With millions of journal articles published yearly, it is impossible to keep up.
Sheffield Children’s Hospital is a tertiary children’s hospital in the very lovely city of Sheffield. It’s a Major Trauma Centre and the ED sees 60-65K children per year. This year, SCH is 150 years old – we’re planning a very big cake!!
In the Bubble Wrap, we have focused on research relevant to paediatric emergency medicine
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: Shockingly early? Or does early adrenaline give better outcomes in paediatric septic shock?
Harley A, George S, Phillips N, King M, Long D, Keijzers G, Lister P, Raman S, Bellomo R, Gibbons K, Schlapbach LJ; Resuscitation in Paediatric Sepsis Randomized Controlled Pilot Platform Study in the Emergency Department (RESPOND ED) Study Group. Resuscitation With Early Adrenaline Infusion for Children With Septic Shock: A Randomized Pilot Trial. Pediatr Crit Care Med. 2024 Feb 1;25(2):106-117. doi: 10.1097/PCC.0000000000003351. Epub 2024 Jan 19. PMID: 38240535; PMCID: PMC10798589. https://pmc.ncbi.nlm.nih.gov/articles/PMC10798589/
What’s it about?
This RCT examined whether early adrenaline administration after a 20mL/kg crystalloid bolus is feasible and reduces fluid exposure versus a standard 40-60mL/kg bolus in children with septic shock.
The study included 40 children (aged 28 days to 18 years) who required further treatment for septic shock after a minimum of 20mL/kg fluid bolus. Adrenaline was given for at least 60 minutes; initially 0.05 to 0.1 mcg/kg/min, titrated up to 3mcg/kg/min on age-based physiological targets. 17 children were assigned to early inotrope intervention, and 23 to standard care.
Results:
- The median IV bolus volume administered in the first 24 hours and the median hospital length of stay were lower in the intervention group than in the standard care group.
- Including inotrope administration in the ED protocol enabled significantly faster administration.
- The intervention did not result in longer or more PICU stays.
Why does it matter?
Whilst an uncommon presentation, septic shock carries a significant risk of morbidity and mortality. Current guidelines recommend large fluid boluses (40–60 mL/kg) for paediatric septic shock despite limited paediatric RCT evidence and concerns that excessive fluid may worsen outcomes. Early vasopressor support could maintain perfusion while limiting fluid‑related harm.
Check out All You Need to Know About Adrenaline – Don’t Forget the Bubbles for more on adrenaline.
Clinically Relevant Bottom Line
Early adrenaline administration in septic shock is practical and safe in real clinical settings and can reduce cumulative fluid exposure. This approach mirrors the current standard of care in adults with septic shock. Larger studies will be needed to determine whether this has a significant effect on outcomes in paediatric patients.
Reviewed by Dr Natassia King and Dr Jacob Hopper
Article 2: Nebulised ketamine for acute pain management in the ED
Cetin M, Brown CS, Bellolio F, Drapkin J, Glatter R, Motov S, E Silva LOJ. Nebulized ketamine for acute pain management in the Emergency Department: A systematic review and meta-analysis. Am J Emerg Med. 2025 Aug;94:110-118. doi: 10.1016/j.ajem.2025.04.051. Epub 2025 Apr 22. PMID: 40286525.
What’s it about?
This thorough systematic review and meta-analysis aims to answer a practical ED question: Can we use nebulised ketamine for pain, and how good is it?
13 studies with 2496 participants (8 randomised control trials (RCTs), 1 retrospective cohort study, 4 case series) were reviewed. 722 patients (a mix of adults and children) received nebulised, aerosolised, or inhaled ketamine. 11 studies were ED-based, and two were pre-hospital.
Primary outcomes were analgesia efficacy (defined by improvements in pain scores rated 0-10 at different timepoints). Secondary outcomes were the need for rescue analgesia and adverse effects.
Why does it matter?
Timely and effective pain relief for moderate to severe pain in paediatric emergency care is essential but can be delayed by tricky IV access and distress to the child. Intranasal options are available but are volume-dependent, making it difficult to achieve higher doses. Therefore, the idea of administering analgesia by an alternative, needle-free option is appealing.
Check out Analgesia and Procedural Sedation Module – Don’t Forget the Bubbles
Ketamine is familiar territory. This NMDA antagonist is commonly given intravenously, intramuscularly, or, less frequently, intranasally. This review demonstrated similar short-term pain reduction compared to other strong analgesics (e.g. IV morphine, IV ketamine), and similar requirements for rescue analgesia.
Limitations include limited paediatric data (only 2 case series), a wide range of causes of pain, differing ketamine dosing regimens (either fixed 50mg or ranges 0.5-5mg/kg) and administration devices, and a variety of comparator analgesics. There were no serious adverse effects (SAE). Non-SAEs included dizziness and nausea/vomiting (but in similar overall proportions to the alternative medications).
Clinically Relevant Bottom Line
A potentially promising option, but with insufficient evidence in the paediatric population. Given established options such as intranasal fentanyl, a paediatric-specific RCT evaluating nebulised ketamine’s effectiveness against a non-IV option would be a more clinically relevant comparator.
Reviewed by Dr Amelia Stacey and Dr Lisa Sabir
Article 3: Point-of-care ultrasound for hip effusion
Diagnostic Accuracy of Point-of-Care Ultrasound for Hip Effusion: A Multicenter Diagnostic Study Ruchika Mohla Jones, MD, MS*; Laurie Malia, DO; Peter J. Snelling, MBBS, PhD, MPHTM; Antonio Riera, MD; William Mak, DO; Douglas Moote, MD, FRCPC; Michael Brimacombe, PhD, MSc, MA; Henry Chicaiza, MD
What’s it about?
This multicentre study set out to answer the question “How does POCUS compare to radiology ultrasound of the hip in children?”
The study involved PEDs in Australia and the USA, with a total of 161 children enrolled, aged 18 and below, whose presentation required radiology-performed ultrasound (RADUS) for evaluation of a hip effusion. Bilateral hip POCUS was performed by a qualified paediatric emergency doctor credentialed to perform hip ultrasound, in addition to RADUS. The primary outcome was the diagnostic accuracy of POCUS using RADUS as the gold standard.
A total of 18 qualified paediatric emergency doctors enrolled the participants. 3 doctors accounted for 61.5% of the subjects enrolled, for whom POCUS had a sensitivity of 98.1% and specificity of 97.8%. Among the remaining 15 doctors, POCUS had a sensitivity of 83.3% and specificity of 97.4%.
A key limitation of this study was that 3 of the 18 doctors performed over half the POCUS scans, and had higher diagnostic accuracy, suggesting that the volume of scans performed may influence diagnostic accuracy and could limit the generalisability of the findings.
Have a look at Top Ten Tips for New Paediatric POCUS providers – Don’t Forget the Bubbles
Why does it matter?
Atraumatic limp is a common presentation to the PED, and differentials vary widely in their severity, from the more common and self-limiting transient synovitis to the less common but time-sensitive septic arthritis. Timely diagnosis could avoid both acute complications and unfavourable long-term outcomes for these patients. POCUS could expedite decision-making, carrying the advantages of being performed at the bedside and being rapidly available, additionally offering potential cost savings.
Clinically Relevant Bottom Line
POCUS has high diagnostic accuracy in identifying hip effusion in children when performed by paediatric emergency physicians with focused training. This study raises the possibility that POCUS could be incorporated into a decision-support algorithm to diagnose septic arthritis of the hip, potentially expediting surgical management and the initiation of antimicrobials. However, it also reinforces the fact that POCUS is operator-dependent, so any algorithm would need to be backed up with training and time to practice.
Reviewed by Dr Sarah Anderson
Article 4: Can a bedside score guide decisions about admission for CAP in children?
Florin TA et al. Predicting paediatric pneumonia severity in the emergency department: a multinational prospective cohort study of the Pediatric Emergency Research Network. Lancet Child Adolesc Health. 2025;9(6):383‑392. https://doi.org/10.1016/s2352-4642(25)00094-x
What’s it about?
This PERN (Paediatric Emergency Research Network) prospective cohort study included 2222 children aged 3 months to 14 years with community-acquired pneumonia (CAP) across 73 EDs in 14 countries between 2019 and 2021. The authors used logistic regression models to create a points-based scoring tool to distinguish mild from moderate/severe disease.
The tool included predictors such as abdominal pain, refusal to drink, use of antibiotics, chest retractions, tachycardia, tachypnoea and absence of coryza. There was a concordance index of 0.82 in both physician-diagnosed and radiographic CAP cohorts, with risk increasing across score bands, suggesting potential to support admission decisions.
The study used a focused question with an appropriate study design, a large multinational sample and ED-based predictors with clinically relevant outcomes, supporting internal validity and relevance to practice. Key limitations are the exclusion of children with complex backgrounds, the lack of external validation and no impact analysis to assess whether using the score changes outcomes.
Why does it matter?
Paediatric CAP is common, but the existing risk assessment tools are mostly adult-based or low-resource focused and so less relevant to UK PEDs.
Physicians often struggle with the “in between child” – well enough not to require escalation of care, however, still unwell enough to make you feel uneasy. A scoring system to help classify the severity of disease could help with decisions regarding the level of care (ICU, HDU, ward, home).
For a deeper dive into treatment, check out How long should we treat children with pneumonia for? – the results of CAP-IT – Don’t Forget the Bubbles
Clinically Relevant Bottom Line
The score performed well and has the potential to aid in risk assessment and disposition decisions. It does require external validation and further implementation studies.
Reviewed by Dr William Wilson
Article 5: Can a PCT Decision Tool Help Us Say No to Antibiotics?
Malorey D, Tavernier E, Drouard A, et al. Point-of-care decision rule for antibiotic prescriptions in young children with fever without source: an open cluster randomised trial. Archives of Disease in Childhood. https://adc.bmj.com/content/early/2025/12/16/archdischild-2025-329438
What’s it about?
This multi-centre, open-cluster randomised clinical trial of more than 4,800 children sought to determine whether a decision rule could help clinicians identify serious bacterial infections in febrile infants presenting without a source. The rule was based on age, toxic appearance, urinalysis and point-of-care procalcitonin (PCT).
25 centres in France and Switzerland recruited children over a 3-year period who presented to ED with fever without source (FWS) lasting no more than 8 days.
The primary outcome was the percentage of children who received any antibiotic therapy within 15 days of attendance. Morbidity and mortality were secondary outcomes.
By 15 days post-attendance, 26.2% in the tool group had received antibiotics, compared with 38.0% in the usual care group. The tool enabled a 11.8% absolute reduction in antibiotic prescription. There was a greater reduction in antibiotic use among young infants than among those over 3 months.
There was no significant difference in treatment failure or serious adverse events. The tool did not miss any cases of invasive bacterial infection.
Why does it matter?
FWS is a common presentation to ED, often with investigations and intravenous antibiotics prior to excluding serious bacterial infection. Antibiotic resistance is considered by the WHO as a major global health threat and is directly linked to antibiotic overuse. Administration of broad-spectrum antibiotics can disrupt the sensitive microbiome and present both immediate and long-term risks.
Clinically Relevant Bottom Line
This decision tool, with sequential assessment of toxic appearance, urinalysis, and bedside PCT, could reduce antibiotic exposure in children with FWS and decrease invasive procedures without compromising morbidity or mortality.
Clinical use in the UK is currently limited by the lack of point-of-care PCT testing.
Reviewed by Dr Andrew Seggie
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.