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The 14th Bubble Wrap

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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: For wheeze a jolly good fellow?

Foster SJ, Cooper MN, Oosterhof S, Borland ML. Oral prednisolone in preschool children with virus-associated wheeze: a prospective, randomised, double-blind, placebo-controlled trial. The Lancet Respiratory Medicine. 2018 Jan 17.

What’s it about?

This single centre double-blind, randomised controlled trial looked at children between the ages of 2 and 6 who presented to a single emergency department with the presenting complaint of wheezing. The authors looked at the length of stay in hospital as a primary outcome measure and included several secondary measures, including the re-presentation rate.

Why does it matter?

Since Panickar et al. in 2009, we have been withholding steroids from the wheezing pre-schooler because we thought it made no difference. This study suggests that not all wheezy children are created equal, and some may be steroid responsive.

Clinically Relevant Bottom Line

We looked at this paper in depth because preschool wheeze is a common presentation in primary care and the ED. There may be a grey zone where the disease entities of bronchiolitis, pre-school wheeze and asthma all live; some are steroid responsive. The challenge is finding which.

Reviewed by: Tessa Davis and Damian Roland

Article 2: Can we leverage technology to improve the uptake of childhood vaccinations?

Glanz JM, Wagner NM, Narwaney KJ, Kraus CR, Shoup JA, Xu S, O’Leary ST, Omer SB, Gleason KS, Daley MF. Web-based Social Media Intervention to Increase Vaccine Acceptance: A Randomized Controlled Trial. Pediatrics. 2017 Nov 6:e20171117.

What’s it about? 

Vaccine acceptance rates here in Victoria are around 94.07%, with a higher proportion belonging to a relatively well-educated group. This RCT randomly assigned pregnant women to one of three groups: a website containing vaccine information and interactive social media elements, a website containing vaccine information, or usual care.  They followed the infants born to these mothers for 200 days, with the primary outcome being days un-vaccinated.

Once a cohort of women, in their third trimester, had been recruited  they had to undertake the Parent Attitudes and Childhood Vaccines (PACV) to assess their pre-existing attitude to vaccination. They were then randomized to one of the three intervention groups. As someone who has something to do with social media I was interested to read how the authors created a platform for their study. They focused on the traditional top-down pushing of information from the website, bottom up creation of content by users and lateral movement of information via interactive forums. This process is very similar to what we do at DFTB.

So, did it make a difference? 14.1% of the participants were classified as vaccine-hesitant before the intervention, with similar PACV scores allocated to each intervention group. Unfortunately, almost 20% of participants were lost to follow-up. More infants in the social media group were up to date at 200 days than in the control arm (Odds ratio = 1.92 95% CI 1.07-3.47), and there was little difference between the users of the static website and the usual care group.

Why does it matter? 

Information is power, and with most modern parents reaching for the internet as their prime source of knowledge (rather than trained professionals), it makes sense that this sort of intervention might improve vaccine acceptance. An interactive, social media-enabled website is undoubtedly more expensive to create and maintain than a computerised version of a pamphlet, but that does not mean it is of less value. It is worth looking at technology to enhance understanding if we are to increase vaccine adherence.

Bottom Line 

Although the difference is slight, adding an element of interactivity and community to a website enhances the user experience and may make a difference in vaccine acceptance rates.

Reviewed by: Andrew Tagg

Article 3: What should we be looking at next?

Deane HC, Wilson CL, Babl FE, Dalziel SR, Cheek JA, Craig SS, Oakley E, Borland M, Cheng NG, Zhang M, Cotterell E. PREDICT prioritisation study: establishing the research priorities of paediatric emergency medicine physicians in Australia and New Zealand. Emerg Med J. 2018 Jan 1;35(1):39-45.

What’s it about?

This was a survey of paediatric emergency physicians (working in both paediatric and mixed EDs) aiming to establish what we think the priorities should be for paediatric emergency research. It started with the open question of “Thinking about your clinical practice in the field of PEM, what are the most important research questions that need addressing?” These answers were then collated and participants were asked to rate the importance of the resulting themes with this question”Thinking about your clinical practice in the field of PEM, how important are the following questions to you in terms of need for future research?’ Additionally a group of 21 active PEM researchers rated each of the conditions on the second survey for prevalence of the condition, seriousness of the condition and feasibility of doing the research required to answer the questions posed. The result should be a consensus based list of research questions we, as a profession, think are important that has been filtered to ensure questions included are weighted for frequency of severity of disease as well as feasibility of actually being able to answer the questions posed.

Why does it matter?

Doing clinical research is expensive and there is significant competition for research funding. It is important that investments are made in the studies that have the most potential to change our practice with maximal benefit to the patients that our practice affects. This is an important way of informing those investment decisions. For us as clinicians it is also helpful knowing what our peers think are important questions when deciding which projects we should pursue on both personal and departmental levels. It is important to note that, though we are very well placed to know what questions most vex us in our clinical practice, we are only one group of stakeholders in the delivery of paediatric emergency care. It is important that all stakeholders get a say in what clinical research gets funded but this paper is very helpful in helping us add weight to our contributions to those conversations.

Clinically Relevant Bottom Line

The complete list of 35 questions is listed as a table in the paper and covers asthma, sepsis, intubation, cognitive aids, risk stratification tools and more. The research question that came out top is, “In children with severe asthma, does a specific intravenous agent compared with another intravenous agent (or placebo) result in improved outcomes?” You can find out how close we are to answering that question by listening to Simon Craig’s DFTB17 talk here.

Reviewed by: Ben Lawton

Article 4: Will this child have another seizure?

What’s it about? 

This was secondary analysis of a cohort study across 6 North American emergency departments of children and young people (< 18 years) with what the authors termed first (incident) unprovoked seizures (known in the UK as a first afebrile convulsion). Excluded in the analysis were children who received any anti-seizure medication at this first visit, had a fever or suffered a head injury and didn’t have a clear cause (such as breath holding). Follow up was via telephone at multiple points up to 6 months. The primary outcome was seizure recurrence at 14 days.

475 patients were included in the final analysis, with a recurrence rate of 15.8% within 14 days and 31.5% within four months. Children, less than three years were at higher risk of recurrence.

It is important to highlight this data is over 12 years old, calling into question its external validity due to changes in the demographics of the population or health system evolution.

Why does it matter?  

I’d learnt through reading the paper that The American Academy of Neurology, and the American Epilepsy Society, recommend EEG as part of the investigation for first unprovoked seizures. In the UK, national guidance recommends an ECG. UK guidance is based on the fact that a significant proportion of children will never have another event, so an initial is essentially a wasted exercise.

Clinically Relevant Bottom Line

The early recurrence rate in this study was relatively high but given there is still a risk of seizure recurrence (reported at 27%) after a routine EEG, the utility of its use after a first seizure should still be questioned.

Reviewed by: Damian Roland

Article 5: Why are preterm newborns at increased risk of infection?

Collins A, Weitkamp J, Wynn JL Why are preterm newborns at increased risk of infection? Archives of Disease in Childhood – Fetal and Neonatal Edition Published Online First: 30 January 2018.

What’s it about?  

Hot off the press from The Archives of Disease in Childhood Fetal and Neonatal edition is this fast-paced assessment of why neonates are so susceptible to infections. One in ten infants is premature, with a significant burden of disease with comorbid sepsis.

Why does it matter?

We tend to simplify this component of neonates. The authors note, It is clear that the immune system of preterm infants exhibits distinct, rather than simply deficient, function as compared with more mature and older humans and that the immune function in preterm infants contributes to infection risk.”

Clinically Relevant Bottom Line

Collins and colleagues approach the question from the perspective of innate & adaptive immunities and consider some therapeutic options. Any four-page paper that can congruently discuss the gut microbiome and basal expression of β2 integrins to inform the importance of hand hygiene and early central line removal scores a read (and reread) in my book.

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

About the authors

  • 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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