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The 35th 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 UK and Ireland) to point out something that has caught their eye.

Article 1: Once a cry baby always a cry baby?

Olsen AL, Ammitzbøll J, Olsen EM, Skovgaard AM. Problems of feeding, sleeping and excessive crying in infancy: a general population study Arch Dis Child. 2019 Nov;104(11):1034-1041. doi: 10.1136/archdischild-2019-316851. Epub 2019 Jul 3.

What’s it about?

This Danish study examined whether regulatory problems of feeding, sleeping and excessive crying in infancy (N=2598) persist in the first year of life. It also explored whether maternal mental health problems and parent-child relationship problems play a role in these problems. Infant regulatory problems were evident in 2.9% of the population between 2 to 6-month-old babies and 8.6% of the population in 8 to 11-month-old babies.

Early infant regulatory problems (2 to 6-month-old) are the main predictor of late infant regulatory problems (8 to 11-month-old). Infants who exhibit regulatory problems at 2 to 6-months-old have an increased risk to continue to show poor regulatory control later in 8 to 11-month-old (OR 3.4; 95% CI 1.8 to 6.6). Early infant regulatory problems may also affect maternal mental health and parent-child relationship. Factors such as having immigrant parents, low maternal schooling, maternal mental health problems and early parent-child relationship problems were associated with an increased risk of late regulatory problems.

Why does it matter?

Infant feeding, sleeping and crying problems are common difficulties reported by parents. These regulatory problems are associated with a higher risk of emotional and behavioural difficulties later in childhood.

Clinically Relevant Bottom Line:

Regulatory problems (feeding, sleeping and excessive crying) in early infancy (2 to 6-month-old) are highly associated with regulatory problems in late infancy (8 to 11-month-old). To reduce the persistence of regulatory problems in the baby’s first year of life, early guidance and intervention for babies < 2-month-old are needed in clinical and community settings to help parents understand and respond to their infant’s cues in a sensitive manner.

Reviewed by: Jessica Win See Wong

Article 2: Do we need to check for urinary tract infection in infants if they are febrile with proven Influenza or RSV?

Salinas A, Hains D, Jones T, Harrell C, Meredith M. Testing for Urinary Tract Infection in the Influenza/Respiratory Syncytial Virus-Positive Febrile Infant Aged 2 to 12 Months. Pediatric Emergency Care 2019;35:666-670.

What’s it about?

The authors conducted a retrospective chart review examining all infants aged 2-12 months with a documented fever higher than 38 deg Celsius who presented to the Emergency Department (ED) of Dell Children’s Medical Center of Central Texas from 2009 to 2013 and tested positive for influenza and/or RSV. Then patients’ electronic medical records were evaluated for positive results in urinalyses obtained within the four days after their ED presentation. The study found that the rate of concurrent UTI and a positive viral direct fluorescent antibody for influenza and/or RSV is extremely low: 10 (0.62%) of 1626 patients (95% CI, 0.3%-1.1%) had positive urine cultures and 8 (0.49%) of 1626 (95% CI, 0.2-0.97%) had positive urine cultures and positive urinalyses. All subjects with positive urine cultures as defined by the 2011 AAP UTI clinical practice guidelines had risk factors for UTI that placed their risk for UTI above 1%.

Why does it matter?

This paper shows that the likelihood of a concurrent UTI in an infant who tested positive for influenza and/or RSV is extremely low, especially if they are identified as lower risk of UTI as per the 2011 AAP UTI clinical practice guidelines. Many studies to date have shown that the presence of viral illness reduces the likelihood of intercurrent serious bacterial infection, including UTIs. However, in patients younger than 3 months with fever and known viral illness, the risk of UTI is still reported as high as 7% (Oray-Schrom et al 2003, Levine et al 2004). On the other hand, a retrospective cross-sectional study of patients 3-36 months in 2005 reported a lower prevalence of UTI in those presenting to ED with fever and positive influenza, compared with those with a negative viral test result (1.8 vs 9.9%) (Smitherman et al 2005).

Previous studies looking into the rates of UTI in infants with influenza or RSV mostly utilised the 1999 AAP diagnostic criteria for UTI. The authors suggest this might be one of the reasons why their study shows a much lower rate of concurrent UTI compared to previous studies. To support their argument, a retrospective comparative study performed by Kaluarachchi et al in 2014 looked into all infants with RSV infections in 2006-2012  and found that the rate of UTIs using the 1999 AAP criteria was 6.1% while the rate was significantly lower (1.1%, P=.001) using the 2011 criteria.

By correctly identifying patients with a lower risk of UTI according to the 2011 AAP criteria on top of their viral illness, we can avoid performing unnecessary catheterisation in infants.

Clinically Relevant Bottom Line

We should remember that this is a single-centre, retrospective review so future prospective studies are still needed to confirm these findings. Furthermore, infants under the age of 3 months with fever and known viral illness still have a significant rate of UTI so they should have a urine culture to rule out concurrent UTI even in the presence of a positive viral test result.

Reviewed by: Jennifer Moon

Article 3: It’s not all about the follows, the shares, the comments and the likes

Boers E, et al. (July 2019) Association of Screen Time and Depression in Adolescence, JAMA Paediatrics, doi: 10.1001/jamapediatrics.2019.1759

What’s it all about?

Facebook, Instagram, Reddit, Tumblr, Snapchat, Twitter…We are all guilty of spending not-so-quality time on one or more of these apps. Recent cross-studies have raised concern that time spent on social media is associated with mental health issues in adolescents, especially depression.

Why does it matter?

This was a secondary analysis, which looked at data collected from a randomized clinical trial assessing the efficacy of personality-targeted drug and alcohol intervention in adolescents enrolled in school (grades 7 – 11). The study was done in Montreal and data included demographics and socioeconomic status, time spent daily on video games, social media apps, watching TV and on the computer. Over the 4 years, the students regularly completed the Brief Symptoms Inventory, looking at depression, and the Rosenberg Self Esteem Scale, looking at self-esteem.

In general, depressive symptoms increased yearly, and analysis showed that “between persons” and “within persons” for every increased hour spent on social media or on the computer, there was an increase in depressive symptoms.

Clinically Relevant Bottom Line:

There are a few limitations in this study, but it highlights a crucial point. As we march into the future, and the quantity of electronic devices and social media, easily accessible at our fingertips, increases exponentially, what measures can we take to ensure our adolescents are not being negatively influenced? More comprehensive studies looking at the association between mental health issues and social media, as well as possible interventions, are necessary.

Reviewed by: Tina Abi Abdallah

Article 4: Attitudes Toward Electronic Sexual Health Assessments Among Adolescents in the Emergency Department

Langerman SD, Badolato GM, Goyal MK. Attitudes Toward Electronic Sexual Health Assessments Among Adolescents in the Emergency Department. Pediatric Emergency Care 2019 [28 Oct 19]

Why does it matter?

Rates of sexually transmitted infections (STIs)  in adolescents presenting to ED are high- ranging from 10% (asymptomatic population) to >25% when patients are symptomatic. Sexual health-related questions are not always asked by clinicians, particularly when not presenting with STI-related complaints, but could still be a useful screening tool. There are also many issues with confidentiality and communication if patients are worried about who might overhear when discussing these sensitive questions.

With most teens being tech-savvy, electronic questionnaires could help and previous studies have shown that electronic questionnaires can increase the rate of STI testing and detection in adolescents. However, this would only be a useful tool if it is accepted by the participants so this study aimed to assess this.

What’s it about?

The aim of the study was to evaluate adolescent attitudes towards the use of electronic sexual health assessments to guide STI screening in Emergency departments, with a secondary aim to assess whether acceptance of this was affected by any patient or visit-related characteristics e.g. sex, race, presenting complaint and insurance status.

The authors did this with a secondary analysis of 2 cross-sectional studies that took place between December 2013 and July 2015 in an urban paediatric ED in a city with the highest rate of chlamydia in the US. The data analysed was from 1159 patients aged between 14 and 19.

The results showed that 80.7% (CI 78.3-77.9) found electronic assessments an acceptable method of asking sexual health-related questions and 75.4% (CI 72.8-77.9) reported a preference for electronic versus other assessments (clinician questions or written assessments).

This means that 19.3% of participants found the tool unacceptable- reasons for this were not collected although the authors postulate that people find the discussion of sexual health (by whatever method) unacceptable, especially if coming in with a complaint unrelated to STI- rather than specifically thinking the electronic assessment is unacceptable.

Additionally, they saw that within this group, those with private insurance (adjusted OR 1.8 (1.2-2.7)) and STI-related chief complaints (aOR 1.7 (1.0-2.7)) were more likely to find electronic sexual health assessments acceptable.

The bottom line

The majority of adolescents find electronic sexual health assessments acceptable, especially when presenting with STI-related complaints or if in health systems where private insurance is available.

Reviewed by: Emily Tough (@tough_emily)

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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