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The 67th Bubble Wrap


With millions upon millions of journal articles published yearly, 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: Can pulse oximetry be used to predict outcomes in children with acute wheeze?

Wertheim D, Anton O, Olden C, Le Maistre SLV, Seddon PC. Pulse oximetry respiratory monitoring for assessment of acute childhood wheeze. Arch Dis Child. 2022;107(12):1083-1087. doi:10.1136/archdischild-2021-323390

What’s it about? 

Acute wheeze is a common problem in young children, and there is a lack of objective measures that we currently use to assess acute wheezing episodes. Pulse oximetry is used to measure oxygen saturation (SpO2) and gives a respiratory rate and pulse rate read-out from the waveform.

In a single-centre study of 44 children, aged 1-7 years, with acute wheeze, Wertheim et al. assessed whether pulse oximetry could accurately measure the respiratory rate compared to a gold standard technique (respiratory inductive plethysmography) following initial burst bronchodilator therapy. Respiratory rate and pulsus paradoxus at 1 hour after burst therapy were also compared with clinical outcomes. (Pulsus paradoxus is an exaggeration of the normal drop in BP that occurs during inspiration).

Excellent agreement was shown in the respiratory rate measurement between pulse oximetry and the gold standard (with a mean difference of -0.5 breaths per minute). Whilst 1 hour after burst therapy, children who needed intravenous bronchodilators had a significantly higher respiratory rate, and all children who required admission had a waveform which showed pulsus paradoxus.

The study is limited by the single centre approach involving only a small number of patients. The wide age range is another potential criticism as it includes both viral-induced wheeze in younger children and asthma in older children. Overall, however, this novel prospective study shows promising utility for a relatively simple bedside measure to help assess acute childhood wheeze and suggests that pulse oximetry-derived respiratory rate and pulsus paradoxus waveforms features predict response to treatment and outcome of children with wheezing in the emergency department.

Why does it matter?

Pulse oximetry has a greater utility than just intermittently monitoring saturations. Continuous pulse oximetry-derived respiratory rate and pulsus paradoxus waveforms are simple and feasible measures which may provide a sensitive and real-time measurement of respiratory distress and help predict response to treatment in the busy emergency department. Respiratory rate may become elevated before a fall in SpO2, and pulse oximetry may facilitate early recognition without additional measuring devices.

Clinically Relevant Bottom Line :

RR can be reliably measured, and pulsus paradoxus waveforms can be identified from the pulse oximeter in children with acute wheeze and these both predict clinical outcomes.

Reviewed by: Owen Hibberd

Article 2: Short course vs long course antibiotics for community acquired pneumonia

Li Q, Zhou Q, Florez ID, et al. Short-Course vs Long-Course Antibiotic Therapy for Children With Nonsevere Community-Acquired Pneumonia: A Systematic Review and Meta-analysis. JAMA Pediatr. Published online November 14, 2022. doi:10.1001/jamapediatrics.2022.4123

What’s it about? 

Combining data from studies which compared longer and shorter courses of antibiotics for children presenting with non-severe community-acquired pneumonia (CAP) to determine the non-inferiority of short versus long courses.

The authors conducted a literature search across several databases and reviewed the titles of 7978 papers. They looked for randomised control trials of shorter vs longer courses of oral antibiotics for non-severe CAP in patients under 18 years old. Studies were excluded if groups received different antibiotics or dosing regimens or if participants included only neonates.

The population demographics in each study vary, so the overall treatment effect seen for the combined papers is due to antibiotic duration, random chance and the differences between the studied populations. To mitigate the population differences across studies (their heterogeneity), the authors used a random effects model to analyse the pooled data, which considers study heterogeneity during meta-analysis.

For the primary outcome of treatment failure, a 3-day course was non-inferior to a 5-day course; likewise, a 5-day course was non-inferior to a 10-day course, although this result was only present for children 2-59 months old. Secondary outcomes included relapse rates and adverse effects, and in the 2–59-month-old group, relapse rates were not different between shorter and longer courses. There was, however, a significantly lower risk of gastroenteritis and rash when shorter courses of antibiotics were used.

Limitations included a lack of microbiological data to show how shorter vs longer courses affect CAP caused by differing bacteria and the lack of universal diagnostic criteria for CAP, meaning there was likely to be heterogeneity between studies (although none were found statistically).

Why does it matter? 

There are clear benefits to shorter courses of antibiotics, including increased compliance, which is thought to decrease antibiotic resistance. Still, too short a course can promote resistance or lead to treatment failure.

A previous Cochrane review showed that the 3-day course of antibiotics, advised by the WHO for non-severe CAP, was as effective as a 5-day course, but this was questioned by further research. This paper combines the results of several randomised control trials to answer the above dispute and show the non-inferiority of short antibiotic courses.

The authors also showed possible harm from longer antibiotic courses by showing a lower risk of gastroenteritis and rash with shorter courses.

Clinically Relevant Bottom Line:

When reviewing this data set, shorter courses of antibiotics are non-inferior to longer courses (3 vs 5 days or 5 vs 10 days). Treatment failure of non-severe CAP in children 2-59 months old and shorter duration may come with lower risks of gastroenteritis or rash.

Reviewed by: Cameron Morrice

Article 3: Does CPAP reduce PICU admissions for bronchiolitis?

Aguera M. et al. Safety and effectiveness of bubble continuous positive airway pressure as respiratory support for bronchiolitis in a pediatric ward.European Journal of Pediatrics. December 2022. doi: 10.1007/s00431-022-04616-3.

What’s it about?

Several trials suggest that continuous positive airway pressure (CPAP) may be effective on the pediatric wards as a rescue treatment for patients with bronchiolitis treated with high flow nasal cannula (HFNC) to reduce admissions to the pediatric intensive care unit (PICU). This prospective observational study aimed to evaluate the safety and effectiveness of b-CPAP (bubble-CPAP) deployment in a pediatric ward. A secondary outcome was to compare the admissions to PICU and the need for invasive mechanical ventilation (IMV) of those treated with HFNC (epidemic season 2018-2019) with those treated with HNFC/b-CPAP (2019-2020).

For the primary aim, patients with moderate to severe bronchiolitis (BROSJOD score 7-11)- a validated scorning system. From 2019-2020 patients who needed CPAP support after HNFC failure were included (CS1; 57 children). Epidemiological and clinical data were retrieved before and after 60 minutes of CPAP and subsequently compared between the responders (R-group; 32 children) and the non-responders (those requiring PICU admission, NR-group; 25 children). The main differences were observed after 60’ of CPAP support (lower HR, RR, BROSJOD score and FiO2 in the R-group). HR after 60 minutes resulted in the primary variable associated with NR.

For the secondary aim, another cohort study (CS2) was performed comparing data from a pre bCPAP season (2018-2019; only HFNC) and the season 2019-2020 (HFNC/b-CPAP). Admissions to PICU were significantly reduced in the b-CPAP season without an increase in the rate of IMV or hospital stay. The only significant variables associated with the reduction in the need for PICU admission were age and b-CPAP season.

This study has limitations. First, it is a single-centre study with relatively small numbers, including only patients up to 3 months which may exclude a significant number of patients with bronchiolitis. Secondly, it was conducted in a general ward with a somewhat limited number of patients treated by CPAP and with an optimised nurse-patient ratio.

Why does it matter?

The deployment of CPAP in the general pediatric wards as a rescue treatment for bronchiolitis may help avoid unnecessary admissions to PICU, thus allowing to treat them to treat only the most unwell patients. HR, RR and FiO2 needs could represent early clues for CPAP success/failure allowing for more timely decision-making.

Clinically Relevant Bottom Line:

CPAP could be effectively used in a general pediatric ward as a rescue respiratory support for children with moderate-severe bronchiolitis as it reduces the rate of PICU admissions. HR, RR and FiO2 needs in the first 60 minutes may be valuable predictors of CPAP success/failure.

Reviewed by: Giacomo Stera

Article 4: Should we restrict screen time after concussion?

Cairncross M, Yeates KO, Tang K, et al. Early Postinjury Screen Time and Concussion Recovery. Pediatrics. 2022;150(5):e2022056835. doi:10.1542/peds.2022-056835

What’s it about?

Recommendations to restrict children’s screen time following a concussion are based on limited evidence and expert opinion. In this prospective longitudinal cohort study, Cairncross et al. compared increasing exposure to screen time in the 7-10 days post-injury to concussion scores at regular intervals for six months. Screen time and concussion symptoms were recorded in children aged 8-16 years for 633 with concussions and a control group of 334 children with isolated orthopaedic injuries and no concussions.

In the short term, the relationship between early screen time and concussion symptoms was not linear in the first 30 days following an injury. The relationship was seen as a “U-shaped” distribution, with those with the lowest and highest screen time reporting the most concussion symptoms. However, after 30 days, there were no differences in concussion symptoms between the concussion and orthopaedic groups.

The study had the advantage of being large, prospective, and multicentre. However, outcomes were self-reported using questionnaires, susceptible to recall bias and the Hawthorne effect (individuals modifying their behaviour in response to the awareness that they are being observed). Additionally, although the duration of screen time was measured, the timing, quality, and nature of screen time were not assessed. However, overall, this study had good internal and external validity for addressing this important question.

Why does it matter?

We often get asked if screen time will harm a child’s brain or delay recovery after a concussion. This study shows that low and high early screen time predicted more severe symptoms after concussion in the first 30 days after injury. Although blanket restrictions on screen time are often recommended, the results suggest that this may also adversely affect children’s recovery. Therefore, we should be balanced in our recommendations and advise moderation in screen time.

Clinically Relevant Bottom Line:

Moderate screen time may be the best approach to concussion management.

Reviewed by: James Bottomley and Owen Hibberd

Article 5: Is Covid-19 associated with neurological complications in children?

Antoon JW, Hall M, Howard LM, et al. COVID-19 and Acute Neurologic Complications in Children. Pediatrics. 2022;150(5):e2022058167. doi:10.1542/peds.2022-058167

What’s it about?

Antoon et al. explored the association between COVID-19 and neurologic complications in children aged two months to <18 years who were discharged from 52 children’s hospitals. Neurological complications were defined as encephalopathy, encephalitis, aseptic meningitis, febrile seizure, nonfebrile seizure, brain abscess and bacterial meningitis, Reye’s syndrome, and cerebral infarction. 

Between March 2020 and 2022 15,137 children were hospitalised with COVID-19, of whom 1060 (7%) had an acute neurological complication. These complications were associated with increased risk of re-admission, ICU admission, and mortality. Children with a chronic neurological condition had greater odds of developing acute neurological changes. Lower odds of acute neurological complications were observed in children treated with remdesivir or dexamethasone, and those who developed COVID-19 during the delta variant predominant time-period. This study has the advantage of being large, multi-centre, and taking place over a time-period which allowed the association with the predominant COVID-19 variant to be considered. Disadvantages were related to the retrospective design which risked misclassification bias. Moreover, the definitions of neurological complications and data collection from children’s hospitals may not have captured milder neurological problems (such as headaches) that children might experience at home or a district general hospital.

Why does it matter?

COVID-19 infection is common. Identifying children with a higher risk of acute neurological complications and worse outcomes creates an opportunity to reduce risk in specific populations by emphasising the importance of prevention (immunisation), early recognition, and treatment.

Clinically Relevant Bottom Line:

Neurological complications are not uncommon in children hospitalised with COVID-19, particularly those with pre-existing neurological conditions, and are associated with worse outcomes.

Reviewed by: Owen Hibberd and James Bottomley

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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