With millions of journal articles published yearly, it is impossible to keep up. This month, clinicians from paediatric emergency and Children’s Ark of University Hospital Limerick, Ireland share a variety of what is new in the world of paediatric literature.
University Hospital Limerick is a regional hospital in the Midwest of Ireland, that serves the population of a large geographical area across counties Limerick, Clare, and North Tipperary.
Led by Kene Maduemem, Paediatric Emergency Medicine Consultant, they review a range of articles displaying illness, trauma, health promotion and patient safety.
Happy reading and Happy festive period!
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: The PECARN rule to identify low-risk febrile infants for SBIs
Orfanos I, Vrijlandt S, van der Walle E, et al. Validating the PECARN rule to identify febrile infants at low risk of serious bacterial infections: an international validation study. Arch Dis Child. 2025 Sep 10:archdischild-2024-328246
What’s it about?
This multicentre study sought to externally validate the Paediatric Emergency Care Applied Research Network (PECARN) rule for identifying serious bacterial infections (SBIs) in febrile (temp > 38 °C) infants under 60 days old. This rule establishes risk using procalcitonin, urinalysis and absolute neutrophil count. The rule’s effectiveness is also evaluated when switching from procalcitonin to the more readily available CRP.
Initially, 536 febrile infants across four Swedish emergency departments (EDs) were included retrospectively to validate the calcitonin PECARN rule. Then, 512 febrile infants from the prospective, multicentre MOFICHE (Management and Outcomes of Fever in Children in Europe) study in 12 EDs across 8 European countries, and a larger Swedish retrospective cohort (2237 infants) were used to validate the PECARN with CRP substituted.
The procalcitonin PECARN rule had a sensitivity of 96.6% and NPV of 99.3% in identifying SBIs. Using a CRP of < 20, the adjusted PECARN rule had a sensitivity of 97.8% and NPV of 99.4% in the Swedish cohort and a sensitivity of 92.2% and NPV of 98.3% in the MOFICHE cohort.
Why does it matter?
Young febrile infants are an extremely common presentation to the ED, with frequently performed extensive investigations (including invasive testing) and hospital admissions to exclude SBIs.
Check out this post: How should we assess febrile infants? Results from the FIDO study – Don’t Forget the Bubbles
Clinically Relevant Bottom Line
This study showed a promisingly high sensitivity of the PECARN rule, both using procalcitonin and CRP, aligning with the US verification study (in identifying SBIs in these European cohorts). A conflicting Spanish validation study and low-invasive bacterial infection rates in both this study and the original verification study suggest further validation is required before clinical reliance.
Reviewed by Michael Lane
Article 2: QI and safety culture interventions in the paediatric emergency department (PED) improve patient outcomes
Onyejesi CD, Elsayed SM, Daniel Isaac JM, et al. Improving patient outcomes through quality improvement and safety culture interventions in pediatric emergency care: a systematic review of best practices. Int J Emerg Med. 2025 Oct 23;18(1):217
What’s it about?
Across 31 studies, simple structured strategies – such as standardised protocols, safety checklists, decision support tools, teamwork practices and simulation training – consistently improved care.
QI interventions lead to 6.45%-20.55% reductions in unnecessary radiation exposure, a 25-minute reduction in PED length of stay (LOS), and decreases in overtreatment for conditions like croup and bronchiolitis. Cost savings were substantial, including $440,000 from simulation-based training and $190 per patient in gastroenteritis care. The few trials reported reductions of 6% in mortality and 23% in ICU admissions. One large simulation-based intervention resulted in a 36.4% reduction in hospital admissions for closed fractures.
Outcomes varied by setting, highlighting the need to tailor interventions to the clinical context, available resources, and staff engagement.
Limitations include few high-quality trials (only one RCT), and limited assessment of safety culture factors with consequent limited testing for sustainability of change following QI interventions.
Why does it matter?
PEDs are busy, high-stakes environments. This review shows that when QI strategies are embedded into existing local workflows – and supported by ongoing education, reinforcement and standardised through clear clinical guidelines – paediatric emergency care becomes safer, faster and more efficient.
Clinically Relevant Bottom Line
Systematic QI interventions consistently improve outcomes by reducing unnecessary tests and treatments, shortening LOS, improving efficiency, and lowering costs in PEDs. While evidence quality varies and safety culture components remain understudied, the consistency of positive results across various clinical settings indicates that QI should be a core part of paediatric emergency care.
Reviewed by Dr Roisin Coyne
Article 3: Penthrox® as a safe and effective analgesic in paediatric trauma
Hartshorn S, et al; Paediatric Emergency Research in the United Kingdom & Ireland (PERUKI). Treatment of acute trauma-related pain in children and adolescents with methoxyflurane (Penthrox®) compared to placebo (MAGPIE): A randomised clinical trial. Injury. 2025;56(12):112830
What’s it about?
Evaluation of the safety and efficacy of methoxyflurane (Penthrox®) in children (aged 6-17 years) with minor trauma and acute pain presenting to emergency departments (EDs) in the UK and Ireland. Participants with minor trauma and pain scores of 55–85 mm on a visual analogue scale (VAS) were recruited. 249 participants were randomised (127 to methoxyflurane, 122 to placebo) and 192 were treated (92 to methoxyflurane, 100 to placebo).
The primary endpoint was the change in VAS from baseline to 15 mins, which showed a significant difference in the methoxyflurane group (-20 mm) vs. placebo (-13.2mm) with an LS mean difference of −6.8 (95 % CI −12.5 to −1.2). The difference between the groups persisted for 1 hour post-baseline.
A secondary endpoint was responder analysis of at least a 30% reduction in VAS score compared to baseline at 15 min. More responders in the methoxyflurane group achieved this reduction, significantly at 5 min (Odds Ratio (OR) 2.77, 95 % CI 1.33 to 6.06, p = 0.006) and 20 min (OR 1.94, 95 % CI 1.07 to 3.58, p = 0.029). Fewer methoxyflurane participants required rescue medication (9.8% vs 30%). There were no serious adverse events related to methoxyflurane.
Why does it matter?
Early pain relief remains one of the most variable aspects of paediatric trauma care. Methoxyflurane (Penthrox® inhaler) is patient-controlled, an essential factor for providing safe and effective analgesia without the need for intravenous cannulation. Methoxyflurane is a non-opioid and fast-acting agent, offering practicality in achieving prompt pain management and reduction in opioid exposure.
For a deeper dive into paediatric analgesia, see this post Paediatric analgesia and pain assessment – Don’t Forget the Bubbles
Clinically Relevant Bottom Line
The MAGPIE trial positions methoxyflurane as a genuinely valuable early-stage analgesic in paediatric trauma. Fast, practical, and well-tolerated, it has the potential to change first-line pain management in busy paediatric EDs.
Reviewed by Muaz Elsamani
Article 4: Surveillance of herpes simplex virus disease in young infants
Dudley JRR, Shears A, Yan G, Heath PT, Ladhani SN, Ribeiro S, Fidler K. Herpes simplex virus disease in infants younger than 90 days: a British Paediatric Surveillance Unit study. Arch Dis Child. 2025 Sep 1:archdischild-2025-329176.
What’s it about?
The largest population-based surveillance study of HSV in infants under 90 days of age in the UK and Ireland. Over two and a half years, 117 infants were identified (6.0/100,000), showing a doubling of incidence in the UK over the preceding 15 years.
The median age at symptom onset was 8 days. 81% of the babies were born to mothers without a known history of genital herpes. Infants with the highest morbidity and mortality frequently presented with nonspecific symptoms and normal inflammatory markers. CNS infection (35.0%) and disseminated disease (32.5%) were the most common presentations. HSV-1 and HSV-2 contributed equally, and 31.3% of infants were born by caesarean section. Two-thirds of infants with CNS or disseminated infection were afebrile and had low CRP values (median 2.8). Among 115 infants with treatment data, 112 received aciclovir; three with disseminated disease died before treatment. A 24-hour delay in aciclovir therapy was associated with poor neurodevelopmental outcomes in 1 out of 3 affected infants. At 1-year follow-up, 7/21 CNS infants had neurodevelopmental impairment. The overall case fatality rate was 23.9%.
Why does it matter?
Although neonatal herpes is relatively uncommon, its incidence is rising and can result in catastrophic outcomes. Typical features of fever, seizures, vesicles, and abnormal labs are often absent. Delayed treatment leads to poor outcomes. The findings emphasise the need for robust antenatal HSV screening to prevent maternal-infant transmission.
Check out Neonatal herpes – Don’t Forget the Bubbles.
Clinically Relevant Bottom Line
Neonatal herpes infections are often associated with an unknown history of maternal genital herpes. These infants can present with nonspecific signs such as respiratory distress or jaundice, often without fever or elevated infection markers.
Reviewed by Komal Moorpani
Article 5: The golden jubilee of Expanded Programme on Immunization (EPI)
Shattock AJ, Johnson HC, Sim SY, et al. Contribution of vaccination to improved survival and health: modelling 50 years of the Expanded Programme on Immunization. Lancet. 2024 May 25;403(10441):2307-2316.
What’s it about?
Fifty years on from its initiation, the impact of the WHO’s Expanded Programme on Immunisation (EPI) is examined. Using modelling data from 194 countries, the authors estimate that, in that time, a staggering 154 million deaths have been prevented – equating to 6 lives saved every minute.
Vaccination has averted an estimated 154 million deaths since 1974, with 146 million of these in children under five years old, including 101 million infants. The study estimates that vaccination against the 14 pathogens included in the EPI accounts for 40% of the observed global fall in infant mortality (with regional variations; 52% in Africa), with measles vaccination alone responsible for over half of the estimated lives saved.
Why does it matter?
Vaccination remains the single most important paediatric public health intervention of our time. In a global climate where misinformation outbreaks [KM1] [LS2] [LS3] pose a serious public health threat equal to that of any vaccine-preventable disease, the onus is on clinicians to arm themselves with accurate, up-to-date information. This study serves to translate decades of evidence into meaningful estimates of impact and inform our conversations with parents and policymakers.
Despite all of these extraordinary efforts, there is, sadly, a rise in some preventable conditions. The resurgence of vaccine-preventable infections: Measles and Pertussis – Don’t Forget the Bubbles
Clinically Relevant Bottom Line
EPI has significantly reduced morbidity and mortality globally. Make each patient meaningful by taking the opportunity to counsel for vaccination, particularly in underserved communities. Ask yourself – is this child appropriately immunised for age and risk?
Reviewed by Laura Stephens
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.