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The 34th Bubble Wrap


With millions of journal articles published yearly, it is impossible to keep up.  Every month, we ask some friends from DFTB and PERUKI (Paediatric Emergency Research in the UK and Ireland) to point out something that has caught their eye.

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 in their 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 judgment. 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, developed guidelines and education materials for implementing the neonatal sepsis calculator, and then re-evaluated blood culture collection and antibiotic use rates.

Why does it matter?

Neonatal early-onset sepsis (EOS) is a culture-positive invasive infection that presents in the first 72 hours of life, with Group B streptococcus (Group B Strep 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 evaluating and treating 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 four months before 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 six months. In the four 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 without clinical reasoning. Indeed, part of their research required clinicians to document the recommendations from the calculator and their reason/s for accepting or rejecting the recommendations.

What’s the bottom line?

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

Reviewed by: Katie Nash

Article 2: To scan or not to scan?

Hong JY, Han K, Jung JH, Kim JS. Association of Exposure to Diagnostic Low-Dose Ionizing Radiation With Risk of Cancer Among Youths in South Korea. JAMA Netw Open. 2019;2(9):e1910584. Published 2019 Sep 4. doi:10.1001/jamanetworkopen.2019.10584

Why does it matter?

With the increasing availability and use of imaging over the past ten 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 Hiroshima and Nagasaki. A previous UK cohort study of 170,000 children under ten undergoing head CT scans showed one excess case of leukaemia and one 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) with a claim made via the National Health Insurance System. From 2006-2015, there were 12,068,821 individuals. 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 two years before a cancer diagnosis were excluded, as these may have been performed in the diagnostic evaluation for malignancy.

Amongst the entire cohort, 21,912 cancers were detected, including 1444 cancers amongst those exposed to radiation (0.1%). In the group exposed to low-dose ionizing radiation, there was an increase in overall cancer incidence compared to 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 evidence that diagnostic ionizing radiation such as CT increases cancer risk. It is important to recognise this risk is small compared to the lifetime risk of cancer, but medical practitioners 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 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. Three years after the introduction, hospitalization in children less than five years due to rotavirus gastro declined by 71% – so, 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 1st 2010 to December 31st 2017. A total of 9517 cases were identified, and age, gender, Aboriginal or Torres Strait Islander status, immunization status and rotavirus genotype were recorded. VE was calculated based on the 2017 dataset, a year with a significant rotavirus gastro outbreak, and looked at children aged 0 – 16 years born after 2008. Two doses of Rotarix appear to be effective, with VE estimates of 88% for the 6 – 11-month-old age group, 83% for the 1 – 3-year-old age group and 78% for the 4 – 9-year-old age group. Notably, VE significantly reduced from 89.5% at one-year post-vaccination to 77% at 5-10 years post-vaccination.

What’s the clinically relevant bottom line?

The vaccine (Rotarix) appears effective, especially in children under 12 months exposed to those G1 strains. However, the emergence of new strains and the waning immunity with age raises two 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 wheeze treatment requires an appropriate inhalation technique, but inhalers are often used incorrectly. Such errors can hinder the 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 recommends that patients be asked to demonstrate their inhaler device technique at every visit to correct improper use 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 in the use of these devices themselves.

What’s it about?

The study aimed 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 two-centre observational study in Switzerland, with 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, three experts in aerosol therapy reviewed and marked the recordings. The second part of the study evaluated healthcare professionals’ inhaler user knowledge using a semi-structured questionnaire.

49% of the healthcare professionals performed all nine steps of the inhalation technique perfectly, with about a third performing eight 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 techniques. 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 was 8.3 (out of 9), and the differences between groups were 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 of 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 of inhaler techniques, which could lead to ineffective medication administration for children with wheezing. Healthcare professionals should receive brief, repeated training programmes on inhaler techniques to provide optimal patient advice. 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 a 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?

Many 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, including parental obesity and feeding practices. Studies have associated short sleep with a heavier weight profile in older children and adults, although negative results have also been reported.

What’s the bottom line?

Short total sleep duration at three months and short night-time sleep duration at eight 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. 


  • 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.