2 PAEDS IN A POD

Episode 87 | Second Thoughts on Sugar Gel

Released: 5th July 2026 | Runtime: ~20 minutes

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EPISODE SUMMARY

This episode opens with the school-age follow-up of the hPOD trial, which found that a single prophylactic dose of dextrose gel given to at-risk newborns made no difference to neurocognitive function at six to seven years and was linked to slightly more emotional and behavioural difficulty — a finding that argues against giving gel as routine prevention, while leaving its role in treating established hypoglycaemia intact. The second main story is a UK multicentre cohort asking whether every child with Staphylococcus aureus bacteraemia needs an echocardiogram, and making the case for risk-stratifying instead. What's Caught My Eye covers decision rules to reduce X-rays in children's limb injuries, a prehospital oral sedation pathway for people with learning disabilities, and a study showing how often clinicians mark the wrong spot for a chest drain.

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MAIN STORY 1: Does prophylactic dextrose gel protect the newborn brain?

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Buccal dextrose gel is established for treating neonatal hypoglycaemia. This is the six-to-seven-year follow-up of the hPOD trial, which tested a different question: whether giving gel prophylactically, before the sugar drops, protects long-term neurodevelopment in at-risk babies.

Key findings:

• Double-blind, placebo-controlled RCT across nine New Zealand hospitals; a single 0.2 g/kg dose of 40% dextrose gel or placebo at one hour of age.
• Just over 1,000 children assessed at 6–7 years, mostly in their own schools.
• No difference in the primary outcome of neurocognitive impairment: 59% (gel) vs 57% (placebo), adjusted difference 3% (95% CI −3% to 9%), not significant.
• The high baseline rate reflects a broad definition (below −1 SD on any 1 of 7 tests), not that most children were impaired.
• On exploratory outcomes, the gel group had more emotional-behavioural difficulty (24% vs 18%) and low psychosocial function (17% vs 12%).

The evidence does not support giving dextrose gel prophylactically to prevent hypoglycaemia in at-risk newborns. It does not change the use of gel to treat an established low glucose alongside a feed, which remains reasonable.

Caveat: the behavioural signals are exploratory secondary outcomes and should be read with caution given multiple comparisons.

Reference: Harding JE, Alsweiler JM, Brown GTL, et al. JAMA Pediatrics. Published June 2026.

DOI: https://doi.org/10.1001/jamapediatrics.2026.2486

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MAIN STORY 2: Does every child with Staph aureus bacteraemia need an echo?

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In adults, Staph aureus in the blood triggers a near-automatic search for infective endocarditis. This UK cohort asks whether children, in whom endocarditis is rare without risk factors, need the same universal approach.

Key findings:

• Retrospective cohort, six North West London hospitals, 2018–2023, 101 children with Staph aureus bacteraemia; 70% had transthoracic echo, 30% did not.
• Endocarditis confirmed in 4 children (5.6% of those scanned), all right-sided, and all with an established risk factor (congenital heart disease, central venous catheter, or intravenous drug use).
• No endocarditis in any child with a structurally normal heart and no risk factor.
• Features associated with endocarditis: embolic phenomena, persistent bacteraemia beyond 72 hours, and polymicrobial growth.

A risk-stratified approach looks defensible: echo can reasonably be omitted in a child with a structurally normal heart, no risk factor and no clinical or microbiological clue, and reserved for those with a heart lesion, an indwelling line, a relevant history, a murmur, embolic signs, or persistent or polymicrobial bacteraemia.

Caveat: retrospective, single-region, small numbers, and the longer stay in the echo group is confounded by indication; prospective validation is needed before changing protocol.

Reference: Gray K, Ahad F, Cunnington A. BMJ Paediatrics Open. Published June 2026.

DOI: https://doi.org/10.1136/bmjpo-2025-004466

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WHAT'S CAUGHT MY EYE

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1. Decision rules to cut X-rays in children's limb injuries

A systematic review and meta-analysis of eight studies and nearly 8,000 children found that ankle decision rules substantially reduce radiography (odds ratio around 0.11), while a wrist rule missed eight fractures and a nurse-applied rule in one trial increased imaging and missed sixteen injuries. Worth your time because it shows imaging reduction is achievable but depends heavily on which rule, which joint, and who applies it.

Reference: Kirkland SW, Lesyk N, Herle E, et al. Emergency Medicine Journal. Published June 2026.

DOI: https://doi.org/10.1136/emermed-2025-215355

2. Prehospital oral sedation for people with learning disabilities

The Barts Health Physician Response Unit built a pathway giving carer-administered oral ketamine and midazolam to let people with learning disabilities tolerate procedures that would otherwise be impossible; in the first year, nine of thirty-six referred patients were sedated with no serious adverse events and every patient tolerated their procedure. Worth your time as a practical model of reasonable adjustments that avoids restraint and parenteral routes.

Reference: Munro A, Kanagaratnam S, Navein J, Mitchinson S. Emergency Medicine Journal. Published June 2026.

DOI: https://doi.org/10.1136/emermed-2025-215424

3. How often do we find the wrong spot for a chest drain?

When fifteen paediatric emergency physicians marked the fifth intercostal space by landmarks and were checked with ultrasound, only 37% of 240 marks were accurate, nearly one in ten sat below the diaphragm, and more experienced clinicians were more likely to mark too low. Worth your time as a strong argument for an ultrasound check before this rare, high-stakes procedure.

Reference: Biela CM, Ruthford MR, Shah A, et al. Pediatric Emergency Care. Published June 2026.

DOI: https://doi.org/10.1097/PEC.0000000000003645

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KEY TAKEAWAYS

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• Prophylactic dextrose gel does not improve neurocognition at 6–7 years in at-risk newborns and may carry a small behavioural cost.
• Gel remains reasonable for treating an established low glucose alongside a feed — prophylaxis and treatment are separate questions.
• Not every child with Staph aureus bacteraemia needs an echo; risk-stratify by heart structure, risk factors, and clinical or microbiological features.
• Ankle decision rules reliably reduce limb X-rays, but the choice of rule and who applies it determines whether that is safe.
• Landmark placement of chest drains is frequently inaccurate and experience does not protect against it — check with ultrasound.

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FULL REFERENCE LIST

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All articles retrieved from PubMed.

1. Harding JE, Alsweiler JM, Brown GTL, et al. Prophylactic Dextrose Gel for Neonatal Hypoglycemia and Neurocognitive Function at 6 to 7 Years of Age: A Secondary Analysis of a Randomized Clinical Trial. JAMA Pediatrics. 2026 (advance online publication).
2. https://doi.org/10.1001/jamapediatrics.2026.2486
3. Gray K, Ahad F, Cunnington A. Transthoracic echocardiography in children with Staphylococcus aureus bacteraemia: a multi-centre retrospective analysis. BMJ Paediatrics Open. 2026;10(1).
4. https://doi.org/10.1136/bmjpo-2025-004466
5. Kirkland SW, Lesyk N, Herle E, et al. Interventions to reduce imaging in children with upper or lower extremity injuries: a systematic review and meta-analysis. Emergency Medicine Journal. 2026;43(7):435–444.
6. https://doi.org/10.1136/emermed-2025-215355
7. Munro A, Kanagaratnam S, Navein J, Mitchinson S. Prehospital pathway offering oral dissociative procedural sedation for patients with learning disabilities. Emergency Medicine Journal. 2026;43(6):374–375.
8. https://doi.org/10.1136/emermed-2025-215424
9. Biela CM, Ruthford MR, Shah A, et al. Evaluating the Accuracy of Chest Tube Thoracostomy Site Selection by Pediatric Emergency Medicine Physicians Using Point-of-Care Ultrasound. Pediatric Emergency Care. 2026 (advance online publication).
10. https://doi.org/10.1097/PEC.0000000000003645

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About 2 Paeds in a Pod

2 Paeds in a Pod is a paediatric medical education podcast hosted by Dr Ian Lewins, Clinical Lead for Paediatric Urgent and Emergency Care at University Hospitals of Derby and Burton NHS Foundation Trust. New episodes fortnightly.

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The content of this podcast is intended for educational purposes only. It does not constitute clinical advice. Always refer to current national guidelines and local protocols when making clinical decisions.