The 46th Bubble Wrap

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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 UK and Ireland) to point out something that has caught their eye.

Article 1: Ten Tips for Breaking Bad News

Brouwer, M.A., Maeckelberghe, E.L.M., van der Heide, A., et al., Breaking bad news: what parents would like you to know (2020) Archives of Disease in Childhood Published Online First: 30 October 2020. doi: 10.1136/archdischild-2019-318398

What’s it about? 

Difficult conversations in paediatrics often revolve around conditions which reduce life expectancy, such as oncological, metabolic, cardiac and neurological diagnoses. In the case of new diagnoses, difficult discussions may happen in the emergency department – an environment that is not designed for sensitive and long (ideally interruption free) discussions. 

This article reviews the experiences of parents who were involved in difficult conversations surrounding their child’s care or condition and provides practical advice on how to provide empathic, timely and optimal communication.

Based in the Netherlands, the authors recruited bereaved and non-bereaved parents of children aged between 1 and 12 years with life threatening conditions. Between November 2016 and October 2018, face to face interviews with the parents were conducted and transcribed verbatim.

Using transcripts, key themes and ten clear barriers to the communication of bad news were identified. The authors then reviewed the transcripts at length to identify positive feedback when breaking bad news; with the key aspects being where and when conversations took place, who was present for the conversation, and the honesty and information that was given.

Why does it matter? 

Breaking bad news or caring conversations are part of our every day work. But for the families and children receiving the information, the high emotional and practical significance means that they remember these conversations for a long, long time. The onus on us as professionals is to develop and grow the insight and skill to thoughtfully, effectively and compassionately communicate during these conversations.

Clinically Relevant Bottom Line:

Communication skills remain the cornerstone of medical practice. Feedback from patients and family often revolves around communication with the team caring for them, and whether it was “good” or “bad”. This article highlights some important factors to optimise communication when breaking bad news, which can be (and should be) utilised on a daily basis.

Reviewed by: Tina Abi Abdallah

Article 2: Risk of traumatic intracranial haemorrhage in children with bleeding disorders

Bressan, S., Monagle, P., Dalziel, S.R., Borland, M.L., Phillips, N., Kochar, A., Lyttle, M.D., Cheek, J.A., Neutze, J., Oakley, E., Dalton, S., Gilhotra, Y., Hearps, S., Furyk, J., Babl, F.E. (2020). Risk of traumatic intracranial haemorrhage in children with bleeding disorders. J Paediatr Child Health, 56: 1891-1897.

What’s it about? 

This multi-centre prospective observational study aimed to assess the rate of  CT use and frequency of diagnosing intracranial haemorrhage (ICH) on CT, in children with bleeding disorders presenting with head trauma.

20 137 children were evaluated in Australian and New Zealand EDs for head trauma, with or without bleeding disorders between April 2011 and November 2014. Congenital or acquired bleeding disorders were present in 0.5% of this population. Head CT use was significantly higher in children with bleeding disorders than those without (3 in 10 vs 1 in 10) despite the latter group presenting more frequently with severe mechanisms of head injury. Children with bleeding disorders who received CT were more likely to present with milder mechanisms of injury as well as clinical signs of vomiting and abnormal behaviour reported by parents, compared to children with bleeding disorders who did not receive CT scans . Only one child with a bleeding disorder had an ICH requiring neurosurgical intervention and no children without CT imaging had evidence of ICH on follow-up.

Why does it matter? 

Minor head injuries present frequently to paediatric EDs. Children with bleeding disorders are at increased risk of ICH following a minor head injury than those without bleeding disorders. Patients with severe haemophilia are reported to have the highest risk of traumatic ICH within this heterogenous disease group. It is important to detect ICH early in order to avoid long term disability and potentially fatal outcomes whilst balancing the decision for imaging against the risks of repeated radiation exposure. Previous clinical decision rules have supported ED clinicians in making judgements on CT use for paediatric head injuries but there is little evidence or guidance on its use for children with bleeding disorders.

Clinically Relevant Bottom Line:

The low incidence of ICH in children with bleeding disorders receiving CT imaging suggests that CT scans may not be routinely necessary in children with congenital or acquired bleeding disorder. The authors suggest a more selective approach to CT decision-making, combining a period of clinical observation with the severity of injury mechanism and the underlying bleeding disorder, rather than a “CT all” strategy.

However, the study is limited in its analysis by the low number of children with bleeding disorders. It would also be interesting to note from Bressan et al.’s study whether the rate of CT use varied with patients’ GCS scores or age of presentation, given the wide age window of children < 18 years.

 Nonetheless, current head injury rules such as PECARN were designed with the explicit exclusion of children with bleeding disorders. This study can therefore support the development of targeted neuroimaging guidelines for children with bleeding disorders.

Reviewed by: Ivy Jiang

Article 3: Can we safely send paediatric head injuries home from triage?

Aldridge, P., Castle, H., Phillips, C., Russell, E., Guerrero-Luduena, R., Rout, R. (2020). Head home: a prospective cohort study of a nurse-led paediatric head injury clinical decision tool at a district general hospital. Emergency Medicine Journal.

What’s it all about?

Head injuries are a common presentation to emergency departments internationally. Recent Australian data has shown that in >19,000 attendances with head injury only 3 in 100 had a traumatic brain injury on CT or a clinically important brain injury.

This study group set out to assess whether children under 17 years could safely be discharged by triage nurses following a pre-set clinical decision tool (HIDATq- Head Injury Discharge At Triage questionnaire). HIDATq was developed using PECARN and NICE guidelines. For a recap on Head Injury Decision tools see Anna Ing’s ‘Head Injury- who to scan?’ on DFTB.  HIDATq was implemented over a 6-month period in children who presented with a head or facial injury to a DGH in the UK.

Over 1700 patients were assessed, and data was analysed retrospectively. 61% were HIDATq negative and 1 in 5 of these patients were felt to be safe for discharge from triage without further investigation or management. A further 3 out of 10 children in the HIDATq negative patients were found to be eligible for discharge following minor wound management. 4 % of patients underwent CT scans (only 1 patient from the HIDATq negative group).

Why does it matter?

Head injuries are a common presentation to the paediatric ED. This study has revealed a patient group who might be eligible, using this screening tool, for a safe discharge from triage that would potentially have a large impact on ED crowding and pressures.

Clinically Relevant Bottom Line:

There were no adverse outcomes and the clinical decision tool used produced a high sensitivity and specificity for determining the need for CT after head injury. More than half of the children who had a negative HIDATq were potentially suitable for a safe discharge from triage.

This study did however have a highly selective population- it was not a major trauma centre so by default likely to have had less severe presentations of head injury. A larger multi centre trial is needed to provide validation for the tool. However, this study provides a useful starting point and identifies possible ways to improve patient management and ED departmental pressures.

Reviewed by: Brent Stevenson

Article 4: Should POC blood ketones be used as a triage tool to assess dehydration and predict likely admission?

Durnin, S., Jones, J., Ryan, E., Howard, R., Walsh, S., Dawkins, I., Blackburn, C., O’Donnell, S.M. and Barrett, M.J., 2020. The utility of ketones at triage: a prospective cohort study. Archives of Disease in Childhood105(12), pp.1157-1161.

What’s it about?

This is a small non-blinded prospective cohort study looking at 198 patients aged 1m-5yrs over a 12-month period. The eligibility criteria were presentation with vomiting/diarrhea/decreased fluid intake or clinical concerns of possible hypoglycaemia. Patients had finger prick blood ketones measured at triage, along with a Gorelick 4-point dehydration score. Repeat ketone measurement at 4hrs later or at discharge, clinical assessment and a 10-point Gorelick dehydration score (a Gorelick score is a validated tool to predict significant dehydration for children aged 1 month to 5 years).

The authors found a weak correlation between POC ketone level and the 10-point Gorelick dehydration scale (a more detailed assessment) and no correlation between POC ketones and Gorelick 4-point dehydration scale score.

Ketone level at triage was not predictive of admission however repeat measurement at 4hrs was weakly predictive; meaning, a larger proportion of the discharged cohort showed a reduction in ketones after rehydration compared to the admitted cohort.

Why does it matter?

Assessing dehydration is an inexact science and an accurate POC test for dehydration would simplify and potentially improve patient care. The Gorelick 4-point scale has previously shown to be oversensitive for assessing percentage dehydration but scales are better than unstructured assessment. This study rules out blood ketones as a tool for assessment of degree of dehydration or for predicting admission in this patient group.

The bottom line

Blood ketones are of little use as a triage tool for assessing degree of dehydration or predicting hospital admission in children with reduced fluid intake / D&V. There is no benefit to routine measurement of blood ketones at triage in patients with dehydration who do not have concerns about potential DKA.

Reviewed by: Sarah Reynolds

Article 5: Is loop-mediated isothermal amplification a useful tool for early identification of invasive meningococcal disease?

Waterfield, T., Lyttle, M.D., McKenna, J., Maney, J.A., Roland, D., Corr, M., Woolfall, K., Patenall, B., Shields, M. and Fairley, D., 2020. Loop-mediated isothermal amplification for the early diagnosis of invasive meningococcal disease in children. Archives of Disease in Childhood105(12), pp.1151-1156.

What’s it about?

A point of care test: Loop mediated isothermal amplification (LAMP) is a potential test for early identification of invasive meningococcal disease (MD).  (LAMP) is a form of rapid nucleic acid amplification and a commercially available LAMP test (using oropharyngeal swabs) can test for all serotypes of Neisseria meningitidis. This study looked to evaluate the diagnostic accuracy of LAMP for identifying invasive (MD) in children and to compare LAMP testing with more familiar tests like CRP and white cell counts (WCC).

 263 children under the age 18 with fever and signs or symptoms of meningococcal septicaemia were included over a 2-year period in 3 ED’s across the UK. 97% of participants were appropriately vaccinated as per UK vaccination schedule with over 1 in 2 of these children having had the Men B vaccination and over 2 in 3 children who had received the Men C vaccine.

Less than 2 per 100 children had confirmed cases of invasive MD. There were 14 positive LAMP tests, and all the confirmed cases of invasive MD were within these. In all the children with negative LAMP tests NONE had invasive MD. The LAMP test in this population performed better than other more commonly used tests (CRP, WCC or neutrophil counts).

Why does it matter?

Whilst vaccination programmes have thankfully made invasive MD more uncommon, it is still a significant cause of morbidity and mortality in children when it does occur. 

Early diagnosis is challenging, meaning potential overuse of broad-spectrum antibiotics or false reassurance for the clinician.

A point of care test for N. meningitidis, which is easy to do, with a low false negative rate has the potential to change this. However, false positives, meaning asymptomatic carriage must be considered.  The study included mostly young children and adolescents who are known to have higher asymptomatic carriage rates of N. meningitis, meaning false positive could be higher in this group.  It has the potential to be used as an adjuvant to PCR and blood culture, but the optimum patient group selection is yet to be determined and it could not be used as a rule out test in low prevalence areas like the UK.

Clinically Relevant Bottom Line:

LAMP testing for IMD, is a potentially useful test to identify children with invasive MD rapidly. However, clinical utility is yet to be determined.

Reviewed by: Sarah Kapur

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.

About the authors

  • Vicki is a Paediatric Registrar in the West Midlands in the UK , starting PEM in September 2021. Vicki is passionate about good communication in teams and with patients along with teaching at undergraduate and postgraduate level. When not editing Bubble wrap Vicki can be found running with her cocker spaniel Scramble or endlessly chatting with friends.

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1 thought on “The 46th Bubble Wrap”

  1. Thanks for this. It is really helpful to have the summaries and to be able to read papers that you have critically appraised so that I can compare my findings to yours. THanks!