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The 77th Bubble Wrap x Chelsea and Westminster Paediatric ED

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With millions of journal articles published yearly, it is impossible to keep up.  Our team have scoured the literature, so you don’t have to… or it might spark an interest to go and have a look at the full article.

We have teamed up with the team from Chelsea and Westminster Paediatric Emergency Department to give you 5 reviews of recent studies.

If you or your team are interested in doing an individual or joint review, please get in touch with Dr Vicki Currie @DrVickiCurrie1 or vickijanecurrie@gmail.com.

Article 1: Paediatric Trauma Imaging Protocols – the CT Chest Conundrum 

Negus, S, Bouamra, O, Roland, D. Have the UK Pediatric Trauma Protocols resulted in a reduction in chest computed tomography imaging for children presenting with major blunt trauma? JACEP Open. 2023; 4:e13041. https://doi.org/10.1002/emp2.13041 

What’s it about? 

In 2014, the Royal College of Radiologists (RCR) Paediatric Trauma Protocols were published, recommending that CT chest imaging be appropriately limited to children in specific high-risk groups. Chest X-ray with CT abdomen and pelvis was recommended as a preferred imaging modality. And for those concerned about missing an injury, you could image just 1cm above the diaphragm, which captures around 91% of all clinically relevant pathology.

This study investigates the impact of these guidelines using CT imaging of the chest in children presenting with traumatic injuries. The primary objective was to determine whether a notable and sustained reduction in the use of paediatric CT chest imaging was achieved.

This retrospective, observational study used data from the UK Trauma Audit & Research Network (TARN) between 2012 and 2021. Records of all children (defined age 0-16) on the TARN database who fulfilled the TARN criteria (had been admitted for longer than 72 hours, admitted to an ICU, or died in hospital) were included. This was then analyzed, taking into account their age category, when they presented and which imaging modalities were performed. 

Immediately following the release of the guidelines in 2014, there was increased adherence to the recommended protocol of CXR with CT AP in all age groups. However, this increase was not sustained and regressed to pre-protocol levels over time. Of concern, requests for WBCT increased from 2.4% in 2012 to 5.3% in 2021 across all age groups. Requests for CTCAP consistently surpassed those for the recommended protocol. 

It is important to note that those who did not meet the TARN criteria (admitted to hospital for > 72 hours, admitted to an ICU, or died in hospital) were not included.

Why does it matter? 

The article addresses the critical issue of radiation exposure in paediatric trauma patients and emphasizes the importance of evidence-based imaging protocols to minimize unnecessary CT scanning. Tissues in the thorax (thyroid and breast tissue) can be particularly sensitive to radiation, with the risk of cancer increasing to as much as 1:500 for those exposed.

It also evaluates the real-life impact of the RCR protocols on clinical practice, with a focus on improving patient safety. Given the well-understood potential harms of ionizing radiation exposure in children (particularly lifetime cancer risk), adherence to diagnostic imaging protocols is crucial. 

Clinically Relevant Bottom Line:

The study notes a trend of rising WBCT and higher-than-expected CTCAP use in paediatric trauma, deviating from the recommended evidence-based guidelines. Paediatric trauma patients are potentially being exposed to unnecessary radiation in the form of CT scans. The study also notes a transient improvement in practice in response to the protocol, highlighting the importance of pairing decision-making tools with regular, ongoing education among relevant clinicians to ensure patient safety.  

Reviewed by: Evan Araia and Katie Brazier 

Article 2: Should we be hypervigilant about children with refractive errors?

Yam JC, Zhang XJ, Zhang Y, Yip BHK, Tang F, Wong ES, Bui CHT, Kam KW, Ng MPH, Ko ST, Yip WWK, Young AL, Tham CC, Chen LJ, Pang CP. Effect of Low-Concentration Atropine Eyedrops vs Placebo on Myopia Incidence in Children: The LAMP2 Randomized Clinical Trial. JAMA. 2023 Feb 14;329(6):472-481. doi: 10.1001/jama.2022.24162. Erratum in: JAMA. 2023 Apr 4;329(13):1123. PMID: 36786791; PMCID: PMC9929700. https://pubmed.ncbi.nlm.nih.gov/36786791/

What’s it about? 

Early onset short-sightedness in children is associated with high myopia later in life and is irreversible once developed.

This randomized, placebo-controlled, double-masked trial at the Chinese University of Hong Kong Eye Centre enrolled 474 nonmyopic children aged 4 – 9. They assigned participants randomly to receive 0.05% atropine, 0.01% atropine and placebo. All children had eye drops applied nightly in both eyes over two years. They then measured the percentage of participants with myopic shift (at least -0.5 D in either eye).

There was a significantly lower incidence of myopia (28.4%) and a lower percentage of participants who developed fast myopic shift at two years using 0.5% atropine, compared with the placebo (53%) and 0.01% atropine (45.9%).

The study, however, has several limitations. The study was only conducted for two years with a sample size large enough for the primary outcome, therefore, the results could be interpreted as delay of disease progression rather than prevention. In addition, though labelled as blinded, there was a potential of unmasking due to atropine-related side effects, e.g. mydriasis. Moreover, the study sample was homogenous in that all participants were Chinese and organized within a single-centred unit, reducing how generalizability.

Why does it matter? 

Children with refractive error are normally treated with corrective lenses. It affects 23% of the world, with incidence estimated to increase to 50% by 2050. Higher proportions of children are at risk of rapidly worsening eyesight that can affect their quality of life and increase the risk of sight-threatening complications. This may be prevented with early intervention.

Clinically Relevant Bottom Line:

The study highlights new research into the prevention of refractive errors, which can significantly reduce future sight-threatening complications.

Reviewed by: Sian Venables and Ashwin Mahtani

Article 3: Are we going to be vaccinating children against RSV?

Sun M, Lai H, Na F, Li S, Qiu X, Tian J, Zhang Z, Ge L. Monoclonal Antibody for the Prevention of Respiratory Syncytial Virus in Infants and Children: A Systematic Review and Network Meta-analysis. JAMA Netw Open. 2023 Feb 1;6(2):e230023. doi: 10.1001/jamanetworkopen.2023.0023. PMID: 36800182; PMCID: PMC9938429.

What’s it about?

This systematic review looked at all randomized control trials from database inception to March 2022 that enrolled infants at high risk of RSV infection and who received antibodies or placebo. It included 15 randomized control trials involving 18,395 participants. All monoclonal antibodies (motavizumab, nirsevimab and palivizumab) were associated with substantial benefits in preventing RSV infection, without an increase in adverse events compared to placebo.

Why does it matter?

Respiratory syncytial virus is the leading cause of acute lower respiratory tract infection in children under five. It causes many hospital admissions and is resource-intensive, particularly over winter. Currently, monoclonal antibodies are given to infants at risk of severe disease, though their ability to prevent admission in all children under the age of one is being studied.

A recent randomised control trial (the HARMONIE trial) was conducted within Europe to include various hospitals in England, assessing the efficacy of nirsevimab as a nationwide vaccination against RSV. The study has not been published, but the initial results appear promising. This may prevent the winter burden of RSV-related infections.


The Clinically Relevant Bottom Line:

There is scope to broaden the use of monoclonal antibodies against RSV in all infants under one to reduce RSV-related hospitalisations.

Reviewed by: Sian Venables and Ashwin Mahtani

Article 4: Does being admitted with a burn impact school performance?

Impact of childhood burns on academic performance: a matched population-based cohort study Halim N, Holland AJA, McMaugh A, et al. Impact of childhood burns on academic performance: a matched population-based cohort study. Archives of Disease in Childhood 2023; 108:808- 814.

What’s it about?

The study compared school performance in children hospitalized with a burn with similar patients who did not require hospitalisation.

It was a retrospective population-based case-comparison cohort study conducted over 13 years in New South Wales, looking at young people under 18. They compared young people with age, sex and postcode-matched peers. The primary outcomes were exam performance in a national examination and completion of high school.

The study found that hospitalized young people with burns had twice the risk (ARR 2.09; 95% CI 1.63 to 2.67) of not completing high school versus their non-hospitalized counterparts.

Female hospitalized burns patients had a 72% higher risk of poor reading skills than their peers.

There was no difference in numeracy performance in the two groups.

The authors identify that using high school completion as a primary outcome has many confounding factors, given how many young people now choose to enter apprenticeships and non-academic pathways.

Why does it matter?

There are approximately 64,000 medical attendances in the UK for paediatric burns annually (1). They can occur in previously fit and well children and have a profound impact on their lives due to the potential psychological complications, disfigurement, and disability.

This study shows unmet learning needs and support issues required in hospitalized burns patients, with little literature or understanding of these and how they can be helped.

The bottom line

There is a significant difference in academic outcomes for hospitalized paediatric burns patients. More research is needed in the hospital and post-discharge support of these patients to improve this.

Ref 1: Davies K, Johnson EL, Hollén L, Jones HM, Lyttle MD, Maguire S, Kemp AM; PERUKI. Incidence of medically attended paediatric burns across the UK. Inj Prev. 2020 Feb;26(1):24-30. doi: 10.1136/injuryprev-2018-042881. Epub 2019 Feb 21. PMID: 30792345; PMCID: PMC7027111.

Reviewed by: Nadia Shad

Article 5: Does giving prophylaxis in vesicoureteral reflux reduce UTIs?

Morello W, et al. PREDICT Study Group. Antibiotic Prophylaxis in Infants with Grade III, IV, or V Vesicoureteral Reflux. N Engl J Med. 2023 Sep 14;389(11):987-997. doi: 10.1056/NEJMoa2300161. Epub 2023 Sep 12. PMID: 37702442.

What’s it about?

This paper assesses the efficacy of continuous antibiotics as a prophylactic measure to prevent urinary tract infections (UTI) in infants who have grade three, four or five vesicoureteral reflux.

Morello et al. performed a randomized open-label trial. with infants from one month to five months of age with grade three, four or five vesicoureteral reflux and who had no previous UTIs.

They split the groups into prophylaxis and untreated groups for 24 months. There were 146 participants in each arm. The trial took place in 39 European centres. 75% of the participants had a median age of three months, and 80.5% had grade four or five vesicoureteral reflux

The primary outcome was the onset of the first UTI during the trial period. The secondary outcomes included the finding of new kidney scarring and the estimated glomerular filtration rate (GFR) at 24 months.

In the prophylaxis group, 31 participants (21.2%) had their first UTI. Pseudomonas species, other non-Escherichia coli organisms, and antibiotic resistance were more common in the UTIs within the prophylaxis group. 52 participants (35.6%) in the untreated group had their first UTI. 64.4% had no UTIs during this trial.

Why does it matter?

The use of prophylaxis antibiotics in infants who have marked vesicoureteral reflux is controversial. Over the last few years, the benefits of using ongoing antibiotics as a preventive measure have been compared against the risks of this management, and it has been argued that there are few benefits compared to the side effects.

Clinically Relevant Bottom Line:

The use of ongoing antibiotics as a prophylaxis measure provided a small but significant benefit in preventing a first UTI despite an increase in non-Escherichia coli organisms and antibiotic resistance. The kidney scarring and the estimated GFR at the end of the trial did not differ substantially between the two groups. Serious adverse events were also similar in the two groups.

Reviewed by: Leila Saadi

If we missed something useful or you think other articles are worth sharing, please add them in the comments!

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.

All articles reviewed and edited by Vicki Currie

Author

  • 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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