With millions of journal articles published yearly, it is impossible to keep up. This month, the team from Bristol Royal Children’s PED showcase the latest research on common presentations and use of technology in ED that you really want to know about!
Bristol Children’s Hospital ED team used Bubble Wrap to springboard their journal club…. what a great idea!
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: How safe is methoxyflurane for kids?
Kelty, E. A., Murray, K., Sanfilippo, F. M., & Preen, D. B. (2024). The Safety of Methoxyflurane for Emergency Pain Relief in Children and Adolescents: A Retrospective Cohort Study. Prehospital Emergency Care, 29(6), 768–775. https://doi.org/10.1080/10903127.2024.2397519
What’s it about?
This is a large retrospective cohort study of prehospital methoxyflurane use in Western Australia over 26 years. The study aims to examine the safety profile of methoxyflurane in this setting by retrospectively looking at hospitalisation, re-admission and death rates, as well as renal and hepatic toxicity and recorded drug side effects.
Routinely collected electronic ambulance data by St John’s Ambulance service across Western Australia between 1990 and 2016 for patients <18 years old was examined, totalling 37,211 children. The data was subdivided into 4 cohorts of analgesia exposure: Methoxyflurane, Opiate, Methoxyflurane and opiate and no analgesia. Those not falling within a cohort were excluded. Cohorts were further stratified by age group, aboriginality, socio-economic status, rurality, urgency of and reason for transfer prior to analysis.
When comparing the primary outcomes of hospitalisation, re-admission, and death rates, the study found low rates of death, ICU admission, and re-admission across all groups, with no significant difference in rates of hospitalisation. With regards to secondary outcomes of side effects, <0.1% of children across the methoxyflurane, opiate, and combined therapy groups had recorded side effects, and zero were found to have renal or hepatic toxicity in the methoxyflurane group.
Whilst there are many biases and limitations within the study design and methodology that limit the drawing of more complex conclusions, it provides data from a large population that suggests low risks and few negatives associated with methoxyflurane use in children.
Why does it matter?
Effective analgesia is paramount to achieving good patient experience and improving clinical outcomes in the emergency department, particularly in injured children, to facilitate examination, build trust and rapport with clinicians and reduce harm to children within healthcare settings.
For more on analgesia, visit Paediatric analgesia and pain assessment – Don’t Forget the Bubbles
Clinically Relevant Bottom Line
Methoxyflurane appears to be a safe analgesic agent when administered to children prehospitally with limited side effects and, therefore, is an appropriate agent for clinical trials within emergency departments.
Reviewed by Joshua Latham
Article 2: How effective is direct admission compared to admission via the Emergency Department?
Leyenaar JK, Acquilano SC, Freyleue SD, Schaefer AP, McDaniel CE, Bode RS, Erdem G, Lauden S, Schmerge C, Choi SS, Felman K, Fleischer A, Houtrow AJ, Bruce ML, O’Malley AJ. Effectiveness of Direct Admission Compared to Admission Through the Emergency Department: A Stepped-Wedge Cluster-Randomized Trial. Pediatrics. 2024 Oct 1;154(4):e2024065776. doi: 10.1542/peds.2024-065776. PMID: 39301600.
What’s it about?
This multicenter, prospective study, published in Pediatrics (2024), evaluated the effectiveness of direct admission (DA) to the hospital for children compared to admission via the emergency department (ED).
Specifically, direct admission means children are being admitted without receiving care in the ED. Conducted across 39 U.S. hospitals, it included over 52,000 paediatric admissions (19% direct, 81% via ED) and used mixed methods: quantitative data analysis and caregiver interviews—to assess timeliness of care, clinical outcomes, and family experience. Specific criteria for children being seen at a participating clinic. The primary outcome was the timeliness of clinical care. Secondary outcomes included caregiver-reported experiences of care, such as clinical deterioration, transfer to the ICU, and escalation to rapid response within 6 hours.
Children admitted directly experienced shorter time to inpatient assessment (median 2.2 vs 3.6 hours) and earlier clinical evaluation. Importantly, there were no significant differences in ICU transfers, length of stay, or 30-day readmission rates, suggesting comparable safety to ED admission.
Caregivers reported greater satisfaction with the direct process, citing less stress and faster care. Interviews highlighted improved continuity, smoother transitions, and more predictable planning. However, successful implementation depends on well-established protocols, strong communication between primary and hospital teams, and careful patient selection, typically children with known diagnoses or non-urgent conditions.
An important factor to consider is that these children were not walk-ins and had already been ‘screened’ by a HCP. Therefore, these results do not apply to a lot of the ED population.
Why does it matter?
Paediatric emergency departments are often overburdened, resulting in prolonged waits and increased healthcare costs. Direct admission could improve system efficiency, reduce strain on EDs, and offer a less chaotic, more family-centred pathway to hospital care. However, concerns have remained about safety and quality of care for those bypassing ED triage. This study addresses that gap, providing robust evidence for when and how DA can be used effectively.
Clinically Relevant Bottom Line
This study supports the expansion of DA models as a clinically sound and patient-friendly alternative to ED-based hospitalisation, especially where timely coordination and infrastructure are available.
Reviewed by Ross Goodson
Article 3: Diagnosis of Septic Arthritis in Children with Acute Limp
Tu J, Lam S, Yamano C, Paul E, Ghobrial O, Gowdie P, Craig S. Test characteristics of clinical findings and clinical decision rules for the diagnosis of septic arthritis in children with an acute limp presenting to the emergency department: a prospective observational study. Emerg Med J. 2025 May 22;42(6):360-366. doi: 10.1136/emermed-2024-214607. PMID: 40199562.
What’s it about?
This was a prospective observational study conducted across three emergency departments (EDs) in Melbourne, Australia, between July 2016 and September 2018. It aimed to evaluate the diagnostic accuracy of two commonly used clinical decision rules—Kocher’s rule and Caird’s rule —for identifying septic arthritis in children presenting with an acute, non-traumatic limp. The study also sought to identify which individual clinical features were most predictive of septic arthritis. A total of 535 children under 16 years were included in the final analysis, out of 674 potentially eligible participants. Children with traumatic injuries, upper limb pain, or non-orthopaedic causes of limp were excluded. Fourteen children (2.6%) were ultimately diagnosed with septic arthritis.
The study found that markedly reduced joint range of motion and inability to weight-bear were the strongest clinical predictors, outperforming traditional markers such as fever or elevated inflammatory markers. However, no single sign or test was sufficient to rule out the diagnosis.
Limitations include the low number of septic arthritis cases, lack of a gold-standard diagnostic test (e.g., joint aspiration was rarely performed), and potential misclassification. Despite this, it remains one of the largest prospective ED-based studies on this topic to date.
For a deep dive into limping children, see The Limping Child Module – Don’t Forget the Bubbles
Why does it matter?
Septic arthritis is rare but serious—delayed diagnosis can lead to long-term disability or even death. However, it’s difficult to distinguish from more benign causes of limp like transient synovitis. The commonly used Kocher and Caird rules were developed in surgical settings, not EDs, and may not perform well in the more undifferentiated ED population. This study challenges their utility in real-world ED practice and highlights the need for better tools.
Clinically Relevant Bottom Line
Septic arthritis is rare but serious in limping children. Markedly reduced joint movement and inability to weight bear are the strongest clinical predictors. However, no single sign or test can reliably exclude the diagnosis. Current decision rules underperform in ED settings—clinical judgment and further research into ED-specific tools are essential.
Reviewed by Nima Maleki
Article 4: What is the prevalence of invasive bacterial infection among febrile infants with a positive urinalysis?
Drummond H, Umana E, Mills C, Waterfield T. Prevalence of invasive bacterial infection among febrile infants with positive urinalysis results: a planned secondary analysis of the Febrile Infants Diagnostic assessment and Outcome (FIDO) prospective observational cohort study. Arch Dis Child. 2025 Jul 8:archdischild-2025-328816. doi: 10.1136/archdischild-2025-328816. Epub ahead of print. PMID: 40628460.
What’s it about?
This study is a secondary analysis of the Febrile Infants Diagnostic assessment and Outcome (FIDO) study. Its aim is to determine the prevalence of invasive bacterial infections (IBIs) in febrile infants aged ≤90 days who have a positive urinalysis. Of the 1480 infants who underwent urinalysis testing, 549 tested positive and 931 tested negative.
There were no significant differences in the prevalence of bacterial meningitis even when the cohort was divided into age bands (≤ 28 days, 29–60 days, and 61–90 days). Notably, no cases were identified in infants aged ≥ 60 days. In contrast, bacteraemia was more common in the positive urinalysis group than in the negative urinalysis group (7.1% vs 1.9%; p < 0.0001).
For a review of the main FIDO study, see How should we assess febrile infants? Results from the FIDO study – Don’t Forget the Bubbles
Why does it matter?
Fever is one of the most common presentations in paediatrics. Febrile infants ≤90 days are at higher risk of IBI such as bacteraemia and bacterial meningitis.
When assessing a febrile infant with a positive urinalysis, clinicians must decide whether to perform a lumbar puncture to rule out bacterial meningitis. This is an invasive procedure which is distressing for both the infant and their families and comes with a risk of rare but serious complications.
Clinically Relevant Bottom Line
This study reinforces that rates of bacterial meningitis are low, especially in infants ≥60 days with a proven UTI. This analysis supports the current NICE guidelines that all febrile infants ≤90 days should undergo blood culture testing to screen for bacteraemia, especially if there is positive urinalysis.
It also provides evidence that invasive lumbar punctures are not routinely required where there is high clinical suspicion of an isolated UTI in infants ≥60 days.
Reviewed by Harry Wong
Article 5: Does therapeutic touch improve colic symptoms?
Ateş Beşirik S, Geçkil E. The effect of therapeutic touch on colic symptoms in infantile colic infants: A randomised controlled study. J Paediatr Child Health. 2024 Oct;60(10):569-578. doi: 10.1111/jpc.16646. Epub 2024 Aug 15. PMID: 39143930.
What’s it about?
This was a randomised control trial examining the effects of therapeutic touch on infantile colic symptoms, as assessed by the Infant Colic Scale (ICS) score, crying time, and sleep time.
64 infants with colic (between 4 and 12 weeks old) were recruited in 2020. Infants were assigned to the intervention group or the control group using a stratified randomisation method. The intervention group received the therapeutic touch six times over a two-week period, in addition to usual care (very clear explanation and diagrams on how to perform this 10-minute activity). The control group received only usual care.
There was a statistically significant difference between the two groups for the ICS score (47.65 in the intervention group compared to 103.43 in the control group, P<0.001), with a low score indicating a decrease in colic and a high score indicating an increase in colic. Additionally, the intervention group exhibited lower levels of crying and improved sleep quality compared to the control group, which was also statistically significant (P < 0.001).
Why does it matter?
Colic is a clinical problem characterised by excessive and repeated prolonged crying. It can negatively affect the sleep, rest and nutrition of babies and can be incredibly challenging for caregivers.
There is no definitive treatment for colic; therefore, the focus is on reducing symptoms. Touch is one of the most developed senses since birth and is known to comfort infants. If therapeutic touch is effective in reducing colic symptoms, improving sleep, and decreasing crying, it could be of significant benefit to both the infant and the caregiver.
This study demonstrated that the therapeutic touch can alleviate symptoms in infants with colic. Although there may be some issues with the study (e.g., it was small and lacked participant blinding), therapeutic touch remains a low-cost, low-risk, and easy-to-implement intervention. For clinicians who frequently encounter this exhausted and exasperated group of caregivers, it provides a resource we can direct them towards. And might it all just be a placebo? Well, maybe, but does it matter?
It is important to note that there was no blinding in this study, either for participants or researchers, which introduces significant biases.
Clinically Relevant Bottom Line
Therapeutic touch could provide caregivers with a positive and proactive approach to managing what can be a very challenging diagnosis – this might, in itself, be enough.
Reviewed by Charlotte Munday
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 all articles.