Two Paeds In A Pod

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.DOI: https://doi.org/10.1097/PEC.0000000000003637Companion: Iio K, Harel-Sterling M, Freire GC. Archives of Disease in Childhood. Published June 2026.DOI: https://doi.org/10.1136/archdischild-2026-330589━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━WHAT'S CAUGHT MY EYE━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━1. Does one pill really kill?A prospective registry across 58 Spanish emergency departments examined accidental ingestions of "highly toxic" drugs — the agents reputed to kill a toddler in a single dose — in children under eight. Of 61 such ingestions, most often cardiovascular drugs and opioids, only four children (under 7%) were symptomatic, none needed advanced airway or circulatory support, and there were no deaths. It is a measured argument for evidence-based risk stratification over blanket alarm, though the number of genuinely toxic cases is small.Reference: Ramírez-Romero J, Mintegi S, Azkunaga Santibañez B, et al. Pediatric Emergency Care. Published June 2026.DOI: https://doi.org/10.1097/PEC.00000000000036342. Did earlier egg introduction actually cut egg allergy?Two population-based cohorts of twelve-month-olds in Melbourne, before and after guidelines changed to recommend earlier egg introduction, had egg allergy confirmed by skin prick test and oral food challenge. As the typical age of introduction fell from eight to six months, confirmed egg allergy dropped from 9.2% to 7.6% overall, and from 34.6% to 21.9% in the highest-risk infants with early eczema. It is real-world, population-level evidence that a weaning guideline change moved the dial — albeit an Australian before-and-after comparison rather than a trial.Reference: Koplin JJ, Shifti DM, Soriano VX, et al. JAMA Pediatrics. Published June 2026.DOI: https://doi.org/10.1001/jamapediatrics.2026.20803. New research priorities for UK and Ireland PEMA James Lind Alliance priority-setting partnership rebuilt the research agenda for paediatric emergency medicine across the UK and Ireland, a decade on from the original and this time with patients and carers alongside clinicians. From 655 submitted questions, the process produced a new top ten research priorities agreed by consensus. These questions will shape what gets funded and studied in the specialty for the next decade, and the work comes from the PERUKI network.Reference: Sloane C, Waterfield T, Evans J, et al. Emergency Medicine Journal. Published June 2026.DOI: https://doi.org/10.1136/emermed-2025-215836━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━KEY TAKEAWAYS━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━A general paediatric team is not powerless with a child in mental health crisis: daily structured safety checks, removing risks from the environment, and engagement-focused one-to-one care are all within reach, and there is now a consensus framework to organise them by risk level.These are consensus strategies, not trial outcomes — use them as a structure for good practice, not as proof of reduced harm.Most early returns after a forearm cast are pain and cast problems, not emergencies, but reduced distal both-bone fractures return roughly one time in four and warrant specific safety-netting.In a large Spanish registry, accidental ingestions of even "highly toxic" drugs rarely caused symptoms and caused no deaths — grounds for sharper risk stratification.Earlier egg introduction was followed by a measurable population fall in egg allergy, most markedly in infants with early eczema.━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━FULL REFERENCE LIST━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━All articles retrieved from PubMed.Kaltsa A, Marufu TC, Carter T, et al. Risk mitigation for children and young people in mental health crisis admitted to acute paediatric care: a mixed methods exploratory study. Archives of Disease in Childhood. 2026 (advance online).https://doi.org/10.1136/archdischild-2025-328977Romem R, Aliev E, Fainzack A, et al. Unplanned Return Visits to the Emergency Department...

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 not the same as nothing having happened; length of stay in bronchiolitis is driven by feeding and overall trajectory far more than by oxygen delivery precision, so it may always have been an insensitive endpoint for this intervention.This sits within the larger UK conversation on permissive hypoxaemia and oxygen saturation targets in bronchiolitis, and is worth reading alongside the BIDS trial and current oxygen-target guidance rather than in isolation.Cros P, Martin A, Consigny M, et al. Automated oxygen flow titration for infants with bronchiolitis: a multicentre randomised controlled trial. Archives of Disease in Childhood. 2026 (advance online publication). https://doi.org/10.1136/archdischild-2025-329523━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━WHAT'S CAUGHT MY EYE ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━1. Do electronic sepsis alerts actually save children?A systematic review and narrative synthesis of twelve studies of EMR-embedded automated sepsis alerts in children under eighteen. Alerts improved process measures — faster time to antibiotics in four of six studies and faster fluids in two of five — without increasing hospital admissions or overall antibiotic use, but a mortality benefit was shown in only one study, in a PICU population. As more NHS trusts switch on electronic sepsis triggers, this is the honest evidence position to know: the process metrics move, the hard outcome data do not yet exist.Driver B, Babl FE, Cheng D, et al. Alerts and Alarms — Can Electronic Medical Records Help Children and Adolescents Survive Sepsis? Journal of Paediatrics and Child Health. 2026 (advance online publication). https://doi.org/10.1111/jpc.704122. The neonatal head injury that happens on your postnatal wardA retrospective cohort across fifteen Italian maternity units of newborns who fell during routine postnatal stay, with the PECARN rule applied retrospectively. Thirty-nine newborns, median age at injury 32 hours, most falls at night in rooming-in; a quarter (25.6%) had a clinically important traumatic brain injury but none needed neurosurgery or had sequelae, while 88.9% of low-risk babies were imaged anyway. A low-severity, high-anxiety event most clinicians never see described, sitting right at the edge of where PECARN was never validated — the newborn.Corsini I, Cecchetti M, Giacalone M, et al. In-Hospital Neonatal Head Injury: A Multicenter Retrospective Cohort Study. Hospital Pediatrics. 2026 (advance online publication). https://doi.org/10.1542/hpeds.2025-0089523. Does a bigger respiratory virus panel change anything?A retrospective cohort of 2,346 children discharged from a paediatric emergency department with a viral respiratory illness, comparing a limited three-pathogen panel against a comprehensive twenty-two-pathogen panel. No difference in seven-day return visit rate after adjustment (aOR 0.96, 95% CI 0.67–1.38) and no difference in interventions or disposition on return. For the well child being discharged with an obvious viral illness, the bigger panel did not change outcomes — a clean stewardship argument for testing less, not more.Stephan AM, Pérez-Lizardi JY, Stern LM, et al. Evaluating the Impact of Respiratory Pathogen Testing on Pediatric Emergency Department Return Visits and Management. Pediatric Emergency Care. 2026 (advance online publication). https://doi.org/10.1097/PEC.0000000000003622━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━KEY TAKEAWAYS ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━Febrile infant care varies widely between hospitals, with full guideline adherence in only one in five presentationsOver-investigation of the well febrile infant is almost as common as under-investigation, and is not a harmless default; the afebrile-on-assessment infant is where guidance is weakestAutomated oxygen titration in bronchiolitis did not reduce length of stay, but a negative primary endpoint in an underpowered trial warrants reading the secondary dataElectronic sepsis alerts reliably speed up antibiotics and fluids but the mortality evidence is not yet establishedFor the well child discharged with a viral respiratory illness, a comprehensive virus panel did not improve outcomes over a limited one━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ FULL REFERENCE LIST ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━Habermann S, Hartzenberg R,...

The audio from our recent video on iv aminophylline. Watch on YouTube or instagram.

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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In our first podcast of 2021, Drs Damian Roland and Ally Monroe discuss New Variant COVID-19. What does this mean and what are the implications for paediatrics?

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