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The 11th Bubble Wrap


With millions upon millions of journal articles published yearly, 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: How quickly should you give a fluid bolus?

Sankar J, Ismail J, Sankar MJ, Meena RS. Fluid Bolus Over 15–20 Versus 5–10 Minutes Each in the First Hour of Resuscitation in Children With Septic Shock: A Randomized Controlled Trial. Pediatr Crit Care Med. 2017 Oct;18(10):e435-e445.

What’s it about?

The call has gone out. You’re expecting a child with a fever, tachycardia and tachypnoea who is mottled, CRT 5 seconds. You’re ready, your team is ready. You have your crystalloid fluid boluses drawn up and ready to give, but how quickly should you administer them?

In this one-year study, 96 children in a large tertiary Children’s Hospital in North India (age <18 years) were randomly allocated to receive initial fluid boluses of up to 60ml/kg in 20ml/kg aliquots delivered within either 15-20 minutes or 5-10 minutes.

The study was terminated early due to intermediate analysis demonstrating that children in the 5-10 minute bolus group from either entry point (Emergency Department (ED) non-ventilated or CICU already ventilated) had an increased rates of intubation and Oxygen Index requirements respectively (mortality, length of stay and resolution of shock were not different between groups). Multivariate logistic regression analysis demonstrated that the only statistically significant factor associated with the need for ventilation in the first hour in the ED participants was duration of bolus (p=0.006).

Why does it matter?

Volume replacement has traditionally been an intrinsic component of treating children presenting with hypovolaemic shock symptoms secondary to sepsis. FEAST was a landmark study that first highlighted issues with fluid administration in patients with shock.

This study, whilst limited by both sample size, external validity and an unusual entry requirement of either de novo ED presentations or already intubated on PICU, appears to demonstrate a link between the speed of administration of fluid boluses and the need for intubation/increase in oxygenation index.

Clinically Relevant Bottom Line

Follow your local guidelines, in combination with clinical judgement, when administering fluid boluses to this group of patients but watch this space for potential rationalisation of current guidance over the next 5 years.

Reviewed by: Felix Hay (@catman161)

Article 2: How does procedural sedation affect behaviour?

Pearce JI et al. Behavioral Changes in Children after Emergency Department Procedural Sedation. Acad Emerg Med. 2017 Oct 9. doi: 10.1111/acem.13332.

What’s it about?

Those working with children in emergency care rarely see the medium/long-term outcomes of their treatments or interventions. This prospective cohort study examined the impact of ketamine procedural sedation on children undergoing peripheral limb fracture reduction in the Emergency Department.

Of 97 patients, 85% completed follow-up, with (17) 22% experiencing negative behaviour changes at 1-2 weeks post-discharge (as measured by a validated scale, the Post-Hospitalization Behavior Questionnaire). There was an association of negative behaviours (anxiety, eating disturbance, aggression and withdrawal) withdrawal with pre-procedure stress and non-white race.

Why does it matter?

While a power calculation was performed, this was a relatively small cohort with a defined clinical problem. There was no long-term follow-up, so we don’t know the ongoing functional impact of the behaviour changes. The study also reported opiates being prescribed at discharge for 96% of the children, which may mean this was not a typical cohort of patients with limb injury or reflects local analgesia protocols in Wisconsin, US.

However, given little, if no, research has been done in this area (compared with extensive research on behavioural outcomes following surgery via general anaesthesia), this is an important study.

The Bottom Line

While there may be no long-term problems following ketamine sedation, further research in this area is needed as it may be this important post-discharge advice for families and carers.

Reviewed by: Damian Roland

Article 3: A new classification of seizures 

Fisher et al. Operational classification of seizure types by the International League Against Epilepsy: Position Paper of the ILAE Commission for Classification and Terminology. Epilepsia. 2017 Apr;58(4):522-530. doi: 10.1111/epi.13670

What’s it about and why does it matter?

A seizure is “a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain. Describing seizures has often been fraught with potentially loose use of language and plenty of assumed meanings, especially among lay people.

The world authority on epilepsy, the International League Against Epilepsy (ILAE), released a new classification of seizures earlier this year. It’s the most significant change since 1981 when the system that many of us learned at medical school was first released.

The new classification does away with several imprecise albeit classic terms such as convulsion, partial and complex. Instead, the new system answers three questions;

What was the onset? (Focal, generalised, unknown)

Is awareness preserved?

Motor vs non-motor symptoms?

The ILAE also provides a précis at their website, which, if you’re time-poor, is well worth checking out even if for the flow charts (they’re also in the paper itself.)

Reviewed by: Henry Goldstein

Article 4: End-of-life care for children with cancer

Johnston EE, Alvarez E, Saynina O, Sanders L, Bhatia S, Chamberlain L. Disparities in the Intensity of End-of-Life care for children with cancer

What’s it about? 

Much progress has been made in paediatric oncology in the last few decades, with an average five-year survival rate of 80%. However, cancer is still the leading cause of non-accidental death in children in the US, UK and Australia.

This retrospective Californian study examined the end-of-life care experienced by 3732 patients with cancer between the ages of 0 to 21 years old. The intensity of end-of-life care was analysed by looking at

  • The last 30 days of life for ICU admission and invasive interventions, including intubation/mechanical ventilation, tracheostomy, gastrostomy or haemodialysis
  • IV chemotherapy in the fortnight before death
  • Hospital death

The authors found that 62% of patients died in hospital and one-fifth of patients had intubation and mechanical ventilation. Children under 5 and those in their later teens were the two groups which were more likely to have intensive end-of-life care. Of note, patients admitted to non-specialty centres were more likely to have increased odds of intense interventions. Racial groups (African, Hispanic and Asian American) were more likely to have a hospital death. Also haematological malignancy was associated with greater intensity of care compared to solid tumours. The study results may be influenced by a large proportion (43%) of patients being between 15-21 years of age.

Why does it matter?

There are many adult oncology studies evaluating end-of-life care but there is less information within paediatrics. Paediatric palliative care is a relatively new subspecialty. This study identifies that intensive interventions and hospital based care is not uncommon for children with cancer at end-of-life. It points towards differences in age and race which increased the odds of intensity of end of life care. It encourages a deeper look into the practice of paediatric end of life care and provides a start towards evaluating whether the intensity of care is reasonable and if it meets the goals of patients and their families.

The bottom line:

Almost 2/3 of children with cancer who die will do so in a hospital, and 22% will receive medically intense therapy. We are likely to encounter these children during part of our practice and should be mindful of the intensity of their care and how it aligns with the goals of both patient and family.

Reviewed by: Grace Leo

Article 5: Should we be concerned when kids fall out of bed?

Mulligan CS, Adams S, Tzioumi D, Brown J. Injury from falls in infants under one year. Journal of Paediatrics and Child Health. 2017 Aug 1;53(8):754-60.

What’s it about?

This was a retrospective chart review of all children under the age of one that presented to a paediatric trauma centre following a low-level fall. So they considered falls from changing tables, sofas, beds and children that were dropped. Over three years, 916 infants presented following such an incident, and 110 (12%) were admitted. 9 of the 916 were admitted to the ICU.

In terms of mechanism, by far, the majority (27%) fell from a bed or sofa, and it is easy to imagine pressured parents putting the baby down for a second to get something and…thud! This was followed by babies falling out of prams (21%) often after being improperly restrained, and finally, 16% were dropped, usually when handed over to another caregiver. Although the numbers were small, these children were three times more likely to require admission.

Why does it matter?

As my nearly one year old becomes progressively more curious – and more mobile – I have become hyper-vigilant. It is impossible to put her down without her trying to dive off the change table or the sofa. Even when she falls from standing there are tears so it can be very hard to assess if there is anything serious going on. And when they do fall though there is often an almighty thud. I imagine this has happened to nearly every parent, but not all of them are paediatric emergency physicians and they may present to the emergency room. Using a validated clinical decision instrument  like PECARN can really help with our decision making but we do need to be aware that there can be serious consequences. Around 10% of the children in this study had a significant injury that required hospitalization. That sounds like a lot –110 out of 916 had an injury serious enough to require admission. But we don’t know the true denominator, the number of children that fall (or have been dropped) and that have not come to the emergency department.

The bottom line

Children can suffer severe consequences from falls, even from such low heights, but we need to be cautious when interpreting this data. Sydney Children’s Hospital is a state-wide paediatric trauma centre, and that may skew the seriousness of the cases that present there. I will still reassure parents that the chances of anything serious going on is low – but only after a thorough history and assessment.

Reviewed by: Andy Tagg

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


  • 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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