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All Subjects Acute Otitis Media  Acute Pain  Concussion  Croup  Diabetic ketoacidosis  Emergency Medicine  Evidence-Based Medicine  Gastroenteritis  Head Injury  Infection  Otitis Media with Effusion  Otitis Media, Suppurative  Pediatrics  Psychiatry  Psychotic Disorders  Research  Severe Head Injury 


Building a connection: TREKK and NENA (more)

June 30, 2015

The 2015 Annual National Emergency Nurses Association Conference (NENA) was held in Edmonton this year and I had the pleasure of not only attending, but also representing TREKK with a poster display on our first Social Networking Analysis.

As a pediatric emergency nurse (The Children’s Hospital of Winnipeg) and a NENA member, I was quite excited to attend this year’s conference, themed “Prepare for the Unexpected”. Those who work in an emergency department (ED) can attest to the uncertainty and lack of a routine that encompasses the ED. The goal of the conference was to prepare and inform emergency nurses for unpredictable scenarios to increase comfort and make the unfamiliar more familiar. This got me thinking – isn’t this exactly what TREKK is all about? Treating children is unfamiliar to many healthcare professionals working in general EDs and can be stressful. TREKK is connecting pediatric and general EDs and creating resources like our bottom line recommendations, to support our general emergency colleagues in getting quicker access to the latest evidence-based care.

NENA connects emergency nurses across Canada by encouraging networking and promoting engagement. As members, we are able to talk about issues that we have in common, explore solutions and learn from one another’s experiences. Talking to general ED nurses at the conference was really exciting. They shared their stories, discussed opportunities to utilize TREKK and were curious to know who was involved in our network from their community, so that they knew who to reach out to for information on treating children.

During the time I spent at our TREKK poster exhibit, I had nurses approach me who remembered our needs assessment from two years ago, to say, “hey, I did that iPad survey!” It was great opportunity to reconnect with them and provide updates on TREKKs accomplishments since the needs assessment and the many resources now available on trekk.ca. I was able to talk with nurses in remote locations such as northern Yukon, nursing stations and big urban centres. Having the NENA conference as a venue to build camaraderie among emergency nurses is amazing. I received great feedback on our Social Networking Analysis and was able to broaden my connections across the country.  

I encourage all TREKK coordinators to reach out to their provincial NENA representative – this is a critical connection to make so that we can continue to work towards our shared goal of improving emergency care for children across Canada.

Written by: Laura Ebenspanger

From team: News and Events



Crisis Interventions in the Emergency Department | Cochrane Child Health Twitter Journal Club – #CochraneChild (more)

May 27, 2015

Thanks to everyone for joining the #CochraneChild Twitter journal club on May 27th, 2015 with TREKK's own Dr. Terry Klassen and Dr. Amanda Newton. The archived discussion is at: http://bit.ly/CrisisJC 

What: Twitter journal club on crisis interventions for pediatric mental health in the emergency department

When: Wednesday, May 27th, 1:00pm PT Vancouver | 2:00pm MT Edmonton & Calgary | 3:00pm CT Winnipeg | 4:00pm ET Toronto 

Where: Follow #CochraneChild on Twitter and join in the discussion by including #CochraneChild in all your posts. See these tips for participating in a Twitter chat.

Link to paper: A systematic review of crisis interventions used in the emergency department: recommendations for pediatric care and research

Questions we will be addressing: 

1. How often do Emergency Department (ED) clinicians see a patient for mental health care? Have visit trends changed over time?

2. Based on the 2010 review, what interventions have been tested for pediatric crisis care in the ED?

3. The studies included in the review were all observational studies. What are the challenges with this? Would other study designs have worked in this context?

4. What care do children and youth currently receiving in EDs for mental health emergencies?

5. Have new studies of ED-based crisis care been published since the 2010 review highlighted today?

Dr Terry Klassen Bio-sketch:

Dr. Klassen graduated from the Faculty of Medicine, University of Manitoba in 1982 and completed his Pediatric Residency training at the University of Manitoba in 1986.  He completed M.Sc. in Epidemiology at McMaster University in 1994.  He has served as CEO and Scientific Director for the Children’s Hospital Research Institute of Manitoba and Associate Dean, Academic in the College of Medicine, Faculty of Health Sciences at the University of Manitoba and Director of the George and Fay Yee Center for Healthcare Innovation since returning to Manitoba in September, 2010.  Since the commencement of his new role as Head of the Department of Pediatrics, he has stepped down from the Associate Dean, Academic position but continues to serve both the Children’s Hospital Research Institute of Manitoba and CHI roles.

From 1999 to 2009 Dr. Klassen was Chair of the Department of Pediatrics, University of Alberta; Director of the Alberta Research Centre for Health Evidence and Director of the Evidence-based Practice Center at the University of Alberta. He is a clinician scientist focused on Pediatric Emergency Medicine, and has been active in Pediatric Emergency Research Canada collaborating on a national research program involving randomized controlled trials, systematic reviews and knowledge translation. He has a consistent record of national and international peer reviewed funding, along with a publication record that has included many articles in the highest impact medical journals.

In 2009, Dr. Klassen co-founded StaR Child Health, an international group aimed at improving the design, conduct and publication of randomized controlled trials in children. In recognition for his lifetime contributions, he was elected into the Institute of Medicine in 2010 in the foreign associate category. He is also a Fellow in the Canadian Academy of Health Sciences. Dr. Klassen’s research has had a large impact on the practice of Pediatric Emergency Medicine, which was recognized when he received a 2011 Canadian Institutes of Health Research – Canadian Medical Association Journal Top Achievements in Health Research Award. In 2011 he was also awarded the Networks of Centres of Excellence (NCE) grant, entitled TRanslating Emergency Knowledge for Kids (TREKK). In 2012 Dr. Klassen was appointed to the Governing Council of the Canadian Institutes of Health Research.

Dr. Amanda Newton Bio-sketch:

Dr. Newton is an Associate Professor in the Department of Pediatrics at the University of Alberta (Edmonton, Alberta, Canada) and clinician scientist affiliated with the Stollery Children’s Hospital in Edmonton. Her research aims to improve mental health care and outcomes for children and youth who are acutely mentally ill.

From team: News and Events

tags: Emergency Medicine Psychiatry    


Journal Club Archive



Crisis Interventions for Pediatric Mental Health Presentations in the Emergency Department (more)

May 20, 2015

May 25, 2015 - This week's post is also available from the Cochrane Child Health blog.

Children’s Mental Health by the Numbers

Every year in Canada, 1.2 million children and youth experience mental health problems and illnesses [1]. Fewer than 20% of them receive appropriate treatment [2]. And from 2006-2007 to 2013-2014, the national rates of visits to the emergency department (ED) for mental disorders among children and youth between the ages of 5 and 24 increased by 45% [3]. 

Beyond the numbers, these statistics describe kids who are battling conditions like depression, harmful and hazardous substance use, and anxiety disorders. Kids who can present to the ED in acute crisis. Kids who often have nowhere else to go.

While ideally, children and youth with mental health needs would receive early intervention and community-based management, this doesn’t always align with service availability or the nature of the treatment need. Sometimes, a crisis can’t be avoided. In all these circumstances, the ED plays an important role in providing care. 

Emergency Department-Based Management Interventions for Mental Health Presentations

A systematic review published in 2010 evaluated the effectiveness of different ED-based management strategies used when children and youth presented with mental health complaints [4]. There were only three studies that focused on pediatric (≤18 years) populations, so nine additional studies in adult populations, or in populations where the age was unknown, were also included. In all cases, patients with a range of mental health conditions were represented.

The authors identified three main categories of interventions: specialized models of pediatric care, patient triage scales, and other ED mental health care.

Specialized Models of Pediatric Care: These interventions included referrals to a specialized psychiatric team, made up of at least a child psychiatrist, and possibly also other psychiatric professionals like a nurse specialist or social worker. In three studies, referrals to these teams were associated with reduced hospital admissions, length of stay in the ED, and a modest cost savings in the ED.

Patient Triage Scales: Five studies evaluated four different triage scales as they were applied to mental health presentations. The outcomes measured across studies were variable, limiting the conclusions that can be made.

Other ED Mental Health Care: While none were evaluated in pediatric populations, three other strategies were described in the systematic review. Changes in legislation allowing psychologists to recommend involuntary patient hospitalization did not lead to significant differences in disposition decisions made by psychologists, or between psychiatrists and psychologists. The use of crisis teams had no impact on patient distress in one study, but reduced hospitalization in another. A computerized reminder system for restraints reduced the time to renewal of restraint orders, as well as time spent in restraints.

Limited evidence on the best strategies to treat children and youth with mental health conditions was available, but this review did find some support for the use of specialized psychiatric teams, and identified gaps in the child health evidence where the adult literature may provide some direction, namely the use of triage scales and developing guidance for restraint.

Dr. Amanda Newton, the senior author of the review, commented “Recent statistics reinforce that addressing emergency mental health care is critical. What is clear from this review is that the pediatric evidence base requires development. Studies that evaluate the quality of care provided and patient reported outcomes are important. Evidence exists outside of this review for specialized care, such as care for intentional self-harm, but a focus on the quality of general emergency mental health care is also important as this is standard care provided in emergency departments.”  

Please join the authors of the systematic review for a live discussion on Twitter this Wednesday May 17 @ 2 pm MT. Check out the journal club announcement here.


1. Mental Health Commission of Canada. (2013). School-based mental health and substance abuse project.

2. Mental Health Commission of Canada. (2015). Topics: Child and Youth.

3. Canadian Institute for Health Information. (2015). Care for Children and Youth with Mental Disorders.

4. Hamm, M. P., Osmond, M., Curran, J., Scott, S., Ali, S., Hartling, L., . . . Newton, A. S. (2010). A systematic review of crisis interventions used in the emergency department: recommendations for pediatric care and research. Pediatr Emerg Care, 26(12), 952-962. doi: 10.1097/PEC.0b013e3181fe9211

From team: News and Events

tags: Psychotic Disorders Emergency Medicine    



Identifying kids at high risk for diabetic ketoacidosis (more)

May 15, 2015

May 18, 2015 - This week's post is also available from the Cochrane Child Health blog.

I am sure you have heard. Type I diabetes is growing in both prevalence and incidence every year. This year alone, nearly 65,000 children and youth under the age of 15 will be diagnosed with type 1 diabetes worldwide [1]. Next year, there will be a 3% increase in the incidence of diagnosis [2]. Unfortunately, this trend is not expected to change in the near future. 

Upon diagnosis, 10-70% of children will present with diabetic ketoacidosis (DKA) [2]. Characterized by hyperglycemia, acidosis, and ketonuria, DKA is a very serious condition that carries substantial risk for life threatening complications, like cerebral edema. Moreover, in comparison to adults, children are at a high risk for severe complications. Because of this, DKA is the most common cause of diabetes related death in kids [2].

It remains unclear whether presenting in DKA at diagnosis is indicative of a more severe form of type 1 diabetes, or if it is linked to delayed diagnosis. However, we do know that children who present with DKA at diagnosis have a poorer long term prognosis, with diminished glycemic control, less residual β cell function for up to two years after diagnosis, and a decreased incidence of remission [2]. 

The mean duration between the onset of symptoms and development of DKA is 14 days, and over one third of children will have at least one medical consultation in this period prior to diagnosis [2]. This represents an ideal time for identifying and triaging children at high risk for developing DKA. To do this, evidence-based risk factors for the development of DKA in children need to be identified. 

Evidence-based factors associated with DKA at type 1 diabetes diagnosis

Usher-Smith et al. conducted a systematic review, including 46 studies with over 24,000 children and youth (ages 0-21 years) from 31 different countries, to determine factors associated with diabetic ketoacidosis at the diagnosis of type 1 diabetes in children and young adults. Together, 23 different factors were considered in this review. Here is the key evidence you need to know to identify a child at risk for presenting in DKA at type 1 diabetes diagnosis.

Risk factors:

Age: Children less than 2 years old were three times more likely to present in DKA than children 2-5 years old.

Ethnicity: Because the populations included in the studies were too heterogeneous, the frequency of DKA could not be determined for specific ethnic groups. However, 5 studies compared differing pairs of ethnic groups, and consistently found the ethnic minority group experienced an increased risk of DKA.

Body mass index (BMI): Children with lower BMIs were at an increased risk for DKA.

Health insurance status: In the United States, children who had either no health insurance or Medicaid were three times more likely to present in DKA at diagnosis when compared to children with private health insurance.

Family income, parental employment, and social status: Children of low SES were at an increased risk for presenting in DKA.

Diagnostic error: Children who were not diagnosed with type 1 diabetes on their first medical consultation due to diagnostic error were three times more likely to present in DKA at diagnosis. Diagnostic error was significantly more likely in young children. The mean age of children presenting in DKA at diagnosis whose diagnosis was missed on the first medical consultation was 5.4 years, compared to mean age of 8.8 years in children whose diagnosis was not missed.

Delayed treatment and presence of structured diabetes team: One European multicenter study showed a greater than 24 hour delay between diagnosis and treatment led to a small increased risk of presenting in DKA at diagnosis. One Kuwaiti study showed that children diagnosed in hospitals without a structured diabetes team were more likely to present in DKA.

Preceding infection or febrile illness: Having a preceding infection or febrile illness increased the risk of presenting with DKA at diagnosis.

Protective factors:

Family history of diabetes: Children who had a first-degree relative with type 1 diabetes were six times less likely to present in DKA on diagnosis.

Parental education: High parental education was protective against DKA, however, the definition of “high” education varied depending on the location of data collection in the included study.

Background incidence of type 1 diabetes: Children who lived in an area with a higher background incidence of type 1 diabetes were less likely to present in DKA.

Factors with no or an unclear effect on rate of presentation in DKA at diagnosis:

The following factors had no impact on the rates of presentation in DKA at diagnosis, or their impact could not be adequately assessed due to limitations of the data: sex, parental consanguinity (i.e., blood relation to a parent with type 1 diabetes), family structure, rural or urban residence, delayed diagnosis, and number of medical consultations before diagnosis.

Summarizing the evidence

The authors of the review concluded: “Younger age, diagnostic error, ethnic minority status, lack of health insurance in the US, lower body mass index, preceding infection, and delayed treatment were all associated with an increased risk of diabetic ketoacidosis, while having a first degree relative with type 1 diabetes at the time of diagnosis, higher parental education, and higher background incidence of type 1 diabetes appear to be protective.”

Implications for practicing clinicians

The authors of the review highlight: “As with other serious illnesses in children, differentiating the occasional child with a serious illness from the large number with minor undifferentiated illness is challenging. The relatively easy access to point of care tests for hyperglycemia, ketonemia, and glycosuria, however, means that diagnosis does not require access to specialist diagnostic services but, instead, a high index of suspicion. Our findings suggest that clinicians should be particularly alert for diabetic ketoacidosis in children under 5 years old, those from ethnic minority groups, and those from families with low education level or socioeconomic status.”


Translating Emergency Knowledge for Kids (TREKK):

Diabetic Ketoacidosis Bottom Line Recommendations (French & English)

Diabetic Ketoacidosis Evidence Repository

Emergency Medicine Cases - Episode 63: Pediatric DKA


1. Karvonen, M. (2006). Incidence and trends of childhood Type 1 diabetes worldwide 1990-1999. Diabetic Medicine, 23(8), 857-866. doi: 10.1111/j.1464-5491.2006.01925.x

2. Usher-Smith, J. A., Thompson, M. J., Sharp, S. J., & Walter, F. M. (2011). Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: A systematic review. BMJ, 343(7815). doi: 10.1136/bmj.d4092



From team: News and Events

tags: Diabetic ketoacidosis    



To CT, or not to CT? Clinical Decision Rules for Concussion (more)

May 08, 2015

May 11, 2015 - This week's post is also available from the Cochrane Child Health blog.

Head trauma. Headache. Nausea. Loss of balance. Dizziness. Difficulty concentrating. Confusion. Behavioural changes. Sleep changes.

It might be a concussion. What next?

With growing attention in research and the media, it is becoming clear that concussions are very serious injuries with sometimes lasting effects. As an emergency physician, the chances are good that you have treated many children with these symptoms – pediatric concussion is considered a silent epidemic [1]. In the US, estimates suggest up to 3.8 million concussions occur every year, resulting in over 700,000 Emergency Department visits [2]. Because of this, head trauma is one of the most common reasons for consultation in the Emergency Department [3]. 

Concussion symptoms typically alleviate within 72 hours, and completely resolve in 7 to 10 days [4]. However, in many cases, children and youth experience ongoing or recurrent headache, behavioural changes, and other physical symptoms, requiring subsequent Emergency Department and primary care physician visits [4]. It was estimated in one Canadian study that 58% of children with concussion remained symptomatic in the first month, 11% at 3 months, and 2% beyond one year [5]. These findings reinforce that concussions are serious injuries that can last over time. 

Considering the significant morbidity of concussion, and its impact on quality of life and school participation, identifying kids at risk for long-term consequences and those in need of neurosurgical intervention is crucial. There is an increasing tendency by physicians to perform early diagnostic imaging through CT scan for suspected concussion because it is linked to better outcomes, lower admission rates, and serves as the diagnostic standard for identifying intracranial injury [6]. However, it isn’t feasible or necessary to conduct this scan with all children presenting with concussion symptoms. This makes a clinical decision rule for CT scans important. With summer around the corner, and team sports ramping up for the season, understanding and using effective and validated clinical decision rules is essential to identify children at risk for intracranial injury. 

When to CT: The evidence

In a recent systematic review, Pickering et al. reviewed evidence from 16 RCTs (representing 14 cohorts and 79,740 patients) to determine which clinical decision tool is most accurate at predicting which pediatric patients will have an intracranial injury on CT or require neurosurgical intervention [6]. Sensitivity and specificity were determined for 11 decision rules: 

  • - UCD Rule
  • - NEXUS II
  • - Chalice Rule
  • - PECARN (≥2yrs <18yrs, and <2 yrs)
  • - Buchanich 2007 Rule
  • - Dietrich 1993 Rule
  • - Greenes 1999 Rule
  • - Greenes 2001 Scoring System
  • - Atabaki 2008 Rule
  • - CATCH Rule
  • - New Orleans Criteria

Which rule? 

Of the 11 clinical decision rules published at the time of the review (2011), methodologically, PECARN was identified as the strongest rule with the greatest validity, largest study cohort, highest sensitivity and acceptable specificity for clinically significant intracranial injury.

PECARN is the recommended clinical decision rule for identifying children at risk for intracranial injury who require imaging in Canada [1]. However, in the UK, because the CHALICE-derived National Institute for Health and Clinical Excellence (NICE) criteria for CT scan forms the basis for 85% of management decisions in the Emergency Department [6], the authors acknowledged its continued use as an acceptable and cost-effective alternative more in keeping with National Health Service-based practice. 

The PECARN Management Algorithm for Children after Head Trauma was initially published in the Lancet in 2009, and was based on a derivation and validation study involving 42,412 children [7]. The algorithm has separate considerations for children younger than 2 years and 2 years or older. It is available through trekk.ca or directly on the Ontario Neurotrauma Foundation website on page 53 of their Guidelines for Diagnosing and Managing Pediatric Concussion [8].

The authors concluded that the PECARN algorithm provides "highly accurate prediction rules for children at very low risk of clinically-important traumatic brain injuries for whom CT scans should be avoided. Application of these rules could limit CT use, protecting children from unnecessary radiation risks” [7].


The heterogeneity of the rules included in the review prevented any meta-analysis of the data. The authors noted that a shift in practice from identification of any lesion on a CT scan to focusing on clinically significant lesions has made results of studies difficult to compare. The authors suggested: “future research efforts in this field should concentrate on the universal application of definitions for patient populations, inclusion criteria, reference standards, and outcome criteria” [7].


Translating Emergency Knowledge for Kids (TREKK):

Concussion Evidence Repository

Emergency Medicine Cases Podcast: Pediatric head injury


1. TREKK Bottom Line Recommendations: Concussion (English Version)

2. McCrory, P., Meeuwisse, W., Aubry, M., Cantu, B., Dvorak, J., Echemendia, R., . . . Turner, M. (2013). Consensus statement on Concussion in Sport - The 4th International Conference on Concussion in Sport held in Zurich, November 2012. Phys Ther Sport, 14(2), e1-e13. doi: 10.1016/j.ptsp.2013.03.002

3. Farrell, C. A. (2013). Management of the paediatric patient with acute head trauma. Paediatrics and Child Health (Canada), 18(5), 253-258.

4. Scorza, K. A., Raleigh, M. F., & O'Connor, F. G. (2012). Current concepts in concussion: Evaluation and management. American Family Physician, 85(2), 124-132.

5. Barlow, K. M., Crawford, S., Stevenson, A., Sandhu, S. S., Belanger, F., & Dewey, D. (2010). Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury. Pediatrics, 126(2), e374-381. doi: 10.1542/peds.2009-0925

6. Pickering, A., Harnan, S., Fitzgerald, P., Pandor, A., & Goodacre, S. (2011). Clinical decision rules for children with minor head injury: A systematic review. Archives of Disease in Childhood, 96(5), 414-421. doi: 10.1136/adc.2010.202820

7. Kuppermann, N., Holmes, J. F., Dayan, P. S., Hoyle, J. D., Jr., Atabaki, S. M., Holubkov, R., . . . Wootton-Gorges, S. L. (2009). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet, 374(9696), 1160-1170. doi: 10.1016/s0140-6736(09)61558-0

8. Zemek, R., Duval, S., Dematteo, C. et al. (2014). Guidelines for Diagnosing and Managing Pediatric Concussion. Toronto, ON: Ontario Neurotrauma Foundation

From team: News and Events

tags: Concussion Head Injury    



Does a child's cough sound like a barking seal? Could be croup (more)

May 01, 2015

May 4, 2015 - This week's post is also available from the Cochrane Child Health blog.

"Michael's barky cough startled Valerie from her sleep. For the last few nights, Valerie had not slept well as her two-year-old son was fighting a cold and had been up off and on with a fever and cough...She desperately hoped the coughing would stop...More barky coughing roused her from her thoughts. This time the cough frightened her. As she ran into his room, Michael seemed to be fighting for breath."

Michael's barky cough is a hallmark sign of croup. The cough that often occurs in the middle of the night, rousing parents from their sleep, can be an intense and worrisome event for parents and their young children. However, croup is a well-defined condition with a strong evidence base supporting effective therapeutic management. 

Croup, or laryngotracheobronchitis, is an illness that affects a child's breathing. It is caused by many different viruses and most often occurs in the cooler fall and winter months. Croup occurs most commonly in children between 6 months and 3 years of age, but can occur in children of all ages. Croup is characterized by a barky cough that can start quite suddenly. Often the child will have a hoarse voice and difficulty breathing. You may hear a high pitched sound when the child breathes in (stridor). Croup is worse at night or when the child is lying flat. The symptoms occur predominately at night with improvement during the day. The barky cough and difficulty breathing usually resolve after a few nights, though occasionally they can last up to a week. Viruses that trigger croup symptoms are picked up from others, and usually spread through coughing, sneezing or contact with the mucous on tissues, toys or hands.

Doctors assess the severity of the child's symptoms by simply watching and listening. If children have an occasional barky cough, but no stridor, they have a mild case. If they have a frequent barky cough and easily heard stridor even while calm, they have a moderate case. If a child’s chest caves in as they breathe, in addition to a frequent barky cough and easily heard stridor, they have a severe case. When the child has severe symptoms they are most commonly very distressed and agitated. In most cases, the illness is mild and lasts a short time; however, in the most severe cases, a small number of children may require hospitalization and intubation [1].

Antibiotics do not work on croup because the infection is caused by a virus. However, there are a number of other treatment strategies. An overview of reviews compiled evidence to determine which treatment strategies were most effective. The overview brought together evidence from four systematic reviews that included 54 studies involving 4,710 children. The authors made the following conclusions:

  • - Glucocorticoids are effective for treating children with mild croup in terms of reduction in symptoms, hospitalizations, and length of stay. Dexamethasone and budesonide were the most commonly studied and there was no evidence that one was superior to the other.
  • - Both nebulized epinephrine and glucocorticoids are effective for children with moderate to severe croup that is accompanied by respiratory distress.
  • - There was insufficient evidence to determine the effectiveness of heliox.
  • - There is sufficient evidence showing that humidified air is not an effective treatment for croup.
  • - Though there are no large scale surveillance studies published which focus on adverse effects from any of these treatments, randomized trials and systematic reviews of glucocorticoids, epinephrine, humidified air and heliox have not reported any significant adverse events. 

Dr. David Johnson of the Alberta Children's Hospital Research Institute has developed bottom line recommendations for treating croup in collaboration with Translating Emergency Knowledge for Kids (TREKK). The recommendations and other resources including clinical practice guidelines are available at trekk.ca. Dr. Johnson suggests: 

“The vast majority of children with croup will resolve their barky cough and difficulty breathing within a few nights. While this will occur regardless of whether their child is treated or not, treatment with glucocorticoids helps reduce both children’s severity and duration of symptoms, allowing parents to relax and return to their normal daily routine sooner than they would otherwise.”


TRanslating Emergency Knowledge for Kids (TREKK):

Croup Bottom Line Recommendations (French & English)

Croup Evidence Repository

Croup Cochrane Pediatric Emergency Medicine Reviews

Croup Storybooks for Caregivers:

University of Alberta, Capital Health, Stollery Children's Hospital. (2012). A Resourceful Father and His Internet Connections: Managing Croup at Home - Mild Croup [Brochure]. Edmonton, Canada.

University of Alberta, Capital Health, Stollery Children's Hospital. (2012). A Late Night Trip to the Emergency Department: Was It The Right Thing To Do? - Moderate Croup [Brochure]. Edmonton, Canada.

University of Alberta, Capital Health, Stollery Children's Hospital. (2012). Things We Take for Granted: A Mother’s Account of Her Child’s Struggle with Croup - Severe Croup [Brochure]. Edmonton, Canada.


1. Bjornson C, Russell K, Foisy M, Johnson DW. The Cochrane Library and the treatment of croup in children: an overview of reviews. Evidence-based Child Health: A Cochrane Review Journal 2010;5(4):1555-65.


From team: News and Events

tags: Croup Infection    



Evidence-Based Treatments for Acute Otitis Media (more)

April 24, 2015

April 27, 2015 – This week's post is also available from the Cochrane Child Health blog.

Acute otitis media (AOM), or middle ear infection, is one of the most common diseases of childhood. AOM presents most frequently in children under the age of two, with 75% of children having at least one episode before one year of age [1,2]. Although AOM is very common, it can be challenging to accurately diagnose – symptoms of AOM often overlap with acute respiratory illness, visualization of the tympanic membrane can be obscured by cerumen, and slight changes in the tympanic membrane can be hard to detect [1]. 

The Canadian Paediatric Society recommends antibiotics for treatment in all children under the age of six months, and for children who are six months to two years when the diagnosis of AOM is certain [2]. For children older than six months with mild symptoms, the Canadian Paediatric Society recommends a ‘watchful waiting’ approach supported by a topical or oral analgesic [2]. Given the prevalence of AOM in these age groups, antibiotics are being prescribed very frequently. With increasing concern about antibiotic resistance, guidelines need to be created to prevent inappropriate prescription for children who have been misdiagnosed with AOM, and treatments need to be supported by strong evidence to justify their use.

Including six systematic reviews, covering 92 randomized controlled trials with 19,695 participants, a Cochrane overview investigated the available evidence on treatments for AOM in children. Below is the key evidence you need to know when treating a child with AOM.  

Effectiveness of Antibiotics

  • Compared to placebo,children treated with antibiotics reported less pain 2-7 days after treatment initiation.
  • Children taking antibiotics were more likely to have vomiting, diarrhea, and rash. 

Short-Course Antibiotics

  • There is no evidence to support one length of antibiotic treatment over another.

Immediate versus Delayed Antibiotics

  • Children who immediately received antibiotics had no difference in pain 3-7 days after treatment initiation compared to children who had a delay in antibiotic receipt.
  • Because the quality of the evidence was poor, no firm conclusions were made in the review about the risks and benefits of delayed start of antibiotic treatment. 

Decongestants and Antihistamines

  • There was no evidence in support of the use of decongestants or antihistamines to treat AOM.
  • The authors discouraged the use of decongestants and antihistamines in young children because of their potentially harmful side effect profile caused by unintentional overdose [3]. 

Topical Analgesia

  • There was some low quality evidence suggesting that topical analgesia may reduce pain after ten minutes of administration in children over five years. However, no adverse events were recorded.
  • Because the quality of the evidence was poor, no firm conclusions were made in the review about the risks and benefits of topical analgesia for AOM.

The authors of the overview concluded:

“The literature to date suggests that antibiotic use in young children with stringently diagnosed AOM appears to be justified, although benefits must be balanced with risk, particularly adverse events and bacterial resistance, and with a role for parental preferences. Improving the accuracy of diagnosis (e.g. training programs for otoscopy and cerumen removal), is thus an important mechanism for reducing inappropriate antibiotic use.”

In 2009, the Canadian Paediatric Society released a position statement with information on treatment and recommendations to guide proper diagnosis of AOM [2].


Translating Emergency Knowledge for Kids (TREKK):

Acute otitis media Bottom Line Recommendations (French & English)
Acute otitis media Evidence Repository
Acute otitis Media Cochrane Pediatric Emergency Medicine Reviews



  1. Oleszczuk, M., Fernandes, R. M., Thomson, D., & Shaikh, N. (2012). The Cochrane Library and acute otitis media in children: an overview of reviews. EvidenceBased Child Health: A Cochrane Review Journal7(2), 393-402.
  2. Forgie, S., Zhanel, G., & Robinson, J. (2009). Management of acute otitis mediaPaediatrics & Child Health14(7), 457-460.
  3. Goldman, R. D., & Hazardous Substances Committee. (2011). Treating cough and cold: guidance for caregivers of children and youthPaediatrics & Child Health16(9), 564.

From team: News and Events

tags: Acute Otitis Media Otitis Media with Effusion Otitis Media, Suppurative    



Making Medical Procedures Less Painful for Kids - Evidence for Clinicians (more)

April 17, 2015

April 20, 2015 – This week's post is also available from the Cochrane Child Health blog.

Today we are going to discuss a topic that will be familiar to any parent, or to anyone who’s ever been a kid: the pain from medical procedures.  These can range from immunizations and blood tests through to less common things like lumbar punctures, inserting a catheter or starting an intravenous line.  All of these procedures have an important goal: supporting diagnosis and treatment.  But they can be really stressful for both children and their caregivers.

Doctors used to think that very young children did not experience pain, and, even if they did, did not remember it.  This has been repeatedly disproven over the past twenty years or so, and we now know that inadequate pain treatment can have a lot of negative effects in both the short and long term.

The experience of pain for a child is complex and is usually accompanied by anxiety, fear and behavioural changes. In the case of pain from medical procedures, health care professionals have a range of options for preventing or reducing the negative experience.

The Child Health Field’s journal, Evidence-Based Child Health, has published an overview of Cochrane evidence on reducing and preventing procedural pain for kids.  The kids in the studies included in this synthesis ranged in age from infancy (but not newborns) up to 19 years. The overview found three main conclusions:

1)  Behavioural therapies, such as showing videos to kids to distract them during a procedure, are effective and inexpensive, and should be used.

2)  Sweet-tasting substances have proven pain-reducing effect for procedures in early infancy, but have not been shown to have similar effect in older children.

3)  Amethocaine, a topical anaesthetic, works and should be used.

Dr. Samina Ali, one of the authors of the synthesis, commented that, “Despite our understanding of the importance of pain relief in children, there remains a significant knowledge-practice gap in clinical practice.”  It is our hope that publishing this overview of evidence will help overcome this gap so that receiving care is less painful for kids!


Translating Emergency Knowledge for Kids (TREKK):

Cochrane Community Podcast:

  • Check out Dr. Ali's comments on the Cochrane overview in this podcast

Other Resources:

  • The Center for Pediatric Pain Research shares suggestions for reducing procedural pain in this video


  1. Curtis, S., Wingert, A., & Ali, S. (2012). The Cochrane Library and procedural pain in children: an overview of reviews. Evidence‐Based Child Health: A Cochrane Review Journal, 7(5), 1363-1399. doi: 10.1002/ebch.1864



From team: News and Events

tags: Acute Pain    



Treating Gastroenteritis: Evidence for Clinicians (more)

April 10, 2015

April 13, 2015 - This week's post is also available from the Cochrane Child Health blog. 

Fever. Vomiting. Diarrhea.

These are the symptoms that characterize one of the most common pediatric illnesses – Acute Gastroenteritis (AGE). In Canada, AGE accounts for 10% of emergency department visits annually and results in the hospitalization of 1 in 25 children under the age of five, keeping primary care physicians busy as ever [1,2]. Although AGE is not a serious condition in the developed world, it exerts significant economic burden. Estimates suggest Canadian AGE specific costs are $3.7 billion annually [2].

Despite the prevalence of AGE, its cost, and the ubiquity of its symptomatic presentation, there is no unified approach to its management in emergency departments (ED) institutionally, nationally, or internationally. Standardized, clinical decision tools targeting improvement of gastroenteritis care are not routinely used in Canadian EDs, which can result in variation in clinical decisions for key treatment approaches [3]. In effort to bring easily accessible, up-to-date evidence for AGE treatment approaches to one place, a Cochrane overview of systematic reviews provides a cohesive summary of treatment options and their effectiveness to help clinicians in their evidence-based decision making. This overview included four systematic reviews containing 95 randomized controlled trials involving over 12,000 participants. Here is the key evidence you need to know when treating a child with AGE.

Oral Rehydration Therapy (ORT) versus Intravenous (IV) Rehydration Therapy

  • ORT is less invasive than IV rehydration and therefore is considered as first line treatment for children with AGE and associated mild-to-moderate dehydration.
  • There are no important clinical differences (e.g. length of hospital stay, adverse effects) between children who receive oral rehydration therapy (ORT) and those administered IV rehydration therapy.


  • Oral ondansetron is the first line anti-emetic agent for children with dehydration and significant vomiting because it lowers hospital admission and IV rehydration rates.
  • IV ondansetron is associated with lower hospital ED admission rates, but should only be used for children who require IV rehydration.


  • Probiotics can reduce hospital duration by over 24 hours.
  • There are no known interactions between probiotics and other medications.
  • Existing evidence favors the use of probiotics as a safe adjunct treatment for AGE, but it is unclear which probiotic should be used, at what dose, and for what duration.
  • Current evidence suggests the use of formulations containing Lactobacillus sp or S. boulardii, but optimal dosage and duration of therapy is unknown.

Dr. Moshe Ipp, a pediatrician and academic clinician from Toronto, shares his conclusions about this overview in this Cochrane Community podcast:

 “In summary, oral rehydration therapy is considered to be the first line choice for rehydration in patients with acute gastroenteritis and mild to moderate dehydration. When there is significant vomiting, ondansetron is the recommended anti-emetic of choice. And probiotics have been shown to be safe and effective for hospitalized children.”

However, Dr. Ipp highlights that ondansetron may not be suitable for all children with AGE: “An interesting finding, and a note of caution, is that in 3 randomized controlled trials there was a higher frequency of diarrhea in the ondansetron group compared to placebo, and because of this finding it is suggested that ondansetron might not be the agent of choice when vomiting is associated with a significant amount of diarrhea.”


Translating Emergency Knowledge for Kids (TREKK):

Cochrane Community Podcast:

  • Check out Dr. Ipp’s comments on the overview in this podcast


[1] Majowicz, S., McNab, W., Sockett, P., Henson, S., Dore, K., Edge, V., ... & Wilson, J. (2006). Burden and cost of gastroenteritis in a Canadian community. Journal of Food Protection, 69(3), 651-659.

[2] Alberta Provincial Pediatric Enteric Infection Team. APPETITE seminar series [PDF document]. Retrieved from: Got Gastro Online Website

[3] Kinlin, L., Bahm, A., Guttmann, A., & Freedman, S. (2013). A survey of emergency department resources and strategies employed in the treatment of pediatric gastroenteritis. Academic Emergency Medicine, 20(4), 361-366. doi: 10.1111/acem.12108

[4] Freedman, S., Ali, S., Oleszczuk, M., Gouin, S., & Hartling, L. (2013). Treatment of acute gastroenteritis in children: an overview of systematic reviews of interventions commonly used in developed countries. Evidence‐Based Child Health: A Cochrane Review Journal, 8(4), 1123-1137. doi: 10.1002/ebch.1932

From team: News and Events

tags: Gastroenteritis    



Bicycle helmets – now that’s using your head! (more)

April 02, 2015

April 6, 2015 - This week's post is also available from the Cochrane Child Health blog. 

Head injuries due to bicycle crashes are a common reason that children present to the emergency department. Bicycle helmets were designed to decrease head injuries. Different approaches to encourage bicycle helmet use have been evaluated. These range from legislation where individuals are required by law to wear a helmet when cycling to media campaigns and other health promotion activities, such as promoting the use of bicycle helmets in schools or offering free helmets through community-based programs.

An overview of Cochrane systematic reviews [1] was conducted in order to bring together evidence from reviews that focused on different aspects of the topic of bicycle helmet use. The reviewers identified three systematic reviews [2-4] that included 35 studies involving children. The reviews looked at:

  • the use of helmets for preventing head and facial injuries in bicyclists
  • bicycle helmet legislation to increase the uptake of helmet use and prevent head injuries
  • nonlegislative interventions to promote use of bicycle helmets in children (these included health education programs, subsidized or free helmets, and media campaigns)

Some of the key findings:

  • helmet use in children decreased medically reported head injuries by 63%
  • helmet use decreased brain injuries by 86%
  • mandatory helmet laws for children decreased the odds of head injury hospitalizations by 45%
  • after helmet legislation, the odds of traumatic brain injuries decreased by 18%
  • legislation resulted in an increase in the number of children wearing a helmet
  • nonlegislative helmet promotion activities also resulted in an increase in the number of children wearing a helmet
  • there were no risks involved with using bicycle helmets

The authors concluded that bicycle helmets are effective in reducing head injuries in children. They also concluded that both legislative and non-legislative interventions are helpful in reducing injuries and promoting helmet use. However, the authors noted that there are some who oppose helmet legislation. The main reasons are that they feel that this may encourage people to cycle more recklessly or less frequently.

Dr. Tony Woodward, Chief of Emergency Medicine at Seattle Children's Hospital states that "there's no question that the best way to protect your child when they're on a bike, scooter, or skates is to wear an appropriately sized helmet. In the emergency department, the children we see who are the most seriously injured are the ones that don't have helmets or have helmets that are inappropriately sized or inappropriately worn."

Finally, check out the TREKK resources on severe head injury. Helmets prevent injury, but accidents still happen! 


[1] Russell, K., Foisy, M., Parkin, P., & Macpherson, A. (2011). The promotion of bicycle helmet use in children and youth: an overview of reviews. Evidence-Based Child Health: A Cochrane Review Journal, 6(6), 1780-1789. doi: 10.1002/ebch.901

[2] Owen, R., Kendrick, D., Mulvaney, C., Coleman, T., & Royal, S. (2011). Non-legislative interventions for the promotion of cycle helmet wearing by children. Cochrane Database of Systematic Reviews, (11). doi:10.1002/14651858.CD003985.pub3

[3] Macpherson, A., & Spinks, A. (2008). Bicycle helmet legislation for the uptake of helmet use and prevention of head injuries. Cochrane Database of Systematic Reviews, (3). doi:10.1002/14651858.CD005401.pub3

[4] Thompson D., Rivara, F., & Thompson, R. (1999). Helmets for preventing head and facial injuries in bicyclists. Cochrane Database of Systematic Reviews, (4). doi:10.1002/14651858.CD001855

More Information:

TREKK (Translating Emergency Knowledge for Kids) Resources:

ChildSafetyLink. (2014). Keep Kids Safe: A Parent's Guide to Helmet and Recreation Safety.

Government of Manitoba. (2013). Bike Helmet Safety Video.

From team: News and Events

tags: Head Injury Severe Head Injury    


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