Merry Christmas and Season’s Greetings!
With millions of journal articles published yearly, it is impossible to keep up. An international team joining DFTB Bubble Wrap from Aghia Sophia Children’s Hospital ED, Athens, Greece, tell us what is new in the paediatric literature…
Led by Spyridon Karageorgos, a Paediatrician enthusiastic about Paediatric Emergency Medicine, reducing antibiotic use in paediatric patients, and Medical Education. He is also a proud QMUL PEM MSc alumni.
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: How to reduce chest x-ray requests in paediatric asthma.
Sakr M, Al Kanjo M, Balasundaram P, Kupferman F, Al-Mulaabed S, Scott S, Viswanathan K, Basak RB. A Quality Improvement Initiative to Minimize Unnecessary Chest X-Ray Utilization in Pediatric Asthma Exacerbations. Pediatr Qual Saf. 2024 Apr 3;9(2):e721. doi: 10.1097/pq9.0000000000000721. PMID: 38576889; PMCID: PMC10990363.
What’s it about?
This single-centre prospective study focused on a quality improvement (QI) project to reduce the overuse of chest X-rays (CXR) in paediatric patients with acute asthma exacerbations (AAE) arriving at the emergency department (ED).
Electronic medical records were evaluated for children aged 2-18 with a preexisting asthma diagnosis. Patients with comorbidities, including congenital heart disease, sickle cell disease, bronchopulmonary dysplasia, gastroesophageal reflux, cystic fibrosis, immunodeficiency, malnutrition, and first-time wheezing, were excluded from the study.
The study was separated into a pre-and post-intervention period, recording the total rate of CXRs and the mean rate of CXRs not aligning with guidelines for AAE. The interventions were based on GINA guidelines 2018 and performed over a 5-month period.
The series of interventions included a person-to-person educational approach, informative posters, guidance card distribution, a general presentation, and an electronic reminder system for CXR indications.
During the preintervention period, 52.2% of patients underwent CXRs, and the monthly mean rate for the performed CXRs not adhering to guidelines was 37.5%. After the postintervention, this dropped to 35.3% and 16.7%, respectively.
This study relied on coding, and if the patient had not been coded as asthma, for example, and coded as pneumonia instead, these patients would not have been included in the study set. It did not look at re-attenders or the disposition of the patients.
Why does it matter?
AAE is a very common cause of hospital visits in pediatric EDs. For this reason, quality indicators must be set to better evaluate and manage paediatric patients.
Check out this post, “Choosing Wisely—Radiographs in Children with Respiratory Symptoms—Don’t Forget the Bubbles,” for a deeper dive into when to perform imaging.
Clinically Relevant Bottom Line
This QI project can be a potential template for other healthcare institutions to avoid unnecessary CXRs in acute asthma exacerbations. Continuous education, visual aids and electronic reminders seem to increase the rate of compliance with current AAE guidelines.
Reviewed by: Thessalia Kamilari and Stavros Antonopoulos
Article 2: Quality Indicators for paediatric asthma in the ED.
Alkhazali IE, Alrawashdeh A, Hashairi Fauzi M, Nik Ab Rahman NH. Quality Indicators of Pediatric Asthma Care in the Emergency Department; a Systematic Review and Meta-Analysis. Arch Acad Emerg Med. 2024 Feb 13;12(1):e26. doi: 10.22037/aaem.v12i1.2214. PMID: 38572217; PMCID: PMC10988188.
What’s it about?
This systematic review aimed to identify and describe existing quality indicators (QIs) designed for use in the ED for paediatric asthma care.
Expert panel studies and observational studies proposed 129 QIs. The majority of them focused on the care process (86.8%), while a smaller percentage focused on care outcomes (9.3%) and structural aspects (3.9%).
Regarding compliance with these proposed QIs, variability was observed across different studies and healthcare systems.
Results showed an overuse of chest X-rays (CXRs) in paediatric asthma cases (43%) and antibiotics. There was a high compliance rate (75%) in steroid use. Compliance rates in discharging asthmatic patients with prescribed steroid therapy were significantly lower.
Why does it matter?
Asthma is one of the top ten reasons for hospital visits in the pediatric ED. Due to variations in medical care, it is important to set quality indicators and assess their implementation.
Clinically Relevant Bottom Line
Medical practice regarding the management of paediatric asthma and compliance with pre-existing QIs appears to vary across different units. Most QIs focus on the care process; however, there is a lack of QIs that assess clinical outcomes. Further research is needed to improve the connection between the care process and optimal clinical outcomes.
Reviewed by: Euphrosyne Giannopoulou and Anastasia Polytarchou
Article 3: Intranasal drug delivery in the paediatric ED.
Intranasal drug delivery in pediatric emergency departments: brief review and future outlook. Hugh McClean, Mohammad Hussein Alsabri, Sania Tahir, Rebecca Song, Christopher Chin. Pediatric Emergency Medical Journal 2023;10(4):109-117. https://doi.org/10.22470/pemj.2023.00745
What’s it about?
This paper reviewed the current literature on intranasal (IN) drug delivery in paediatric emergency departments. Data regarding pharmacokinetics, drug delivery methods, safety, contraindications, and clinical effectiveness were recorded.
Why does it matter?
The nasal mucosa’s proximity to the central nervous system (CNS) and its unique innervation make IN medications effective and promising for future drug development. IN administration offers a noninvasive way to bypass the blood-brain barrier, allowing drugs to rapidly enter the brain.
IN medications can be administered through drip devices or mucosal atomiser devices (MAD). MAD use is preferred due to less drug loss to the oropharynx, higher drug concentrations in the cerebrospinal fluid, better tolerance, and better clinical efficacy.
Adverse events may be caused by the nasal mucosa’s complex anatomy, proximity to the brain, and innervation by sensory and cranial nerves. Minor AEs include nasal discomfort, unpleasant taste, and itchiness. There were limited reports of serious AEs related to using IN medications in PEDs.
One study showed that benzodiazepines, such as midazolam, are effective when administered IN, IV, or per rectum among patients of all ages. However, IN administration was faster and more comfortable for patients without any significant difference in potency among the three routes.
For a closer look at all things paeds analgesia, take a look at our Analgesia and Procedural Sedation Module
Clinically Relevant Bottom Line
PEDs are appropriate settings for the rapid-acting, easily delivered, relatively safe option of IN medication, especially when time, resources, and vascular access are all important considerations.
Reviewed by: Sotiris Argyrakis and Stavros Antonopoulos
Article 4: What are the risk factors for otitis media with effusion?
Paing A, Elliff-O’Shea L, Day J, Joshi D, Arnold S, Holland Brown T, Kennedy V. Modifiable risk factors for developing otitis media with effusion in children under 12 years in high-income countries: a systematic review. Arch Dis Child. 2024 Sep 19: archdischild-2024-327454. doi: 10.1136/archdischild-2024-327454. Epub ahead of print. PMID: 39304206.
What’s it about?
This systematic review identified and evaluated potential modifiable risk factors associated with developing otitis media with effusion (OME) in children under 12. Cohort studies published between 2000 and November 2022, with ≥ 40 children, were included in the review. Seven studies, with 2,760,292 children, were included in the analysis. The overall quality of evidence was low.
The most significant risk factors for developing OME were the presence of ear discharge or pus (OR 2.1, 95% CI 1.01 to 4.35) and exposure to other children (RR 2.79, 95% CI 1.98 to 3.93).
Other notable risk factors included frequent colds or coughs (OR 1.91, 95% CI 1.22 to 2.99), recurrent breathing problems (RR 1.78, 95% CI 1.26 to 2.53), and a history of ear infections in the past year (RR 1.95, 95% CI 1.39 to 2.72).
Adenoid hypertrophy was also strongly associated with recurrent OME (OR 9.96, 95% CI 5.17 to 19.19).
Why does it matter?
OME is a common condition that, if left untreated, may impair children’s hearing and developmental progress. Approximately 80% of children experience at least one episode of OME before age ten. Identifying modifiable risk factors is crucial for preventive strategies that could reduce the incidence of OME in children. However, the low quality of evidence highlights the need for further research.
Learn more about Otitis Media here. Otitis media – Don’t Forget the Bubbles
Clinically Relevant Bottom Line
Major risk factors, including upper respiratory tract infections, ear infections, adenoid hypertrophy, and exposure to other children, are potentially associated with the development of OME in children.
Reviewed by: Maria Berikopoulou and Vassiliki Theologi
Article 5: How good are we at diagnosing elbow injuries by X-ray?
Dann L, Edwards S, Hall D, Davis T, Roland D, Barrett M. Black and white: how good are clinicians at diagnosing elbow injuries from paediatric elbow radiographs alone? Emerg Med J. 2024 Oct 23;41(11):662-667. doi: 10.1136/emermed-2024-214047. PMID: 39181700
What’s it about?
Interpretation of paediatric trauma elbow radiographs is challenging, and there is a potential for harm if misdiagnosed. The changing appearances as the child ages and the cartilaginous nature of the elbow in a developing skeleton complicate the interpretation. Single-center cohort studies showed suboptimal accuracy in correctly identifying elbow injuries. This may lead to either missing potential fractures or overcall injuries, leading to increased use of hospital resources and increased morbidity.
This study aimed to assess the ability of healthcare professionals (HCP) to correctly identify elbow injuries and formulate the correct diagnosis by reading elbow X-rays.
This prospective international study included a multidisciplinary team of healthcare professionals (paediatric EM, EM, GPs) who were asked to interpret and diagnose ten elbow X-rays. The final cohort included 318 HCPs from 18 countries, of which 237 (74.5%) were doctors and 59 (18.6%) were advanced clinical practitioners. Approximately half of the X-rays were correctly interpreted, whereas only nine (2.8%) participants correctly identified all diagnoses. This finding remained true when comparing the level of experience and across specialities.
The study’s main limitations included the absence of medical history and clinical examination that could assist in correctly identifying the diagnosis. Also, potential selection bias due to the nature of recruitment (via the DFTB FOAMed site) cannot be precluded.
Why does it matter?
Paediatric elbow X-rays are challenging to interpret. Missing potential fractures or overcall injuries may lead to increased use of hospital resources and increased morbidity.
Take a look at some excellent resources here to improve your skills: Elbow X-Rays – Don’t Forget the Bubbles CRITOE Quick Quiz.
Clinically Relevant Bottom Line
The results of this study revealed that even experienced HCPs may have difficulty correctly diagnosing paediatric elbow injuries via X-rays. This highlights the need for departments to ensure timely radiology reports and continuous education of HCPs.
Reviewed by: Anastasios Panagiotis Chantzaras and Loukia Ioannidou
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.
