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The 41st Bubble Wrap


With millions upon millions of journal articles being published yearly, 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: Finding the right words for the death of a 20-23 week gestation neonate.

Smith LK, Dickens J, Bender Atik R, Bevan C, Fisher J, Hinton L. Parents’ experiences of care following the loss of a baby at the margins between miscarriage, stillbirth and neonatal death: a UK qualitative study. BJOG: An International Journal of Obstetrics & Gynaecology. 2020 Jan 24.

What’s it about? 

We don’t often feature O&G papers in BubbleWrap, but this article significantly overlaps Neonatal Intensive care. As we’ve heard from Andy Tagg and Andrew Weatherall, language matters when it comes to losing a baby.

This qualitative study explored the healthcare experiences of parents whose baby died before, during or shortly after birth between 20+0 and 23+6 weeks of gestation in England. Thirty-eight parents (10 parent pairs and 18 mothers) were interviewed from 2016 to 2017, with each interview focusing on parents’ experiences following the loss of their baby and the definitions of ‘stillbirth,’ ‘miscarriage,’ and ‘neonatal death.’

The key themes in the interviews were the use of terminology with parents to define their loss, parent’s preparedness for the birth experience, seeing their baby and making memories and parents’ physical and emotional well-being in the long term. Parents were more prepared for the labour and birth experience when they were told they were ‘losing a baby’ rather than ‘having a miscarriage’.

Since babies born showing no signs of life before 24 weeks of gestation did not receive official birth or death certificates, parents found it helpful to remember their baby by creating memory boxes with artefacts such as photographs, a lock of hair and handprints.  Parents also found the terminology ‘losing a baby’ helped them to process their grief in the long term, as it was easier for them to talk about their loss with friends and family. 

Why does it matter? 

Miscarriage, stillbirth and neonatal death are painful and traumatic experiences which have a substantial psychological and social impact on parents in the long term.

Clinically Relevant Bottom Line:

Words matter. Utilising the “losing a baby” terminology to describe a baby loss shortly before 24 weeks of gestation prepares parents for labour and birth, seeing their baby and making memories. This terminology also validated their loss, which will ultimately positively impact parents’ experiences and improve longer-term outcomes in the future.

Reviewed by: Jessica Win See Wong

Article 2: Can chlorhex baths prevent central-line-associated bloodstream infections?

Martinez T, Baugnon T, Vergnaud E, Duracher C, Perie AC, Bustarret O, Jugie M, Rubinsztajn R, Frange P, Meyer P, Orliaguet G, Blanot S. Central‐line‐associated bloodstream infections in a surgical paediatric intensive care unit: Risk factors and prevention with chlorhexidine bathing. J Paediatr Child Health 2020;56:936-942. doi:10.1111/jpc.14780

What’s it about? 

A single-centre retrospective cohort study in a paediatric surgical intensive care unit in Paris, France, evaluated whether implementing a bathing protocol of 4% chlorhexidine (CHG4%) for high-risk patients would alter the central-line associated bloodstream infection (CLABSI) incidence rate. Patients were included for analysis if they were 18 or younger and received a temporary percutaneous central venous catheter (CVC) for at least one day during ICU admission. 

The bathing protocol involved daily CHG4% skin bathing and the hospital’s usual CVC hygiene care procedures. This was implemented for those patients with at least one factor considered to be high-risk for CLABSI, including skin colonised with Staphylococcus aureus, presence of an invasive medical device, or immunosuppression. 

Incidence rates from pre-intervention in 2014 and post-implementation of CHG4% protocol implementation in January 2015 were 6.1 and 2.3/1000 days respectively (P=0.007). The risk of CLABSI significantly increased in patients with more than one factor present, previous S. aureus carriage presence of at least one IMD.

Why does it matter? 

CLABSIs are known to be a leading cause of healthcare-associated infections (HAIs). It has significant morbidity and mortality, with the incidence higher in paediatric than in adult hospital populations. Chlorhexidine is a recognised measure in preventing CLABSIs, as previously considered here. This paper further augments that post’s summary.

Clinically Relevant Bottom Line:

The additional CHG4% bathing procedure for high-risk PICU populations can significantly reduce the incidence of CLABSI. Here, the authors report the significant risk factor of IMD as a novel finding compared to other factors previously described in the literature. Comparatively, US-based guidelines propose using CHG2% rather than CHG4% for preventing HAI. It would be interesting to consider if there was a marked difference for paediatric ICU populations. Understanding whether CLABSI rates differed between short-term and long-term invasive medical devices would also be interesting.

Reviewed by: Ivy Wei Jeng

Article 3: Racial and Ethnic Differences in Emergency Department Pain Management of Children with Fractures

Goyal MK, Johnson TJ, Chamberlain JM, et al. Racial and Ethnic Differences in Emergency Department Pain Management of Children With Fractures. Pediatrics. 2020;145(5)

What’s it all about?

There is a long and challenging history of under-recognising and undertreating pain in children. This study highlights discrepancies in pain management of long-bone fractures in children from ethnic minority backgrounds. The PECARN network was utilised for a retrospective analysis of paediatric emergency department visits for long-bone fractures across seven paediatric emergency departments in the USA from July 2014 to June 2017.

The outcomes measured were whether children received any analgesia during their visit and whether opiate analgesia was received. Reduction of pain by a score of 2 or more points on a 10-point pain scale within 90 minutes of the highest documented pain score was also measured, as was whether ‘optimal’ pain control was achieved as defined by a pain score of 0-3 (none to mild pain). 

Of 21069 children with moderate-to-severe pain, 86% received analgesia. Interestingly, children from minority backgrounds were more likely to receive analgesia in any form for moderate-to-severe pain at the hospital. 45% of children with moderate-to-severe pain received opiate analgesia; however, children from African-American or Hispanic backgrounds were less likely to receive opiate analgesia when compared to White children. 

Of 8533 children whose pain scores were reassessed and documented, 89.2% had their pain score reduced by two or more points within 90 minutes. Although African American and Hispanic children were more likely to reduce pain by a score of 2 or more, they were also less likely to achieve optimal pain control (pain score of 0-3).

Why does it matter?

Most kids with long-bone fractures receive some form of analgesia for long-bone fractures, and most children receive a reassessment of their pain after the intervention. However, although African American and Hispanic children experienced significant reductions in their pain, these children were less likely to receive opiate analgesia and less likely to achieve optimal pain reduction, as defined by having none to minimal pain. This indicates that children from African-American and Hispanic backgrounds are likely to tolerate worse pain for longer than their White counterparts.

Clinically Relevant Bottom Line:

Children are less likely than adults to receive adequate analgesia in the emergency department. In addition, disparities in pain management amongst children from ethnic minority backgrounds seeking care in the emergency department for abdominal pain have previously been documented by the same authors.

As clinicians, we must be mindful of cultural differences in attitudes towards pain and ensure that we continue reassessing and offering adequate and appropriate analgesia to all children suffering from painful conditions.

Reviewed by: Monica Parker

Article 4: Lung function in Aboriginal and Torres Strait Islander kids with respiratory diagnoses.

Blake, T.L., Change, A.B., Marchant, J.M., McElrea, M.S. (2020) Respiratory Health Profile of Indigenous Australian Children and Young Adults, Journal of Paediatric and Child Health, doi: 10.1111/jpc.14817

What’s it about?

Over the last two decades, progress has been made regarding reducing the mortality gap between Aboriginal and Torres Strait Islander and non-Indigenous Australians. However, further research and collaborative approaches to implementing positive changes need to occur to continue to Close The Gap. Respiratory illnesses remain the most common reason for primary health care visits and the second most common reason for hospitalisations in Indigenous Australians, with little objective data (e.g. spirometry) across various geographic and demographic groups. This study looked at the respiratory health (diagnosis and FEV1) of Aboriginal and Torres Strait Islander children from various communities in Queensland and the Northern Territory (NT).

Why does it matter?

Children and young adults aged 3 – 25 years from eight Queensland communities and one NT community were recruited (n=1,278). Each child completed spirometry, and their medical history was recorded (from medical records and self-reported) to identify children with a history of respiratory disease (asthma, bronchiectasis, bronchiolitis, bronchitis or pneumonia) or no respiratory disease. 

Data was then available for 1245 children, with 1106 reliable spirometry tests (3 acceptable tests required). Asthma is the most common respiratory diagnosis (n = 243) across city/regional and rural/remote communities, followed by bronchitis (n=209), bronchiolitis (n=64), pneumonia (n=41) and bronchiectasis (n=19). Bronchitis and bronchiolitis admissions were significantly higher in rural/remote communities compared with city/regional communities. There were no significant differences in asthma and pneumonia admissions. 

Spirometry revealed lower lung function testing for patients with any respiratory diseases and was lowest for patients with a history of asthma and bronchiolitis. There was no statistically significant difference between city/regional and rural/remote communities. 

Interestingly, 47.7% of patients with no history of respiratory disease were found to have mild or moderate FEV1 impairment. For those patients with a history of respiratory disease, 3 in 5 children had a mild or moderate FEV1 impairment.

The bottom line

This study provides baseline data for respiratory health in Indigenous children in city/regional and rural/remote communities. The study did not specifically look at management, intervention and outcome. It did not look into confounding factors, e.g. history of prematurity/chronic lung disease, smoke exposure, management of chronic respiratory. Given the burden of respiratory illness in Indigenous children, further longitudinal studies are required to examine interventions, objective assessments and disease management.

Reviewed by: Tina Abi Abdullah

Article 5: Competence is not the same as capacity

Wheeler R. Don’t equate competence with capacity. Arch Dis Child 2020;105:419–420

What’s it about?

The author, a paediatric surgeon and director of clinical law, discusses the considerations of the consent process in adolescents. A clinical case illustrates the pitfalls of neglecting to consider capacity when the principles of assessing competency alone are applied. 

The author highlights the differences between the common law principles of Gillick competency and the Mental Capacity Act 2005 (UK). The main differences include:

  • The Act assumes the capacity of young persons from 16 years with two criteria required to refute it (demonstration of impairment of the mind and evidence this impacts their ability to decide as a consequence). It mandates ‘… all practical and appropriate support’ is provided to assist decision making. 
  • Gillick competency is based on analysis of the young person’s ability to understand and assess risks. It is used to refute the Act’s principle that they cannot make independent decisions (under 16 years). 

“The threshold for a young person to establish they are competent is higher than for the same person to defend the presumption they have capacity.” 

The author suggests if young people are faced with a clinical decision and their capacity is in doubt, the first step should be to test the presumption of their capacity.

Why does it matter?

Consenting adolescents can be complicated. Understanding the differences and applications of the principles of capacity and competence is important for anyone working with adolescents.

Clinically Relevant Bottom Line:

From a legal and ethical perspective, we need to understand the principles of assessing capacity and competency.

Reviewed by: Priya Shenton

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.


  • The house-elves are still hard at work, copying, pasting, and occasionally weaving a little magic!


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