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  • Episode 86: Mental Health Crisis on the Wards

    Episode 86: Mental Health Crisis on the Wards
    2026/06/21
    EPISODE SUMMARYThis episode leads on a problem every acute paediatric unit now lives with: the child in mental health crisis admitted to a general children's ward while waiting for specialist care. A new UK consensus study sets out sixteen practical, risk-stratified strategies that a non-specialist team can use to keep these young people safer. The second story turns to the forearm fracture, with a large cohort showing that one child in eight returns to the emergency department within a week of casting — rising to one in four for reduced distal both-bone fractures — and a companion piece asking whether ultrasound can guide the reduction itself. What's Caught My Eye covers whether "highly toxic" drugs really threaten toddlers after a single dose, real-world evidence that earlier egg introduction cut egg allergy, and the refreshed top ten research priorities for paediatric emergency medicine across the UK and Ireland.━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━MAIN STORY 1: Keeping children in mental health crisis safe on the ward━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━Children and young people in mental health crisis are routinely admitted to acute paediatric wards that were never designed to hold them, cared for by staff with little mental health training. This UK mixed-methods study asked a deliberately practical question: while these young people are in our care, what can a general team actually do to reduce risk?Key findings:Twenty-six candidate risk-mitigation strategies were generated from a systematic review and qualitative interviews.Sixteen reached expert consensus (≥70% agreement) for clinical usefulness among a panel of 16 healthcare professionals and experts by experience.Prioritised strategies included structured safety checks on admission and daily thereafter, proactive environmental modification to remove triggers and ligature risks, one-to-one observation reframed around therapeutic engagement rather than surveillance, timely escalation to specialist mental health services, and routine multidisciplinary safety huddles.Each strategy was mapped to clinical risk level (low, medium, high, very high) using a validated paediatric mental health risk assessment framework.For practice, this converts a familiar sense of helplessness into a structured, risk-matched checklist that any acute paediatric team in the NHS can adopt immediately, without waiting for system-level reform.The caveat: these are consensus-derived strategies from a small expert panel, not outcomes from a trial, so this is a framework for good practice rather than proof of reduced harm — and escalation to specialist services remains part of it, not an alternative to it.Reference: Kaltsa A, Marufu TC, Carter T, et al. Archives of Disease in Childhood. Published May 2026.DOI: https://doi.org/10.1136/archdischild-2025-328977━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━MAIN STORY 2: Forearm fractures — life after the cast, and guiding the reduction━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━The forearm fracture is everyday work in paediatric emergency medicine, but we rarely track what happens once the child leaves with a cast. This single-centre cohort quantified unplanned return visits within the first week, and a companion Archives piece asks whether point-of-care ultrasound could improve the reduction at the bedside.Key findings:Among 551 children treated with circumferential casting (from 4,661 forearm fractures reviewed), 67 (12.2%) made an unplanned return to the ED within seven days.92.5% of returns were for pain and around 95% required cast modification.Return rates varied sharply by pattern: distal radius and ulna 23.8%, midshaft both-bone 15.7%, distal radius alone 8.5%, other 5.5%.Returns were more than three times as likely after reduction than after in-situ casting (16.1% vs 4.3%), peaking at 27.1% for reduced distal both-bone fractures.There were no cases of compartment syndrome and 98.4% completed non-operative treatment successfully.The clinical bottom line is about specific, risk-matched safety-netting: a reduced distal both-bone fracture carries a one-in-four chance of a painful early return, so families with high-risk patterns need tailored expectations and follow-up rather than a generic discharge.This is single-centre data from outside the UK, so absolute rates will differ here, but the pattern — reduced wrist fractures being the ones that bounce back — will be familiar to any UK ED or fracture clinic, and the ultrasound question speaks to whether a better first-time reduction could cut returns at source.Reference: Romem R, Aliev E, Fainzack A, et al. Pediatric Emergency Care. Published June 2026....
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    16 分
  • Episode 85: The Trouble With Boluses

    Episode 85: The Trouble With Boluses
    2026/06/07
    2 PAEDS IN A POD Episode 85 | The Trouble With BolusesReleased: 07/06/2026 | Runtime: ~20 minutesEPISODE SUMMARYThis episode leads on fluid in childhood sepsis. A new multicentre cohort from Australia and New Zealand found that mortality rose with the volume of bolus fluid given in the first day, but not with the total volume of fluid — a finding set alongside the recently published PRoMPT BOLUS trial, which showed that balanced fluid and saline produce the same kidney outcomes. The second story returns to the febrile infant for a third time, with a meta-analysis quantifying the risk of serious bacterial infection in the well sixty-to-ninety-day-old. What's Caught My Eye covers the TWIST score and ultrasound for the acute scrotum, nirsevimab versus the maternal RSV vaccine head to head, and language barriers and safety in the paediatric emergency department.━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━MAIN STORY 1: How much fluid is too much in childhood sepsis? ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━Fluid is the first thing we reach for in the septic child, and the volume question has never been fully settled. This cohort measured the fluid children actually received in the first twenty-four hours and asked how it related to outcome, arriving just as PRoMPT BOLUS reported on the separate question of which fluid to use.Key findings:5,352 children with suspected community-acquired sepsis across 11 emergency departments in Australia and New Zealand (2021–2023); median age 2.6 years.In-hospital mortality was low at 1.1%; around 5.5% met Phoenix sepsis criteria.Median total fluid in the first 24 hours was 40 mL/kg, of which the bolus component was 10 mL/kg.Mortality rose with increasing bolus volume but not with increasing total fluid; the unadjusted odds ratio for death with more than 55 mL/kg versus less than 15 mL/kg of bolus fluid was 20.5 (95% CI 8.0–52.5).For context, PRoMPT BOLUS (9,041 children, 47 departments, five countries) found no difference in major adverse kidney events between balanced fluid and 0.9% saline (3.4% vs 3.0%), with less hyperchloraemia in the balanced-fluid group.For practice, the converging message is that the fluid you choose matters less than hoped, while the volume you give may matter more than thought. This supports the titrated, reassess-after-each-bolus approach that NICE and APLS already ask for, rather than a fixed escalator.Important caveat: the bolus–mortality association is unadjusted and observational, and the sickest children in refractory shock receive the most bolus fluid, so this does not show that boluses cause harm and is not a reason to withhold fluid from a shocked child.Reference: Long E, Selman C, Borland ML, et al. Archives of Disease in Childhood. Published May 2026. DOI: https://doi.org/10.1136/archdischild-2025-330189━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━MAIN STORY 2: How risky is the febrile two-month-old? ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━The sixty-to-ninety-day-old is the febrile infant our guidelines treat least consistently — some pathways stop at sixty days, others lump the whole under-ninety group together. This meta-analysis supplies the missing denominator for that group, completing a run that has moved from risk stratification, through practice variation, to underlying prevalence.Key findings:59 studies, 20 distinct datasets, just under 34,835 well-appearing, previously healthy febrile infants aged 60–90 days.Pooled prevalence of invasive bacterial infection was 1.11% (95% CI 0.84–1.47), roughly 1 in 90.Almost all of that was bacteraemia at 1.01%; bacterial meningitis was rare at 0.11%, roughly 1 in 900.Estimates held across every sensitivity analysis, including removal of the single largest study.The clinical bottom line is a number to carry into both your own reasoning and the conversation with parents: in the well infant in this band, meningitis risk of around one in nine hundred is a reasonable thing to weigh when deciding whether this particular baby needs a lumbar puncture or a more measured pathway with good safety-netting.These are international data, so map the figures onto your local febrile infant pathway and the NICE traffic-light thresholds rather than applying them in isolation.Reference: Dionisopoulos Z, Sabhaney V, D'Arienzo D, et al. JAMA Pediatrics. Published May 2026. DOI: https://doi.org/10.1001/jamapediatrics.2026.1815━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━.WHAT'S CAUGHT MY EYE ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━1. TWIST and ultrasound for the acute scrotumA retrospective study of just...
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    16 分
  • Episode 84: The Febrile Infant Lottery

    Episode 84: The Febrile Infant Lottery
    2026/05/24
    2 PAEDS IN A POD Episode 84 | The Febrile Infant Lottery Released: 24/5/2026 | Runtime: ~20 minutes━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ EPISODE SUMMARY ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━This episode opens with a large London study showing that the care a febrile young infant receives depends heavily on which hospital they attend, with full adherence to national guidance achieved in only one in five presentations and over-investigation almost as common as under-investigation. The second main story examines a French randomised controlled trial of automated closed-loop oxygen titration in bronchiolitis — negative on its primary endpoint of length of stay, but with coherent secondary signals on saturation targeting and oxygen flow that make it a useful lesson in reading past the abstract. What's Caught My Eye covers a systematic review of electronic sepsis alerts in children, a multicentre cohort of in-hospital neonatal head injury on the postnatal ward, and a study asking whether comprehensive respiratory virus panels change outcomes in discharged children.━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━MAIN STORY 1: How much does the febrile infant's hospital matter? ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━The febrile infant under ninety days is one of the highest-stakes presentations in paediatric emergency and acute care. National guidance exists precisely to compress that diagnostic uncertainty into something consistent. This retrospective study across twenty-one London hospitals, run through the London REACH network, tested whether care actually looks the same once that guidance is applied — and the answer is that it does not.Key findings:2,008 presentations of infants aged 90 days or younger; 41.1% were febrile at the point of assessmentBlood tests performed in 73.7% overall, but ranging from 55.4% to 96.7% across sites; lumbar puncture 40.8% overall, range 17.1% to 70.7%; urinalysis 63.4% overall, range 43.4% to 85.4%Antibiotics started in 57.7% overall (site range 35.4% to 90.2%); admission in 63.5% overall (site range 46.7% to 99.2%)Full adherence to national clinical practice guidelines in only 21.9% of presentations; partial adherence 24.4%; non-adherence 31.2%; over-adherence 23.5%Adherence was higher in infants under 28 days and in those febrile during assessmentThe clinical message is that variation runs hard in both directions. We tend to fear under-investigation and the missed serious bacterial infection, but over-investigation — unnecessary lumbar puncture, septic screen, intravenous antibiotics and admission in a well baby — was almost as common, and it is not a neutral act. The practical focus for departments is the infant who is afebrile by the time they are assessed, where the guidance gives least direction and the variation is widest.This is London-specific, retrospective, and the study period overlaps the later pandemic, so the absolute numbers will not transfer directly to a district general setting.Habermann S, Hartzenberg R, Loucaides EM, et al. (London REACH Network). Variation in management of febrile infants younger than 90 days across London: a retrospective cohort study. European Journal of Pediatrics. 2026;185(6). https://doi.org/10.1007/s00431-026-06938-y━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━MAIN STORY 2: Automated oxygen titration in bronchiolitis ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━Oxygen titration in bronchiolitis is a constant low-level drain on nursing time across the winter. This trial tested whether handing the titration to a closed-loop device improves the outcome that matters to families and to flow — length of hospital stay.Key findings:Multicentre randomised controlled trial, ten paediatric departments in France, 2018 to 2023; 103 infants aged 1 to 12 months with acute bronchiolitis requiring oxygen, severe bronchiolitis excludedPrimary endpoint negative: median stay 71.0 hours with the FreeO2 device versus 69.6 hours with manual titration (p=0.39)Time within the target oxygen saturation zone 89.4% with automation versus 74.9% with manual titration (p<0.05)Median oxygen flow 0.1 L/min with automation versus 0.3 L/min manual (p<0.05); no significant difference in re-hospitalisation at 7 or 30 days or in non-invasive ventilation useThe bottom line is that automated titration does not shorten length of stay, so it should not be argued for on that basis, but the secondary signals are coherent — better time in target range at lower oxygen flows. The wider teaching point is that a negative primary endpoint in an underpowered trial is ...
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    18 分
  • Episode 83: Knife Crime, Febrile Infants, and What's Caught My Eye

    Episode 83: Knife Crime, Febrile Infants, and What's Caught My Eye
    2026/05/10
    2 Paeds in a PodShow Notes — Episode 83Knife Crime, Febrile Infants, and What's Caught My EyeReleased: May 2026 | Runtime: ~20 minutesIn this episode, Ian covers what's caught his eye in the paediatric literature this fortnight. The main story looks at a landmark national review of child deaths from knife wounds in England — and what it means for those of us working in paediatric emergency and urgent care. He then turns to new data on febrile infants aged 29 to 60 days and the evolving evidence base around risk stratification in that notoriously tricky age group. The episode closes with three quick picks from this fortnight's journal sweep: point-of-care lung ultrasound for pneumonia, reframing conversations about paediatric palliative care, and a flag for the new Surviving Sepsis Campaign paediatric guidelines — which we'll be coming back to in a dedicated episode soon.Main Story 1 — Knife Crime Deaths in Children in England (2019–2024)Knife-related deaths in children and young people represent one of the most pressing — and most inequitable — public health challenges in England today. This month, Roberts and colleagues published a review using the National Child Mortality Database covering every child under 18 who died of a knife wound between April 2019 and March 2024.The headline findings:145 children died over the five-year period — roughly one every two weeksMean age at death was 14.4 years; 90% were maleBlack or Black British children died at a rate more than 13 times higher than white children when corrected for population sizeChildren in the most deprived areas of England had over 7 times the risk of death compared with those in the least deprived areas60% of children died before reaching hospitalOf those who reached hospital, 57% underwent a thoracotomy — reflecting the severity of injuries sustainedInjuries to the chest and neck were responsible for 76% of fatal wounds75% of children had been known to social services prior to their death58% had experienced domestic violence and abuse51% had documented neurodiversity or mental health concernsWhy this matters for paediatric practice: These were not invisible children. The vast majority were known to statutory services. For clinicians working in paediatric emergency and urgent care, this paper is a reminder that every child who comes through our doors carries a history — and that our role extends beyond the presenting complaint. It also raises important questions about pre-hospital intervention, penetrating trauma training in paediatric settings, and the role of the ED as a potential point of early intervention for children at risk.Knife injuries are not confined to major urban centres — the data show deaths distributed across all regions of England.Reference: Roberts T, Odd D, Coveney J, et al. Emergency Medicine Journal. Published April 2026. https://doi.org/10.1136/emermed-2025-215154Main Story 2 — Bacteraemia and Bacterial Meningitis in Low-Risk Febrile Infants Aged 29–60 DaysThe febrile infant aged 29 to 60 days occupies some of the most uncomfortable clinical territory in paediatric emergency medicine. Too old for the automatic full-septic-screen approach applied under 28 days, but too young to rely on clinical examination alone. This paper from Burstein, Xie, and Kuppermann — published in JAMA Pediatrics — examines how the updated PECARN (Pediatric Emergency Care Applied Research Network) febrile infant rule performs in an international sample.What the PECARN rule involves: The rule uses a combination of clinical and laboratory parameters to stratify infants into low, intermediate, and higher risk for invasive bacterial infection (bacteraemia and bacterial meningitis). Key components include temperature, urinalysis findings, absolute neutrophil count, procalcitonin, and — where indicated — CSF analysis.Why this paper matters: The original PECARN derivation and validation studies were predominantly North American. This international validation is an important step in understanding how the rule performs across different healthcare systems, bacterial epidemiology, and rates of prior antibiotic exposure. The full data are behind a paywall, but the publication itself signals continued maturation of the evidence base.For UK practice: NICE guidance for this age group tends towards more liberal investigation. Whether structured risk stratification tools like PECARN could safely reduce lumbar punctures and admissions in a subset of genuinely low-risk infants is an active and important question for UK paediatric emergency practice.Key learning point: Know the PECARN framework. Know its components. And watch this space — this is a field moving quickly.Reference: Burstein B, Xie J, Kuppermann N. JAMA Pediatrics. Published April 2026. https://doi.org/10.1001/jamapediatrics.2026.0971What's Caught My Eye1. Point-of-Care Lung Ultrasound for Paediatric PneumoniaA review in Pediatric Emergency Care summarising the ...
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    18 分
  • IV Aminophylline in Acute Severe Asthma: Does It Still Have a Role in Paediatric Emergency Care?

    IV Aminophylline in Acute Severe Asthma: Does It Still Have a Role in Paediatric Emergency Care?
    2025/10/25

    Clinical Question

    In children presenting with acute severe asthma, does intravenous aminophylline improve meaningful clinical outcomes compared to standard therapy?


    ⸻


    Background


    IV aminophylline has historically been used as a second-line infusion in severe paediatric asthma. However, contemporary escalation strategies increasingly prioritise:

    • Oxygen

    • High-dose nebulised salbutamol

    • Systemic corticosteroids

    • IV magnesium sulphate


    This raises the question: does aminophylline still offer incremental benefit?


    ⸻


    The Evidence Reviewed


    A systematic review published in Archives of Disease in Childhood analysed:

    • 9 randomised controlled trials

    • 466 children

    • Standard therapy ± IV aminophylline


    Outcomes assessed:

    • Asthma severity scores

    • Length of stay

    • Admission rates

    • PICU admission

    • Intubation rates

    • Adverse effects


    ⸻


    Key Findings


    No significant benefit in:

    • Speed of clinical improvement

    • Admission rates

    • PICU transfer

    • Intubation rates

    • Length of hospital stay


    Significant increase in adverse effects:

    • Nausea and vomiting (3–5x higher)

    • Headache

    • Tremor

    • Irritability

    • Arrhythmias


    Overall: No improvement in meaningful outcomes, with increased morbidity.


    ⸻


    Important Caveat


    A 1998 study (Young & South) suggested possible benefit in the most critically unwell, treatment-refractory children, including:

    • Reduced duration of intubation

    • Potential improvement in lung function


    This suggests a potential narrow rescue-therapy window.


    ⸻


    Implications for Paediatric Emergency Practice (2025)


    Current best evidence supports:

    1. Oxygen

    2. Nebulised salbutamol

    3. Systemic corticosteroids

    4. IV magnesium

    5. Structured escalation planning


    IV aminophylline should be considered:

    • A rescue therapy of last resort

    • Not routine second-line treatment


    ⸻


    Take-Home Message


    IV aminophylline has historical presence but limited modern evidence of benefit. For most children with acute severe asthma, it increases adverse effects without improving outcomes.


    Its role in 2025: rare, selective, and critically contextual.
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    3 分
  • Episode 82: The FIDO study

    Episode 82: The FIDO study
    2024/12/20

    In this episode we talk to Dr Etimbuk Umana, the lead author of the FIDO study looking at the management of febrile infants in the Emergency Department. FIDO is a PERUKI sponsored study and was recently published in The Lancet: https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(24)00540-6/fulltext
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    31 分
  • Episode 81: Priority Setting in PEM research with PERUKI

    Episode 81: Priority Setting in PEM research with PERUKI
    2024/05/12
    2 Paeds returns with a fresh new look, new in association with team at PERUKI. In our first collaboration we talk to Dr Charlotte Sloane about the current major PERUKI project - establishing the current research priorities for the next 5 years in paediatric emergency medicine. If you want to get involved go to www.peruki.org.uk or email Charlotte at csloane04@qub.ac.uk You can also watch us on YouTube
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    26 分
  • Episode 80: Dexmedetomidine for paediatric sedation

    Episode 80: Dexmedetomidine for paediatric sedation
    2022/05/08

    We talk to Dr Tom Jackson about his article in Archives of Disease in Childhood looking at the use of Dexmedetomidine as a sedative agent fro children undergoing MRI scans in a district general hospital. Is it better the NICE recommended medications? Article can be found here: https://adc.bmj.com/content/early/2022/03/10/archdischild-2021-322734
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    27 分