With millions of journal articles published yearly, it is impossible to keep up.
In this edition, we’re taking it back to DFTB26, where, in bonnie Scotland, we experienced a truly magical Bubble Wrap Live. This is the first of 3 instalments. Looking at 5 important papers in Paediatrics by Sarah McNab.
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: Adjunctive Prednisolone Treatment for Kawasaki disease
Lin S, He Y, He L et al. Randomized Trial of Adjunctive Prednisolone for Kawasaki Disease. N Engl J Med. 2026 Apr 16;394(15):1480-1490. doi: 10.1056/NEJMoa2511478. PMID: 41985133.
What’s it about?
The first study is on Kawasaki disease, so for those of you who treat Kawasaki disease, many of you would be familiar with the RAISE trial, but what has been tricky, certainly for us at I work in Melbourne, is the interpretation of the trial, and which children really do benefit from steroids versus children who don’t need steroids.
This was a randomised controlled trial conducted in China, and it included about 3000 children. The population were kids with Kawasaki disease over the age of one month. The intervention was prednisolone plus standard therapy (IV methylprednisolone) versus standard therapy alone.
They used a high dose, with two milligrams per kilogram for a long period of time, so they used IV methylprednisolone until the temperature had normalised for three days; then they continued to use oral prednisolone until the CRP normalised, and then they continued to use prednisolone for another two weeks while they slowly weaned it.
Standard treatment was IVIG plus aspirin, and the outcome was coronary artery dilatation at one month.
Importantly, they randomised children who already had coronary artery lesions.
Why does it matter?
They found no difference at one month, so the children who got steroids had slightly more, but not statistically significantly more, coronary artery lesions at one month compared to those who did not receive prednisolone. Now it’s worth having a look at this paper. I personally disagree with their outcomes and some of their discussion.
So, in their discussion, they are not committal, but I want to look at some of the secondary outcomes. By using prednisolone, they halved their use of rescue therapy (4.6% vs 10.1%), so by that I mean a second dose of IVIG or, you know, other types of rescue therapies, including biologics. They reduce the duration of fever by a little bit (8.4 hours vs 13.2 hours).
Clinically Relevant Bottom Line
But how I interpret this is, in the short term, steroids are good. You can probably stop, or at least halve your need for IVIG, which is not nothing, right? I prefer them only to have as much IVIG as they need, but I’m not going to go for weeks and weeks of steroid therapy for these kids. A short dose, turn off their fever, get them home, and then I would probably stop the prednisone; that’s my interpretation.
Reviewed by Sarah McNab
Article 2: Are you worried your child is getting worse?
Mills E, Lin P, Asghari-Jafarabadi M et al. Association between caregiver concern for clinical deterioration and critical illness in children presenting to hospital: a prospective cohort study. Lancet Child Adolesc Health. 2025 Jul;9(7):450-458. doi: 10.1016/S2352-4642(25)00098-7. Epub 2025 May 29. PMID: 40451224.
What’s it about?
This study was conducted at Monash in Melbourne, and it addresses the age-old question we are all taught in medical school: to listen to the parents. This was not a study per se, in which they conducted an intervention.
This was a whole hospital practice change study, and so what they did was, for all children in hospital, before they took observations and vital signs, they asked parents a very simple but brilliant question:Â Are you worried your child is getting worse?
They didn’t say, ” Are you worried about your child?” That’s kind of a trick question. If you’re in hospital, right? Like, if you’re in hospital, you’re worried about your child, and I would be scared that if I said I wasn’t worried, they’d send me home. So, it’s a very clever question.
Then they looked at those who were concerned at any point during the admission, those who were not concerned at any point during the admission, and they compared PICU admission rates.
Why does it matter?
It was a massive study: 25,000 children of interest out of 70,000 admitted in that time. So they asked a third of the eligible families the question at some point. Out of the 25,000, if you were worried at some point during admission, you had a 6.9% chance of going to the ICU, and if you didn’t have a concern, there was a 1.8% chance. Yeah, they looked at other big things, mechanical ventilation, death, and they found a difference there, although that difference was not statistically significant, and that makes sense, because it’s not powered for that.
Clinically Relevant Bottom Line
Remember that there were 25,000 children, but you could be asked the question more than once, and so, of 189,708 responses, about 5% of them were yes, per admission per child, remembering that they didn’t ask everyone, so there were some kids that there’s a bit of a selection bias here, but per admission per child was 20% so is that high or is that low?
What was interesting was that caregiver concern was more strongly associated with ICU admission than any abnormal vital sign, so my take-home from this is we should all be asking this question.
Reviewed by Sarah McNab
Article 3: Mild asthma reliever therapy – CARE study
Hatter L, Holliday M, Oldfield K et al. Budesonide-formoterol versus salbutamol as reliever therapy in children with mild asthma (CARE): a 52-week, open-label, multicentre, superiority, randomised controlled trial. Lancet. 2025 Oct 4;406(10511):1473-1483. doi: 10.1016/S0140-6736(25)00861-X. Epub 2025 Sep 28. PMID: 41033330.
What’s it about?
This is a study from New Zealand. This compared budesonide-formoterol with salbutamol as a reliever therapy in children aged 5 to 15 years. This is similar to the Maintenance And Reliever Therapy (SMART) trial that I think hopefully a lot of you who treat asthma are aware of, but it was different in an important way.
SMART therapy looked at PRN (as-needed) Symbicort versus everyday Flixotide; this one looked at PRN budesonide-formoterol versus PRN salbutamol, so there was no regular Flixotide. Â Patients were given either budesonide-formoterol, two puffs PRN, or salbutamol, two puffs PRN, when they had an exacerbation. Their outcomes were asthma presentations, which they defined as not necessarily including asthma admissions.
These were well kids, so they excluded children who had had asthma admission in the past year, they excluded kids that needed more than six canisters per year and previous life-threatening asthma.
Why does it matter?
Their primary outcome is a little bit hard to conceptualise. So, if each child had one attack a year, that would be 1.0. Not all children had an attack in the year, but the asthma attack rate for the budesonide-formoterol group was 0.23 per participant per year versus 0.41 in the salbutamol group, so another way of saying that is they halved asthma attacks. The chance that you would have at least one asthma attack in the year was 17% versus 32%.
Interestingly, when looking at the additional data, they didn’t find a difference for children 5- 11 years old (RR 0.72 (0.46–1.12). For the 12- to 15-year-olds, there was a great improvement there (RR 0.06 (0.01–0.43)). What I get really confused about is this: it didn’t work for females, which I don’t know why, and I do not know how to interpret this, except that maybe we need some more data.
Clinically Relevant Bottom Line
Maybe we need to keep studying this question, especially for the 5- to 11-year-olds. What I know from this study is that if I have a teenage boy, they need budesonide-formoterol. Everyone else, let’s wait for more data.
Reviewed by Sarah McNab
Article 4: Screening-to-intervention pathway for child anxiety problems
Reardon T, Ukoumunne OC, Taylor L et al. Screening-to-intervention pathway for child anxiety problems alongside usual school practice versus usual school practice only (iCATSi2i): a cluster-randomised, controlled trial in primary schools in England. Lancet Psychiatry. 2026 May;13(5):396-412. doi: 10.1016/S2215-0366(26)00064-7. Epub 2026 Apr 9. PMID: 41969016.
What’s it about?
Screening for anxiety problems in primary schools and offering parent-led cognitive behavioural therapy (CBT) via online and telephone support for those who screen positive could address key barriers to effective early intervention for some of the most prevalent child mental disorders.
Why does it matter?
This was a study from England on anxiety: a pragmatic, parallel-group, superiority, cluster-randomised, controlled trial conducted in 84 primary and junior schools with at least two Year 4 classes.
They screened the children within the schools for anxiety symptoms, and then they randomized the school, so that’s called cluster randomization, rather than randomizing the individual child, that they randomized the school, and to the schools that got the intervention, they had a whole class session on anxiety and mental health for the kids who were anxious and the kids who were not, and then for the kids who were anxious in the intervention arm, the parents got online CBT modules. The primary outcome was screen-negative for anxiety problems (score 0-2 on the parent-reported iCATS-2) versus screen-positive (score 3-6) in the target population at 12 months.
They found quite an impressive difference. 61% had no anxiety at 12 months if they got the intervention versus 38% in the control group. They also found that it worked quickly; by six months, you could already see the difference, and it was maintained for seven modules. 24 months later, they were maintaining the no-anxiety difference, and it was cheap. Â
There was time invested with phonecalls after each session; Â but across each child that was only 150 minutes, and I don’t know what it’s like in your part of the world, but for me, I see a lot of kids who are going to a psychologist literally every second week for an hour each time, and I don’t know that they’re seeing this sort of difference.
Clinically Relevant Bottom Line
An integrated screening-to-intervention pathway for child anxiety problems in primary schools reduced parent-reported child anxiety problems compared with assessment and usual provision only, providing a promising way to improve access to effective early intervention. However, economically disadvantaged families and minority ethnicities were underrepresented, and that is something to bear in mind.
Reviewed by Sarah McNab
Article 5: Epinephrine nasal spray for anaphylaxis – are we there yet?
Ebisawa M, Takahashi K, Takahashi K et al. Epinephrine Nasal Spray Improves Allergic Symptoms in Patients Undergoing Oral Food Challenge, Phase 3 Trial. J Allergy Clin Immunol Pract. 2025 Oct;13(10):2787-2794. doi: 10.1016/j.jaip.2025.06.038. Epub 2025 Jul 8. PMID: 40639499.
What’s it about?
This is about intranasal epinephrine, or adrenaline, versus intramuscular, so we know that some children, and some parents, and some teachers are really worried about sticking a needle into a kid’s leg because it seems like a really big deal.
Families worry that you’ve got to be really sure that they’ve got anaphylaxis before you go near them with a needle, and you’ve never done it before, and they did that study where you stab yourself as often as you stab the child; there are lots of reasons why adrenaline might be delayed in children with anaphylaxis.
There is a device now that delivers intranasal epinephrine; it’s small, easy to use, and you can store it at room temperature.
Why does it matter?
From a pharmacokinetic perspective, they know it works, but they haven’t studied it in anaphylaxis. So, this was a study in which they had children come in for oral food challenges.
About 80 children came in for their challenges, and if they had anaphylaxis, they received Neffy, which is nasal epinephrine at different doses. They didn’t have a control group; they didn’t do an IM version, but that’s okay. Their outcome was the improvement rate at 15 minutes, and it worked.
Out of the 80 kids, 15 got anaphylaxis; they were all given Neffy and improved. One did have a biphasic reaction two and a half hours later, and as per their protocol, they got IM adrenaline at that point.
Clinically Relevant Bottom Line
This is really promising. I’ve spoken to our head of allergy at my workplace, and they are using this now. They’re using it in oral food challenges. I know not everyone here is Australian; this is likely to come on the Pharmaceutical Benefits Scheme (PBS) in Australia relatively quickly, so it’s something that we should be familiar with, because families are going to be asking about it.
Reviewed by Sarah McNab
Sarah is a major paediatric fluid expert and could not finish presentation without discussing the results of the recent PRoMPT bolus trial covered here PRoMPT BOLUS: Does fluid type matter in kids? – Don’t Forget the Bubbles.
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.