Network Five: Paediatrics

Network Five: Episode 5 – Paediatrics

Participants: Dr Surbhi Rikhi, Dr Kerf Tan, Dr Pramod Chandru, Johann De Alwis (PEM trainee) Omal Fernando (PEM trainee), Min Park (EM trainee), Shreyas Iyer, Kit Rowe, Caroline Tyers and Samoda Wilegoda Mudalige.

Part 1

In this episode, we first look at the reliability of a clinical prediction rule to identify febrile infants who are at low of serious bacterial infections. Presenter – Johann De Alwis

• Kuppermann N et al. A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatr. 2019 Apr 1;173(4):342-351

Take-Home Points:

• Serious bacterial infections (SBIs); which include UTI, meningitis, and bacteraemia, lead to dangerous complications in infants.
• This was a prospective observational study between 2011 and 2013, looking at previously healthy febrile infants aged 60 days or younger, who were evaluated for SBIs.
• The clinical rule considered the urinalysis, absolute neutrophil count (ANC), and serum procalcitonin, and had a sensitivity of 97.7%, with a specificity of 60%, and a negative predictive value of 99.6%.
• One infant with bacteraemia and two with UTI who were misclassified. 
• This tool decreased the number of lumbar punctures performed, antibiotics administered, and infants admitted to the hospital. 
• Remember that these infants are the most at-risk population; do more rather than less.
• Safety net: no matter what you do or what investigations reveal, always have a safety net! 

Part 2

In this second part of the series, we discuss the role of the plot twisting TWIST score in diagnosing testicular torsion in children with acute scrotum. Presenter – Omal Fernando.

• Pan P. Validation of the Testicular Workup for Ischemia and Suspected Torsion (TWIST) Score in the Diagnosis of Testicular Torsion in Children With Acute Scrotum. Indian Pediatr. 2020 Oct 15;57(10):926-928

Take-Home Points:

• This score reminds us what we should be looking for when assessing a patient with acute testicular pain and thus help to build clinical gestalt, however, there is not enough evidence at present to rely on this tool alone (although this may change in the years to come). 
• It is important to involve the urologist/general surgeon if there is any suspicion of torsion.
• Given the time-critical nature of this presentation, patients should be taken to the theatre (rather than further investigated with ultrasound) if testicular torsion is suspected.

Part 3

In this final part of the series, we discuss the effectiveness of different treatment formulations (inhaler vs. nebulizer) in the management of acute exacerbation of asthma. Presenter – Min Park

• Iramain R, Castro-Rodriguez JA, Jara A, Cardozo L, Bogado N, Morinigo R, De Jesús R. Salbutamol and ipratropium by inhaler is superior to nebulizer in children with severe acute asthma exacerbation: Randomized clinical trial. Pediatr Pulmonol. 2019 Apr;54(4):372-377.

Take-Home Points:

• MDIs may be at least equally effective if not more effective than nebulizers.
• MDIs are also cheaper and provide an opportunity to educate patients regarding their use.
• It is important to re-assess your patients following initial treatment.
• There may be variability in the way you approach each patient to meet their individual needs. 
• Always refer to your local guidelines. 

Other references

“Step by step” approach to the febrile infant

• Mintegi S, Bressan S, Gomez B, Da Dalt L, Blázquez D, Olaciregui I, de la Torre M, Palacios M, Berlese P, Benito J. Accuracy of a sequential approach to identify young febrile infants at low risk for invasive bacterial infection. Emerg Med J. 2014 Oct;31(e1):e19-24

Original study validating the TWIST score

• Barbosa JA, Tiseo BC, Barayan GA, Rosman BM, Torricelli FC, Passerotti CC, Srougi M, Retik AB, Nguyen HT. Development and initial validation of a scoring system to diagnose testicular torsion in children. J Urol. 2013 May;189(5):1859-64

Starship Hospital (NZ) study examining nebuliser vs. MDI delivery for asthma

• Klassen T. Spacers were better and less expensive than nebulisers for giving albuterol to children with moderate to severe acute asthma. Evidence-Based Medicine, 2001; 6(1): 31

These episodes were produced with help of HETI’s Emergency Medicine Training Network 5. Please send us an email to let us know what you thought. You can contact us at [email protected]