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The 34th Bubble Wrap


Article 1: Implementation of the neonatal sepsis calculator

Akangire G et al. Implementation of the Neonatal Sepsis Calculator in Early-Onset Sepsis and Maternal Chorioamnionitis. Advances in Neonatal Care. September 2019; Publish Ahead-of-Print: doi: 10.1097/ANC.0000000000000668 (accessed 20 October 2019)

What’s it about?

This quality improvement project aimed to develop guidelines and education materials for implementing the neonatal sepsis calculator published by Kaiser Permanente in 2017 in a neonatal intensive care unit (NICU). The calculator predicts the probability of neonatal early-onset sepsis (EOS) in babies ≥34 weeks gestation, based on maternal risk factors for chorioamnionitis and the baby’s clinical presentation.

The calculator then makes a clinical recommendation (no blood culture or antibiotics, blood culture but no antibiotics, or blood culture and antibiotics), and recommends the frequency of recording vital signs for the baby. The calculator relies on users knowing the incidence of early- onset sepsis for their particular hospital/neonatal unit. The calculator is gaining in popularity (certainly in my recent experience), but guidelines for its implementation in individual neonatal units are lacking. One of the concerns is that the calculator will take the place of clinical judgement. The researchers were based at a Level III NICU in the USA. They evaluated current blood culture collection and antibiotic use for suspected EOS in their unit, then developed guidelines and education materials for implementing the neonatal sepsis calculator, and then re-evaluated rates of blood culture collection and antibiotic use.

Why does it matter?

Neonatal early-onset sepsis (EOS) is culture-positive invasive infection that presents in the first 72 hours of life, with Group B streptococcus (GBS or S. agalactiae) the main culprit. Guidelines for screening for and treating suspected neonatal EOS vary, with the conventional wisdom suggesting at least 48 hours of empirical antibiotics for treatment of suspected EOS due to maternal chorioamnionitis. The definition of maternal chorioamnionitis also varies based on maternal symptoms, including intrapartum and postpartum fever and clinical instability. EOS guidelines vary for and within each state and territory in Australia, with some units implementing the neonatal sepsis calculator, and others using stricter guidelines for evaluation and treatment of suspected neonatal EOS. NICE Guidelines from the UK do not refer to the calculator, but use risk factors, clinical indicators, and red flags to guide antibiotic management decisions (

In the study, in the 4 months prior to implementing the neonatal sepsis calculator, antibiotic use for suspected EOS was 11%, and blood culture was done on 14.8% of live births. The calculator was subsequently implemented for 6 months. In the 4 months post-implementation, neonatal sepsis calculator use was more than 95%, antibiotic use decreased significantly to 5%, and blood culture use dropped to 7.6%.

Importantly, the researchers considered the management of asymptomatic neonates, for whom the implementation of the neonatal sepsis calculator represented the greatest change in practice. The calculator uses the highest antepartum maternal temperature to indicate chorioamnionitis. In asymptomatic infants, if there is no maternal fever, but a clinical diagnosis of chorioamnionitis is made, the neonatal sepsis calculator may recommend observation only, with no blood culture or antibiotics. By contrast, the neonatologists in the study agreed that in these cases, a full blood count and blood culture should be done, with antibiotics withheld.

The researchers did not advocate blanket implementation of the neonatal sepsis calculator in the absence of clinical reasoning. Indeed, part of their research required clinicians to document the recommendations from the calculator, and then document their reason/s for accepting or rejecting the recommendations.

What’s the bottom line?

In this quality improvement project around implementation of the neonatal sepsis calculator, high uptake was achieved (>95%). In comparision at 4 months pre and post implementation, there was an associated reduction in antibiotic use from 11% to 5%, with blood cultures taken dropping from 14.8% to 7.6% of live births. The neonatal sepsis calculator provides objective data that can be used along with clinical judgement to make decisions about investigations and treatment of EOS. 

Reviewed by: Katie Nash


Article 2: To scan or not to scan?

Why does it matter?

With increasing availability and use of imaging over the past 10 years there has been a growing concern regarding the risks of diagnostic ionizing radiation. Previously our data regarding this has been based on studies of atomic bomb survivors from Hirsoshima & Nagasaki. A previous UK cohort study of 170,000 children under 10 undergoing head CT scans showed 1 excess case of leukaemia and 1 excess case of brain cancer for every 10,000 scans performed (Pence 2012).

What’s it about?

This was a retrospective population based cohort study of South Korean children (under 19 years of age) who had had a claim made via the National Health Insurance System. From 2006-2015 there were 12,068,821 individuals include. Of these 1,275,829 (10.6%) were exposed to low-dose ionizing radiation (defined as CT and other modalities such as IV urography but not plain X-Rays) with 92% being CT. Any scans performed 2 years before a diagnosis of cancer was excluded as these may well have been performed in the diagnostic evaluation for malignancy.
Amongst the entire cohort there were 21,912 cancers detected and this included 1444 cancers amongst those exposed to radiation (0.1%). In the group exposed to low-dose ionizing radiation there was in increased in overall cancer incidence than in the non-exposed group. (Incidence Rate Ratio of 1.64 [95% CI 1.56-173] p<0.001).

What’s the bottom line?

This study adds to the evidence that diagnostic ionizing radiation such as CT does increase the risk of cancer. It is import to recognise this risk is small compared to the lifetime risk of cancer but medical practioners should judge carefully the risks and benefits of performing any scan and adhere to the “as low as reasonably achievable” (ALARA) principles (RCR guidelines 2012).
Reviewed by: Jamie Pope


Article 3: Rotavirus Vaccine Effectiveness in NSW

Maguire J.E et al.  Rotavirus Epidemiology and Monovalent Rotavirus Vaccine Effectiveness in Australia: 2010 – 2017, Pediatrics[Internet]. 2019 Oct;144(4). pii: e20191024. doi: 10.1542/peds.2019-1024. Epub 2019 Sep 17 [cited 2019 Oct 29].

Why does it matter?

Rotavirus gastroenteritis is a frequently encountered and unpleasant illness. In 2007, a monovalent live attenuated vaccine covering for several G1 strains was introduced into the Australian Immunization schedule. Vaccine effectiveness (VE) is the percentage reduction of disease when comparing immunized and unimmunized patients. 3 years after the introduction, hospitalization in children less than 5 years due to rotavirus gastro declined by 71% – so just how effective is the vaccine?

What’s it about?

A retrospective cross-sectional study looked at laboratory confirmed cases of rotavirus in NSW from January 1 st 2010 to December 31 st 2017. A total of 9517 cases were identified, and age, gender, ATSI status, immunization status and rotavirus genotype recorded. VE was calculated based on the 2017 dataset, a year where there was a significant rotavirus gastro outbreak, and looked at children aged 0 – 16 years, born after 2008. It appears that 2 doses of Rotarix are effective, with VE estimates of 88% for the 6 – 11month age group, 83% for the 1 – 3 year old age group and 78% for the 4 – 9 year old age group. It is notable that VE significantly reduced from 89.5% at 1 year post vaccination to 77% at 5-10 years post vaccination.

What’s the clinically relevant bottom line?

The vaccine (Rotarix) appears to be effective, especially in children under 12 months who are exposed to those G1 strains, however the emergence of new strains and the waning immunity with age raises 2 questions: should a new and improved vaccine be developed and do adults (particularly those who work in healthcare) need booster doses?

Reviewed by: Tina Abi Abdallah


Article 4:  How well do you know your inhaler technique?

Spaggiari S, Gehri M, Di Benedetto et al. Inhalation technique practical skills and knowledge among physicians and nurses in two pediatric emergency settings. J  Asthma [Internet]. 2019 Oct 17 [cited 2019 Nov 1]. doi: 10.1080/02770903.2019.1674329. [Epub ahead of print]

Why does it matter?

Effective treatment of wheeze requires an appropriate inhalation technique but inhalers are often used incorrectly. Such errors can hinder deposition of the active compound into the lungs, thus diminishing treatment efficiency, which can lead to inadequate treatment or control of the disease. To overcome this problem, the Global Initiative for Asthma report recommend that patients be asked to demonstrate their inhaler device technique at every visit to enable improper use to be corrected and ongoing use technique to be monitored. Unfortunately, many healthcare professionals who are charged with providing instruction and monitoring aimed at optimizing inhaler use are not well versed with the use of these devices themselves.

What’s it about?

The aim of the study was to assess the ability and knowledge of physicians and nurses to use a pMDI with a masked VHC in paediatric emergency units. They conducted a 2 centre observational study, in Switzerland, with a total of 100 participants (50 nurses and 50 physicians). Their inhaler technique instructions were checked using a manikin and were video recorded. Using a 9 point operational checklist the recordings were reviewed and marked by 3 experts in aerosol therapy. The second part of the study evaluated health care professionals inhaler user knowledge by using a semi-structured questionnaire.

49% of the healthcare professionals performed all nine steps of the inhalation technique perfectly, with about a third performing eights steps correctly, and less than a fifth performing five, six, or seven steps correctly. The most frequent errors were forgetting to shake the pMDI before the second dose and incorrect patient or VHC positioning.


Site 1 (Lausanne)

Site 2 (Geneva)



Mean Sore










Only 18% of physicians and 64% of nurses reported having had specific training on inhalation technique. A notable portion of the healthcare professionals lacked practical knowledge about pMDI and VHC use. Differences between sites, professions and grades were statistically significant but probably not clinically relevant. The mean score being 8.3 (out of 9) and differences between groups being no more than 0.6 (Nurses performed better than  Doctors, Registered Nurses better than  nurses with a diploma in emergency care but there was no difference between junior and senior doctors)

This study has several limitations. Participants were recruited during their work time. Thus, it is possible that their inhalation technique and survey responses were influenced by stress. On the other hand, the participants may have exhibited better performance because they knew that the study was underway and that they were being observed (Hawthorne effect).

Healthcare professionals’ practical skills and knowledge related to inhalation therapy were not completely mastered. In light of their results, they provided information to participating healthcare professionals to help them observe good practices and provide suitable inhalation technique support.

What’s the bottom line?

Overall this study demonstrates that some professionals lack knowledge on inhaler technique which could lead to ineffective administration of medication to children with wheeze. It is recommended that health care professionals receive brief repeated training programmes on inhaler technique to provide optimal advice to patients. Do you know how good your unit’s education of inhaler technique is?

Reviewed by: Suzannah Johnson


Article 5: Is there a link between shorter sleep in infancy and becoming more overweight later?

Tuohino T et al. Short Sleep Duration and Later Overweight in Infants. J Paediatr [Internet]. 2019 Sep [cited 2019 Nov 4];212:13-19. doi: 10.1016/j.jpeds.2019.05.041. 

What’s it about?

The longitudinal study examined the relationship between sleep duration and excess weight gain in infants. Sleep data (N=1679) was reported by parents at 3, 8, 18 and 24 months of age in Finland from 2011 to 2017. In 3-month-old infants, short sleep is associated with lower weight-for-length/height (p≤0.026) and body mass index (p≤0.038). Short sleep duration in 3-month-old infants was associated with greater risk for excess weight-for-length/height at 24-month-old (aOR 1.56; 95% CI 1.02- 2.38) and a predisposition to gain excess weight between 3 and 24-month-old (aOR 2.61; 95% CI 1.75-3.91). Short night-time sleep duration in 8-month-old infants was associated with greater weight-for-length at 24-month-old (aOR 1.51; 95% CI 1.02-2.33)

Why does it matter?

Numerous factors contribute to the obesity epidemic in children, such as sedentary behaviour and the increasing use of electronic devices. Previous studies have explored potential mechanisms for infant weight gain, which include parental obesity and feeding practices. Studies have associated short sleep with a heavier weight profile in older children and adults, although negative results also have been reported.

What’s the bottom line?

Short total sleep duration at 3 months and short night-time sleep duration at 8 months are associated with the risk of gaining excess weight at 24 months. Sleep is important for child growth and development. To prevent the childhood obesity epidemic in the future, parents are encouraged to be aware of their child’s circadian rhythm, bedtime routines and sleep hygiene.

Reviewed by: Jessica Wong


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. 

About the authors

  • 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 34th Bubble Wrap”

  1. Bubble wrap is a pliable transparent plastic material used for packing fragile items. Regularly spaced, protruding air-filled hemispheres (bubbles) provide cushioning for fragile items.



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