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The 17th Bubble Wrap


With millions upon millions of journal articles being published every year 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: Can we use the NEXUS head CT decision rules in paediatric patients with blunt head injuries?

Gupta M, Mower WR, Rodriguez RM, Hendey GW.Validation of the Pediatric NEXUS II Head CT Decision Instrument for Selective Imaging of Pediatric Patients with Blunt Head Trauma. Acad Emerg Med. 2018 Apr 17. doi: 10.1111/acem.13431.

What’s it about? 

The authors conducted a prospective study over nine years in four emergency departments in the US. Children with a blunt head injury had the NEXUS head CT rules applied prior to having the actual head CT. 1018 patients were included; 27 required neurosurgical intervention and 49 had significant intracranial injuries.

NEXUS correctly identified all 27 patients requiring neurosurgical intervention. It identified 48 out of 49 patients with significant intracranial injuries, but incorrectly classified the 49th patient as low risk (and therefore would not have had a CT with NEXUS – although the patient was observed only).

Why does it matter? 

We have a tendency to over-CT in children with head injury – we worry about the consequences of missing a significant injury. The use of NEXUS in this study incorporates clinician judgement. The patient have already been deemed by a clinician to need a head CT, and then NEXUS is applied. The implication is that it could be used to rule out the need for head CT in this group of patients.

Clinically Relevant Bottom Line:

NEXUS has high sensitivity, meaning that it won’t miss patients who need neurosurgical intervention. But the consequence is that it has low specificity, meaning that there will be many false positives. Consequently we could end up scanning way more patients than we need to. However if we use NEXUS as a rule-out (one way) test, then there may be some potential. If we use clinical judgement to decide whether patients need a CT scan, and then before we scan we apply NEXUS – due to its high sensitivity it could be possible to reduce some unnecessary CTs. However, NEXUS did miss a significant intracranial injury, so maybe it’s not that sensitive after all.

Reviewed by: Tessa Davis


Article 2: How about D-dimers instead of head CT scans?

Langness S, Ward E, Halbach J, Lizardo R, Davenport K, Bickler S, Kling K, Thangarajah H, Grabowski J, Fairbanks T. Plasma D-dimer safely reduces unnecessary CT scans obtained in the evaluation of pediatric head trauma. Journal of pediatric surgery. 2018 Apr 1;53(4):752-7.

What’s it about? 

TBI (Traumatic Brain Injury) related visits to the emergency department have increased substantially over the last decade. Head CT scans are considered the most definitive test in ruling out TBI but expose children to radiation. D-dimer serum analysis has been proposed as a potential biomarker for paediatric traumatic brain injury. This retrospective study aimed to estimate the efficacy of using D-dimer to predict TBI.

The authors analysed 663 patients over a 3 year period who presented head trauma. They included 403 patients with isolated head trauma in the final analysis. Subsequently, they calculated which cut-off value would be most effective in preventing head CT scans without missing significant TBI.

The paper found that using D-dimer with a cut off value <750 pg/µL was effective in preventing 209 CT-scans (39.7%) without missing any significant TBI (isolated skull fractures were considered non-significant, n=2).

Why does it matter? 

Ionizing radiation, rising costs and potential sedation are potential side-effects of CT imaging. Moreover, several screening algorithms have been suggested, but they rely on complete and accurate history taking, subjective to variation. This study suggests that we can safely use D-dimer analysis <750 pg/µL as negative predictive value to rule out significant TBI.

Clinically Relevant Bottom Line:

This early study suggests that D-dimer analysis may become a useful adjunct in ruling out clinically important TBI.  More research is needed in the space and in particular, comparison or combination with existing head injury decision rules.

Reviewed by: Anke Raaijmakers


Article 3: What about an EEG?

Koutroumanidis M., & Smith S. Use and Abuse of EEG in the Diagnosis of Idiopathic Generalized Epilepsies. Epilepsia, 46(Suppl. 9):96–107, 2005 International League Against Epilepsy

What’s it all about?

This elegantly titled article notes in the introduction that “EEG interpretation is still empirical and may be completely meaningless and even misleading without knowledge of the clinical problem”; the crux of this 12 page paper published in Epilepsia in 2005, complete with examples of classical waveforms, and a neat evolution of theories of epilepsy.

Why does it matter?

With the increased availability of EEG in tertiary centres, the need to be thoughtful and rational about the usage of this investigation has evolved commensurate with the ease of access. To further inform and guide your outpatient investigative planning, the authors discuss the usage of EEG in the diagnosis of Idiopathic generalised Epilepsies, and it’s uses for other epilepsy presentations.

Clinically Relevant Bottom Line:

Jump to the bullet points on pages 11 and 12 for the entire list of conclusive for what EEG can and cannot offer your patient. Remember,“ Interictal EEG alone cannot be used for a) Establishing or excluding the diagnosis of epilepsy (including IGEs), b) Providing oversimplified clues for reliable syndromic diagnosis (GSW discharges do not always indicate IGE, and focal changes do not necessarily suggest a symptomatic focus), and c) Prognostication and prediction of possible relapse after the discontinuation of AED treatment.

Reviewed by: Henry Goldstein – Sugggested by Dr Sophie Calvert, Paediatric Neurologist


Article 4: Winter is coming – we’d better vaccinate!

What’s it about?

The Australian National Immunisation Program covers 16 infecious diseases including diphtheria, rotavirus, measles, meningococcal disease and poliomyelitis to name a few. This paper reviewed the NSW Child Death Register and NSW Health notifiable conditions register to identify any child deaths between 2005 to 2014 that may have been prevented by vaccination.

Why does it matter?

Overall fifty-four deaths occurred that were identified as potentially having been preventalble with vaccination. One third of these occurred in children with comorbidities. The most common conditions were influenza (12 deaths) and meningococcal disease (5 deaths). The paper also identified changes in maternal vaccination introduced in 2016 as another avenue to reduce child deaths from influenza.

Aus & UK Free Influenza Vaccines

(Note: In Australia for 2018, all children between 6 months and 5 years are eligible for a free seasonal influenza vaccine in addition to all children over 5 with chronic medical conditions such as cardiac disease,respiratory conditions including severe asthma and other chronic illnesses requiring regular follow up or hospitalisation. Aboriginal and Torres Strait Islander people over 15, pregnant women and those aged 65 years and older are also included in the program. See for details.

For Autumn/Winter in the UK, the NHS is providing  free nasal spray flu vaccination for children aged 2-3 on August 31st 2017, children in preschool until year 4 and those between 2-17 years of age with long term health conditions. See for details.

The bottom line

Vaccines save lives. Winter is coming! Remember to check your patients’ immunisation status. We should support routine vaccinations as well as the influenza vaccine for families with children who would qualify for or benefit from it.

Reviewed by: Grace Leo


Article 5: Excuse me… Can I ask you a personal question?

What’s it about?

 The NHS winter crisis occurs every year, with news outlets seemingly delighting in showing pictures of patients lining up in corridors waiting to be seen. Our friends in the North have done an amazing job under very trying conditions. Whilst this paper is not strictly about paediatrics it is worth taking a look at its subject matter. Do we take less of a history when we see the patient in the corridor?

To begin to answer this question the authors undertook a survey of 409 emergency physicians at the 2015 ACEP Scientific Assembly. It comprised of three key areas :- demographics, history taking and physical examination. The latter two used Likert scales to report various behaviours. There was a great response rate with 409 of the 568 (72%) physicians approached consenting to take part. 90% reported that they had altered their history taking and 56% their physical exam if other people were present. This lead to delays or failure to diagnose in 35% (of those who altered their usual history taking) and 41% (of those that did not do their usual exam).

Why does it matter?

 Winter is coming for us in the South and an increase in seasonal illnesses. I think it unlikely that we will be subjected to the caseload that the UK has seen but we still have patients show-horned into all corners of the department. We know (intuitively) that clinical care is compromised – delivery of timely antibiotics or pain relief, for example – but this paper makes it apparent that even basic history taking is compromised, increasing the potential for error. I wonder what impact the curtains around our cubicles have?

Clinically Relevant Bottom Line:

 Be mindful that you may (un)consciously alter your history and physical exam technique if you are seeing a patient in the corridor. If you need to ask questions of an intimate nature then do so, in an appropriate environment.

Reviewed by: Andy Tagg


Bubble Wrap Plus

The Bubble Wrap introduced our new Plus segment last month featuring a monthly journal club reading list  from Anke Raaijmakers working with Professor Jaan Toelen & his team of the University Hospitals in Leuven. This comprehensive list of ‘articles to read’ across paediatrics is derived from 34 journals, including  major and subspecialty paediatric journals.

This month’s list features answers to intriguing questions such as: ‘Can a major increase in inhaled corticosteroids prevent asthma exacerbations?’, ‘Can CRP and neutrophil analysis guide us in our decision to perform LP in neonatal sepsis?’ and ‘What is the relation between prolonged breastfeeding and caries?’. They have also included an April’s Fools Day hoax as well, can you spot it?

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

1.Reviews and opinion articles

Tramadol, breast feeding and safety in the newborn.

Palmer GM, et al.  Arch Dis Child. 2018 Mar 29.

Intrathoracic tuberculous lymphadenopathy in children: a guide to chest radiography.

George A, et al.  Pediatr Radiol. 2017 Sep;47(10):1277-1282.

Imaging of thoracic tuberculosis in children: current and future directions.

Sodhi KS, et al.  Pediatr Radiol. 2017 Sep;47(10):1260-1268.

Bronchopulmonary Dysplasia: Executive Summary of a Workshop.

Higgins RD, et al.  J Pediatr. 2018 Mar 16.

Diagnosis delays: a threat for patients and researchers?

Launay E, et al.  J Pediatr. 2018 Mar 15.

Red Blood Cell Transfusion in Preterm Infants: Current Evidence and Controversies.

Howarth C, et al.  Neonatology. 2018 Mar 16;114(1):7-16.

Candida auris, what do paediatricians need to know?

Warris A. Arch Dis Child. 2018 Mar 15.

The paediatrician and the management of common gynaecological conditions.

Ritchie JK, et al.  Arch Dis Child. 2018 Mar 15.

Please Test My Child for a Cancer Gene, but Don’t Tell Her.

Bester J, et al.  Pediatrics. 2018 Mar 13.

The Role of the Microbiome in the Developmental Origins of Health and Disease.

Stiemsma LT, et al.  Pediatrics. 2018 Mar 8. pii: e20172437.

Air pollution and asthma.

Vardoulakis S, et al.  Arch Dis Child. 2018 Mar 8.

Sleep disorders during childhood: a practical review.

Ophoff D, , et al.  Eur J Pediatr. 2018 Mar 3.

Status Complexicus? The Emergence of Pediatric Complex Care.

Cohen E, et al.  Pediatrics. 2018 Mar;141(Suppl 3):S202-S211.

Genomics for paediatricians: promises and pitfalls.

Hammond CL, et al.  Arch Dis Child. 2018 Mar 24.

2. Original clinical studies

Quadrupling Inhaled Glucocorticoid Dose to Abort Asthma Exacerbations.

McKeever T, et al.  N Engl J Med. 2018 Mar 8;378(10):902-910.

Quintupling Inhaled Glucocorticoids to Prevent Childhood Asthma Exacerbations.

Jackson DJ, et al.  N Engl J Med. 2018 Mar 8;378(10):891-901.

C-reactive protein and immature-to-total neutrophil ratio have no utility in guiding lumbar puncture in suspected neonatal sepsis.

Goldfinch CD, et al.  J Paediatr Child Health. 2018 Mar 30.

Bacterial Load and Molecular Markers Associated with Early-Onset Group B Streptococcus.: A Systematic Review and Meta-Analysis.

Seedat F, et al.  Pediatr Infect Dis J. 2018 Mar 27.

Early-onset neonatal infections in Australia and New Zealand, 2002-2012.

Singh T, et al.  Arch Dis Child Fetal Neonatal Ed. 2018 Mar 27.

Clinical Monitoring of Well-Appearing Infants Born to Mothers With Chorioamnionitis.

Joshi NS, et al.  Pediatrics. 2018 Mar 29.

Estimating neonatal length of stay for babies born very preterm.

Seaton SE, et al.  Arch Dis Child Fetal Neonatal Ed. 2018 Mar 27.

Antibiotic Overuse in Children with Respiratory Syncytial Virus Lower Respiratory Tract Infection.

van Houten CB, et al.  Pediatr Infect Dis J. 2018 Mar 29.

Yield and Examiner Dependence of Digital Rectal Examination in Detecting Impaction in Pediatric Functional Constipation.

Pradhan S, et al.  J Pediatr Gastroenterol Nutr. 2018 Mar 29.

Neurodevelopmental Outcomes in Children With Liver Diseases: a Systematic Review.

Rodijk LH, et al.  J Pediatr Gastroenterol Nutr. 2018 Mar 29.

Proton Pump Inhibitors and Infant Pneumonia/Other Lower Respiratory Tract Infections: National Nested Case-control Study.

Blank ML, et al.  J Pediatr Gastroenterol Nutr. 2018 Mar 29.

Detection of Cytomegalovirus in Colonic Mucosa of Children With Inflammatory Bowel Disease.

El-Matary W, et al.  J Pediatr Gastroenterol Nutr. 2018 Mar 29.

Vomiting With Head Trauma and Risk of Traumatic Brain Injury.

Borland ML, et al.  Pediatrics. 2018 Mar 29.

Plasma D-dimer safely reduces unnecessary CT scans obtained in the evaluation of pediatric head trauma.

Langness S, et al.  J Pediatr Surg. 2018 Apr;53(4):752-757.

Urinary stone risk factors in the descendants of patients with kidney stone disease.

Dissayabutra T, et al.  Pediatr Nephrol. 2018 Mar 28.

Obesogenic habits among children and their families in response to initiation of gluten-free diet.

Levran N, et al.  Eur J Pediatr. 2018 Mar 29.

Vaccination Patterns in Children After Autism Spectrum Disorder Diagnosis and in Their Younger Siblings.

Zerbo O, et al.  JAMA Pediatr. 2018 Mar 26.

Pediatric Hoverboard and Skateboard Injuries.

Bandzar S, et al.  Pediatrics. 2018 Mar 26.

Validation of a novel smartphone App for infant-physician verbal interaction in the outpatient department.

Wit NT, et al, Arch Dis Child Ed Pract Joke. 2018 Mar 17.

Accuracy of Pulse Oximetry Screening for Critical Congenital Heart Defects after Home Birth and Early Postnatal Discharge.

Narayen IC, et al.  J Pediatr. 2018 Mar 23.

The effects of prebiotic supplementation on weight gain, diarrhoea, constipation, fever and respiratory tract infections in the first year of life.

Shahramian I, et al.  J Paediatr Child Health. 2018 Mar 26.

Allergen-Specific Immunotherapy in the Treatment of Pediatric Asthma: A Systematic Review.

Rice JL, et al.  Pediatrics. 2018 Mar 23.

Neurocognitive outcomes in children following immersion: a long-term study.

Manglick MP, et al.  Arch Dis Child. 2018 Mar 23.

Fidget Spinner Ingestions in Children-A Problem that Spun Out of Nowhere.

Reeves PT, et al.  J Pediatr. 2018 Mar 20.

A Meta-Analysis of Gaze Differences to Social and Nonsocial Information Between Individuals With and Without Autism.

Frazier TW, et al.  J Am Acad Child Adolesc Psychiatry. 2017 Jul;56(7):546-555.

Suicide After Deliberate Self-Harm in Adolescents and Young Adults.

Olfson M, et al.  Pediatrics. 2018 Mar 19. pii: e20173517.

The Impact of Clinical Pathways on Antibiotic Prescribing for Acute Otitis Media and Pharyngitis in the Emergency Department.

Dona D, et al.  Pediatr Infect Dis J. 2018 Mar 14.

Accuracy of five formulae to determine the insertion length of umbilical venous catheters.

Lean WL, et al.  Arch Dis Child Fetal Neonatal Ed. 2018 Mar 17.

Cost-Effectiveness Analysis of Nasal Continuous Positive Airway Pressure Versus Nasal High Flow Therapy as Primary Support for Infants Born Preterm.

Huang L, et al.  J Pediatr. 2018 Mar 15.

Standardized reporting of appendicitis-related findings improves reliability of ultrasound in diagnosing appendicitis in children.

Sola R Jr, et al.  J Pediatr Surg. 2018 Feb 8.

Metabolomic Profile of Amniotic Fluid and Wheezing in the First Year of Life-A Healthy Birth Cohort Study.

Carraro S, et al.  J Pediatr. 2018 Mar 13.

Paediatric outcomes and timing of admission.

Ramsden L, et al.  Arch Dis Child. 2018 Mar 15.

Mandatory imaging in the work-up of children suspected of having appendicitis reduces the rate of unnecessary surgeries.

de Castro SMM, et al.  J Pediatr Surg. 2018 Feb 17.

Refining the Use of Nasal High-Flow Therapy as Primary Respiratory Support for Preterm Infants.

Manley BJ, et al.  J Pediatr. 2018 Mar 9.

Does size matter? Correlation of ultrasound findings in children without clinical evidence of acute appendicitis.

Wijayanayaka T, et al.  J Pediatr Surg. 2018 Feb 9.

Point-of-Care Fecal Calprotectin Monitoring in Preterm Infants at Risk for Necrotizing Enterocolitis.

Nakayuenyongsuk W, et al.  J Pediatr. 2018 Mar 6.

Diagnostic characteristics of anterior cutaneous nerve entrapment syndrome in childhood.

Siawash M, et al.  Eur J Pediatr. 2018 Mar 7.

Predicting inflammatory bowel disease in children with abdominal pain and diarrhoea: calgranulin-C versus calprotectin stool tests.

Heida A, et al.  Arch Dis Child. 2018 Mar 7.

Long-term Treatment With Proton Pump Inhibitors Is Effective in Children With Eosinophilic Esophagitis.

Gutiérrez-Junquera C, et al.  J Pediatr Gastroenterol Nutr. 2018 Mar 5.

Association of Severity of Coronary Artery Aneurysms in Patients With Kawasaki Disease and Risk of Later Coronary Events.

Miura M, et al.  JAMA Pediatr. 2018 Mar 5:e180030.

Prolonged breastfeeding and dental caries.

Isaacs D, et al.  J Paediatr Child Health. 2018 Mar;54(3):333.

Clinical Predictors of Residual Sleep Apnea after Weight Loss Therapy in Obese Adolescents.

Van Eyck A, et al.  J Pediatr. 2018 Mar 1.

Identifying Clinically Significant Irritability in Early Childhood.

Wiggins JL, et al.  J Am Acad Child Adolesc Psychiatry. 2018 Mar;57(3):191-199.e2.

Psychosocial Effects of Parent-Child Book Reading Interventions: A Meta-analysis.

Xie QW, et al.  Pediatrics. 2018 Mar 27.

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.

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.


High flow therapy – when and how?

Chest compressions in traumatic cardiac arrest

Searching for sepsis

The missing link? Children and transmission of SARS-CoV-2

Don’t Forget the Brain Busters – Round 2

An evidence summary of Paediatric COVID-19 literature


The fidget spinner craze

Parenteral Nutrition

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