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The 18th 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: The burden of mental health presentations in Victoria

Hiscock H, Neely RJ, Lei S, Freed G. Paediatric mental and physical health presentations to emergency departments, Victoria, 2008-15. Medical journal of Australia. 2018 Apr 23.

What’s it about? 

Anec-data suggests that the number of young people presenting to our emergency departments with mental health disorders seems to be on the rise. The researchers analysed the Victorian Emergency Minimum Dataset between – 2008-09 and 2014-25 and looked at all presentations in children and young people (zero to 19 years of age) over that seven-year time frame. They then pulled out all of those patients whose diagnosis was of a mental health disorder.

Absolute numbers of mental health presentations increased by 46% between 2008-9 and 2014-15. This representated an increase in the overall proportion from 1.7% to 2.2%. The most frequent reasons for presentation were:- intentional self-harm (22.5% of all mental health cases), and problems related to psychoactive substance use (22.3%) followed by stress/anxiety, mood disorders and behavioural/emotional disorders.

Patients with mental health disorders (compared to young people with physical problmes) are more likely to be admitted and have longer lengths of stay.

There are some problems with the VEMD system. It only allows for a single diagnosis and that relies on the treating doctors being bothered to put it in accurately. If they patient presents with a self-inflicted injury it might not be coded as such.

Why does it matter? 

The mental status examination is one of the most commonly accessed guidelines on the Royal Children’s Hospital website. As someone who routinely deals with mental health challenges in an adult population, I am disappointed with the lack of services available to our younger population. Perhaps this data will highlight the importance of mental health services for younger people.

Reviewed by: Andy Tagg

Article 2: Burns and School Performance

Azzam N, Oei J, Adams S, Bajuk B, Hilder L, Mohamed AL, Wright IMR, Holland AJA. Influence of early childhood burns on school performance: an Australian population study. Arch Dis Child. 2018 May; 103(5):444-451

What’s it about? 

The acute impact of burns is obvious to anyone but in this paper the authors took the long-term view and assessed the impact a burn may have on a child’s educational performance. They compared those admitted with a burn to those admitted without a burn.

Why does it matter? 

Firstly, the paper provides rich epidemiological data on burns admissions in Australia. The majority being toddlers, TBSA<10% with deep partial thickness. The most common areas affected were the hands and the wrists.

When the team compared national education performance for those admitted with a burn compared to those admitted for other reasons,  they identified that the mean test scores for children with burn injuries were significantly lower (P<0.05) in every test domain although this difference decreased with age.

Associated factors included schooling in a government (public) facility, having a multiparous mother or a mother who smoked during pregnancy and being indigenous. There appeared to be a protective factor in those attending a metropolitan school or with a mother over 35 years of age.

There may be multiple other unmeasured variables that impact on the outcome for example social services input (there no mention if the burns may be a consequence of neglect or physical abuse), maternal mental health, alcohol and drug abuse.

Clinically Relevant Bottom Line:

As emergency clinicians it is easy to get fixated on the managing the acute problem while not appreciating the other factors that may impact the patients quality of life. This study suggests an admission for a burn is an independent variable that may impact educational and economic outcomes for a patient, recommending targeted interventions for these patients. While we may not think we have time should screening for some of these variables be a public health objective in the Emergency Department?

Reviewed by: Stephen Mullen

Article 3: What’s in a label?

Vyles D, et al.  Antibiotic Use After Removal of Penicillin Allergy Label. Pediatrics. 2018 May;141(5).

What’s it all about?

The authors had tested children with low-risk symptoms after penicillin use and found 100% tolerated penicillin. They hypothesised that prescription practices would change after removal of the childrens’ allergy label.

This article reports the follow-up case series of 100 children investigating the safety and calculating the cost-effectiveness. In 58% of antibiotic prescriptions penicillin derivatives were included. One child developed a rash within 24 hours, but there were no serious adverse reactions reported. They calculated that the practice of removing the label of penicillin allergy from children represents a potential cost saving of nearly 200.000 USD a year for a paediatric ED.

Why does it matter?

Many children present to ED with a history of penicillin allergy. A proportion of these children actually have a history of low-risk symptoms that may be the result of other causes such as viruses or viral-drug interaction. Prescribing alternatives to penicillin for these children may result in antibiotic choices that can place additional burden on the healthcare system including longer hospital admissions, encouraging antibiotic resistance or increasing the likelihood of Clostridium difficile infections.

Interestingly in this study, there was a huge discrepancy between parents who reported that they had informed their primary care provider of the child not being allergic (80%), whereas only 16% of primary care providers reported that they were informed (and 52% of primary care medical records still contained the allergy label). Moreover, 28% of families were not completely comfortable with receiving penicillin treatment for their child despite the label removal.

Clinically relevant bottom line

This study suggests that reversing the label of penicillin allergy in children is safe and cost saving. More research/guideline development is needed in the optimal dissemination of results after testing. Informing and educating both parents and their child’s primary care providers is likely to be as important as delabeling the child in the first place.

(If you are interested in the topic, this is a nice review, published in the same journal last month: Antibiotic Allergy in Pediatrics. Norton et al. Pediatrics. 2018 May; 141(5).)

Reviewed by: Anke Raaijmakers

Article 4: Is it all in the wee?

Sheikh N, Hoberman A, Hum SW, Alberty A, Muniz G, Kurs-Lasky M, Shope T. Development and Validation of a Calculator for Estimating the Probability of Urinary Tract Infection in Young Febrile Children. JAMA Paediatrics Published online April 16

What’s it about?

The research team at the Children’s Hospital of Pittsburg use a training database of 1686 children under 2years old with fever presenting to ED presentations who had a urine catheter specimen taken between 2007-2013. They created a nested case control study (1:2) to develop a calculator, UTICalc to estimate the probability of UTI both pre-test and post-test (urinalysis). They then go on to demonstrate the effectiveness of UTICalc in 384 children seen between 2015-2016 and compare their calculator as being more effective than the American Academy of Paediatrics algorithm.

The sensitivity of the calculator is over 95%. The team set a pre-test probability of UTI of 2% or higher as recommending urine collection and the number needed to test with this cut off is 9.8. A post-test probability of 5% was chosen for recommending antibiotics whilst awaiting the formal culture results.

Clinical characteristics  in UTIcalc were

  • Age <12 months
  • Fever >39
  • African American
  • Female or an uncircumcised male
  • Other source of fever.
  • Similar to other studies, the highest risk group was a non-black child over 12 months with a fever over 39 and no other source of fever.

Laboratory characteristics for urinalysis used were:

  • Presence of absence of nitrites
  • Leucocyte esterase (nil, trace, 1,2,3+)
  • WCC concentration
  • Presence of bacteria on gram stain.

For UTICalc to work, all clinical fields are required however only presence of nitrates and leucocytes were mandatory for the lab portion.

Why does it matter?

Children under two often present with minimal history or help with localising of symptoms of a UTI. It is useful to have a greater understanding of the likelihood and risk factors for a UTI to help determine whether it is worth performing a urinalysis as well as whether or not these children should be started on antibiotics before the urine culture result returns. Playing around with the calculator, any combination of leucocytes with nitrates appears to yield a probability of UTI over the 5% threshold for recommending antibiotic treatment. In terms of practically influencing decision making the calculator has some potential in reducing urine testing of infants (the study reports a reduction of 8.1% in a hypothetical group of 1000 children), but I see greater potential in rationalising early antibiotic use in cases where urinalysis results yield nitrates or leucocytes alone or feature trace results. 

The bottom line

UTICalc is a new calculator assessing pre and post urinalysis probability of UTI in infants under 2 year old with fever and suspected UTI. It is based off a larger population group than previous UTI probability calculators and may help inform and guide antibiotic treatment when urinalysis results are available but culture is still pending. The results are based off a training database of children who all had urine collected from one centre in Pittsburgh and future avenues include prospective use and validation in other patient populations.

Reviewed by: Grace Leo

Article 5: Should children get a whole-body CT after an accident?

Meltzer JA, Stone ME, MD, Reddy SH, Silver EJ. Association of Whole-Body Computed Tomography With Mortality Risk in Children With Blunt Trauma. JAMA Pediatrics. Published online April 9, 2018. doi:10.1001/jamapediatrics.2018.0109

What’s it about?

Whole body CT (WBCT) scans have been promoted as the standard for imaging in adult major trauma, and this practice has gradually been extrapolated to children. Often, this was irrespective of the clinical picture, leading many clinicians to question the practice of blanket WBCTs as compared with selective imaging.

In order to determine whether WBCT is associated with improved mortality in injured children (compared with selective CT), the authors analysed 5 years of the US national trauma data bank. They included almost 43000 children between the ages of 6 months and 14 years who received a CT scan within 2 hours of ED arrival for blunt trauma. They replicated (as much as reasonable) the baseline balance in co-variables seen in randomised trials (RCTs). After pragmatically matching for differences in setting, mechanism, injury severity, isolated head injury and interventions (to mitigate the selection bias inherent to database studies), there was no difference in 7-day mortality between children who had WBCT compared with those who had selective CT.

Children who had WBCT spent around 25 minutes less in the ED, but had a longer hospital length of stay.

Why does it matter?

While a RCT has answered the question of WBCT versus selective scanning in adults (no survival benefit, by the way), a similar study in children would be impractical (and perhaps unethical) due to the relative rarity of paediatric major trauma. The value of occult injury identification is also questionable as most are managed conservatively in children anyway. Also, and more importantly, children are more susceptible to the long term consequences of radiation exposure, which adds a key dimension to risk-benefit considerations.

This well designed analysis provides good (perhaps the best so far) evidence that a selective CT strategy is non- inferior to a WBCT approach in paediatric trauma, whilst supporting the principle of ALARA.

Clinically Relevant Bottom Line:

In children with blunt trauma, an approach favouring selective CT imaging (based on individualized clinical assessment) rather than WBCT, avoids unnecessary radiation exposure without missing clinically significant injuries.

Reviewed by: Shammi Ramlakhan

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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