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The 38th 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: Comparing parental and healthcare professional priorities in managing fever in children

Leigh S, Robinson J, Yeung S, et al. What matters when managing childhood fever in the emergency department? A discrete-choice experiment comparing the preferences of parents and healthcare professionals in the UK. Archives of Disease in Childhood Published Online First: 27 February 2020

What’s it about?

With febrile children accounting for a large proportion of ED presentations, these researchers explored the preferences of both parents and healthcare providers managing these children. They were gathering this information to help introduce point-of-care C-reactive protein (CRP) testing, which may prevent unnecessary antibiotic use.

Why does it matter?

While many children exhibit signs and symptoms of specific infections to explain fever, ~20% of children have no apparent cause and may be subjected to investigations to rule out a serious bacterial infection. This diagnostic process can take significant time, use substantial resources, and may include painful diagnostic tests. Understanding parental preferences can help to guide these interactions in the ED.

What did they do?

This unusual study uses two methods for gathering data: focus groups and coin-ranking exercises conducted with parents, followed by a discrete-choice experiment (DCE) performed with a different set of parents and healthcare workers.

The focus groups consisted of parents of children <11 years from seven community locations in northwest England: they discussed any theme relevant to managing fever in children. Afterwards, the parents were given 100 coins and instructed to allocate them to the themes/attributes they considered most important: these ultimately made up the options in the DCE.

The DCE presented two hypothetical scenarios for managing a febrile illness, with respondents choosing their preferred options. The process repeated, with the values or levels of the options changing each time. The DCE was conducted with parents of children <11 years recruited from soft play centres and nursing and medical staff working in a children’s ED. There were 14 discrete-choice tasks.

Not surprisingly, the most important concerns for both parents and healthcare workers were avoiding pain from diagnostic tests, receiving a faster diagnosis, and minimizing waiting times. Parents were willing to pay £16.89 (~AUD 33.23) for every one-hour reduction in waiting times. Both groups preferred point-of-care testing at triage, and both groups also preferred treatment by consultants and nurse practitioners instead of doctors in postgraduate training; in fact, parents were willing to wait longer to be seen by a consultant and to avoid additional pain from diagnostic tests.

As expected, reducing antibiotic prescribing was important to healthcare workers, but interestingly parents showed no significant preference for receiving/not receiving antibiotics, which contradicts existing evidence and traditional thinking.

What’s the clinical relevance?

Most of the findings were not surprising, apart from the parental indifference to antibiotics. The researchers were reassured about the planned implementation of point-of-care diagnostic testing (CRP) at triage. However, the nature of this point-of-care testing was not defined in the DCE: the text was “Receive a quick test during triage”, which parents wouldn’t necessarily interpret as a blood test.

The preference for seeing a consultant (or, secondarily, a nurse practitioner) compared with a “doctor in postgraduate training” was interesting. I’m curious how people in the general public interpret “doctor in postgraduate training”: there’s a big difference between an FY1/intern compared with a paediatric registrar, but that distinction doesn’t seem to have been made in the DCE, or explained to participating parents. Gender of the treating healthcare worker was also not explored: in the DCE, the options for the treating healthcare worker were presented as photos: male junior doctor (“doctor in postgraduate training”), female nurse practitioner, and female consultant. The presence of photos itself may have added bias from creating associations with the images presented rather than their positions. It would have been interesting to see results from various iterations of these.

The parents were recruited from the community; it would have been good to also see responses from parents presenting to ED or to GPs or potentially at a follow-up post-visit.

Reviewed by: Katie Nash

Article 2: Extended CPAP for  premature babies

Lam R, Schilling D, Scottoline B, Platteau A, Niederhausen M, Lund KC, Schelonka RL, MacDonald KD, McEvoy CT. The effect of extended continuous positive airway pressure on changes in lung volumes in stable premature infants: a randomized controlled trial. The Journal of Pediatrics. 2020 Feb; 217:66-72.

What’s it about?

This study from the neonatal intensive care unit at the Oregon Health and Science University looked at premature infants ≤32 weeks of gestation who required ≥24 hours of CPAP for respiratory distress. Overall, 44 premature infants from between 2014-16 were included. After commencement of CPAP, following stability criteria (4-5cm H2O and FiO2 21% for over 24 hours, tolerating CPAP off during cares, sats >86% for 90% of the time and not being treated for PDA or sepsis), they were randomized to either continue CPAP for an additional 2 weeks (extended CPAP/eCPAP) or to unsupported breathing in room air for an additional 2 weeks (CPAP discontinuation/dCPAP). The mean age of the babies at the time of randomization was 32 weeks with the youngest participants being 25.3 weeks old in each arm. Pulmonary function testing with functional residual capacity measurements (FRC) was measured in these 2 groups at randomization, the 2-week mark and at the time of discharge.

The study found a greater increase in FRC through the 2-week study period in the infants randomized to eCPAP vs dCPAP (12.6mL vs 6.4mL; adjusted 95% CI, 0.78-13.47; P=0.03). There was also a greater increase in FRC through hospital discharge in infants randomized to eCPAP vs dCPAP (27.2mL vs 17.1mL; adjusted 95% CI, 2.61-17.59; P=0.01).

Why does it matter?

Premature infants in the eCPAP group had a more significant increase in FRC through hospital discharge than those in the dCPAP group.  Increasing the FRC may result in better respiratory benefits over the infant’s lifetime.

Clinically Relevant Bottom Line:

This study suggests that eCPAP in premature infants improves FRC, and may serve as a safe, non-pharmacological approach to optimize the distribution of mechanical stress to enhance lung remodeling and stimulate lung growth, and improve childhood respiratory health.

Reviewed by: Jessica Win See Wong


Article 3: Should the 4C-Meningococcal B Vaccine (Bexsero) be included in the national immunisation schedule?  

Marshall HS, McMillan M, Koehler AP, et al. Meningococcal B Vaccine and Meningococcal Carriage in Adolescents in Australia. N Engl J Med. 2020;382(4):318–327. doi:10.1056/NEJMoa1900236

What’s it about?

Oropharyngeal carriage of N. meningitides in the general population is common, especially in infants and adolescents. They are mostly asymptomatic, however, certain risk factors can trigger serious infection. Invasive meningococcal disease (IMD) is mostly caused by serogroups A, B, C, W-135 and Y. IMD is associated with high mortality and morbidity. The current Australian National Immunisation Program (NIP) funds the MenACWY vaccine, whilst the 4C-MenB vaccine can be purchased separately for $250 – $500. The 4C-Men B vaccine is less immunogenic and may not be as effective in inducing an immune response, which provides protection and reduces oropharyngeal carriage rates.

What’s it about?

Researchers in South Australia (and GlaxoSmithKline) looked at whether the vaccine reduced population carriage rates of N. meningitides in adolescents. The assumption is that reduced carriage rates will reduce the risk of IMD. All 260 secondary schools in South Australia were invited to participate, with eligible students from Years 10 – 12 (aged 15 – 18 years) enrolled. The schools were randomised into two groups: those who received 4C-MenB at the start of the trial (vaccines donated by GSK) and those who did not. The baseline characteristics of the groups (specifically, risk factors for carriage of N. meningitidis) were similar.

All students had their oropharynx swabbed at the start of the trial and 12 months later to assess for the presence of N. meningitidis, which was identified using PCR. Despite all statistical analysis, no significant difference in carriage prevalence of N. meningitidis between the vaccination and control groups was found.

Clinically Relevant Bottom Line:

There was no evidence that the 4C-MenB vaccine was effective in reducing carriage of N. meningitides in adolescents aged 15 – 18 years. Given the cost, it is hard to justify including 4C-Men B in the NIP. We should encourage parents who can afford it to vaccinate their children as a study from the UK did show serological evidence of protection for up to 2 years after vaccination. Future studies should look at the NNT for reducing IMD in at risk populations.

Reviewed by: Tina Abi Abdallah

Article 4: Effectiveness of oral sucrose for analgesia in children 3 months – 3 years undergoing transurethral bladder catheterization

London K, Watson H, Kwok S, Nanan R, Liu Anthony. Oral sucrose for analgesia in children aged between 3 months and 3 years under undergoing transurethral bladder catheterisation: A randomised, double─blinded, clinical trial. Journal of Paediatrics and Child Health 2020; 56:207-214

What’s it about?

A randomised, double─blind, placebo─controlled study was conducted at Nepean Hospital, Sydney, NSW, from June 2005 to June 2010. A total of 40 participants undergoing transurethral bladder catheterisation (TUBC) were randomly assigned to receive 4 ml of 75% oral sucrose (n = 20) or a placebo (sterilised water) (n = 20). The outcome measures included changes in paediatric pain scale scores (using the FLACC pain scale and the OUCHER pain scale), assessed by the parent/guardian(s), the doctor performing the TUBC and the nurse assisting; the changes in heart rate; and the duration of crying.

The study showed that 65% favoured the oral sucrose group, 31% favoured the placebo group and 4% found no difference between the oral sucrose and placebo groups. However, these results were not statistically significant.

Why does it matter?

This study is consistent with previous studies (eg a 2016 Cochrane review by Stevens et al), which have shown the effectiveness of oral sucrose in reducing procedural pain from single events (such as venepuncture or intramuscular injection) in neonates, but not in reducing pain from other painful procedures (including bladder catheterization) or in older children. This is the only study to evaluate the effectiveness of oral sucrose in reducing procedural pain in children aged older than 3 months undergoing TUBC. Even though the results did not reach statistical significance (especially given small sample size), it is encouraging to note that the majority of participants favoured the oral sucrose.

Clinical bottom line?

There is room to expand on this interesting study on procedural analgesia, given oral sucrose is readily available in most hospitals offering paediatric/neonatal care in Australia and it is an easy and (usually) safe mode of analgesia. It is to note though that this study used a higher concentration of oral sucrose than the usually available 24% oral sucrose formulation. Even though a larger study would be helpful in further evaluating outcomes assessed in this paper, I would not mind trialing oral sucrose next time I have to perform TUBC.

Editor’s note: I would have liked to have seen a larger enrollment in this study and potentially a narrower age window used but the work is interesting. Looking at some local policies for the use of minor procedures in infants there is a range in recommendations; Sydney Children’s Hospital Network uses sucrose for infants up to 3 months, The Canadian Paediatric Society Position statement suggests effectiveness up to 12 months (with insufficient research regarding older children) and Royal Children’s Hospital recommends sucrose for children up to 18 months. -GL

Reviewed by: Jennifer Moon

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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