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The 15th 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 accurate is urinalysis?

Tzimenatos L, Mahajan P, Dayan PS, et al. Accuracy of the urinalysis for urinary tract infections in febrile infants 60 days and younger. Pediatrics. 2018; 141(2):e20173068.

What’s it about?

The study aimed to look at how accurate urinalysis was in diagnosing a urinary tract infection in febrile infants under 60 days old. It was a large PECARN study which analysed 4147 infants across 26 emergency departments over five years. All infants had urinary samples taken by either suprapubic aspirate or an in-out catheter.

The primary definition of a urinary tract infection was >50,000 colony-forming units per ml (CFU/ml) from a catheter sample or >1000 CFUs/ml from a suprapubic aspirate.

The definition of a positive urinalysis was: any amount of leukocytes (including trace); or nitrite positive, or  >5 white blood cells per high-power field (pyuria).

289 (7%) patients had a urinary tract infection. For these patients, a positive urinalysis had 91% specificity and 94% sensitivity.

Why does it matter?

We are involved in plenty of daily discussions around the significance of finding leukocytes in a urine sample. Still, this study clarifies that even a trace of leukocytes in a clean sample is significant.

Clinically Relevant Bottom Line:

The biggest takeaway here should be our method of urine sample collection. Many of us still use ‘clean catch’ samples in infants, and we need to consider the accuracy of these. SPAs and in-out catheters are relatively simple procedures. Given that the sensitivity and specificity of these tests are so high, it is worth considering making this part of our daily practice.

Also, this study highlights the importance of understanding how your hospital’s lab presents urine MC&S results – please make sure you know about the measurements they use and the standard to indicate a positive urinary tract infection.

Reviewed by: Tessa Davis

Article 2: Don’t just do something, stand there

Hiscock H, Neely RJ, Warren H, Soon J, Georgiou A. Reducing unnecessary imaging and pathology tests: a systematic review. Pediatrics. 2018 Jan 30:e20172862.

What’s it about?

Low value care is care that has little or no benefit, may cause patient harm, or yields marginal benefits at a disproportionately high cost. This systematic review by a team from RCH Melbourne looked at 64 original research articles, which made interventions to reduce unnecessary imaging or pathology results with follow-up greater than 6 months. Of these studies, 32 targeted imaging only, ten targeted pathology only and 22 targeted both. There was only one randomised control trial. There was significant variability in interventions, and many studies were evaluated as having a high risk of bias. Most of the studies had positive effects. Those which appeared to have more significant outcomes targeted only pathology or radiology and aimed at only one low-value care practice but took a multifaceted approach (including audit and feedback, education and system-based changes). Four of the studies were co-designed with families and clinicians.

Why does it matter?

There is growing recognition of the importance of the cost and importance of tackling low value care. This is seen in ventures such as the international Choosing Wisely movement, UK NICE “do not do” guidelines and the RACP EVOLVE projects. This paper provides a useful starting point in considering direction of future research to tackle this issue. It highlights the importance of moving from quality improvement projects towards more rigorous research design and taking a multifaceted approach, including design input from both families and clinicians.

Clinically Relevant Bottom Line:

Low-value care is a significant problem to be tackled, but existing research is difficult to compare due to considerable variance in scope and approach. It will be important to use insights from this review to optimise future planning of projects.

Reviewed by: Grace Leo

Article 3:  Minimally-invasive and non-invasive autopsies in children

Lewis C, et al. Health professionals’ and coroners’ views on less invasive perinatal and paediatric autopsy: a qualitative study. Arch Dis Child 2018;0:1–7.

What’s it about?

I’d speculate that paediatricians and emergency doctors have a similar distaste for autopsies. We don’t like talking about bad outcomes or children dying. Do you remember being appalled by the idea of “The Black Crow award” in Shem’s House of God? Since the 1970s, rates of autopsies have plummeted in paediatrics.

Why does it matter?

There is something powerful in understanding the process of autopsy for children; thanks to this qualitative study published recently, we have some clinical insights into minimally invasive autopsy by the Archives of Disease in Childhood, which contains data from 29 clinicians (including four coroners) involved in performing autopsies of infants and children. This research seeks opinions regarding the quality and utility of noninvasive and minimally invasive autopsies compared to the current gold standard – a conventional autopsy. Do these clinicians perceive it possible to maintain our diagnostic thresholds, reducing the rate of misdiagnosis and robust auditing processes while having as few fresh scars as possible?

Clinically Relevant Bottom Line:

The death of a child is a rare and psychologically traumatic event. In this frame, the desire for an accurate contemporary definitive diagnosis is held in tension with the ideals of a child being returned to their parents for dignified death-related rituals promptly. Radiographic non-invasive and minimally invasive autopsies start us down this path, but conventional autopsy remains the gold standard.

Reviewed by: Henry Goldstein

Article 4: Should we be swabbing all snotty children?

Schnell J, Schroeder L, Sinclair K, Patel L, Dowd D. The Effect of Early Knowledge of Respiratory Syncytial Virus Positivity on Medical Decision Making and Throughput Time Within the Pediatric Emergency Department. Pediatric emergency care. 2018 Jan.

What’s it about?

Bronchiolitis is a ubiquitous winter condition that can overwhelm emergency departments during particularly virulent years. While the diagnosis is clinical, rapid antigen testing has been used to allow for early cohort decisions to be made (i.e. grouping bronchiolitis patients together on wards). In this retrospective cohort study, a team from Kansas aimed to determine if early knowledge of RSV at triage improved ED length of stay.

713 children had a rapid RSV test performed between 2008-2013. In the first analysis all infants with positive results (231; 35.3%) were compared with negative ones. Those children testing positive were less likely to have a chest x-ray or cultures (urine and blood), but overall length of stay in the department was not significantly different between the groups. In a second analysis, all those with a discharge diagnosis of bronchiolitis were split into RSV-positive and negative groups. Again the positive cohort was less likely to have additional tests but was not in the department for a shorter period.

Why does it matter?

In this cohort of infants early testing for RSV conferred little benefit on processing times. It isn’t easy to know whether these results are generalisable. The inclusion criteria was an age of 2-24 months with a fever > 39 degrees in the last 24 hours (at presentation or reported). Interestingly, children admitted to the hospital were excluded from the analysis; the reasons for doing this needed to be clarified, and shockingly, there would have only been 16 admitted patients anyway. The authors also noted RSV-positive patients were less likely to be diagnosed as having a concomitant bacterial infection, but this may well be a result of premature closure of diagnostic decision-making (and therefore represents a risk rather than benefit)

Clinically Relevant Bottom Line:

Rapid testing for RSV at triage tells you what you probably already know.

Reviewed by: Damian Roland

Article 5: Time to crack out the colouring books?

Robinson EM, Baker R, Hossain MM. Randomized Trial Evaluating the Effectiveness of Coloring on Decreasing Anxiety Among Parents in a Pediatric Surgical Waiting Area. Journal of Pediatric Nursing. 2018 Feb 10.

What’s it about?

Every time I go into the local bookshop I see a mountain of colouring books for adults. There are hipster colouring books, Harry Potter colouring books and Serenity colouring books. Perhaps, rather than a stack of out-of-date copies of Hello magazines we should be stocking our waiting rooms with pictures of mandalas and pots of pencils? These researchers took a look, not at children, but their parents, mindful that their child undergo an operation was stressful for them too. Based on a small study from the Journal of the American Art Therapy Association, the researchers surmised that actively colouring in patterns could potentially reduce anxiety in adults. At a single tertiary centre, parents were randomised to either the ‘dull‘ or ‘colourful‘ groups. Trained nurses handed out the short form of the Spielberger State-Trait Anxiety inventory to assess stress levels and then repeated a similar test 30 minutes after the intervention.

A total of 106 patients were enrolled (54 in the intervention group) based on a priori power calculations that suggested a sample size of 100 patients would be needed. Anxiety levels dropped in both groups after thirty minutes. The score declined from 43.79 to 42.09 in the ‘dull’ group and 49.88 to 39.69 in the colourful group. Why the group that did the colouring was more anxious was not explored.

Why does it matter?

These were the parents of children undergoing elective procedures – tonsillectomies, grommet insertion, orthopaedic procedures – but one wonders if this study could be extrapolated to the sorts of patients I see. If anyone wants to survey the waiting room of a busy paediatric emergency department, please feel free to list me as an author and use this design for colouring in.

Clinically Relevant Bottom Line:

 Spending waiting time colouring the DFTB logo may reduce anxiety and stress in waiting parents.

Reviewed by: Andy Tagg (with thanks to @SwearyPaed for the paper)

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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