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The 30th Bubble Wrap


Article 1: What’s the risk of infants 29-90 days having both UTI and meningitis?

Nugent, J., et al Risk of Meningitis in Infants Aged 29 to 90 Days with Urinary Tract Infection: A Systematic Review and Meta-Analysis. Journal of Paediatrics; 2019 June [eprint] doi: 10.1016/j.jpeds.2019.04.053

What’s it about?

Urinary tract infections remain the most common serious bacterial infection in infants, and infants under 28 days routinely undergo a complete septic workup when presenting to ED with a fever. For infants between 29 – 90 days, the decision to LP is guided by clinical findings and left to the treating physician. So, what are the chances that a febrile baby with a positive urinalysis also has meningitis?

Why does it matter?

This systematic review examined the pooled prevalence of co-existing meningitis, bacterial or aseptic. The authors searched three databases for studies reporting on the rates of meningitis in infants aged 29 – 90 days who had abnormal urinalysis or culture results (but were not necessarily febrile at presentation) and who also had lumbar punctures performed as part of their workup. Twenty studies (3 prospective and 17 retrospective) were identified.

The pooled prevalence of concomitant bacterial meningitis in infants with UTI was 0.25% (95% CI, 0.09%-0.70%). This translates to a number needed to investigate with LP for one diagnosis of meningitis of 400. The pooled prevalence for aseptic meningitis over the 20 studies could be calculated, but in some studies, the prevalence was as high as 29%.

Clinically Relevant Bottom Line:

Based on this systematic review, the risk of bacterial meningitis in infants aged 29-90 days with evidence of UTI is low. Still, the decision to LP should always consider the clinical picture instead of a calculated pre-test probability.

Reviewed by: Tina Abi Abdallah

Article 2: Anima sana in corpore sano: Does a healthy body equal a healthy soul?

Easterlin MC, et al. Association of Team Sports Participation With Long-term Mental Health Outcomes Among Individuals Exposed to Adverse Childhood Experiences. JAMA Pediatr. 2019 May 28 [Epub ahead of print].

What’s it about?

Adverse childhood experiences (ACEs) and/or mental health problems are unfortunately very common. This article asks whether team sports influence wellbeing in adulthood following ACEs. These were defined as physical and sexual abuse, emotional neglect, parental alcohol misuse, parental incarceration, or living with a single parent and extracted from the data of the National Longitudinal Study of Adolescent to Adult Health (National Population sample of US adolescents – 1994 and 2008). Multivariable logistic regression models were used to score factors associated with team sport participation. About half of the participants (9668 individuals included in the study – 4888 (49.3%)) reported 1 or more ACE. Among those with ACE, team sports participation during adolescence was associated with lower odds of receiving a diagnosis of depression, anxiety or having current depressive symptoms (adjusted odds ratios, 0.76, 0.70 and 0.85 respectively).

Why does it matter?

Adverse childhood experiences can have long-term mental health consequences. This study showed an association with team spots and improved mental health and could be an ‘easy’ tool to improve wellbeing in traumatized children.

Clinically Relevant Bottom Line:

Team sport participation in adolescence was associated with better mental health outcomes in children with ACEs. Team sports may be an important and scalable resilience builder.

Reviewed by: Anke Raaijmakers 

Article 3: Another look at risk factors for cervical spine injury in children with blunt trauma

Leonard JC, et al. Cervical Spine Injury Risk Factors in Children with Blunt Trauma. Pediatrics 2019, 144 (1).

What’s it about?

Four tertiary care hospitals which are part of the USA based Paediatric Emergency Care Applied Research Network (PECARN) ran a prospective observational study to look at risk factors of cervical spine injury in children with blunt trauma. They then compared the PECARN model with a de novo model of risk factors. After screening 11809 children with blunt trauma, approximately were found to be eligible and 4144 children were enrolled. Of 4091 children, 1.8% (74) had a cervical spine injury.  Children who didn’t receive cervical spine imaging had medical record and subsequent call follow up (if no imaging) to verify the absence of injury.  Treating clinicians filled out an electronic questionnaire before finding out the results of the imaging. These questionnaires assessed for risk factors including injury mechanism, patient variables and physical findings.

Fourteen risk factors were identified as having significant association with CSIs in this study. PECARN criteria currently include 8 risk factors (high-risk MVC, diving mechanism, conditions predisposing for CSI, neck pain, reported inability to move neck, altered mental status, limited neck range of motion on exam, substantial torso injury and focal neurological deficits). Three of these variables were not found to be independently associated with CSIs in the analysis of data collected: high risk MVC, conditions predisposing for CSI and limited neck range of movement on examination

A de novo model was proposed of 7 variables: diving mechanism, axial load, neck pain, reported inability to move neck, altered mental status, respiratory distress, and intubation.

Comparing PECARN with this de novo model slightly increased the sensitivity (90.5 to 91.9%) and specificity (45.6% to 50.3%). Extrapolated imaging rates using the PECARN and de novo risk model would decrease from 78.2% to 55.1% and 50.5% respectively and roughly halve CT scan. Both models missed children with CSIs – 7 in PECARN and 6 with the de novo model however on retrospective chart review 6 of the 7 missed children had a PECARN risk factor. None of those missed had surgical intervention but two were managed with medical devices (brace or rigid cervical collars).

The Bottom Line

This study presents data from 4 US trauma centres to improve identification of cervical spine injury risk factors in children. A de novo model with 7 risk factors has been examined and compared with the existing PECARN model and would yield slightly improved results and would have missed one less child with CSI in the group of over 4000 children studied.

Reviewed by: Grace Leo

Article 4: Drowning in the school holidays

Peden A et al. The association between school holidays and unintentional fatal drowning among children and adolescents aged 5-17 years. Journal of Paediatrics and Child Health. 2019 May; 55(5), pp. 533-538.

Why does it matter?

Australia is an island where 85% of its population lives within 50 km of the coast. Thanks to a mostly temperate climate, many families and young people enjoy spending time at beaches, rivers and lakes, or in the swimming pool. Therefore, drowning becomes a very real problem, especially for children and young people. Drowning is a leading killer of young people, however children and adolescents aged 5-17 years have one of the lowest rates. This may be due to the protective effect of time spent in formal schooling. This study shows how the risk of drowning differs between term time and school holidays.

What’s it about?

The investigators extracted the data from the Australian Royal Life Saving National Fatal Drowning Database over 2005-2014. A total of 188 children/adolescents aged 5-17 years drowned during the study period. There was a significant difference between drowning incidence during school holidays (including public holidays) and school days (P value <0.01), with relative risk (RR) of drowning on a holiday being 2.40 times higher than on a school day (CI 1.82-3.18). The risk was higher for children 5-9 years (RR = 3.05; CI 1.98-4.72) than adolescents 10-17 years (RR = 2.02; CI 1.38-2.93). The risk was similar for males and females in this age group. Most drowning incidents occurred at a river, creek or stream, as opposed to a beach or swimming pool.

Clinically Relevant Bottom Line:

As might be expected the rate of drowning in children and adolescents is much higher during school holidays than during formal schooling (with this study finding a relative risk 2.4 times higher). Although there are limitations to this study,  it advocates for ongoing drowning risk reduction strategies but particularly in the lead-up to school holiday periods in school-aged children and adolescents.

Reviewed by: Jennifer Moon

Article 5: The global impact of rotavirus vaccine in children under 5 years of age

Aliabadi N, et al. Global impact of rotavirus vaccine introduction on rotavirus hospitalisations among children under 5 years of age, 2008–16: ndings from the Global Rotavirus Surveillance Network. Lancet Glob Health 2019; 7: e893-903

Why does it matter?

In 2015, Rotavirus gastroenteritis  accounted for an estimated 250,000 deaths and 1·9 million episodes per year of severe acute gastroenteritis requiring hospital admis­sion in the under 5 year old age group. This paper cites that rotavirus vaccination has an efficacy of ranging from 57% to 85% for RV1 and from 45% to 90% for RV5 based on countries’ mortality strata. WHO recommends rotavirus vaccination as part of the national immunisation scheme for all countries. This study helps to assess the impact of introduction of rotavirus vaccinations.

What’s it about?

This paper presents the findings of the World Health Organisation (WHO) co-ordinated Global Rotavirus Surveillance Network (GRSN) to examine the rates of rotavirus confirmed hospital admissions prior to and following introduction of rotavirus vaccine globally between 2008-16 across 69 countries. Whilst it covers areas in Africa, the Americas, Eastern Mediterranean and European region, some of the countries the GRSN does not include are UK, American, Canadian, Russia, Australia or New Zealand. As China joined after 2016 it was also not included in the assessed population.

The prospective study looked at children under 5 years old admitted to hospital across the GRSN sites with acute gastroenteritis who subsequently had stool PCR within 48 hours to assess for rotavirus infection. It assessed the difference in cases pre and post-vaccine periods. The was a main analysis of data included sites with over 1 year of enrolment and over 100 specimens tested per year (305789 cases across 69 countries). Three further sensitivity analysis looked at cases 1) that did not have both pre and post vaccine data 2) regions with vaccine coverage <60% or vaccine not introduced, 3) Slightly relaxed lab inclusions to account for smaller labs. There was insufficient data to be able to combine these three groups. The study reports one third of children (32.9%) included had confirmed rotavirus gastroenteritis. Presentations of rotavirus gastroenteritis reduced 38% pre-vaccination to 23% post vaccination of cases included (with a relative reduction of 39.6%, CI 35.4-43.8). This data uses the mean proportion of children who were positive and the actual range between the two groups overlapped. The three other sensitivity analysis showed similar rates of overall reduction in rotavirus presentations.

The Bottom Line

This WHO-GSRN large impact analysis of rotavirus vaccination in children under 5 included 305,789 children, of which one third had confirmed rotavirus gastroenteritis. Between pre and post-vaccination periods, there was a relative decline in rotavirus gastroenteritis hospital presentations of almost 40%.  Rotavirus vaccination is effective in reducing hospital admissions for rotavirus gastroenteritis and should be considered for introduction in countries not yet covered such as part of Africa and southeast Asia.

(Ed note: If you’re interested in gastroenteritis, you may also be interested to know that Archives of Disease of Childhood has just published a systematic review and meta-analysis looking at Gelatin tannate (a protective gelatin with  astringent, antibacterial, and anti-inflammatory properties) in the use of acute diarrhoea and gastroenteritis in children. There was no difference with placebo).

Reviewed by: Grace Leo

If we have missed out on something useful or you think other articles are absolutely worth sharing, please add them in the comments! We are also looking to expand the Bubble Wrap team so please contact us if you’re interested in this! 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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1 thought on “The 30th Bubble Wrap”

  1. Great Bubble Wrap!

    Regarding the global impact of rotavirus study – it’s worth noting that the rotavirus vaccines are live attenuated vaccines, which means that rota is detectable in your stool following the vaccine (even up to 3 months). Some of the cases detected by ELISA in this study would have been virus from the vaccines, so may well have undersold the effect of the vaccine programme.