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The 1st 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 the world of paediatrics to point out something that has caught their eye. This is the 1st Bubble Wrap.

Article 1 – Traumatic lumbar puncture in neonates

Traumatic Lumbar Puncture in Neonates. PMID: 18989240 ; Greenberg RG, et al. Traumatic Lumbar Puncture in Neonates. Pediatr Infect Dis J. 2008; 27(12): 1047-1051

What’s it about? 

This was a cohort study of 6,347 lumbar punctures performed over seven years from 150 neonatal intensive care units. It focused on the 2517 lumbar punctures which were traumatic (>500 red cells in the tap) and whether the practice of adjusting CSF white blood cell (WBC) counts based on CSF and peripheral red blood cell counts was valid.

The paper compared the WBC count on CSF of neonates with traumatic LPs with and without meningitis to predicted count based on ratios (such as 500:1 CSF RBC:WBC). Adjusting the WBC count to account for traumatic taps increases the specificity and positive likelihood ratio at the expense of sensitivity.

Of the 18 cases of missed meningitis, using a 500:1 correction would miss 5 cases. Using an unadjusted cut off of 20 cells/mm3 would only miss 3. This must be weighed against having 422 false positives, compared with 246 false positives with the 500:1 correction.

Why does it matter? 

Many of us have been taught that traumatic LP results can be “adjusted” to determine whether there is “true” leukocytosis or that the elevated WBC count is due to hitting an artery. We need to be cautious and recognize that adjustment of the WBC count in traumatic taps, whilst reducing rates of false positives, also contributes towards an increase in false negatives.

Read more on Pediatric EM Morsels

Reviewed by: Sean Fox

Article 2 – A clinical pathway for chest pain

 Mohan S, Nandi D, Stephens P, M’Farrej M, Vogel R and Bonafide C. Implementation of a Clinical Pathway for Chest Pain in a Pediatric Emergency Department. Pediatric Emerg Care 2016

What’s it about? 

Chest pain is a common complaint in children and young people presenting to emergency departments but generally isn’t caused by serious cardiac disease. This paper looked at a methodology of reducing inappropriate investigations and referrals in children with chest pain, which were felt to be too high at the institution the study took place in. A chest pain pathway was introduced which included a specific history taking and electronic order set.

Why does it matter? 

This paper is a useful read for a couple of reasons. Namely, because there is a paucity of improvement studies in Paediatric Emergency Medicine literature. While we are excited by drug-based therapies and which way round you should twist an elbow; long term benefits for patients will come from applying evidence-based practice in a consistent manner.

Despite some limitations of applicability (it is a US study whose health system dynamics may not translate internationally) and design (case identification was only based on looking for ‘chest’ and ‘pain’ together), this is a relatively well constructed study which clearly identifies a problem and sets out a clear intervention to solve it. It would have been useful to have had longer follow up to confirm the sustainability and it may be argued that the intervention wasn’t iterative (i.e. it was a before and after design rather than a sequence of PDSA cycles). However, the authors were honest enough to report all outcomes. They discovered a moderate reduction in blood testing (troponin use decreased from 5.3 to 3.9% – a test I’ve ordered fewer times than I have fingers) but referral rates for out-patient follow up increased. The biggest deficit was the absence of truly patient-centred outcomes. Although the length of stay was examined (a reduction from 3.3 to 3.08 hours), it is not clear what the patient experience of this endeavor was.

Ultimately to improve quality we need an efficient and safe pathway that families have confidence in. Whether you are research active or not, everyone has a role to play in improving quality of care and more studies like this will hopefully engage others in this pursuit.

Reviewed by: Damian Roland

Article 3 – Consuming energy drinks at 14 predicted substance use at 16.

Barrense-Dias Y, Berchtold A, Akre C, Surís JC. Consuming energy drinks at the age of 14 predicted legal and illegal substance use at 16. Acta Paediatr. 2016 Nov;105(11):1361-1368. doi: 10.1111/apa.13543. Epub 2016 Sep 2

What’s it about?

Dr. Joan Carles Suris and his team at the Institute of Social and Preventive Medicine in Lausanne, Switzerland produce some excellent research to help us understand adolescents. This paper identifies energy drink usage at 14 as an independent predictor of illegal substance use at 16 years of age, using a logistic regression model from a longitudinal study of 621 youths over 2 years. The authors postulate one of two possible theories – energy drinks represent a gateway substance to illegal substances, or that energy drinks are part of an overall milieu of substance usage, including alcohol, tobacco, cannabis.

One of the acknowledged limitations of the study is the high attrition rate from the initial wave of 3367 young people surveyed. Additionally, energy drink usage was not measured at both time points, and consequently, it is harder to draw conclusions about temporal relationships between energy drinks and illegal substance use.

Why does it matter?

Pragmatically, asking young people about energy drinks is likely to be less confrontational than discussing cannabis use, tobacco smoking or drunkenness. When talking to young people, specifically asking about energy drinks and potentially using this as a segue into a discussion about illegal substance use is a reasonable approach. 

Reviewed by: Henry Goldstein

Article 4 – Effective of maneuvers to treat nursemaid’s elbow (pulled elbow)

Bexkens R, Washburn FJ, Eygendaal D, van den Bekerom MP, Oh LS. Effectiveness of reduction maneuvers in the treatment of nursemaid’s elbow: A systematic review and meta-analysis. The American Journal of Emergency Medicine. 2016 Nov 2

What’s it about? 

Nursemaid’s or pulled elbow is a common presentation to the emergency department.  Recognizing it from the clinical history then fixing it with what appears to be a bit of sleight of hand makes you look amazing (as long as you warn the parents that there is going to be some tears).

This systematic review aimed to find out the answer to a question that I constantly get asked – “Which way do I twist it?“. Is hyper-pronation or supination-flexion more effective? Understandably all the trials entered into the review were somewhat heterogeneous and only managed to include small numbers. It does seem, however, that hyper-pronation is more effective with an NNT of 4.

Why does it matter? 

Now when that next child walks into the ED with a pulled elbow, it might be worthwhile choosing a technique with hyper-pronation of the elbow! For more FOAMed on the subject check out Casey Parker’s BroomeDocs.

Recommended by: Andy Tagg

Article 5 – Assessing the effectiveness of the “Step-by-Step” approach to young febrile infants

Gomez B, Mintegi S, Bressan S, et al. Validation of the “Step-by-Step” Approach in the Management of Young Febrile Infants. Pediatrics. 2016;138(2):e20154381

The step-by-step approach is a method to risk stratify infants with fever without focus. An infant is classified as high risk if any of the following criteria are present: abnormal paediatric assessment triangle/unwell looking; leukocytouria; or procalcitonin >0.5ng/ml. If these are negative, and the child has a CRP >20mg/l or ANC >10,000/mm3 then they are an intermediate-risk patient. If the infant has none of these variables they are classified as low risk.

What’s it about? 

This large scale European study looked at 2185 infants with fever with no focus on presentation in ED. The objective was to identify a low-risk group of infants who could be safely managed as outpatients without lumbar puncture nor empirical antibiotic treatment.  Data was collected prospectively, however, no intervention was made, and the study retrospectively compared three different systems for evaluating infants with fever: the Step-by-Step criteria; Rochester criteria; and Lab-Score.  In the study of 2185 infants with fever without source, 87 (4%) were diagnosed as having an invasive bacterial infection either during admission or by 30 day follow up. Seven infants (8% of those with IBI, 0.3% of all patients) were misclassified by the Step-by-Step approach compared to 16 by Rochester and 35 by Lab-Score. The prevalence of IBI was significantly higher in infants classified by Step-by-Step as “high risk” or “intermediate risk” compared with “low risk” patients.

Why does it matter?

This paper shows the Step-by-Step approach better identifies low-risk patients who might be suitable for outpatient management compared with Rochester Criteria or Lab score. This approach could help be a useful adjunct to assessment of fever without focus in infants and encourage greater practice of observation or outpatient management over LP and empirical antibiotics. The Step-by-Step approach missed 8% of all patients who were later diagnosed as having an invasive bacterial infection. Furthermore, as the criteria includes clinical assessment, it is still user-dependent. In young infants, the consequences of missed invasive or serious bacterial infections can be catastrophic and we would advise Step-by-Step should always be a tool rather than a rule.

For more read this post from Henry.

Recommended by: Grace Leo

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.  If you think they have missed something amazing then let us know.


  • 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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