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The 55th 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 UK and Ireland) to point out something that has caught their eye.

Article 1: What is the risk of TBI in young infants with minor head trauma?

Abid, Z, Kupperman, N, Tancredi, DJ, Dayan, PS. (2021) Risk of Traumatic Brain Injuries in Infants Younger than 3 Months With Minor Blunt Head Trauma. Annals of Emergency Medicine, 78(3), 321-330.

What’s it about? 

This study aimed to evaluate whether prediction rules could accurately identify infants younger than three months old who were at low risk of clinically important and CT-diagnosed traumatic brain injury (TBI). The authors performed a secondary analysis of data from the prospective observational study by Pediatric Emergency Care Applied Research Network (PECARN) on children presenting with minor blunt head trauma. They looked at outcomes in infants who did and did not meet the PECARN low-risk criteria for minor blunt head trauma. Clinically important TBI was defined as death following TBI, requiring neurosurgery, intubation of over 24 hours, or hospitalisation for two or more nights. 

Of the 1,081 infants identified to be less than three months old, 47.5% (n=514) infants met the PECARN low-risk criteria with 0.2% (n=1), 5.1% (n=10) and 4.6% (n=9) of patients identified to have clinically important TBI, TBI on CT and skull fractures respectively. Of the remaining infants (n=567) who did not meet the low-risk PECARN criteria, 4.2% (n=24), 21.3% (n=94), and 28% (n=122) had clinically important TBI, TBI on CT, and skull fractures respectively. Interestingly, four of the 10 infants who met the low-risk PECARN criteria but had TBI on CT were entirely asymptomatic.

Why does it matter? 

Blunt head trauma is a common paediatric emergency presentation, and prediction rules have helped to guide whether CT scans can be avoided in the workup for minor head trauma. However, it is more challenging for infants younger than 3 months old to apply these rules. Despite having a clinically important TBI, they may only have subtle signs on assessment, prompting a low threshold for investigating with CT.  The risk of missing clinically important traumatic brain injury must be balanced with the risk of radiation-induced malignancies from imaging, where radiation risks increase with younger age.

Clinically Relevant Bottom Line:

While PECARN’s TBI low-risk criteria accurately identified infants at low risk of clinically important TBIs, these children remained at risk of TBI found on CT. The higher prevalence of clinically important TBI in children who did not meet the PECARN low-risk criteria also suggests the need to maintain a low threshold for CT. This suggests the need to be cautious when assessing and managing our youngest infants.

Reviewed by: Ivy Jiang

Article 2: How can we distinguish between orbital and preseptal cellulitis?

Ibrahim L, Babl F, Hopper S and Bryant P. What is the risk of missing orbital cellulitis? Archives of Disease in Childhood. 2021. 106:896-899.

What’s it about? 

This prospective Australian cohort study investigated 216 patients (3 to 18 months) diagnosed with suspected preseptal cellulitis. Preseptal cellulitis was diagnosed if a child presented with periorbital swelling, erythema and normal eye movement.  Children were excluded if there were underlying complications (post-op, abscess, immunosuppression, injury) or if suspected or confirmed orbital cellulitis (severe swelling, impaired or painful eye movements or imaging). ED clinicians decide to treat patients with either intravenous (IV) or oral antibiotics, depending on clinical judgment and guidelines. All patients received a follow-up phone call within 14 days of the initial presentation.

Of the 216 patients, 5 (2%) were subsequently diagnosed with orbital cellulitis. All five had fever compared to 66/211 (31%) with preseptal cellulitis. In 4/5 of the orbital cellulitis, children had headaches or vomiting, which was more common than in preseptal cellulitis.  In the ED, 75 (35%) were treated with oral antibiotics, and 141 (65%) received intravenous antibiotics. Only 2 (3%) in the oral group represented to ED within 48 hours and subsequently started on intravenous antibiotics without further complications.

Royal Children’s Hospital Melbourne uses the ASSET score to risk stratify preseptal and orbital cellulitis– a score of four or more should be treated with IV antibiotics, and <4 can be treated with oral antibiotics. Results showed that clinicians did not follow that plan because 40% of patients who scored <4 were given IV antibiotics, and equally, 14% of patients with 4 or more got oral antibiotics.

All five children with orbital cellulitis had an Asset score of 4 or more.

Why does it matter? 

This study showed that clinicians are conservative in their approach to children with preseptal cellulitis. The majority of children who present with signs and symptoms are more likely to be over-treated, admitted to the hospital and started on intravenous antibiotics. With appropriate risk stratification and a less conservative approach, more children could avoid hospital admission.

Clinically Relevant Bottom Line:

We tend to be cautious in treating periorbital cellulitis and give more IV antibiotics than needed.

The study showed that the actual rates of orbital cellulitis are quite low (2%), and there is a low risk of misdiagnosing orbital cellulitis clinically. The authors recommend using the Asset score guidance to determine whether IVs or orals are suitable.

If your patient has a fever, vomiting or headache with their eye swelling or a difficult eye examination, get an ophthalmology review, as these patients are more likely to have orbital cellulitis.

Reviewed by: Melanie Ranaweera

Article 3: Is giving short courses of steroids for URTIs and asthma exacerbations?

Tsung-Chieh Yao, Jiu-Yao Wang et al., “Association of Oral Corticosteroid Bursts With Severe Adverse Events in Children”, JAMA Pediatrics, 2021;175(7):723-729

What’s it all about?

We know about long-term complications of corticosteroid use in adults and children, but how about short-term risks? 

In this population-based study, Yao et al. used a self-controlled case series design to analyse data from 4.5 million children, with just over 1 million of these Taiwanese children receiving at least 1 course of ‘corticosteroid burst’ over 5 years. The study looked at incidence rates and incidence rate ratios (IRRs) of 4 adverse events after a short course (<14 days) of oral corticosteroids. In 65% of the cases, the indication was respiratory tract infection or allergic condition. 

The IRRs for GI bleeding, sepsis, pneumonia, and glaucoma within 5-30 days after starting oral corticosteroids were 1.41, 2.02, 2.19, and 0.98, respectively. Essentially, children were between 1.4 and 2.2 times more likely to have GI bleeding, sepsis, and pneumonia 5-30 days after starting steroids. These increased risks appear to be mitigated after 30 days.

Why does it matter?

We frequently prescribe short courses of oral corticosteroids for URTIs and asthma exacerbations without much thought to the potential short-term adverse effects. This study highlights that this treatment is certainly not risk-free. Should we be more stringent, particularly in those we consider more at risk of these adverse events? Should we be counselling parents on these potential harms? Is the short-term benefit worth the short-term risk? 

Although these results observe association and do not prove causality, the methods used included syncope as a control condition, and no increased incidence was seen.  

The study did not consider medication compliance or co-prescription of antibiotics – which would be useful to look at in further studies.

The Bottom Line:

With winter on the way in the northern hemisphere, our use of oral corticosteroids will undoubtedly increase. Consider pausing to evaluate not just the short-term benefits but also the short-term risk of harm. 

Reviewed by: Hannah Cooper

Article 4: Do outcomes change for out-of-hospital cardiac arrest with compression-only CPR?

Y. Goto, A. Fundi, T. Maeda et al., Dispatcher-assisted conventional cardiopulmonary resuscitation and outcomes for paediatric out-of-hospital cardiac arrests, Resuscitation,

What’s it about?

Dispatchers are the first critical link in the cardiac arrest chain of survival. They deliver CPR instructions to the caller and quickly dispatch the appropriate level of help.

This study aimed to determine optimal dispatcher-assisted CPR instructions for bystanders during a paediatric OHCA. Current CPR guidelines for paediatric cardiac arrest recommend that conventional CPR should be provided for infants and children during cardiac arrest and compression-only CPR for bystanders unwilling to perform rescue breaths before the arrival of Emergency Services. Compression-only CPR is superior to no-bystander CPR.

(Editor—The new resus council guidance emphasizes systems saving (more) lives, including education and technology to improve CPR.)

The authors studied the records of 8172 children in Japan who received bystander dispatcher-assisted CPR from 2005 to 2017. Patients were divided into conventional CPR (with breaths) and compression-only CPR groups. The primary outcome of the study was a 1-month neurologically intact outcome (scored by using the Cerebral Performance Category (CPC) scale- range of 1-5  (category 1= good cerebral performance up to category 5= death)). The secondary outcome measure was 1-month survival after OHCA.

The team performed a rigorous adjustment for differences in baseline characteristics by performing multivariable logistic regression analyses and propensity score matching analyses to adjust for selection bias when comparing outcomes between the two groups.

Why does it matter?

The 1-month CPC 1–2 rate was significantly higher in the dispatcher-assisted conventional CPR group than in the dispatcher-assisted compression-only CPR (5.7% vs 3.1%) (p<0.0001). When adjusted for variables it was still significant (6% vs 2.6% respectively) (p<0.0001).

Conventional CPR with rescue breaths was associated with an increased likelihood of survival one month after OHCA compared with compression-only CPR (relative increase of 59%), an increase in pre-hospital ROSC (71% relative increase) and an increase in 1 month neurologically intact survival (relative increase of 142%).

However, the outcomes were similar in both groups in certain situations: patients with an initial shockable rhythm, pre-hospital time>20 mins, those receiving public attempts at defibrillation, advanced airway management or those who received adrenaline.

As most causes of paediatric OHCA have a noncardiac aetiology, ventilation during bystander CPR is crucial for achieving favourable outcomes after OHCA. Despite the attempts to control confounders, such as comorbidities, location of arrest, and quality of bystander, CPR could not be adjusted for.

The bottom line

Emergency service response times vary worldwide, and bystander CPR is a significant link in the chain of survival. Prevention of ischemic brain injury and its effect on neurological outcomes is an important determinant of health after an out-of-hospital cardiac arrest (OHCA).

Conventional CPR with rescue breaths is shown to have better outcomes and should be encouraged. Recording all resuscitation efforts pre-hospital and in-hospital is essential in determining results.

Reviewed by: Tara McCormack

Article 5: CAM boot or full leg cast for un-displaced spiral tibial fracture (Toddler’s fracture)

Bradman K, Stannage K, O’Brien S, et al. Randomised controlled trial comparing immobilisation in above-knee plaster of Paris to controlled ankle motion boots in un-displaced paediatric spiral tibial fractures. Emergency Medicine Journal 2021;38:600-606

What’s it about?

This was a prospective RCT performed in Australia that looked at comparing different methods of immobilising an un-displaced toddler’s fracture (also known as a spiral tibial fracture), comparing a full leg cast (above knee plaster of Paris) against a CAM (controlled ankle motion) boot. They included 87 children aged 1-5 with radiologically confirmed (68%) or clinically suspected spiral tibial fracture (25%) over two years and assigned them to have a cast (AK-POP) or a CAM boot. The primary outcomes were the care and comfort of the patient, as scored by a questionnaire that measured the ease of performing daily living activities. Secondary outcomes were fracture healing, weight-bearing and pressure wounds. These were reviewed on Day 2, day 7-10 and day 28.

The results show that the CAM boot provided better care and comfort scores than the AK-POP at all reviews (P=<0.001) and better weight-bearing goals at day 7-10 and on 6-8 week follow-up. There was no difference in pain score, fracture healing or pressure wounds.

Why does it matter?

Historically, all un-displaced tibial fractures (also known as toddler’s fractures) required a full-length leg cast, leading to many difficulties for toddlers, who do not tolerate the cast well and have difficulty with mobilisation. Furthermore, they are also difficult to apply and can cause discomfort to the small child. Further research has even questioned whether casts are required at all as children with a tibial fracture are often reluctant to mobilise on the affected leg.

This trial adds that we are still able to protect the affected leg while providing much better comfort and tolerance than previously achieved with the above-knee plaster of Paris, along with improving mobilisation. A limiting factor in practice is the availability of CAM boots for children aged 1-5.

Clinically Relevant Bottom Line:

CAM boots may provide better comfort and care for toddler fractures than above-knee casts without additional adverse outcomes.

Reviewed by: Laura Riddick

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 were reviewed by Vicki Currie.


  • 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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