With millions of journal articles published yearly, it is impossible to keep up. This time the team from Bristol Royal Children’s Hospital ED tell us what is new in the world of paediatric literature….
Led by Dr John Coveney a Paediatric Emergency Medicine Trainee in Bristol who has revived The Journal Club at Bristol Royal Children’s Hospital ED on a monthly basis . The team are using the Bubble Wrap formula as a way to summarise the discussion in their journal club (killing two birds with one stone!). John has organised the reviews and an ongoing partnership between BRCH and Bubble Wrap is planned :). This month there are several new articles but one older one that sparked the teams interest.
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: What are the signs and symptoms of serious illness in infants up to 6 months old?
Maramba IDC, Lim E, Menzies JC, Nijman R, Zhou S, Latour JM. Signs and
symptoms of serious illness in infants aged up to 6 months: rapid review of
clinical guidelines. BMJ Paediatr Open. 2024 Jul 29;8(1):e002737. doi:
10.1136/bmjpo-2024-002737.
What’s it about?
This paper reviewed current clinical guidelines to identify key signs and symptoms of serious illness in infants up to 6 months old. The review aimed to inform updates to the Baby Check App, a tool parents use to assess their baby’s health. The current data on the app was based on data collected from 1991. A systematic review was performed, and 14 guidelines, 2 quality standards, and one NICE guideline were included in the review.
A list of 60 signs and symptoms, culled from 14 guidelines, that could signify conditions requiring urgent medical attention.
Of the 60, 23 were already in the Baby Check App.
Of the 37 signs not in the Baby Check App, two, parental concern and clinician concern, were recommended for inclusion as they were flagged as red flags of serious illness in most guidelines. The others, such as respiratory rate, heart rate, and decompensated shock, were excluded due to the presumed difficulty for non-healthcare professionals to assess them accurately.
There is a significant misalignment between parent and professional scoring systems. The Baby Check App lacks key indicators, including respiratory and heart rate, which are essential in the Paediatric Early Warning System.
The data included was within the last five years, ensuring that the clinical information was up to date. This was a rapid review, which in itself has some limitations, including the possibility of missing some important studies.
Why does it matter?
Young infants visit A&E more than any other age group. With reduced health visits and increased pressure on primary care, it is crucial that parents can accurately assess their baby’s health.
The Baby Check App, helps parents of non-medically complex children identify serious illness, and is the only app recommended by NICE,
It must contain the most current and accurate information to be effective for parents and healthcare professionals.
Clinically Relevant Bottom Line
The scoring system for serious illness used by parents and healthcare professionals must be aligned to accurately identify those requiring care. It must be based on the latest guidelines to signpost parents to the most appropriate healthcare professional.
Reviewed by: Isabella Davenport
Article 2: Does it improve outcomes if you replace the nail in nail bed repair?
Jain A, Greig AVH, Jones A, Cooper C, Davies L, Greshon A, Fletcher H, Sierakowski A, Dritsaki M, Nguyen TTA, Png ME, Stokes JR, Dakin H, Cook JA, Beard DJ, Gardiner MD; NINJA Collaborative. Effectiveness of nail bed repair in children with or without replacing the fingernail: NINJA multicentre randomized clinical trial. Br J Surg. 2023 Mar 30;110(4):432-438. doi: 10.1093/bjs/znad031
What’s it about?
This was a multi-centre randomised controlled trial performed across 20 UK hospitals. Children with nail bed injuries were randomly assigned to nail replacement or discarding, with the primary outcomes being secondary infection in 7 days and cosmetic outcome in four months.
227 children were randomised to nail replacement and 224 to nail discard. The groups were similar in age, type of injury, and proportion of crush injuries and nail avulsions. Surgical site infections were more common at seven days in the nail replacement group (2.2% vs 0.9%), but this was not statistically significant.
Cosmetic outcome was measured using a scale of 0-5, with 5 being the best appearance. The assessors scored both groups 5. However, in the secondary outcome of parental assessment, nail discard patients had higher median scores.
The study excluded complex nail bed injuries, including those with distal phalanx fractures, germinal matrix injury or pulp lacerations, meaning outcomes are only relevant to simple nail bed injuries. Whilst the statistical analysis is generally robust, other limitations include the loss to follow-up of 156 patients across the two arms about cosmetic outcomes and a change in cosmetic reporting part way through, which meant parents provided the scores rather than an assessor.
Why does it matter?
Fingertips are the most common site of injury in children’s hands, accounting for more than two-thirds of paediatric hand trauma. Ten thousand children in the UK are operated on a year for fingertip injuries, and 96% of surgeons currently report replacing the nail plate intra-operatively. Nail plate replacement requires a longer duration of surgery and has higher financial costs, with nail replacement costing an additional £75 per patient.
For all things fingers, check out these two posts: Finger injuries: basics and bones – Don’t Forget the Bubbles (dontforgetthebubbles.com) Finger Tips – tendons and ligaments – Don’t Forget the Bubbles (dontforgetthebubbles.com)
Clinically Relevant Bottom Line
Nail discard during surgical repair of simple nail bed injuries does not increase post-operative infection rates or negatively affect the final cosmetic outcomes of the fingertip. Adopting this approach would reduce time in surgery for the child as well as the financial cost of nail bed repair.
Reviewed by: Laura Gabbott
Article 3: What do parents want to know when their infant has a fever?
Wilson K, Umana E, McCleary D, Waterfield T, Woolfall K. Exploring communication preferences and risk thresholds of clinicians and parents of febrile infants under 90 days presenting to the emergency department: a qualitative study. Arch Dis Child. 2024 Jul 10:archdischild-2023-326727. doi: 10.1136/archdischild-2023-326727. Epub ahead of print. PMID: 38986575
What’s it about?
In this qualitative study, two participant groups were recruited: 18 parents of infants recruited into the Febrile Infant Diagnostic Assessment and Outcomes study and seven clinicians who had recruited infants. Data from semi-structured interviews was thematically analyzed.
Clinicians felt there was a cultural shift towards individualized care based on sequential assessment. They felt the burden of decision-making was theirs, and they adjusted the information provided to parents based on perceived parental preferences. They tended to communicate a broad overview of differential diagnoses, investigations, and treatment and did not feel that giving numerical data was helpful. They felt that clinical decision aids may be useful, particularly as a communication aid and for junior staff. However, there would need to be national guidelines to support their use.
Parents felt overwhelmed initially, preferring a staggered approach to information provision, with time to reflect and ask questions. Their confidence increased if the clinician was confident, if different clinicians repeated the same information, and if guidelines were referenced. Most parents were happy to follow the clinician’s recommendation if informed of their rationale. Some parents wanted all risks, including statistical data, explained, but others preferred an overview. Although parents were generally happy with the initial information, some wanted more information later in the admission.
Take a closer look at these articles: Management of Febrile Infants in the Emergency Department in the UK and Ireland – Don’t Forget the Bubbles (dontforgetthebubbles.com) Well appearing febrile infants – Don’t Forget the Bubbles (dontforgetthebubbles.com)
Why does it matter?
Managing febrile infants is time-critical due to higher rates of serious bacterial infection, and effective clinician-parent communication is therefore important. Good communication reduces parental stress, improves understanding and can reduce negative feedback and complaints.
Clinically Relevant Bottom Line
Attending ED with a febrile infant is stressful and overwhelming for parents. Generally, if parents have confidence in the clinician, and have opportunities to reflect and ask questions, they are happy to consent to the initial suggested management. Later in the admission they prefer more collaborative decision-making.
Reviewed by: Abigail Nye
Article 4: Discharge advice for acute wheeze do we all do it the same way?
Hannah R, Chavasse RJPG, Paton JY, Walton E, Roland D, Foster S, Lyttle MD; PERUKI. Emergency department discharge practices for children with acute wheeze and asthma: a survey of discharge practice and review of safety netting instructions in the UK and Ireland. Arch Dis Child. 2024 Jun 19;109(7):536-542. doi: 10.1136/archdischild-2023-326247.
What’s it about?
This study aimed to assess discharge practices for children presenting with acute wheeze in emergency departments in the Paediatric Emergency Research in the UK and Ireland (PERUKI) network.
66 of 71 departments responded to an initial questionnaire, in which research leads in each department were asked to answer questions describing typical departmental discharge practices for childhood wheeze. In the project’s second phase, research leads were asked to submit the written discharge material routinely provided on discharge in their institution. 61 out of 77 departments responded. Researchers evaluated the questionnaire and discharge plans against pre-defined criteria.
Most sites (94%) provided written safety netting advice, assessed inhaler technique (79%) and provided bronchodilator plans (82%) on discharge. However, a review of medication (32%) and adherence to medication (21%) was performed less commonly. While the majority of sites advised a fixed dose of bronchodilator on discharge to be tapered down, there was significant variability in the doses and tapering advised. There was also significant variability in the advice on how to manage the child should they deteriorate. Â
For all things wheezy check out DFTB module here : Asthma Module – Don’t Forget the Bubbles (dontforgetthebubbles.com)
Of note these responses were based on research leads reporting of practice and analysis of the plans provided and there is the potential for differences between this and clinical practice occurring in the departments.
Why does it matter?
Acute wheeze is an extremely common paediatric emergency department presentation, however there is limited evidence available to guide treatment strategy and safety-net advice post discharge. This survey, which assessed a large number of emergency departments in the UK and Ireland, with a high response rate, identifies significant variance in practice in this area. It highlights the need for further evidence to guide practice in this area.
Clinically Relevant Bottom Line
Given the frequency of paediatric emergency department presentation with wheeze and the variation in practice described regarding discharge treatment regimens and safety-netting advice, this study highlights the need for further research in this area.
Reviewed by: Sarah Blakey
Article 5: (An oldie but a goodie) Short or long course PO ABX for Strep pharyngitis
Altamimi S, Khalil A, Khalaiwi KA, Milner RA, Pusic MV, Al Othman MA. Short-term late-generation antibiotics versus longer-term penicillin for acute streptococcal pharyngitis in children. Cochrane Database Syst Rev. 2012 Aug 15;(8):CD004872. doi: 10.1002/14651858.CD004872.pub3. PMID: 22895944.
What’s it about?
Sore throat is one of the most common causes of presentation to healthcare among the paediatric population. The most common bacterial cause is group A beta-hemolytic streptococcus (GABHS).
This review aimed to compare short-course antibiotic regimens with longer-course regimens in the treatment of strep throat. Inclusion criteria required documented acute streptococcal pharyngitis, as per positive throat swab culture or rapid antigen testing, in patients 1-18 years of age. Twenty studies were included (13,102 patients).
The primary outcome was the number of days to the resolution of fever and sore throat. Secondary outcomes included treatment failure, compliance, and the presence of complications (this included acute rheumatic fever, acute post-streptococcal glomerulonephritis, and suppurative and non-suppurative complications).
The majority of outcomes, both primary and secondary, favoured the groups within the studies with shorter antibiotic duration. Risks of clinical recurrence were not statistically different between short duration and standard duration (10 days of penicillin) groups.
For a deeper dive into all things Strep-related see this post: Diagnosing acute post-streptococcal glomerulonephritis – Don’t Forget the Bubbles (dontforgetthebubbles.com) and Scarlet fever – Don’t Forget the Bubbles (dontforgetthebubbles.com)
Why does it matter?
Globally, GABHS infections are an important cause of morbidity and mortality and the leading cause of bacterial sore throat. The prevailing school of thought is that treatment with a prolonged 10-day course of penicillin prevents complications such as rheumatic heart disease and post-streptococcal glomerulonephritis. However, the incidence of rheumatic fever in high-income countries has declined significantly since the 1950s. The shorter courses of antibiotics measured in this review had shorter periods of fever, sore throat, and lower risk of early clinical treatment failure – potentially due to higher rates of compliance in patients.
It is worth noting that the outcomes measured by each individual study varied, and no studies followed the cases long enough to assess whether shorter courses of alternative antibiotics are adequate for preventing rheumatic heart disease.
Clinically Relevant Bottom Line
In many areas of the world, a shorter course of antibiotics will be sufficient for treating strep throat, improving compliance levels and patient comfort. In areas where rheumatic heart disease is endemic, there remains insufficient evidence to stray from the use of a prolonged course of penicillin.
Reviewed by: Julia Dumesh
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.
Dr John Coveney has taken charge of the Journal Club at BRCH. He has organised all the reviewers to produce such great reviews 🙂
