With millions of journal articles published yearly, it is impossible to keep up. Clinicians from The Royal London Hospital tell us what is new in the world of paediatric literature…

The Royal London Hospital is a paediatric major trauma centre in the heart of East London. Here they review a range of articles showcasing PEM, neonatal care and communication with parents

Happy reading!

**If you or your team want to submit a review, please get in touch with Dr Vicki Currie at @DrVickiCurrie1 or vickijanecurrie@gmail.com. **

Article 1: Coming in hot: using emotional journey maps to examine parental perceptions associated with presentations of their child with fever to the emergency department in England

Franklin C, Taylor-Robinson D, Carrol ED, Moran P, Carter B. Coming in hot: using emotional journey maps to examine parental perceptions associated with presentation of their child with fever to the emergency department in England. BMJ Paediatrics Open. 2025;9:e003640. https://doi.org/10.1136/bmjpo-2025-003640

**What’s it about? **

Emotional Journey Maps (EJMs) have been widely used in the commercial industry to analyse the consumer journey; their use in healthcare is relatively new and allows for development of patient-centred care models. In this study EJMs were co-produced with parents to explore the journeys from recognising a fever to contacting primary care, attending the Emergency Department and discharge.

Parents of children aged 0-18 who attended ED with a fever could self-refer via recruitment adverts shared online and at local schools and community centres. During a recruitment window of January 2022-January 2023 11 parents completed a total of 15 EJMs.

Emotional mapping using a six-point visual scale was mapped to set “touchpoints” (encounters) along the patient journey to examine trends in parents’ concerns and anxieties. At each point qualitative detail was added to explore the experience of seeking healthcare. The EJMs were analysed to identify repeating patterns of behaviour.

10 of the 15 journeys initially involved contacting primary care, 7 of these were then referred to ED, and 3 were left to decide themselves whether to attend ED.

Key drivers for anxiety among parents were the** feeling of not being listened** to, feeling stigmatised for attending inappropriately, and feeling **uncertainty **about the medical advice or treatment offered.

Most parents reported a need for better education and support with symptoms of fever, especially febrile convulsions.

**Why does it matter? **

Fever is one of the commonest causes for presentation to the paediatric emergency department, and numbers are increasing despite little evidence for increased disease severity.

Emotional aspects such as anxiety, fear and uncertainty impact parental decision making and influence health-seeking behaviour.

Check out Are You Worried Your Child Is Getting Worse? – Don’t Forget the Bubbles

Anxiety around fever can lead to parents becoming hypervigilant and risk averse in the self-management of fever and can increase ED attendances. The impact of this is increased with delivery of mixed messages about how to manage fever.

Clinically Relevant Bottom Line

Every patient interaction is an opportunity for good communication and elimination of conflicting information. Clear, consistent messaging about fever management and safety netting improves health literacy, validates

**Reviewed by **Dr Natalie Clark

Article 2: ARFID and health complications….

James RM, O’Shea J, Micali N, et al. Physical health complications in children and young people with avoidant restrictive food intake disorder (ARFID): a systematic review and meta- analysis. BMJ Paediatrics Open 2024;8:e002595. doi:10.1136/ bmjpo-2024-002595

**What’s it about? **

Avoidant restrictive food intake disorder (ARFID) is characterised by persistent restricted intake in quantity or variety of food, leading to failure to meet nutritional needs and/or significant impacts on psychosocial functioning. These difficulties arise from lack of interest in food, sensory difficulties and/or fear of the consequences of food.

This was the first systematic review of the published literature on physical health complications in children and young people up to 25 years old with ARFID, which included 132 studies.

The meta-analysis included 13 studies and compared ARFID with healthy controls and children and young people with anorexia nervosa.

Their findings highlighted that children and young people with ARFID are at risk of complications such as** low bone mineral density** (BMD) and nutritional deficiencies. Some of the most severe cases of micronutrient deficiencies and low BMD were reported in individuals of healthy or overweight status; therefore unlike anorexia nervosa a lower BMI is not a predicting factor of health complications.

Children and young people with ARFID on average present with higher heart rates and lower levels of hypotension and bradycardia compared to individuals with **anorexia nervosa **despite similar levels of low weights.

The study’s limitations include the low level of quality of studies and its high heterogeneity in their meta-analysis.

**Why does it matter? **

We have seen a recent increase in children and young people with ARFID, affecting** 3-15%** of primary school children. It is a relatively new diagnosis with limited research on the physical health impact and clinical findings. Previously the physical health findings from research on anorexia nervosa has been applied as a model for ARFID, therefore the true health complications were not fully understood.

Check out Medical Emergencies in Eating Disorders – Don’t Forget the Bubbles

Clinically Relevant Bottom Line

Children and young people with ARFID can present across the whole weight spectrum and health complications, which can be serious, do not discriminate based on the individual’s weight. With this in mind more research must be done to recognise nutritional adequacy in children with adequate growth or who are overweight.

Reviewed by Dr Cate Luce

Article 3: What is the optimal dose of intranasal midazolam for procedural sedation?

Tsze DS, Woodward HA, McLaren SH, et al. Optimal Dose of Intranasal Midazolam for Procedural Sedation in Children: A Randomized Clinical Trial. JAMA Pediatr. 2025;179(9):979–986. doi:10.1001/jamapediatrics.2025.2181

What’s it about?

This is a double-blind randomised control trial from an American children’s hospital emergency department, looking at the optimal intranasal (IN) midazolam dose for sedation in minor laceration repair. They compared four doses (0.2, 0.3, 0.4, 0.5 mg/kg with a maximum dose of 10mg) in children aged 6 months to 7 years, using an adaptive sequential selection design to drop inferior doses and compare the remaining ones.

The primary outcome was achieving an “adequate sedation state” for ≥ 95% of the procedure without unacceptably deep sedation requiring intervention, procedural delays, or failure to complete the repair. Secondary outcomes included ideal sedation state, time to onset, adverse events, recovery time, and satisfaction (both from clinicians and caregivers).

The two lower doses (0.2 and 0.3 mg/kg) were eliminated during the trial and the remaining doses, 0.4 and 0.5 mg/kg, both performed equally well with no significant differences in secondary outcomes or adverse events.

Why does it matter?

Intranasal midazolam is widely used for paediatric sedation as it’s non-invasive and avoids IV access, but optimal dosing has been unclear. This trial found** 0.4–0.5 mg/kg** provides effective sedation with minimal adverse effects.

However, even at this dose, adequate sedation occurred in only 65–70% of children. IV or IM options like ketamine typically achieve better rates of adequate sedation but involve needles, deeper sedation, longer recovery, and potentially greater risk. The authors note higher IN doses (e.g., 0.6 mg/kg or >10 mg total) may improve rates of adequate sedation, but data on this and the adverse effects associated are lacking.

Limitations included exclusion of children with developmental delay or autism – groups who might benefit most from non-invasive sedation – and the focus on minor lacerations means there is uncertainty about applicability to more painful procedures.

For more on procedural sedation check out Analgesia and Procedural Sedation Module – Don’t Forget the Bubbles.

Clinically Relevant Bottom Line

This study has shown that procedural sedation (specifically minor laceration repair) in children aged ~6 months to 7 years, 0.4 to 0.5 mg/kg intranasal midazolam appear to be the optimal doses. Lower doses were inadequate and there was no clear advantage.

Reviewed by Emma Dyer

**Article 4: **How good are we at recognising and managing cardiac causes of a collapsed neonate in the PED?

Kuok MCI, Lambert J, Janjanam A, Lillie J. Cardiac-related neonatal collapse presenting to the emergency department: a retrospective cohort study. BMJ Paediatrics Open. 2025;9:e003149. https://doi.org/10.1136/bmjpo-2024-003149

What’s it about?

This article is a retrospective cohort study of neonates who presented to departments PEDs in collapse due to cardiac disease and subsequently transferred to a PICU, over 8 years. It is examining how often the cardiac cause was missed initially, what types of cardiac defects were responsible, and delays in diagnosis and treatment (notably prostaglandin initiation).

The most common cardiac cause of collapse was structural heart defects (69%), of which the most common defect was left ventricular outflow tract obstruction (LVOTO; 71%). After this, arrhythmia and cardiomyopathy/myocarditis were rarer causes of cardiac collapse (17% and 14% respectively).

Importantly, the PED making the referral recognised a cardiac cause in 69% of cases. In the remaining cases, the main presumed diagnoses were sepsis and bronchiolitis. They showed that conditions that had mixing of circulation (eg TGA, TAPVD), were better picked up due to marked cyanosis and higher proportion of clinical murmurs. They postulated that LVOTO conditions were more likely missed due to the babies presenting similar to sepsis, e.g. delayed capillary refill, lack of heart murmur and lack of central cyanosis. This study did identify that weak/absent femoral pulses is an important distinguishing factor between LVOTO and sepsis.

This study reminds us that ECGs should be performed in all neonatal collapses so as not to miss signs of viral myocarditis and arrhythmia.

They showed that prostaglandin administration to neonates with duct-dependent lesions increased from** 44% to 97%** from time of referral, to departure of the transport team. Early administration stabilises the neonate and allows time for transfer and comprehensive assessment by cardiologist, and ultimately is a life-saving treatment. With this, they also showed an increase of ionotropic support and intubation with the transport team’s involvement.

The Collapsed Cardiac Child: Kath Browning Carmo at DFTB18 – Don’t Forget the Bubbles

Why does it matter?

This study shows us that cardiac causes of neonatal collapse are relatively rare. It is therefore an important diagnosis to not forget when presented with a collapsed neonate. Maintaining a high index of suspicion for cardiac causes of neonatal collapse ensures timely recognition and therefore initiation of treatment, most importantly prostaglandin infusion and consideration of intubation and ionotropic support

Clinically Relevant Bottom Line

Always maintain cardiac lesions in your differential in the collapsed neonate and have a low threshold to start a prostaglandin infusion.

Reviewed by Dr Sarah Crew

**Article 5: **Timing of repeat epinephrine to inform paediatric anaphylaxis observation periods: a retrospective cohort study

Dribin TE, Sampson HA, Zhang Y, Boyd S, Zhang N, Michelson KA, Neuman MI, Brousseau DC, Mistry RD, Freedman SB, Aronson PL, Bergmann KR, Boswell B, Chinta SS, Chua WJ, Cohen AR, Cohen JS, Daggett A, Davis JR, Freeman JF, Khanna K, Knoles CL, Kwan KY, Larsen CD, Lee J, Lubell TR, Metcalf AM, Moake MM, Nesiama JO, Ngo TL, Pulcini CD, Russo CJ, Singh NV, Srivastava G, Strutt J, Thapar V, Wyst CV, Walsh PS, Wolnerman Y, Schnadower D; Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. Timing of repeat epinephrine to inform paediatric anaphylaxis observation periods: a retrospective cohort study. Lancet Child Adolesc Health. 2025 Jul;9(7):484-496. doi: 10.1016/S2352-4642(25)00139-7. PMID: 40506197; PMCID: PMC12279388.

What’s it about?

This multicentre retrospective cohort study aimed to establish how long children presenting with anaphylaxis to Paediatric

Emergency Departments (PEDs) need to be observed after adrenaline is given to spot clinically significant biphasic reactions. They did this through analysing the electronic medical records of over 5000 children from ages 6 months to 17 years who presented to 31 North American PEDs and recorded the incidence and timings of repeated adrenaline doses being given, as well as severity of the reaction.

Kaplan-Meier analyses were used to plot cumulative incidence of repeat adrenaline doses over time and identified when that risk dropped below 2%.

Why does it matter?

When looking at all 5641 patients together (across all illness severities), by 115 minutes after the initial adrenaline dose,** 98% **of those who would need a repeat adrenaline dose had already received it, and fewer than 2% of patients would require another dose after that time. For those with respiratory involvement only, this 2% risk threshold was crossed at 105 minutes, and for those with cardiovascular involvement it was longer at 160 minutes.

From this data, the researchers proposed that most children without cardiovascular involvement could be safely discharged at 2 hours after adrenaline, and those with cardiovascular involvement would require a longer observation period of 4 hours.

Currently, observation times after paediatric anaphylaxis are highly variable between departments, reflecting differing national guidelines and limited evidence. These results suggest that emergency departments could safely adopt observation strategies based on patient risk, helping to reduce unnecessary admissions and enhance the experience for children and caregivers.

Check out Anaphylaxis Module – Don’t Forget the Bubbles

Clinically Relevant Bottom Line

Most children requiring adrenaline for anaphylaxis who do not have cardiovascular involvement can be safely observed for around 2 hours after adrenaline before discharge. Children with cardiovascular features should be observed for at least 4 hours or admitted if concerns persist.

**Reviewed **by Eloise Graham

If we missed something useful or you think other articles are worth sharing, please add them in the comments!

That’s it for this month—many thanks to our reviewers for scouring the literature so you don’t have to.

Vicki Currie, DFTB Bubble Wrap Lead, reviewed all articles.