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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 hypoglycaemia, respiratory panels, and herpes.

Let's do it...

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WEEKLY BUBBLE WRAP: DO LOW BLOOD SUGARS MATTER?

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What’s It About?

This American single-centre retrospective review of 145 previously-well children referred to endocrinology to evaluate hypoglycaemia (<3.9 mmol/L) with acute illness between 2013 and 2018. In this group, a hypoglycaemic disorder was identified in 12 patients (8%) – seven hyperinsulinism, three inborn errors of metabolism, one growth hormone deficiency and one impaired hepatic insulin clearance due to acute hepatic insufficiency.

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Limitations of this study are being a single centre and a retrospective review that introduces multiple biases. A threshold of 3.9mmol was used, higher than that used in UK practice. Could this have resulted in more children being picked up than if a cut-off of 2.6mmol had been used? Many patients met the criteria (1410), which was reduced to 145 due to exclusion criteria.

Underlying disorders were only found in patients who went on to have a diagnostic fast. This was conducted in just under half of patients, emphasising the need for correct workup in these children.

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Why Does It Matter?

Younger age, higher bicarbonate levels and lower ketones in children with acute illness and hypoglycaemia on presentation to ED are potential predictors of establishing a hypoglycaemia diagnosis.

The reported prevalence of undiagnosed hypoglycaemia disorders among children seen in the emergency department (ED) for any reason ranges between 10% and 28%.

Previously well children presenting with acute illness are often thought hypoglycaemic due to prolonged fasting. There is a lack of data to indicate whether these children require endocrine evaluation.
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Clinically Relevant Bottom Line:

All children presenting to ED with an acute illness and hypoglycaemia should have a diagnostic evaluation (with endocrinology guidance).

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Reviewed by: Anandini Arumugam and Anandi Singh. Read the full Bubble Wrap here.

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TOPIC OF THE WEEK: WHY YOU SHOULD BE USING HEADSMART

How common are brain tumours in children?

Brain tumours make up a quarter of all childhood cancers, and sadly more children die of brain tumours than any other childhood cancer.

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How do brain tumours present?

Symptoms are often non-specific and may mimic many common childhood illnesses, such as viral infection. Headaches and other symptoms are linked to the size, speed of growth, and position of the tumour and worsen as the tumour progresses. Sadly, deaths occur due to delayed presentations with raised intracranial pressure.

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) from the start of symptoms to the confirmation of the diagnosis is 14.4 weeks in the UK. This is three times longer than in the US. Although the reasons for this are unclear, it may be related to disease awareness, the availability of imaging, and delayed referral times in the UK.

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What is HeadSmart?

​HeadSmart was created due to the prolonged TDI. The aim is to separate children whose parents can be reassured, those who need urgent review, and those who need imaging.

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How was HeadSmart developed?

HeadSmart was developed in a three-step process. Step one looked at all relevant studies through a systematic review and meta-analysis. The second step was a workshop incorporating the opinions of the multi-disciplinary team, the patient and their families. The final stage was a Delphi consensus process. This is a series of questionnaires with expert feedback designed to reach an agreed outcome.

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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 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, this should prompt a thorough history and examination. Red flags are shown in the figure below.

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Certain predisposing factors increase the risk of brain tumours and lower the threshold for referral and investigation. These include a personal or family history of brain tumours, leukaemia, sarcoma or early onset breast cancer, prior radiation to the brain, or neurocutaneous conditions such as tuberous sclerosis.

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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, and behavioural changes.

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Common pitfalls

• Failing to reassess children with migraine or changing tension headache
• Failing to assess vision
• Not doing a thorough assessment if there is a change in behaviour
• Not considering the diagnosis in children with persistent nausea and vomiting
• Not considering diabetes insipidus in children with excessive thirst or urination
• Thinking that vomiting is due to infection without any supporting findings
• Thinking that abnormal balance or funny walking is because of middle ear disease when there are no supporting findings

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To read more about HeadSmart check out Owen Hibberd's DFTB post.

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HIGHLIGHT: VIRAL RESPIRATORY PANELS

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The Choosing Wisely® campaign is an initiative that promotes collaborative conversations between clinicians and families to safely avoid unnecessary and potentially harmful tests.

The American Academy of Paediatrics Section on Emergency Medicine (AAP SOEM) created a list of five key recommendations for Paediatric Emergency Medicine after a structured review process and expert consensus opinion.

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​What do the guidelines say?

They are generally not routinely recommended in the UK, USA, Canadian, and Australian guidelines for bronchiolitis and community-acquired pneumonia.

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What is the evidence for avoiding respiratory viral panels (RVP)?

We cannot think about using RVPs without this quote from Archie Cochrane, “Before ordering a test, decide what you will do if it is positive or negative. If both answers are the same, don’t take the test.”

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In a world where we want information now, it is easy to see why respiratory virus panels are so popular. Before RVPs, viral cultures were the gold standard. Unfortunately, this method is slow. Respiratory swabs give much faster results by detecting genetic material but are expensive. They may tell you what virus(es) a child has, but often, you can’t do anything about it anyway. There are some exceptions like Bordetella pertussis or influenza (although oseltamivir use is questionable, and if your index of suspicion for pertussis is high enough, you should start treatment before test results) that are on certain RVPs. But if you have clinical suspicion, why not just order the more specific test?

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What are the limitations of respiratory viral panels?

Before discussing the technical and clinical limitations, we must acknowledge the discomfort and stress these tests may add to children and their families.

1. Lingering positivity – a test may be positive even if the virus is not manifesting clinically. During this time, the patient may still be shedding the virus. Children under five seem to have a longer duration of positive RVP tests despite being asymptomatic. A positive RVP does not tell you whether the virus is still causing symptoms.
2. Concurrent infection – a positive result on an RVP can feel reassuring, but should it? Unfortunately, a positive RVP does not eliminate the possibility of another infection. For example, the child with a fever for five days, red eyes, and a positive adenovirus result on RVP can still have Kawasaki disease or the child with a fever and positive influenza result can still have a bacterial pneumonia or otitis media.
3. What to do with a negative RVP – Not all RVPs are created equal. Different RVPs detect different pathogens. A negative result on RVP could mean that an inadequate sample was collected (not surprising given that I have yet to meet a child who enjoys getting a nasal swab) or that the child has another virus that the RVP does not detect. Do not forget that a major pathogen that most RVPs do not detect is Streptococcus pneumoniae – the most common bacterial cause of pneumonia.

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Which children need a respiratory viral panel?

There may be a role in viral respiratory panels for children admitted to the hospital or intensive care unit. In addition, RVPs are valuable in immunocompromised paediatric patients and children with chronic medical problems (e.g., cystic fibrosis).

​One study found that a respiratory virus panel had no significant impact on the length of stay but was associated with a shorter duration of intravenous antibiotics in some patient groups.

However, this finding does not seem to apply in all settings. Respiratory viral panel testing did not reduce antibiotic use in the emergency department. The role of RVPs in decreasing antibiotic use is still contested.

Of note, during COVID-19, some hospitals used RVPs to differentiate patients who had been infected with SARS-CoV-2 from other viral infections.

Some facilities may also use the results from RVPs to cohort patients in the hospital.

Finally, viral testing may also play a role in disease tracking during outbreaks.

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What should we say to parents and caregivers?

We should tell families their child likely has a virus causing respiratory symptoms. While there is testing that may be able to identify the virus, there are important limitations. More importantly, we have no treatments for most viruses. We recommend supportive care, which includes antipyretics as needed for fever and encouraging hydration in addition to closely monitoring the child’s breathing.

We strive to provide high-quality, high-value care based on the best available evidence. So, the next time you plan to order a respiratory viral panel, ask yourself, “Will this change my management?” If the answer is “no,” it is a useless test.

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Read more about choosing wisely in Dennis, Spyros, and Brad's post here.

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EVENT OF THE WEEK

The 13th October is World Herpes Day.

Disease caused by Herpes Simplex Virus (HSV) types 1 and 2 can have devastating consequences.

It can be caused by vertical transmission from mother to child during pregnancy and delivery, but horizontal transfer after birth can also occur.

Neonatal herpes can present with various symptoms, and diagnosis can be challenging.

Check out Marijn Verwijs's post on 10 neonatal herpes here.

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TIP OF THE WEEK

The oculocardiac reflex gives a reduction of the heart rate resulting from direct pressure placed on the extraocular muscles (EOM), globe, or conjunctiva.

Beware of bradycardia with eye injuries.

Read more here.

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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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