With millions of journal articles published yearly, it is impossible to keep up. This time, RCPCH trainees from the West Midlands are taking over to bring you some of their finds in paediatric literature…
Happy Reading 🙂
If you or your team want to submit a review, please contact Dr. Vicki Currie at @DrVickiCurrie1 or vickijanecurrie@gmail.com.
Article 1: Making Antibiotic Use Safer – Removing incorrect allergy label
Wong J, Atkinson A, Timberlake K, Beck CE, Maguire B, Science M. Improving inpatient paediatric de-labelling of allergies to beta-lactams: a quality improvement study. Arch Dis Child. 2024 Apr 25:archdischild-2023-326533. doi: 10.1136/archdischild-2023-326533. Epub ahead of print. PMID: 38663978.
What’s it about?
This study evaluated the effectiveness of a structured program to de-label beta-lactam allergy in paediatric inpatients using direct oral provocation tests (OPTs). It was conducted in a tertiary paediatric hospital over one year (Jan 2018-Jan 2019).
109 patients were identified to have reported beta-lactam allergies via the EMR (Electronic Medical Record).
29 patients (27%) were not considered for OPT assessment due to anticipated short admissions, weekend admissions, or early discharge. 80 patients (73%) underwent assessment for OPT. Half of these patients (40) were not suitable due to clinical considerations or the nature of their reported reactions.
Among the 40 eligible patients, 28 (70%) were successfully de-labelled, 10 (25%) were de-labelled based on their history, and 18 (45%) were de-labelled through OPT with no adverse reactions reported. An additional 16 patients who did not qualify for inpatient OPT were assessed in the allergy clinic, leading to 9 more de-labellings.
Overall, nearly half of the 80 patients were de-labelled (37 patients, 46%).
Interestingly, 80% of the reported reactions were low-risk or not in keeping with allergy. Each allergy clinic assessment and OPT testing (assuming all de-labelled inpatients would have been referred to an allergist) resulted in an estimated cost reduction of $145 USD.
Why does it matter?
Patients who have been incorrectly labelled as allergic to beta-lactam antibiotics often receive less effective and costlier antibiotics. Removing these incorrect labels can improve antibiotic usage and patient care.
For a deeper dive into adverse drug reaction vs antibiotic allergy and taking a focused allergy history, see Tackling Penicillin Allergy in Acute Paediatrics – Intercepting an Avalanche – Don’t Forget the Bubbles (dontforgetthebubbles.com)
Clinically Relevant Bottom Line
This study shows how targeted inpatient beta-lactam allergy de-labelling programs can safely remove inappropriate allergy labels and ultimately improve patient care.
Reviewed by: Olawumi Ogunkanmi
Article 2: Are We Considering the Future in Mind?
Malley M, Hall M, Parry G, et al. Assessment of mental health presentations to the paediatric emergency department: a poorly standardised process.Archives of Disease in Childhood 2023; 108:591.
What’s it about?
This study looked at variability in mental health assessment between healthcare professionals. It included 54 staff in a tertiary PED that sees 1222 mental health presentations annually.
The study highlights the lack of training and clinical expertise in managing mental health disorders in children and adolescents, emphasising the need for standardised assessments.
Real mental health presentations were anonymised and turned into video vignettes—participants rated them as ‘red’, ‘amber’, or ‘green’ risk. Then, the authors looked at agreement between the assessors. There was little concordance between staff, meaning that staff working in the same PED didn’t agree on their MH assessments. Concordance increased with experience and was highest amongst CAMHS staff.
Why does it matter?
Suicide is one of the leading causes of death (14%) in children and young people aged 10-19 years.
Current data from the National Centre for Social Research in England 2023 shows that 1 in 5 children (20.3%) aged 8 to 16 years have a probable mental health disorder, a rise from 18% in 2022, 16.7% (1 in 9) in 2020, 12.1% (1in 6) in 2017. With only 1 in 4 children getting the right support, often after a long wait ranging from 4 days up to 147 days.
Children with mental health problems are at risk of performing poorly at school, engaging in risky behaviour, and having mental health problems as adults. They may self-harm, have suicidal thoughts, depression, anxiety disorder, post-traumatic stress disorder and eating disorders.
Staff must have the clinical expertise for an accurate initial mental health assessment to evaluate and manage children with mental health disorders in PED.
For a deeper dive into managing children with mental health disorders, delve into:
The HEADSSSS Screen
Using your HEADS-ED
Sedation for the Agitated Adolescent
Clinically Relevant Bottom Line
PED staff must work together to make the “Five Big Ideas*” to support children and young people’s mental health and well-being.
*Early detection; Easier access to the right support; Prompt Care; Honesty among services about what they are doing; and the Right staff in the Right place at the Right time with no stigma*.
Reviewed by: Chigozie Okwujiako
Article 3: Can Younger Children Swallow Tablets?
Klingmann V, Hinder M, Langenickel TH, et al. Acceptability of multiple coated mini-tablets in comparison to syrup in infants and toddlers: a randomised controlled study Archives of Disease in Childhood 2023;108:730-735.
What’s it about?
Drug treatment of children is mostly limited to liquid preparations. Recent research has shown that using mini-tablets improves dose accuracy and issues regarding storage and drug stability.
This study examined the acceptability of film-coated mini-tablets in children ages 1-6 compared to a similar dose of glucose syrup. It also checked the swallowability and safety of the two preparations.
This was a single-centre, open-label, randomised study that used two-way cross-over stratification in five age groups. A total of 109 children were approached in a General Paediatric Department in Germany, and 50 (45.9%) met the inclusion criteria.
Since treatment often requires multiple tablets, this study looked at the acceptability and swallowability of up to 28 film-coated drug-free mini tablets (2mm). As children grew older, they were offered increasing numbers of mini tablets and larger volumes of syrup.
Coated mini-tablets were acceptable in most age groups: 1-<2 (100%), 4-<5 (100%) and 5-<6 (90%). There was no clinically significant difference between the mini-tab group and liquid formulation groups. The swallowability of the mini-tablets did not differ significantly either across age groups. Surprisingly, none of the children choked on either preparation.
Why does it matter?
Health professionals may be concerned about particle inhalation when it comes to mini-tablets. This study has shown that children will take and swallow coated mini-tablets with no safety concerns.
Clinically Relevant Bottom Line
Coated mini-tablets are a suitable mode of oral medication for children aged one and above and may be particularly cost-effective in poor resource settings.
Reviewed by: Dr. Josephine Quaynor
Article 4: Are Paediatric Suicide Risk Screening Tools Accurate?
Lowry NJ, Goger P, Hands RuzM, et al. Suicide Risk Screening Tools for Pediatric Patients: A Systematic Review of Test Accuracy. Pediatrics. 2024;153(3):e2023064172
What’s it about?
Suicide in children and young people is a major public health problem. Universal suicide risk screening tools can be used in paediatric patients in medical settings, including emergency departments, to identify and manage those who do not require further assessment. However, this is only practical if they are reliable.
This systematic review addressed the accuracy of suicide risk screening tools used in young people across different medical settings. It included five screening tools, which had been assessed in 13 studies with a total of more than 33,000 patients. Sensitivity among individual studies ranged from 50% to 100%, and specificity ranged from 58.8% to 96%.
Of these five screening tools, the Ask Suicide-Screening Questions (ASQ) tool and The Computerised Adaptive Screen for Suicidal Youth (CASSY) tool were the most accurate.
The ASQ tool was the most studied (8 studies), with a sensitivity of 89.7% and a specificity of 84.5%. When used in the emergency department, this increased to a sensitivity of 96.9% and specificity of 87.6%.
The Computerised Adaptive Screen for Suicidal Youth (CASSY) tool demonstrated 82.4% sensitivity and 72.5% specificity when used in a large prospective study of 2754 patients aged 12–17-year-olds in the emergency department.
Other tools that had limited evidence and poorer psychometric properties included the Patient Health Questionnaire-9 (PHQ-9), the Risk of Suicide Questionnaire (RSQ), and the Behavioural Health Screen (BHS) tool.
In addition to the low number of eligible studies for this systematic review, study heterogenicity meant statistical testing was not undertaken between the identified tools.
Why does it matter?
With increasing suicide prevalence, organisations are considering integrating suicide risk tools as a screening tool in all paediatric patients who present to a healthcare setting regardless of their presenting complaint. This is so that at-risk individuals are identified and receive timely intervention.
Clinically Relevant Bottom Line
This systematic review supports the use of suicide risk screening tools in children and young people.
In particular, it advocates for particular tools such as the Ask Suicide Screening Questions and Computerised Adaptive Screen Suicidal Youth tools for integration into clinical practice, with strong evidence suggesting their reliability in identifying suicide in children and young people who present to the emergency department.
Reviewed by: Shoshana Layman
Article 5: Childhood Obesity, a Growing Pandemic. Are we missing vital opportunities?
Marsh R, Gill S, Lowry N, Hayden G, Ryan M, Gwini SM, Allender S, Stella J. Childhood obesity in the ED: A prospective Australian study. Emerg Med Australas. 2024 Apr 22. doi: 10.1111/1742-6723.14414. Epub ahead of print. PMID: 38649794.
What’s it about?
This prospective observational study included children aged ≥2 and <18 years who presented to any of three EDs over 18 months and had their height and weight measured to look at the prevalence of overweight and obese children. Of the 3827 children who presented, one-third of children who presented with ED were overweight (19.8%) and obese(11.6%), with increased risk among children aged 8 -14 years, those from lower-income areas and minority groups.
Why does it matter?
With the growing prevalence of childhood obesity, there is a looming global health challenge. Data from the National Child Programme England indicates that 1 in 5 children (22%) are obese or overweight by the time they start primary school at age 5, and 1 in 3 children (37%) are in this category when they leave primary school at age 11.
Untreated Obesity can lead to serious health issues, including type 2 diabetes, asthma, hypertension (20-26%), Obstructive sleep apnoea, non-alcoholic fatty liver disease (22.5%-52.8%), gall stones, psychosocial problems including eating disorders, bullying, low esteem/depression, heart disease, cancer, orthopaedic abnormalities, prolonged hospitalization, increased health care costs, and premature mortality.
This study emphasizes the increasing number of obese/overweight children visiting the emergency department and being at risk of presenting with associated co-morbidities and complications.
For an in-depth approach to obesity, check out this post.
Clinically Relevant Bottom Line
Health professionals in the Paediatric emergency department should play a vital role in recognizing, identifying and intervening with brief guidance on healthy diet and lifestyle and referral to primary care services. Every interaction is an opportunity to have a positive impact.
Reviewed by: Chigozie Okwujiako
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 for scouring the literature so you don’t have to.
Vicki Currie, DFTB Bubble Wrap Lead, reviewed and edited all articles.
