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The 65th 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 the UK and Ireland) to point out something that has caught their eye.

Article 1: Do vital signs change when kids have a fever?

Heal C, Harvey A, Brown S, Rowland AG, Roland D. The association between temperature, heart rate, and respiratory rate in children aged under 16 years attending urgent and emergency care settings [published online ahead of print, 2022 Sep 6]. Eur J Emerg Med. 2022;10.1097/MEJ.0000000000000951. doi:10.1097/MEJ.0000000000000951

What’s it about? 

This UK multicentre prospective study looked at the association between heart rate, respiratory rate, and temperature in >180,000 patients under 16 years old. It took place over three years, reducing the bias of seasonal variability, and included undifferentiated emergency department patients.

Multiple linear regression reduced potential confounders (age, oxygen saturation). There were other confounders, however, that were more challenging to exclude – pain and anxiety. Big data methodology helps mitigate this but these factors can play a significant role. Respiratory rates were calculated manually – meaning that there is potential inter-rater variability. Heart and respiratory rates were measured at one point in time and vary from minute to minute. This introduces randomness into the data dependant.

Heal et al. demonstrated that for every 1oC increase in body temperature the mean heart rate increased by 12.3 (95%CI 12.2–12.4) beats per minute (bpm). There was some signal of age interaction: a mean of 13.3 and 8.7 bpm in one- and 15-year-olds per degree increase respectively. For the same increase in body temperature, there was a 0.3 (95%CI 0.2-0.4) per cent decrease in respiratory rate.

Why does it matter?

Pulse rate increases in children and young people with fever. Understanding the relationship between changes in temperature, heart rate, and respiratory rate could help clinicians appreciate the relevant co-variance, act as a cognitive prompt to consider serious illness, and help inform disposal decisions.

Clinically Relevant Bottom Line :

Paediatric patients in the ED demonstrate a 12 bpm increase in heart rate for every 1oC increase in body temperature. However, there is no clinically relevant association between temperature and respiratory rate in this study.

Reviewed by: Owen Hibberd and Ed Barnard

Article 2: Paediatric adenotonsillectomy and adenoidectomy – when is the right time?

Schneuer FJ, Bell KJL, Dalton C, Elshaug A, Nassar N. Adenotonsillectomy and adenoidectomy in children: The impact of timing of surgery and post-operative outcomes. Journal of Paediatrics and Child Health. 2022 June 3; 58(9): 1608-1615. doi: 10.1111/jpc.16052

What’s it about? 

This retrospective cohort study looked at data on all children aged younger than 16 years who underwent an adenotonsillectomy (ADT) or adenoidectomy (AD) in New South Wales, Australia, between January 2008 to December 2017. The researchers wanted to look at the timing of surgery and the rate of postoperative complications.

156,500 children underwent surgery – including 112,361 ADT procedures and 44,139 AD procedures. The number of procedures has increased in the past decade. Adenotonsillectomy rates have jumped from 69 to 79 per 10,000 children between 2008 to 2017. Adenoidectomy rates have increased from 25 to 34 per 10,000 children. Patients are also getting younger. The most common indication for ADT (primary diagnosis) was for disease of tonsils and adenoids (68%). Ear conditions accounted for 44% of adenoidectomies.

7262 (6.5%) ADT patients and 1276 (2.9%) of adenoidectomy patients experienced postoperative complications. This was most often haemorrhage either in the initial admission or in the 30-day readmission window. Respiratory complications were also to blame for 30-day readmissions following adenoidectomy. The complication rates were highest among children aged 0-1 years and lowest for those 2–5 years. 4320 (3.8%) ADT patients and 5394 (12.2%) AD patients required a return to theatre, with at least half undergoing a repeat of the original operation. The Three-year reoperation rates were highest amongst children under one year of age. 9.0% of these were after an adenotonsillectomy and 25.9% were after an adenoidectomy.

Why does it matter? 

ADT and AD are the most common operations performed in children. More and more kids are having them at younger and younger ages. As with everything in medicine, no intervention or procedure is without risk. Clinical guidelines recommend that these procedures be performed for obstructive sleep apnoea affecting growth, school performance or behaviour and/or recurrent throat infections.

The data set showed that 6.5% and 2.9% of children experienced postoperative complications following ADT and AD, respectively. The rate of postoperative complications and the need for reoperation were highest in the youngest cohort. There was a lack of information about primary care attendance. Some children may have presented to their primary care provider with complications that were not recorded. Hospital coding systems may have also led to a loss of data.

Clinicians and families should carefully weigh up the potential benefits of removing tonsils and/or adenoids against the risks of postoperative complications, reoperation or long-term adverse effects. These also need to be compared to the very real possibility that symptoms may resolve naturally without the need for an operation. Redirecting focus towards non-operative approaches for low-risk children may be an alternative approach.

Clinically Relevant Bottom Line:

Adenotonsillectomy and adenoidectomy are very common procedures in our paediatric population, but are not without risk of postoperative complications or risk of reoperation. Each individual case should carefully weigh up the benefits and risks of the procedure to ensure a fully informed decision is reached, and one that is best for that patient.

Reviewed by: Emma Chan

Article 3: Should we just use oral antibiotics for joint infections?

Alcobendas Rueda R, Núñez E,  Martín L et al On behalf of the Rioped Group. Oral Versus Intravenous Antibiotics for Pediatric Osteoarticular Infection: When and to Whom?. The Pediatric Infectious Disease Journal. September 2022. doi: 10.1097/INF.0000000000003619

What’s it about?

Osteoarticular infections (OAIs) are typically treated with intravenous (IV) antibiotics initially then patients are switched to oral therapy. There has been growing evidence in support of shorter IV courses for pediatric joint infections. The authors evaluated whether children meeting the criteria for a benign presentation could be treated with oral antibiotics alone.

The study was based on data from the Spanish Network of Osteoarticular Infections, a nationwide registry of 37 hospitals across Spain. They looked at the clinical characteristics, lab and imaging data, treatment and outcomes of children with OAIs (septic arthritis or osteomyelitis). One of the hospitals included offered oral treatment to children meeting certain criteria. The patients were divided into two groups – those receiving initial IV therapy (893 children) and those treated exclusively with oral antibiotics (64 children).

Patients treated exclusively with oral antibiotics were younger (33.9 vs. 20.3 months), and had a lower percentage of Staphy. aureus (23.3.% vs. 3.1%), a higher proportion of Kingella kingae (12.1% vs. 28.1%), higher erythrocyte sedimentation rate/C-reactive protein (CRP) ratio (1.4 vs. 3.3) and a lower rate of fever (63% vs. 48.8%) than those solely treated with IV antibiotics. No complications were found in the oral antibiotics group.

Exclusive oral administration can be a safe option in selected patients with osteomyelitis and septic arthritis.

    They proposed these low-risk criteria:

  • Good general condition
  • No underlying chronic disease
  • Aged 6 months to 3 years old
  • Appropriate oral tolerance
  • C-reactive protein <80mg/L
  • Erythrocyte sedimentation rate/C- reactive protein ratio ≥0.67
  • No skin injury, no recent surgery, no cervical spondylodiscitis and no local complications at the onset.

It is important to recognize the limitations of this study. The oral antibiotic group had a much smaller sample size. This may have had a significant impact on the results. In more than 68% of cases, no microbiology was provided.

Why does it matter?

Specific low-risk criteria could be considered to select potential children with osteoarticular infections who may benefit from exclusive treatment with oral antibiotics. This may reduce the admission of mild cases.

Clinically Relevant Bottom Line:

Giving an exclusively oral treatment to a subset of patients with osteoarticular infections may be considered after discussion with specialists if low-risk criteria are met.

Reviewed by: Giacoma Stera

Article 4: Is there a link between air pollution and neonatal jaundice?

Chen CC, Chen SM, Chang YZ, Sun HL, Ku M. Maternal exposure to air pollution is associated with neonatal jaundice: a retrospective cohort study. The Journal of Paediatrics. 2021 Oct 20. doi: 10.1016/j.peds.2021.09.064

What’s it about?

This study looked to see if there is a correlation between maternal ambient air pollutant exposure and the incidence of neonatal jaundice requiring treatment. They conducted a retrospective cohort study assessing both epidemiological data and clinical data of newborns recruited from Taichung, Taiwan. Nine air pollutants were analyzed, including CO (carbon monoxide), CH4 (methane), NO (nitric oxide), NO2 (nitrogen dioxide), NMHC (nonmethane hydrocarbon), SO2 (sulfur dioxide), O3 (ozone), PM2.5 (≤2.5µm diameter particles) and PM10 (≤10µm diameter particles).

The epidemiological study

The average concentrations of the air pollutants from 1st October 1999 to 31st December 2010 were calculated and then categorised into low, medium and high levels. They also analyzed the records of 13,297 newborns (6,153 males and 7,144 females) born in Taichung, Taiwan between 1st January 2000 to 31st December 2010. The infants were then split into either low, middle or high-level exposure to air pollutants three months prior to birth. Finally, they compared the Incidence of neonatal jaundice requiring phototherapy treatment (adjusted by sex, preterm birth and small for gestational age) between the low and high exposure groups.

176 boys and 209 girls received phototherapy (rate = 2.9%). The boys born to mothers exposed to high levels of CO, NO, NO2 and CH4 had statistically significant higher rates of phototherapy. A similar correlation was found between CO and CH4 and rates of phototherapy in girls. There was A negative correlation between high levels of SO2 and O3 exposure and phototherapy.

The clinical study

376 newborns (189 boys and 187 girls) born between 1st January to 31st December 2018 and requiring neonatal jaundice treatment were recruited from a hospital in Taichung, Taiwan. Exclusion criteria included a history of prematurity, congenital anomalies, congenital heart disease, neonatal intensive care admission, neonatal infection, birth trauma, or neonatal asphyxia. They compared the serum bilirubin, haemoglobin, reticulocyte levels, and level of prenatal exposure to air pollutants three months prior to birth.

There was statistically significant correlation between CO, CH4, NO, NO2, NMHC, PM2.5 and PM10 exposure at 3 months prior to birth and elevated serum bilirubin levels in the boys. There was a correlation between CH4 exposure and serum bilirubin in the girls. There were elevated serum haemoglobin levels in boys exposed to CO, CH4, NO2, NMHC, PM2.5 and PM10 in the girls. No correlation was found between the pollutants and newborn serum reticulocyte counts.

Why does it matter?

Neonatal jaundice / hyperbilirubinemia, requiring phototherapy, can lead to more investigations, interventions, and a prolonged hospital stay. If it is untreated it can lead to rare long-term neurological sequelae. Exposure to air pollutants may be an under-recognised risk factor. Pollutants may induce the release of inflammatory mediators, increase blood viscosity and coagulability, and induce placental inflammation. This may lead to decreased placental blood flow, and fetal hypoxia, triggering the production of erythropoietin. Increased RBC production and haemoglobin levels can lead to greater bilirubin production, and increase the risk of hyperbilirubinemia. This study should improve awareness and drive action to reduce pollutant levels.

Clinically Relevant Bottom Line:

Prenatal maternal exposure to certain pollutants may increase the use of phototherapy rates, Knowing this may guide risk stratification for those at risk. Given this was a single-centre study, further studies are needed to assess its validity.

Reviewed by: Emma Chan

Article 5: Early reattenders to the paediatric emergency department.

Stokle, M. et al. (2022) “Early reattenders to the Paediatric Emergency Department: A prospective cohort study and multivariate analysis,” Journal of Paediatrics and Child Health, 58(9), pp. 1616–1622. Available at: 

What’s it about?

This was a prospective single-centre cohort study identifying why a child or young person might need to come back to the Paediatric Emergency Department (PED). They included every patient within a 12-month period who had an unplanned reattendance within 7 days of their first visit. The presenting complaint had to be the same (or related) to their initial visit.

There were 19420 patients visiting the department. 1234 were re-attendees (6.4%). Those factors associated with higher or lower reattendance were:

  • Age – Younger children had the highest reattendance rates. Children under 5 represented 68.9% of reattenders. Children aged under 1 year represented 28.1% of reattenders.
  • DiagnosisRespiratory illness was the strongest predictor of reattendance (32.2%). The specific diagnoses with the highest rate of reattendance were croup, bronchiolitis, gastroesophageal reflux disease, viral gastroenteritis and bacterial tonsillitis. Traumatic and surgical presentations were much less common.
  • Time of year – Patients who presented in September were more likely to reattend.
  • Clinician role – Patients seen by junior clinicians had a lower risk of reattendance.

The median number of days between first visit and reattendance was 2. 1234 patients reattended within a week with 509 having a change in management. 143 needed admission to hospital. 116 patients had additional investigations or further follow-ups arranged.

This was a single centre study. The duration of consultation and opportunities for discussion were not considered. They may have impacted the reattendance rate.

Why does it matter?

Early reattendance rates are above the national target of 1-5%. Identification of common factors in reattenders may direct improvements in safety netting advice as well as patient information leaflets. This study was the first to look a week beyond the first visit instead of 3 days.

Clinically Relevant Bottom Line:

Young children with respiratory illnesses will always have a high reattendance rate but understanding some of the other reasons that they may come back is crucial to reach the 1-5% reattendance rate national target.

Reviewed by: Philippa Wright

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


  • 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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