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: Are steroids of any use in pre-school wheeze?
Wallace A, Sinclair O, Shepherd M, et alImpact of oral corticosteroids on respiratory outcomes in acute preschool wheeze: a randomised clinical trialArchives of Disease in Childhood 2021;106:339-344
What’s it about?
This paper looks at a common problem and one where there is huge variation in practice: should we give oral steroids to preschool children who present to the emergency department with wheezing?
This was a double-blinded, randomised, placebo-controlled trial based in three hospitals in New Zealand. Children were either allocated 3 days of oral prednisolone or a placebo of similar colour, taste and viscosity (yuk!). The primary outcome was measured by a change in the Preschool Respiratory Assessment Measure (PRAM) score at 24 hours, although several interesting secondary outcomes were also measured. The authors looked at 24–59-month-olds to exclude bronchiolitis cases. 3247 children were identified as eligible, with 477 children making it to the intention-to-treat analysis.
Why does it matter?
In 2009, Panikar et al. found no reduction in the duration of hospitalization when giving steroids for preschool wheeze to children from 10 months to 6 years of age. However, in 2018, Foster et al. found that giving oral steroids to children aged between 2 and 6 reduced their average length of stay from 540 to 370 minutes.
The authors of this paper found no difference in PRAM score at 24 hours between the groups (their primary outcome measure) and also no difference in the number of doses of salbutamol administered, length of stay for those admitted or representation rates within 7 days. A novel finding was that at 24 hours, the median PRAM score was 0 for both groups, and only one child still had severe disease (PRAM 9-12). This might be the fact that 218 children were excluded for ‘severe disease’ despite this not being in the exclusion criteria, as well as 175 children excluded for previous life-threatening asthma and 123 excluded for chronic respiratory or cardiac disease.
However, the authors did find that the prednisolone group had less respiratory distress 4 hours after medication administration and reduced requirement for hospital admission, additional corticosteroid or intravenous treatment.
Clinically Relevant Bottom Line:
The results of this study suggest that giving oral steroids for pre-school wheeze is of limited benefit. However, it may explain why there is a perceived benefit: Children clinically respond in the first 4-6 hours even if the overall outcome isn’t altered. It’s not clear from the study how long after arrival steroids were given, and this may be an interesting area of further study.
Many centres now give single-dose dexamethasone, which concords with the findings of this study in that 3 days of prednisolone may not be necessary given the median PRAM score of 0 at 24 hours. Some clinicians may find the reduced need for intravenous medications or hospital admission sufficient benefit to give a single dose of dexamethasone in the PED, so it is unlikely the debate about which preschool children should receive steroids has been put to bed.
Reviewed by: James Thyng
Article 2: This is just how I cope
Herrick SS, Hallward L, Duncan LR. “This is just how I cope”: An inductive thematic analysis of eating disorder recovery content created and shared on TikTok using #EDrecovery. International Journal of Eating Disorders. 2021 Apr;54(4):516-26.
What’s it about?
This Canadian study investigated the impact of eating disorder (ED) recovery videos shared on the social media platform TikTok.
The study completed a thematic analysis of the first 150 TikTok posts under the hashtag #EDrecovery (Eating Disorder Recovery) in June 2020 (454.5 million views as of June 2020 and around 1,500 posts with this hashtag).
Five themes were identified: ED awareness (N=32), Inpatient story time: “ED unit tings” (N=28), Eating in recovery (N=27), Transformations: “how about a weight gain glow up?” (N=27) and Trendy gallows humour: “let’s confuse people who have a good relationship with food” (N=36).
In around 1 in 5 of the posts, creators shared different aspects of recovery to encourage a better understanding of recovery and EDs. Four subthemes were found: recovery victories, the reality of recovery, education and sharing positivity within these raising awareness posts.
Although the #EDrecovery videos raised awareness about eating disorders, some videos contain content which blurs the line between ED recovery and pro-ED content and may be harmful to some TikTok users.
Why does it matter?
Social media channels such as TikTok have a large impact on their user base, the majority of which are children and teenagers. TikTok, formed in 2017, is one of the fastest-growing mobile apps, with over 2 billion downloads (as of January 2020) and a whopping estimated 80 billion active users, the majority of whom are children and young adults.
TikTok can be used to spread ED awareness and build a supportive community for ED recovery users. It is important to explore whether TikTok can be used as a tool to assist in ED recovery.
Clinically Relevant Bottom Line:
A fine line exists between ED recovery and pro-ED content. Some users find #EDrecovery videos helpful, while others may misinterpret the videos as triggering their ED behaviour.
Reviewed by: Jessica Win See Wong
Article 3: Do rapid diagnostic methods improve antibiotic prescribing in bacteraemia?
Faugno, AK., Laidman, AY., Perez Martinez, JD., Campbell, AJ., & Blyth, CC. (2021). Do rapid diagnostic methods improve antibiotic prescribing in paediatric bacteraemia? J Paediatr Child Health, 57(4), 574–580. https://doi.org/10.1111/jpc.15272
What’s it all about?
Rapid diagnostic methods are being developed to identify causative pathogens earlier to optimise early antibiotic therapy for patients with bacteraemia. The authors performed a retrospective study of 255 bacteraemia cases at a tertiary referral hospital in Western Australia. They compared patient outcomes in cohorts receiving antibiotics before and after implementing two rapid diagnostic tests: matrix-assisted laser desorption ionisation time-of-flight (MALDI-TOF) and GeneXpert Xpert MRSA/SA.
The median time taken to administer optimal therapy was not significantly different between those undergoing rapid diagnostic testing and those who did not (39.1 vs 44.4 hrs, p= 0.66). Similarly, there was no significant difference in hospital length of stay (7 vs 9 days), number of ICU admissions (20 vs 15), or all-cause mortality (1.6 vs 1.6%).
Why does it matter?
It is well-established that timely administration of empirical antibiotic therapy in cases of sepsis can reduce mortality and morbidity. In fact, one-third of paediatric deaths within intensive care units are associated with sepsis or septic shock. Moreover, prolonged use of broad-spectrum antibiotics and delay in targeting optimal therapy can potentiate antibiotic resistance.
Adult studies have already shown that timely identification of pathogens can improve appropriate antibiotic therapy, but little is known about its effect on paediatric populations, which present with different clinical and microbiological profiles.
The Bottom Line:
The lack of significant difference in this clinical outcome data suggests that implementing rapid diagnostic testing in paediatric populations with bacteraemia has no beneficial impact. The authors suggested possible reasons for this, such as the lack of explanations or training in interpreting rapid diagnostic test results for treating doctors and, therefore, the need for a real-time programme to support clinical decision-making.
However, it would be interesting to compare this data to other paediatric hospitals through a multi-centre study, given that other regions may have higher rates of antimicrobial resistance and candidaemia, which can alter the effectiveness of empiric antibiotic therapy. Moreover, changes to hospital guidelines for empirical therapy may be better captured through prospective studies in the future.
Reviewed by: Ivy Jiang
Article 4: What’s the time, Mr Wolf?
Stellman, R., Redfern, A., Lahri, S., Esterhuizen, T., Cheema, B. (2021) How much time do doctors spend providing care to each child in the ED? A time and motion study. Emergency Medicine Journal, Published Online First: 15 April 2021. doi: 10.1136/emermed-2019-208903
What’s it about?
The authors conducted a cross-sectional observational study over a 5-week period in two EDs – a tertiary centre and a large district hospital, both with separate paediatric ED areas – in the Western Cape of Africa. The “time and motion” methodology was used, where a single trained, independent observer was placed in the ED and observed and timed Doctors’ interaction with patients that met inclusive criteria. Criteria included age (0-13 years), unplanned presentation (not referred by another source) and an initial assessment by a qualified medical officer employed by that site. As per the South African Triage Scale, the patient triage category was also recorded. Primary objective: to measure the total time taken by doctors to assess and manage each of a series of paediatric patients. Secondary objective: whether acuity of patient—as estimated by triage category affected the average time taken, and to compare these averages to the estimated benchmarks used to calculate hospital staffing allocations in the region.
A total of 100 patients were included, and the median DTPP (doctor time per patient) for each triage category was as follows:
- Green (routine; see within 4 hours): 31 minutes (Target set for staffing calculations are: 15 minutes for green)
- Yellow (urgent; see within 1 hour) 39 minutes (Target 40mins/ patient)
- Orange (very urgent; see within 10 minutes) 48 minutes (Target 50min/patient)
- Red (emergency; see immediately) 96 minutes (Target 50min/ patient)
These time frames were compared with the local hospital benchmarks (developed to guide assigning ED staffing) and found that the median timing for patients triaged as green and red were significantly higher (p=0.001 and p=0.002, respectively).
Why does it matter?
Time often seems warped inside the Emergency Department (ED) – some shifts fly by while others seem to drag on. Sometimes, you see a new patient every 30 minutes; other times, you spend 3 hours with just one patient! Whilst most EDs have audits to monitor Key Performance Indicators (KPI) looking at waiting times, time to treatment, time to admission/time to discharge, etc, few studies actually look at the (DTPP), which is the time spent assessing and managing a patient. This value depends on many medical and psychosocial variables, but if it can be accurately measured, it can be used to determine the right staffing required in a department.
The bottom line
Even with the limitations of this study (small sample size, only a single observer collecting data for a short period of observation per day), the DTPP was significantly higher than the local expected time frame for the highest and lowest triage categories. This study could be repeated at your local ED (with the limitations addressed), and the information could be useful in determining whether your ED is adequately staffed, which would, in turn, improve a variety of KPIs.
Reviewed by: Tina Abi Abdallah
Article 5: Is excessive non-resuscitation fluid associated with worse outcomes?
Barhight MF, Nelson D, et al.Non-resuscitation fluid in excess of hydration requirements is associated with higher mortality in critically ill children [published online ahead of print, 2021 Mar 17]. Pediatric Research. 2021;1-6.
What’s it about?
This study looks at whether giving excessive non-resuscitation fluid to critically unwell children is associated with a worse clinical outcome.
The authors conducted an observational study in PICUs of two large American hospitals between 2010 and 2018. They reviewed 14,483 patients and calculated their daily fluid balance for the first 3 days of their stay. This included all fluid given that wasn’t prescribed as a ‘bolus’. They then used the cumulative fluid balance at the end of day 3 to work out a percentage fluid overload (FO), which they stratified into <10%, 10-20% and >20%. The primary outcome was in-hospital mortality, and the secondary outcome was ventilator-free days at 28 days.
For each FO category, the volume of fluid that was given over the estimated requirement (using the Holliday-Seger method) was calculated. This demonstrated that excess non-resuscitation fluid was given in just over 1 in 2 of the patients and that maintenance fluid and nutrition were the largest contributors to fluid input. The number of patients receiving excess fluid increased with each FO category, equating to an excess of 164ml/kg in the >20% group.
Analysis was performed for each FO strata to find an association between % FO and mortality, adjusting for confounders such as age and illness severity. This demonstrated an increase in adjusted odds of death compared to the <10% group of 1.8 times in the 10-20% group and 2.6 times in the >20% group.
The authors also found that for every 10ml/kg of excess fluid given, the odds of death were 1.01 times higher. There was also a 1% decrease in the likelihood of having a ventilator-free day.
As this is an observational study, it can only demonstrate associations and not causality.
Why does it matter?
In the adult population, studies have shown that almost 60% of the fluid administered to patients was in the form of maintenance fluids and “fluid creep” (the combined volume used from medications, electrolytes, and continuous infusions to keep access lines open).
Even though this study relates to critically unwell children, maintenance fluids are something we prescribe routinely in paediatrics. This study highlights the need for a carefully considered approach to their use in all children, with frequent readjustment according to fluid balance so as not to cause harm.
Further studies are required to examine whether our current prescribing practices should be modified, but nevertheless, this study should make us think more carefully about how much fluid we give to our patients.
Clinically Relevant Bottom Line:
This study shows that non-resuscitation fluids are frequently given to patients above their hydration requirements and could represent potential iatrogenic harm.
Reviewed by: Laura Duthie
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.
All articles reviewed and edited by Vicki Currie
