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The 45th 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: Are children having enough sleep?

Tsao, H.S., Gjelsvik, A., Sojar, S., & Amanullah, S. (2020). Sounding the Alarm on Sleep: A Negative Association Between Inadequate Sleep and Flourishing. The Journal of Pediatrics.

What’s it about? 

The US National Survey of Children’s Health (NSCH) dataset included almost 50,000 parental respondents; this cross-sectional study assessed the prevalence of inadequate sleep in school-aged children aged 6-17 years old and its association with measures of childhood flourishing. The study used the AAP Sleep Guideline definitions of Inadequate sleep duration: under 9 hours for 6-12 year-olds and <8 hours for 13-17 year-olds. Flourishing was assessed by five individual questions such as “How well does your child… show interest and curiosity in learning new things?”.

More than 1 in 3 primary school-aged children were underslept; a slightly lower proportion of high schoolers also had inadequate sleep. There was a correlation between being underslept, having a high number of ACES, a high poverty score, low parental education, psychiatric comorbidity and non-TV screen time > 4 hours.

Inadequate sleep was also associated with “failure to flourish” – underslept kids were more likely to be reported as “not showing interest in learning“,  “not doing homework”, and not finishing tasks. Similar results were present in 13-17 year-olds. Strikingly, 6-12-year-olds with more than 4 hours each day of non-TV screen time were twice as likely to undersleep.

Why does it matter? 

This study is predicated on the premise that enough sleep leads to flourishing. Chronic sleep loss is a well-established public health concern affecting adults and younger persons. In adolescents, inadequate sleep has been associated with impaired decision-making and obesity, and in younger children, it has been associated with reduced perceptual reasoning and worse academic performance. 

While previous studies have focused on determining adolescent sleep patterns, this study targeted younger children and a broader range of physical and mental health outcomes. Notably, this data set is cross-sectional in nature and parent-reported, which leaves some gaps in our understanding of the complexity of the interaction whilst also suffering additional desirability and recall biases.

Clinically Relevant Bottom Line:

Despite the endorsement of sleep guidelines for children by the American Academy of Sleep Medicine, Tsao et al. highlighted that 1 in 3 children still experience inadequate sleep. The association between inadequate sleep and numerous demographic characteristics highlight that educational interventions to raise awareness of sleep duration in schools and by public health workers need to be considered in the context of a child’s structural, home, and neighbourhood environments. 

Further studies to explore sleep duration in younger age groups below six years old can assist in providing data on early childhood development and school readiness. More research can further assist in understanding the causal relationships between sleep duration and sociodemographic factors which may affect childhood flourishing. 

For those of us interacting with children and their families, this data is an important reminder of the opportunities for brief interventions around sleep hygiene and the signalling associated with taking a sleep history.

Reviewed by: Ivy Wei Jiang

Article 2: When severe Pelvic Inflammatory Disease complicates EBV

Tamura S, Jwa SC, Tarumoto N, Ishihara O. Septic Shock Caused by Fusobacterium Necrophorum after Sexual Intercourse during Recovery from Infectious Mononucleosis in an Adolescent: A Case Report. J Pediatr Adolesc Gynecol. 2020 Oct;33(5):566-569. doi: 10.1016/j.jpag.2020.06.018.

What’s it about? 

This case report describes a rare combination of pathology revolving around a sexually active adolescent with a primary EBV infection who subsequently contracted severe pelvic inflammatory disease (PID) complicated by Fusobacterium necrophorum ovarian abscess and sepsis without evidence of throat symptoms or infection. There’s a previously suggested link between EBV and Lemierre’s syndrome, and the case adds further weight to this conjecture.

Why does it matter? 

I found this case interesting for four reasons. Firstly, case reports remain an interesting way to learn about medicine, provided you hold in mind the observer and reporting bias inherent in interesting cases. 

Secondly, it’s a nice reminder of Hickham’s dictum, “a [patient] can have as many diseases as [one] damn well pleases”.

Thirdly, the importance of an accurate sexual history as part of a sepsis history in adolescents, not just as part of a  robust HEADSS assessment and fourthly, I was reminded about LITFL’s summary of Lemierre’s disease, most commonly caused by Fusobacterium necrophorum (in one of the early quizzes, Chris Nickson deigned that if you make the diagnosis of Lemierre’s, you get to be king for the day!!)

Clinically Relevant Bottom Line:

This is a rare case – the rarity that sees it published in the literature – but that doesn’t mean the key learning points are hyper-specific or irrelevant. Next time you’re perusing the journals dig deeper into a case report – beyond the camera obscura of the particular clinical conundrum – as there are often more general and instructive insights. In this case, the authors suggest there’s a reasonable basis to encourage patients recovering from an acute EBV infection to avoid sexual intercourse.

Reviewed by: Henry Goldstein

Article 3: Neonatal SARS-CoV2

Gale C, Quigley MA, Placzek A, Knight M, Ladhani S, Draper ES, Sharkey D, Doherty C, Mactier H, Kurinczuk JJ. Characteristics and outcomes of neonatal SARS-CoV-2 infection in the UK: a prospective national cohort study using active surveillance. Lancet Child Adolesc Health. 2020 Nov 9:S2352-4642(20)30342-4. PMID: 33181124.

What’s it all about?

The objective of this study was to describe the incidence, characteristics, transmission, and outcomes of SARS-CoV-2 infection in neonates who received inpatient hospital care in the UK. This was a prospective UK population-based cohort study of babies with confirmed SARS-CoV-2 infection in the first 28 days of life who received inpatient care between March and April 2020.

Of 66 babies with confirmed SARS-Cov-2 recruited through national surveillance, two in five had severe neonatal SARS-CoV-2 infection, with 1 in 4 of these babies born preterm. SARS-CoV2 infection incidence (per 10000 live births) was higher in Black (18), and Asian (15.2) than in mixed, other ethnic groups (5.6) or white (4.6) babies.

A quarter of babies with confirmed infection were born to mothers with known perinatal SARS-CoV-2 infection; two babies were considered to have a possible vertically acquired infection (SARS-CoV-2-positive sample within 12 h of birth where the mother was also positive). Eight babies had suspected nosocomially acquired infection. Follow-up at several months (end of  July 2020) identified one infant death (unrelated to SARS-CoV2) and ongoing admission for ~10% of the cohort.

Why does it matter?

There is widely different guidance on managing neonates at risk of SARS-CoV-2. Whilst this is evolving, at the time of press, some countries – including China – recommend the immediate separation of newborns from mothers who are SARS-COV-2 positive and recommend no breastfeeding.

Mother-infant separation can have harmful outcomes for perinatal mental health, breastfeeding and mother-infant bonding. This study tackled an important question to help address the gap in the research around this issue and provide robust, unbiased guidance for mothers and their babies alike.

Clinically Relevant Bottom Line:

Disease severity appears to be greater in neonates than in older children. This study supported current UK and international guidance to avoid routine separation of mother and baby and ensure that new parents can make informed decisions about neonatal care. Further, babies from BAME ethnic groups require investigation. We’re discovering more about SARS-CoV2 infection in neonates all the time in our rapid literature review here.

Reviewed by: Taryn Miller

Article 4: Does sport help with developmental delay?

Neville RD, Guo Y, Boreham CA, Lakes KD. Longitudinal association between participation in organized sport and psychosocial development in early childhood. The Journal of Pediatrics. 2020 Nov 3.

What’s it about?

The Growing Up in Ireland project investigated whether participating in organised sports impacts the associations between developmental delays in the first year of life and psychosocial outcomes in preschool children from a cohort of over 11,000 infants born (December 2007 and June 2008.

Data were collected at 1,3 and 5 years of age (~80% retention rate). At one year of age, parents reported on child development (Ages and Stages Questionnaire). At 3 and 5 years of age, parents reported psychosocial characteristics (Strengths and Difficulties Questionnaire). At five years of age, parents reported engagement in organised sports. At one year of age, 3 out of 20 children in the cohort were classified as showing developmental delays. At three years of age, these children exhibited more behavioural difficulties and fewer prosocial behaviours.

For boys with early developmental delay, weekly participation in sports was associated with a significant decrease in behavioural difficulties between 3 and 5 years of age. The effect of sport on changes in behavioural difficulties for boys with developmental delays was statistically significant, compared to their “no sport” peers. However, participation in sport was not associated with significant changes in behavioural difficulties for girls nor in prosocial behaviours for both boys and girls.

Why does it matter?

Recent studies have shown that routine physical activity enhances a child’s cognitive, emotional and behavioural regulation development. Early interventions in the first five years of a child’s life have a significant impact on the child’s developmental trajectory. Recently, early interventions have focused on setting up healthy lifestyle habits such as participating in organised sports.

The bottom line

Early participation in organised sports in the preschool years may improve behavioural regulation in boys with early developmental delay.

Reviewed by: Jessica Win See Wong

Article 5: ECG in the acute setting – How often is a concerning abnormality found?

Theiler C, Arms J, Cutler G, Krause E, Burton D. Utilization of the electrocardiogram in the pediatric emergency department. Am J Emerg Med. 2020 Dec 2;41:21-27. doi: 10.1016/j.ajem.2020.11.070. Epub ahead of print. PMID: 33383267.

What’s it about?

This study is a US population-based retrospective analysis of paediatric ECGs (<18 years) performed in a large tertiary paediatric ED from 2005- 2017, amounting to more than 16000 ECGs. This study compared characteristics of clinically insignificant ECGs (zero abnormality or mild abnormality, requiring no cardiology follow-up) to clinically significant ECGs (moderate abnormality with follow-up required or immediate treatment/ cardiology input required).  Secondary outcomes included the indication for ECG testing, as well as factors associated with clinically significant ECGs (patient demographics, vital signs at presentation, and any pre-admission cardiac medications). 

One in every 8 ECGs had a clinically significant result, although only one in 500 required immediate treatment or cardiology consultation in the ED. Infants (1 in 5) and males (1 in 6) were significantly more likely to warrant further follow-up. 

Indications for ECG associated with increased odds of a clinically significant ECG finding included suspected arrhythmia, cardiac concern, electrolyte abnormality, blank indication (hypothesised by authors that if the child was so unwell, for example requiring resus that the clinician did not have time to fill in the indication- hence blank), emergent or critical triage level and the presence of pre-admission cardiac regular medication.

Protective indications for ECG that reduced the risk of having a clinically significant result were found to be syncope, toxicology/ingestion, seizure, or another neurological complaint. Left axis deviation was the most common clinically significant ECG finding overall (14.6%), followed by prolonged QTc (10.5%).

Why does it matter?

Paediatric care has a lower volume of ECG exposure for clinicians than other physicians or acute care specialities. This low exposure, in combination with the evolving electrophysiologic profile of the heart through childhood, places ECG interpretation as a potentially higher-risk skill, in particular, the challenge of detecting a rare but severe abnormality. Prior smaller studies have shown that clinically significant ECG findings are rare in paediatrics. Simply put, as clinicians, our exposure to abnormalities is low, the prevalence is low, and the consequence of misdiagnosis is potentially catastrophic.

Clinically Relevant Bottom Line:

This study usefully highlights those who may be more at risk of having a clinically significant finding on ECG (infants <1, males), although it is not powered to understand why this may be the case. The study reveals some indications for ECG that have been shown here to increase the risk of ECG abnormality, which, after reviewing this study, can perhaps encourage clinicians to be even more mindful when interpreting ECGs performed for these specific reasons. 

Past medical history or presenting complaint data was conspicuously absent from this dataset, which is particularly challenging given the controversy and prevalence of essentially unnecessary pre-sports ECG screening in asymptomatic well children during the study period. Ultimately, clinicians can be reassured from the results of this study that children requiring immediate treatment or cardiology input from severe ECG abnormality are still rare but not to be missed in the acute setting. Anna McCorquodale has a robust approach here.

Reviewed by: Vicki Currie

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.



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