The 87th Bubble Wrap

A very Happy New Year- 2025!

With millions of journal articles published yearly, it is impossible to keep up. The Bubble wrap team scoured the literature for the first of 2025- so you don’t have to. With a wide variety of topics, take a few minutes out of your New New Year routine and look at what’s new in paediatrics.

Happy Reading 🙂

If you or your team want to submit a review, please get in touch with Dr Vicki Currie at @DrVickiCurrie1 or vickijanecurrie@gmail.com.

Article 1: Is lung ultrasound a viable alternative to chest x-ray in diagnosing community-acquired pneumonia?

Hughes-Davies H, Ukwatte U, Fanshawe TR, Roberts N, Turner PJ, Hayward GN, Bird C et al. Diagnostic accuracy of point-of-care lung ultrasound for community-acquired pneumonia in children in ambulatory settings: A systematic review and meta-analysis. Ultrasound. 2024 Oct 29;

What’s it about? 

This systematic review assessed the diagnostic accuracy of point-of-care lung ultrasound (POC LUS) for 0-21-year-olds with suspected community-acquired pneumonia in ambulatory settings.

The six included studies (1099 children) used chest X-rays interpreted by radiologists or patient-facing clinicians as the reference test. Pneumonia was classified as lung consolidation. The POC LUS could be performed by any clinician ‘managing sick children’ with training – although the degree of training varied between studies.

The pooled sensitivity was 90.9%  (95% CI [85.5-94.4]), whilst the pooled specificity was 80.7% (95% CI [63.6-91.0]). This high sensitivity suggests that a POC LUS could be an effective diagnostic tool with minimal training. However, the lower specificity could lead to unnecessary antibiotic prescriptions. The specificity of this paper was lower than other similar meta-analyses, but these included inpatients with a higher likelihood of positive findings.

Six studies met the inclusion criteria. They all used different ultrasound devices with varying levels of operator training. Be mindful that many national guidelines do not recommend using CXR routinely to diagnose community-acquired pneumonia and rely on clinical findings, which were not analysed. Only six studies met the criteria for this study, which is a relatively small number.

If you are inspired and want to start thinking about POCUS, look at this post: Top Ten Tips for New Paediatric POCUS Providers – Don’t Forget the Bubbles.

Why does it matter? 

Pneumonia accounts for 14% of deaths in < 5 year-olds. 30-50% of paediatric cases result in hospitalisation.

Lung ultrasound can be taught and performed quickly at the bedside, but it is not currently included in national guidelines for diagnosing pneumonia. CXRs are only recommended in severe cases or if there is diagnostic uncertainty, but they are used in up to 73% of children with suspected pneumonia, exposing them to unnecessary radiation.

Clinically Relevant Bottom Line

POC LUS has a high pooled sensitivity but a lower specificity in ambulatory settings. Further studies are needed to clarify appropriate training requirements.

Reviewed by: Mikaeel Jaffer

Article 2: Does the duration of pre-hospital CPR affect neurological outcomes?

Yasuda M, Amagasa S, Kashiura M, et alDuration of prehospital and in-hospital cardiopulmonary resuscitation and neurological outcome in paediatric out-of-hospital cardiac arrestEmergency Medicine Journal 2024;41:742-748.

What’s it about? 

This retrospective cohort study aimed to determine the association between CPR duration (from initiation pre-hospital by emergency medical services) and neurological outcomes in paediatric out-of-hospital cardiac arrest (OHCA). It used a Japanese registry that prospectively collects pre- and in-hospital data on patients with OHCA. The primary outcome was 1-month survival with a moderate disability or better neurological outcome after OHCA. This is a bit of a mouthful, so let’s refer to this as a favourable neurological outcome.

Of the 1007 eligible children in the data set, 252 achieved ROSC after CPR was started. These were included in the study. At one month, 53 had a favourable neurological outcome.

The probability of achieving a favourable neurological outcome dropped below 0.01 when the total duration of CPR reached 64 minutes. As the duration of CPR increased, both crude and adjusted odds ratios for favourable neurological outcomes steadily declined. With increasing CPR duration, crude and adjusted odd ratios for favourable neurological outcomes decreased.

Why does it matter? 

Prolonged CPR is linked to poor neurological outcomes in paediatric patients. However, there is limited evidence to guide decisions on when to stop resuscitation efforts in this population.

Figuring out when to stop resuscitation can be challenging and emotional. This study provides evidence that a longer duration of CPR results in poor neurological outcomes. This evidence can help inform decision-making around the difficult decision of when to stop CPR.

There are several limitations to this study. These include confounding factors which have not been adjusted for, small sample size and some wide confidence intervals. So, while the numbers they produce are interesting, I’m unsure whether this study would change my practice. If a well-child had a sudden cardiac arrest with no downtime before good CPR was started, I’m sure everyone would be doing a fairly long resuscitation effort regardless of this research. But this would be different if there had been a long down time or if another negative predictor of poor outcome was identified in the resuscitation effort.

Clinically Relevant Bottom Line

This study provides further evidence that prolonged CPR is associated with less favourable neurological outcomes.

Its conclusion suggests that CPR duration may need to be continued for at least 64 minutes to maximise the number of paediatric patients who can achieve a favourable neurological outcome after OHCA. This is three times as long as the 20 minutes suggested by APLS, and it is unlikely that resuscitation efforts will be successful if ROSC has not been achieved (except in certain circumstances).

Reviewed by: Frederick Smith

Article 3: Does this infant have a dislocated hip? And how good are our tests at picking it up? 

Singh A, Wade RG, Metcalfe D, Perry DC. Does This Infant Have a Dislocated Hip? The Rational Clinical Examination Systematic Review. JAMA. 2024;331(18):1576–1585. doi:10.1001/jama.2024.2404

What’s it about?

This is a systematic review to evaluate the diagnostic accuracy of clinical examination in identifying dislocated hips in infants.  

Nine included studies reported the diagnostic accuracy of clinical examination and diagnostic hip ultrasound in infants aged 3 months or younger. The Graf method of ultrasound assessment was used to classify hip abnormalities.  

In five studies, the prevalence of a dislocated hip was 0.94% in infants screened with a clinical examination and diagnostic ultrasound.  

Eight studies (n=44,827) evaluated the use of Barlow and Ortolani manoeuvres, which can dislocate and relocate an unstable hip. These tests had a sensitivity of 46% (95% CI 26-67%) and a specificity of 99.1%.

Other studies evaluated limited hip abduction and clicking sound with lower sensitivity and specificity.  

Why does it matter?

Delayed diagnosis of a dislocated hip in infants can lead to complex childhood surgery, interruption to family life and premature osteoarthritis.  Equally, there are a lot of referrals for ongoing assessment of babies with a ‘clicky hip’ or restricted movement.

To find out more about what these tests are looking for, check out this post: Diagnosing DDH – Don’t Forget the Bubbles.

Clinically Relevant Bottom Line

A positive Barlow or Ortolani manoeuvre was the finding most strongly associated with an increased likelihood of a dislocated hip. In contrast, limited hip abduction and a clicking sound were not found to have clear diagnostic value.

Reviewed by: Shaza Gaafar 

Article 4: Thunderstorm Asthma

Charles G Stewart, Ayushi Mahesh, Claire Mulvenna – Thunderstorm asthma: a paediatric emergency department experience in London: BMJ Paediatrics Open 2024;8:e002572.

What’s it about?

A retrospective cross-sectional study explored a sudden surge in wheeze presentations to a Paediatric Emergency Department (PED) in London following a thunderstorm in June 2023. This spike coincided with a sharp rise in pollen counts. It is hypothesised that lightning and rain can break down pollen particles into smaller, more easily inhaled fragments, often referred to as ‘pollen bombs’—a phenomenon known as Thunderstorm Asthma (TA).

The thunderstorm occurred on 12th June 2023, and there was a significant increase in wheeze presentations, 28% of total PED admissions on 12th June vs 19% on 13th June (n = 50 and n = 19 respectively). In the week preceding 12th Jun,e the number of admissions with wheeze was consistently <20 and often <10 per day.

This is a rare phenomenon, and as such, there is limited literature available on the topic. This study focuses on a single region in the UK, so it would be valuable to investigate whether other areas, both within the country and internationally, experienced similar effects. The comparison was made using wheeze-related attendances the following day. However, examining data from additional time points might have provided further insights, as a single day may not have been sufficient to capture the full impact or resolution of the Thunderstorm Asthma (TA) event.

Why does it matter?

TA is an increasingly recognised phenomenon, even if it is only sparsely reported. It was first recognised following an episode in Birmingham, UK, in 1983. Since then, it has only been reported five times in the UK and 26 times globally.

A key observation about the patient cohort presenting to the Paediatric Emergency Department (PED) is that the majority (57%) had no prior history of wheeze. This highlights the need for public health warnings to target the general population, not just individuals with a known history of wheezing or asthma. Preventative measures to reduce risk include wearing masks, taking antihistamines, maintaining good adherence to prescribed treatments, and staying indoors during high-risk weather conditions.

For a deeper dive into asthma check out Asthma Module – Don’t Forget the Bubbles.

Clinically Relevant Bottom Line

Medical services should know that thunderstorms can precipitate wheeze, even in those without an asthma diagnosis. Considering preparedness (e.g., ensuring working nebulisers, sufficient medications, and oxygen availability) when a thunderstorm is forecast will help manage an increase in presentations safely in both primary and secondary care.

Reviewed by: Reviewed by Andy Moriarty, Ben Tyler, Katie Sproson and Priya Patel, GPST3 Chesterfield and the Derbyshire Dales GPSTP.

Article 5: Are temporal temperature measurements accurate or affected by age or race?

Rama A. Salhi, Melissa A. Meeker, Carey Williams, Theodore J. Iwashyna and Margaret E. Samuels-Kalow, Inaccuracy of temporal thermometer measurement by age and race, Academic Pediatrics, (2024) doi:https://doi.org/10.1016/j.acap.2024.102620

What’s it about?

This retrospective study evaluated the error rates of temporal thermometer measurements by age and race among paediatric patients in the ED. This comes on the back of recent studies highlighting racial bias when looking at pulse oximetry measurements.

This study included paediatric patients (aged ≤18 years) identified as either Black or White who presented to an Emergency Department (ED) over 2 years. Eligibility required at least one paired temperature measurement—temporal and oral/rectal—taken within 30 minutes of each other. 1,526 paired temperature measurements were recorded from 1,412 patients (16% Black, 84% White).

Discordance was defined as one measurement method detecting a fever (>38°C) or hypothermia (<36°C for patients ≤28 days or ≤35°C for patients >28 days) while the other method did not.

They noted 26% discordance; of the discordant temperature readings, 88% were clinical fevers missed by the temporal thermometer.

The study found that younger children (≤12 years) were 2-3 times more likely to have discordant measurements than older children ( >12 years). Thus, younger children (≤12 years) had increased odds of having a missed fever by temporal thermometry.

There was no significant difference in discordance between Black and White patients. The authors were interested in looking at discordance based on race, as skin pigmentation can affect the accuracy of pulse oximetry. Pulse oximetry measures saturations through spectrophotometry, whereas temperature measurement relies on skin emissivity, which may not be impacted by skin pigmentation.

Secondary analysis also found that Black patients aged 1-4 years and male patients were more likely to receive temporal thermometry only. This may be due to anticipated tolerance or indicate differences in clinical practice based on race/sex.

The study’s limitations included using race as a surrogate for skin pigmentation. Race includes people with a broad spectrum of skin pigmentation and may have altered the ability to truly measure rates of discordance.

Axillary temperature measurements were not included in this study. Given this route’s ease of use and tolerability, it would be interesting to see a study comparing the accuracy of oral/rectal vs axillary temperature.

Why does it matter?

Temperature is a vital sign and is particularly important in the paediatric population. Temperature measurement can affect room placement, triage category, medical interventions (such as the need for LP and timing of antibiotics), disposition, hospital length of stay, and ongoing follow-up.

These findings highlight the need for consistent, accurate measurement protocols among paediatric patients presenting to the ED.

For a deep dive into the febrile child, check out the DFTB module Febrile Child Module – Don’t Forget the Bubbles.

Clinically Relevant Bottom Line

Temporal thermometer measurements can miss clinical fevers, particularly in younger patients ( ≤12 years). Given the clinical implications, it would be valuable to have a standardised approach to ensure accurate temperature measurements in the department (oral/rectal) to minimise missed fevers.

Reviewed by: Sugandha Gupta

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.