Episode 5 - Paediatrics

This episode is all about the little humans - we first look at the reliability of a clinical prediction rule to identify febrile infants who are at low of serious bacterial infections. Then we discuss the role of the plot twisting TWIST score in diagnosing testicular torsion in children with acute scrotum and, finally, we discuss the effectiveness of different treatment formulations (inhaler vs. nebulizer) in the management of acute exacerbation of asthma. This month’s interlude segments will be presented by Dr Surbhi Rikhi and Dr Kerf Tan.

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.

Discussion 1:
Kuppermann, N., Dayan, P., Levine, D., Vitale, M., Tzimenatos, L., & Tunik, M. et al. (2019). A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatrics, 173(4), 342. https://doi.org/10.1001/jamapediatrics.2018.5501.

Presenter - Johann De Alwis.

  • 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. 
Take-Home Points:
  • 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! 

Discussion 2:
Pan, P. (2020). Validation of the Testicular Workup for Ischemia and Suspected Torsion (TWIST) Score in the Diagnosis of Testicular Torsion in Children With Acute Scrotum. Indian Pediatrics, 57(10), 926-928. https://doi.org/10.1007/s13312-020-1992-6.

Presenter - Omal Fernando.

  • The TWIST score includes - testicular swelling (2), hard testicle (2), absent cremasteric reflex (1), nausea or vomiting (1), a high-riding testicle (1). 
  • Low risk was a score of 0-2, intermediate risk was a score of 3-4 and high risk was a score 5-7.
  • Of those with testicular torsion, the mean TWIST score was 5.7 (none in low-risk category, 13 in intermediate-risk group, and 55 in high-risk group). 
  • Of those without testicular torsion, the mean TWIST score was 1.46 (21 in low-risk group, 7 in the intermediate-risk group, and 0 in the high-risk group).
  • All patients with a high-riding testis or absent cremasteric reflex were found to have testicular torsion.

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.

Discussion 3:
Iramain, R., Castro‐Rodriguez, J., Jara, A., Cardozo, L., Bogado, N., Morinigo, R., & De Jesús, R. (2019). Salbutamol and ipratropium by inhaler is superior to nebulizer in children with severe acute asthma exacerbation: Randomized clinical trial. Pediatric Pulmonology, 54(4), 372-377. https://doi.org/10.1002/ppul.24244.

Presenter - Min Park.

Take-Home Points:
  • 103 children between the age of 2 and 14 years with severe asthma exacerbations (pulmonary score 7) were randomly allocated to a nebulizer or metred dose inhaler (MDI) and spacer with nasal prong oxygen.
  • The primary outcome was the rate of hospitalization with the secondary outcome being oxygen saturations at 60 and 90 minutes.
  • Children in the MDI group had significantly improved oxygen saturation from 60 minutes compared with the nebulizer group, with significantly lower rates of admission to hospital (5.8% vs. 27.5%). 
  • 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. 

Interlude Segment 1:
Presenter - Dr Surbhi Rikhi.

Interlude Segment 2:
Presenter - Dr Kerf Tan.

Resources (to support doctor well-being) - 
  • Applications: Shift (Black Dog Institute app for healthcare workers), Calm, Headspace, Feeling Good, Smiling Minds, Insight Timer.  
  • JMO support line (NSW): 1300 566 321.
  • Access EAP (free confidential service for all NSW Health employees).
  • Doctors for doctors: www.drs4drs.com.au.
  • Beyond Blue: 1300 224 636.
  • Lifeline: 13 11 14. 
  • Suicide call-back service: 1300 659 467. 

Other References:
“Step by step” approach to the febrile infant - 
Mintegi, S., Bressan, S., Gomez, B., Da Dalt, L., Blázquez, D., & Olaciregui, I. et al. (2013). Accuracy of a sequential approach to identify young febrile infants at low risk for invasive bacterial infection. Emergency Medicine Journal, 31(e1), e19-e24. https://doi.org/10.1136/emermed-2013-202449.

Original study validating the TWIST score -
Barbosa, J., Tiseo, B., Barayan, G., Rosman, B., Torricelli, F., & Passerotti, C. et al. (2013). Development and Initial Validation of a Scoring System to Diagnose Testicular Torsion in Children. Journal Of Urology, 189(5), 1859-1864. https://doi.org/10.1016/j.juro.2012.10.056.

Starship Hospital (NZ) study examining nebuliser vs. MDI delivery for asthma -
Klassen, T. (2001). Spacers were better and less expensive than nebulisers for giving albuterol to children with moderate to severe acute asthma. Evidence-Based Medicine, 6(1), 31-31. https://doi.org/10.1136/ebm.6.1.31.

Further evidence regarding female ACS presentations (as covered in our previous episode) -
van Oosterhout, R., de Boer, A., Maas, A., Rutten, F., Bots, M., & Peters, S. (2020). Sex Differences in Symptom Presentation in Acute Coronary Syndromes: A Systematic Review and Meta‐analysis. Journal Of The American Heart Association, 9(9). https://doi.org/10.1161/jaha.119.014733.

Sederholm Lawesson, S., Isaksson, R., Thylén, I., Ericsson, M., Ängerud, K., & Swahn, E. (2018). Gender differences in symptom presentation of ST-elevation myocardial infarction – An observational multicenter survey study. International Journal Of Cardiology, 264, 7-11. https://doi.org/10.1016/j.ijcard.2018.03.084.

The discussions were mediated by PEM consultant Dr Surbhi Rikhi, ED consultant Dr Kerf Tan and, ED consultant Dr Pramod Chandru. 

This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney, Deepa Dasgupta, Cynthia De Macedo Franco, and Paul Scott.

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See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

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