With millions of journal articles published yearly, it is impossible to keep up.
This edition, we’ve teamed up with the team from Wexham Park Hospital ED, coordinated by Dr Mohomed Ashraf, Consultant in Emergency Medicine/PEM and Deputy Clinical Director for Emergency Medicine — five papers, five clinical questions that actually change practice: from pulse oximetry monitoring in bronchiolitis, to whether URTIs should delay procedural sedation, to a meta-analysis that quietly upends the “antibiotics-are-fine” narrative on paediatric appendicitis. Some of the papers are a few years old but still very relevant and sparked interest of the group.
As a Trauma Unit within the Thames Valley Trauma Network, Wexham Park draws trainees across acute specialties and serves one of the more diverse corners of Berkshire, UK — the reviews below reflect that range of clinical interest.
Happy reading 🙂
If you or your team want to submit a review, please get in touch with Dr Vicki Currie at @DrVickiCurrie1 or vickijanecurrie@gmail.com.
Article 1: What factors are predictive of parental anxiety in the Paediatric Emergency Department?
Martin, S.R., Hung, I., Heyming, T.W., Fortier, M.A. and Kain, Z.N. (2023). Predictors of parental anxiety in a paediatric emergency department. Emergency Medicine Journal. 40:715–720.
What’s it about?
A cross-sectional study looking at parents of children presenting to a paediatric ED in California, USA over a 3-month period. The aims were to understand factors contributing to higher parental anxiety found 42.5% of parents disclosed significant anxiety.
Factors most associated with higher parental anxiety were; poor parental mental health and children who tended to have a less energetic temperament. However, the severity of clinical conditions was not found to influence parental anxiety.
The study did not include patients who were admitted to hospital or families that were not fluent in English. These are two really important groups that ideally would have been captured.
Why does it matter?
We regularly meet particularly anxious parents, and it is important to explain our clinical decisions and address their concerns. Higher parental anxiety is closely linked to higher child anxiety and many studies have shown that parental anxiety influences a child’s perception of pain during procedures and can impact their recovery, and interactions with healthcare.
Interestingly, this study alludes to a factor we might not often consider – a child’s temperament. A child’s temperament influences how they experience and interact with their environment. Children with a ” higher activity temperament” are perceived by their parents to better tolerate the ED environment, which in turn eases their anxiety. In this way, taking the appropriate time to bond with a child and make them feel safe in their environment may help to gain parental support and reduce anxiety.
The other factor highlighted was parental mental health. Being mindful of this and asking about any underlying stresses may help to give those who need additional support.
Clinically Relevant Bottom Line
In conclusion, two risk factors were found to correlate with higher parental anxiety; parent mental health and a child’s temperament.
Armed with this knowledge, you can keep an eye out for those who may be more anxious and help you to address it despite the severity of the clinical condition.
Consider adding a screening tool for parental anxiety to your history, however more evidence is required.
Reviewed by Dr. Rebecca Kassam
Article 2: How good is lung US compared to a CXR in non-critically ill children?
Edelman J, Taylor H, Goss A, et al Point-of-care ultrasound as a diagnostic tool in respiratory assessment in awake paediatric patients: a comparative study Archives of Disease in Childhood Published Online First: 14 December 2023
What’s it about?
Comparing 100 POCUS (Point-of-care-ultrasound scan) images captured by trained physicians (in FUSIC/CACTUS) and assessing their adequacy in diagnosis and monitoring in children (<18 years) with suspected lung pathology that were deemed to require a chest X-ray (CXR).
100 children that presented to a tertiary paediatric trauma centre were recruited as a convenience sample and analysed. Independent FUSIC or CACTUS practitioners reviewed POCUS images and their findings were compared to a paediatric radiologist reporting on CXRs. 30% of the POCUS scans were normal and subsequently had a normal CXR. Of the 70% of abnormal POCUS, 6% identified abnormalities that were not reported on CXR.
The overall results when analysed showed POCUS has a sensitivity of 98.51% (95% CI 91.96% to 99.96%) and a specificity of 87.9% (95% CI 71.8% to 96.6%) when compared with CXR.
An important exclusion criterion was any child in the neonatal or paediatric intensive care unit or any child who had been in the hospital more than 12 hours.
Check out Top Ten Tips for New Paediatric POCUS providers – Don’t Forget the Bubbles
Why does it matter?
CXR has been the main way to image children with respiratory pathology but is associated with additional ionising radiation exposure, thus limiting its utility in getting repeated studies.
The use of POCUS in assessing lung pathology in children offers higher sensitivity and specificity than CXR and may easily provide diagnoses sooner than visible on CXR. POCUS is more amenable to the paediatric population due to lower subcutaneous tissue, decreased depth of image acquisition, and incomplete ossification of the ribs leading to easier image acquisition in general. To perform these scans there needs to be more accredited trainers to be able to train these skills.
Clinically Relevant Bottom Line
Lung POCUS when used in a ward based setting by appropriately trained members of the paediatric multi-disciplinary team is highly sensitive and specific compared to standard CXR.
With excellent positive and negative predictive values, it can reduce the need for repeat CXRs in awake paediatric patients; keeping in mind this was a pragmatic study and has some issues with external validity.
Reviewed by Dr Ellis Callow
Article 3:How good is point of care ultrasound in the diagnosis of testicular torsion in children?
Mori T, Ihara T, Nomura O Diagnostic accuracy of point-of-care ultrasound for paediatric testicular torsion: a systematic review and meta-analysis Emergency Medicine Journal 2023;40:140-146
What’s it about?
Testicular torsion is a surgical emergency that can lead to loss of the testis if not diagnosed and treated quickly. Ultrasound examination by specialist radiologists is over 90% sensitive and specific for testicular torsion in children. This systematic review and meta-analysis sought to evaluate the accuracy of point-of-care ultrasound (POCUS) by frontline clinicians in diagnosing paediatric testicular torsion.
The review included 4 diagnostic test accuracy studies that reported data on 784 children presenting to hospital with acute testicular pain. The index test was POCUS by a clinician, which was compared to a mixed reference standard that included the results of ultrasound by radiologists, intra-operative findings, and clinical follow-up.
Meta-analysis of included studies estimated that the sensitivity of POCUS for testicular torsion was 98.4% (95% CI 88.5% to 99.8%) and specificity 97.2% (95% CI 87.2% to 99.4%).
An important limitation is that only one study evaluated POCUS undertaken by paediatric emergency physicians with the other three by urologists. It is also not clear what level of training or degree of experience is necessary to reliably distinguish between torsion and other causes of acute testicular pain.
Check out Testicular torsion – Don’t Forget the Bubbles
Why does it matter?
Although testicular torsion can have devastating consequences when not recognised promptly, this diagnosis only accounts for 10-15% of children with acute testicular pain. As no single examination finding can distinguish torsion from other causes of testicular pain (such as torsion of the appendix testis and epididymo-orchitis) many children undergo surgical exploration unnecessarily.
A quick, safe, and readily accessible diagnostic modality could help identify a cohort of children with testicular pain who do not need to undergo surgical exploration.
Clinically Relevant Bottom Line
Although surgical exploration is the accepted standard for diagnosing testicular torsion in many countries, this study suggests a potential role for POCUS. Many clinicians will still favour a definitive test (i.e. surgical exploration) given the consequences of missing a case of testicular torsion.
However, it is possible that future diagnostic algorithms could include a combination of clinical features and POCUS findings to determine which children should undergo surgical exploration.
Reviewed by Dr David Metcalfe
Article 4: What are the patterns and predictive factors of healthcare utilization after a diagnosis of concussion?
Meyer EJ, Correa ET, Monuteaux MC et al. Patterns and Predictors of Health Care Utilization After Pediatric Concussion: A Retrospective Cohort Study. Academic Pediatrics 2024 24 1 51-58
What’s it about?
This retrospective cohort study was conducted in Boston Children’s Hospital and affiliated paediatric outpatient clinics between 2016 and 2019 and recruited 784 children between the ages of 5 and 17 diagnosed with a ‘concussion’ either in the ED or in primary care. The authors examined attendance numbers 6 months before and after a concussion and analyzed factors associated with re-attendance.
There was a significant increase in all-cause presentation to services in the 28 days after concussion. Before injury, children attended services on average 17 visits/1000 patients/day. In the 28 days after, this rose to 83 visits/1000 patients/day (p <0.001).
Factors significantly associated with re-attendance in the 6 months after injury included being on public insurance – more common among those of lower socioeconomic (SE) status, having a higher baseline number of attendances, and those previously diagnosed with depression/anxiety.
A history of headache disorders was also significantly associated with prolonged concussion-related healthcare (>28 days after injury).
For more information on concussion check out Persistent Post-Concussion Syndrome – Don’t Forget the Bubbles
Why does it matter?
Concussion is a relatively common presentation. Understanding which patients might be more likely to re-attend means we can provide more specific guidance to these patients and provide reassuring but appropriate follow-up advice on what to look out for.
This may improve healthcare utilization and allow healthcare providers to pre-empt appropriate follow-up clinics in specific children with concussions.
Clinically Relevant Bottom Line
Children with multiple previous ED attendances, those of a lower SE status, and those with headache disorders and mental health problems are all more likely to re-attend following a concussion.
Consider discharging these patients with specific written advice and detailed safety-netting with their follow-ups planned in either a clinic or their primary health care practitioner.
Reviewed by : Dr. Miranthi Huwae
Article 5: ‘How good are some analgesic agents in a pre hospital setting in children with acute pain?
Abebe, Y., Hetmann, F., Sumera, K. et al. The effectiveness and safety of paediatric prehospital pain management: a systematic review. Scand J Trauma Resusc Emerg Med 29, 170 (2021)
What’s it about?
A systematic review looking at the preferred drugs for pain relief in pre-hospital patients under the age of 18 with acute pain found 8 papers between 2000 and 2020.
They looked for common agents with their effect on the reduction of pain and any associated adverse events.
Both intravenous (IV) and intranasal (IN) fentanyl were found to be effective and as good as morphine. IV Morphine was found to be equally effective as fentanyl without quoting any adverse events.
Methoxyflurane (which is not licensed in the UK for under 18’s yet) was deemed effective at reducing pain but conflicting evidence on whether it is better than morphine or fentanyl or combination drugs.
Ketamine wasn’t looked at in terms of effectiveness but was found to be safe at analgesic doses.
A combination of drugs would work well according to this review however there was no evidence that they were more effective than fentanyl or morphine alone.
There are various limitations of the review: retrospective chart review and a paucity of high-level evidence. NSAIDs, paracetamol, entonox, and nerve blocks weren’t included in any of the studies.
For a deep dive on pain management check out Analgesia and Procedural Sedation Module – Don’t Forget the Bubbles
Why does it matter?
Why should in-hospital clinicians care about pre-hospital drug choices? Well, we want a lot of the same things from our analgesia – speedy, safe, and efficacious. Unsurprisingly, we also experience some of the same challenges; IM is painful and IV access might be challenging.
Prehospital pain has implications for pain assessments in our emergency department and effective pre-hospital analgesia contributes to timely ED analgesia and not having adequate analgesia can contribute to anxiety and poorer outcomes.
Clinically Relevant Bottom Line
IN fentanyl and morphine are comparable and seem to be the drugs of choice due to ease of administration, short duration of action, and safety profile – bearing in mind that paracetamol and ibuprofen were not looked at on their own.
Any analgesic agents are better than none!
Reviewed by Dr Emma Maxwell
If we missed something useful or you think other articles are worth sharing, please add them in the comments!
That’s it for this month—many thanks to our reviewers for scouring the literature so you don’t have to.
Vicki Currie, DFTB Bubble Wrap Lead, reviewed all articles.