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The 9th Bubble Wrap

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With millions upon millions of journal articles being published every year it is impossible to keep up.  Every month we ask some of our friends from PERUKI (Paediatric Emergency Research in UK and Ireland) to point out something that has caught their eye.

Article 1: How good is ultrasound in diagnosing pneumonia?

Yilmaz HL, Özkaya AK, Gökay SS, Kendir ÖT, Şenol H. Point-of-care lung ultrasound in children with community acquired pneumonia. The American Journal of Emergency Medicine. 2017 Feb 1.

What is it about?

This study assessed the role of lung ultrasound (LUS) in Emergency Departments in diagnosing children with pneumonia. The overall aim was to demonstrate the benefit of LUS over chest x-ray (CXR) in diagnosing children with pneumonia.

The researchers conducted a prospective observational study at a single emergency department over 4 months

Children between the ages of 1 month to 18 years were included in this study. Exclusion criteria included relevant PMH of respiratory disease, treatment for pneumonia within one month or who were haemodynamically unstable on presentation.

Children with clinically suspected pneumonia received a CXR and had LUS performed. Pneumonia was positively diagnosed on CXR in the presence of peribronchial thickening and consolidated areas. The CXR findings were examined by two independent clinicians who were blinded to the LUS results. Pneumonia was positively diagnosed on LUS with the presence of consolidation, defined as hyperechoic areas reflecting air bronchograms in hypo-echoic or anechoic areas and pleural irregularities. LUS was performed by a single trained sonographer.

250 children with suspected pneumonia presented to the emergency department, of which 160 were included in the study (mean age 3.3 years ) and 149 were diagnosed with pneumonia.

Children Diagnosed with PneumoniaUltrasound Positive Ultrasound Negative 
CXR Positive 1275
CXR Negative 152

The results demonstrated a statistically significant observed difference between LUS and CXR (p = 0.041)

Why does it matter?

There are challenges around diagnosing pneumonia in children, with a lack of specific diagnostic clinical criteria. Furthermore, the majority of symptoms associated with pneumonia in this population are often also seen with other infectious causes.

The British Thoracic Society (BTS) reports that CXR is performed at rates of 90% in children with suspected pneumonia. Based on their findings, this study advocates that LUS is at least as effective as CXR for diagnosing pneumonia and offers additional benefits, including avoiding radiation exposure, being easily performed at the bedside and being cost-effective.

However, user ability and reliability remain undetermined influence, and ongoing inpatient care is often dependent on reviewing CXR. In the future, can we review a real-time ultrasound video instead?

Reviewed by: Katie O’Loughlin

Article 2: Should we perform a lumbar puncture in children presenting with status epilepticus?

Michelson KA, Lyons TW, Johnson KB, Nigrovic LE, Harper MB, Kimia AA. Utility of Lumbar Puncture in Children Presenting With Status Epilepticus. Pediatric Emergency Care. 2017 Jul 11.

What is it about?

A retrospective study across 17 years of children (aged 1 month to 21 years) who presented with status epilepticus and had a lumbar puncture performed. The results are difficult to extrapolate as this is a single centre study that crosses many years of different immunisation schedules and with a wide age range. However among the 126 children who had an LP performed only 8 (6%) had a CSF pleocytosis with only one having confirmed bacterial meningitis (2 had enterovirus, 1 herpes simplex and 5 had received antibiotics before the LP)

Why does it matter?

There is a large challenge in continually reviewing the rate of serious bacterial generally and especially in distinct cohorts of presentations (status epilepticus, less than 3 months, chronic disease etc).

Bottom line

We must all be mindful that immunisation programmes and changing demographics will continually alter the risk assessment we must make when making decisions about screening and investigating for infections.

Reviewed by: Damian Roland

Article 3: Is there a link between bullying and suicidal ideation in children?

Barzilay S, Klomek AB, Apter A, Carli V, Wasserman C, Hadlaczky G, Hoven CW, Sarchiapone M, Balazs J, Keresztény A, Brunner R. Bullying victimization and suicide ideation and behavior among adolescents in Europe: a 10-country study. Journal of Adolescent Health. 2017 Apr 5.

What’s it about?

In this study involving 11,100 students in 10 countries involved in the SEYLE study (Saving and Empowering Young Lives in Europe study), 15-year-olds answered questions designed to investigate the relationship between physical, verbal or relational bullying with suicidal ideation or attempted suicide. Anxiety and depression were measured as risk factors. Peer and parental support were also assessed for a protective effect.

Why does it matter?

The teenager presenting to a GP, ED or paediatric ward with suicidal ideation or after an attempt such as paracetamol overdose can be a real heart-sink for some doctors as there are no quick-fixes. This study helps by provides a snapshot in a large international cohort to help us better understand bullying and relation to suicidal ideation and attempts. The study found 51.6% of students reported experiencing some form of bullying. Compared to boys, girls were more likely to report relational victimization (37.8% vs 26%), suicidal ideation or attempts (8.9% total vs 4.7%) and depression (14.6% vs 6.2%). Boys were more likely to report physical bullying (13.9% vs 6.3%) or verbal bullying (37.6% vs 35.1%).  The results and discussion of the paper were mainly focused on their significant findings relating to verbal bullying. As might be expected, interpersonal factors of peer and parent support were protective and of note, parental support appeared to moderate both suicidal ideation and attempts whereas peer support was only found significant for suicidal ideation. Another interesting point made was although the authors had hypothesised that anxiety and depression increased risk of suicidality overall; this was only a significant result in context of verbal bullying and low parental support. Furthermore, depression increased likelihood of suicidal ideation whereas anxiety increased likelihood of suicidal attempts.

Bottom line:

Bullying victimisation is common, and there are gender differences in how it is perpetrated. It is essential to carefully assess teenagers for suicidal ideation, behaviour and concurrent mental health and social support issues. The study also highlights the importance of parental consent and involvement in their child’s wellbeing.

Reviewed by Grace Leo

Article 4: How does Australia’s antibiotic prescribing rates compare to the rest of the world?

Anderson H, Vuillermin P, Jachno K et al. Prevalence and determinants of antibiotic exposure in infants: a population-derived Australian birth cohort study. Journal of Paediatrics and Child Health. 2017, doi 10.1111/jpc.13616.

What is it about?

660 infants in Victoria were included in this study assessing the rates and indications for antibiotic prescribing in the first year of life. This information was collected by a series of five parental questionnaires over the course of their child’s first year.

50% of infants in the study had received antibiotics in their first year, and 13% had received three antibiotic prescriptions. The most common type of antibiotic prescribed were penicillins, followed by cephalosporins.

31.5% of antibiotics were prescribed for ear infections while URTI/bronchiolitis accounted for a further 17.8% of prescriptions. Ambiguous indications were clarified in the medical notes. In fact, parental recollection was up to 98% accurate for antibiotic name and indication.

Infants were more likely to receive antibiotics if they had siblings, if their father was unemployed, if their parents were young, if they were not breast-fed at four weeks of age, or if there was maternal smoking.

Why does it matter?

Australia has the second highest antibiotic prescribing rate of all high-income countries (after Italy). Our over-prescribing contributes to unnecessary infant interventions, and the potential of increasing antibiotic resistance. It should be noted that with otitis media there are higher rates of serious complications amongst the Aboriginal population (chronic suppurative otitis media and tympanic membrane perforation). This may cause doctors to have a lower threshold for prescribing antibiotics in this population. We need to make sure we are all familiar with the indications for antibiotics in otitis media and URTIs.

Reviewed by: Tessa Davis

Article 5: Single dose PO dexamethasone or 3 days of PO prednisolone in acute exacerbation of asthma

Cronin, J.J., et al. A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department. Annals of Emergency Medicine. 2016. 67(5): 593-601. May 2016.

What’s it about?

The treatment of moderate asthma is well established, including bronchodilators and oral steroids. This randomised trial seeks to identify whether a single oral dose of dexamethasone is non-inferior to a 3-day course of oral prednisolone by day 4 of illness, according to a validated clinical score; the Paediatric Respiratory Assessment Measure (PRAM).

Our Irish colleagues randomized a cohort of 245 presentations of children aged 2-16yo with an exacerbation of acute asthma, to receive either 0.3mg/kg dexamethasone (single dose), or 1mg/kg prednisolone for 3 days.

Essentially, the PRAM scores were not significantly different at day 4 for any of the groups, both overall and when adjusted for severity, gender or age (a secondary analysis looking at 2-5yo aka preschool wheeze).

Why does it matter?

“Three days of oral pred” is almost a mantra for the many kids we see each month in both ED and on the Paeds ward. One of the frames for this clinical question is Could we reduce the number of doses?  – ergo compliance, costs, extra medications in the community – and cumulative steroid dose to achieve the same outcomes?

One of the key limiters in this study was that 13% of the DEX arm received additional steroid in the 14 days study period. The authors speculate that although physicians were not limited in subsequent steroid prescribing as per “appropriate care”, it may be that patients were more likely to be prescribed additional steroids (in the DEX arm) because of a perception that a single dose was insufficient.

Bottom Line

This is the eighth randomised controlled trial comparing dexamethasone to prednisolone for the management of acute asthma in kids, ranging as far back as the mid-nineties. It illustrates that a single dose of 0.3mg/kg oral dexamethasone is likely non-inferior to a three day course of 1mg/kg oral prednisolone in this population.

Reviewed by: Henry Goldstein

That’s it for this month.  Many thanks to all of our reviewers who have taken the time to scour the literature so you don’t have to. Next months Bubble Wrap will be a little different as Tim Horeczko prepares us for his Defence Against the Dark Arts of EBM session at DFTB17.

About the authors

  • Grace is a Registrar at Sydney Children's Hospital. She loves innovative medical education and paediatrics. She is on the organising committee for the DFTB18 and SMACC conference. Grace is a former internal director of the AMSJ. She enjoys board games, cooking and graphic design.

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