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The 29th 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: #foodstagram – food marketing on social media, what’s the harm?

Coates A et al. Social Media Influencer Marketing and Children’s Food Intake: A Randomized Trial. Pediatrics. 2019 April; 143(4)

Why does it matter?

In the current day and age, it is nearly impossible to avoid exposure to social media. While social media can be a platform for social communication and digital education, they can also have a negative, and sometimes dangerous, influence on their audience. Children are particularly vulnerable, and therefore, it is important to understand the implications of digital marketing. This paper focuses on the impact of marketing of healthy versus unhealthy snacks on children’s food intake. This is particularly relevant given childhood obesity is a global health concern.

What’s it about?

176 children (9-11 years) were randomly assigned to view mock Instagram profiles of two popular YouTube influencers. These Instagram profiles feature photos of the influencers with either unhealthy snacks (n = 58), healthy snacks (n = 59) or non-food products (n = 59). Participants first completed the hunger rating and then viewed the assigned profiles for one minute. Participants were then served four snacks and were given 10 minutes to eat ad libitum.

The study showed that children who viewed influencers with unhealthy snacks had significantly increased overall intake (448.3 kcals; P = 0.001) and significantly increased intake of unhealthy snacks specifically (388.8 kcals; P = 0.001), compared with children who viewed influencers with non-food products (26% and 32% more kcals respectively). On the other hand, viewing influencers with healthy snacks did not significantly affect intake.

Clinically Relevant Bottom Line

This randomized control study demonstrates that social media marketing of unhealthy foods has an immediate effect on children’s intake of food (especially unhealthy snacks). It is interesting to note that influencer promotion of healthy foods bears no such effect. Given children tend to spend more and more time on social media and exposure to digital marketing is inevitable, it will be important to advocate for appropriate food-marketing restrictions regarding unhealthy foods.

Reviewed by: Jennifer Moon

Article 2: Procedural and resuscitation skills of non-tertiary paediatricians

Hardy A et al. Survey of procedural and resuscitation requirements for paediatricians working in a non-tertiary centre: Implications for training. Journal of Paediatrics and Child Health 2019; 55: 441-445.

Why does it matter?

Paediatricians working in non-tertiary centres manage a large and diverse amount of acute illnesses. They are also required to perform a variety of procedures and to lead neonatal and paediatric resuscitations.

There is no mandated continuing medical education (CME) for the maintenance of these skills after completion of physician training. These skills are performed infrequently; hence, there is a need for revision and retraining of these skills.

(Note from KN: I confess to having a vested interest in this study, as I’m planning to be a non-tertiary paediatrician in the next couple of years.)

What’s it about?

The researchers of this study wanted to investigate how the frequency with which procedural and resuscitation skills are used by paediatricians in non-tertiary hospitals. The study was based on a single regional non-tertiary hospital in Victoria, Australia, with 24-hour paediatric registrar cover with on-call paediatricians. Over a period of 12 months, all paediatricians completed a weekly retrospective electronic survey, in which they reported their inpatient workload (delivery attendances and recalls to the hospital whilst ‘on call’); instances of taking a leading role in the management of a seriously ill child requiring resuscitation; and procedures performed or directly supervised.

They found that non-tertiary paediatricians were required to lead the resuscitation of unwell children and to perform and supervise the performance of a large variety of procedures on multiple occasions during the year. Still, the paediatricians had limited opportunity to maintain the relevant skills.

The four most commonly performed procedures were intravenous cannulation, commencement of neonates on CPAP, administering IPPV to neonates, and lumbar puncture. Each 0.27 FTE paediatrician performed 0.9 and supervised 1.6 neonatal intubations during the 12-month period. They performed 0 and supervised 0.3 non-neonatal intubations.

Clinically relevant bottom line

In this limited study, paediatricians in a non-tertiary hospital utilised procedural and resuscitation skills infrequently (apart from intravenous cannulation). Methods for paediatricians to maintain their procedural and resuscitation skills include Advanced Paediatric Life Support (APLS) courses and regular participation in simulation (particularly high-fidelity simulation).

The researchers recommended that general paediatrician training and consultant paediatrician CME programmes should be designed to ensure not just the acquisition but also the maintenance of procedural and resuscitation skills.

Reviewed by: Katie Nash

Article 3: Does rebound stridor after nebulized adrenaline really exist?

Sakthivel M, Elkashif S, Al Ansari K, Powell, CVE,  Rebound stridor in children with croup after nebulised adrenaline: does it really exist? Breathe (Sheff). 2019 Mar; 15(1): e1–e7. Sakthivel M, Elkashif S, Al Ansari K, Powell, CVE,  Rebound stridor in children with croup after nebulised adrenaline: does it really exist? Breathe (Sheff). 2019 Mar; 15(1): e1–e7.

What’s it about? 

This is a slightly different Bubble Wrap. The paper in question isn’t a study itself but a brief review of a topic. I’ve picked it because it is well-written and comprehensive and contains some real gems that all acute paediatricians should be aware of (and it is open access!)

The paper investigates the phenomenon of rebound stridor post-adrenaline nebulisation in children with croup. This has been noted in the literature since 1978 and continues to be described to date.

Why does it matter?

The paper looked to answer the question:

Do children with croup (patient group) when treated with nebulised adrenaline (intervention) develop re-emergence of stridor, worse than the initial baseline presentation (comparison) as defined by changes in symptoms score (outcome)?

The study team found 10 papers (the time frame was not described, nor was it clear whether non-English papers were included). In these 10 studies, there was no evidence that symptoms post-adrenaline were worse than prior to administration, i.e., rebound effects appeared not to exist.

What was really interesting about the paper was some of the facts the team highlighted in the introduction, with the real gem of the findings of the most recent Cochrane review on the subject.

When treated with a placebo, 204 out of every 1000 children will return for medical care. When treated with glucocorticoids, 74–153 out of every 1000 children will return for medical care.

While clearly, steroids have an impact, even without treatment, the majority of children will get better all by themselves.

Clinically Relevant Bottom Line:

Rebound stridor appears to be an anecdotal phenomenon.

Reviewed by: Damian Roland

Article 4: Don’t forget to flush

Kleidon et al. Flushing of peripheral intravenous catheters: A pilot, factorial, randomised controlled trial of high versus low frequency and volume in paediatrics. J Paediatr Child Health. 2019 Apr 29.

What’s it about?

Failure of peripheral intravenous cannulas (PIVC) in paediatrics is a common problem. Therefore, the use of cannula flushes, continuous infusions, or heparin are all practices that have been tried over many years with mixed success. The authors of this article tested the feasibility of an efficacy trial comparing different flushes and intervals to reduce cannula failure. Their primary endpoint was feasibility. Secondarily, they looked at cannula failure and/or complications. The most important feasibility problem they encountered was the lack of patients that could be included. Of the 919 children screened, only 55 could be enrolled. Due to commonly used continuous infusions or early (planned) removal of cannula, most children couldn’t be included.

Nevertheless, based on this study (with 100% protocol adherence), 3ml flushes gave significantly more PIVC failure compared to 10ml flushes (hazard ratio = 2.90, 95% confidence interval: 1.11-7.54). However, flushing cannulas 6 hourly or 24 hourly was not significantly different (hazard ratio = 0.91, 95% confidence interval: 0.36-2.33) and there was no interaction effect objectified (P = 0.22).

Why does it matter?

Children (and also parents and health care professionals) would benefit from peripheral cannula salvage if that would mean no new procedure. The more cannulas could be saved, the better for our paediatric)patients.

Clinically relevant bottom line

Flushing a peripheral cannula with 10ml flushes seems to be more likely to save the cannula for longer compared to 3ml flushes, but doing so 6 hourly or 24 hourly didn’t seem to make a difference. However, because of small numbers and challenging eligibility criteria, we still need to search for the magic bullet of saving a cannula.

Reviewed by: Anke Raaijmakers

Article 5: How many dudes you know roll like this?

Walker et al. (2019) Impact of scribes on emergency medicine doctors’ productivity and patient throughput: a multicentre randomised trial

Why does it matter?

Data from the AIHW has revealed that the number of presentations to Australian public hospital Emergency Departments (EDs) has increased steadily each year, with an average of 22,000 patients every day!

As the demand on EDs continues to grow, staffing and resources need to be reassessed, with new procedures implemented to ensure patients are receiving quality and efficient health care.

What’s it about?

This was a prospective, non-blinded, randomised multi-centre trial from November 2015 until January 2018 involving five EDs in Victoria (a mix of urban, tertiary, regional and paediatric EDs). Over this time, 88 doctors were observed, and a scribe was randomly assigned to shifts with these physicians. Scribes performed clerical duties such as documentation, arranging tests and referrals, booking appointments, printing discharge summaries, etc.

The researchers measured doctor productivity (total patients seen) and patient length of stay. There were 589 shifts with a scribe and 3296 shifts without a scribe. Unsurprisingly, scribes increased physician productivity, from 1.13 patients per hour to 1.31 patients per hour, and decreased the median patient length of stay by 19 minutes. A cost-benefit analysis of the data showed that scribes were beneficial from a financial point of view, with the cost of employing a scribe for a shift being offset by the savings made by the increased productivity and patient flow through the ED.

Clinically relevant bottom line

The idea of having clerical assistants/scribes sounds too good to be true and would allow doctors to spend more time on assessment and management of patients rather than documentation. Although we are still some way from this workplace utopia, different ways to improve doctor productivity should be considered as new hospitals are built and existing EDs are upgraded.

Reviewed by: Tina Abi Abdallah

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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