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The 23rd Bubble Wrap


With millions upon millions of journal articles being 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 well do we retain our Basic Life Support skills?

Binkhorst M, Coopmans M, Draaisma J, Bot P, Hogeveen M. Retention of knowledge and skills in pediatric basic life support amongst pediatricians. Eur J Pediatr. 2018 Jul; 177(7): 1089-1099 [Full Text]

What’s it all about?

This Dutch study involved 58 participants with a range of experience (<1 year to >20 years in paediatrics) from 1 academic hospital and five general hospitals (3 of which were teaching hospitals). The goal was to assess the retention of basic life support skills, demonstrated through simulation, and MCQ results at a random time point in the year (when the participants were not prepped beforehand).

All participants went through a standard Dutch PBL scenario (an 8-year-old boy found unconscious on the pavement), which lasted approximately 2 minutes and included the initial approach through delivering compressions and ventilation. All participants were examined by the same two examiners, one to observe technique and one to record time intervals.

The participant’s performance was assessed with the Modified Berden Score. An MCQ followed with ten questions, which had been developed by four PBLS course instructors and three experts. Only 21% of participants passed the practical PBLS exam. Almost a third (29%) failed on compressions/ventilations, and 69% did not utilise the correct 15:2 CPR ratio.

Performance was better in the MCQ (69% passed), but only 19% of participants passed both elements. As might be expected, participants who had more recently undertaken a PBLS course performed better on the MCQ than those who’d been on a course > two years ago. However, this difference was not statistically significant. There was no significant difference between participants divided by sex, frequency of PBLS courses, role as a PBLS instructor, type of hospital the participant worked at or the number of witnessed in-house cardiac arrests.

Participants who were older, attending, and more experienced in terms of years working in paediatrics had higher penalty scores than their younger colleagues.

Why does it matter?

Thankfully, cardiac arrest in children is uncommon. In their introduction, the authors reference several papers that highlight inadequacies in the delivery of basic life support among paediatricians. They suggest that poor skills retention is partly the reason for this, citing further studies that show deterioration within 3-6 months of training if skills aren’t used frequently. This could lead to difficulties and delays in the delivery of effective PBLS.

PBLS skills are usually examined immediately after training, and most people pass these exams. When people are re-tested, this tends to be at a pre-defined time, allowing one to prepare themselves or practice. The authors feel this doesn’t represent paediatricians’ ability to resuscitate a child ad hoc.

Clinically Relevant Bottom Line

We all feel great after completing a life support course, especially if it has gone well. If you’re like me, you probably forget most of it within a few months – maybe sooner if you’re not practising any element of the course in your day-to-day or week-to-week practice. The authors of the paper dedicated a large section to the strengths and limitations of their study, but for me, the bottom line is ‘if you don’t use it you’ll lose it’! Integrating simulation routinely into our work will help keep our BLS skills primed in order for us to deliver better patient care in critical situations.

Reviewed by: Vikram Baicher

Article 2: Does the Yale Observation Scale accurately predict the risk of SBI in febrile infants?

Nigrovic LE, Mahajan PV, Blumberg SM, et al. The Yale Observation Scale Score and the Risk of Serious Bacterial Infections in Febrile Infants. Pediatrics. 2017;140(1):e20170695

What’s it about? 

Fever in infants < 90 days is a common presentation to emergency departments. Of such infants, 5-10% will have a serious bacterial infection (SBI). Tools such as the Rochester Criteria, The Lab Criteria and, more recently, the Step by Step approach help to guide our management of febrile infants. However, we are still searching for a tool which can reliably identify low-risk infants to avoid unnecessary invasive investigations and antibiotics.

Why does it matter? 

This was a prospective cross-sectional study that used the Yale Observation Scale Score (YOS) and applied it to around 4,500 febrile (>38oC) infants under 60 days. A YOS Score < 10 was normal and low risk for SBI. The treating clinician also gave their subjective estimate as to the chance of the infant having an SBI, which ranged from <1% to > 50%.  Clinicians conducted investigations at their own discretion, and investigators reviewed the results. Any positive culture was considered an SBI (classified as non-invasive, i.e. UTI or invasive, i.e. meningitis, bacteraemia).

They found the YOS Score could not confidently discriminate between infants with and without SBIs. Of the 4,058 infants with a normal YOS Score (< 10), 388 (9.6%) had SBIs (Sensitivity 11.6%), and 72 (1.8%) had invasive SBIs (Sensitivity 24.2%). The clinicians were only slightly better. Of the 436 infants with clinician suspicion of < 1%, 106 (6.4%) had SBIs, and 16 (1%) had invasive SBIs.

Clinically Relevant Bottom Line

At this stage, we would not recommend relying on the YOS Score or even your own judgment! Identifying the febrile infant with SBI is difficult, and many local guidelines recommend a full septic workup with empiric treatment while you await negative cultures. We are still searching for that elusive, multivariate predictive model with high sensitivity which can identify low-risk patients and prevent unnecessary and invasive tests, antibiotics and hospitalisation.

Reviewed by: Tina Abi Abdallah

Article 3: Is this infant’s fever all past history?

Ramgopal S, et al. Risk of Serious Bacterial Infection in Infants Aged ≤60 Days Presenting to Emergency Departments with a History of Fever Only. Journal of Pediatrics. 2018 [Epub]

What’s it about? 

The febrile neonate is a common presentation in ED, and management of this population is important, given the significant morbidity and mortality associated with untreated serious bacterial infection (SBI; bacteraemia, bacterial meningitis, and urinary tract infection). As Tina has mentioned above, there are several risk stratification guidelines for evaluating this population and determining the extent to which they are investigated. These infants can also present with a history of fever at home but no fever in ED, which can complicate decision-making.

Why does it matter? 

This prospective study was a secondary analysis of the multi-centre PECARN dataset. Infants aged ≤60 days were evaluated due to fever in participating EDs. The primary aim was to evaluate whether the presence or absence of fever (≥38°C) at the time of evaluation in ED was significantly associated with SBI, and secondary aims were to assess the risk of SBI stratified by age ≤28 days and 29-60 days.

Infants who were afebrile in ED had a lower risk of SBI than those who were febrile in ED, with urinary tract infection the most common SBI. There was an overall lower risk of SBI in the afebrile in the ED group in both the age ≤28 days and age 29-60 days subgroups.

Clinically Relevant Bottom Line

Although the results were statistically significant, the effect sizes were not large; the study also has some significant limitations. With such a vulnerable population, these results do not change current practice.

Reviewed by: Katie Nash

Article 4: Is breast milk from a bottle as good as breast milk from the breast?

Azad, M.B., Vehling, L., Chan, D., Klopp, A., Nickel, N.C., McGavock, J.M., Becker, A.B., Mandhane, P.J., Turvey, S.E., Moraes, T.J. and Taylor, M.S., 2018. Infant feeding and weight gain: separating breast milk from breastfeeding and formula from food. Pediatrics142(4).

What’s it about?

The authors investigated if breast milk keeps the promise of obesity prevention when given from a bottle in a large prospective Canadian birth cohort (n=2553). There are numerous studies about the advantages of breast milk, but few separate directly from expressed breast milk. Moreover, studies about supplementation with formula or solid foods are scarce, too.

This article reports on the incidence of a slightly higher BMI in infancy when breast milk is given from a bottle and a profound increase when supplemented with formula (but not for the introduction of solid food). Compared with exclusive direct breastfeeding at three months of age, the β was +.12 for some expressed milk, +.28 for partial breastfeeding and +.45 for exclusive formula feeding (brief formula feeding in hospital did not alter β).

Why does it matter?

Donor breast milk is a hot item nowadays. If breast milk from a bottle is as good as breast milk from a breast, this potentiates higher breast milk rates and potential obesity prevention, especially for mothers who are unable to breastfeed. This study shows that breast milk is still beneficial even if it comes from a bottle compared to partial breastfeeding or formula feeding.

The bottom line

Breastfeeding is a healthy, low cost and environmentally friendly way of feeding infants. However, if the breast milk comes from a bottle, the benefits are slightly reduced but still outweigh partial breastfeeding and formula feeding. Moreover, formula supplementation substantially weakens the benefits, whereas solid introduction after five months did not alter the associations.

Reviewed by: Anke Raaijmakers

Article 5: Transgender Adolescent Suicide Behaviour

Toomey, R.B., Syvertsen, A.K. and Shramko, M., 2018. Transgender adolescent suicide behavior. Pediatrics142(4).

What’s it about?

This paper sheds light on the difficulties that the current generation of adolescents face. Although the title of the paper acknowledges the focus of this study is the transgender adolescent, it is applicable to the entire adolescent cohort.

Why does it matter?

In this US study, adolescents were defined as 11-19 years with the authors performing a secondary data analysis on a previous survey. The survey was conducted over a three-year period with an impressive sample size of 120 617 participants, which included questions regarding previously attempted suicide (not just suicidal ideation), gender identity and the more typical demographic questions.

In this cohort, 50.6% identified as female and 48% male, with 0.7% identifying as transgender and a further 0.9% unsure.  A total of 14.1% of adolescents (n = 17 007) in the sample reported having tried to kill themselves. This is a concerningly high figure, but when the sub-group analysis was performed, this percentage rose dramatically in those who identify themselves as transgender. The highest rate was reported in female-to-male adolescents (50.8%), followed by adolescents who identified as not exclusively male or female (41.8%), male-to-female adolescents (29.9%), questioning adolescents (27.9%), female adolescents (17.6%), and male adolescents (9.8%)

The research team further interrogated the data using logistic regression models, identifying that transgender, questioning, and female adolescents had higher odds of suicide behaviour than their male counterparts. They also noted that beyond gender identity, a non-heterosexual sexual orientation was associated with higher odds of suicide behaviour, as was identifying as a racial or ethnic minority.

Clinically Relevant Bottom Line:

The results in themselves will not take many of us by surprise and certainly reflect the changing adolescent workload we are all experiencing in PEM. What did surprise me was how high the percentage was, both in the entire cohort and, more worryingly, in those who identify themselves as transgender.

I work in the UK in an area with one of the highest suicide rates in Europe and in a society that is yet to endorse many of the rights the LGBT community have in other parts of the world.

This paper should encourage us to analyse how our departments are tailored to meet the needs of all adolescents, in particular those who are identified as high risk and what services are available to refer to.

Reviewed by: Stephen Mullen


  • 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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