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The 62nd 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 the UK and Ireland) to point out something that has caught their eye.

Article 1: Short-course intravenous antibiotics for young infants with urinary tract infection

Lawrence J, Pittet LF, Hilmat S et al. Short-course intravenous antibiotics for young infants with urinary tract infection. Arch Dis Child. 2022 2022 Apr 25;archdischild-2021-323554. doi: 10.1136/archdischild-2021-323554

What’s it about? 

This was a single-centre retrospective audit of 451 infants younger than 90 days old with a positive urine culture at the Royal Children’s Hospital Melbourne.  Patients were split into two groups – non-bacteraemic (427) and bacteraemic infants (24). Lawrence et al. looked at how safe it was to step down from IV to oral antibiotics at < 48 hours for those with non-bactaeremic UTI and <7 days for those with bacteraemic UTI.

Treatment failure was defined as a subsequent positive urine culture with the same bacteria ≥ 48 hours but less than 30 days after commencing antibiotics. Serious complications of UTI were meningitis, new bacteraemia or UTI-related death. The study did not actually define bacteraemia.

Infants with non-bacteraemic UTIs, treated with a shorter course of IV antibiotics had a low treatment failure rate (1.4%) and no serious complications. There were no treatment failures (or complications) in Infants with a bacteraemic UTI, receiving IV antibiotics for <7 days. 4 of the 6 infants that failed treatment in the non-bactaeremic group were premature.

Why does it matter?

Urinary tract infections (UTI) are a common cause of infection in infants under 3 months. Young infants with a UTI are at risk of serious complications including sepsis and meningitis. Guidelines for treatment recommend intravenous antibiotics initially but there is no consensus on when it is safe to switch to oral antibiotics. Shorter courses of intravenous antibiotics have many advantages including shorter hospital stay, reduced healthcare costs and improved quality of life for the child and their parents.

Clinically Relevant Bottom Line:

This study supports other emerging evidence that shorter courses of IV antibiotics for infants ≤ 90 days are effective. Infants with bacteraemic UTI or bacterial meningitis appear to need longer intravenous antibiotic therapy.

Reviewed by: Cristina Hearnshaw

Article 2: Does point-of-care testing reduce antibiotic use in paediatric ED

Mattila S, Paalanne N, Honkila M, Pokka T, Tapiainen T. Effect of Point-of-Care Testing for Respiratory Pathogens on Antibiotic Use in Children: A Randomized Clinical Trial. JAMA Netw Open. 2022;5(6):e2216162. doi:10.1001/jamanetworkopen.2022.16162

What’s it about? 

Acute respiratory tract infections are a leading cause of paediatric ED (PED) visits and antibiotic overuse. Better diagnostic tools may guide judicious antibiotic use in the PED. Polymerase chain reaction (PCR) assays that can simultaneously detect multiple respiratory pathogens within a one-hour turnaround time have been developed and tested in the ED. There are limited data available on their clinical impact and cost-effectiveness.

This was an unblinded RCT conducted in a PED for a 10-month period. The aim was to correlate the result of point-of-care multiplex PCR testing on antibiotic use in paediatric patients presenting with respiratory tract infections.

1243 paediatric patients were enrolled (829 in the intervention and 414 in the control group). The test did not reduce the overall antibiotic use (226 children [27.3%] in the intervention group vs 118 children [28.5%] in the control group; risk ratio, 0.96; 95%CI, 0.79-1.16). There was no difference between groups regarding the number of diagnostic tests or total cost.

It is important to note that this study took place in a high-income European country with an educated population that had low antibiotic use. Most children also had a CRP performed. This might have guided clinical care.

Why does it matter? 

The development of better diagnostic tools for patients with acute respiratory tract infections may reduce the unnecessary use of antibiotics and halt the development of antimicrobial resistance.

Clinically Relevant Bottom Line:

The use of point-of-care multiplex PCR in the PED did not reduce the overall antibiotic use in paediatric patients presenting with acute respiratory tract infection.

Reviewed by: Spyridon Karageorgos

Article 3: Ball magnet ingestion in children

Price J, Malakounides G, Stibbards S, Agrawal S. Ball magnet ingestion in children: a stronger and more dangerous attraction? Emerg Med J. 2022 Jun;39(6):467-470. doi: 10.1136/emermed-2021-211767. Epub 2021 Sep 20. PMID: 34544782.

What’s it about?

Super-strong earth magnets AKA ‘ball magnets’ are made from alloys of neodymium and are 5-10 times stronger than traditional ferrite magnets.  Strong magnetic forces can pull through multiple layers of bowel resulting in ischaemia, pressure necrosis and life-threatening injuries.

The objective of this paper was to report the incidence and management of ‘ball magnet’ ingestion in the UK and to discuss potential implications for policymakers.

Researchers sent out an electronic survey to all UK major trauma centres (MTCs) asking for details of children who had a history of magnet ingestion between January and December 2020.

They received responses from 11 MTCs (52%) reporting a total of 53 children. The median age was 7 years, although all age groups were equally represented. Fifty-one (96%) were unintentional ingestions. Thirty-six (68%) of patients presented asymptomatically. Those with symptoms commonly included abdominal pain and vomiting, although one patient presented in shock.

Twenty-seven (50.9%) patients underwent operative management, 12 of which were asymptomatic on presentation.  The most common operation was a standard laparotomy (88.9%). No patients presenting with single magnet ingestion required operative management.

There was a small sample size of retrospective data with only half of the MTCs invited responding. It is therefore likely to underrepresent the true incidence of ingestion in the UK.

There was a concerning level of severe morbidity following ‘ball magnet’ ingestion in children.

Why does it matter?

This survey contributes to growing concern around the morbidity associated with ‘ball magnet’ ingestion in this country. RCEM issued a recent safety alert.

Sales have been banned in Canada, Australia, New Zealand and the United States.  In the UK they are easily accessible.

Clinically Relevant Bottom Line:

‘Ball magnet’ ingestion can occur in any child from toddlers to teenagers.

Clinicians need a high index of suspicion and be aware of the sequelae of ingestion, involving the paediatric surgical team without delay.

Reviewed by: Anna Russell

Article 4: Opioids: Do we need them?

DePhillips, M, Watts, J, Sampe, J, Dowd, MD. Use of Outpatient Opioids Prescribed from a Pediatric Acute Care Setting. Pediatric Emergency Care 2022;38(6): e1298-e1303.

What’s it about?

This study looked at the prescription of opioid medicines (oxycodone and hydrocodone) for children discharged with acute pain from two busy Midwestern US hospital emergency departments (total number of admissions / year > 140,000) and compared them to the number of doses taken. Children with chronic pain, those who had received an opioid prior to their visit, those presenting with post-op pain or those whose parents could not read or write in English were excluded from the study. The commonest reason for prescription was an acute fracture, abscess, or burn. The dose range was not provided. Recall bias (as the study relied on parents/ carers answering the questions 5 days after the admission to ED) was mitigated by the provision of medication logs that were provided to document opioid use at home.

The majority of children were prescribed more doses of opioid medicines than were required and 30% did not use any opioids following discharge. Whilst 3% of patients took all prescribed doses, only 4% of the cohort would have required further doses if their supply had been limited to a 3-day supply. The median number of prescribed doses was 12, the equivalent of the researcher’s definition of a 3-day supply. Patients who took over-the-counter medicines used a median of 1 less dose of medication (2 vs 3). Lower limb fractures were associated with the highest number of doses required (median of 8). Older children aged 15 to 17 years, used a slightly higher (4) average number of doses.

The majority of families (57%) said that the unused opioids were kept at home. Only 14% reported disposing of their opioid medication.

Why does it matter?

This study provided further evidence that short duration (3 days) of opioid medication may be sufficient for most children being discharged from emergency departments with an acutely painful condition. This would reduce the risk of accidental pediatric ingestion or diversion of the remaining opioids. Researchers also advocated for better education around disposing of opioid medicines for families.

Opioid overuse and deaths are at an all-time high in the US. Reducing the prescription of opioids reduces the volume circulating in the community.

Clinically Relevant Bottom Line:

Opioid prescriptions from emergency departments may be more than what is required for pediatric patients. When children and young people present with acutely painful conditions, they often only require opioid pain management for a couple of days. Reducting prescriptions may have the secondary benefit of reducing the supply available for accidental ingestion or opioid misuse.

Reviewed by: Georgie Jacko

Article 5: What factors affect parental satisfaction during emergency paediatric intensive care retrieval?

Evans, Ruth; Barber, Victoria; Seaton, Sarah; Ramnarayan, Padmanabhan; Davies, Patrick; Wray, Jo (2022): Is parental presence in the ambulance associated with parental satisfaction during emergency paediatric intensive care retrieval?: a cross-sectional questionnaire study. University of Leicester. Journal contribution. https://hdl.handle.net/2381/19706500.v1

What’s it about?

Around 5000 children are transported annually by Paediatric Critical Care Transports (PCCTs) in the UK. Recent data shows that ~75% of these patients are accompanied by a parent, but until now there was not any investigation into parents’ thoughts on travelling with their children.

The authors performed a national cross-sectional questionnaire study of parents of children who were transported between January 2018 and January 2019. As there is no standardized measure available, they created an 8-page tool that included free text, tick boxes, and rating scales.

All emergency admissions to 24 NHS PICUs in England and Wales were evaluated. Families were approached in person by PICU clinical staff within 48 hours of admission. Of the 4558 eligible transfers, 2838 families consented to take part, and 2084 complete questionnaires were received. 87% of the transfers were performed by PCCTs, with the rest being transported by other specialist and non-specialist services.

Why does it matter?

Parents who travel with their children generally have higher satisfaction with transport services. Conversely, if they were not permitted to travel with their child, they had lower satisfaction scores. There were many reasons parents choose not to travel with a patient, but stress and logistical concerns were highest on the list. Often, if only one seat was offered to a parent, they would instead stay behind with the other parent and travel separately from their child so they could support one another.

Clinically Relevant Bottom Line:

Parents of paediatric patients being transported to a PICU should be offered the choice to travel with their child, and if possible, both parents should be included. If they cannot do so, understanding the reason(s) can support families at a time of acute stress, and provide insights into future service developments in order to improve transport experiences for families.

Reviewed by: Justin Hensley

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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