With millions of journal articles published yearly, it is impossible to keep up. This time, Doctors from ‘The Bridge‘ tell us what is new in the world of paediatric literature….
The Bridge: Is a Post Graduate Doctor in Training (PGDiT) -led paediatric research forum in Yorkshire and Humber, UK, with the aim of bridging the gap in research access amongst PGDiT.
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: Which paediatric weight estimation method is most accurate?
Shieh A, Rogers AJ, Chen CM, Ramgopal S. Comparing the performance of pediatric weight estimation methods. Am J Emerg Med. 2024 Aug;82:26-32. doi: 10.1016/j.ajem.2024.04.053. Epub 2024 May 3. PMID: 38759251.
What’s it about?
This is a retrospective cross-sectional study of children (<18 years) seen in the emergency department (ED) or ambulatory clinic of a tertiary academic paediatric centre in the Midwest region of the US over 10 years comparing the performance of nine age-based formulae and two length-based methods for weight estimation in children presenting to the ED.
361,755 children (<18 years) were included in the study. Children with extremely high weights or body mass indices ≤5 or ≥100 kg/m2 were excluded from the study, and random selection was done for children with multiple visits. The median patient age was 8.2 years (IQR 2.5–14.2 years), with a slight male predominance (51.5% were male). 51,181 (14.1%) children had complex medical conditions.
In this study, the Broselow tape had the best overall accuracy, with 50.7% (vs 30.88% for APLS 2011) of estimates occurring within 10% of measured weight and 80.0% (vs 55% for APLS 2011) estimates within 20% of measured weight. It also predicted weight most accurately compared to the other methods in children with complex medical conditions. However, children with complex medical conditions, especially GIT and metabolic conditions, had the least accurate weight estimation overall.
The Antevy formula was the most accurate age-based formula, probably due to its lower age restriction. However, age-based estimation methods have limited accuracy, with only 28–50% of the weight estimates noted to be within 10% of the child’s actual weight.
Table 1. Paediatric weight estimation methods studied.
Why does it matter?
Most paediatric medications and fluids are based on weight, and accurate weight estimation is important for safe and effective care. Children with complex medical conditions are at higher risk of morbidity and mortality, and this may be compounded by inaccurate weight estimation and leading to inaccurate medication dose administration.
In the emergency department resuscitation room, weight is usually estimated using an age-based formula until the child is stabilised and can be safely weighed. Therefore, it is important that the method used gives the most accurate weight estimate.
In the NHS, the ED is one of the areas with the most paediatric medication error claims, and accurate weight checking has been recommended as a good practice (1)
Visual estimation of weight is not a valid weight measurement method.
For a post on this see I can guess your weight – Don’t Forget the Bubbles (dontforgetthebubbles.com)
Clinically Relevant Bottom Line
Accurate weight estimation is important in the treatment of CYP. While the Broselow is the most accurate for children with normal BMI and complex medical conditions, it has a large margin of error. There should be an attempt to weigh the child once it is safe, particularly for overweight/underweight children, children with complex medical and older children.
- NHS Resolution. Did you know? Paediatric medication errors. Available at https://resolution.nhs.uk/wp-content/uploads/2023/03/Did-You-Know-Paediatric-Medication-Errors.pdf, Accessed August 2024
Reviewed by: Dyanne Imo-Ivoke
Article 2: Are overweight children more likely to present with MSK issues?
Firman N, Homer K, Harper G, Robson J, Dezateux C. Are children living with obesity more likely to experience musculoskeletal symptoms during childhood? A linked longitudinal cohort study using primary care records. Arch Dis Child. 2024 Apr 18;109(5):414-421. doi: 10.1136/archdischild-2023-326407. PMID: 38471744
What’s it about?
Obesity is considered a contributing factor for some musculoskeletal outcomes. A recent systematic review found that children with obesity at school entry are more likely to experience back pain, slipped capital femoral epiphysis or fractures during childhood.
This study aimed to assess whether there is a higher incidence of musculoskeletal consultations in general practice among children with obesity. It involved longitudinal research conducted among participants from the National Child Measurement Programme (NCMP) in north-east London linked to general practitioners’ electronic health records (EHRs). The main outcome measure was a GP consultation with a recorded musculoskeletal symptom or diagnosis. Included was 123 836 of 128 544 (96.3%) of the NCMP participants in the area. Ethnicity specific BMI adjustments were made to the NCMP recorded BMI status. These were categorized into 4 mutually exclusive groups: (underweight) <2nd centile, (healthy weight) 2nd– 91st centile, (overweight) 91st to 98th and (obese) >98th centile. The study sample comprised 63 418 (50.9% boys) 4- to 5-year-olds and 55 364 (50.8% boys) 10- to 11-year-olds in the Reception and Year 6 cohorts, respectively. The majority of children lived in the most deprived areas and were from Black or minority ethnic groups.
Why does it matter?
The findings indicate that girls with obesity at the beginning or end of primary school are more likely to visit their GP for musculoskeletal consultations. This study highlights the importance of recognizing obesity as a contributing factor to musculoskeletal symptoms in children. The routine linkage of NCMP data to EHRs can provide valuable insights into childhood health conditions related to excess weight in early childhood, emphasizing the need for early intervention and management strategies. The most common MSK diagnoses were related to knee and back pain.
Recognizing obesity as a potential contributor to musculoskeletal symptoms in girls and understanding the increased likelihood of musculoskeletal consultations in children with obesity can inform clinical management strategies, particularly in addressing early intervention and preventive measures in primary care settings. This emphasizes the importance of considering obesity as a significant risk factor for musculoskeletal issues in children and the relevance of timely interventions to mitigate these health concerns.
For a deeper dive into this topic, see Obesity – Don’t Forget the Bubbles (dontforgetthebubbles.com).
There are a few limitations: GPs may be more likely to diagnose MSK issues in children with obesity; there was no record of how long each child had been living with obesity; and there was a lack of information about physical activity participation.
Clinically Relevant Bottom Line
In a large ethnically diverse population of primary school children, girls, but not boys, living with obesity are more likely to have at least one general practice consultation for a musculoskeletal symptom or diagnosis.
Reviewed by: Haroon Afridi
Article 3: Something upcoming….. The ELSA Study: A Ground-breaking Approach to Type 1 Diabetes Screening in Children
Watch this space: The ELSA study – EarLy Surveillance for Autoimmune diabetes (digitrial.com)
What’s it about?
The ELSA Study in the UK is a pioneering initiative to assess the feasibility and benefits of early screening for type 1 diabetes (T1D) in children. Targeting 20,000 participants, the study aims to identify at-risk children by testing for specific autoantibodies linked to T1D. The screening involves five steps: an initial finger-prick test, a confirmatory venous blood test for positives, further tests to stage T1D, and concluding with educational sessions for parents and feedback interviews. The study’s goal is to enhance early detection and intervention.
Why does it matter?
The ELSA Study is crucial for revolutionising early detection of type 1 diabetes (T1D) by identifying at-risk children before symptoms appear. Early identification enables timely intervention, reducing emergency admissions and allowing participation in trials to delay or prevent T1D. The study also prioritises educating families on T1D signs and symptoms, which is essential for managing and slowing the disease’s progression.
Hopefully earlier detection presentations in DKA could be avoided. For more on DKA, see Diabetic Ketoacidosis – Don’t Forget the Bubbles (dontforgetthebubbles.com).
Clinically Relevant Bottom Line
Clinically, the ELSA Study could redefine T1D management in paediatric healthcare. By implementing routine screenings and providing educational support, the study offers a proactive approach to identifying and managing T1D, ultimately improving outcomes and quality of life for affected children and their families. The ELSA Study represents a significant step forward in T1D research, potentially shaping future screening and intervention strategies globally.
Reviewed by: Mai Ali
Article 4: Neo-Tip Tracker: Ultrasound Guidance for Umbilical Catheter Placement
Xie HQ, Xie CX, Liao JF, Xu FD, Du B, Zhong BM, He XG, Li N. Point-of-care ultrasound for monitoring catheter tip location during umbilical vein catheterization in neonates: a prospective study. Front Pediatr. 2023 Aug 23;11:1225087. doi: 10.3389/fped.2023.1225087. PMID: 37691771; PMCID: PMC10483067.
What’s it about?
This prospective observational study investigated the use of Point-of-Care Ultrasound (POCUS) to guide and monitor umbilical vein catheter (UVC) placement in 68 neonates. Of the 68 neonatal participants, 34 (50.0%) were male, with an average gestational age of 33.4 ± 4.1 weeks and birthweight of 2,059.26 ± 842.43 g. All participants underwent UVC under ultrasound guidance within 24 h after birth, and the mean catheter use duration was 7.1 (6.0, 9.0) days.
The findings showed that catheter tip displacement occurred in 94.1% of cases, predominantly within the first 2-4 days post-placement, with 14.7% experiencing misalignment. Daily POCUS monitoring effectively detected and corrected these issues, preventing complications like pericardial tamponade and liver necrosis. It also eliminated the need for X-ray imaging, thus reducing radiation exposure.
Why does it matter?
Proper positioning of UVCs is vital to prevent serious complications, such as arrhythmia, pericardial effusion, and liver necrosis. Conventional methods, like chest radiography, are limited in accuracy and involve radiation. POCUS provides a noninvasive, radiation-free option for real-time monitoring, which can mitigate the risks of catheter misplacement.
For more information on neonatal lines and tubes, see Neonatal lines and tubes – Don’t Forget the Bubbles (dontforgetthebubbles.com).
The study’s limitation is its small size. Training will have to occur to locate the UVC tip accurately, and while this is available at this centre, it is not yet widely taught or standardised.
Clinically Relevant Bottom Line
Daily monitoring of UVC tip position with POCUS is crucial due to the high incidence of displacement and misalignment, especially within the first 2-4 days post-placement. This approach prevents severe complications and improves patient safety by enabling timely catheter adjustments.
Reviewed by: Mervat Elyas
Article 5: Are children with prolonged fever at a higher risk for serious illness?
Nijman RG, Tan CD, Hagedoorn NN, Nieboer D, Herberg JA, Balode A, von Both U, Carrol ED, Eleftheriou I, Emonts M, van der Flier M, de Groot R, Kohlmaier B, Lim E, Martinón-Torres F, Pokorn M, Strle F, Tsolia M, Yeung S, Zachariasse JM, Zavadska D, Zenz W, Levin M, Vermont CL, Moll HA, Maconochie IK; PERFORM consortium. Are children with prolonged fever at a higher risk for serious illness? A prospective observational study. Arch Dis Child. 2023 Aug;108(8):632-639. doi: 10.1136/archdischild-2023-325343. Epub 2023 Apr 25. PMID: 37185174.
What’s it about?
This is a secondary analysis of data collected for a prospective observational study done in 12 European EDs over a period of a year, comparing children with fever >= 5days and their risks for serious bacterial infection and children with fever <5 days including diagnostic accuracy of nonspecific symptoms, warning signs and CRP.
A total of 3778/35 705 that is 10.6% of febrile children had fever ≥5 days. Incidence of Serious bacterial illness (SBI) in children with fever ≥5 days was higher than in those with fever <5 days (8.4% vs 5.7%). Fever was defined as >38 degrees Celsius at triage or at home within preceding 72 hours.
Most children with fever >5 days had a lower respiratory tract or a urinary focus with invasive bacterial infections being rare <0.4%. Triage urgency, life-saving interventions and intensive care admissions were similar for fever ≥5 days and <5 days.
Absence of warning signs was not sufficiently reliable to rule out SBI (sensitivity 0.92 (95% CI 0.87–0.95).
There were 66 cases (1.7%) of non-infectious serious illnesses, including 21 cases of Kawasaki disease (0.6%), 28 inflammatory conditions (0.7%) and 4 malignancies.
Limitations to this study were that the data was analysed as a secondary analysis (not what was the original intent for the data), there was some missing values in the data and CRP was an important value- but was not uniformly included as rule in or rule out value for SBI (some were allocated as SBI irrespective of CRP value and some were deemed as not SBI depending on CRP value).
For a deeper dive into the differential diagnosis of fever see When is a fever not ‘just a fever’? – Don’t Forget the Bubbles (dontforgetthebubbles.com).
Why does it matter?
Children with prolonged fever have a higher risk of serious bacterial infection (SBI), warranting a careful clinical assessment and diagnostic workup. Warning signs of SBI occurred infrequently but, if present, increased the likelihood of SBI.
Clinically Relevant Bottom Line
Warning signs of SBI occurred infrequently but, if present, increased the likelihood of SBI in children with prolonged fever. CRP <20 mg/L was useful for ruling out SBI. Clinicians should consider the possibility of important non-infectious causes of prolonged fever even if less frequent.
Reviewed by: Shaza Gaafar
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.
