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The 56th 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: Aerobic exercise vs stretching for post concussive symptoms- which is better?

Leddy JJ et al. Early targeted heart rate aerobic exercise versus placebo stretching for sport-related concussion in adolescents: a randomised controlled trial. Lancet Child Adolesc Health 2021:(5):792-99

What’s it about? 

This study aimed to determine whether stretching exercises or targeted heart rate aerobic exercise within 10-days after a sport-related concussion would improve clinical recovery. A prospective multi-centre randomised controlled trial of 118 adolescents was performed across community sports medicine and hospital clinics in the United States. Patients were recruited if they were aged 13-18 and presented within 10 days of a concussion. Four weeks of twenty minutes of daily exercise or stretching were prescribed. Trial outcomes included clinical recovery (i.e. normal exercise tolerance, return to baseline symptoms with normal physical exam) and persistence of post-concussive symptoms using the Post-Concussion Symptom Inventory score beyond 28 days after injury.

After four weeks, aerobic exercise had a significant effect on clinical recovery and a 48% reduced risk of persistent post-concussive symptoms (0.52 hazard ratio [95% CI 0.28-0.97], p=0.039). Those at hospital-affiliated sites had a higher rate of delayed recovery than community clinics, but they also tended to be more symptomatic.

Why does it matter? 

The management of sport-related concussions has traditionally recommended strict cognitive and physical rest until symptoms resolve. However, research has shown benefit in early moderate spontaneous activity and mild to moderate aerobic exercise. It can help improve parasympathetic tone and improve cerebral blood flow regulation.

This study had a larger sample size and took place at a variety of trial centres. This allow for greater generalisability compared to previous studies. In this trial, exercise adherence was also more accurately and objectively measured using heart monitors in this trial compared to previous studies which used self-reported adherence.

Clinically Relevant Bottom Line:

Adolescents assigned to early sub-symptom threshold aerobic exercise recovered safely, faster, and with reduced likelihood of persistent post-concussive symptoms compared to adolescents assigned to non-aerobic stretching exercises.  

Reviewed by: Ivy Jiang

Article 2: A look at paediatric trauma in London and the SE

 Elbourne C, Cole E,  Marsh S, et al. At risk child: a contemporary analysis of injured children in London and the South East of England: a prospective, multicentre cohort study. BMJ Paediatrics Open 2021;5:e001114. doi:10.1136/ bmjpo-2021-001114

What’s it about? 

This is a 3-month prospective multicentre cohort evaluation of injured children across the London Major Trauma System. Children were selected if they required trauma team activation or NICE head injury criteria were met. Injury demographics and mechanism of injury were reviewed.

The primary outcome was in-hospital mortality and secondary outcome was safeguarding concerns.

Why does it matter? 

659 children were reviewed in the study. Young children (0-5) were more likely to be injured at home (around 70%). Head trauma caused 1 in 2 (50%) of injuries under 5.

Adolescents were more likely to be injured in the street (42%), and more than 1 in 5 adolescents suffered penetrating trauma. A quarter of adolescents had third sector involvement, and a quarter of young children had safeguarding concerns raised at the time of injury.  Most children had a hospital stay of less than 3 days. This is a change from the traditional view of paediatric trauma.

Clinically Relevant Bottom Line:

This study suggest that paediatric trauma is under-reported by normal TARN (Trauma Audit Research network (UK)) and MTC (Major Trauma Centre) criteria (this may be as in order to to trigger a referral to TARN a higher ISS (Injury severity score) is required than that used in this study). Even ‘minor’ head injuries can have long standing neurological affects. Of note there is a bimodal distribution of safeguarding concerns, in the youngest and oldest of the population cohort in this study.  With the changing demographics of paediatric trauma care, we need to look at different ways of safeguarding future generations; a low threshold for multi-disciplinary team working is a must.

Reviewed by: Sam Danaher

Article 3: Do we do more c- spine imaging  dependant on which rule we use? 

 Phillips N, Rasmussen K, McGuire S, et al. Projected paediatric cervical spine imaging rates with application of NEXUS, Canadian C-Spine and PECARN clinical decision rules in a prospective Australian cohort. Emergency Medicine Journal 2021;38:330-337.

What’s it all about?

This was a prospective observational study carried out in the Emergency Department of a paediatric trauma centre in Australia. The study looked at imaging rates in children presenting with C-spine injury (CSI) and comparing these to predicted imaging rates if NEXUS, Canadian C spine or PECARN clinical decision rules (CDR’s) were applied.

ED clinical staff identified and enrolled patients and were instructed to manage patients as they normally would. Data was collected at initial assessment and post discharge. The primary outcome was the presence of any radiological determined CSI on XR, CT or MRI as reported by a Paediatric Radiologist.

973 patients were included in the study. The most common mechanism was from falling, followed by motor vehicle related accidents. Neck pain, followed by spinal tenderness on examination were the most common complaints. Only 6% had focal neurology.

41% had their C-spine imaged with the most common modality being X-ray, followed by CT.

5 children (0.5%), who were aged between 7-14 years, were found to have radiologically determined CSI. All 3 CDR’s if applied, would have identified the children with these injuries.

When the CDRs were applied, only 50-75% of those considered ‘rule positive’ were imaged in this study, depending on the rule applied.  If the CDRs had been strictly adhered to, projected imaging rates were found to increase to 44-68%.

Why does it matter?

Paediatric CSI only occurs in 1-2% of paediatric trauma presentations but can have devastating consequences.

In adults, well evidenced clinical decision rules can be used to guide the decision of whether to image or not. However, in children, the performance and validity of these CDRs has been shown to be limited, particularly in younger children, meaning that they are often used in an adhoc manner in clinical practice.  They also do not address which imaging modality should be used.

The Bottom Line:

This study demonstrates that if existing clinical decision rules for assessment of C-spine injuries were strictly adhered to, projected imaging rates would increase and would differ considerably depending on the CDR applied.This highlights the need for a validated, paediatric specific, C-spine imaging CDR – not only to determine who we should image, but also which modality we should be using.

You can hear Natalie Phillips talking about the study at DFTB19.

Reviewed by:  Laura Duthie

Article 4: An extra angle in the history for male adolescents with eating disorder symptoms?

The Course of Weight/Shape Concerns and Disordered Eating Symptoms Among Adolescent and Young Adult Males. Glazer K B, Zibrowski H N, Horton N J, Calzo J P and Field A E.Journal of Adolescent Health. Vol 69 (2021) 615-21. DOI:https://doi.org/10.1016/j.jadohealth.2021.03.036

What’s it about?

I found this study in an old-school print version of the October ‘21 JAH. This large general population prospective cohort study of 4489 US males looked at behaviours consistent with bulimia, binge eating disorder and purging disorder and the relationship over time with concerns around thinness, muscularity and muscle-enhancing products. Of the ~1% of young people with high concerns about weight, nearly 95% also had concerns about muscularity.

Why does it matter?

In the COVID-19 pandemic era, eating disorders have exploded. This includes more males with eating disorders, traditionally a smaller proportion of this diagnosis. The pre-pandemic study sought to understand the relationship between concerns about muscularity in the context of other eating disorder cognitions (worry about thinness), and validates the need to ask about concerns regarding muscles.

The bottom line

If you have concerns that a male has disordered eating, rather than asking about “thinness”, a better line of questioning is around muscularity. “How often have you thought about wanting bigger muscles?” This framework may also be useful in prevention of harmful body image or weight control behaviours; certainly it will change the way I ask these questions for this cohort.

Reviewed by: Henry Goldstein

Article 5: Understanding the complexities of childhood trauma

Forkey, H., Szilagyi, M., Kelly, E., Duffee, J. (2021) Trauma – Informed Care, American Academy of Paediatrics, Vol 148 (2), Online e publication: 2021052580

What’s it about?

A difficult aspect of paediatrics is seeing children who have experienced different types of trauma, including (but not limited to) physical or emotional trauma at home, living through natural disasters, acts of terrorism, discrimination, racism, or witnessing traumatic incidents such as domestic violence, caregiver mental illness or substance abuse. The scientific understanding of how trauma affects the developing brain has increased significantly in recent years, however guidelines for Trauma Informed Care (TIC) are still being established.

This article provides a thorough explanation of the types of trauma that can be experienced, and the subsequent physiological and developmental effects which occur. Initially, with any traumatic event, the primal survival response (fight, flight or freeze) occurs as an immediate protective measure, to help reduce the level of danger to the child in the situation. With ongoing trauma, the long- term stress response turns on and children can have long lasting consequences. Which can manifest development delay or regression and the development of maladaptive behaviours, which may be protective in the traumatic environment, but not appropriate elsewhere. There are also three significant physiological changes in the brain, the immune system and our genetic code: 

1)      Overactivity of the amygdala, with underactivity of the hippocampus and being unable to access the prefrontal cortex, predisposing them to depression, anxiety and reactivity disorders

2)      Up regulation of the inflammatory system with more circulating cytokines, leading to symptoms such as abdominal pain, decreased appetite, fatigue, nausea as well as poor cognitive function, irritability and depression

3)      Methylation patterns which can be mediated by cortisol levels, which can lead to chronic mental health issues

 This article also explores the effects of trauma on the child’s primary caregiver as they watch their child change under the effects of trauma and stress. This can lead to a stress response in the caregivers themselves. Which may cause subsequent break down in the child-caregiver relationship leads to yet more stress in the child, and loss of a crucial relationship, which is a key protective factor for the child’s healthy development.

Why does it matter?

With the complex behavioural and physiological changes in the child and caregiver summarised above, it is important to understand that TIC is an integrated, longitudinal and relational health care model. The goal of which is rebuilding relationships and promoting resilience. An open, honest discussion, in a safe space will allow the paediatrician to evaluate the strengths in the child and caregiver, to help guide them onto a path to rebuild a healthy relationship. It is important to monitor a child’s physical symptoms (particularly headaches, abdominal pain, nausea etc), mood, development, growth, eating habits and sleeping patterns. Sometimes, medication can be utilised to help optimise sleep, improve mood or reduce symptoms. Psychological treatments should also be incorporated to help promote positive parenting skills, emotional regulation and build self esteem for both the caregiver and child to help promote positive behaviours, decrease stress responses and build resilience.

Clinically Relevant Bottom Line:

 If this sounds like a lot – it is. This is a complex model of care that needs to be introduced and integrated over time, with a strong foundation of trust. This article discusses in great detail the complexities of trauma and all its effects, as well as an introductory guide on how to approach and support children and their caregivers through their individual traumatic experiences.

Reviewed by: Tina Abi Abdallah

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

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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