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The 28th 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 the UK and Ireland) to point out something that has caught their eye.

Article 1: To glue or not to glue?

Ste-Marie-Lestage et al. Complications following chin laceration reparation using tissue adhesive compared to suture in children. Injury. 2019 Mar 29. pii: S0020-1383(19)30165-2. doi: 10.1016/j.injury.2019.03.047. [Epub ahead of print]

Why does it matter?

Children, adorable as they are, are a bit clumsy and often fall over, resulting in facial lacerations. These minor traumas are often present in ED, and the majority are repaired using tissue adhesive, which is fast and pain-free. This study aims to determine if the dehiscence rate differed amongst simple wounds repaired with tissue adhesive compared with sutures.

What’s it about?

The electronic records of children presenting to a tertiary paediatric centre (between Dec 2015 and Nov 2017) with a diagnosis of traumatic facial/head lacerations were reviewed. Children who had wounds at risk of infection (i.e. animal bites, heavily soiled, required debridement) or complex wounds (i.e. greater than 5cm, in high mobility areas, extended to muscle layers) were excluded.

A total of 2044 children were eligible, and 89% of the wounds were repaired using tissue adhesive. The primary outcome was dehiscence in the 30 days after repair, with the secondary outcome being infection. Electronic records were reviewed, and parents of eligible children were called and asked about wound healing.

For facial lacerations, there was no statistically significant difference in rates of dehiscence or infection between tissue adhesive and sutures. The same was found for chin lacerations, which have a 5x higher rate of dehiscence compared with other facial lacerations.

Clinically Relevant Bottom Line

As no guidelines exist to guide our decision-making process for using tissue adhesives or sutures, we use our clinical judgment. It is reassuring to know that tissue adhesive does not have statistically significant higher complication rates for low-risk wounds and, thus, should continue being the first choice for repair.

Reviewed by: Tina Abi Abdallah

Article 2: Long-Term Follow-Up of Infants After a BRUE–Related Hospitalization

Ari A, Atias Y, Amir J. Long-Term Follow-Up of Infants After a Brief Resolved Unexplained Event-Related Hospitalization. Pediatr Emerg Care. 2019 April 3. doi: 10.1097/PEC.0000000000001816. [Epub ahead of print]

What’s it about?

The change of the terminology of an ALTE (acute life-threatening event) to a BRUE (brief resolved unexplained event) by the American Academy of Pediatrics was a welcome change for those who believed a more pragmatic approach to this not-uncommon presentation was needed. However, the change in definition did mean that some children previously categorised as ALTE may not have had the investigations or observations they would normally have received. This study looked at the outcomes of infants at 5 years following their presentation with a BRUE.

A brief resolved unexplained event (BRUE) is defined as “an event occurring in an infant <1 year of age when the observer reports a sudden, brief and now resolved episode of ≥1 of the following:

  • Cyanosis or pallor
  • Absent, decreased or irregular breathing
  • Marked changes in tone
  • Altered level of responsiveness

Importantly, although parental attempts at resuscitation are obviously acknowledged, a BRUE diagnosis is based on how the clinician defines the event and not on a caregiver’s perception that this was a life-threatening event.

This was a single-centre retrospective study performed in a relatively large children’s Emergency Department (54,000 children a year) in Israel from 2009-13. These dates are important as (i) data collection is very retrospective, meaning that it’s difficult to know what the clinicians definitely did, and (ii) it predates the emergence of the term BRUE, so while strict BRUE criteria were applied to selected patients, the concept wasn’t a working diagnosis for clinicians at that time. It is also important to note that only hospitalised children were included i.e. those discharged from ED were not part of the cases. This means that the findings of this study may not be comparable to other centres that discharge directly or admit to an ED short-stay unit.

Essentially, of 87 children who were followed up via telephone questionnaire, 71 (81.6%) were described as having normal development, one (1.1%) child had global developmental delay, 12 (13.8%) had verbal delay, and 3 (3.4%) had autistic spectrum disorder. These, apart from a 1% ASD incidence, are not grossly different from population statistics. In this cohort, 2.3% had had a febrile seizure, and 1.15% had nonfebrile seizures, again not dissimilar from population norms.

Clinically Relevant Bottom Line:

The longer-term outcomes, in this small study, of a child with a retrospective diagnosis of a BRUE are not alarming.  A prospective study is clearly needed to confirm this.

Reviewed by: Damian Roland (@damian_roland)

Article 3: Which medication is best for neonatal abstinence syndrome?

Disher et al. Pharmacological Treatments for Neonatal Abstinence Syndrome: A Systematic Review and Network Meta-analysis. JAMA Pediatrics. 2019 Mar; 173(3)

What’s it about?

The aim of this meta-analysis was to compare the different pharmacological agents available for the treatment of neonatal abstinence syndrome (NAS) and identify the most effective therapy in terms of reducing the length of treatment, the length of stay, the need for adjuvant therapy and adverse events.

The study analysed eighteen randomised clinical trials (N = 1072) which compared buprenorphine, clonidine, diluted tincture of opium and clonidine, diluted tincture of opium, morphine, methadone and phenobarbital.

Buprenorphine was found to be the best treatment, given the reduction in the length of treatment of 12.75 days (95% CI, -17.97 to -7.58) compared to morphine. Buprenorphine also reduced the length of stay but not the need for adjuvant treatment, compared to other pharmacological agents. On the other hand, morphine and phenobarbital were the worst treatments in terms of relative effects and rankings.

Why does it matter?

Morphine is the most commonly used pharmacological agent in the treatment of NAS, however this meta-analysis suggests that it may be the worst treatment choice in terms of length of treatment and hospital stay! The benefit of buprenorphine could be due to its longer half-life and, therefore, prevention of sudden withdrawal symptoms. It was also interesting to note the “less mainstream” therapy options, such as diluted tincture of opium, for the treatment of NAS in some centres.

Clinically relevant bottom line:

While the findings of this meta-analysis make us wonder whether buprenorphine should be used more widely as the first-line treatment for NAS, the authors emphasise that there is a need for a large multisite trial that compares buprenorphine with other treatments before it can be accepted as the standard treatment for NAS. Watch this space!

Reviewed by: Jennifer Moon

Article 4: Sorry, where was I? I was a little distracted…

Westbrook JI, Raban MZ, Walter SR, Douglas H. Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working memory capacity: a prospective, direct observation study. BMJ Qual Saf. 2018 Aug; 1;27(8):655-63.

What’s it about?

A team of observers followed 36 emergency physicians around on shift and watched them in three-hour blocks to codify how many times they were interrupted. By using  WOMBAT (Work Observation Method By Activity Timing), the observers were able to capture the minute-by-minute adventures of the physicians. They found that, on average, an emergency physician was interrupted 7.9 times per hour. They also looked at prescribing errors (by collecting the paper charts) and found 208 prescribing errors in 238 medication orders. Now, it must be pointed out that a number of these errors were what is termed as legal errors (unapproved abbreviations, for example) rather than clinical errors, but this number is still very shocking. Drilling down further in the data, it is apparent that interruptions whilst prescribing lead to a 2.82 x increase in clinical errors.

Why does it matter?

It seems that I can barely make it through my first coffee of the shift before someone hands me an ECG to look at or asks me to review a patient. I’ve switched to drinking long blacks, so it doesn’t matter if I have to leave my caffeine, but what happens if I am doing something more important – charting medications, working out fluid regimes – for example? This research took place in a department using analog rather than digital prescriptions, so one would hope the error rate might be less in this era of the dreaded EMR. For now, though, if I am writing something more than just paracetamol, then I’ll try and remain laser-focused on the task at hand.

Clinically-relevant bottom line?

Doctors get interrupted all the time at work. Whilst the interrupter might think it is a trivial task they have for you, it is worth thinking about how you can change the culture to reduce the chance of significant prescribing errors occurring when you are asked to ‘just take a look at this ECG’.

We discussed this post with Casey and the gang at SMACC in Sydney.

Reviewed by: Andrew Tagg (@andrewjtagg)

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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