Grace Leo. The 3rd Bubble Wrap, Don't Forget the Bubbles, 2017. Available at:
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 the world of paediatrics to point out something that has caught their eye.
Article 1 – In ED Practice: Can we reduce the use of x-rays to detect metallic foreign bodies?
Nation J, Jiang W. The utility of a handheld metal detector in detection and localization of pediatric metallic foreign body ingestion. International Journal of Pediatric Otorhinolaryngology. 2017 Jan 31;92:1-6.
What’s it about? Kids like swallowing shiny things so it’s likely on any given shift you’ll see a toddler who has swallowed a coin, small toy or “something, but we are not sure what!” Apparently 4% of all parents report their child has swallowed a coin. A team in San Diego undertook a 2 year prospective study looking at whether a hand held metal detector (HHMD) is useful in children who present with a history of swallowed metal foreign body (MFB).
Why does it matter? I have always been puzzled by the use of metal detectors in these cases. I am pretty sure that no-one would use an unlicensed or unapproved machine to undertake observations on a child. However people seem happy to take a metal detector off a security guard and wave it over a child’s chest. Maybe it’s just me but I am not sure the medical device regulatory body of any country in the world would be supportive of this although you will be pleased to know that it appears metal detectors don’t affect pacemakers or other internal devices! Therefore fair play to the authors for highlighting their Hand Held Metal Detector wasn’t FDA approved for the specific medical purpose they were using it for.
In this study 38 patients who were clinically stable with a suspected MFB ingestion were recruited. Subjects with respiratory distress who required immediate resuscitation and urgent operating room intervention were excluded. Clinical stability wasn’t defined though so we don’t know if patients with drooling and a sensation of a difficulty swallowing or breathing were included in the 38.
Thirty-seven of the patients had ingested MFBs (the other object being a sunflower seed). Interestingly 31 objects were located in the neck and four in the chest, all of which were removed endoscopically. This doesn’t quite tally with my own local experience either, in terms of outcome, as the majority of children I see don’t need any intervention.
When compared to X-rays “There were 33 true positives, 0 false positives, 4 false negatives, and 1 true negative. This resulted in a sensitivity of 89% (95% CI of 75%–96%), specificity of 100% (95% CI of 2.5%–100%)”.
The authors have created a flow chart of how to use HHMDs to manage these cases. Reassuringly they highlight the importance of a slightly different approach if a button battery is suspected. Sadly though it is not always possible to know what has and hasn’t been ingested. Their algorithm suggests using a positive HHMD scan to contact ENT – the challenge in the UK and in other health systems is certainly in the clinically stable child ENT are likely to want confirmation of location prior to any intervention.
This study certainly supports the effectiveness of detecting a MFB if it is present however the nirvana of being able to discharge at triage with one has still yet to be conclusively evidenced.
Reviewed by: Damian Roland
Article 2 – Rethinking an old practice: Fluids in paediatric DKA
What’s it about? This double-blind randomised control trial compared Hartmann’s solution (HS) to 0.9% Normal Saline (NS) as initial IV fluid for children presenting with diabetic ketoacidosis (DKA). The study involved 77 children over the age of 1 admitted with moderate to severe DKA to PICU at the Women’s and Children’s Hospital, Adelaide. They were stratified into moderate pH (>7.1) or severe pH (<7.1) groups. Hypovolaemic patients were given resuscitation fluid with NS as required. They were then randomised to either NS or HS as their initial fluid for at least 12 hours.
The primary end point was time to reach venous HCO3 ≥ 15. Although subjects receiving Hartmann’s solution reached the endpoint for bicarbonate earlier than NS (6.2 vs 8.6 hrs), this difference was not significant. Secondary outcomes were also measured and it was found that children in the severe subgroup receiving HS arrived significantly faster at endpoints for pH (7.3) and bicarbonate compared to the NS group. The median PICU/HDU length of stay was also significantly shorter in the group receiving HS solution (17.3 vs 23.8 hrs). There was no difference found in minimal corrected sodium between the two groups (mean 139 mmol/l) or minimum sodium concentration (mean 136 mmol/l). One limitation of this study was that after the initial 12 hours, non study fluids were allowed to be administered.
Why does it matter? International guidelines support the use of NS or Ringer’s Lactate (HS) for initial fluid management of DKA. However some state and local protocols only recommend the use NS. This may be due to concerns about hypotonicity of HS leading to hyponatraemia and increased risk of cerebral oedema. Fluid treatment with NS can sometimes lead to development of hyperchloremic metabolic acidosis due to urinary loss of ketoanions and retention of chloride. This study suggests HS can be used an appropriate alternative choice to NS given that the plasma bicarbonate was corrected at similar rates without increased risk of hyponatraemia. Furthermore, in children with severe diabetic ketoacidosis, giving HS may resolve acidosis faster and reduce length of stay.
Reviewed by: Grace Leo
Article 3 – Assessing the effectiveness of: Inhaled steroids in pre-school wheeze
What’s it about? Due to the long standing challenge of differentiating transient viral induced hyper-reactivity of the airways (viral wheeze), and the more chronic atopic mediated disease of asthma, the subject of steroids in the acutely wheezy child has always been an area of controversy.
This study looked at using budesonide, at a high dose (3mg), in a randomized, double blind, placebo-controlled, study for children presenting to an Emergency Department with acute wheeze.
Why does it matter? My gut feeling was that the addition of an inhaled steroid was unlikely to have any impact on admission rates as the study group in question (6 months – 6 years) was not a group I would traditionally expect steroids to have a valid mechanism of action on. Although this study used the not universally accepted, “machine gun” approach to treatment (nebulisers every 20 minutes for the first hour and then hourly afterwards) the addition of budenoside did appear to have an independent impact on admission rates and length of stay. This was present even after taking into account potential atopic tendencies. The study should give us food for thought as it indicates age isn’t a risk factor in length of stay, challenging the assumption that viral wheezers aren’t steroid responsive. However given all patients received one dose of intramuscularly administered methylprednisolone (1mg/kg/dose) at the onset of the treatment I wonder if this study would (and could) be replicated in other countries.
Reviewed by: Damian Roland
Article 4 – Just In: Can we increase the safe apnoeic time in children during intubation?
S Humphreys, P Lee-Archer, G Reyne, D Long, T Williams, A Schibler :Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) in children: a randomized controlled trial British Journal of Anaesthesia 2017, 118 (2): 232-238
What’s it about? Most of us are familiar with the use of high flow nasal cannulae in children. We also know that we are not as good at intubating children in emergency situations as we would like to think. With desaturation events reported in 14% number of cases at a quaternary paediatric centre we should be doing everything we can to mitigate the risk. This was a proof of concept study, carried out in 48 healthy children, in an operating room setting rather than a busy ED.
Why does it matter? I use apnoeic oxygenation every time I intubate an adult so why shouldn’t I do the same in children? Given that the majority of children I have had to intubate in the last year have been because of status epilepticus, I want to give myself as a long a safe apnoea time as possible. When it has been because of respiratory failure they already have had a trial of HFNC so it would seem odd to remove them. Their higher metabolic rate and smaller FRC is only going to make desaturation occur more quickly.
The researchers randomized their patients between standard care (no intubation) and the intervention group (HFNC with THRIVE). Crucially, both groups maintained a patent airway with a jaw thrust during the apnoeic period.
Time to desaturation (SpO2 less than 92%) was 109.2 seconds in the control group and 192 seconds in the intervention group. Even with confidence limits accounted for this averaged out to an extra minute of safe apnoea time. It would be interesting (but unethical) to see how long the period extended out. The investigators began ventilation as soon as the subjects had a time that was double the expected. The investigators also measured transcutaneous CO2 in order to determine whether this would be effected by the technique. There was a minimal rise in CO2 with both groups, but it did rise. This should be considered in patients who may already be profoundly acidotic pre-intubation.
Reviewed by: Andy Tagg
Article 5 – Case series: Paediatric Tetanus and its management.
What’s it about? Tetanus is almost unheard of and unseen in clinical practice in the developed world, thanks to vaccination. This paper seeks to review the management of four children admitted with tetanus to New Zealand’s only tertiary paediatric centre from 2000 to 2013. The authors undertook a retrospective chart review of four children aged 0–15 years admitted with tetanus in this period. As tetanus does not convey future immunity, the authors also assessed follow-up of post-infection immunisation status via official channels. In each case the children were both unimmunised and required PICU admissions of between 2 and 7 weeks, for ventilatory support. Specific tetanus treatment included metronidazole, tetanus immunoglobulin and antispasmodic medications such as magnesium sulphate and benzodiazepines. Three remain partially or unimmunised following discharge.
Why does it matter? Tetanus is a rare and vaccine preventable disease. This means, for junior clinicians in particular, that case reports of a rare but serious presentation such as this are a goldmine of information. Case reviews are often criticised for lacking scientific clout, but this is the best kind of paper we have to emulate clinical experience itself. The series openly and frankly discusses the challenges of diagnosis and management and highlights several ways that tetanus can present. Rather than reading about an amorphous “tetanus” in a text book, this series describes each of the four cases in solid detail; their juxtaposition allows us to consider both similarities and differences in what tetanus may look like. The imaginative clinician might review each of these cases at particular time points along the trajectory, considering the presentation, differential diagnoses, evolution and available investigations. It may not be a thousand patient RCT, but series like this one remain powerful teaching tools.
Reviewed by: Henry Goldstein
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. If you think they have missed something amazing then let us know.