Hey Reader,

Welcome to another edition of Bursting The Bubbles, DTFB's newsletter with some top tips, evidence highlights, and the best dad jokes.

This week we look at COVID impact, identifying brain tumours early, and try to unravel whether we should be giving Tranexamic Acid to children with head injuries.

Let's do it...

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WEEKLY BUBBLE WRAP: THE IMPACT OF COVID ON INFANT DEVELOPMENT

What’s It About?

This study examined the developmental outcomes of 12 months olds from a “pandemic” cohort of babies (309 babies). Babies born between March-May 2020 were compared with a historic baseline” cohort of babies (1629 babies) born between 2008-2011. The assessment was via a parental-reported questionnaire close to the child’s first birthday

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There were significant differences between the cohorts: one definite and meaningful word (RR 0.86), ability to point (RR 0.91) and ability to wave bye-bye (RR 0.94)] with a confidence interval of 95%.

Unfortunately, the developmental assessment was not standardized and given that it was completed by parents, it was open to recall bias. The researchers and parents were not blinded to the purpose of the study.

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Why Does It Matter?

We don't know the impact of sustained lockdowns on the social development of children who will have missed out on opportunities to socialise outside the family unit.

There has been a significant increase in the number of children being referred for an autism assessment leading to long waiting lists and tightening of referral criteria.

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Clinically Relevant Bottom Line:

Despite its limitations, this study showed that lockdown delayed children attaining key social communication by one year of age. We can use this information in our discussions with families. It might also provide some insight into the effects of lockdown on the social development of children.

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Reviewed by: Kathryn Allen, Atif Ali, and Gireesha Verma. Read the full Bubble Wrap here​

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TOPIC OF THE WEEK: IDENTIFYING BRAIN TUMOURS

Brain tumour symptoms are often non-specific and may mimic many common childhood illnesses, like viral infections.

Headaches and other symptoms are linked to the size, speed of growth, and position of the tumour and become worse as the tumour progresses.

Sadly, deaths occur due to delayed presentations with raised intracranial pressure.

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How long does it take to get a diagnosis?

The longer it takes for a diagnosis, the worse the outcome is. The median total diagnostic interval (TDI) – the time from the start of symptoms to the confirmation of diagnosis – is 14.4 weeks in the UK. This is three times longer than in the US.

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What is HeadSmart?

​HeadSmart was created due to the prolonged TDI. The aim is to separate out children whose parents can be reassured, those who need urgent review, and those that need imaging. The public awareness campaign, decision support tool, and associated guideline are a partnership between the Children’s Brain Tumour Research Centre in Nottingham, the Royal College of Paediatrics and Child Health, and the Brain Tumour Charity.

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What are the red flags in children?

Parents and carers of children presenting to the Emergency Department may be reluctant to tell you that they are worried about a brain tumour.

It might be better to explicitly ask, “Is there anything in particular that you are worried about?” Often they can be reassured and the patient discharged with the appropriate information, sign-posting and a safety net. If you are considering the diagnosis then this should prompt a thorough history and examination.

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How should we investigate children with red flags?

Children needing imaging should have an MRI or contrast CT with MRI as the imaging of choice. The HeadSmart Quick Reference provides further details and guides decisions based on head circumference, growth and endocrine changes, as well as behavioural changes.

Specific red flags mandate imaging.

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Read more about HeadSmart here.

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If you want to learn more about elbows (so you can show off your skills to your colleagues) then click here to sign up for our Free Elbow Excellence Email Course:

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HIGHLIGHT: TXA IN HEAD INJURIES

There's a lot of chat about the use of Tranexamic Acid in trauma.

Where do we sit when it comes to children with head injuries?

Give it or leave it?

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What's the controversy?

We want to stop any clot breakdown to try and slow any potential bleeding. During normal clot breakdown, plasminogen is converted to plasmin, and plasmin causes fibrinolysis and clot breakdown.

TXA stops the conversion of plasminogen to plasmin and therefore stops clot busting.

In theory, TXA should slow down or stop intracranial bleeding. But, there’s always been a worry that giving TXA could cause clotting in the cerebral vessels. This is not good.

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Ok, so what's the evidence?

First up is PED-TRAX, the Paediatric Trauma and Tranexamic Acid Study, a retrospective review of >750 paediatric trauma admissions to Camp Bastion in Afghanistan.

They found that the more injured a child was (higher ISS, hypotension, acidosis or coagulopathy), the more likely they were to receive TXA. Interestingly, even though kids who received TXA were much more severely injured, the children who received TXA had better survival outcomes than those who didn’t, with no complications.

Next of interest is a secondary analysis of the MATIC study – the MAssive Transfusion In Children study, published in 2022. MATIC was a prospective observational study of children with life-threatening bleeding – an international data set of 450 children with life-threatening haemorrhage who needed >40mL/kg of blood products. Just under half of the children had bleeding secondary to trauma, and the authors found children who received TXA, or other antifibrinolytics, had better survival outcomes at 6 and 24 hours—another win for TXA.

So this sounds very interesting – TXA sounds beneficial in paediatric trauma.

But it’s not all rosy.

Last year, Kornelson et al. looked through all the evidence around TXA in paediatric trauma and published a systematic review and meta-analysis. Based on the 14 included studies, TXA only seemed to improve survival in children injured in combat and didn’t improve survival in injured civilian children.

But – these findings are all from observational cohort studies with small numbers and significant heterogeneity, especially regarding the dosing of TXA.

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Read more about TXA in head injuries here.

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EVENT OF THE WEEK

Last month saw Learning Disability Week

Children with complex needs (like autism, learning disabilities, or multiple health issues) are at higher risk of serious illness, yet, they can be challenging to assess.

Children with complex needs are five times more likely than the rest of the population to die from a treatable condition.

You can read more about what we can do to improve the care we deliver here​

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TIP OF THE WEEK

The oculocardiac reflex reduces the heart rate resulting from direct pressure placed on the extraocular muscles, globe, or conjunctiva.

Beware of bradycardia with eye injuries!

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JOKE OF THE WEEK

Why don't scientists trust atoms?

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Because they make up everything!

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That's it for this week, Reader.

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Remember, your work makes a difference in the lives of paediatric patients every day.

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Stay tuned for next week's edition of Bursting The Bubble.

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From Tessa (on behalf of Team DFTB)

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