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The 37th 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 the UK and Ireland) to point out something that has caught their eye.

Article 1:  Cases of 2019-nCoV from Wuhan (Lancet)

Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020 Jan [epub]

Why does it matter?

In December 2019, a novel coronavirus (2019-nCoV) emerged from Wuhan, China; possibly originating around the Hunan seafood market. As of the 1st February (using data available from WHO Situation update 12.) Coronavirus cases in China are numbered at 11,953; with 1795 patients who are severely unwell and 259 deaths. There has been spread of confirmed 2019-nCoV cases to 23 other countries (with these cases outside China numbering 132).

What’s it about?

This retrospective study included all patients with confirmed 2019-nCoV in Wuhan Jinyintan Hospital admitted from Jan 1-20. Of 99 patients seen, 49% had exposure to the Hunan seafood market. Half the patients had chronic diseases and the mean age of patients was 55.5 years, with 32% being female. Patients were likely to present with symptoms of respiratory infection including fever (83%), cough (82%) and feeling short of breath (31%). Other symptoms experienced included muscle aches (11%), confusion and headache (8-9%). A smaller proportion of patients (<5%) experienced signs of coryza and sore throat, diarrhoea or nausea/vomiting.

The 2019-nCov predominantly manifested as viral pneumonia, with 75% of the patients having bilateral pneumonia confirmed on imaging. Progression to acute respiratory distress syndrome occurred in 17% of the patients. Patients were managed in isolation, with around three quarters being given some form of antiviral treatment (oseltamivir, ganciclovir, lopinavir and/or ritonavir) and 70% given antibiotics to cover for bacterial co-infection. In terms of endpoint outcomes, 11 of the patients in this cohort have passed away as of 25th of January (the last time of follow up data collected). Of those who passed away, the majority (n=7, 64%) were over 60 years of age.

A bigger picture: In comparison to other coronavirus outbreaks

In comparison to previous coronavirus strain outbreaks, the 2002 SARS-CoV spread to 37 countries, causing over 8000 cases and 774 deaths over 8 months. In 2012 the Middle East respiratory syndrome coronavirus (MERS-CoV) caused 2494 cases and 858 deaths to date. The numbers of those infected with 2019-nCoV infection have exceeded both these outbreaks and are likely related to the longer incubation period (SARS having an incubation period of 3-4 days, compared to up to 14 days with 2019-nCoV).

Whilst the death rate in this case study was 11%, the true fatality rate of 2019-nCoV remains to be seen given this study of 99 patients represents less than 1% of infected cases. Using all current known cases and deaths, the 2019-nCoV fatality rate currently sits around 3% although it does not take into account the progression of patients over time.

What about the flu?

It is also important to also frame the 2019-nCoV against a more familiar virus family – influenza. In Australia in 2019 alone, there were 298,120 laboratory-confirmed cases of influenza, with a death toll of 430. In the UK, flu season is well underway and since October 2019 to the end of January, there have been over 2000 patients hospitalised in intensive care units and 195 deaths.

We may not have a vaccine for coronavirus at present, but we do have a vaccine for influenza which is updated from year to year with predicted strains. It is not perfect (estimated effectiveness 40-60%) but even so, it has the potential to prevent thousands of infections and hundreds of deaths. Of the paediatric population in the UK influenza vaccine rates are particularly low in the 2-3-year-olds at only 43-45%. We would highly encourage all eligible for the vaccine (>6 months), and particularly those with risk factors to be vaccinated.

The Bottom Line

This case report gives us a snapshot of 99 patients affected with 2019-nCoV virus from Wuhan. It shows the 2019-nCoV virus manifests in the majority of patients with lower respiratory tract symptoms including fever, cough and shortness of breath; which can develop into a viral, often bilateral, pneumonia. The elderly and those with pre-existing medical conditions are at higher risk of severe illness and death.

Editor’s Comments

Whilst the 2019-nCoV virus continues to dominate the news headlines, it is important to keep perspective and not be swept into excessive alarm. For those living outside of China, the case numbers of 2019-nCoV remain low and governments and health care organisations in China and around the world have taken precautions to help minimise the risk of further spread.

Maintaining compassion for instead of criticism of of all those affected in China is essential. Keeping discrimination and racist sentiments out of the conversation around coronovirus is essential. It is worth noting that 8% of the UK and 15% of Australians come from an ethnically Asian background and have just as much right to work and live in these countries as someone of any other background.

What else we should do for now includes things we should aim to practice regardless of the 2019-nCoV virus – that is – stay informed and up to date with reputable sources of information, follow your local healthcare policy recommendations, practice good hand hygiene and cough/sneeze etiquitte. Lastly, ensure that you, your family and community are up to date with vaccinations that we do have available, including the seasonal influenza vaccine.

Official resources for keeping up to date: WHO Coronavirus Information & Updates | The Lancet Coronavirus Center |

| CDC America Coronavirus Information | UK Government Coronavirus Updates | Australian Department of Health Coronavirus Updates |

From the FOAMed community: Thinking about Coronavirus with St Emlyn’s.

Reviewed by: Grace Sze Yin Leo

Article 2: Definite bacterial infection in recently vaccinated febrile infants

Raba AA,  Krebit I. Definite bacterial infection in recently vaccinated febrile infants. J Paediatr Child Health. 2020 Jan [epub] doi:10.1111/jpc.14770

Why does it matter?

Young infants (less than 3 months) presenting to the emergency department with fever can be difficult to assess as they can appear well, despite having serious bacterial infections.  Recent vaccination induces short term fever, irritability and sleepiness which can mimic features of infection. The UK’s national guidelines of fever in infants (NICE) don’t take post-vaccination fever formally into account (and few other international guidelines give specific advice). The NICE guideline recommends blood tests for full blood count and C-reactive protein levels in any infant under 3 months with fever ≥38° C, with further lumbar puncture and intravenous antibiotics if they appear unwell. The infant presenting with fever within 72 hours of immunization represents a specific clinical challenge as the incidence of true invasive bacterial infection is unclear in this group.

What’s it about?

This retrospective study reviewed records of infants aged 6-12 weeks presenting with fever (≥38° C) to the paediatric emergency department at a University Hospital in Ireland who had at least a urine culture taken. Bacterial infection was defined as one or more true growth cultures of organisms in the infant’s urine, CSF or blood. All of the proven bacterial infections in the recently vaccinated group were urinary tract infections (UTI)s and all were in infants presenting <24 hours after vaccination (one appeared unwell with the other two appearing well during initial assessment).  Another recently vaccinated infant who appeared unwell was diagnosed with HHV6 viral meningitis.

In this cohort, the incidence of bacterial infections was lower in recently vaccinated (3/60 or 5%) compared to non-recently vaccinated (19/138 or 15.2%) febrile infants. However febrile infants attending following vaccination were excluded if they had not had any investigations (thereby potentially falsely elevating the incidence rate.

Clinically Relevant Bottom Line:

This cohort had an overall incidence of bacterial infection similar to other studies meaning it is likely its findings have external validity.  Their results may support collecting a urine culture in infants presenting within 24 hours of vaccination if there is any clinical concern.

Reviewed by: Emily Tough

Article 3: Keeping cannulas alive: how much and how often should you flush them?

Kleidon TM, Keogh S, Flynn J, Schults J, Mihala G, Rickard CM. Flushing of peripheral intravenous catheters: A pilot, factorial, randomised controlled trial of high versus low frequency and volume in paediatrics. Journal of Paediatrics and Child Health 2020; 56:22-29.

What’s it about?

A pilot randomised controlled trial (RCT) was performed to compare four different arms of flushing frequencies and volumes in order to maintain the patency of peripheral intravenous cannulas (PIVCs). The four arms of the trial were: 1) low frequency (q24h) and low volume (3ml); 2) low frequency (q24h) and high volume (10ml); 3) high frequency (q6h) and low volume (3ml); 4) high frequency (q6h) and high volume (10ml). A total of 919 children were screened for eligibility at Queensland Children’s Hospital from April to November 2015, with 55 enrolled. 80% of approached patients agreed to enrol, however, 94% of screened patients were ineligible due to the exclusion criteria. PIVC failure was significantly higher (hazard ratio = 2.90, 95% CI: 0.36-2.33) in the low volume (3ml) group than in the high volume (10ml) group. There was no difference in PIVC failure between the frequency groups (hazard ratio = 0.91, 95% CI: 0.36-2.33)

Why does it matter?

PIVCs are amongst the most commonly used medical devices. However, the reported PIVC failure rate in acute care paediatrics is reported to be as high as 49%1. PIVC failure adds to the stress and anxiety of paediatric patients and their parents, as well as to the health care outcomes and costs. Effective flushing strategies may help reduce PIVC failure and improve patient and health care outcomes.

Clinically relevant bottom line:

This is a small trial which attempted to test the feasibility of conducting a larger efficacy trial in this subject. Therefore, no definitive conclusions can be drawn yet, but this study suggests that flush volume may impact failure rates of PIVCs, rather than frequency of flushing.

1 Kleidon TM, Cattanach P, Mihala G, Ullman AJ. Implementation of a paediatric peripheral intravenous catheter care bundle: A quality improvement initiative. Journal of paediatrics and child health. 2019 Oct;55(10):1214-23.

Reviewed by: Jennifer Moon

Article 4: The ups and downs of indoor trampoline parks

Hadley-Miller N, Carry PM, Brazell CJ, et al. Trends in Trampoline Fractures: 2008–2017. Pediatrics. 2020; 145(1): e20190889

Why does it matter?

The first indoor trampoline park opened in the USA in 2004 and America now hosts over 600 parks. Australia and the UK followed suit later, opening their first indoor trampoline parks in 2012 and 2014 respectively. Indoor trampoline parks have become a staple of childhood recreational activity (they are pretty fun) however with their popularity has come a noticeable increase in business for paediatric EDs and orthopaedic surgeons.

What’s it about?

This American group assessed presentions to the emergency department with injuries sustained whilst using a trampoline – either at home or at a recreational/sports facility. Data was collected via the National Electronic Injury Surveillance System in the US, which looks a mix of hospitals including tertiary, regional, urban, mixed and paediatric EDs. A retrospective analysis was performed for the years 2008 to 2017, looking at children aged 0 – 17 years who presented to hospital with a fracture and/or a trampoline-related injury. Data was then narrowed down to specifically look at trampoline-related fractures.

Multivariable logistic regression analyses found there was an average increase of 3.85% in trampoline-related fractures per person per year. They also found that injuries were more likely to occur at a recreational/sports facility (however the data could not discriminate between trampoline parks vs other recreational facilities). Despite the increase in the number of fractures, the need for admission rates remained stable over the decade.

Clinically Relevant Bottom Line

With trampoline-related injuries in the US on the rise, we would expect a similar trend may occur in Australia and the UK now and in the future. All of us working in ED would have definitely seen a fracture or two (or five) with a trampoline being a key figure. In order to look at improving safety and reducing childhood injuries, more studies could be done specifically looking at trampoline parks and injuries incurred, and the subsequent effects i.e. cost to health system/individuals, impact on school, work and long-term implications of injury.

Reviewed by: Tina Abi Abdallah

Article 5: Nutrition, Growth, Brain Volume, and Neurodevelopment in Very Preterm Children

Power VA, Spittle AJ, Lee KJ, Anderson PJ, Thompson DK, Doyle LW, Cheong JL. Nutrition, Growth, Brain Volume, and Neurodevelopment in Very Preterm Children. The Journal of Pediatrics. 2019 Sep 24.

What’s it about?

This Australian prospective cohort study explored the relationship between nutrition in the first 28 days with growth, brain volumes and neurodevelopment (cognitive, language and motor development) in very preterm infants. The study recruited 149 preterm infants (born at < 30 weeks of gestation) and collected data on their nutritional intake (protein, fat and carbohydrate) and growth measurements (weight and head circumference). Total brain tissue volumes were calculated from brain MRI. At 2 years of corrected age, the children’s neurodevelopmental outcomes were assessed with the Bayley Scales of Infant and Toddler Development-Third Edition.  A 1g/kg/day higher mean protein intake was associated with a mean increase in weight z-score per week of 0.05 (95% CI 0.05, 0.10; P= 04). No significant relationships were found between any nutritional variables with head circumference growth, brain volumes or 2-year neurodevelopment.

Why does it matter?

With increased energy requirements and immature gastrointestinal tract, very preterm infants are at high risk of postnatal growth failure and poorer neurodevelopmental outcomes. Many factors such as fat, carbohydrate and protein intake in early life affect growth in weight and head circumference, brain growth and functional neurodevelopment in very preterm infants. It is important to optimise nutritional intake for these infants to ensure optimal growth and neurodevelopment.

Clinically Relevant Bottom Line

This study adds to the evidence that higher protein intake in the first 28 days after birth is associated with better weight growth in very preterm infants.

Reviewed by: Jessica Win See Wong

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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