Top 5 Papers in PEM

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Do you remember pre-pandemic when we had to check the ears and throat of EVERY child we saw in ED with fever?

It’s the thing that we taught all the medical students. An ENT exam was essential because it might help us find the source of infection.

Then COVID happened. 

Everything changed. We were told that we shouldn’t do an ENT exam unless we really needed to. 

This started the important process of us questioning why we do the things we do. We’re ED clinicians. We like fixing things, moving things, sorting things, investigating things.  But actually in paediatrics, it may be that we intervene too readily.

I’ve picked five papers from the last year that lead us to ask the question, are we doing too much?

Paper 1

You’re on a Paeds ED shift. Parents bring in their 3 week old baby because when they were at home that morning, they measured the temperature and it was 38°C. You take the history and examine the baby. The baby looks really well. Other than the temperature (which was measured correctly at home), the parents don’t have any other concerns.

You’ve got to make a decision. 

This is a well looking neonate with a fever. We know what the NICE guidelines say, and that’s why you’re worried about this baby, even though you know they look well. You’re worried that you’re going to send them home and they’re going to get really sick.

You’re worried you’re missing something.

Do all these babies need a full septic screen for antibiotics, or is there a way that we can differentiate which ones are sick from those that are not? 

That’s where the first paper comes in:

Pantell RH, Roberts KB, Adams WG, Dreyer BP, Kuppermann N, O’Leary ST, Okechukwu K, Woods CR. Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old. Pediatrics 2021;148 (2) e2021052228; DOI: 10.1542/peds.2021-052228

This is an American Academy of Pediatrics guideline and you can read our full review here.

Who were the patients?

The paper looked at term babies between 8 and 60 days old with a fever (either in hospital, in the clinical setting or at home) within the preceding 24 hours.

They excluded babies with other complex conditions and also excluded babies who had immunisations in the preceding 24 hours. 

What did they look at?

They looked at their blood results, urine culture, and CSF culture. They aimed to determine whether there were any markers that could indicate which babies were sick and which were well. 

Bottom Line

White cell count isn’t that great. It is less useful than the neutrophil count, which is less useful than the CRP, which is less useful than procalcitonin. Procalcitonin is the best and most accurate indicator of an underlying significant infection in this group.

If you can’t use procalcitonin, use CRP + neutrophils. Most of us don’t have access to procalcitonin testing. The next best thing is to use a combination of CRP, neutrophil count, and temperature status.

Remember herpes simplex virus infection. This is easy to forget but we must keep it in mind – particularly in the first three weeks of life.

Overall, we should still be very cautious in this age group. It’s not that we’re going to stop septic screening them – in our 3 week old patient, we will still be doing a full septic screen and giving IV antibiotics.

This AAP guideline points us in the direction of being able to tailor our guidelines, and work out which babies are more likely to be unwell in this group of febrile newborns.

Paper 2

Our next patient on the shift is Jessica. Jessica is two years old. She’s been brought in because she’s had a fever at home. And then her parents have noticed that she has some spots on her arm. They weren’t too worried about Jessica in herself, as she wasn’t looking unwell. But they noticed that these spots don’t go away when they press them.

What are we going to do?

We are worrying about meningococcal sepsis, but also we know that Jessica looks very well.

This is the question asked by the Petechiae in Children study that was published by Waterfield et al – you can see our full review of it here.

Waterfield T, Maney J-A, Fairley D, Lyttle MD, McKenna JP, Roland D, Corr M, McFetridge L, Mitchell H, Woolfall K, Lynn F, Patenall B, Shields MD, Validating clinical practice guidelines for the management of children with non-blanching rashes in the UK (PiC): a prospective, multicentre cohort study, The Lancet, 2020

Previous guidance on meningococcal sepsis was based on data from before the introduction of the meningococcal B and C vaccine. Back then the prevalence of meningococcal disease was 10 to 20%. As vaccination rates increased the prevalence of meningococcal disease has dropped.

Who were the patients?

This study included children under the age of 18, who presented to one of 37 Paeds EDs in the UK over a 16 month period.

They were included if they had a fever (>38°C), a new onset non-blanching rash, or if they had features suggestive of meningococcal disease

They were excluded if they had another haematological condition or Henoch-Schonlein purpura. 

What did they look at?

Children were recruited without prior consent. They were entered into the study at the time they presented AND met the inclusion criteria. Consent was obtained within 24 hours of presentation.

Data collected included demographics, observations, and blood results.

They were also followed up to determine which ended up having meningococcal disease (i.e. a positive PCR or a positive culture). As well as looking at the hospital records, researchers checked for representations to ED, and checked with Public Health England for notifications of meningococcal disease.

The outcomes measured here were to look at eight clinical guidelines that are widely used across the UK and see how they fared in picking up the children with meningococcal disease. 

The secondary outcomes were consideration of how good they were at picking up other bacterial infections. And then looking at the cost. 

What did they find?

The PICC study included 1344 children.

1% of them had meningococcal disease and 2% (which included the 1% with meningococcal disease) had bacterial infections like pneumonia or a urine tract infection. Of these patients, 2 children died and both had N. meningitides.

The good news is that all of the guidelines picked up every single patient with a bacterial infection. That’s 100% sensitivity! This is important because we don’t want to have guidelines that miss patients with meningococcal disease or a significant bacterial infection.

Where it becomes trickier is when it comes to specificity. We know that we will have a tendency to over treat these patients. The NICE sepsis guidelines treated every single patient in this group – 0% specificity. This is not very cost effective and it’s also going to lead to over treatment with antibiotics. 

The best performing guideline was Bart’s Health. This guideline had 100% sensitivity and a specificity of 36%. It was the best at tailoring the plan so that it only treats the patients that actually need it. It was also the lowest cost as well (£490 per patient).

There were times when clinicians deviated from the guidelines (less than 50% of the patients in this study stuck to the guidelines). Clinician-specified decisions improved the specificity i.e. we were treating less patients. Unfortunately though, it reduced the sensitivity to 89%. 2 patients were sent home had meningococcal infections. They later represented and received treatment. This demonstrates that clinician instinct can cause us to miss positive cases.

Bottom line

Stick to the guidelines. The guidelines are good and they work. Our goal though is to find guidelines that are tailored. It’s through the tailoring that we can still have a high sensitivity while fine-tuning our specificity.

Barts Health is the best trust in the whole of the UK. And we have the best guideline. (COI I am an employee of Barts Health).

Paper 3

Your next patient is Sally. Sally is eight years old. She is the lead striker on her local football team. Today she was playing a match and as she was striding towards the opposition goal with the ball at her feet, she unfortunately tripped over and landed on her outstretched hand.

In ED she has what looks like a broken arm, and indeed on x-ray she has displaced radius and ulna fractures. 

You think it needs reduction. Just as you’re about to reach for the phone to call for Ortho to come and help you suddenly think….should I be doing this myself?

This paper by Rimbaldo et al answers the question, and you can see our full review of it here.

Rimbaldo KM, Fauteux-Lamarre E, Babl FE, Kollias C, Hopper SM. Deformed pediatric forearm fractures: Predictors of successful reduction by emergency providers. The American Journal of Emergency Medicine. 2021 Jul 2. doi.org/10.1016/j.ajem.2021.06.073

Who were the patients?

This paper looked at patients aged between 0 and 18 years old, who had a reduction of a forearm fracture at the Royal Children’s Hospital in Melbourne over a one year period

There were 340 patients included, and of these 60% had both radius and ulna fractures, and 37% had radius fracture. 

What did they find?

80% had an attempted reduction in ED by the ED team. Of these, 90% were successful. 2% of patients needed Ortho to get involved and have another attempt at manipulation after the ED clinician.

Across all the reductions, 14% of patients went to theatre (mostly for surgical fixation).

The patients requiring orthopaedic intervention were those with significantly displaced fractures, or mid-shaft radius/ulna fractures. 

Bottom line

We’re pretty good in ED at reducing radius and ulna fractures.

It’s important to know when to call ortho for help – consider this for the ones that are severely displaced or mid-shaft fractures. 

We should also be mindful about CRAFFT and the impact that that’s going to have on the management of these patients. CRAFFT is looking at whether we need to be reducing these fractures at all,  or whether we can just cast them and leave them to remodel themselves. 

Whilst this paper is reassuring that we’re pretty good at reducing them in ED, CRAFFT is going to look at whether we need to be reducing them at all.

Paper 4

Johnny is 10 years old. After 2-3 weeks of drinking lots and lots of water, peeing a lot, and losing weight, he starts to become more and more unwell at home. His parents bring him into ED. He is pretty lethargic and dehydrated. 

He does, of course, have DKA and it’s our job to manage his DKA safely.

The thing we worry about in DKA management is that we’re going to cause harm by the amount of fluids we give.

We know that around 1% of patients develop cerebral oedema. This paper by Glaser et al looks at how sodium concentration (or the drop in sodium) affects the risk of cerebral oedema. You can see our full review here.

Glaser NS et al. Serum sodium concentration and mental status in children with diabetic ketoacidosis. Pediatrics 2021; 148(3):e2021050243

Who were the patients?

The 2018 fluid trial by the same team looked at whether giving fluids faster or slower and with different concentrations of saline affected the rate of cerebral oedema. This paper uses the same data, but it looks specifically at sodium concentration during DKA resuscitation. 

This study looked at DKA presentations in children in 13 US hospitals over a five-year period. And there were over 1400 episodes of DKA included.

What did they look at?

They looked at glucose and sodium concentration at presentation, and then three hours after commencement of fluids. Patients were split into one of four arms (quick/slow fluids and normal/half normal saline).

They looked at the data at 0, 4, 8 and 12 hours after treatment commenced. In particular looking at the sodium and glucose concentrations and any changes in mental status

They looked at two groups:

  • Glucose-corrected-sodium was stable during that time period 
  • Glucose-corrected-sodium dropped during that time period 

They compared these two groups to see whether there was any change in mental status (and therefore any cerebral injury)

What did they find?

There was a clinically apparent brain injury in less than 1% of DKA patients across both groups.

Bottom line

This is a controversial topic amongst PICU specialists. We alll worry about causing cerebral oedema. While this paper won’t change our practice, and we will still be using BSPED guidelines, it’s definitely food for thought. It may be that the previous sodium concentration drops that we saw in patients with cerebral oedema were actually BECAUSE of the cerebral oedema and not the cause of cerebral oedema.

This team continue to produce data that shows us we should be questioning what’s causing cerebral oedema. It may not be fluid speed or sodium concentration.

Paper 5

Our final patient is 3 year old Kate. Kate has woken up this morning with swelling and redness around her eye. Her parents have noticed that she’s got a fever today. They bring her into ED because the swelling seems to be getting worse and she’s struggling to open her eye. She actually seems quite well in herself. 

You have the discussion with your colleagues about the common question: is this inflammation or is it infection? You think it’s probably infection. And then the next question comes: is it orbital or peri-orbital cellulitis? 

We know in orbital cellulitis, patients need appropriate treatment, otherwise they’re at risk of optic neuropathy and intra-cerebral abscesses.

Most of the patients we see are reasonably well, and in the majority it’s probably not orbital cellulitis. So, are we over treating them with IV antibiotics? 

This paper is by Ibrahim et al. 

Ibrahim et al. What is the risk of missing orbital cellulitis in children? Arch Dis Child 2021; doi:10.1136/archdischild-2020-320590

Who are the patients?

This team looked at patients aged between three months and 18 years of age presenting to the Royal Children’s Hospital in Melbourne, over a five-year period.

They were included if he had periorbital oedema or erythema. They were excluded if they didn’t have normal eye movements or if it was considered to be caused by an allergic reaction or bites. Clinicians made their own decisions about treatment.

What did they find?

There were 216 patients included in this study. 5 patients (2%) had orbital cellulitis. All of these 5 patients had fever (compared to just 30% of those with peri-orbital cellulitis), Four out of five had vomiting or headaches (compared with just 3% of the peri-operative cellulitis group). The fifth patient was a three month old baby who had osteomyelitis.

35% of patients were treated with oral antibiotics and 65% were treated with IV antibiotics. 

RCH uses the Asset score –  a score of four or more should be treated with IV antibiotics and <4 can be treated with oral antibiotics.

Results showed that clinicians weren’t really following that plan because 40% of patients who scored <4 were given IV antibiotics, equally 14% of patients with 4 or more got oral antibiotics.

All five children who had orbital cellulitis has an Asset score of 4 or more. 

Bottom line

We tend to be cautious in treating periorbital cellulitis, and we give more IV antibiotics than needed.

Actual rates of orbital cellulitis are quite low (2%). The authors recommend that we stick to the Asset score guidance to determine whether IVs or orals are suitable.

If your patient has vomiting or headache with their eye swelling, then get an Ophthalmology review. These patients are more likely to have orbital cellulitis. 

Not unreasonably, we don’t want to miss things in children, but these papers all illustrate that the emerging evidence will help us tailor our treatment to avoid unnecessary interventions while still staying safe.

About the authors

  • Tessa Davis is a Consultant in Paediatric Emergency Medicine at the Royal London Hospital and a Senior Lecturer at Queen Mary University of London.

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