It’s Only Wheeze – Treatment Is Simple, Isn’t It?: Meredith Borland at DFTB19

Cite this article as:
Team DFTB. It’s Only Wheeze – Treatment Is Simple, Isn’t It?: Meredith Borland at DFTB19, Don't Forget the Bubbles, 2020. Available at:

Meredith Borland is a paediatric emergency physician and the Director of Emergency Medicine at Perth Children’s Hospital in Perth, Western Australia. She was a founding member of the PREDICT Executive and is the current chair of PREDICT.

Last year at DFTB18, Meredith continued an ongoing discussion about the use of steroids in wheeze. This year, she took us on a journey through an emergency department visit for a number of children who may or may not receive various interventions. This was a fun, interactive and thought-provoking talk that highlighted some common differences in practice.

#doodlemed on this talk by @char_durand below

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal.

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.

Bubble Wrap Live – Top 5 papers in PEM: Edward Snelson at DFTB19

Cite this article as:
Team DFTB. Bubble Wrap Live – Top 5 papers in PEM: Edward Snelson at DFTB19, Don't Forget the Bubbles, 2020. Available at:

In the three years since we launched the Bubble Wrap segment, we have been able to highlight a number of key articles in paediatric research.  In this talk from the popular Bubble Wrap Live! sessions, Edward Snelson brought us his top five favourite articles from the world of paediatric emergency medicine.

He eloquently confronts his own biases and suggests a more critical way of looking at the patient in front of us.


Here are the five articles Edward chose.

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 Feb 1;6(2):97-106.
Kuppermann N, Dayan PS, Levine DA, Vitale M, Tzimenatos L, Tunik MG, Saunders M, Ruddy RM, Roosevelt G, Rogers AJ, Powell EC. A clinical prediction rule to identify febrile infants 60 days and younger at low risk for serious bacterial infections. JAMA pediatrics. 2019 Apr 1;173(4):342-51.
Borland ML, Dalziel SR, Phillips N, Lyttle MD, Bressan S, Oakley E, Hearps SJ, Kochar A, Furyk J, Cheek JA, Neutze J. Delayed presentations to emergency departments of children with head injury: a PREDICT study. Annals of emergency medicine. 2019 Jan 14.
Abe T, Aoki M, Deshpande G, Sugiyama T, Iwagami M, Uchida M, Nagata I, Saitoh D, Tamiya N. Is Whole-Body CT Associated With Reduced In-Hospital Mortality in Children With Trauma? A Nationwide Study. Pediatric Critical Care Medicine. 2019 Jun 1;20(6):e245-50.
Lyttle MD, Rainford NE, Gamble C, Messahel S, Humphreys A, Hickey H, Woolfall K, Roper L, Noblet J, Lee ED, Potter S. Levetiracetam versus phenytoin for second-line treatment of paediatric convulsive status epilepticus (EcLiPSE): a multicentre, open-label, randomised trial. The Lancet. 2019 May 25;393(10186):2125-34.
DoodleMedicine sketch by @char_durand

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

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


Eczema Management: Jean Robinson at DFTB19

Cite this article as:
Team DFTB. Eczema Management: Jean Robinson at DFTB19, Don't Forget the Bubbles, 2019. Available at:

Jean Robinson is paediatric dermatology nurse specialist working at the Royal London Hospital. Her area of expertise is something we could all be a bit better managing – eczema. She might be one of the few people that can actually describe a rash in twenty words or less. She also knows more than just steroids and wet dressings.







This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

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


The 34th Bubble Wrap

Cite this article as:
Grace Leo. The 34th Bubble Wrap, Don't Forget the Bubbles, 2019. Available at:

Article 1: Implementation of the neonatal sepsis calculator

Akangire G et al. Implementation of the Neonatal Sepsis Calculator in Early-Onset Sepsis and Maternal Chorioamnionitis. Advances in Neonatal Care. September 2019; Publish Ahead-of-Print: doi: 10.1097/ANC.0000000000000668 (accessed 20 October 2019)

What’s it about?

This quality improvement project aimed to develop guidelines and education materials for implementing the neonatal sepsis calculator published by Kaiser Permanente in 2017 in a neonatal intensive care unit (NICU). The calculator predicts the probability of neonatal early-onset sepsis (EOS) in babies ≥34 weeks gestation, based on maternal risk factors for chorioamnionitis and the baby’s clinical presentation.

The calculator then makes a clinical recommendation (no blood culture or antibiotics, blood culture but no antibiotics, or blood culture and antibiotics), and recommends the frequency of recording vital signs for the baby. The calculator relies on users knowing the incidence of early- onset sepsis for their particular hospital/neonatal unit. The calculator is gaining in popularity (certainly in my recent experience), but guidelines for its implementation in individual neonatal units are lacking. One of the concerns is that the calculator will take the place of clinical judgement. The researchers were based at a Level III NICU in the USA. They evaluated current blood culture collection and antibiotic use for suspected EOS in their unit, then developed guidelines and education materials for implementing the neonatal sepsis calculator, and then re-evaluated rates of blood culture collection and antibiotic use.

Why does it matter?

Neonatal early-onset sepsis (EOS) is culture-positive invasive infection that presents in the first 72 hours of life, with Group B streptococcus (GBS or S. agalactiae) the main culprit. Guidelines for screening for and treating suspected neonatal EOS vary, with the conventional wisdom suggesting at least 48 hours of empirical antibiotics for treatment of suspected EOS due to maternal chorioamnionitis. The definition of maternal chorioamnionitis also varies based on maternal symptoms, including intrapartum and postpartum fever and clinical instability. EOS guidelines vary for and within each state and territory in Australia, with some units implementing the neonatal sepsis calculator, and others using stricter guidelines for evaluation and treatment of suspected neonatal EOS. NICE Guidelines from the UK do not refer to the calculator, but use risk factors, clinical indicators, and red flags to guide antibiotic management decisions (

In the study, in the 4 months prior to implementing the neonatal sepsis calculator, antibiotic use for suspected EOS was 11%, and blood culture was done on 14.8% of live births. The calculator was subsequently implemented for 6 months. In the 4 months post-implementation, neonatal sepsis calculator use was more than 95%, antibiotic use decreased significantly to 5%, and blood culture use dropped to 7.6%.

Importantly, the researchers considered the management of asymptomatic neonates, for whom the implementation of the neonatal sepsis calculator represented the greatest change in practice. The calculator uses the highest antepartum maternal temperature to indicate chorioamnionitis. In asymptomatic infants, if there is no maternal fever, but a clinical diagnosis of chorioamnionitis is made, the neonatal sepsis calculator may recommend observation only, with no blood culture or antibiotics. By contrast, the neonatologists in the study agreed that in these cases, a full blood count and blood culture should be done, with antibiotics withheld.

The researchers did not advocate blanket implementation of the neonatal sepsis calculator in the absence of clinical reasoning. Indeed, part of their research required clinicians to document the recommendations from the calculator, and then document their reason/s for accepting or rejecting the recommendations.

What’s the bottom line?

In this quality improvement project around implementation of the neonatal sepsis calculator, high uptake was achieved (>95%). In comparision at 4 months pre and post implementation, there was an associated reduction in antibiotic use from 11% to 5%, with blood cultures taken dropping from 14.8% to 7.6% of live births. The neonatal sepsis calculator provides objective data that can be used along with clinical judgement to make decisions about investigations and treatment of EOS. 

Reviewed by: Katie Nash


Article 2: To scan or not to scan?

Why does it matter?

With increasing availability and use of imaging over the past 10 years there has been a growing concern regarding the risks of diagnostic ionizing radiation. Previously our data regarding this has been based on studies of atomic bomb survivors from Hirsoshima & Nagasaki. A previous UK cohort study of 170,000 children under 10 undergoing head CT scans showed 1 excess case of leukaemia and 1 excess case of brain cancer for every 10,000 scans performed (Pence 2012).

What’s it about?

This was a retrospective population based cohort study of South Korean children (under 19 years of age) who had had a claim made via the National Health Insurance System. From 2006-2015 there were 12,068,821 individuals include. Of these 1,275,829 (10.6%) were exposed to low-dose ionizing radiation (defined as CT and other modalities such as IV urography but not plain X-Rays) with 92% being CT. Any scans performed 2 years before a diagnosis of cancer was excluded as these may well have been performed in the diagnostic evaluation for malignancy.
Amongst the entire cohort there were 21,912 cancers detected and this included 1444 cancers amongst those exposed to radiation (0.1%). In the group exposed to low-dose ionizing radiation there was in increased in overall cancer incidence than in the non-exposed group. (Incidence Rate Ratio of 1.64 [95% CI 1.56-173] p<0.001).

What’s the bottom line?

This study adds to the evidence that diagnostic ionizing radiation such as CT does increase the risk of cancer. It is import to recognise this risk is small compared to the lifetime risk of cancer but medical practioners should judge carefully the risks and benefits of performing any scan and adhere to the “as low as reasonably achievable” (ALARA) principles (RCR guidelines 2012).
Reviewed by: Jamie Pope


Article 3: Rotavirus Vaccine Effectiveness in NSW

Maguire J.E et al.  Rotavirus Epidemiology and Monovalent Rotavirus Vaccine Effectiveness in Australia: 2010 – 2017, Pediatrics[Internet]. 2019 Oct;144(4). pii: e20191024. doi: 10.1542/peds.2019-1024. Epub 2019 Sep 17 [cited 2019 Oct 29].

Why does it matter?

Rotavirus gastroenteritis is a frequently encountered and unpleasant illness. In 2007, a monovalent live attenuated vaccine covering for several G1 strains was introduced into the Australian Immunization schedule. Vaccine effectiveness (VE) is the percentage reduction of disease when comparing immunized and unimmunized patients. 3 years after the introduction, hospitalization in children less than 5 years due to rotavirus gastro declined by 71% – so just how effective is the vaccine?

What’s it about?

A retrospective cross-sectional study looked at laboratory confirmed cases of rotavirus in NSW from January 1 st 2010 to December 31 st 2017. A total of 9517 cases were identified, and age, gender, ATSI status, immunization status and rotavirus genotype recorded. VE was calculated based on the 2017 dataset, a year where there was a significant rotavirus gastro outbreak, and looked at children aged 0 – 16 years, born after 2008. It appears that 2 doses of Rotarix are effective, with VE estimates of 88% for the 6 – 11month age group, 83% for the 1 – 3 year old age group and 78% for the 4 – 9 year old age group. It is notable that VE significantly reduced from 89.5% at 1 year post vaccination to 77% at 5-10 years post vaccination.

What’s the clinically relevant bottom line?

The vaccine (Rotarix) appears to be effective, especially in children under 12 months who are exposed to those G1 strains, however the emergence of new strains and the waning immunity with age raises 2 questions: should a new and improved vaccine be developed and do adults (particularly those who work in healthcare) need booster doses?

Reviewed by: Tina Abi Abdallah


Article 4:  How well do you know your inhaler technique?

Spaggiari S, Gehri M, Di Benedetto et al. Inhalation technique practical skills and knowledge among physicians and nurses in two pediatric emergency settings. J  Asthma [Internet]. 2019 Oct 17 [cited 2019 Nov 1]. doi: 10.1080/02770903.2019.1674329. [Epub ahead of print]

Why does it matter?

Effective treatment of wheeze requires an appropriate inhalation technique but inhalers are often used incorrectly. Such errors can hinder deposition of the active compound into the lungs, thus diminishing treatment efficiency, which can lead to inadequate treatment or control of the disease. To overcome this problem, the Global Initiative for Asthma report recommend that patients be asked to demonstrate their inhaler device technique at every visit to enable improper use to be corrected and ongoing use technique to be monitored. Unfortunately, many healthcare professionals who are charged with providing instruction and monitoring aimed at optimizing inhaler use are not well versed with the use of these devices themselves.

What’s it about?

The aim of the study was to assess the ability and knowledge of physicians and nurses to use a pMDI with a masked VHC in paediatric emergency units. They conducted a 2 centre observational study, in Switzerland, with a total of 100 participants (50 nurses and 50 physicians). Their inhaler technique instructions were checked using a manikin and were video recorded. Using a 9 point operational checklist the recordings were reviewed and marked by 3 experts in aerosol therapy. The second part of the study evaluated health care professionals inhaler user knowledge by using a semi-structured questionnaire.

49% of the healthcare professionals performed all nine steps of the inhalation technique perfectly, with about a third performing eights steps correctly, and less than a fifth performing five, six, or seven steps correctly. The most frequent errors were forgetting to shake the pMDI before the second dose and incorrect patient or VHC positioning.


Site 1 (Lausanne)

Site 2 (Geneva)



Mean Sore










Only 18% of physicians and 64% of nurses reported having had specific training on inhalation technique. A notable portion of the healthcare professionals lacked practical knowledge about pMDI and VHC use. Differences between sites, professions and grades were statistically significant but probably not clinically relevant. The mean score being 8.3 (out of 9) and differences between groups being no more than 0.6 (Nurses performed better than  Doctors, Registered Nurses better than  nurses with a diploma in emergency care but there was no difference between junior and senior doctors)

This study has several limitations. Participants were recruited during their work time. Thus, it is possible that their inhalation technique and survey responses were influenced by stress. On the other hand, the participants may have exhibited better performance because they knew that the study was underway and that they were being observed (Hawthorne effect).

Healthcare professionals’ practical skills and knowledge related to inhalation therapy were not completely mastered. In light of their results, they provided information to participating healthcare professionals to help them observe good practices and provide suitable inhalation technique support.

What’s the bottom line?

Overall this study demonstrates that some professionals lack knowledge on inhaler technique which could lead to ineffective administration of medication to children with wheeze. It is recommended that health care professionals receive brief repeated training programmes on inhaler technique to provide optimal advice to patients. Do you know how good your unit’s education of inhaler technique is?

Reviewed by: Suzannah Johnson


Article 5: Is there a link between shorter sleep in infancy and becoming more overweight later?

Tuohino T et al. Short Sleep Duration and Later Overweight in Infants. J Paediatr [Internet]. 2019 Sep [cited 2019 Nov 4];212:13-19. doi: 10.1016/j.jpeds.2019.05.041. 

What’s it about?

The longitudinal study examined the relationship between sleep duration and excess weight gain in infants. Sleep data (N=1679) was reported by parents at 3, 8, 18 and 24 months of age in Finland from 2011 to 2017. In 3-month-old infants, short sleep is associated with lower weight-for-length/height (p≤0.026) and body mass index (p≤0.038). Short sleep duration in 3-month-old infants was associated with greater risk for excess weight-for-length/height at 24-month-old (aOR 1.56; 95% CI 1.02- 2.38) and a predisposition to gain excess weight between 3 and 24-month-old (aOR 2.61; 95% CI 1.75-3.91). Short night-time sleep duration in 8-month-old infants was associated with greater weight-for-length at 24-month-old (aOR 1.51; 95% CI 1.02-2.33)

Why does it matter?

Numerous factors contribute to the obesity epidemic in children, such as sedentary behaviour and the increasing use of electronic devices. Previous studies have explored potential mechanisms for infant weight gain, which include parental obesity and feeding practices. Studies have associated short sleep with a heavier weight profile in older children and adults, although negative results also have been reported.

What’s the bottom line?

Short total sleep duration at 3 months and short night-time sleep duration at 8 months are associated with the risk of gaining excess weight at 24 months. Sleep is important for child growth and development. To prevent the childhood obesity epidemic in the future, parents are encouraged to be aware of their child’s circadian rhythm, bedtime routines and sleep hygiene.

Reviewed by: Jessica Wong


If we have missed out on something useful or you think other articles are absolutely worth sharing, please add them in the comments! We are also looking to expand the Bubble Wrap team so please contact us if you’re interested in this! 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. 

The 33rd Bubble Wrap

Cite this article as:
Grace Leo. The 33rd Bubble Wrap, Don't Forget the Bubbles, 2019. Available at:

Article 1: More evidence for lower dexamethasone dosing in croup

Parker C, Cooper M. Prednisolone Versus Dexamethasone for Croup: a Randomized Controlled Trial. Pediatrics. 2019; 144(3):e20183772 

Why does it matter?

There is a lack of data comparing prednisolone and low-dose dexamethasone for the treatment of childhood croup. Early trials have shown the safety and efficacy of 0.6mg/kg of oral dexamethasone and there have been some studies showing potential efficacy of 0.3mg/kg and 0.15mg/kg dosing. These  studies however have not been adequately powered to detect clinical significance.  It is known that 1mg/kg of prednisolone is effective in croup patients requiring intubation and shortens the time to extubation for patients with croup in intensive care1.

What’s it about?

A prospective, double-blind, noninferiority randomised controlled trial was conducted over two urban emergency centres in Perth, Australia. 1252 children >6 months old, and <20kg with croup were randomised to oral dexamethasone (0.6mg/kg; n=410), low-dose dexamethasone (0.15mg/kg; n=410), or oral prednisolone (1mg/kg; n= 411).  

The Westley Croup Score (WCS), a clinical score based on stridor, retractions, air entry and level of consciousness was assessed at baseline, and then hourly up to 6 hours, and again at 12 hours, if the patients were not yet discharged.  Results showed no statistically significant difference between the 3 groups for the WCS at the 1-hour assessment: 0.03 (95% CI- 0.09 to 0.15; p=0.62) for low-dose dexamethasone and 0.05 (95% CI -0.07 to 0.17; p=0.40) for prednisolone.  Both of these groups fell within the prescribed noninferiority margin of 0.5.  Interestingly, WCS for low-dose dexamethasone was 0.11 higher at 2 hours and 0.23 higher at 3 hours compared to 0.6mg/kg dexamethasone group.  The difference was significant at 3 hours (p=0.04), however, the upper limit of 95% CI (0.45) was within the noninferiority margin. Authors propose that the “ceiling effect,”theory, where steroid effect above a certain threshold does not have additional benefit, may be at a dose higher than 0.15mg/kg for a minority of patients. 

Re-attendance rates (to GP and ED) within 7 days after treatment were 17.8% for 0.6mg/kg dexamethasone, 19.5% (p=0.59) for low-dose dexamethasone and 21.7% (p=0.19) for prednisolone. 

Clinically Relevant Bottom Line

Noninferiority was demonstrated for both low-dose dexamethasone (0.15mg/kg) and single dose prednisolone (1mg/kg) compared with 0.6mg/kg dexamethasone. There was no clinically significant difference on efficacy in the acute period, as well as re-attendance rates to both GP and ED.  

Reviewed by: Lorraine Cheung

1.   Tibballs J, Shann FA, Landau LI. Placebo-controlled trial of prednisolone in children intubated for croup. Lancet. 1992:340 (8822): 745-748

2.   Geelhoed GC, Macdonald WB. Oral dexamethasone in the treatment of croup: 0.15mg/kg versus 0.3mg/kg versus 0.6mg/kg. Paediatric Pulmonology. 1995;20(6):362-368 


Article 2: The dangers of VALI (not the son of Loki)  

Ween MP, Hamon R, Macowan MG, Thredgold L, Reynolds PR, Hodge SJ. Effects of E cigarette E liquid components on bronchial epithelial cells: Demonstration of dysfunctional efferocytosis, Respirology. 2019 Sep 22. doi: 10.1111/resp.13696 [Epub ahead of print]

Why does it matter?

The e-cigarette was released in 2003, being marketed as safer for smokers and everyone around them. The use and popularity amongst adolescents continues to rise, despite new information about Vaping Associated Lung Injury (VALI), as well as injuries related to malfunctioning devices. In Australia, e-cigarettes containing nicotine liquid have been banned, but the base composition of a fruit flavour, vegetable glycerine (VG) and propylene glycol (PG) may still have harmful effects.

What’s it about?

An in vitro study which compared the effects of cigarette smoke extract to apple flavoured E liquid and nicotine (in a VG and PG base). The authors looked at cytokine release, cell necrosis, apoptosis and efferocytosis in healthy bronchial epithelial cells.

The results show that all individually (glycol bases alone, apple flavouring alone, nicotine alone) and combination (apple + nicotine) had significant toxic effects, when compared with the control of cigarette smoke extract. E cigarette components caused apoptosis and necrosis, reduced efferocytosis by down regulation of receptors, and reduced the production of certain inflammatory cytokines.

Clinically Relevant Bottom Line

To the surprise of nobody, e-cigarettes are not harmless. Ongoing research into the effects of first hand and second hand E- Cigarettes vapour, both containing nicotine and nicotine free, will be crucial in determining new policies and regulations, especially to curb the rise of use amongst our young population.

Reviewed by: Tina Abi Abdallah


Article 3:  Optimal fasting regimens – what does the evidence suggest?

Real fasting times and incidence of pulmonary aspiration in children: Results of a German prospective multicenter observational study. Beck et al. Paediatr Anaesth. 2019 Aug 22.

What’s it about?

Unfortunately, prolonged fasting times before a general anaesthesia is still common in paediatrics. The authors of this article hypothesised that shortened fasting times could improve the child’s condition during induction of anaesthesia and improve children’s and parental satisfaction. This prospective observational study in Germany looked at real fasting times and proposed reduced fasting times, but an (adapted) national guideline is lacking. Over 3000 children were included at 10 paediatric centres in Germany. Surprisingly, the real fasting times were 14 hours for large meals, 9 hours for light meals, 6 hours for formula, 5 hours breast milk and 3 hours for clear fluids. The authors report a prolonged fasting (defined as over 2 hours deviation from guideline) for large meals in 88%, for light meals in 55%, for formula milk in 44%, for breast milk in 26% and for clear fluids in 34%.

Eleven cases (0.33%) of regurgitation, four cases (0.12%) of suspected pulmonary aspiration and two cases (0.06%) of confirmed pulmonary aspiration were reported, without any prolonged anaesthetic.

Why does it matter?

Children having an anaesthetic should not be fasted longer than necessary as this negatively impacts tolerability of the child, the parents and their environment. This study shows that prolonged fasting is very common, from large meals to clear fluids. All cases could be extubated after the end of the procedure and recovered without any incidents which may suggest we are too strict with our fasting times.

Clinically Relevant Bottom Line

This study shows that prolonged fasting is still common in paediatric anaesthesia and that complications related to not fasting are rare and that improvements to current local fasting regimens and national fasting guidelines are urgently needed. Short fasting guidelines for children could potentially improve anaesthetic tolerance and satisfaction.

Reviewed by: Anke Raaijmakers


Article 4:  Family Chaos and Asthma Control

Weinstein SM, Pugach O, Rosales G, Mosnaim GS, Walton SM, Marin MA. Family Chaos and Asthma Control. Paediatrics. 2019. Aug;144(2). doi: 10.1542/peds.2018-2758. Epub 2019 Jul 9.

What’s it about?

This cohort study focused on 223 children (5 to 16 years-old) of low-income minority background with poorly-controlled asthma in the United States.  The study explored the relationship between asthma severity and psychosocial factors such as parental and child depression, post-traumatic stress disorder (PTSD) symptoms and family functioning.    Both parents and children showed higher rates of depression and PTSD symptoms compared to the general population. Parental and child depression symptoms were associated with poor asthma control, asthma severity and limitations of activity (P<0.001). PTSD symptoms were unrelated to child asthma outcomes. Family chaos serve as a predictor of poor asthma outcomes and a mediator for the relationship between parental depression and child asthma (P<0.05).  

Why does it matter?

Previous studies have shown a high prevalence of poorly-controlled asthma among school-aged children (6 to 17 years old). Studies have found increased rates of parental depression and anxiety, associated with poor child asthma outcome. Child depression and anxiety symptoms are predictors of poor asthma outcomes, including increased functional impairment, asthma severity and frequency of emotional triggers.

Clinically Relevant Bottom Line

Child and parent depression and family chaos are predictors of uncontrolled asthma. Family chaos also serves as the mediator between parent depression and asthma outcomes. To optimise asthma care, measures to screen youth and parent depression in community settings should be made aware and become part of the clinical guideline.

Reviewed by: Jessica Wong


Article 5:  Mother knows best?

Vanderkooi OG, Xie J, Lee BE, Pang X, Chui L, Payne DC et al. on behalf of Alberta Provincial Pediatric EnTeric Infection TEam (APPETITE) and Pediatric Emergency Research Canada (PERC). A prospective comparative study of children with gastroenteritis: emergency department compared with symptomatic care at home . Eur J Clin Microbiol Infect Dis. 2019 Sep 9. doi: 10.1007/s10096-019-03688-8. [Epub ahead of print]

What’s it about?

The “apple juice” paper highlighted that treatment of gastroenteritis can be simple but led many to question why some of the children recruited needed any formal fluid trials at all. This study by the same author (Stephen Freedman) was designed to compare the treatment and outcomes of children with gastroenteritis seen in the Emergency Department with those who were managed at home.

The recruitment strategy was dependent on a national helpline, those in the UK will know this as similar to 111, which triages and directs parents to call to either self-care at home or suggest onward referral.

A cohort of patients presenting to the Emergency Department with gastroenteritis (1317 children, median age 20.8 months) were compared with those who were managed at home (296 children, median age 17.4 months). The groups were essentially similar (both had a high rate of having a rectal swab for bacteria.viruses performed, in the ‘at home’ cohort this was taken by the parents).

Isolated vomiting was higher in the ED group but isolated diarrhea more frequent at the home cohort. While the median dehydration scores in the ED (3 IQR 2-4) were significantly different from at home (1 IQR 0-2) the clinical significance is not clear as both would rank as ‘some dehydration’ and the scale goes up to 8.

Why does it matter?

This could have been a ‘so-what’ study. You would expect that a group of children presenting to an ED with symptoms of gastroenteritis would vomit more than those staying at home and would be more clinically dehydrated. However this study again shows how minor dehydration generally is with gastroenteritis and how isolated vomiting causes concern in parents. Of most interest was over 35% of the at home group had norvovirus. This means if we can direct public health efforts to further educating parents on managing gastroenteritis it is possible we can further safely reduce ED attendance.

Clinically Relevant Bottom Line

Children are more unwell with gastroenteritis if their parents choose to bring them to hospital. But not by a massive amount and they do successfully look after children with infections often associated with need for admission.

Reviewed by: Damian Roland


If we have missed out on something useful or you think other articles are absolutely worth sharing, please add them in the comments! We are also looking to expand the Bubble Wrap team so please contact us if you’re interested in this! 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. 


Cite this article as:
Davis, T. Eczema, Don't Forget the Bubbles, 2019. Available at:

This post is based on teaching by Jean Robinson, Clinical Nurse Specialist in Paediatric Dermatology at the Royal London Hospital; and notes by Joe Piper.

The broad principles are of eczema are:

Emollients are to put moisture into the skin

Steroids are to reduce inflammation

Note: a skin flare up is always itchy – if it’s not, then question the diagnosis.


Can we cure it?

Atopic eczema is seen in 15-20% of children. There is no cure, and so treatment aims to control rather than cure the eczema. The aim is to get it under control. 80% will improve by puberty/teenage years with topical treatments. There will be remits and relapses, and children and families require education and support.

50% will resolve by age 7, but be careful with the figures you share with parents, as they may be disappointed when it does not improve. 85% of eczema sufferers have mild eczema, and most start with symptoms after one year of age.


Bad disease is usually due to poor management from the practitioner, or being on the right treatment but having poor compliance.

Poor adherence is the number one reason for a flare. There are often lots of psychological issues: embarrassment; bullying; confusion around treatment. Well-meaning relatives/friends can give contradictory advice and suggests alternative therapies.

Families will present with a mixture of frustration, stress, reduced quality of life, and are often miserable, with sleep disturbance. Eczema needs to be taken seriously and managed well. There is a similar reduction in quality of life to families of other chronic disease patients – partly due to sleep disturbance, but also a because it is a very visible disease.


Management principle 1 – Bathing

Bathing was previously advised for 15 minutes daily, in lukewarm water, with added oil.

The recent publication of the BATHE trial has turned this advice on its head. The Southampton-based trial randomised 483 children with atopic dermatitis to either have emollient added to the bath for 12 months or no emollient added to the bath for 12 months. Outcomes were eczema control and eczema severity. The BATHE trial showed no benefit in adding emollients to the bath.

However, there is ongoing debate amongst dermatologists as to whether this study is applicable to those being treated by specialist dermatology teams.

  1. The BATHE trial was conducted in patients being managed in primary care.
  2. No benefit was shown in the group who bathe 4 times or less per week; however, when looking at those who bathed more frequently, a clinically meaningful benefit was demonstraed (although it was small).

So for now, our hospital-based dermatology team at my own hospital in London, still recommends emollients in bath oils.

For bath oil, use Oilatum Junior or Hydromol. Use one capful for one baby bath. If a normal bath is being used, then use two to three capfuls and make sure it is mixed in well.

Oilatum Plus has antiseptic in it, and hence can cause bad dermatitis if not mixed in water well. Many centres do not recommend this version any more.

When washing with water – use a soap-free cleanser when washing as the water on its own will dry out the skin. The most infected use Dermol 500 as a soap substitute, and it can be used on the face. Consider applying this after washing hands, at nursery (this can be hard to do at school).

These are all prescribable: we should encourage GPs and us to prescribe it, so that parents do not have to buy it (to improve compliance)

Reactions to aqueous cream in children are so common that it should only be used as a soap substitute, and not as a leave-on emollient.


Management principle 2 – Steroids

There are four different strengths:

Mild: 1% hydrocortisone, (Fucidin H: Fucidin & Hydrocortisone)

Moderate: Eumovate (clobetasone butyrate 0.05%) – this is the strongest you should use on the face, Betnovate RD (reduced dilution 0.025%). These can be used for those over one year (if repeated courses are needed despite the eczema not improving then the patient should be refered to dermatology)

Potent: Betamethasone 0.1%, Fucibet (fucidin & betamethasone) –  microbial resistance is high in the UK, so only use for 14 days),  Elocon (mometasone furoate). These are the strongest for the body. They can be used for short term treatment i.e. one to two weeks, but you probably need a dermatology opinion if there is no response to the initial course.

Super-potent: Dermovate (clobetasol propionate), Clobaderm. These are dermatology recommended only.


Know the generic names as well as the brand names and check the percentage.

Hydrocortisone cream vs ointment – ointment is oilier and better.

The cream has more water and more additives. Only give the cream if the patient doesn’t  like ointments.

Note: If very very infected and ointment will slide off, then cream has better application, but this is very rare, even within dermatology (<2%).


How do you apply steroids?

As a rough guide – one finger tip unit (i.e. squeezed over adult finger) should be enough to cover two adult palm-sized areas.

It is much easier to say ‘apply enough so it looks shiny’. Do all the application with a finger, not with the hand, otherwise the majority will be absorbed before it reaches the child.

Make sure steroids are applied to inflamed areas, including open areas. But don’t apply it on surgical wounds or ulcers.

Skin thinning is rarely an issue (we hardly ever see skin thinning from topical steroid use, but we see loads of under treated children) – so avoid saying ‘apply a thin layer’.

The advice should be:

  • Start with pea-sized lump
  • Apply to all of the active area, including lichenified areas, hyperpigmented areas
  • Leave the healthy bits
  • For papular areas – anything that is thickened is inflamed and needs treating with steroids

Apply steroids twice a day in general, but there is a move to use them once a day (Mometasone is once a day)


Which steroids to choose?

Start with hydrocortisone on the face. If the eczema is severe, you can go up to a moderately potent steroid (e.g. Eumovate) on the face and potent on the body, but often this should be discussed with dermatology, and should certainly be discussed if it is not improving after two weeks. However, be more cautious in babies – from four months of age, you can use Eumovate (moderately potent) on the body.

Do not use potent steroids without specialist advice.

Only apply the steroids to active eczema. Use the steroids for seven days, and you can stop if it has completely cleared with no inflammation. There may be a need for longer steroid use e.g. for 14 days, 28 days, or 33 days for small, persistent parts.

Chronic relapse is very common and people struggle on for long time with too weak steroids. Often it is better to then try short dose of stronger steroids. Moderate or potent steroids for short periods only can be used in the axillae and groin – it can be difficult with skin folds to get to the active area. Generally, do not use potent steroid in children (e.g. Betnovate) without specialist advice. You can go up to potent/moderately potent on scalp.

Make sure you show people how to use the steroids i.e. consider it the same as checking inhaler technique.


Management principle 3 – Emollients

Use the greasiest the family are happy to use. If the child has very sore skin, then 50/50 is the greasiest.

With paraffin, beware of smoking, and open fires.

Lotions are acceptable, but not as greasy, so should be used only if the family are finding a greasy emollient too difficult.

The rough estimate is using one pot every two weeks (250g-500g), and use it four times a day if it’s bad enough for hospital presentation, otherwise they can step it down to twice a day

Pump dispensers are cleaner, but you cannot use emollients in a pump dispenser. From a tub, use a clean spoon at home, ideally with a saucer. Apply the emollient in the direction of hairs, so that it does not upset hairs and potentially lead to folliculitis. After a bath, the skin is very moist and so there is better absorption.

Put the steroid on first and then wait for 20-30 minutes and then put the emollient on top.

Keep going with emollients even when the eczema is clear. If the child is still scratching, use emollients.



If you want to dive a little deeper then read these previous posts…

The basics by Dilshad Marikar

Living with eczema by Andrea Coe

Complications by Andrea Coe