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The 79th Bubble Wrap x Bristol Royal Hospital For Children


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 the Emergency Department at Bristol Royal Hospital, who have used this as a springboard for their journal club. (It’s a great idea and maybe something for other centres to copy!)

The Bristol Royal Hospital for Children (BRHC) is a tertiary paediatric hospital that provides a local service for Bristol children and a referral service for specialist care for families across the South-West. The children’s Emergency department sees approximately 50,000 presentations per year. The hospital is the Paediatric Major Trauma Centre for the South-West.

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

Article 1: Infections in Foreign Travellers

Bird C, Hayward GN, Turner PJ, Wasala D, Merrick V, Lyttle MD, Mullen N, Fanshawe TR; for Paediatric Emergency Research in the UK and Ireland (PERUKI). Infections diagnosed in children and young people screened for malaria in UK emergency departments: a retrospective multi-centre study. Paediatr Int Child Health. 2024 Jan 11:1-7. doi: 10.1080/20469047.2023.2299576. Epub ahead of print. PMID: 38212934.

What’s it about? 

This study retrospectively identified 1,414 children, presenting to 15 UK EDs (2016 -2017), who had been screened for malaria. Most were febrile (84%) and had recently travelled to a malaria-endemic area (according to the excellent website The aim was to estimate the number and origin of malaria and other febrile illnesses.  

This was a secondary outcome embedded in the Travel Fever study – a multi-centre, retrospective diagnostic accuracy study for imported malaria. This compared the reference test (standard microscopy) with the index test (standard rapid diagnostic test (RDT)).

Children were included if they had a malaria screen in ED. This is a reasonable method to retrospectively identify those presenting with symptoms concerning for a tropical infection. Still, it is not as good as a prospective study with pre-defined inclusion criteria. It provides an estimate of illness prevalence in this cohort rather than a definitive assessment.

The prevalence of selected diagnoses was:

– Infections found in both tropical and non-tropical settings 50%
– No diagnosis recorded 29%
Gastroenteritis 13%
– Malaria 4.2% (77% were P. falciparum)
– Typhoid 1.5%

Malaria was 7.4 times more likely in those arriving from sub-Saharan Africa compared with those returning from South Asia. A higher proportion of those returning from South East Asia had typhoid than those returning from sub-Saharan Africa.

Why does it matter? 

An up-to-date understanding of the potential diagnoses in those presenting with fever following travel to a malaria-endemic area should guide clinical practice. Accepting the limitations of the study’s retrospective design, it identifies the prevalence of different diagnoses within this cohort.

Clinically Relevant Bottom Line:

This study offers the most up-to-date assessment of the prevalence of infections in children with a fever and recent travel to a tropical region, presenting to UK EDs. It highlights the need to be vigilant for tropical infections, including malaria (especially in travellers from sub-Saharan Africa) and typhoid.

Reviewed by: John Coveney

Article 2: How do we define sepsis in children?

Schlapbach LJ, Watson RS, Sorce LR, et al. International Consensus Criteria for Pediatric Sepsis and Septic Shock. JAMA. Published online January 21, 2024. doi:10.1001/jama.2024.0179

What’s it about? 

If you work in acute paediatrics, you don’t need me to tell you about the significance of the term ‘sepsis’. What you may not know is that defining sepsis is a relatively new and ongoing process. The aim of this paper was to update and evaluate the criteria for sepsis and septic shock in children.

This is an international consensus dataset collected from ten sites across four continents and three million paediatric hospital presentations. It was then reviewed by an international group of experts. The task force (Society of Critical Care Medicine) was made up of paediatric experts in critical care, emergency medicine, infectious diseases, general paediatrics, nursing, and public health from six continents.

Data used came from three areas:

– An international survey on how the diagnosis of sepsis was made
– A systematic review and meta-analysis looking at mortality outcomes in cases defined as sepsis
– A study creating a sepsis scoring system based on infection-related organ dysfunction – the Phoenix score.

In this dataset, children with suspected infection had in-hospital mortality of 0.7% (in higher-resource settings) and 3.6% in lower-resource settings in the first 24 hours of presentation.

Most clinicians used the word ‘sepsis’ to refer to children with infection and evidence of life-threatening organ dysfunction. It concluded that ‘sepsis’ should be defined by using the Phoenix Sepsis Score of at least 2 points (see the full article for this Scoring system).

Children with a Phoenix Sepsis Score of at least 2 in the first 24 hours of presentation had an in-hospital mortality of 7.1% in higher-resource settings and 28.5% in lower-resource settings.

Check out DFTB’s module on SIRS, Sepsis and Shock Module – Don’t Forget the Bubbles (

Why does it matter? 

Clinically, a new definition may not change what we do, but it may help us identify admitted patients at higher risk. Without a clear definition, tailoring research and audit is difficult. This is a step forward to creating a better understanding.

Clinically Relevant Bottom Line:

This new definition progresses our understanding of sepsis. It doesn’t help to diagnose or exclude sepsis. There has been data creep influencing screening guidelines.

Reviewed by: James Hambidge

Article 3: Nitrous Oxide for Paediatric Procedural Sedation 

Croughan S, Barrett M, O’Sullivan R, Beegan A, Blackburn C. Safety and efficacy of a nitrous oxide procedural sedation programme in a paediatric emergency department: a decade of outcomes. Emerg Med J. 2024 Jan 22;41(2):76-82. doi: 10.1136/emermed-2022-212931. PMID: 38123983.

What’s it about?

This single-centre observational study retrospectively reviewed sedation data over 10 years of paediatric procedural sedation. The researchers focussed on nitrous oxide (up to 70% concentration) delivered using a continuous flow system. The paediatric emergency department developed its own training programme with sedation delivered primarily by nursing staff. 

The study included all 1 – 16-year-olds receiving nitrous oxide for procedural sedation – a total of 831 cases. 

Primary outcomes were sedation success and adverse event rates. 

  • Sedation was successful in 97.4
  • 87% of cases were nurse-led.
  • There was no difference in success or adverse events between physician or nurse-delivered sedation.
  • There were zero serious adverse events (desaturation, apnoea, aspiration, or hypotension)
  • 137 minor adverse events were recorded (16.5%). Vomiting was the most common (13.6% of cases) 
  • The combination of nitrous and intranasal fentanyl increased sedation but also increased vomiting risk. 
  • 87% of cases that received sedation were discharged on the same day.

Why does it matter?

This study demonstrates that, with appropriate training, nurse-led sedation with nitrous oxide can be safely implemented in a paediatric emergency department. Empowering and training more members of the MDT improves our ability to distribute the workload. In addition, the data helps with understanding the risks we explain when consenting. This study was limited by its single-centre and observational design. 

Clinically Relevant Bottom Line:

Nitrous oxide can provide effective and safe sedation using continuous flow N20 in a paediatric emergency department and can be delivered by nursing staff with appropriate training.

Reviewed by: Kieran McDonnell

Article 4: Diagnosing Paediatric Distal Forearm Fractures with Ultrasound

Snelling PJ, Jones P, Bade D, Bindra R, Davison M, Gillespie A, et al. Diagnostic accuracy of point-of-care ultrasound versus radiographic imaging for pediatric distal forearm fractures: A randomized controlled trial. Annals of Emergency Medicine. 2023 Nov; doi:10.1016/j.annemergmed.2023.10.008

What’s it about?

This was an RCT comparing the accuracy of point-of-care ultrasound to x-ray in diagnosing non-deformed distal forearm fractures. They recruited 270 children between 5 and 15 years old across four centres in SE Queensland, Australia.

They were randomised on a 1:1 ratio to either undergo point-of-care ultrasound or x-ray, and the treating clinician needed to make a diagnosis of one of: “no fracture”, “buckle fracture”, or “other fracture” (i.e. a break in the cortex), based on the initial images. Clinicians underwent a training program in POCUS for distal forearm fractures.

An expert panel (paediatric radiologist, PEM doctor and paediatric orthopaedic surgeon) then reviewed the images and made their own diagnosis without knowing the initial diagnosis. The initial diagnosis was deemed accurate if the treating clinician and the panel agreed on the diagnosis. The expert panel achieved a consensus in 83.7% of cases.

Of the 270 participants, 31.1% had ‘no fracture’, 39.3% had a ‘buckle fracture’, and 29.6% had ‘another fracture’. Of the 135 participants in the POCUS group, 97.8% received an accurate diagnosis compared with 83% in the X-ray group.

For a more in-depth review of the study, take a look at The BUCKLED trial – Don’t Forget the Bubbles (

Why does it matter?

It is easy to miss or misidentify fractures on an X-ray. This study suggests that ultrasound reduces these incidents. Whether this is cost-effective is debatable. Bearing in mind that all missed “other fractures” on the x-ray were subtle and adequately managed with a wrist splint, is it worth investing in training clinicians to use ultrasound for this purpose?

On the other hand, there were more buckle fractures mistaken for “other fractures” on X-ray than on ultrasound. This led to more children in the X-ray arm being placed in a plaster cast unnecessarily. Another point in favour of investing in point-of-care ultrasound is that it’s a viable alternative when radiology is not available, e.g. out of hours.

Clinically Relevant Bottom Line

With appropriate training, point-of-care ultrasound is a safe and feasible alternative to X-ray for diagnosing distal forearm fractures.

Reviewed by: Anne Wang

Article 5: Nasal Suctioning in Bronchiolitis

Schuh S, Coates AL, Sweeney J, et al for Paediatric Emergency Research Canada (PERC) Network. Nasal Suctionin Therapy Among Infants with Bronchiolitis Discharged Home from the Emergency Department: A Randomized Clinical Trial. JAMA Netw Open. 2023 Oct 2;6(10). Doi: 10.1001/jamanetworkopen.2023.37810. PMID: 37856126;

What’s it about?

This randomised controlled trial looked at 367 infants presenting to four Canadian paediatric emergency departments with bronchiolitis who were discharged home with suctioning advice.

Participants were randomised to enhanced suctioning with a battery-operated device or minimal suction with a bulb device for 72 hours before all feeds. Researchers looked at the number of healthcare visits within 72 hours of discharge or the additional use of an unassigned device. Secondary outcomes included feeding, sleep, parental sleep, healthcare attendance, satisfaction with care, satisfaction with the device, and adverse events.

There was less additional device use (6% vs 18%) and much higher parental satisfaction (79% vs 34%) with enhanced suction. There was no significant reduction in reattendance or any of the other secondary measures. Adverse events were rare with both.

Why does it matter?

Bronchiolitis is a leading cause of infant hospitalisation with few effective treatments. Many clinicians and parents use nasal suctioning to relieve congestion, but there is little information on the benefits.

Clinically Relevant Bottom Line:

This study showed that parents like suctioning their infants when they have bronchiolitis, and it is safe. It did not significantly reduce healthcare reattendance or improve feeding or sleep.

Reviewed by: Michael King

If we have missed out on 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 were reviewed and edited by Vicki Currie and Dr Mohomed Ashraf Vahedna.


  • 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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