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The 13th 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.

Unless you have triskaidekaphobia then here is this month’s round-up…

Article 1: Does every admitted patient need IV access?

Hollaway W, Broeze C, Borland ML. Prospective observational study of predicted usage of intravenous cannulas inserted in a tertiary paediatric emergency department. Emergency Medicine Australasia. 2017 Dec 1;29(6):672-7.

What’s it about? 

This study looked to find how many of the cannulae inserted in a single paediatric emergency department were never used after insertion and thus were unnecessary and unneeded. They also wanted to know if the healthcare workers that inserted them could predict if they were going to be used or not. It was a single-centre prospective and concealed observational study. The investigators sneakily did not let on the true reason they were collecting data for fear it might skew the results. They got healthcare workers to fill in a questionnaire on cannula insertion and asked for another to be filled out when it was removed. If the second questionnaire was absent the researchers went back to the nursing charts to find out if the cannula had been used or not.

Over a four-month period, the ED saw 26 199 patients of which 806 had forms returned (around 3.1% of patients were cannulated).  Once the cannulas that were unused but necessary were taken out of the mix (e.g. for post-tonsillectomy bleeds, profound sepsis, trauma) 22% or 1 in 5 of the cannulas were never used.  Looking at the patient presentations, the researchers found that cannula insertion could be reduced in certain patient presentation groups – painful joints (that did not appear septic), drug overdoses when the history was suggestive of a non-serious dose, stable patients with rashes, and most importantly, those that the senior doctor did not think necessary.

Why does it matter?

One of the reasons I left the UK was the over-reliance on registrars to stop a patient from ‘breaching’ the magical 4-hour target. Unfortunately, it seemed to follow me to Australia. While it can be challenging to meet such an expectation in adult patients, it is nigh-on impossible in some children, especially if they require cannulation and all the attendant struggles that may involve. One US study found that blood collection via cannulation took 41 minutes compared to an average of 17 for phlebotomy alone. That is a potential saving of 24 minutes for the patient, the doctor and any helpers they need.

Clinically Relevant Bottom Line

If you don’t think a patient needs a cannula you are probably right.

Reviewed by: Andy Tagg

Article 2: Still in search for magic medicine to treat bronchiolitis? This isn’t it.

Williamson K, Bredin G, Avarello J, Gangadharan S. A Randomized Controlled Trial of a Single Dose Furosemide to Improve Respiratory Distress in Moderate to Severe Bronchiolitis. The Journal of Emergency Medicine. 2017 Nov 23.

What’s it about?

In a nutshell – the impact of bronchiolitis on the lungs is not entirely dissimilar to acute lung injury. It is therefore plausible that fluid-restrictive strategies used in chronic lung disease may improve respiratory function in bronchiolitis.

This study randomized infants with bronchiolitis to 1mg/kg of furosemide or placebo.  Recruitment proved to be challenging with only 46 infants included. This was a very small number given it took place over 3 years, could include any admitted child and the power calculation for demonstrating a 25% reduction in the respiratory rate would have been 98 participants. Ultimately no difference in respiratory rate was shown between the furosemide (n=22) and placebo (n=24) groups at 2 or 4 hours.

Why does it matter?

Any intervention that may improve the length of stay or parent/carer experience is welcome in bronchiolitis. Sadly, this study gives us no new answers, and it could be argued that their primary outcome of respiratory rate alone is not helpful in clinical practice. Given that the study didn’t achieve its power target, there is the potential for a type 2 error; therefore, further research may be warranted.

Clinically Relevant Bottom Line

Like salbutamol, steroids, adrenaline and antibiotics don’t use furosemide in bronchiolitis hoping that it will change the course of this most refractory of illnesses.

Reviewed by: Damian Roland

Article 3: What do we know about survival in extremely pre-term infants?

Helenius K, Sjörs G, Shah PS, Modi N, Reichman B, Morisaki N, Kusuda S, Lui K, Darlow BA, Bassler D, Håkansson S. Survival in very preterm infants: an international comparison of 10 national neonatal networks. Pediatrics. 2017 Nov 21:e20171264.

What’s it about?

The iNEO team looks at data from multiple neonatal networks worldwide to produce a snapshot of neonatal survival for preterm infants with very low birth weight. The data is limited by problems common to large-scale research, including incomplete coverage within networks and insufficient or inconsistent data collection on other variables. Despite this, there is still food for thought surrounding mortality by age and differences between networks. 

91835 infants were born 24-29 weeks gestation within the networks between 2007-2013. After excluding those over 1500 grams or admitted after 36 weeks, 88327 infants remained. Overall 87% survived to discharge, with increasing age trending up with improved survival.

There was a more significant discrepancy between networks in survival for younger babies compared to older ones. The most notable difference was found between the Israel Neonatal Network, with 35% survival at 24 weeks, and the Neonatal Research Network Japan, with 84%

Looking at deaths overall, the median age of death was 8 days of life. Unfortunately, the research did not include the cause of death which would have been a valuable contribution to understanding outcomes.

Why does it matter?

This study confirms expectations that the survival of very preterm infants improves with gestation. However, it also highlights gaps between network outcomes for the timing of death and survival of extremely preterm infants. This will hopefully continue a trail towards identifying harmful or beneficial practices for caring for this at-risk infant population.

Reviewed by: Grace Leo

Article 4: More questions about steroids for little wheezers

Paniagua N, Lopez R, Muñoz N, Tames M, Mojica E, Arana-Arri E, Mintegi S, Benito J. Randomized Trial of Dexamethasone Versus Prednisone for Children with Acute Asthma Exacerbations. The Journal of Pediatrics. 2017 Dec 1;191:190-6.

What’s it about?

Hang on,” you say. “This is repetition, wasn’t Dex vs Pred for asthmas covered in Bubble Wrap 9?

Well, it’s the same question but from a different study group (a Spanish Paediatric Emergency Medicine Team). The critical inclusion criteria for this study are worth noting.

12 months to 14 years old with asthma exacerbations who presented to the ED. Asthma was defined as either a previous medical diagnosis of asthma or at least two previous episodes of B2- agonist–responsive wheezing or a first episode of wheezing in children over two years and a history of atopy.

Patients received two doses of 0.6mg/kg of dexamethasone (the higher end of the dose range in many countries) or 1.5mg/kg of prednisolone with a 1mg/kg twice daily regime for the four days afterwards (again the higher end of the recommended dose range)

5.1% were diagnosed with asthma during their ED visit in the year-long recruitment period (total presentations to the ED were 57865) with 710 approached and 590 undergoing randomization.

There was essentially no difference between the groups in any of the outcome measures, the primary ones being the percentage of patients with persistence of symptoms at day 7 dexamethasone (56.6%, 95% CI 50.6-62.6) and prednisone/prednisolone group  (58.3%, 95% CI 52.3-64.2) and quality of life scores.

Why does it matter?

The headline figure is that again dexamethasone has non-inferiority to prednisolone but there are some important further questions from this work. The persistence of symptoms in both groups raises questions about the impact of asthma in the community (in this cohort, less than 25% were admitted to an observation or hospital ward) and whether current treatment strategies are productive. Given that 43% of the participants were less than five years old (a group, with even the definition used by the study group, likely to have a high incidence of viral wheeze), does this raise the need for a third arm in these studies – one of no steroid at all?

Bottom Line

Switching from prednisolone to dexamethasone probably won’t change outcomes for large cohorts of children. The Paediatric emergency research community now needs a universally agreed definition of asthma and viral wheeze so the cohort of children most likely to benefit can be determined.

Reviewed by: Damian Roland

Article 5:  And finally for something to see you through the rest of January

 Special Issue: Surgical Conditions in Children (2017), I. J Paediatr Child Health, 53: 1039. doi:10.1111/jpc.13402

What’s it about?

It’s rare to recommend an entire edition of a journal, but this month it’s exactly what I’m doing. In November (2017) the Journal of Paediatrics and Child Health published an entire issue on Paediatric Surgery.

Why does it matter? 

In the words of Prof Spencer Beasley’s editorial,

“[t]his issue is unique. It provides paediatricians with a concise and practical overview of many of the surgical conditions that they may encounter in their daily clinical practice but which tend to be at the edge of their knowledge or expertise. This special issue answers many of those questions paediatricians have always wanted answered but were too afraid to ask.”

Clinically Relevant Bottom Line 

This issue is jam-packed with two dozen articles covering everything from acute appendicitis to undescended testes. I read my hard copy from cover to cover – an extreme rarity for any academic publication. So, fill your New Year with surgical knowledge, starting with the Open Access papers at …

Reviewed by: Henry Goldstein

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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