Thread by @TessaRDavis

In paediatrics we used to do an ENT exam on every child with fever.

Then in 2020 everything changed.

It caused us to rethink our practice + ask...do we do too much?

My pick of these top 5 papers in PEM aim to change the way we think about the interventions we do #RCEMasc: 🧵👇

Paper #1: Should we treat all well-appearing febrile newborns?

Most of us are (reasonably) scared of febrile neonates.

Pantell et al developed an AAP guideline to help us treat only sick babies.

dontforgetthebubbles.com/well-appearing…

Could this mean we no longer have to treat them all?

Which group did the guideline consider?

• Term babies 8-60 days old with fever
• Exclusions: complex conditions, recent imms

What factors did the working group include?

• Blood results, urine culture, CSF culture

This is a guideline based on the Working Group's findings.

What were the key findings?

• WCC isn't that great a marker
• Procalcitonin is best
• If you can't use procalcitonin then use CRP + neutrophils + temp status
• Don't forget about HSV

At the moment we will still be cautious, but tailored guidelines are in the future.

Paper #2: Should we treat every child with a non-blanching rash (NBR) as meningococcal disease?

Families know the 'glass test'.

But in our practice we see so many well children with NBR.

Waterfield et al consider this:

dontforgetthebubbles.com/petechiae-in-c…

Could this change our practice?

Who were the patients?

• <18 years presenting to UK EDs over 16 months (1344 children)
• Inclusion: fever, new NBR, features of mening disease
• Exclusions: haem conditions, HSP

They looked at how good 8 UK guidelines were in identifying those with meningococcal disease.

What did they find?

• 1% had meningococcal disease
• 2% had bacterial infection

All 8 guidelines had 100% sensitivity - no patients were missed.

But NICE had 0% specificity - it treated EVERYONE.

The best was (of course) Barts Health:

•100% sensitivity
• 36% specificity

Paper #3: For displaced forearm fractures, should we call Ortho or do it ourselves?

We see radius/ulna fractures commonly in kids.

Should we be trying to reduce them in ED?

Or rather, how to we decided when to call ortho?

Rimbaldo et al answers this:

dontforgetthebubbles.com/pull-the-other…

Who were the patients?

• 0-18 years with reduction of a forearm fracture at RCH, Melbourne over 1 year
• 340 patients

What did they find?
• 80% had attempted reduction in ED, 90% were successful
• 14% went to theatre
• 2% needed ortho after a failed ED reduction

We are good at reducing these fractures in ED.

Ortho involvement could be used for severely displaced or midshaft fractures.

But importantly, we have the CRAFFT study coming up.

It asks: do we actually need to reduce these fractures at all?

Can we just leave them to remodel?

Paper #4: Do dropping sodium levels cause cerebral oedema in DKA?

Our worry about causing cerebral injury in DKA has been longstanding.

Around 1% of DKA patients get cerebral oedema.

What role do the sodium levels play here?

Glaser et al answers this:

dontforgetthebubbles.com/sodium-and-cer…

Who were the patients?

• DKA presentations to 13 US hospitals over 5 years

What did they look at?
• Glucose-corrected sodium (G-CS) at 0, 4, 8, and 12 hours after treatment commenced

There were 2 groups:
1. G-CS stable over that period
2. G-CS dropped over that period

They found cerebral injury in <1% of patients across both groups.

Although we may not change our practice solely based on this, this wonderful team continue to raise discussion.

We have always assumed we were causing cerebral oedema through fluid speed or sodium.

But are we?

Paper #5: Do we need to treat children with eye swelling with IVs?

Most of us know when we see eye swelling, we need to ask:

Is it orbital cellulitis?

None of us want to miss orbital cellulitis.

But are we over-treating?

Ibrahim et al investigate:

adc.bmj.com/content/archdi…

Who were the patients?

• 3m-18y presenting to RCH Melbourne over 5 years
• Inclusions; periorbital oedema or erythema
• Exclusions: allergic reaction or bites

What did they find?
• 216 patients
• 5 (2%) had orbital cellulitis
• 65% overall were treated with IV antibiotics

We tend to be cautious in treating periorbital cellulitis.

All 5 had fever
4/5 had vomiting/headache

The actual rates of orbital cellulitis are low (2%).

• If your patient has vomiting or headache then refer to Ophthal
• Use the Asset score to direct IV v oral management

TL;DR- 5 PEM papers to change your practice

• Do all febrile neonates need treatment?
• Should we treat everyone with a non-blanching rash?
• Are we good at forearm fracture reduction?
• Does ⬇️ sodium cause cerebral oedema in DKA?
• Do we over-treat periorbital cellulitis?

Thanks all - if you liked this please subscribe to my YouTube channel:

youtube.com/channel/UC6Gth…

If you found this thread valuable:

1. Follow me for more threads on paediatrics and education → @tessardavis

2. Read the full blog post on @dftbubbles here:

dontforgetthebubbles.com/top-5-papers-i…