children making it to the intended to treat analysis.

Why does it matter? 

In 2009 Panikar et al found there was no reduction in duration of hospitalization when giving steroids for pre-school wheeze, looking at children from 10 months to 6 years of age. However, in 2018 Foster et al found that giving oral steroids for children aged between 2 and 6 years old reduced their average length of stay from 540 to 370 minutes.

The authors of this paper found no difference in PRAM score at 24 hours between the groups (their primary outcome measure) and also no difference in the number of doses of salbutamol administered, length of stay for those admitted or representation rates within 7 days. A novel finding was that at 24 hours the median PRAM score was 0 for both groups and only one child still had severe disease (PRAM 9-12).  This might be the fact that 218 children were excluded for ‘severe disease’ despite this not being in the exclusion criteria, as well as 175 children excluded for previous life-threatening asthma and 123 excluded for chronic respiratory or cardiac disease.

However, the authors did find that the prednisolone group had less respiratory distress 4 hours after medication administration and reduced requirement for hospital admission, additional corticosteroid or intravenous treatment.

Clinically Relevant Bottom Line:

The results of this study suggest that giving oral steroids for pre-school wheeze is of limited benefit. However it may explain why there is perceived benefit, children clinically respond in the first 4-6 hours even if the overall outcome isn’t altered. It’s not clear from the study how long after arrival steroids were given and this may be an interesting area of further study.

Many centres now give single-dose dexamethasone which concords with the findings of this study in that 3 days of prednisolone may not be necessary given the median PRAM score of 0 at 24 hours. Some clinicians may find the reduced need for intravenous medications or hospital admission sufficient benefit to give a single dose of dexamethasone in the PED and so it is unlikely the debate about which pre-school children should receive steroids has been put to bed.

Reviewed by: James Thyng

Article 2: This is just how I cope

Herrick SS, Hallward L, Duncan LR. “This is just how I cope”: An inductive thematic analysis of eating disorder recovery content created and shared on TikTok using #EDrecovery. International Journal of Eating Disorders. 2021 Apr;54(4):516-26.

What’s it about? 

This Canadian study investigated the impact of eating disorder (ED) recovery videos shared on the social media platform TikTok.

The study completed a thematic analysis of the first150 TikTok posts under the hashtag #EDrecovery (Eating Disorder recovery) in June 2020 (454.5 million views as of June 2020 and around 1,500 posts with this hashtag).

Five themes were identified: ED awareness (N=32), Inpatient story time: “ED unit tings” (N=28), Eating in recovery (N=27), Transformations: “how about a weight gain glow up?” (N=27) and Trendy gallows humour: “let’s confuse people who have a good relationship with food” (N=36).

In around 1 in 5 of the posts creators shared different aspects of recovery to encourage a better understanding of recovery and ED’s. Four subthemes were found: recovery victories, reality of recovery, education and sharing positivity within these raising awareness posts.

Although the #EDrecovery videos raised awareness about eating disorder, some videos contain content which blur the line between ED recovery and pro-ED content and may be harmful to some TikTok users.

Why does it matter? 

Social media channels such as TikTok has a large impact on its user base, the majority of which are children and teenagers. TikTok formed in 2017 is one of the fastest growing mobile apps- with over 2 billion downloads (as of January 2020) and a whopping estimated 80 BILLION active users, the majority being children and young adults.

TikTok can be used to spread ED awareness and build a supportive community for ED recovery users. It is important to explore whether TikTok can be used as a tool to assist in ED recovery.

Clinically Relevant Bottom Line:

A fine line exists between ED recovery and pro-ED content. Some users find #EDrecovery videos helpful, while others may misinterpret the videos as triggering their ED behaviour.

Reviewed by: Jessica Win See Wong

Article 3: Do rapid diagnostic methods improve antibiotic prescribing in bacteraemia?

Faugno, AK., Laidman, AY., Perez Martinez, JD., Campbell, AJ., & Blyth, CC. (2021). Do rapid diagnostic methods improve antibiotic prescribing in paediatric bacteraemia? J Paediatr Child Health, 57(4), 574–580. https://doi.org/10.1111/jpc.15272

What’s it all about?

Rapid diagnostic methods are being developed to identify causative pathogens earlier to optimise early antibiotic therapy for patients with bacteraemia. The authors performed a retrospective study of 255 bacteraemia cases at a tertiary referral hospital in Western Australia. They compared patient outcomes in cohorts receiving antibiotics before and after the implementation of two rapid diagnostic tests: matrix-assisted laser desorption ionisation time-of-flight (MALDI-TOF) and GeneXpert Xpert MRSA/SA.

The median time taken to administer optimal therapy was not significantly different between those undergoing rapid diagnostic testing and those who did not (39.1 vs 44.4hrs, p= 0.66). Similarly, there was no significant difference in hospital length of stay (7 vs 9 days), number of ICU admissions (20 vs 15) or all-cause mortality (1.6 vs 1.6%).

Why does it matter?

It is well-established that timely administration of empirical antibiotic therapy in cases of sepsis can reduce mortality and morbidity. In fact, one-third of paediatric deaths within intensive care units are associated with sepsis or septic shock. What’s more, the prolonged use of broad-spectrum antibiotics and delay in targeting optimal therapy can potentiate antibiotic resistance.

Adult studies have already shown that timely identification of pathogens can improve appropriate antibiotic therapy but there is little known about its effect in paediatric populations who present with a difference clinical and microbiological profile.

The Bottom Line:

The lack of significant difference in this clinical outcome data suggests that there is no beneficial impact of implementing rapid diagnostic testing in paediatric populations with bacteraemia. The authors suggested possible reasons for this, such as the lack of explanations or training in interpreting rapid diagnostic test results for treating doctors, and therefore the need for a real-time programme to support clinical decision making. 

However, it would be interesting to compare this data to other paediatric hospitals through a multi-centre study, given that other regions may have higher rates of antimicrobial resistance and candidaemia which can alter the effectiveness of empiric antibiotic therapy. Moreover, changes to hospital guidelines for empirical therapy may be better captured through prospective studies in the future.

Reviewed by: Ivy Jiang

Article 4: What’s the time, Mr Wolf?

Stellman, R., Redfern, A., Lahri, S., Esterhuizen, T., Cheema, B. (2021) How much time do doctors spend providing care to each child in the ED? A time and motion study. Emergency Medicine Journal, Published Online First: 15 April 2021. doi: 10.1136/emermed-2019-208903

What’s it about?

The authors conducted a cross-sectional observational study over a 5-week period in two EDs – a tertiary centre and a large district hospital, both with separate paediatric ED areas – in the Western Cape of Africa. The “time and motion” methodology was used, where a single trained, independent observer was placed in the ED and observed and timed Doctors’ interaction with patients that met inclusive criteria. Criteria included age (0-13 years), unplanned presentation (not referred  by another source) and had an initial assessment by a qualified medical officer employed by that site. The patient triage category, as per the South African Triage Scale, was also recorded. Primary objective: to measure the total time taken by doctors to assess and manage each of a series of paediatric patients. Secondary objective: whether acuity of patient—as estimated by triage category affected the average time taken, and to compare these averages to the estimated benchmarks used to calculate hospital staffing allocations in the region.

A total of 100 patients were included and the median DTPP (doctor time per patient) for each triage category was as follows:

  • Green (routine; see within 4 hours): 31 minutes (Target set for staffing calculations are: 15 minutes for green)
  • Yellow (urgent; see within 1 hour) 39 minutes (Target 40mins/ patient)
  • Orange (very urgent; see within 10 minutes) 48 minutes (Target 50min/patient)
  • Red (emergency; see immediately) 96 minutes (Target 50min/ patient)

These time frames were compared with the local hospital benchmarks (developed to guide assigning ED staffing) and found that the median timing for patients triaged as green and red were significantly higher (p=0.001 and p=0.002, respectively). 

Why does it matter?

Time often seems warped inside the Emergency Department (ED) – some shifts fly by while others seem to drag on. Sometimes, you see a new patient every 30 minutes, and other times, you spend 3 hours with just one patient! Whilst most ED have audits to monitor Key Performance Indicators (KPI) looking at waiting times, time to treatment, time to admission / time to discharge etc few studies actually look at the (DTPP), which is the time spent assessing and managing a patient. This value depends on a large number of medical and psychosocial variables but if it can be accurately measured, it could be used to determine the right staffing required in a department.

The bottom line

Even with the limitations of this study (small sample size, only a single observer collecting data for a short period of observation per day), the DTPP was found to be significantly higher than the local expected time frame for the highest and lowest triage categories. This study could be repeated at your local ED (with the limitations addressed) and the information could be useful in determining whether your ED is adequately staffed, which would in turn improve a variety of KPIs.

Reviewed by: Tina Abi Abdallah

Article 5: Is the use of excessive non-resuscitation fluid associated with worse outcomes?

Barhight MF, Nelson D, et al.Non-resuscitation fluid in excess of hydration requirements is associated with higher mortality in critically ill children [published online ahead of print, 2021 Mar 17]. Pediatric Research. 2021;1-6.

What’s it about?

This study looks at whether giving excessive non-resuscitation fluid to critically unwell children is associated with a worse clinical outcome.

The authors conducted an observational study in PICUs of two large American hospitals between 2010 and 2018. They reviewed 14,483 patients and calculated their daily fluid balance for the first 3 days of their stay. This included all fluid given that wasn’t prescribed as a ‘bolus’. They then used the cumulative fluid balance at the end of day 3 to work out a percentage fluid overload (FO) which they stratified into <10%, 10-20% and >20%. The primary outcome was in-hospital mortality and the secondary outcome was ventilator-free days at 28 days.

For each FO category, the volume of fluid that was given in excess of the estimated requirement (using the Holliday-Seger method) was calculated. This demonstrated that excess non-resuscitation fluid was given in just over 1 in 2 of the patients and that maintenance fluid and nutrition were the largest contributors to fluid input. The number of patients receiving excess fluid increased with each FO category and equated to an excess of 164ml/kg in the >20% group.

Analysis was performed for each FO strata to look for an association between % FO and mortality, adjusting for confounders such as age and illness severity. This demonstrated an increase in adjusted odds of death when compared to the <10% group of 1.8 times in the 10-20% group and 2.6 times in the >20% group.

The authors also found that for every 10ml/kg of excess fluid given, there was 1.01 times higher odds of death. There was also a 1% decrease in likelihood of having a ventilator free day.

As this is an observational study, it can only demonstrate associations and not causality.

Why does it matter?

In the adult population studies have shown that almost 60% of the fluid administered to patients was in the form of maintenance fluids and “fluid creep” (the combined volume used from medications, electrolytes, and continuous infusions used to keep access lines open).

Even though this study relates to critically unwell children, maintenance fluids are something we prescribe routinely within paediatrics, and this study highlights the need for a carefully considered approach to their use in all children, with frequent readjustment according to fluid balance so as not to cause harm.

Further studies are required to examine whether our current prescribing practices should be modified, but nevertheless, this study should make us think more carefully about how much fluid we are giving to our patients.

Clinically Relevant Bottom Line:

 This study shows that non-resuscitation fluids are frequently given to patients in excess of their hydration requirements and could represent potential iatrogenic harm. 

Reviewed by: Laura Duthie

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

That’s it for this month. Many thanks to all of our reviewers who have taken the time to scour the literature so you don’t have to.

All articles reviewed and edited by Vicki Currie

Croup

Cite this article as:
Laura Riddick. Croup, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32637

It’s 0200 hours in the Emergency Department and you hear a seal …

As children have returned to school we have seen more croup through the ED so it’s time to refresh your memories!

What is it?

Viral laryngotracheobronchitis. It is essentially inflammation around the main large breathing structures and caused usually by parainfluenza 1 + 3. Other respiratory viruses including SARS-CoV-2 and RSV may also be involved. This inflammation causes a tell-tale cough and noisy breathing due to the obstruction to flow. There may be signs of increased work of breathing too such as sub-costal recession or a tracheal tug. They are generally quite well and are running around the waiting room!

Who gets it?

A lot of children – roughly 2-3% of all children per year! These kids are usually between six months and four years of age, and occurs at the beginning of autumn, though this spring we are seeing a lot of cases. Children with croup may present with a preceding coryza-like illness and a low-grade fever. This then develops into a barking “seal-like” cough and, for some reason, always seems worse at night. Boys are more commonly affected than girls, and some children seem to get it yearly.

How do we treat it?

This depends on your assessment of the child. Croup is a self-limiting viral illness and treatment tends to look to short term reduction in the inflammation to improve the work of breathing. Historically clinicians have used Westley scoring system to score croup and assess their severity before giving medication.

Westley Croup scxore
Westley Croup Score

In children who look unwell, it is important to not upset them by avoiding unnecessary interventions such as excessive handling or performing an ENT exam.

Steroids

If the child is able to take the medication, dexamethasone or prednisolone should be given to all cases of croup where any stridor or increased effort in breathing is present.

Dexamethasone appears to be more efficacious than prednisolone. It has an onset of action within 1 hour (30 minutes – 4 hours) and has a half-life of up to 36-72 hours (Schimmer 2005). There has been debate overdosing with doses of 0.15mg/kg, 0.3mg/kg and 0.6mg/kg of dexamethasone. Ultimately, 0.15mg/kg not inferior to 0.6mg/kg. At the time of writing both NICE and the BNFc recommend 0.15mg/kg as the initial dose of dexamethasone. If there are concerns about re-occurrence patients are occasionally sent home with an additional dose to be taken 12 hours later.

Prednisolone tends to be favoured in the primary care setting, at a dose of 1mg/kg with two additional daily doses. There appears to be no significant clinical difference between the two different steroids in terms of the need for additional treatment or length of stay. Dexamethasone was associated with a reduction in re-attendances, which may be due to the shorter half-life of Prednisolone (Gates 2018, Schimmer 2005)

Nebulised budesonide (2mg stat dose) is reserved for children who cannot take the dose. This may be because it was spat ou tor because they are working too hard to breathe. A Cochrane review in 2018 shows that budesonide is not superior to dexamethasone, with Westley Croup scores better in the dexamethasone group at 6 and 12 hours compared to budesonide. A combination of treatment does not appear to lead to additional benefit (Gates 2018)

Adrenaline/epinephrine

In severe cases, when the child has features of severe work of breathing, including significant recession, hypoxia or tiring, nebulised adrenaline has been used (0.4-0.5ml/kg, maximum 5ml of 1:1000). Adrenaline provides short term relief from respiratory distress and can be a bridge to getting steroids on board. The effects are short-acting and wear off after a couple of hours. It can be repeated every 30 minutes, although if you need repeat doses, anaesthetics and senior colleagues should be involved in this patients’ care.

How do we not treat it?

In the olden days parents tried treating croup at home with steam inhalation (not effective). In hospitals, humidified oxygen has also been tried though this has not been proven to be effective either (Moore 2007). Heliox (oxygen and helium combined) has also been looked at as it may improve airflow. The evidence is limited and safety and efficacy remain questionable (More, 2018). There is no evidence that salbutamol works in croup.

They sound better, what’s next?

If they are well and the stridor has resolved, patients can be discharged home with safety-netting advice. The effects of dexamethasone should last as croup itself is usually limited to 2-3 days of symptoms. Parents need to be aware that some symptoms of respiratory distress can return, usually the following night.

Patients may require a prolonged period of observation if:

  • stridor is still present at rest, or there is increased work of breathing
  • the child is very young (<3 months)
  • an adrenaline nebuliser had to be given
  • there is a past history of severe croup
  • there is a history of upper airway problems (i.e. laryngomalacia or subglottic stenosis)
  • concerns about the child returning (i.e. long-distance, social concerns)

When is it not croup?

  • Epiglottitis – a rare condition thanks to the HiB vaccine. A child would present with sudden onset, fever, drooling and looks unwell holding the head back and neck extended. This is a medical emergency and keeping the patient calm is paramount.
  • Tracheitis– thankfully also rare. It presents with the child acutely unwell after a prolonged course similar to Croup.
  • Anaphylaxis/allergy – this may be accompanied with angioedema, rash and wheeze, and requires swift treatment with IM adrenaline
  • Quinsy/retropharyngeal abscess
  • Foreign body – Usually the history would help suggest this, with a sudden onset history in a well-child.

COVID and croup

Most children admitted into hospital are now swabbed for COVID. This can provide a challenge – balancing upsetting the child (and making the upper airway obstruction worse) and performing an invasive swab. It is sensible not to swab the child whilst there is still concern about acute stridor and work of breathing..

There have been some case studies to suggest a small cohort of patients with croup who were SARS-CoV-2 positive are less responsive to the usual treatment (Venn 2020). These cases may need prolonged admission due to lack of response and the need for additional supportive therapy.

Selected references

  1. Al-Mutairi B, Kirk V. Bacterial tracheitis in children: Approach to diagnosis and treatment. Paediatr Child Health. 2004;9(1):25-30. doi:10.1093/pch/9.1.25
  2. Garbutt JM, Conlon B, Sterkel R, et al. The comparative effectiveness of prednisolone and dexamethasone for children with croup: a community-based randomized trial.  Clin Pediatr (Phila). 2013;52(11):1014–1021.
  3. Gates  A, Gates  M, Vandermeer  B, Johnson  C, Hartling  L, Johnson  DW, Klassen  TP. Glucocorticoids for croup in children. Cochrane Database of Systematic Reviews 2018, Issue 8. Art. No.: CD001955. DOI: 10.1002/14651858.CD001955.pub4. Accessed 28 April 2021
  4. Moore M, Little P. Humidified air inhalation for treating croup: a systematic review and meta-analysis.  Fam Pract. 2007;24(4):295–301
  5. Moraa I, Sturman N, McGuire TM, van Driel ML. Heliox for croup in children. Cochrane Database of Systematic Reviews 2018, Issue 10. Art. No.: CD006822. DOI: 10.1002/14651858.CD006822.pub5
  6. Schimmer B P, Parker K L. Adrenocorticotropic hormone: adrenocortical steroids and their synthetic analogs: inhibitors of the synthesis and actions of adrenocortical hormones. Goodman and Gilman’s the pharmacological basis of therapeutics, 9th edition. New York: McGraw‐Hill, 20051459–1485
  7. Smith DK, McDermott AJ, Sullivan JF. Croup: Diagnosis and Management. Am Fam Physician. 2018 May 1;97(9):575-580. PMID: 29763253.
  8. Sparrow A, Geelhoed G. Prednisolone versus dexamethasone in croup: a randomised equivalence trial. Arch Dis Child. 2006;91(7):580-583. doi:10.1136/adc.2005.089516
  9. Venn AMR, Schmidt JM, Mullan PC. A case series of pediatric croup with COVID-19 [published online ahead of print, 2020 Sep 15]. Am J Emerg Med. 2020;S0735-6757(20)30829-9. doi:10.1016/j.ajem.2020.09.034
  10. https://www.rch.org.au/clinicalguide/guideline_index/Croup_Laryngotracheobronchitis/
  11. https://cks.nice.org.uk/topics/croup/