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The 49th Bubble Wrap


With millions of journal articles 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: The Associations between Initial Serum pH and Out-Of-Hospital Cardiac Arrest Outcomes

Okada A, Okada Y, Kandori K, Nakajima S, Okada N, Matsuyama T, Kitamura T, Hiromichi N, Iiduka R. Associations between initial serum pH value and outcomes of pediatric out-of-hospital cardiac arrest. Am J Emerg Med. 2021 Feb;40:89-95. doi: 10.1016/j.ajem.2020.12.032. Epub 2020 Dec 17. PMID: 33360395.

What’s it about? 

This paper reviewed the association between initial pH, obtained via intra-arrest VBG, and patient outcomes to evaluate if pH can be used to forecast in paediatric out-of-hospital cardiac arrest.

The authors reviewed a large, multicentre, prospective register of out-of-hospital cardiac arrests in 87 hospitals in Japan. They included paediatric out-of-hospital cardiac arrest patients younger than 16 between June 2014 and December 2017 (458 patients were included in the analysis; however, over 35,000 were listed in the registry). The primary outcome was one-month survival. They divided the patients into four groups (based on the initial blood gas pH) and compared this to the patient’s outcome.

Interestingly, the median age of the patients was one year. Just over six in 10 of the patients were male. In seven out of 10 patients, the first monitored rhythm was asystole. Cardiogenic arrest occurred in four out of 10 patients.

Mortality and survival with good neurologic function were looked for. The survival rate at one month was just over 1 in 10 patients. In the group with pH > 6.82, the survival rate was around 4 in 10 patients. However, with a pH< 6.47, the survival rate was 1 in 100.

Of particular interest, in the entire study population of 458 patients, no patients survived with good neurological function with a pH <6.8.

Why does it matter? 

Deciding when to stop resuscitation in a paediatric cardiac arrest can be difficult. Guidance is sparse, and no universally recommended measures help providers determine when to halt resuscitative measures. This is a stark contrast to adult cardiac arrest management, where many validated termination of resuscitation rules are based on measurements such as end-tidal CO2.

This is the first study to assess the association between pH and prognosis in paediatric out-of-hospital cardiac arrest. It presents robust evidence to support an objective, easily obtained measure that can assist decision-making around the termination of resuscitation. Important exclusions in this study were patients where resus was not attempted at a hospital, unknown age, traumatic or arrest secondary to hanging and those with no pre-hospital data.

This exciting paper provides guidance in an area sorely lacking previous data. It gives providers a valuable tool that can substantially assist them in making difficult decisions.

Clinically Relevant Bottom Line:

In out-of-hospital paediatric cardiac arrest, according to this study, no patients with a pH <6.8 survived with a neurologically favourable outcome. Survival, in general, was significantly lower in patients with an initial pH <6.8.

Reviewed by: Sean Croughan

Article 2: Should we use focused cardiac ultrasound to guide therapy in children with sepsis?

Arnoldi s, Glau CL et al. integrating focused cardiac ultrasound into Pediatric septic shock assessment. Pediatr Crit Care Med. 2021 mar 1;22(3):262-274

What’s it about? 

This paper examines whether integrating FCU (a focused cardiac ultrasound) in the clinical assessment of children with sepsis would alter clinicians’ evaluation of their haemodynamic characteristics.

The authors conducted a retrospective, observational study from January 2014 – December 2016 in a large PICU in America. They reviewed 74 PICU patients who received FCU within 72 hours of sepsis pathway initiation. Assessment by clinicians before FCU was compared to the evaluation after FCU in 46 patients to determine if there was a difference in the haemodynamic characterisation of patients.

They demonstrated that incorporating FCU changed the clinician’s characterisation of the haemodynamic assessment made before FCU in more than 2 out of 3 cases. The most common new finding identified post-FCU was myocardial dysfunction in (7 out of 22) cases. The most commonly ruled-out physiologies by clinicians after FCU performance were obstructive physiology (5 in 8 cases) and fluid responsiveness (13 in 26 cases).

Why does it matter? 

Sepsis in children continues to be one of the leading causes of mortality and morbidity worldwide.  Furthermore, most children who die of sepsis suffer from refractory shock and/or multiple organ dysfunction within the initial 48 -72 hours of treatment, thus demonstrating the need for early and targeted interventions.

The previous method of classifying patients as having either ‘warm shock’ or ‘cold shock’ to guide therapy has been demonstrated to correlate poorly with cardiac function and systemic vascular resistance and has not led to improved outcomes. It is now recommended that more advanced techniques such as focused cardiac ultrasound (FCU) be used alongside clinical assessment to identify haemodynamic status and direct therapy.  This is already widely the case in adult practice, and algorithms have been created to integrate it into patient management. 

Although this is a small study, it makes us think about the use of cardiac ultrasound alongside clinical assessment of children with sepsis to understand the haemodynamic characterisation of these patients.

This may be particularly useful in relation to fluid responsiveness, as half of the children thought to be fluid-responsive pre-FCU were found not to be after an FCU was performed. In addition, we know that children with sepsis often receive significantly more fluid per kilogram than adults, which is associated with worse outcomes.

Clinically Relevant Bottom Line:

FCU, when incorporated into shock assessment, has the potential to identify myocardial dysfunction earlier and could result in reduced fluid administration as well as more targeted therapy based on haemodynamic status. However, further work is needed to determine how this can be used within paediatric practice.

Reviewed by: Laura Duthie

Article 3: Don’t Forget The Planet

Di Cicco, M.E., Ferrante, G., Amato, D., Capizzi, A., De Pieri, C., Ferraro, V.A., Furno, M., Tranchino, V., La Grutta, S. (2020) Climate Change and Childhood Respiratory Health: A Call to Action for Paediatricians. Int J Environ Res Public Health, Vol 24;17(15):5344

What’s it all about?

The authors systematically reviewed papers examining the connection between respiratory illnesses in children aged 0 – 18 years. Keywords used separately and in combination were (allergic rhinitis, rhinitis, asthma, bronchitis, pneumonia, and infections) and key environmental phrases (climate change, pollution, particulate matter, ozone, nitrogen dioxide, allergen, pollen). There was no limitation on the date of paper or country of origin.

Whilst much of the research at this stage is not completely conclusive key points from the review include:

  • Several studies from different countries found a connection between the increased prevalence of rhinitis and asthma and the frequency of symptoms with increased global temperatures, which has changed many plant species’ lifecycles and led to longer pollen seasons.
  • Positive correlations between the incidence of pneumonia and other acute respiratory tract infections in the context of increased extreme weather events such as heatwaves, fires and floods
  • Positive associations between the increased relative humidity and increased activity of respiratory viruses such as respiratory syncytial virus

Why does it matter?

Climate change is the long-term shift in weather conditions (temperature, humidity, winds, and extreme weather events). It is often discussed regarding protecting our wildlife or preventing further damage to our oceans and forests. However, it should be talked about more when considering its impact on our health. A child born in 2020 will live in a world that is more than 4 degrees warmer than the pre-industrial average and will be at greater risk of various acute illnesses and long-term health consequences.

The Bottom Line:

More research is needed to accurately define the burden of climate change on our health. But in the interim, we can all be environmental champions, making changes in our own lives to reduce our carbon footprint and educating and influencing our colleagues and patients to do the same.

 …And for those with spare time, conducting research into the direct effects of climate change on specific health conditions, and contributing to government policies to create change at a higher level and reduce the carbon footprint of our healthcare systems, are excellent places to start! 

Reviewed by: Tina Abi Abdallah

Article 4: Domo arigato, Mr Roboto

Littler BKM, Alessa T, Dimitri P, et al Reducing negative emotions in children using social robots: systematic review Archives of Disease in Childhood  Published Online First: 08 March 2021. doi: 10.1136/archdischild-2020-320721

What’s it about?

The paper examines several studies using social robots in paediatric outpatient settings to interact with patients and provide multi-sensory patient experiences. The author postulates that using social robots provides better interaction and distraction for children, thus reducing anxiety and distress during the visit.

This systematic review found ten studies that used social robots ranging from humanoid-based robots to ones simulating toy bears, dinosaurs and seals. The robots interact verbally and physically and can respond to patient cues and tactile stimulation. They were used before or during the intervention. The studies included randomised controlled, exploratory, and pilot and observational studies, with patient numbers varying from 2 to 73 (320).

Why does it matter?

For lots of children, a visit to the hospital can be a stressful and anxiety-inducing event. There has been research to suggest that social robots have a positive impact on supporting adults with dementia, and in children with autism, they have been a useful tool in conducting therapy. The outcomes of this study were measured by observation and by recording levels of distress, anxiety, pain and emotion using a variety of behavioural questionnaires. Overall, the studies’ feedback showed positive patient engagement with their robots, reducing negative emotions, distress and pain.

The bottom line

Good data suggests that robots may improve children’s experience in the healthcare environment. However, the evidence could be more substantial due to the nature of the studies, lack of uniformity in the measurements, and low patient numbers. More research is needed on this topic to change practice, but this sci-fi intervention may become a reality.

Reviewed by: Laura Riddick

Article 5: Children visiting the Paediatric Dmergency Department during Ramadan

Sawaya,R., Wakil, C., et al (2021) Pediatric emergency department utilisation during Ramadan: a retrospective cross-sectional study. Archives of Disease in Childhood 2021;106:272-275.

What’s it about?

This study investigates the impact of Ramadan on patient characteristics, diagnoses, and metrics in the paediatric emergency department (PED). Unfortunately, limited data exists on how Ramadan impacts paediatric EDs.

Why does it matter?

The authors looked at patient and illness characteristics and PED metrics, including peak patient load, presentation timings, length of stay, time taken to order tests, receive samples and reporting of results to see how these were affected during the months of Ramadan and those before and after. 

This is a retrospective cross-sectional study on paediatric patients from 0 – 18 years presenting to a PED tertiary centre in Lebanon. Data was collected from all PED visits with any complaint during Ramadan and the months (30 days) before and after in 2016 and 2017. A bivariate analysis was performed between the Ramadan and non-Ramadan groups. The main outcomes were illness severity, chief complaints, final diagnoses, PED metrics, including peak patient load, presentation timings, length of stay, and PED efficiency metrics such as time to order tests and times to samples being received and reported. 5711 patients were included, and 1672 of them presented during Ramadan. There was no significant difference between age, gender or illness severity between the Ramadan or non-Ramadan groups. This study found a substantial difference in the number of GI complaints during Ramadan (39%) compared with the non-Ramadan group (35%). 

Trauma-related complaints increased during Ramadan (3 in 100) vs (2 in 100) in non-Ramadan periods. Especially during the non-fasted periods of Ramadan (4 in 100) vs (2 in 100) during the fasted period of Ramadan. The number of daily visits during Ramadan (28.3) was reduced compared with non-Ramadan attendance (31.5). The Ramadan group did not have to wait longer for tests to be ordered or samples collected. 

This study was a single centre, and the reviewed charts did not have information on the patient’s fasting status. This would be interesting to see if the patient’s status affected the diagnosis. The team used months immediately before and after Ramadan to reduce the confounding effects of seasonal bias.

Clinically Relevant Bottom Line:

This study revealed changes in GI and trauma presentations during Ramadan. There was also a reduction in cases in this centre—if the patient population reflected that of the people in this study, this could help to influence staffing during this time.

Reviewed by: Vicki Currie

If we have missed out on something useful or you think other articles are 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.

All articles reviewed and edited by Vicki Currie


  • Vicki is a consultant in the West Midlands in the UK. She 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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