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The 10th 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 the UK and Ireland) to point out something that has caught their eye.

Article 1: Should we be worried about abnormal vital signs at discharge?

Winter J, Waxman MJ, Waterman G, Ata A, Frisch A, Collins KP, King C. Pediatric Patients Discharged from the Emergency Department with Abnormal Vital Signs. Western Journal of Emergency Medicine. 2017 Aug;18(5):878.

What’s it about?

You’d seen a child earlier in the evening who almost certainly had an upper respiratory tract infection. During the night safety huddle, you notice she is still on the computer screen despite the fact that you’d thought you’d discharged her. It’s handed over to you that the discharge observations demonstrated that her heart rate and respiratory rate were slightly above normal for her age.

Does this change your plan?

In a nearly four-year retrospective review of patients discharged from a Children’s Emergency Department in New York of 33,185 children, 5,540 (17%) had at least one abnormal vital sign.

There were only 24 adverse events (0.43%) in those discharged with at least one abnormal vital sign, but this was significantly different from the 0.17% risk in those discharged with normal observations.

Why does it matter?

All those working in acute paediatric care must balance risk. Be sensitive enough not to miss catastrophic illness and be specific enough to avoid overloading services already at capacity. Observations are a key part of decision-making, with the physiological status of children often used retrospectively to highlight deficient care (why did you not treat that child?) and prospectively to avoid intervention (they don’t need admission as their observations are normal).

This study highlights two key practice points. The first is that lots of children are discharged with abnormal vital signs, and the second is that while agreeing on adverse outcomes may be simple, stopping them is complex.  As a definition of the adverse outcome, this study used death, re-presentation to the hospital and admission for ≥ five days, cardiopulmonary resuscitation, endotracheal intubation, and unexpected surgery. In the study, the authors found only 1 case of potentially preventable permanent disability (a testicular torsion who had a normal testicular examination on the initial visit). Abnormal vital signs at discharge rarely, if ever, are related to the reasons for the adverse outcomes.

Clinically Relevant Bottom Line

Don’t start ignoring discharge observations just yet, but do start looking at your department’s practice and aim to base it on outcome data from your local population.

Reviewed by: Damian Roland

Article 2: The ‘best interests’ of whom?

Birchley, G. et al.,’Best interests’ in Paediatric intensive care:an empirical ethics study. ADC, 2017; 102:930-935 

What’s it about, and why does it matter?

We use the phrase ‘in the child’s best interests’ frequently in practice, often without a robust understanding of the term. The pointy end of understanding this is usually in the PICU, where there may be disagreements between medical staff and parents, in particular around withdrawal of care. The few situations where the courts become involved are often entered into as the result of an irreconcilable impasse, or ‘stalemate’, despite a child’s poor prognosis.

This English qualitative study interviewed 39 parents and PICU staff to critically describe the way in which a ‘best interests’ standard operates in PICU, with the existing medical ethical literature in mind.

Interviews with the participants identified three broad themes. The article goes on to describe both the parental and clinician viewpoints on these themes.

The themes are:-

  • How decisions should be made
  • What happens in practice
  • The role of the courts.

These sections make for some fascinating and open reading about how this group of clinicians – as surrogates for the rest of us – might approach conscientious discussions with families where a child’s life is chronically in the balance. I strongly suggest you read it for yourself; the paper is open-access.

The bottom line

In short, deciding ‘best interests’ is a collaborative process. In cases where there is a disagreement between parents and clinicians, visible deterioration of the child can often be instrumental in helping parents understand the child’s best interests while avoiding the courts. This current approach is crude and risks losing sight of the attendant medical burden for the child.

Reviewed by: Henry Goldstein

Article 3: What are the risks of procedural sedation in the ED

Bhatt M, Johnson DW, Chan J et al. Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children. JAMA Pediatr.

What’s it about?

This is the second-largest study ever done on procedural sedation in children and the first to have this degree of consistency in the way the data was collected. 6295 patients underwent procedural sedation in six Canadian paediatric emergency departments, and their demographics, drugs used, and adverse events encountered were recorded on a standardized form.

3916 patients (62%) got ketamine alone. This group experienced the lowest rates of serious adverse events (0.4%). Adverse event rates increased when either fentanyl (3.2%) or propofol (2.1%) was used in combination with ketamine. The addition of midazolam also led to more adverse events but to a lesser degree than either fentanyl or propofol. Ketamine was given IV in the dose range 1-2mg/kg. There is no mention of the IM use of ketamine, which has previously been associated with higher rates of vomiting.

Use of prophylactic anti-emetics decreased vomiting significantly (OR 0.5), though previous studies have suggested this is less relevant in younger children (<5yrs). Larger doses of ketamine were associated with more vomiting and more frequent oxygen desaturation, which contrasts with previously accepted wisdom.

Why does it matter?

Procedural sedation is commonly undertaken in the pediatric emergency department. This study provides really the best data we have on some of the finer points of doing it well. As a routine, we should be using anti-emetics prophylactically, particularly in patients over 5 years of age who have had opiate analgesia earlier in their emergency care journey. We should be sticking to the KISS principle and only using medications in combination with ketamine if there is a strong rationale to do so. Specifically, this adds to the body of evidence suggesting that ketofol is not better than ketamine alone. This also provides a useful standard to audit our own departments’ adverse event rates.

The bottom line

Procedural sedation in the emergency department is safe and effective. Ketamine as a single agent is associated with lower rates of adverse events than any commonly used combination of medications. Anti-emetics are associated with a significant reduction in vomiting in this context.

Reviewed by: Ben Lawton

Article 4: What helps build the socio-emotional well-being of refugee children?

Zwi K et al. Protective factors for social-emotional well-being of refugee children in the first three years of settlement in Australia. Arch Dis Child. Published online Jul 11, 2017.

What’s it about?

This study involved looking at the social-emotional well-being and readjustment of refugee children aged 4-17 years in a regional health district in Australia. There were 43 children involved, and data was collected through parent reports using a structured interview, the Strengths and Difficulties Questionnaire (SDQ) and the Social Readjustment Rating Scale at 2 and 3 years post-arrival.

They found children’s SDQ improved with time and at 3 years post-arrival in Australia and that <10% of children had ongoing social-emotional difficulties. The authors looked at a wide range of protective factors (such as feeling supported by the community, younger age (0-5yo), and absence of pre-arrival trauma). Children from Africa and children with fathers present on arrival had significantly higher SDQ scores. The authors also looked at cumulative factors (note: using eight but not all of the factors investigated) – and found that increased protective factors were significantly associated with lower mean SDQ scores. Normal SDQ scores were also found in all children with ≥4 protective factors (63%).

Why does it matter?

In the last two decades, the number of forcibly displaced people in the world has almost doubled from 33.9 million in 1997 to 65.6 million in 2016 (Australian Refugee Council). Refugee numbers are growing, and it is important to consider how we can best support refugee children and their families in adjusting to a new environment.

The sample size of this study is small and only powered to show significant associations with a 30% difference in outcome between groups, so it likely missed possible significant factors. The selection of factors ‘with the highest p-value’ for cumulative analysis could also be questioned. However, considering there is limited research in this field and the difficulty of conducting research with refugee populations– the study does help add to our understanding of protective factors for resilience in refugee children. It also argues that social-emotional well-being can be modified by reducing cumulative risk in childhood.

[As a side note–  The holistic health of refugee children is difficult to isolate from society and politics. The study supports that having a child’s father present on arrival with the child is a protective factor. This raises questions about how well we support split families in achieving family reunions. From reading around the topic- it seems there are difficulties with which minors can apply for family reunions through our current Special Humanitarian Program – including limited eligibility, the number of places available and the cost of relocation. For example, children who arrive by boat are ineligible to apply for a family reunion.

The bottom line

This was a small longitudinal study. Being from Africa and the presence of a father during the child’s arrival are protective factors for social-emotional well-being. There also appears to be a cumulative benefit from having ≥4 protective factors. The study also shows the resilience of refugee children with >90% having normal SDQ at 3 years post-arrival.

Reviewed by: Grace Leo

Article 5: Say my name, say my name.

Wilks-Gallo L, Aron CZ, Messina CR. “Hi Mommy”: Parental Preferences of Greetings by Medical Staff. Clinical Pediatrics. 2017 Sep 1:0009922817728700.

What’s it about?

Children call their parents all sorts of names – Mum, Mom, Ma, Mummy, Mater. Mumsy – but we shouldn’t. We should use their proper names. In this study, a 20-article questionnaire was sent to 137 parents. The parents were asked if they had been addressed as Mom/Mommy-Dad/Daddy in any previous hospital visits and what they would prefer if they were not being greeted by name. 79.5% of fathers had been called Dad or Daddy, and 90% of mothers had been called Mom or Mummy. Given the choice, fathers would rather be called Dad over anything else (including Daddy, Sir, or no name at all), and mothers would rather be called Mum (or, as the Americans would say, “Mom”).

Whilst this was a single-centre study relying on parents’ recollection of past events, the question of preference still holds true.

Why does it matter?

J.K. Rowling taught us always to use ‘.. the proper name for things’, but we don’t do it that often. Amer and Fischer found that only 14% of residents and 24% of attending physicians actually used a parent’s given name.

If you never found out their name or have forgotten it, then what should you call them? The therapeutic relationship between parent and physician is as important as that between patient and doctor in the world of paediatrics.

The bottom line

If you cannot remember a name, then call them Mum or Dad – but please make the effort actually to find out their proper name. It is the second thing I do after I introduce myself to the patient.

Reviewed by: Andrew Tagg


  • Grace is a Registrar at Sydney Children's Hospital. She loves innovative medical education and paediatrics. She is on the organising committee for the DFTB18 and SMACC conference. Grace is a former internal director of the AMSJ. She enjoys board games, cooking and graphic design.


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