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The 81st Bubble Wrap

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With millions of journal articles published yearly, it is impossible to keep up. Our team has scoured the literature, so you don’t have to—or it might spark an interest in reading the full article.

Happy Reading 🙂

If you or your team are interested in an individual or joint review, please contact Dr. Vicki Currie at @DrVickiCurrie1 or vickijanecurrie@gmail.com.

Article 1: Fever after Immunisations in Infants- What should we do?

 Casey K, Reilly ER, Biggs K, Caskey M, Auten JD, Sullivan K, Morrison T, Long A, Rudinsky SL. Serious bacterial infection risk in recently immunized febrile infants in the emergency department. Am J Emerg Med. 2024 Jun;80:138-142. doi: 10.1016/j.ajem.2024.03.025. Epub 2024 Mar 24. PMID: 38583343

What’s it about? 

This retrospective observational cohort study at two U.S. military academic Emergency Departments over a four-year period compared the prevalence of serious bacterial infection (SBI) in well-appearing infants aged 6–12 weeks who presented with a fever ≥38 °C and who had been recently immunised (<72hrs) with infants who had not received immunisations (NRI) in the preceding 72hrs. 

508 febrile infants met the study criteria, with 22.4% being recently immunised (RI) and 55% considered unimmunized on presentation. The overall prevalence of SBI was 11.4% (95% CI = 8.9–14.6) with the prevalence being higher in NRI infants 3.7% (95% CI = 10.6–17.6) vs RI 3.5% (95% CI = 1.1–9.3)]. In the RI group, the prevalence of SBI was lower in infants immunised <24 h compared to >24 h before presentation (2% vs 14.3% respectively). Most infections were UTIs. 

Why does it matter? 

Up to 40% of infants may develop a fever >38.0 °C within 48 h of immunisation, with a significant proportion presenting to the emergency department. However, recently immunised infants are not included in fever guidelines, so the optimal approach to this population remains poorly defined. This study adds to the body of evidence suggesting that recently immunised febrile infants are at a lower risk of invasive bacterial infection and may not require as extensive a workup. 


Recent American Academy of Paediatrics guidance, along with other studies, suggest a less invasive, tailored approach to febrile infants <60 days- have a look at this guidance here Well appearing febrile infants – Don’t Forget the Bubbles (dontforgetthebubbles.com).

Clinically Relevant Bottom Line:

The prevalence of SBI in febrile infants in the initial 24 hours following immunizations is low. However, there is still a substantial risk of UTI. Therefore, consider testing the urine in febrile infants who present within 24 hours of immunisation. 

Reviewed by: Aiesha Alexander

Article 2: Are Oxygen Saturations Accurate Across Different Skin Tones?

Martin D, Johns C, Sorrell L, Healy E, Phull M, Olusanya S, Peters M, Fabes J. Effect of skin tone on the accuracy of the estimation of arterial oxygen saturation by pulse oximetry: a systematic review. Br J Anaesth. 2024 May;132(5):945-956. doi: 10.1016/j.bja.2024.01.023. Epub 2024 Feb 17. PMID: 38368234; PMCID: PMC11103098

What’s it about? 

A systematic review of 44 studies examined whether pulse oximetry-derived saturations (SpO2) accurately estimate true arterial oxygen saturations (SaO2) across different skin tones. A total of 772,722 paired measurements across healthy participants and patients in clinical trials were assessed. 2.7% were children.

The majority of measurements (>700,000) came from retrospective clinical trials published in the last four years. Apart from one small study, all reported an overestimation of SpO2 pulse oximeters in people whose self-reported ethnicity is associated with darker skin tones, i.e., the pulse oximeter gave an inaccurate higher reading than the true arterial oxygen saturations. Several studies stated that this overestimation got worse when true SaO2 was lower.

Compared to individuals with self-reported white skin, those with Black ethnicity experienced a threefold increase in diagnostic inaccuracy for true hypoxia. For people of Asian ethnicity, this inaccuracy was nearly twofold.

Three studies involving children all noted greater inaccuracy in children of Black ethnicity.

Over half of the studies noted a high risk of bias. Themes included non-randomized or non-consecutive selection of participants in healthy volunteer studies and unique clinical scenarios such as measurement during hypothermia, exercise, and newborns. Retrospective clinical studies also revealed a variable time delay between the SpO2 and SaO2 measurements.

Why does it matter? 

Clinicians rely on medical device accuracy to help determine thresholds for investigation and treatment. This systematic review suggests caution when interpreting peripheral oxygen saturation in patients with darker skin tones.

Check out this post for a deeper dive on: Pulse oximetry – Don’t Forget the Bubbles (dontforgetthebubbles.com)

Clinically Relevant Bottom Line:

Peripheral oxygen saturation readings should be interpreted more carefully in people with increasingly darker skin tones, especially when they record lower oxygen saturations. 

Reviewed by: Rehana Dyson

Article 3: Recognition of Child Abuse in the Paediatric Emergency Department

Akkaya, B., İnan, C., Ünlü, İ. İ., Güneylioğlu, M. M., Bodur, İ., Göktuğ, A., Öztürk, B., Yaradılmış, R. M., Aydın, O., Özcan, A. S., Güngör, A., & Tuygun, N. (2024). A silent scream in the pediatric emergency department: child abuse and neglect. European Journal of Pediatrics. https://doi.org/10.1007/s00431-024-05526-2

What’s it about?

Child abuse is any form of maltreatment that harms the development of a child. Children who have been abused and who present to the Paediatric Emergency Department may go unrecognised due to a lack of communication and fear of the offender.

This study analysed the demographic and clinical features of children presenting with abuse to the PED. This single-centre retrospective cohort study examined 371 children in Turkey between 2017 and 2022. These children had confirmed diagnoses of either physical abuse, sexual abuse, emotional abuse, neglect or medical child abuse.

Adolescents were the most common age group presenting with child abuse, accounting for 59.8% of cases. Among patients, 187 (50.4%) were victims of neglect, and 90 (24.2%) had sustained physical abuse. A total of 108 patients (29.1%) required PICU care. Fourteen patients (3.7%) were admitted with abusive head trauma, the majority of whom (10 patients, 71.4%) were infants. Additionally, four patients (1%) presented as out-of-hospital cardiac arrests. Interestingly, 177 patients (47%) had previously visited the PED with similar presentations.

Why does it matter?

Cases of child abuse vary widely, and it is the responsibility of paediatric emergency physicians to adopt a holistic approach to clinical evaluation and management to safeguard every child.

For a detailed explanation into how to have a deep conversation when you suspect abuse, see Safeguarding Module – Don’t Forget the Bubbles (dontforgetthebubbles.com) and How to talk to parents about safeguarding – Don’t Forget the Bubbles (dontforgetthebubbles.com).

Clinically Relevant Bottom Line:

Staff working in the Paediatric Emergency Department play a crucial role in detecting, treating and preventing the recurrence of child abuse.

Reviewed by: Josephine Quaynor

Article 4: Does how we repair wounds affect behaviour?

Martin SR, Heyming TW, Fortier MA, Kain ZN. Paediatric laceration repair in the emergency department: post-discharge pain and maladaptive behavioural changes. Emerg Med J. 2024 May 8:emermed-2023-213858. doi: 10.1136/emermed-2023-213858. Epub ahead of print. PMID: 38724104.

What’s it about?

This prospective observational study investigates post-discharge recovery in 173 children aged 2-12 in the USA after laceration repair in the emergency department (ED). 

Children who achieved a certain Emergency Severity Score and were fluent in English and Spanish were eligible for recruitment. Caregivers, not children, gave a reported pain score, which is an important limitation. A behavioural questionnaire was completed, and a scoring system was implemented; this included things like sleep, eating, anxiety, aggression, and withdrawal. This was completed on days 1, 3, 7, and 14 after laceration repair. 

Of 173 families, there were 144 participants who completed the surveys on all of the days. Over the 2-week period, 43% of families reported new maladaptive changes. This dropped to 10% at 2 weeks post-discharge. The most commonly reported changes were ‘needs help to do things, ‘upset when alone’, ‘has temper tantrums’ and ‘has trouble getting to sleep at night’. 

The family reporting of pain and behaviours does not allow for the voice of the child. There is also no way to account for other potential biases that could have additionally impacted behaviours.

Why does it matter?

Most of the literature on this subject surrounds the functional repair of wounds

Understanding post-discharge recovery is crucial, as over 40% of children exhibit behavioural changes after laceration repairs. Identifying factors influencing these changes can improve pain management and support better recovery outcomes in paediatric patients.

For a deep dive into wound management, see these two DFTB posts: Wound Management Module – Don’t Forget the Bubbles (dontforgetthebubbles.com) and Managing wounds – Don’t Forget the Bubbles (dontforgetthebubbles.com).

Clinically Relevant Bottom Line

The study highlights the importance of managing pain on the first day after discharge to reduce the likelihood of maladaptive behavioural changes. Proactive pain management and awareness of potential behavioural issues are essential for improving post-procedural care in paediatric patients.

Reviewed by:Rishikesh Chittimalla

Article 5: Is eating family meals together important for young people and families?

Brown CL, Kay MC, Thompson LA. Eating Family Meals Together at Home. JAMA Pediatr. Published online March 25, 2024. doi:10.1001/jamapediatrics.2023.6669 (https://jamanetwork.com/journals/jamapediatrics/fullarticle/2816155)

What’s it about?

In March, our colleagues at JAMA Paediatrics highlighted the importance of the family meal with an infographic and opinion piece highlighting that family meals benefit children, parents, and carers.

Eating together three or four times weekly has significant emotional and health benefits. It has been shown to improve things like rates of overweight children and obesity, substance abuse, teen pregnancy, depression, and eating disorders, higher self-esteem, and better academic performance. 

Why does it matter?

In clinical care, we often take a disease-based approach to food, diet, nutrition or intake as part of screening or diagnostics. Our colleagues remind us that family meals benefit all members of the family. Although Brown et al’s paper is an opinion piece, there is robust evidence in service of this statement. Utter et al. (2018) surveyed 889 parents and identified that more frequent family meals were associated with many indicators of parental social and emotional well-being, as well as lower levels of depressive symptoms, lower stress and greater self-esteem.

Clinically Relevant Bottom Line:

When exploring a child or adolescent’s dietary or intake history, seek to understand the context in which the young person eats. If there is an opportunity, provide a brief intervention on the benefits of family meals—including for parents—and validate these as healthy and prosocial if they are already occurring.

Reviewed by: Henry Goldstein

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 are reviewed and edited by Vicki Currie, DFTB Bubble Wrap Lead.

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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