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The 2nd Bubble Wrap


With millions of journal articles published yearly, 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.

Article 1 – How can we provide adequate safety netting?

Curran JA, Murphy A, Burns E, Plint A, Taljaard M, MacPhee S, Fitzpatrick E, Bishop A, Chorney J, Bourque M. Essential Content for Discharge Instructions in Pediatric Emergency Care: A Delphi Study. Pediatric Emergency Care. 2016 Dec 20.

What’s it about? 

Most children who present to urgent and emergency paediatric care will go home.

Discharge safety netting advice, i.e. what to expect and what to look out for, is so commonly given it is incredible in the 21st Century, but we still don’t know what the ideal advice looks and sounds like. Curran et al. attempt to help answer this question by conducting a Delphi approach to determine the critical content of discharge advice in six common illness presentations.

Why does it matter?

Delphi studies are an easy concept but often difficult to deliver. Traditionally, they should use a number of experts who make choices on questions over several rounds. A facilitator collates responses so that, for subsequent rounds, the experts can make more informed decisions about the questions they are answering. The term ‘modified’ Delphi has become increasingly used to avoid the hard work of manually summating the feedback by reducing the number of rounds and just presenting aggregated scores or responses in an electronic format.

In this study, experts were doctors and nurses of at least eight years of experience selected by invitation from the Emergency Departments of the Paediatric Emergency Research Canada group. Four rounds of survey were used, with more than 75% of the original 49 participants completing all the rounds.

The initial round listed all possible content items (anything relevant to tell the parents at discharge) obtained from a literature search from a previously published systematic review. The second round only included items where 70% of the experts scored a 4/5 or 5/5 in importance. The third round retained items that scored 80% (experts were shown their ratings against the mean ratings at this stage). Content Items were then listed in order of preference, and finally, each expert’s top five items chosen were collated.

Some of the findings were not unsurprising.

For Diarrhoea and Vomiting – the colour of vomit, the intensity of abdominal pain and being very drowsy all made the final cut.

Key admission criteria for bronchiolitis (i.e. drowsiness, very reduced feeding) were essentially the suggested return advice given to parents.

For fever, advice was more about emphasising features that are normal (fever itself causes no harm; symptoms are more important than the fever itself).

Abdominal pain used red flag symptoms such a blood in the stool and asthma advice highlighted the use of plans and appropriate use of spacers. Advice for abdominal pain had 100% consensus for all the items, for asthma a range between 54% and 91%.

However, for the final condition, Head Injury the highest agreement was 64.9% (return to the ED if the headache isn’t helped by analgesia). The authors were unsure as to why but wondered whether different interpretations of language were the cause.

It could be argued that perhaps an independent moderator collating responses during the rounds, as originally intended by Delphi methodology, may have solved this issue. Alternatively, this study has identified an inherent weakness in our joint practice. We may think we are saying and doing similar things when it comes to discharge advice for head injury (and asthma), but perhaps we aren’t. The study needs to be repeated in different countries, and it would be helpful to extrapolate some of this work with the parent and caregiver work, which already exists but provides some powerful food for thought. Is it good enough to write ‘safety net advice’ in the notes?

Reviewed by: Damian Roland

Article 2 – The problem with bronchiolitis guidelines

What’s it about?

Plint et al. looked at historical data to see how bronchiolitis was managed in 28 community hospitals in Ontario, Canada. Given that it is such a high prevalence condition, it is essential that emergency physicians, whether they have received specific sub-speciality training or not, can manage the condition to the best of their ability.

Why does it matter?

While there are ongoing controversies regarding the management of this common disease, there appear to be some discrepancies in areas for which the evidence is pretty solid.

Plint found that 80% of children received bronchodilators in the ED, 31% received a dose of steroids, and 5% received antibiotics for this viral condition. She also found that over half of the children had a chest x-ray.

The SGEM team, led by Ken Milne, examines some of the issues involved in this excellent podcast. We also cover some of the possible reasons for this failure of knowledge translation here.

Recommended by: Ken Milne

Article 3 – Does design matter in neonatal resuscitation algorithms?

McLanders ML, Marshall SD, Sanderson PM, Liley HG. The cognitive aids in medicine assessment tool (CMAT) applied to five neonatal resuscitation algorithms. Journal of Perinatology. 2016 Dec 22.

What’s it about?

Everyone should know that I’m a big fan of style with substance.  This Australian group of researchers used a validated assessment tool to examine several neonatal resuscitation flowcharts.  By looking at the physical characteristics of the charts (such as font size, use of contrast and colour), the structure of the content and the actual layout, they could assess how effective it might be as a memory aid.

Why does it matter?

Like the ‘Can’t Intubate, Can’t Intubate’ scenario, neonatal resuscitation is a High Acuity, Low Occurrence (HALO) task.  Unlike CICO,  it is something that most of us are likely to be involved in on a semi-regular basis.

Resuscitation is a team sport, however, and it will not go well if the whole team is not using the same shared mental model. There are several algorithms in widespread use – ILCOR, ANZCOR, AHA/AAP, ERC and RCSA – and it’s interesting to see that the ILCOR iteration scores highest on using the CMAT tool, given that the ANZCOR one looks nicer.

Reviewed by: Andy Tagg

Article 4 – Gentamicin Monitoring in Paediatric Patients with Febrile Neutropenia

Bialkowski S1, Staatz CE, Clark J, Lawson R, Hennig S.Gentamicin Pharmacokinetics and Monitoring in Pediatric Patients with Febrile Neutropenia. Ther Drug Monit. 2016 Dec;38(6):693-698.

What’s it about?

The authors describe gentamicin pharmacokinetics in a population of 69 children with febrile neutropenia. For 121 doses, the gentamicin AUC and Cmax were assessed to identify if the currently recommended dosing achieved pre-defined targets. This is important given the risks of ototoxicity and neurotoxicity with higher peaks and concentrations compared to the need for attaining clinical efficacy with adequate dosage.

This is primary literature, pure and simple. It’s great to see raw data underpin (and potentially change) guidelines that can appear murky. The subsequent challenge is that this paper is quite meaty and mathematically dense. Clinicians who aren’t up to speed with their pharmacokinetics might be challenged to wade through the data.

(For a reminder about these values and what they mean, I read the paper in concert with this diagram and my copy of Don Birkett’s Pharmacokinetics Made Easy.)

Why does it matter?

I made three main inferences from the paper.

First and foremost, initial doses of gentamicin frequently lead to Cmax and AUC values that are lower than ideal. Specifically, patients may require a higher initial dose of gentamicin on presentation to the Emergency Department than recommended.

Secondly, with repeated doses in the same patient, these tend to be corrected – that is, therapeutic drug monitoring works.

Thirdly, although levels were more likely in range in patients with proven Gram-negative bacteraemia, this was more likely due to dose adjustments with repeated doses rather than altered pharmacokinetics secondary to sepsis.

Reviewed by: Henry Goldstein

Article 5 – How long do children with acute otitis media need antibiotics?

Hoberman A, Paradise JL, Rockette HE, et al. Shortened antimicrobial treatment for acute otitis media in young children. N Engl J Med 2016;375:2446-2456

What’s it about?

I’d be remiss if I didn’t include this paper in the list of what to read this month. The authors compared a 5-day course of co-amoxiclav (plus placebo) against ten days in children under 24 months of age with acute otitis media.

Why does it matter?

Most cases of AOM get better on their own with minimal intervention, so why should we prescribe a ten-day course of antibiotics to reduce (possibly) otalgia in this patient group?  You can read more about my take on the paper here or read Rory Spiegel’s take here.

Reviewed by: Andy Tagg

That’s it for this month.  Many thanks to our reviewers who have taken the time to scour the literature, so you don’t have to.  If you think they have missed something unique, 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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