Two Paeds In A Pod

2 PAEDS IN A POD Episode 85 | The Trouble With Boluses
Released: 07/06/2026 | Runtime: ~20 minutes
EPISODE SUMMARY
This episode leads on fluid in childhood sepsis. A new multicentre cohort from Australia and New Zealand found that mortality rose with the volume of bolus fluid given in the first day, but not with the total volume of fluid — a finding set alongside the recently published PRoMPT BOLUS trial, which showed that balanced fluid and saline produce the same kidney outcomes. The second story returns to the febrile infant for a third time, with a meta-analysis quantifying the risk of serious bacterial infection in the well sixty-to-ninety-day-old. What's Caught My Eye covers the TWIST score and ultrasound for the acute scrotum, nirsevimab versus the maternal RSV vaccine head to head, and language barriers and safety in the paediatric emergency department.
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
MAIN STORY 1: How much fluid is too much in childhood sepsis? ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Fluid is the first thing we reach for in the septic child, and the volume question has never been fully settled. This cohort measured the fluid children actually received in the first twenty-four hours and asked how it related to outcome, arriving just as PRoMPT BOLUS reported on the separate question of which fluid to use.
Key findings:
5,352 children with suspected community-acquired sepsis across 11 emergency departments in Australia and New Zealand (2021–2023); median age 2.6 years.
In-hospital mortality was low at 1.1%; around 5.5% met Phoenix sepsis criteria.
Median total fluid in the first 24 hours was 40 mL/kg, of which the bolus component was 10 mL/kg.
Mortality rose with increasing bolus volume but not with increasing total fluid; the unadjusted odds ratio for death with more than 55 mL/kg versus less than 15 mL/kg of bolus fluid was 20.5 (95% CI 8.0–52.5).
For context, PRoMPT BOLUS (9,041 children, 47 departments, five countries) found no difference in major adverse kidney events between balanced fluid and 0.9% saline (3.4% vs 3.0%), with less hyperchloraemia in the balanced-fluid group.

For practice, the converging message is that the fluid you choose matters less than hoped, while the volume you give may matter more than thought. This supports the titrated, reassess-after-each-bolus approach that NICE and APLS already ask for, rather than a fixed escalator.
Important caveat: the bolus–mortality association is unadjusted and observational, and the sickest children in refractory shock receive the most bolus fluid, so this does not show that boluses cause harm and is not a reason to withhold fluid from a shocked child.
Reference: Long E, Selman C, Borland ML, et al. Archives of Disease in Childhood. Published May 2026. DOI: https://doi.org/10.1136/archdischild-2025-330189
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
MAIN STORY 2: How risky is the febrile two-month-old? ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
The sixty-to-ninety-day-old is the febrile infant our guidelines treat least consistently — some pathways stop at sixty days, others lump the whole under-ninety group together. This meta-analysis supplies the missing denominator for that group, completing a run that has moved from risk stratification, through practice variation, to underlying prevalence.
Key findings:
59 studies, 20 distinct datasets, just under 34,835 well-appearing, previously healthy febrile infants aged 60–90 days.
Pooled prevalence of invasive bacterial infection was 1.11% (95% CI 0.84–1.47), roughly 1 in 90.
Almost all of that was bacteraemia at 1.01%; bacterial meningitis was rare at 0.11%, roughly 1 in 900.
Estimates held across every sensitivity analysis, including removal of the single largest study.

The clinical bottom line is a number to carry into both your own reasoning and the conversation with parents: in the well infant in this band, meningitis risk of around one in nine hundred is a reasonable thing to weigh when deciding whether this particular baby needs a lumbar puncture or a more measured pathway with good safety-netting.
These are international data, so map the figures onto your local febrile infant pathway and the NICE traffic-light thresholds rather than applying them in isolation.
Reference: Dionisopoulos Z, Sabhaney V, D'Arienzo D, et al. JAMA Pediatrics. Published May 2026. DOI: https://doi.org/10.1001/jamapediatrics.2026.1815
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━.
WHAT'S CAUGHT MY EYE ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
1. TWIST and ultrasound for the acute scrotum
A retrospective study of just over 500 boys aged fifteen and under with an acute scrotum tested how the TWIST score and point-of-care ultrasound perform in the hands of emergency physicians and paediatricians. The TWIST score had a sensitivity of around 91% and a negative predictive value of 99%, and adding ultrasound pushed sensitivity to 96% and negative predictive value to 100%. Worth your time because it supports front-door risk stratification of the acute scrotum, though the residual false negatives mean it cannot be used to rule torsion out.
Reference: Nakamura T, Kinoshita M, Ihara T, et al. Emergency Medicine Journal. Published May 2026. DOI: https://doi.org/10.1136/emermed-2025-215067
2. Nirsevimab versus the maternal RSV vaccine, head to head
A French national cohort of more than 164,000 infants across the 2024–25 season compared nirsevimab given at birth against maternal RSVpreF vaccination. Nirsevimab was associated with about a 22% lower chance of RSV-related hospitalisation (OR 0.78, 95% CI 0.70–0.86), but that advantage disappeared when the maternal vaccine had been given at least eight weeks before delivery. Worth your time because both products are now live in the UK, so this speaks directly to counselling families and to the timing of maternal vaccination.
Reference: Valtuille Z, Fafi I, Kaguelidou F, et al. The Lancet Child & Adolescent Health. Published May 2026. DOI: https://doi.org/10.1016/S2352-4642(26)00075-1
3. Language barriers and safety in the paediatric emergency department
A scoping review of 33 studies mapped where, along the emergency care journey, language barriers threaten the safety of children's care. Risk appeared at every stage, but discharge — the moment we hand over safety-netting and home-care advice — was flagged most often. Worth your time as a pointed reminder that, in a multilingual NHS population, the discharge conversation is a safety-critical step rather than an afterthought.
Reference: Odedra R, Averill P, Nijman RG, et al. Emergency Medicine Journal. Published May 2026. DOI: https://doi.org/10.1136/emermed-2025-215617
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
KEY TAKEAWAYS ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
PRoMPT BOLUS shows balanced fluid and saline produce the same kidney outcomes in paediatric septic shock; the choice of fluid matters less than once hoped.
New observational data suggest it is bolus volume, not total fluid, that tracks with mortality — a reason to give a measured bolus, reassess, and only repeat if the child still needs it, not a reason to withhold fluid.
In the well sixty-to-ninety-day-old, invasive bacterial infection runs at about 1 in 90 and meningitis at about 1 in 900 — a denominator for proportionate investigation and honest parent conversations.
The TWIST score and ultrasound can risk-stratify the acute scrotum at the front door but cannot rule torsion out.
In a multilingual population, discharge and safety-netting are the highest-risk points for language-related harm.

━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
FULL REFERENCE LIST ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
All articles retrieved from PubMed.
Long E, Selman C, Borland ML, et al. IV bolus, maintenance and medication carrier fluid in children with community-acquired sepsis: a multicentre cohort study. Archives of Disease in Childhood. 2026. Advance online publication. https://doi.org/10.1136/archdischild-2025-330189
Dionisopoulos Z, Sabhaney V, D'Arienzo D, et al. Prevalence of Invasive Bacterial Infections Among Febrile Infants Aged 60 to 90 Days: A Systematic Review and Meta-Analysis. JAMA Pediatrics. 2026. Advance online publication. https://doi.org/10.1001/jamapediatrics.2026.1815
Nakamura T, Kinoshita M, Ihara T, et al. Evaluating the TWIST score and point-of-care ultrasound for paediatric testicular torsion. Emergency Medicine Journal. 2026;43(6):334–340. https://doi.org/10.1136/emermed-2025-215067
Valtuille Z, Fafi I, Kaguelidou F, et al. Effectiveness of nirsevimab immunisation after birth versus RSVpreF maternal vaccination in...

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 assessment
Blood 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 assessment

The 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 excluded
Primary 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 use

The 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.70412
2. The neonatal head injury that happens on your postnatal ward
A 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.2025-008952
3. 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 presentations
Over-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 weakest
Automated oxygen titration in bronchiolitis did not reduce length of stay, but a negative primary endpoint in an underpowered trial warrants reading the secondary data
Electronic sepsis alerts reliably speed up antibiotics and fluids but the mortality evidence is not yet established
For 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,...

2 Paeds in a Pod
Show Notes — Episode 83
Knife Crime, Febrile Infants, and What's Caught My Eye
Released: May 2026 | Runtime: ~20 minutes
In this episode, Ian covers what's caught his eye in the paediatric literature this fortnight. The main story looks at a landmark national review of child deaths from knife wounds in England — and what it means for those of us working in paediatric emergency and urgent care. He then turns to new data on febrile infants aged 29 to 60 days and the evolving evidence base around risk stratification in that notoriously tricky age group. The episode closes with three quick picks from this fortnight's journal sweep: point-of-care lung ultrasound for pneumonia, reframing conversations about paediatric palliative care, and a flag for the new Surviving Sepsis Campaign paediatric guidelines — which we'll be coming back to in a dedicated episode soon.
Main Story 1 — Knife Crime Deaths in Children in England (2019–2024)
Knife-related deaths in children and young people represent one of the most pressing — and most inequitable — public health challenges in England today. This month, Roberts and colleagues published a review using the National Child Mortality Database covering every child under 18 who died of a knife wound between April 2019 and March 2024.
The headline findings:
145 children died over the five-year period — roughly one every two weeks
Mean age at death was 14.4 years; 90% were male
Black or Black British children died at a rate more than 13 times higher than white children when corrected for population size
Children in the most deprived areas of England had over 7 times the risk of death compared with those in the least deprived areas
60% of children died before reaching hospital
Of those who reached hospital, 57% underwent a thoracotomy — reflecting the severity of injuries sustained
Injuries to the chest and neck were responsible for 76% of fatal wounds
75% of children had been known to social services prior to their death
58% had experienced domestic violence and abuse
51% had documented neurodiversity or mental health concerns

Why this matters for paediatric practice: These were not invisible children. The vast majority were known to statutory services. For clinicians working in paediatric emergency and urgent care, this paper is a reminder that every child who comes through our doors carries a history — and that our role extends beyond the presenting complaint. It also raises important questions about pre-hospital intervention, penetrating trauma training in paediatric settings, and the role of the ED as a potential point of early intervention for children at risk.
Knife injuries are not confined to major urban centres — the data show deaths distributed across all regions of England.
Reference: Roberts T, Odd D, Coveney J, et al. Emergency Medicine Journal. Published April 2026. https://doi.org/10.1136/emermed-2025-215154
Main Story 2 — Bacteraemia and Bacterial Meningitis in Low-Risk Febrile Infants Aged 29–60 Days
The febrile infant aged 29 to 60 days occupies some of the most uncomfortable clinical territory in paediatric emergency medicine. Too old for the automatic full-septic-screen approach applied under 28 days, but too young to rely on clinical examination alone. This paper from Burstein, Xie, and Kuppermann — published in JAMA Pediatrics — examines how the updated PECARN (Pediatric Emergency Care Applied Research Network) febrile infant rule performs in an international sample.
What the PECARN rule involves: The rule uses a combination of clinical and laboratory parameters to stratify infants into low, intermediate, and higher risk for invasive bacterial infection (bacteraemia and bacterial meningitis). Key components include temperature, urinalysis findings, absolute neutrophil count, procalcitonin, and — where indicated — CSF analysis.
Why this paper matters: The original PECARN derivation and validation studies were predominantly North American. This international validation is an important step in understanding how the rule performs across different healthcare systems, bacterial epidemiology, and rates of prior antibiotic exposure. The full data are behind a paywall, but the publication itself signals continued maturation of the evidence base.
For UK practice: NICE guidance for this age group tends towards more liberal investigation. Whether structured risk stratification tools like PECARN could safely reduce lumbar punctures and admissions in a subset of genuinely low-risk infants is an active and important question for UK paediatric emergency practice.
Key learning point: Know the PECARN framework. Know its components. And watch this space — this is a field moving quickly.
Reference: Burstein B, Xie J, Kuppermann N. JAMA Pediatrics. Published April 2026. https://doi.org/10.1001/jamapediatrics.2026.0971
What's Caught My Eye
1. Point-of-Care Lung Ultrasound for Paediatric Pneumonia
A review in Pediatric Emergency Care summarising the diagnostic performance of bedside lung ultrasound (LUS) for pneumonia in children. Multiple meta-analyses demonstrate sensitivity up to 94% and specificity up to 96% — at least comparable to chest X-ray, often better, and without the radiation burden or logistical delay.
The key caveat: distinguishing bacterial consolidation from viral illness or asthma on ultrasound requires training and careful clinical correlation. Overlapping sonographic appearances are common and the technique is operator-dependent.
For anyone working in paediatric ED or acute settings who hasn't yet developed confident POCUS skills for respiratory presentations — this is the evidence base saying it's worth the investment.
Reference: Marzook N. Pediatric Emergency Care. Vol 42(5):391–399. Published April 2026. https://doi.org/10.1097/PEC.0000000000003533
2. Shifting the Narrative Around Paediatric Palliative Care
Stewart and colleagues at Evelina London Children's Hospital, writing in BMJ Paediatrics Open, have produced a thoughtful narrative review examining why paediatric palliative care referral happens late — and what we can do about it.
The central argument: the words "palliative care" carry such strong associations with dying that clinicians often delay conversations for fear of undermining hope, and families often hear "giving up" where clinicians intend "additional support." Crucially, directly debunking this myth — saying "palliative care isn't just about end-of-life" — can backfire by activating the very association you're trying to dispel.
What works better, the authors argue, is replacing the narrative rather than fighting it. Lead with what palliative care actually looks like — coordinated, holistic, life-enhancing support that runs alongside active treatment from the point of diagnosis. The paper offers a useful metaphor: palliative care is the umbrella, not the rain. You reach for it before the storm, not once you're soaked.
A practical, communication-focused paper with something genuinely useful for anyone — trainee or consultant — who has ever felt uncomfortable raising that conversation.
Reference: Stewart CE, Vare C, Kerr-Elliott T, et al. BMJ Paediatrics Open. Vol 10(1). Published April 2026. https://doi.org/10.1136/bmjpo-2025-004413
3. Surviving Sepsis Campaign Paediatric Guidelines 2026 — Flag
The 2026 update to the Surviving Sepsis Campaign international guidelines for paediatric sepsis and septic shock is out. A panel of 68 international experts produced 61 statements — including 20 new recommendations and 13 updates from the 2020 version. Of note: only three of the 61 recommendations are based on high or moderate quality evidence.
We'll be covering this in full in an upcoming episode. For now — get it on your reading list.
Reference: Weiss SL, Peters MJ, et al. Pediatric Critical Care Medicine. Vol 27(4):379–434. Published March 2026. https://doi.org/10.1097/PCC.0000000000003927
Key Takeaways
The knife crime mortality data are a call to action for every clinician working with children — clinically, in terms of safeguarding awareness, and as advocates for the children most at risk
PECARN febrile infant risk stratification is maturing internationally — if your department doesn't use a structured approach for the 29–60 day febrile infant, now is the time to revisit
Point-of-care lung ultrasound for paediatric pneumonia has strong diagnostic performance — sensitivity and specificity both exceed 90% in meta-analyses, and the skill is worth developing
When introducing paediatric palliative care, replace the narrative rather than debunking it — lead with what it is, not what it isn't
The new Surviving Sepsis Campaign guidelines are out — full episode coming soon

References
All articles retrieved from PubMed. Based on articles retrieved from PubMed:
Roberts T, Odd D, Coveney J, et...

Clinical Question
In children presenting with acute severe asthma, does intravenous aminophylline improve meaningful clinical outcomes compared to standard therapy?

⸻

Background

IV aminophylline has historically been used as a second-line infusion in severe paediatric asthma. However, contemporary escalation strategies increasingly prioritise:
• Oxygen
• High-dose nebulised salbutamol
• Systemic corticosteroids
• IV magnesium sulphate

This raises the question: does aminophylline still offer incremental benefit?

⸻

The Evidence Reviewed

A systematic review published in Archives of Disease in Childhood analysed:
• 9 randomised controlled trials
• 466 children
• Standard therapy ± IV aminophylline

Outcomes assessed:
• Asthma severity scores
• Length of stay
• Admission rates
• PICU admission
• Intubation rates
• Adverse effects

⸻

Key Findings

No significant benefit in:
• Speed of clinical improvement
• Admission rates
• PICU transfer
• Intubation rates
• Length of hospital stay

Significant increase in adverse effects:
• Nausea and vomiting (3–5x higher)
• Headache
• Tremor
• Irritability
• Arrhythmias

Overall: No improvement in meaningful outcomes, with increased morbidity.

⸻

Important Caveat

A 1998 study (Young & South) suggested possible benefit in the most critically unwell, treatment-refractory children, including:
• Reduced duration of intubation
• Potential improvement in lung function

This suggests a potential narrow rescue-therapy window.

⸻

Implications for Paediatric Emergency Practice (2025)

Current best evidence supports:
1. Oxygen
2. Nebulised salbutamol
3. Systemic corticosteroids
4. IV magnesium
5. Structured escalation planning

IV aminophylline should be considered:
• A rescue therapy of last resort
• Not routine second-line treatment

⸻

Take-Home Message

IV aminophylline has historical presence but limited modern evidence of benefit. For most children with acute severe asthma, it increases adverse effects without improving outcomes.

Its role in 2025: rare, selective, and critically contextual.

In this episode we talk to Dr Etimbuk Umana, the lead author of the FIDO study looking at the management of febrile infants in the Emergency Department. FIDO is a PERUKI sponsored study and was recently published in The Lancet: https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(24)00540-6/fulltext