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The 16th 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 UK and Ireland) to point out something that has caught their eye.

Article 1: The immediate impact of different types of television on young children’s executive function.

Lillard AS, Peterson J. The immediate impact of different types of television on young children’s executive function. Pediatrics. 2011 Oct 1;128(4):644-9.

What’s it about? 

The impact of television on children is a controversial topic with its effect on development needing to be clarified. Recently the increase in mobile phone use has changed the focus of debate, but it remains essential to understand how increasing levels of screen time will affect our future generation. To test how television impacts on executive function (a collection of pre-frontal skills which impact on attention and working memory) children were shown two programmes. The first a “very popular fantastical cartoon about an animated sponge that lives under the sea”, and the second is a more educationally orientated cartoon about a preschool-aged boy. The core difference between the programmes was that the former was defined as fast-paced (the scene completely changed every 11 seconds), whereas the latter had a slower pace (scene change every 34 seconds)

After watching the cartoons, the children completed three tasks to test executive function. An example of one test was a delayed gratification exercise in which they could choose a bag of marshmallows or goldfish crackers. They could have ten if they could wait for the experimenter to return to the room (but wouldn’t know how long that would be) or have two immediately.

The results demonstrated a 9-minute episode of a fast-paced television cartoon significantly impaired executive function compared to the educational programme.

Why does it matter? 

The pace of change in television shows may impact decision-making immediately after watching them. While familiar events are processed by established pathways, new and unexpected events, which the authors note “fantastical events often are”, do not have a neurological framework to follow. There is no comment about at what age this effect may stop.

Clinically Relevant Bottom Line:

Watching Sponge Bob Square-Pants as a distraction video for a child you are cannulating may impact your decision-making immediately afterwards.

Reviewed by: Damian Roland

Article 2: Subthreshold phototherapy to prevent readmission

Wickremasinghe AC, et al.  Efficacy of Subthreshold Newborn Phototherapy During the Birth Hospitalization in Preventing Readmission for Phototherapy. JAMA Pediatr. 2018 Feb 26.

What’s it about?

This retrospective study aimed to estimate the efficacy of subthreshold phototherapy in preventing readmissions. Phototherapy is considered a low-risk intervention, whereas hospital readmissions soon after discharge are often seen as negative indicators of quality of care.

The authors analysed over 25 000 infants over 4 years with bilirubin levels just below threshold for phototherapy. The decision tree for performing these on infants was not specified.

The authors found that subthreshold phototherapy was effective in preventing readmission (4.9% vs. 12.8%) but the number needed to treat to prevent 1 admission was approximately 14 (NNT 14). Subthreshold phototherapy also led to a longer length of stay at 22 hours. Formula feeding had a similar protective effect against readmission for phototherapy (although this is not surprising as breastfeeding is a known risk factor of hyperbilirubinemia).

Why does it matter?

As clinicians we sometimes initiate treatment in anticipation of a possible treatment threshold – ‘to be on the safe side’ – but this study seems to suggest we do more harm by keeping them in hospital through unnecessary intervention, increased length of stay and higher hospitalization costs.

Clinically relevant bottom line

This study suggests that performing subthreshold phototherapy in healthy newborns has a NNT of 14 and is likely to  unnecessarily increase their length of birth hospitalization by approximately a day.

Reviewed by: Anke Raaijmakers

Article 3: Be brave

Lyons S. Be Brave. (Published 28 March 2018) BMJ 2018;360:k1299 

What’s it about and why does it matter?

When a child goes through a difficult procedure in hospital, it’s common for many of us to praise them as being brave. But is this akin to shoving tissue boxes into the face of a grieving patient in that it may well serve the purpose of easing our own discomfort? In this short BMJ opinion piece,  Sophie, a young adult with congenital heart disease shares her perspective on the challenge of constantly being told in hospital that she was so ‘brave’ and that there was nothing to be scared of.  She discusses how it often made her feel that she shouldn’t be crying or talk about her distress during difficult procedures. Importantly she shares that we can find other ways to support children by acknowledge their distress, explaining, empathizing with them, giving them breaks and opportunities to feel more in control of tough situations.

Bottom Line 

The next time you tell a child that they are ‘so brave’ – stop and think about whether you’re sending the right message and how you might be able to best support and empathise with this individual.

Reviewed by: Grace Leo

Article 4: Fevers and the full septic screen

Aldridge P., Rao A., Sethumadavan R., Briggs N. Fever under 3 months and the full septic screen: Time to think again? A retrospective cohort study at a tertiary-level paediatric hospital. J Paediatr Child Health. 2018 Mar;54(3):272-278. doi: 10.1111/jpc.13743. Epub 2017 Oct 30.

What’s it about?

Febrile neonates can be very challenging when it comes to differentiating a serious bacterial infection from other relatively benign presentations. A number of papers have set out protocols whereby a “partial” septic screen can be undertaken. In this retrospective cohort study, based in the ED of a Sydney tertiary children’s hospital, 219 neonates presenting as febrile had their notes analysed to assess adherence with local guidelines. Further, the primary outcome sought to identify whether a risk stratification protocol would be both safe and effective compared to current practice and local guidelines.

Why does it matter?

We know that clinical variance is widespread; the question is when and why this happens. In this pragmatic assessment of clinical practice, Aldridge et al discuss both warranted and unwarranted variance in the adherence to guidelines.

Additionally, adherence to a risk stratification protocol reduces the number of unnecessary interventions (particularly lumbar punctures and chest xrays), whilst maintaining a low miss rate for both serious and invasive bacterial infections (both of which are simply and elegantly defined in this paper). I’ve previously written about the “Step-by-step” approach, and this study sits alongside that and other papers in the space of an algorithmic approach. Notably, this paper’s risk stratification protocol does not use procalcitonin. I strongly recommend you read the teams work in its entirety here.

Reviewed by: Henry Goldstein

Bubble Wrap Plus

The Bubble Wrap would like to introduce a new segment from Dr Anke Raaijmakers working with Professor Jaan Toelen & his team of the University Hospitals in Leuven (Belgium) to share their monthly Journal Club Reading List. The content covers a broad range of relevant topics for anyone that looks after children. This comprehensive list of ‘articles to read’ comes from 34 journals, including the major Paediatric Journals (Pediatrics, The Journal of Pediatrics, Archives of Disease in Childhood, JAMA pediatrics, Journal of Paediatrics and Child Health) as well as general journals (NEJM, Lancet, JAMA, BMJ) and may also include papers from several subspecialist paediatric journals.

This month’s list from February features answers to intriguing questions such as: ‘Does your neonatal ibuprofen exposure affect renal function during adolescence?’, ‘What is the prevalence of sexting in our youths’ and ‘Do we over-diagnose Kawasaki disease?’ We would like to encourage all of our readers to use this list as a useful starting point for exploring other recent articles in Paediatrics.

You will find the list is broken down into four sections:

1.Reviews and opinion articles

Fitness to fly in the paediatric population, how to assess and advice.

Israëls J, et al. Eur J Pediatr. 2018 Feb 26.

Head lice infestations: A clinical update.

Cummings C, et al. Paediatr Child Health. 2018 Feb;23(1):e18-e24.

Recent advances in the management of childhood dental caries.

Innes NPT, et al. Arch Dis Child. 2018 Feb 20.

Failure Is an Option: Using Errors as Teaching Opportunities.

Beck JB, et al. Pediatrics. 2018 Feb 13.

The Psychology of Clinical Decision Making – Implications for Medication Use.

Avorn J. N Engl J Med. 2018 Feb 22;378(8):689-691.

Should basic science matter to clinicians?

Filewod NC, et al. Lancet. 2018 Feb 3;391(10119):410-412.

2. Original clinical studies

Ibuprofen exposure in early neonatal life does not affect renal function in young adolescence.

Raaijmakers A, et al. Arch Dis Child Fetal Neonatal Ed. 2018 Mar;103(2):F107-F111.

Prevalence of Multiple Forms of Sexting Behavior Among Youth: A Systematic Review and Meta-analysis.

Madigan S, et al. JAMA Pediatr. 2018 Feb 26.

Sexting-Prevalence, Age, Sex, and Outcomes.

Englander E, et al. JAMA Pediatr. 2018 Feb 26.

Fractures in the Pediatric Emergency Department: Are We Considering Abuse?

Lavin LR, et al. Clin Pediatr (Phila). 2018 Feb 1

Neurologic Involvement in Primary Immunodeficiency Disorders.

Yildirim M, et al. J Child Neurol. 2018 Jan 1:883073817754176.

Efficacy of Subthreshold Newborn Phototherapy During the Birth Hospitalization in Preventing Readmission for Phototherapy.

Wickremasinghe AC, et al. JAMA Pediatr. 2018 Feb 26.

Initiating Phototherapy at Subthreshold Levels: The Slippery Slope.

Taylor JA, et al. JAMA Pediatr. 2018 Feb 26.

Safety of Oats in Children with Celiac Disease: A Double-Blind, Randomized, Placebo-Controlled Trial.

Lionetti E, et al. J Pediatr. 2018 Mar;194:116-122.e2.

The diagnostic accuracy of presepsin in neonatal sepsis: a meta-analysis.

Bellos I, et al. Eur J Pediatr. 2018 Feb 23.

Comparison of ultrasound versus computed tomography for the detection of kidney stones in the pediatric population: a clinical effectiveness study.

Roberson NP, et al. Pediatr Radiol. 2018 Feb 23.

Switching Between Antibiotics Among Danish Children 0-4 Years of Age: A Nationwide Drug Utilization Study.

Reilev M, et al. Pediatr Infect Dis J. 2018 Feb 22.

Acid suppressants for managing gastro-oesophageal reflux and gastro-oesophageal reflux disease in infants: a national survey.

Bell JC, et al. Arch Dis Child. 2018 Feb 22.

Paediatric overdiagnosis modelled by coronary abnormality trends in Kawasaki disease.

Coon ER, et al. Arch Dis Child. 2018 Feb 22.

Cesarean Section on the Risk of Celiac Disease in the Offspring: The Teddy Study.

Koletzko S, et al. J Pediatr Gastroenterol Nutr. 2018 Mar;66(3):417-424.

Prevalence of Occult Bacteremia in Infants with Very High Fever Without a Source.

Gangoiti I, et al. Pediatr Infect Dis J. 2018 Feb 16.

Failure to Predict High-Risk Kawasaki Disease Patients in a Population-Based Study Cohort in Germany.

Jakob A, et al. Pediatr Infect Dis J. 2018 Feb 3.

Infliximab Plus Intravenous Immunoglobulin (IVIG) Versus IVIG Alone as Initial Therapy in Children with Kawasaki Disease Presenting with Coronary Artery Lesions: Is Dual Therapy More Effective?

Jone PN, et al. Pediatr Infect Dis J. 2018 Feb 15.

Cognitive Outcomes of Children Born Extremely or Very Preterm Since the 1990s and Associated Risk Factors: A Meta-analysis and Meta-regression.

Twilhaar ES, et al. JAMA Pediatr. 2018 Feb 19.

Sepsis calculator implementation reduces empiric antibiotics for suspected early-onset sepsis.

Achten NB, et al. Eur J Pediatr. 2018 Feb 18.

Parent-reported prevalence and persistence of 19 common child health conditions.

Liu T, et al. Arch Dis Child. 2018 Feb 16.

Epilepsy in Children After Pandemic Influenza Vaccination.

Håberg SE, et al. Pediatrics. 2018 Feb 15.

Invasive bacterial infections in young afebrile infants with a history of fever.

Mintegi S, et al. Arch Dis Child. 2018 Feb 15.

Tuberculin skin test versus interferon-gamma release assay in refugee children: A retrospective cohort study.

Elliot C, et al. J Paediatr Child Health. 2018 Feb 14.

Nutrient Intake in the First Two Weeks of Life and Brain Growth in Preterm Neonates.

Schneider J, et al. Pediatrics. 2018 Feb 13.

Cerebrospinal Fluid Reference Values for Young Infants Undergoing Lumbar Puncture.

Thomson J, et al. Pediatrics. 2018 Feb 2.

High versus standard dose caffeine for apnoea: a systematic review.

Vliegenthart R, et al. Arch Dis Child Fetal Neonatal Ed. 2018 Feb 7.

Management of suspected paediatric meningitis: a multicentre prospective cohort study.

Ramasamy R, et al. Arch Dis Child. 2018 Feb 7.

Spontaneous resolution of labial adhesions in pre-pubertal girls.

Norris JE, et al. J Paediatr Child Health. 2018 Feb 13.

Are Senna based laxatives safe when used as long term treatment for constipation in children?

Vilanova-Sanchez A, et al. J Pediatr Surg. 2018 Jan 31.

Group B Streptococcal Cellulitis and Necrotizing Fasciitis in Infants: A Systematic Review.

Wojtera M, et al. Pediatr Infect Dis J. 2018 Feb 7.

Routine Supplementation of Lactobacillus rhamnosus GG and Risk of Necrotizing Enterocolitis in Very Low Birth Weight Infants.

Kane AF, et al. J Pediatr. 2018 Feb 2.

The Inverse Relationship between Digital Media Exposure and Childhood Flourishing.

Ruest S, et al. J Pediatr. 2018 Feb 1.

Risk of Death in Infants Who Have Experienced a Brief Resolved Unexplained Event: A Meta-Analysis.

Brand DA, et al. J Pediatr. 2018 Feb 2.

Clinical spectrum of paediatric coeliac disease: a 10-year single-centre experience.

Van Kalleveen MW, et al. Eur J Pediatr. 2018 Feb 1.

Obese Children Require Lower Doses of Pantoprazole Than Nonobese Peers to Achieve Equal Systemic Drug Exposures.

Shakhnovich V, et al. J Pediatr. 2018 Feb;193:102-108.e1.

Incidence of neonatal necrotising enterocolitis in high-income countries: a systematic review.

Battersby C, et al. Arch Dis Child Fetal Neonatal Ed. 2018 Mar;103(2):F182-F189.

C reactive protein in healthy term newborns during the first 48 hours of life.

Perrone S, et al. Arch Dis Child Fetal Neonatal Ed. 2018 Mar;103(2):F163-F166.

Lung ultrasound immediately after birth to describe normal neonatal transition: an observational study.

Blank DA, et al. Arch Dis Child Fetal Neonatal Ed. 2018 Mar;103(2):F157-F162.

If we have missed out on something useful or you think other articles are absolutely worth sharing, please add them in the comments!

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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