Research Appraisals
Evidence-based critical appraisals of the latest medical research, systematically evaluated using Oxford CEBM methodology.
Showing 11 appraisals
JAMA
Prone Positioning in Infants With Acute Bronchiolitis: The PROPOSITIS Randomized Clinical Trial
IMPORTANCE: Prone positioning has been shown to improve respiratory mechanics and oxygenation, but its clinical benefit in infants with acute viral bronchiolitis receiving high-flow nasal cannula (HFNC) support remains unknown. OBJECTIVE: To investigate whether prone positioning in infants with moderate to severe acute bronchiolitis and HFNC support reduces escalation to noninvasive or invasive ventilation. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, randomized, open-label trial conducted in 15 pediatric intermediate or intensive care units in France. Infants aged 6 months or younger admitted for 24 hours or less with a diagnosis of acute bronchiolitis with moderate to severe respiratory distress requiring HFNC support were enrolled between January 2021 and November 2023 and followed up until hospital discharge (last patient discharged on December 11, 2023). INTERVENTIONS: Participants were randomly assigned to the prone position (n = 221) or supine position (n = 230). Infants in the prone position group received prone positioning for 24 hours or longer during the first 48 hours. All participants received standardized HFNC support at 2 L/kg/min. MAIN OUTCOMES AND MEASURES: The primary outcome was the need for escalation of care to noninvasive or invasive ventilation within the first 72 hours, according to prespecified criteria. Secondary outcomes included treatment failure, determined by an independent clinical adjudication committee; tolerance of prone positioning; length of hospital stay; duration of respiratory support; infant comfort; and adverse events. RESULTS: Among 451 infants randomized, 446 were included in the primary analysis (median age, 41 [IQR, 19-72] days; 54% male). Escalation of care occurred in 80 infants (17.9%), with no significant difference between the prone position (33/220 [15.0%]) and supine position (47/226 [20.8%]) groups (adjusted odds ratio, 0.66 [95% CI, 0.40-1.07]; P = .09). Secondary outcomes did not differ significantly between the 2 groups. In the safety analysis, serious adverse events occurred in 2 of 180 infants (1.1%) in the prone position group and 2 of 264 (0.8%) in the supine position group. CONCLUSIONS AND RELEVANCE: Prone positioning in infants with moderate to severe bronchiolitis receiving HFNC support did not significantly reduce escalation of care. However, the wide 95% confidence interval around the observed odds ratio suggests that this study was not definitive and further research is warranted. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03976895.
30 July 2026
Read appraisal →Pediatric surgery international
Pediatric colonic diverticulitis: clinical presentation, management, and review of the literature
Colonic diverticulitis is rare in the pediatric population and often presents with nonspecific symptoms that may be misdiagnosed as other causes of acute abdominal pain, such as appendicitis, leading to diagnostic uncertainty and variability in management. We report a case of pediatric colonic diverticulitis and present a systematic review to characterize its clinical presentation, diagnostic challenges and management. Clinical data for the index patient were retrospectively reviewed, and parental consent was obtained. A structured literature search was performed using PubMed, Scopus, and Embase. Studies reporting patients younger than 18 years were included. A 16-year-old male presented with right lower quadrant pain. CT suggested cecal diverticulitis. Worsening symptoms prompted diagnostic laparoscopy, revealing an inflamed diverticulum adjacent to a normal appendix. The postoperative course was uneventful. The review identified 27 studies including 101 patients. Median age was 14 years (IQR 12-16; range 3-17), with 57% male preponderance. Most cases involved a solitary right-sided diverticulum. CT correctly identified diverticulitis in 85%. Complicated disease occurred in 17%. In conclusion, in the pediatric age diverticulitis often arises from a solitary cecal diverticulum and can closely mimic appendicitis. Awareness may improve diagnosis, and uncomplicated cases can be treated conservatively with careful follow-up and appropriate clinical monitoring.
21 July 2026
Read appraisal →Neurosurgical review
Mechanical thrombectomy for pediatric large-vessel occlusion: a systematic review and meta-analysis with post hoc analysis
OBJECTIVE: To investigate the outcome of pediatric large vessel occlusion (LVO) treated with mechanical thrombectomy (MT). INTRODUCTION: Pediatric LVO is a rare subtype of ischemic stroke. In adults, MT is recommended; however, the efficacy and safety of MT in pediatric LVO are less explored. The available studies are mostly observational studies; yet, these studies show inconsistent findings. METHOD: This review adhered to the PRISMA 2020 guideline. Studies comparing MT with medical management in pediatric with LVO were included. The primary endpoint was the favourable outcome. The mortality rate was sought as well. Subgroup analysis compared MT with intravenous thrombolysis (IVT) and conservative management. Post hoc exploratory analyses comprised Bayesian inference and trial sequential analysis (TSA). RESULT: Six studies comprising a total of 230 MT-treated and 206 non-MT patients were included. In the primary analysis, favourable outcome did not differ significantly between the MT and medical management groups (OR 1.83; 95% CI 0.97-3.43), while supported by exploratory Bayesian inference (OR 1.75; 95% CrI 1.05-2.67; BF10 5.05). Subgroup analysis showed favourable outcomes of MT over IVT (OR 2.39; 95% CI 1.19-4.79) and conservative treatment (OR 2.22; 95% CI 1.41-3.51), although the Bayesian model did not support these findings. The available evidence was insufficient to detect or exclude a difference in mortality between MT and medical management (OR 1.32; 95% CI 0.45-3.89). TSA indicated that the required information size was not reached and that additional trials are needed to reach the minimum sample requirements. CONCLUSION: In this synthesis of observational data, the MT may be associated with favourable outcome in pediatric LVO, however, these findings are hypothesis-generating only. Adequately powered prospective studies are needed before MT can be recommended for pediatric LVO. CLINICAL TRIAL NUMBER: not applicable.
13 July 2026
Read appraisal →Emergency medicine journal : EMJ
Interventions to reduce imaging in children with upper or lower extremity injuries: a systematic review and meta-analysis
BACKGROUND: Radiation exposure, transition delays and costs associated with unnecessary imaging in children have stimulated research into clinical decision rules and other interventions to reduce imaging in the emergency department (ED). The objective of this systematic review is to examine the effectiveness of implementing interventions to reduce imaging in children with upper/lower extremity injuries in the ED. METHODS: Seven databases and the grey literature were searched up to May 2024. Comparative studies assessing interventions to reduce imaging in children with upper/lower extremity injuries implemented in the ED were eligible. Two independent reviewers screened for study eligibility, quality assessment and data extraction, with disagreements settled via third-party adjudication. Changes in imaging are reported as ORs with 95% CIs, using a random effects model. RESULTS: From 9387 citations, eight unique studies enrolling 7793 children were included with the majority using a before-after design. Potential concerns for bias were documented due to a lack of reporting of key quality domains. Decision rules for ankle injuries successfully reduced radiography (OR=0.11; 95% CI 0.07 to 0.16, I2=38%). A decision rule for wrist injuries reduced imaging (OR=0.06; 95% CI 0.03 to 0.11); however, eight injuries were missed. Two studies implementing clinical guidelines reported decreases in radiographs per patient (p<0.001). One trial reported increased imaging in children assessed by triage nurses using an established clinical decision rule (OR=5.44; 95% CI 2.96 to 10.02), with 16 missed injuries identified. CONCLUSIONS: Guidelines incorporating clinical decision rules, particularly decision rules for ankle injuries, can reduce radiography for children with extremity injuries in the ED. Further investigations are warranted to identify other extremity injuries, the components of the intervention and the most efficient clinicians to target. PROSPERO REGISTRATION NUMBER: CRD42016042875.
1 July 2026
Read appraisal →European journal of emergency medicine : official journal of the European Society for Emergency Medicine
Effect of a liquid crystal vein locator on intravenous catheterization in young children: a randomized trial
BACKGROUND AND IMPORTANCE: Peripheral intravenous catheterization (PIVC) in young children is notoriously challenging because of factors like poor patient cooperation and small vessel diameter. Repeated attempts cause distress and delay critical emergency treatment. OBJECTIVES: This study aimed to evaluate the effect of a novel liquid crystal display-based near-infrared vein locator on PIVC performance in children aged under 3 years. DESIGN: This is a prospective, randomized controlled trial. SETTINGS AND PARTICIPANTS: A total of 105 children aged 0-3 years requiring PIVC were enrolled in a pediatric emergency department. INTERVENTION: Participants were randomly assigned to undergo PIVC using either a liquid crystal vein locator (study group, n = 50) or the traditional landmark-based method (control group, n = 55). OUTCOME MEASURES AND ANALYSIS: The primary endpoint was the first-attempt success rate. Secondary endpoints included the number of puncture attempts, vein localization time, and total insertion time. Multivariable logistic and Poisson regression models were used to adjust for covariates, such as vein difficulty and patient demographics. Analyses included effect sizes with 95% confidence intervals (CIs). MAIN RESULTS: The baseline characteristics of both groups were comparable. The first-attempt success rate was significantly higher in the study group compared to the control group (86.0% vs. 54.5%; absolute difference: 31.5%; 95% CI: 15.2-47.8%). The study group also demonstrated a significantly shorter median vein localization time (16.5 vs. 60.0 s) and median total insertion time (40.0 vs. 185.0 s). In addition, the device significantly reduced the median number of puncture attempts (adjusted rate ratio: 0.77; 95% CI: 0.66-0.90). Multivariable analysis revealed that device assistance was an independent predictor of first-attempt success (adjusted odds ratio: 3.35; 95% CI: 1.13-9.95). CONCLUSION: In this study, the use of a liquid crystal vein locator was associated with a significantly higher first-attempt success rate, fewer puncture attempts, and reduced procedural times for PIVC in young children.
24 June 2026
Read appraisal →International journal of biometeorology
Machine learning and dose response effect models: an integrated approach to analyze the association between environmental variables and Cuneo Emergency Department admissions for Acute Otitis Media (2007-2015)
Acute otitis media (AOM) is a leading cause of pediatric Emergency Department visits, particularly among children under five years of age. Although its seasonal pattern is well established, the role of air pollution and meteorological factors remains unclear. This study aims to investigate their impact on daily AOM visits by integrating machine learning and epidemiological approaches. We conducted a retrospective analysis of pediatric AOM diagnoses (2007-2015) at S. Croce and Carle Hospital (Cuneo, Italy). Predictors included PM10, NO₂, O₃, and eleven meteorological variables. Ensemble machine learning models (Random Forest, XGBoost, and AdaBoost) were trained and validated using 10-fold cross-validation. Model interpretability was assessed through SHAP values. Distributed Lag Nonlinear Models (DLNM) were applied to estimate delayed exposure-response relationships over lag periods of 0-1, 0-3, 0-5, and 0-10 days, with results expressed as Relative Risks (RRs) and 95% Confidence Intervals (CIs). AdaBoost showed the best performance (R² = 0.974; MAE = 0.019 cases/day; cross-validated R² = 0.987). SHAP analysis identified mean temperature as the most influential predictor (44%), while PM10, NO₂, and O₃ each contributed approximately 10%. DLNM analysis confirmed a strong and consistent effect of temperature across all lag periods (RR > 1.20, CI > 1). Moderate associations were observed for NO₂ and PM10 (RR: 1.02-1.04). O₃ exhibited smaller but significant effects at shorter lags (RR = 1.01 at 0-1 days; RR = 1.02 at 0-3 days; CI > 1). Environmental factors, particularly temperature, play a significant role in pediatric AOM incidence. The integration of machine learning and DLNM enhances predictive accuracy and improves the understanding of exposure timing. These findings support the development of early warning systems and targeted preventive strategies under adverse environmental conditions. Further validation in larger urban settings is needed.
20 May 2026
Read appraisal →Injury prevention : journal of the International Society for Child and Adolescent Injury Prevention
Injuries from falling out of bed in infants under 1 year of age: a systematic review
CONTEXT: Falls from beds are a leading cause of unintentional injuries in infants under 1 year of age. While most cases result in mild outcomes, the potential for severe injuries, such as skull fractures or intracranial haemorrhages, exists. Despite the prevalence of these incidents, no systematic review has focused specifically on injuries from bed falls in this specific age. OBJECTIVE: To evaluate the risk and severity of injuries caused by falls from beds in infants under 1 year of age through a systematic review. DATA SOURCES: We searched in PubMed, Embase, Cochrane Library and Lilacs Scielo for studies published between 1984 and December 2024. STUDY SELECTION: We included observational studies that reported injuries from falls from beds in infants under 1 year. DATA EXTRACTION: We extracted the relevant data from the included study details, recruitment setting, study design, sample size and outcome measures. We conducted a quality assessment using the Newcastle-Ottawa Scale. RESULTS: Out of 297 initially identified studies, three met inclusion criteria, comprising a total of 2034 infants under 1 year of age. Most falls resulted in minor or no injuries. Warrington et al reported <1% of cases leading to concussion or fractures. Samuel et al identified two cases of intracranial haemorrhage and linear skull fractures without intervention. Kolulu et al observed significant injuries, including skull fractures and cerebral contusions, in 10.2% of infants. CONCLUSIONS: Falls from beds are frequent in infants under 1 year, with most resulting in minor outcomes. However, serious injuries occur in around 5% of infants below 1-year old, emphasising the need for prevention strategies and clinical guidelines for managing post-fall assessments. Further research is required to refine understanding and improve prevention and management practices. PROSPERO REGISTRATION NUMBER: CRD42024626255.
17 May 2026
Read appraisal →Injury prevention : journal of the International Society for Child and Adolescent Injury Prevention
Large language models in public health: opportunity or threat? The case of button battery injuries.
BACKGROUND: Button battery (BB) injuries in children represent a severe and growing public health burden. The literature on the topic is extensive; however, there is a notable lack of structured public health initiatives addressing the problem. The present study aimed to test the feasibility of using large language models (LLMs) to draft recommendations for preventing and managing BB ingestion in children. METHODS: A set of questions was generated and submitted to ChatGPT-4o and ChatGPT-o1-preview. Questions were based on statements and websites of scientific societies and not-for-profit organisations and were developed to produce comprehensive recommendations that provided information on BB risks, primary and secondary prevention, clinical management and follow-up, and general public health initiatives. Two independent reviewers rated the accuracy and readability of the questions submitted to the LLMs. The accuracy was rated using a four-level scale, while the readability was assessed using two established readability tools, the Flesch Reading Ease (FRE) and the Flesch-Kincaid Grade Level (FKGL). RESULTS: None of the answers provided by the LLMs were rated as completely incorrect or partially incorrect. ChatGPT-o1-preview outperformed ChatGPT-4o in accuracy, with eight answers rated as accurate and complete. Both models showed similar readability levels, with high FKGL and FRE scores indicating college-level comprehension. DISCUSSION: LLM demonstrated a strong performance in this study, with no responses rated as incorrect or partially incorrect, showing its great potential and feasibility for use in public health. CONCLUSIONS: The present findings suggested the potential feasibility of LLMs in public health for preventing paediatric injuries.
17 May 2026
Read appraisal →Archives of disease in childhood
How accurate is point-of-care ultrasound for detecting paediatric appendicitis? A systematic review and meta-analysis.
OBJECTIVES: Primary: To evaluate the diagnostic accuracy of point-of-care ultrasound (POCUS) in the diagnosis of appendicitis in paediatric patients presenting with suspected appendicitis.Secondary: To investigate how the use of POCUS affects length of stay in the paediatric emergency department and CT utilisation. METHODS: We searched MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) up until February 2025 for studies involving patients presenting to the paediatric emergency department with suspected appendicitis, who underwent POCUS. Studies were assessed for risk of bias using the Quality Assessment Tool for Diagnostic Accuracy Studies framework. The primary outcome of interest was the ability of POCUS to detect appendicitis in terms of sensitivity and specificity. RESULTS: Eight studies were included encompassing 993 patients. Calculated pooled sensitivity was 85.6% (95% CI 68.9% to 94.1%) with a specificity of 90.2% (95% CI 86.5% to 93.0%). There was a wide range of reported sensitivities for POCUS, ranging from 53% to 100%. There was less variation in reported specificities that ranged from 82% to 95.2%. The studies analysed were of variable quality with the reference standard and flow and timing being the main areas subject to bias. CONCLUSIONS: Based on the findings of this systematic review and meta-analysis, it is reasonable to conclude that POCUS can be used as an effective tool to diagnose paediatric appendicitis. With a moderately high sensitivity, it may not be recommended to be used to exclude appendicitis based on POCUS findings alone. Further prospective studies evaluating the reliability of POCUS in excluding appendicitis, either alone or when combined with a clinical prediction rule, are required. Secondary findings from this study demonstrate that POCUS may result in a reduced length of stay in the paediatric emergency department and lead to a reduction in CT utilisation, though insufficient data were available to draw firm conclusions in relation to this.
19 Apr 2026
Read appraisal →European journal of pediatrics
Facilitator-guided vs self-guided debriefing in immersive virtual reality paediatric emergency training: a randomised pilot study on learning outcomes and feasibility
UNLABELLED: This study evaluated the feasibility and effectiveness of immersive virtual reality (VR)-based paediatric emergency training, comparing facilitator-guided with self-guided debriefing methods. In a single-blinded, randomised controlled pilot trial, 24 healthcare professionals (12 interprofessional dyads) were randomised to VR-based paediatric emergency training followed by either facilitator- or self-guided debriefing. Both groups received a standardised preparatory lecture and skills workshop. We collected data on the feasibility of the interventions and additional trial procedures. For pre- and post-performance assessment, all dyads were video-recorded whilst managing a mannequin-based paediatric emergency. Two independent, blinded raters assessed the dyads' teamwork, ABCDE adherence, and time to critical actions based on the videos. We also collected data on participants' cognitive load and perceived effectiveness of the two debriefing methods. The study demonstrated the feasibility of interprofessional VR-based paediatric emergency training with both facilitator- and self-guided debriefing in a clinical setting. Twenty-two healthcare professionals completed the intervention, and 20 completed follow-up. VR was acceptable and usable, though 46% of participants reported some cybersickness. Additional trial procedures were feasible but required substantial logistical coordination. VR training significantly improved teamwork (facilitator-guided mean 1.2, confidence interval (CI) 0.5 to 1.9, p = 0.005; self-guided mean 1.4, CI 0.8 to 2.0, p < 0.001) and ABCDE adherence (facilitator-guided mean 0.5, CI 0.1 to 1.0, p = 0.02; self-guided mean 0.5, CI 0.1 to 0.9, p = 0.01), with similar outcomes between the debriefing methods. However, participants perceived the facilitator-guided debriefing to be more effective (mean difference 1.4, CI 0.1 to 2.7, p = 0.04). CONCLUSION: Immersive VR-based paediatric emergency training with facilitator-guided and self-guided debriefing was feasible in a pilot context and yielded comparable performance outcomes. A larger, adequately powered trial is warranted to formally evaluate non-inferiority between debriefing methods. WHAT IS KNOWN: • Simulation-based paediatric emergency training improves clinical outcomes, but widespread implementation is limited by logistical challenges and high costs. • Immersive virtual reality (VR) may help overcome these barriers, yet evidence on its feasibility and effectiveness in this context is limited. WHAT IS NEW: • VR-based paediatric emergency training is feasible and effectively improves interprofessional performance. • Self-guided and facilitator-guided debriefing yielded comparable outcomes, highlighting the potential for scalable use.
5 Apr 2026
Read appraisal →BMJ paediatrics open
Oxygen therapy for children with an oxygen saturation of 90-93% in Malawi: the NoGoLO2 pilot randomised controlled trial
OBJECTIVE: Oxygen is a cornerstone treatment for pneumonia with hypoxaemia. WHO guidelines recommend oxygen therapy for children with a peripheral arterial haemoglobin oxygen saturation (SpO2) <90%. Children in low- and middle-income countries with an SpO2 of 90-93% are at increased risk of mortality and may benefit from oxygen therapy. We aimed to determine the feasibility of a randomised controlled trial comparing standard of care (no oxygen), low-flow nasal cannula (LFNC) and high-flow nasal cannula (HFNC) among children with pneumonia and an SpO2 of 90-93%. DESIGN: Pilot, open-label, three-armed randomised control trial (NCT06176664). SETTING: Salima District Hospital, Malawi. PATIENTS: Children 1-59 months old with WHO-defined pneumonia and an SpO2 of 90-93%. INTERVENTIONS: Standard care (no oxygen), LFNC or HFNC. MAIN OUTCOME MEASURES: The primary outcome was feasibility defined as an average of ≤2 protocol deviations per participant. Secondary outcomes included consent refusal, participant attrition and treatment failure within 14 days. Treatment failure was defined as an SpO2 <90% for standard care participants or <94% in the LFNC and HFNC arms despite maximum therapy as described, any new severe respiratory distress (grunting, very severe chest indrawing) or any new WHO-defined emergency sign. RESULTS: Of the 29 eligible patients, 21 (72%) were enrolled and randomised. There was an average of 0.8 (16/21) deviations per participant. Seven (43.8%) protocol violations were related to study intervention protocols and nine (56.3%) to medication availability and routine care. No participants withdrew from the study. Three of 21 participants (14.3%) had treatment failure. All participants were successfully followed to obtain the 14-day outcome. CONCLUSIONS: A three-armed, open-label randomised control trial is feasible to compare standard of care, LFNC and HFNC oxygen for children with pneumonia and an SpO2 of 90-93% in Malawi. TRIAL REGISTRATION NUMBER: NCT06176664.
4 Apr 2026
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