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The 12th Bubble Wrap


With 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: Can we let children with isolated tachycardia go home?

Wilson PM, Florin TA, Huang G, Fenchel M, Mittiga MR. Is Tachycardia at Discharge From the Pediatric Emergency Department a Cause for Concern? A Nonconcurrent Cohort Study. Annals of Emergency Medicine. 2017 Feb 24.

What’s it about?

This paper, and a similar one from the 10th Bubble Wrap, highlights the shortcomings of using a single observation in isolation to guide management. While this may seem obvious, the implicit pressure of litigation and retrospective evaluation of decision-making challenge discharge decisions when there is a physiological abnormality.

In this one-year retrospective study, over 125,000 paediatric attendances were analysed, of whom 8.3% were tachycardic at discharge (defined using the 99th centile from Fleming et al.)

There were increased rates of reattendance (RR 1.3), with the need for oxygen (RR 1.8), respiratory drugs and admission (RR 2.0), antibiotics and admission (RR 1.5) or IV with admission (RR 1.4) in tachycardic children compared with those were not tachycardic at the index discharge.

Tachycardic children did not, however, have higher admission rates or need for clinically essential interventions overall at revisit.

One child required CPR at revisit but was not tachycardic at discharge from the index visit.

Interestingly, around 90% of children discharged with a heart rate above the 99th centile had this recorded more than a half-hour before discharge. It is unclear whether these were the last medical contacts or whether any interventions occurred subsequently to address the cause of the tachycardia.

Why does it matter?

This paper highlights the importance of context – not surprisingly, children with tachycardia at discharge were more likely to have been febrile or treated with inhalers. Still, surprisingly, there was no association with pain.  Interventions or revisits are likely to represent the progression of the illness. It is therefore important to perhaps reflect on the discharge decision, give clear safety net advice and anticipate the possibility of re-attendance rather than alter management based on a single physiological observation in a child otherwise assessed as suitable for discharge.

Clinically Relevant Bottom Line

Children with isolated tachycardia at discharge, in whom serious causes are clinically excluded, can be safely discharged with safety netting.

Reviewed by: Shammi L Ramlakhan

Article 2: Taking it lying down

Julliand S, Desmarest M, Gonzalez L, Ballestero Y, Martinez A, Moretti R, Rivas A, Lacroix L, Biver A, Lejay E, Kanagarajah L. Recovery position significantly associated with a reduced admission rate of children with loss of consciousness. Archives of Disease in Childhood. 2016 Jan 4:archdischild-2015.

What’s it about?

This prospective study in eleven European paediatric emergency centres looked at the association between caregivers’ use of the recovery position (RP) after loss of consciousness (LOC) and subsequent hospital admission. 

The study of 533 patients showed a significant independent association between using the recovery position and a reduced admission rate (p<0.001).  If the recovery position was used, the likelihood of a child being admitted dropped by 72%, although it was used in only 26.2% of cases. Other manoeuvres used included shaking, splashing water on the face and blowing on the face.

Why does it matter?

Actual or perceived loss of consciousness is a common presentation, with many parents believing their child has died or is seriously unwell.

The Resuscitation Council recommend that an unconscious child who is breathing with a patent airway should be placed in the recovery position.  

In this study, the caregiver’s ability to recognise that the person is breathing without airway compromise is not apparent.

Whether the recovery position is used or not, it is no doubt better than doing nothing and certainly better than doing potentially dangerous manoeuvres such as shaking.

Clinically Relevant Bottom Line

The study highlights the poor use of recovery position as an essential first aid response by caregivers.

Healthcare professionals should educate caregivers before discharge.  This is particularly important in children with a seizure disorder. This improve the safety of our patients, and reduce admission rates as a bonus.

Reviewed by: Nicola Goodall

Article 3: You had better watch out…

Park JJ, Coumbe BGT, Park EHG, Tse G, Subramanian SV, Chen JT. Dispelling the nice or naughty myth: a retrospective observational study of Santa Claus. BMJ 2016;355:i6355

What’s it about?

This interesting original UK research looks at whether children in hospitals are being naughty or nice. Surrogate markers for naughtiness included school absenteeism and conviction rates for juniors in the local area. Other variables investigated included contextual socioeconomic deprivation and distance from the North Pole.

Santa Claus has good coverage across the UK, with 100% of Northern Irish paediatric wards being visited. 93% of children’s wards in Scotland, 92% in Wales and 89% in England were also lucky enough to receive a visitor.

There was no correlation between a visit and naughtiness, and distance from the North Pole had no impact. Unfortunately, Santa Claus is less likely to visit children in hospitals in areas with lower socioeconomic characteristics. T

he study also looked at other local superheroes and found that elves, followed by footballers, were most likely to visit.

Why does it matter?

This study has several important implications.

It challenges the traditional understanding of Santa Claus treating children who are nice better. It cannot, however, determine whether or not illness is factored into Santa Claus’ algorithm for visiting children.

This study highlights the need for further investigation as to why he visits hospitals with socioeconomic deprivation less. It also provides reasonable recommendations to address this issue, including a review of Santa Claus’ contract and hiring local helpers in disadvantaged areas.

Based on this study’s outcomes, several popular Christmas tunes may need to be revised to be more accurate. There is also a serious concern about what should happen if the general paediatric population gets wind of these findings.

Reviewed by: Grace Leo

Article 4: Is it going to be busy at work this holiday season?

Krinsky-Diener M, Agoritsas K, Chao JH, Sinert R. Predicting Flow in the Pediatric Emergency Department: Are Holidays Lighter? Pediatric emergency care. 2017 May 1;33(5):339-43.

What’s it about? 

This American group asked an important question – is it busier in the paediatric emergency department on holidays – Thanksgiving, Christmas Day, New Year’s Day – than the rest of the year? My own experience is that it seems less busy, but that could be because the staff are generally happier; there are snacks aplenty, and time seems to fly by. The counterpoint is that new death-dealing Christmas presents (trampolines, quad bikes and Orbeez) have just been handed to some sugar-enhanced youngsters.

This group from New York looked at the presentations to an urban paediatric ED between July 2006 and June 2013 and categorised them into holiday or non-holiday presentations. They broke up the presentations into time blocks or ‘tours’.

Fewer patients presented over Thanksgiving (81 vs 92), Christmas day (70 vs 90) and New Year’s Day (82 vs 90).

This is data based on one American Paeds ED, so it may not have great external validity, but it would be an easy data exercise in your ED.

Why does it matter?

It might be too late to volunteer to work the holidays, but it might be a nice shift if you have to work it.

Reviewed by: Andy Tagg

Article 5: What should you buy the kids this Christmas?

Weingart GS, Glueckert L, Cachaper GA, Zimbro KS, Maduro RS, Counselman F. Injuries associated with hoverboard use: a case series of emergency department patients. Western journal of emergency medicine. 2017 Oct;18(6):993.

What’s it about?

As films go, the Back to the Future series are classics and commonly rewatched at Christmas with Gremlins, Jaws and Raiders of the Lost Ark.

I got excited at seeing this particular study, thinking I’d missed out on the arrival of the Hoverboard. As a youngster, I remember injuring myself trying to replicate the film scene. Alas, the Hoverboard here refers to “a two-wheeled device that can reach speeds up to 16 miles per hour”.

It’s not a high volume cause of injury, only 83 cases across 10 EDs over six months, but children came off worse than adults. They were more likely to have fractures (46.2%), and a large proportion weren’t wearing helmets.

Why does it matter?

Bicycles, skateboards, Heelies, Trampolines and now Hoverboards – there will undoubtedly now be a debate between the ‘safety’ brigade and those who believe kids will be kids about whether they should be allowed.

As with all mechanised devices, used safely and supervised adequately, hoverboards are probably not bad.

Clinically Relevant Bottom Line

Life happens. Teach children how to ride responsibly (and given a 78-year-old was also injured in this cohort), perhaps adults too…

Reviewed by: Damian Roland

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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