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The 6th 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 the world of paediatrics to point out something that has caught their eye.

Article 1: Does it matter what kids are drinking?

Bashir D, Reed-Schrader E, Olympia RP, Brady J, Rivera R, Serra T, Weber C. Clinical symptoms and adverse effects associated with energy drink consumption in adolescents. Pediatric emergency care. 2016 Nov 1;32(11):751-5.

What’s it about? 

This study aimed to determine the prevalence of energy drink consumption by adolescents (12-18 years), identify clinical symptoms and adverse effects that may be associated with their consumption, and understand why adolescents use more caffeinated drinks.

This prospective, observational, self-administered questionnaire was conducted at two medical centres in the USA.

The results were gathered from 612 completed questionnaires; 33% of responders were considered frequent energy drink consumers. These regular consumers were less likely to be involved in academic activities and more likely to consider themselves “risk takers” (smoking, ETOH intake, carrying a weapon). Frequent energy drink consumers were more likely to report symptoms such as headache, anger and increased urination and were more likely to require medical assessment for headache and difficulty breathing in the previous six months than infrequent energy drink consumers.

Why does it matter?

It has been suggested that energy drink consumption by adolescents has evolved into “a national health hazard” in the USA, with consumers of caffeinated drinks being unaware of the caffeine content of many popular caffeinated beverages.

The way that caffeinated drinks are advertised may suggest that consuming these drinks will result in increased energy, weight loss, stamina, athletic performance and concentration – with children in this study stating that caffeinated drinks help with “doing better in school”, “help me do better in sports” and “help me stay up at night”.

The use of energy drinks in the American adolescent population is growing with 30-50% of children/adolescents/young adults consuming at least one energy drink per month. It has been suggested that 75% of children consume caffeine on a daily basis with 6% being energy drinks.  The problem with caffeine is that it is considered a “safe” substance. Therefore, the caffeine content of energy drinks is not regulated, and this may mean that adverse effects may occur in adolescents who consume these items. The metabolism of high concentrations of caffeine has not been studied in children; therefore, the consequences can be unpredictable and unexpected; they may be more prone to caffeine intoxication due to the absence of pharmacologic tolerance.

Medical Centre surveys of this sort may over-emphasise the problem compared to a larger cohort and it must be noted these are just results pertinent to North America.

Clinical Bottom Line:

It may well be worth considering including specific questions about caffeine and energy drink consumption in children with relevant symptoms such as anxiety, insomnia or tachycardia.  

Reviewed by: Alanna Watkins

Article 2: Are we any closer to knowing how to avoid cerebral oedema in DKA?

Long B, Koyfman A. Emergency Medicine Myths: Cerebral Edema in Pediatric Diabetic Ketoacidosis and Intravenous Fluids. The Journal of Emergency Medicine. 2017 Apr 12.

What’s it about?

The child who presents with severe diabetic ketoacidosis (DKA) should concern you, regardless of how experienced you are. It is a disease entity where symptoms and signs can rapidly fluctuate, and outcomes can be poor despite optimal treatment. The archetypal ‘paediatric’ fluid calculation is for resuscitation, replenishment and maintenance of the acidotic patient with diabetes, and it has evolved in only a generation of practice. In this review article, Koyfman and Long look at the literature about cerebral oedema (CE) in paediatric DKA, an area where firm evidence has been difficult to find.

Why does it matter?

This paper appealed to me as I liked the presentation format. The ‘questions’ were posed as myths with clearly stated clinical bottom lines.

Myth: Cerebral Edema in Pediatric DKA is Rare and Always Clinically Apparent”

Bottom Line (my interpretation): Cerebral oedema is more common than thought, but severe clinical consequences are rare.

Myth: The Mechanism of Cerebral Edema is Predominantly Due to Rapid Osmotic Changes with Treatment

Bottom Line (my interpretation): Mechanisms are complex, and hypoperfusion is a potential contributor to cerebral oedema.

Myth: Cerebral Edema is Directly Linked to Greater Rates of Intravenous Fluid Infusion or Larger Fluid Boluses

Bottom Line: Intravenous fluid infusion, either in size of bolus or infusion rate, is likely not associated with the development of cerebral oedema.

It would have been good to see a structured analysis of the quality of the papers reviewed, mainly as only 15 studies relating directly to CE were found, and 11 were case reviews or retrospective evaluations. The selection of journals could have been more transparent. However, the literature search also included “FOAM” – the first time I have seen this directly stated in a paper: “Authors searched Google Scholar, PubMed, Google FOAM, and Medline.”

The authors highlight that the Pediatric Emergency Care Applied Research Network (PECARN) is currently completing a trial evaluating fluid infusion in pediatric DKA. This will provide vital information on this challenging topic.

Clinically relevant bottom line

How to best protect against the adverse consequences of CE in DKA still needs to be wholly understood, and following nationally approved guidance should remain the approach to treatment.

Reviewed by: Damian Roland

Article 3: On rating pain

James F, Edwards R, James N, Dyer R, Goodwin V. The Royal College of Emergency Medicine composite pain scale for children: level of inter-rater agreement. Emerg Med J. 2017 Mar 24:emermed-2015.

What’s it about?

Currently, there is no gold standard for paediatric pain assessment in the emergency department partly because, given the differences in children developmentally, it is accepted that no single assessment tool will be suitable for all age ranges. Parents and practitioners are poor judges of pain in children, even with both self-reporting and observational techniques available.

The Royal College of Emergency Medicine (UK) Composite Pain Scale was first included in the Best Practice Guidelines for the management of pain in children in 2004 – this combines the numerical rating scale (ladder), a modified Wong-Baker FACES Pain Rating Scale (FACES scale) and a behaviour score. These allow pain to be grouped into four categories based on severity. Despite this composite pain scale being widely used and recommended by RCEM, the reliability of the pain scale had never been assessed, either as a whole or as individual tools.

This single-centre prospective study aimed to assess the inter-rater agreement of the RCEM Composite Pain Scale when used in an emergency department. This study was performed in a single centre in Wales with a study population thought to be similar to other emergency departments around the UK.

Participants aged 0-16 years with a limb injury acquired on the same day of presentation to the emergency department with no analgesia taken before being seen in the emergency department were included.

In children under eight years old, there was a substantial inter-rater agreement between nurses and doctors using the FACES Scale (kappa score 0.778) and moderate inter-rater agreement using the behavioural indicators of the composite tool (kappa score 0.573)

In children aged >8-16 years, there was a fair strength of agreement between the child’s self-report using the FACES Scale and the nurses’ and doctors’ behaviour assessments. The use of the pain ladder in this age range demonstrated “slight inter-rater agreement” in comparison with the nurses’ and doctors’ behaviour assessments.

Why does it matter?

Accurate pain assessment in children is often underestimated and therefore undertreated in the emergency department, probably due to the many complicating factors that come with assessing and treating children!

This paper suggests that the Ladder score could be omitted from the RCEM Composite Pain Scale for children as it has poorer inter-rater agreement than the other indicators. There appears to be little benefit from using the ladder, even for older children – the different aspects of the tool had fair to substantial levels of inter-rater agreement.

The experience for a child when they present to the emergency department with an injury is no doubt a frightening and painful experience – especially when we as clinicians insist on palpating the injured part to prove it is painful! The early administration of analgesia may help make this experience less traumatic for the child and parent(s). Finding a reliable and reproducible way of assessing pain at different age ranges means consistency in treatment provided to patients and, hopefully, more happy faces in the department.

Clinical Bottom Line:

The Pain ladder is probably not a valuable mechanism of pain assessment. The question now is whether to continue trying to develop new pain-scoring tools or accept that this will always be an inexact science….

Reviewed by: Alanna Watkins

Article 4: Predicting rebound hyperbilirubinaemia

Chang, PW et al, A clinical prediction rule for rebound hyperbilirubinemia following inpatient phototherapy, Pediatrics, 2017, 139(3), doi: 10.1542/peds.2016-2896

What’s it all about?

When we discontinue phototherapy too early in infants, there is a risk of rebound hyperbilirubinaemia. The authors looked at establishing a way to predict this risk.

This US study (based on the AAP’s phototherapy guidelines) included 7048 infants <14 days old. Thirty-four were readmitted for phototherapy within 72 hours of ceasing it. The authors found that the risk of rebound hyperbilirubinaemia was lower in African American infants and those at an older postnatal age at phototherapy initiation. Infants with a BW<2.5kg, those who received >4 formula feeds, and those who had home phototherapy after inpatient treatment all had lower odds of rebound hyperbilirubinaemia.

Why does it matter?

Rebound hyperbilirubinaemia is where the TSB returns to above the treatment threshold within 72 hours of termination of phototherapy. This can result in prolonged periods under phototherapy and readmission to the hospital, so it is best avoided.

The authors put together a prediction rule using three predictors: gestational age, age at phototherapy initiation, and relative TSB at the termination of phototherapy. These predictors are used to produce a prediction score. The prediction gives a percentage risk of rebound hyperbilirubinaemia.

The bottom line

This prediction rule can help produce a percentage risk which can assist our decision-making on when to discontinue phototherapy. This risk could also be discussed with families. The impact of readmission may be more significant to some families depending on their social circumstances or geographical location from a treatment centre.

Reviewed by: Tessa Davis

Article 5: Does “Quick-Wee” make wee come quicker?

Kaufman J, Fitzpatrick P, Toss S, Hopper S, Donath S, Bryant P, Babl F. Faster clean catch urine collection (Quick-Wee method) from infants: Randomised Control Trial. BMJ 2017;346:j1341 doe:

What’s it all about?

This paper is an RCT comparing the rate of voiding using the “Quick-Wee method” compared to standard clean catch urine within a 5-minute time frame.  The study used 354 children aged between 1-12 months of age in an ED setting. All children had their genitals cleaned with room temperature water for 10 seconds, followed by either waiting or the “Quick-Wee” method of up to 5 minutes of gentle suprapubic stimulation with gauze soaked in cold saline. Using the Quick-Wee method, 31% of children voided within 5 minutes vs 12% without intervention.

Why does it matter?

ED departments face a lot of time pressures. At 3am in the morning the last thing most doctors or parents feel like doing is waiting for an infant to wee spontaneously. Lumbar/bladder simulation (where the infant is held up by the arms and the bladder percussed over 30 seconds) is reasonably practical (studies range between 27-89% efficacy with this technique being much more effective in neonates). However this technique requires more than one member of staff. The “Quick-wee” method is easy to use and has the advantage of being able to be performed by a single doctor/nurse with limited equipment.

The bottom line

The “Quick-wee” method, if used in infants (1-12 months), may reduce the need for other more invasive interventions with an  NNT 4.7. Next time you’re waiting on a wee, it might be worth getting involved!

Read more about urine collecting in this post from Andrew Tagg and see what Tim Horeczko has to say at the PEM Playbook.

Reviewed by: Grace Leo

That’s it for this month.  Many thanks to our reviewers who have taken the time to scour the literature, so you don’t have to.  If you think they have missed something unique, 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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