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The 5th Bubble Wrap – Redux


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 the world of paediatrics to point out something that has caught their eye.

And now it’s time to return to our scheduled program…

Article 1 – Pediatric Resident Burnout and Attitudes Toward Patients

Baer ET, Feraco AM, Sagalowsky ST, Williams D, Litman HJ, Vinci RJ. Pediatric Resident Burnout and Attitudes Toward Patients. Pediatrics Mar 2017, 139 (3) e20162163; DOI: 10.1542/peds.2016-2163

What’s it about?

In the last few years, it has become more acceptable to talk about burnout, not just as a rare consequence of undertaking a medical career but as something all healthcare professionals may suffer from. Burnout rates are known to be high, but there is little specific information relating to paediatrics and child health. This questionnaire study, nested in a larger study on work-life balance, used the Maslach Burnout Inventory to assess doctors in the first 3 years of paediatric training.

Why does it matter?

It’s important the context of this study is appreciated. A narrow group of participants (largely female (78.9%) white junior doctors in the early years of training) in a relatively fixed geographical region (New England, United States) with a questionable response rate (53%). Of this cohort, 39% reported burnout if they answered affirmatively (at least weekly in frequency) to either the question “I feel burned out from my work” or depersonalization by the prompt, “I’ve become more callous toward people since I took this job.”

However, the study also examined patient care attitudes and behaviours. Those who identified as being burned had higher (self-reported) odds of:

  • Reporting suboptimal patient care attitudes and behaviours, including discharging patients to make the service more manageable,
  • Not fully discussing treatment options or answering questions
  • Making treatment or medication errors
  • Ignoring the social or personal impact of an illness
  • Feeling guilty about how a patient was treated

The odds ratios ranged from 3.5 to 9.6 (confidence intervals were relatively wide in some cases) and held true in adjusted and unadjusted analyses. What I have taken from this is that while the extent of burnout may not be valid for my organisation, the incidence of behaviours in staff that would make me very uncomfortable is probably higher than I think. Although burnout may not be a direct cause (correlation, not causation, has been shown here), this is food for thought for all clinical directors.

The Bottom Line

Don’t panic about burnout in your paediatric service, but it is worth considering a staff survey to understand attitudes and behaviours better.

Reviewed by: Damian Roland

Article 2 – Fish oil supplementation in pregnancy for reducing the risk of persistent wheezing

Bisgaard H, Stokholm J, Chawes BL, Vissing NH, Bjanadottir E et al. Fish Oil-Derived Fatty Acids in Pregnancy and Wheeze and Asthma in Offspring. N Engl J Med 2016; 375:2530-2539 DOI: 10.1056/NEJMoa1503734

What’s it about? 

Considering the large burden of disease that asthma represents, there is still so much to learn about its causes and prevention. The Copenhagen Prospective Studies on Asthma in Childhood (COPSAC) is a dedicated clinical research unit for paediatric asthma which uses longitudinal trials based on their 2010 birth cohort to investigate the gene-diet-microbe interactions in asthma and atopic conditions of childhood.

In this study, COPSAC looked into whether taking fish oil supplements in the third trimester of pregnancy could reduce the rate of persistent wheezing and/or asthma in offspring. A double-blinded placebo-controlled trial was performed with the COPSAC 2010 cohort over a 5-year period. The intervention was a high dose (2.4 grams) of fish oil (EPA and DHA)†  per day versus an olive oil placebo. There were 695 children included for analysis, with 346 children involved in the fish oil arm. The primary diagnostic endpoint of persistent wheezing or asthma was based on a combination of information, including diary recordings of symptoms, use of beta2 agonists or requirements for inhaled glucocorticoids.

Why does it matter?

The study found a one-third (7%) reduction in the incidence of persistent wheezing or asthma in the fish oil group (17.4%) compared to the control group (24.6%). The number needed to treat (NNT) was 14.6. The benefits of fish oil supplementation appeared to be stronger for mothers with low pre-intervention blood levels (<4.3% EPA+DHA of total fatty acid). The NNT was only 5.4, with an incidence of persistent wheezing/asthma being 17.4% compared to 34.3% for the control group.

It is interesting to note the dose for fish oil supplementation was quite high – an estimated 10x the usual daily intake of Danish women (and 20x the usual daily intake of the United States!). It is possible that a lower dose could still have beneficial effects.

The Bottom Line

This large prospective double-blinded placebo-controlled Danish trial appears to support fish oil supplements in the third trimester of pregnancy as a way to reduce the risk of persistent wheezing or asthma in offspring with an NNT of 14.6.

† Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are two long-chain polyunsaturated fatty acids found in cold water fish.

Recommended by: Jamie Cheah

Article 3: Factors Contributing Towards Early Puberty in 11-year-old girls

Kelly Y, Zilanawala A, Sacker A, et al. Early puberty in 11-year-old girls: Millennium Cohort Study findings Archives of Disease in Childhood 2017;102:232-237.

What’s it about?

Children these days seem to be growing up faster than ever, and in one way, this has been seen in the steady decline in the age of puberty for both girls and boys. Early puberty has been linked to numerous outcomes, including an increased risk of early sexual activity, teen pregnancy and poorer mental health in adolescence.

The data from the study comes from 5839 girls in the UK millennium cohort.  In the UK, the median age of puberty is 12.9 years of age. This paper looked at ethnicity, socioeconomic status, adiposity and early psychosocial stress as factors for early puberty in girls, with the main outcome measured as reported menstruation by girls’ mothers at 11 years of age.

Why does it matter?

Of the cohort examined, 9.5% had begun menstruation. There was a strong ethnic component with early menstruation seen in Indian, Pakistani, Bangladeshi and black African groups, with Indian girls being 3 times as likely as Caucasians to have begun menstruation. A social gradient was also found, with the poorest income quintile at age 5 being twice as likely as the richest quintile to have begun menstruation (14.1% vs 6.8%). Furthermore, girls with higher Body Mass Index or Fat mass index at age 7 were significantly more likely to have had menarche. Psychosocial stress was measured by a combination of Kessler-6 scoring on mothers if girls were in a single-parent household and the girl’s socio-emotional difficulties score from mother a reported Strengths and Difficulties Questionnaire at age 7 as well as local area racist attacks and insults at age 5.  It is unfortunate that data on adiposity collected at 11 years of age did not appear to be collected. The findings of the study add to the body of work on pubertal development; however, the authors of the study did not provide much by way of discussion of potential interventions into the factors investigated.

The Bottom Line

It is important to screen for early puberty in young girls. This study supports ethnicity, poorer income, early psychosocial stress, and increased adiposity as factors that may increase the likelihood of early menstruation (at age 11) for girls.

Reviewed by: Grace Leo

Article 4 – Proton Pump Inhibitors for Infantile Reflux?

Gieruszczak-Białek, D. et al. No Effect of Proton Pump Inhibitors on Crying and Irritability in Infants: Systematic Review of Randomized Controlled Trials. Journal of Paediatrics. 2015;166:767-70

What’s it about?

Gieruszczak-Białek and colleagues undertook a systematic review of randomised controlled trials investigating the use of PPIs for infantile GERD (or GORD as we call it in Australia). Their search included 5 trials and 430 infants aged <12 months. The primary outcome measures were excessive crying and irritability and were recorded via a range of measures, including diaries, video monitors and validated questionnaires. This review focuses specifically on infants; studies with a broader age range were excluded. They appear relatively heterogeneous in nature, but none showed any benefit for the stated primary outcomes.

Why does it matter?

Infantile reflux is a big business. It’s controversial, and the treatment options are marketed to primary providers of vulnerable new parents who feel as if they’re in a hopeless situation. My impression is that on the basis of “low risk”, PPIs are frequently prescribed out of desperation in these infants. I think the most interesting thing about this paper is that despite the hefty influence of pharmaceutical companies in the funding, planning and publication of these trials, there was no difference between PPI and placebo. Indeed, the only difference of any significance was that patients receiving PPI in one of the trials were more likely to have adverse effects. Although not the most well-powered systematic review, this is another reminder that for interventions with zero benefit, the risk-benefit ratio becomes infinite.

The bottom line

There is no evidence that PPIs have any positive impact on infants.

Reviewed by: Henry Goldstein

Recommended by: Dr Richard Brown, General Paediatrics, Lady Cilento Children’s Hospital, Brisbane, Australia.

Article 5 – Time for the paediatric fashion police?

Habeshian K, Kirkorian AY, Marathe K. The Fanny Pack: No Ifs, Ands, or Buts. Pediatric Dermatology. 2017 Mar 1.

What’s it about?

Most of the world has done away with doctors wearing white coats. They have the potential to scare kids and harbour deadly diseases within their starched recesses. These US authors suggest that a fanny pack (what those of us from the UK would call a bum bag) is the ideal fashion accessory for the modern paediatrician. They start with a little fashion history, reminding us that the glory days of the fanny pack/bum bag have long since passed, making it a cheap carry. They reel off a list of positive reasons for wearing one, including ergonomics, efficiency, hygiene and kid-friendliness. Paediatricians are known for carrying lots of extraneous things around with them, such as squeaky toys, finger puppets and the perfect IV fixative, so perhaps, rather than stretching the lining of your skinny jeans, you should invest in one?

Why does it matter?

I could never be called fashionable. I wear pyjamas to work. But I find that I have plenty of room in my pockets for pens, a Sharpie, my mobile and a scalpel (you never know).  Whilst fanny packs/bum bags may be kid-friendly, just imagine what the teenagers are thinking.  All credibility would fly out the window.

The bottom line

No, just no.

Reviewed by: Andy Tagg

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.  If you think they have missed something amazing then let us know.


  • Grace is a Registrar at Sydney Children's Hospital. She loves innovative medical education and paediatrics. She is on the organising committee for the DFTB18 and SMACC conference. Grace is a former internal director of the AMSJ. She enjoys board games, cooking and graphic design.


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