Presentations and Outcomes Among Infants ≤90 Days With and Without SARS-CoV-2.

OBJECTIVES: To compare symptoms and outcomes among infants aged ≤90 days tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a broad, international sample of emergency departments (EDs). METHODS: This was a secondary analysis of infants aged 0 to 90 days with suspected SARS-CoV-2 infections tested using molecular approaches and with 14-day follow-up. The parent studies were conducted at 41 EDs in 10 countries (the global Pediatric Emergency Research Network; March 2020-June 2021) and 14 EDs across Canada (Pediatric Emergency Research Canada network; August 2020-February 2022). Symptom profiles included presence and number of presenting symptoms. Clinical outcomes included hospitalization, ICU admission, and severe outcomes (a composite of intensive interventions, severe organ impairment, or death). RESULTS: Among 1048 infants tested for SARS-CoV-2, 1007 (96.1%) were symptomatic at presentation and 432 (41.2%) were SARS-CoV-2-positive. A systemic symptom (any of the following: Apnea, drowsiness, irritability, or lethargy) was most common and present in 646 (61.6%) infants, regardless of SARS-CoV-2 status. Although fever and upper respiratory symptoms were more common among SARS-CoV-2-positive infants, dehydration, gastrointestinal, skin, and oral symptoms, and the overall number of presenting symptoms did not differ between groups. Infants with SARS-CoV-2 infections were less likely to be hospitalized (32.9% vs 44.8%; difference -11.9% [95% confidence interval (CI) -17.9% to -6.0%]), require intensive care (1.4% vs 5.0%; difference -3.6% [95% CI -5.7% to -1.6%]), and experience severe outcomes (1.4% vs 5.4%; difference -4.0% [95% CI -6.1% to -1.9%]). CONCLUSIONS: SARS-CoV-2 infections may be difficult to differentiate from similar illnesses among the youngest infants but are generally milder. SARS-CoV-2 testing can help inform clinical management.

Post-COVID-19 Condition in Children 6 and 12 Months After Infection.

Importance: There is a need to understand the long-term outcomes among children infected with SARS-CoV-2. Objective: To quantify the prevalence of post-COVID-19 condition (PCC) among children tested for SARS-CoV-2 infection in pediatric emergency departments (EDs). Design, Setting, and Participants: Multicenter, prospective cohort study at 14 Canadian tertiary pediatric EDs that are members of the Pediatric Emergency Research Canada network with 90-day, 6-month, and 12-month follow-up. Participants were children younger than 18 years who were tested for SARS-CoV-2 infection between August 2020 and February 2022. Data were analyzed from May to November 2023. Exposure: The presence of SARS-CoV-2 infection at or within 14 days of the index ED visit. Main Outcomes and Measures: Presence of symptoms and QoL reductions that meet the PCC definition. This includes any symptom with onset within 3 months of infection that is ongoing at the time of follow-up and affects everyday functioning. The outcome was quantified at 6 and 12 months following the index ED visit. Results: Among the 5147 children at 6 months (1152 with SARS-CoV-2 positive tests and 3995 with negative tests) and 5563 children at 12 months (1192 with SARS-CoV-2 positive tests and 4371 with negative tests) who had sufficient data regarding the primary outcome to enable PCC classification, the median (IQR) age was 2.0 (0.9-5.0) years, and 2956 of 5563 (53.1%) were male. At 6-month follow-up, symptoms and QoL changes consistent with the PCC definition were present in 6 of 1152 children with positive SARS-CoV-2 tests (0.52%) and 4 of 3995 children with negative SARS-CoV-2 tests (0.10%; absolute risk difference, 0.42%; 95% CI, 0.02% to 0.94%). The PCC definition was met at 12 months by 8 of 1192 children with positive SARS-CoV-2 tests (0.67%) and 7 of 4371 children with negative SARS-CoV-2 tests (0.16%; absolute risk difference, 0.51%; 95% CI, 0.06 to 1.08%). At 12 months, the median (IQR) PedsQL Generic Core Scale scores were 98.4 (90.0-100) among children with positive SARS-CoV-2 tests and 98.8 (91.7-100) among children with negative SARS-CoV-2 tests (difference, -0.3; 95% CI, -1.5 to 0.8; P = .56). Among the 8 children with SARS-CoV-2 positive tests and PCC at 12-month follow-up, children reported respiratory (7 of 8 patients [88%]), systemic (3 of 8 patients [38%]), and neurologic (1 of 8 patients [13%]) symptoms. Conclusions and Relevance: In this cohort study of children tested for SARS-CoV-2 infection in Canadian pediatric EDs, although children infected with SARS-CoV-2 reported increased chronic symptoms, few of these children developed PCC, and overall QoL did not differ from children with negative SARS-CoV-2 tests.

National Survey on the Emergency Department Management of Febrile Infants 29 to 60 Days Old With an Abnormal Urinalysis.

OBJECTIVES: Recent clinical practice guidelines recommend that decisions regarding lumbar puncture (LP) for febrile infants older than 28 days should no longer be based on urinalysis results, but rather independently determined by inflammatory markers and sometimes guided by shared decision-making (SDM). This study sought to assess management decisions for febrile infants aged 29 to 60 days with an abnormal urinalysis. METHODS: A scenario-based survey was sent to emergency department physicians at all 15 Canadian tertiary pediatric centers. Participants were asked questions regarding management decisions when presented with a well-appearing febrile infant in the second month of life with either an abnormal or normal urinalysis. RESULTS: Response rate was 50.2% (n = 116/231). Overall, few respondents would perform an LP based on either an abnormal or normal urinalysis alone (10.3% and 6.0%, respectively). However, regression analysis demonstrated that decisions regarding LP were influenced by urinalysis results (P < 0.001), with respondents more likely to defer to inflammatory marker results for infants with a normal urinalysis result (57.8%) compared with those with an abnormal urinalysis (28.4%). Hospitalization (62.1%) and empiric antibiotic treatment by intravenous route (87.9%) were both frequent for low-risk infants with an abnormal urinalysis. Nearly half of respondents reported rarely (<25% of encounters) engaging families in SDM regarding LP decisions. CONCLUSIONS: Knowledge translation initiatives reflecting current evidence should target use of inflammatory markers rather than urinalysis results to guide decisions regarding LP. Efforts emphasizing outpatient management with oral antibiotics and SDM for low-risk infants with an abnormal urinalysis could also further align management with current evidence and guidelines.

Impact of SARS-CoV-2 Infection on the Association Between Laboratory Tests and Severe Outcomes Among Hospitalized Children.

Background: To assist clinicians with identifying children at risk of severe outcomes, we assessed the association between laboratory findings and severe outcomes among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected children and determined if SARS-CoV-2 test result status modified the associations. Methods: We conducted a cross-sectional analysis of participants tested for SARS-CoV-2 infection in 41 pediatric emergency departments in 10 countries. Participants were hospitalized, had laboratory testing performed, and completed 14-day follow-up. The primary objective was to assess the associations between laboratory findings and severe outcomes. The secondary objective was to determine if the SARS-CoV-2 test result modified the associations. Results: We included 1817 participants; 522 (28.7%) SARS-CoV-2 test-positive and 1295 (71.3%) test-negative. Seventy-five (14.4%) test-positive and 174 (13.4%) test-negative children experienced severe outcomes. In regression analysis, we found that among SARS-CoV-2-positive children, procalcitonin ≥0.5 ng/mL (adjusted odds ratio [aOR], 9.14; 95% CI, 2.90-28.80), ferritin >500 ng/mL (aOR, 7.95; 95% CI, 1.89-33.44), D-dimer ≥1500 ng/mL (aOR, 4.57; 95% CI, 1.12-18.68), serum glucose ≥120 mg/dL (aOR, 2.01; 95% CI, 1.06-3.81), lymphocyte count <1.0 × 109/L (aOR, 3.21; 95% CI, 1.34-7.69), and platelet count <150 × 109/L (aOR, 2.82; 95% CI, 1.31-6.07) were associated with severe outcomes. Evaluation of the interaction term revealed that a positive SARS-CoV-2 result increased the associations with severe outcomes for elevated procalcitonin, C-reactive protein (CRP), D-dimer, and for reduced lymphocyte and platelet counts. Conclusions: Specific laboratory parameters are associated with severe outcomes in SARS-CoV-2-infected children, and elevated serum procalcitonin, CRP, and D-dimer and low absolute lymphocyte and platelet counts were more strongly associated with severe outcomes in children testing positive compared with those testing negative.

Inhaled nitrous oxide for painful procedures in children and youth: a systematic review and meta-analysis.

OBJECTIVES: The objective of this study was to synthesize indication-based evidence for N2O for distress and pain in children. STUDY DESIGN: We included trials of N2O in participants 0-21 years, reporting distress or pain for emergency department procedures. The primary outcome was procedural distress. Where meta-analysis was not possible, we used Tricco et al.'s classification of "neutral" (p ≥ 0.05), "favorable," or "unfavorable" (p < 0.05, supporting N2O or comparator, respectively). We used the Cochrane Collaboration's Risk of Bias tool and the Grading of Recommendations Assessment, Development, and Evaluation system to evaluate risk of bias and quality of evidence, respectively. RESULTS: We included 30 trials. For pain using the Visual Analog Scale (0-100 mm) during IV insertion, 70% N2O (delta:-16.5; 95%CI:-28.6 to -4.4; p = 0.008; three trials; I2 = 0%) and 50% N2O plus eutectic mixture of local anesthetics (EMLA) (delta:-1.2; 95%CI:-2.1 to -0.3; p = 0.007; two trials; I2 = 43%) were superior to EMLA. 50% N2O was not superior to EMLA (delta:-0.4; 95%CI:-1.2 to 0.3; p = 0.26; two trials; I2 = 15%). For distress and pain during laceration repair, N2O was "favorable" versus each of SC lidocaine, oxygen, and oral midazolam but "neutral" versus IV ketamine (five trials). For distress and pain during fracture reduction (three trials), N2O was "neutral" versus each of IM meperidine plus promethazine, regional anesthesia, and IV ketamine plus midazolam. For distress and pain during lumbar puncture (one trial), N2O was "favorable" versus oxygen. For distress and pain during urethral catheterization (one trial), N2O was "neutral" versus oral midazolam. For pain during intramuscular injection (one trial), N2O plus EMLA was "favorable" versus N2O and EMLA alone. Common adverse effects of N2O included nausea (4.4%), agitation (3.7%), and vomiting (3.6%) AEs were less frequent with N2O alone (278/1147 (24.2%)) versus N2O plus midazolam (48/52 (92.3%)) and N2O plus fentanyl (123/201 (61.2%)). CONCLUSIONS: There is sufficient evidence to recommend N2O plus topical anesthetic for IV insertion and laceration repair. Adverse effects are greater when combined with other sedating agents.

RéSUMé: OBJECTIFS: Synthétiser les données probantes fondées sur l'indication pour le N2O pour la détresse et la douleur chez les enfants. Plan d'étude : Nous avons inclus des essais de N2O chez des participants âgés de 0 à 21 ans, signalant une détresse ou une douleur pour les procédures des services d'urgence. Le critère de jugement principal était la détresse procédurale. Lorsqu'une méta-analyse n'était pas possible, nous avons utilisé la classification de Tricco et al. "neutre" (p>0,05), "favorable" ou "défavorable" (p<0,05, en faveur de la N2O ou du comparateur, respectivement). Nous avons utilisé l'outil risque de biais de la Collaboration Cochrane et le système Grading of Recommendations Assessment, Development, and Evaluation pour évaluer respectivement le risque de biais et la qualité des preuves. RéSULTATS: Nous avons inclus 30 essais. Pour la douleur sur l'échelle visuelle analogique (0-100 mm) pendant l'insertion IV, 70 % de N2O (delta : -16,5 ; IC à 95% : -28,6 à -4,4 ; p = 0,008 ; trois essais ; I2 = 0 %) et 50 % de N2O plus un mélange eutectique d'anesthésiques locaux (EMLA) (delta : -1,2 ; IC à 95 % : -2,1 à -0,3 ; p = 0,007 ; deux essais ; I2 = 43 %) étaient supérieurs à l'EMLA. La N2O à 50 % n'était pas supérieure à l'EMLA (delta : -0,4 ; IC à 95 % : -1,2 à 0,3 ; p = 0,26 ; deux essais ; I2 = 15 %). En ce qui concerne la détresse et la douleur pendant la réparation des lacérations, le N2O était "favorable" par rapport à la lidocaïne SC, à l'oxygène et au midazolam oral, mais "neutre" par rapport à la kétamine IV (cinq essais). Pour la détresse et la douleur pendant la réduction des fractures (trois essais), le N2O était « neutre ¼ par rapport à la mépéridine IM plus prométhazine, l'anesthésie régionale et la kétamine IV plus midazolam. Pour la détresse et la douleur lors de la ponction lombaire (un essai), le N2O était "favorable" par rapport à l'oxygène. Pour la détresse et la douleur pendant le cathétérisme urétral (un essai), N2O était "neutre" par rapport au midazolam oral. Pour la douleur pendant l'injection intramusculaire (un essai), le N2O plus EMLA était « favorable ¼ par rapport au N2O et à l'EMLA seuls. Les effets indésirables les plus fréquents de la N2O étaient les nausées (4,4 %), l'agitation (3,7 %) et les vomissements (3,6 %). Les EI étaient moins fréquents avec la N2O seule (278/1147 (24,2 %)) par rapport au N2O plus midazolam (48/52 (92,3 %)) et le N2O plus fentanyl (123/201 (61,2 %)). CONCLUSIONS: Il existe suffisamment de preuves pour recommander le N2O plus un anesthésique topique pour l'insertion intraveineuse et la réparation des lacérations. Les effets indésirables sont plus importants lorsqu'ils sont combinés avec d'autres agents sédatifs.

Optimal Dose of Intranasal Dexmedetomidine for Laceration Repair in Children: A Phase II Dose-Ranging Study.

STUDY OBJECTIVE: To determine the optimal sedative dose of intranasal dexmedetomidine for children undergoing laceration repair. METHODS: This dose-ranging study employing the Bayesian Continual Reassessment Method enrolled children aged 0 to 10 years with a single laceration (<5 cm), requiring single-layer closure, who received topical anesthetic. Children were administered 1, 2, 3, or 4 mcg/kg intranasal dexmedetomidine. The primary outcome was the proportion with adequate sedation (Pediatric Sedation State Scale score of 2 or 3 for ≥90% of the time from sterile preparation to tying of the last suture). Secondary outcomes included the Observational Scale of Behavior Distress-Revised (range: 0 [no distress] to 23.5 [maximal distress]), postprocedure length of stay, and adverse events. RESULTS: We enrolled 55 children (35/55 [64%] males; median [interquartile range {IQR}] age 4 [2, 6] years). At 1, 2, 3, and 4 mcg/kg intranasal dexmedetomidine, respectively, the proportion of participants "adequately" sedated was 1/3 (33%), 2/9 (22%), 13/21 (62%), and 12/21 (57%); the posterior mean (95% equitailed credible intervals) for the probability of adequate sedation was 0.38 (0.04, 0.82), 0.25 (0.05, 0.54), 0.61 (0.41, 0.80), and 0.57 (0.36, 0.76); the median (IQR) Observational Scale of Behavior Distress-Revised scores during suturing was 2.7 (0.3, 3), 0 (0, 3.8), 0.6 (0, 5), and 0 (0, 3.7); the median (IQR) postprocedure length of stay was 67 (60, 78), 76 (60, 100), 89 (76, 109), and 113 (76, 150) minutes. There was 1 adverse event, a decrease in oxygen saturation at 4 mcg/kg, which resolved with head repositioning. CONCLUSION: Despite limitations, such as our limited sample size and subjectivity in Pediatric Sedation State Scale scoring, sedation efficacy for 3 and 4 mcg/kg were similarly based on equitailed credible intervals suggesting either could be considered optimal.

Comparison of Symptoms Associated With SARS-CoV-2 Variants Among Children in Canada.

Importance: Clinical manifestations of SARS-CoV-2 variants have not been systematically compared in children. Objective: To compare symptoms, emergency department (ED) chest radiography, treatments, and outcomes among children with different SARS-CoV-2 variants. Design, Setting, and Participants: This multicenter cohort study was performed at 14 Canadian pediatric EDs. Participants included children and adolescents younger than 18 years (hereinafter referred to as children) tested for SARS-CoV-2 infection in an ED between August 4, 2020, and February 22, 2022, with 14 days of follow-up. Exposure(s): SARS-CoV-2 variants detected on a specimen collected from the nasopharynx, nares, or throat. Main Outcomes and Measures: The primary outcome was presence and number of presenting symptoms. The secondary outcomes were presence of core COVID-19 symptoms, chest radiography findings, treatments, and 14-day outcomes. Results: Among 7272 participants presenting to an ED, 1440 (19.8%) had test results positive for SARS-CoV-2 infection. Of these, 801 (55.6%) were boys, with a median age of 2.0 (IQR, 0.6-7.0) years. Children with the Alpha variant reported the fewest core COVID-19 symptoms (195 of 237 [82.3%]), which were most often reported by participants with Omicron variant infection (434 of 468 [92.7%]; difference, 10.5% [95% CI, 5.1%-15.9%]). In a multivariable model with the original type as the referent, the Omicron and Delta variants were associated with fever (odds ratios [ORs], 2.00 [95% CI, 1.43-2.80] and 1.93 [95% CI, 1.33-2.78], respectively) and cough (ORs, 1.42 [95% CI, 1.06-1.91] and 1.57 [95% CI, 1.13-2.17], respectively). Upper respiratory tract symptoms were associated with Delta infection (OR, 1.96 [95% CI, 1.38-2.79]); lower respiratory tract and systemic symptoms were associated with Omicron variant infection (ORs, 1.42 [95% CI, 1.04-1.92] and 1.77 [95% CI, 1.24-2.52], respectively). Children with Omicron infection most often had chest radiography performed and received treatments; compared with those who had Delta infection, they were more likely to have chest radiography performed (difference, 9.7% [95% CI, 4.7%-14.8%]), to receive intravenous fluids (difference, 5.6% [95% CI, 1.0%-10.2%]) and corticosteroids (difference, 7.9% [95% CI, 3.2%-12.7%]), and to have an ED revisit (difference, 8.8% [95% CI, 3.5%-14.1%]). The proportions of children admitted to the hospital and intensive care unit did not differ between variants. Conclusions and Relevance: The findings of this cohort study of SARS-CoV-2 variants suggest that the Omicron and Delta variants were more strongly associated with fever and cough than the original-type virus and the Alpha variant. Children with Omicron variant infection were more likely to report lower respiratory tract symptoms and systemic manifestations, undergo chest radiography, and receive interventions. No differences were found in undesirable outcomes (ie, hospitalization, intensive care unit admission) across variants.

Test characteristics of ultrasound for the diagnosis of peritonsillar abscess: A systematic review and meta-analysis.

BACKGROUND: Distinguishing peritonsillar abscess (PTA) from peritonsillar cellulitis using clinical assessment is challenging as many features overlap for both conditions, and physical examination is only about 75% sensitive and 50% specific for diagnosing PTA. The primary objective of this systematic review was to determine the test characteristics of ultrasound for diagnosing PTA when compared to a reference standard of computed tomography or acquisition of pus via needle aspiration or incision and drainage. METHODS: This systematic review was performed in accordance with the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy (PRISMA-DTA) guidelines. We searched seven databases from 1960 to November 2022. Two independent reviewers completed study selection, data extraction, and QUADAS-2 risk-of-bias assessment. We used a bivariate random-effects model to calculate pooled sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-). We also conducted subgroup analyses on radiology ultrasound compared to point-of-care ultrasound (POCUS) and intraoral compared to transcervical scanning techniques. RESULTS: From 339 citations, we identified 18 studies for inclusion. Because one study only reported positive cases of PTA (thereby preventing the calculation of specificity), it was excluded from the analysis, so the analysis included a total of 17 studies with 812 patients, of whom 541 had PTA. Pooled bivariate sensitivity was 86% (95% confidence interval [CI] 78%-91%), specificity 76% (95% CI 67%-82%), LR+ 3.51 (95% CI 2.59-4.89), and LR- 0.19 (95% CI 0.12-0.30). On subgroup analysis, radiology-performed ultrasound had a sensitivity and specificity of 89% and 71%, compared to POCUS, which had a sensitivity and specificity of 74% and 79%. Comparing the two different techniques, intraoral had a sensitivity and specificity of 91% and 75% while transcervical had a sensitivity and specificity of 80% and 81%. CONCLUSIONS: Ultrasound demonstrates high sensitivity for ruling out PTA, but it only has moderate specificity for ruling in the diagnosis.

Post-COVID-19 Conditions Among Children 90 Days After SARS-CoV-2 Infection.

Importance: Little is known about the risk factors for, and the risk of, developing post-COVID-19 conditions (PCCs) among children. Objectives: To estimate the proportion of SARS-CoV-2-positive children with PCCs 90 days after a positive test result, to compare this proportion with SARS-CoV-2-negative children, and to assess factors associated with PCCs. Design, Setting, and Participants: This prospective cohort study, conducted in 36 emergency departments (EDs) in 8 countries between March 7, 2020, and January 20, 2021, included 1884 SARS-CoV-2-positive children who completed 90-day follow-up; 1686 of these children were frequency matched by hospitalization status, country, and recruitment date with 1701 SARS-CoV-2-negative controls. Exposure: SARS-CoV-2 detected via nucleic acid testing. Main Outcomes and Measures: Post-COVID-19 conditions, defined as any persistent, new, or recurrent health problems reported in the 90-day follow-up survey. Results: Of 8642 enrolled children, 2368 (27.4%) were SARS-CoV-2 positive, among whom 2365 (99.9%) had index ED visit disposition data available; among the 1884 children (79.7%) who completed follow-up, the median age was 3 years (IQR, 0-10 years) and 994 (52.8%) were boys. A total of 110 SARS-CoV-2-positive children (5.8%; 95% CI, 4.8%-7.0%) reported PCCs, including 44 of 447 children (9.8%; 95% CI, 7.4%-13.0%) hospitalized during the acute illness and 66 of 1437 children (4.6%; 95% CI, 3.6%-5.8%) not hospitalized during the acute illness (difference, 5.3%; 95% CI, 2.5%-8.5%). Among SARS-CoV-2-positive children, the most common symptom was fatigue or weakness (21 [1.1%]). Characteristics associated with reporting at least 1 PCC at 90 days included being hospitalized 48 hours or more compared with no hospitalization (adjusted odds ratio [aOR], 2.67 [95% CI, 1.63-4.38]); having 4 or more symptoms reported at the index ED visit compared with 1 to 3 symptoms (4-6 symptoms: aOR, 2.35 [95% CI, 1.28-4.31]; ≥7 symptoms: aOR, 4.59 [95% CI, 2.50-8.44]); and being 14 years of age or older compared with younger than 1 year (aOR, 2.67 [95% CI, 1.43-4.99]). SARS-CoV-2-positive children were more likely to report PCCs at 90 days compared with those who tested negative, both among those who were not hospitalized (55 of 1295 [4.2%; 95% CI, 3.2%-5.5%] vs 35 of 1321 [2.7%; 95% CI, 1.9%-3.7%]; difference, 1.6% [95% CI, 0.2%-3.0%]) and those who were hospitalized (40 of 391 [10.2%; 95% CI, 7.4%-13.7%] vs 19 of 380 [5.0%; 95% CI, 3.0%-7.7%]; difference, 5.2% [95% CI, 1.5%-9.1%]). In addition, SARS-CoV-2 positivity was associated with reporting PCCs 90 days after the index ED visit (aOR, 1.63 [95% CI, 1.14-2.35]), specifically systemic health problems (eg, fatigue, weakness, fever; aOR, 2.44 [95% CI, 1.19-5.00]). Conclusions and Relevance: In this cohort study, SARS-CoV-2 infection was associated with reporting PCCs at 90 days in children. Guidance and follow-up are particularly necessary for hospitalized children who have numerous acute symptoms and are older.

Outcomes of SARS-CoV-2-Positive Youths Tested in Emergency Departments: The Global PERN-COVID-19 Study.

Importance: Severe outcomes among youths with SARS-CoV-2 infections are poorly characterized. Objective: To estimate the proportion of children with severe outcomes within 14 days of testing positive for SARS-CoV-2 in an emergency department (ED). Design, Setting, and Participants: This prospective cohort study with 14-day follow-up enrolled participants between March 2020 and June 2021. Participants were youths aged younger than 18 years who were tested for SARS-CoV-2 infection at one of 41 EDs across 10 countries including Argentina, Australia, Canada, Costa Rica, Italy, New Zealand, Paraguay, Singapore, Spain, and the United States. Statistical analysis was performed from September to October 2021. Exposures: Acute SARS-CoV-2 infection was determined by nucleic acid (eg, polymerase chain reaction) testing. Main Outcomes and Measures: Severe outcomes, a composite measure defined as intensive interventions during hospitalization (eg, inotropic support, positive pressure ventilation), diagnoses indicating severe organ impairment, or death. Results: Among 3222 enrolled youths who tested positive for SARS-CoV-2 infection, 3221 (>99.9%) had index visit outcome data available, 2007 (62.3%) were from the United States, 1694 (52.6%) were male, and 484 (15.0%) had a self-reported chronic illness; the median (IQR) age was 3 (0-10) years. After 14 days of follow-up, 735 children (22.8% [95% CI, 21.4%-24.3%]) were hospitalized, 107 (3.3% [95% CI, 2.7%-4.0%]) had severe outcomes, and 4 children (0.12% [95% CI, 0.03%-0.32%]) died. Characteristics associated with severe outcomes included being aged 5 to 18 years (age 5 to <10 years vs <1 year: odds ratio [OR], 1.60 [95% CI, 1.09-2.34]; age 10 to <18 years vs <1 year: OR, 2.39 [95% CI 1.38-4.14]), having a self-reported chronic illness (OR, 2.34 [95% CI, 1.59-3.44]), prior episode of pneumonia (OR, 3.15 [95% CI, 1.83-5.42]), symptoms starting 4 to 7 days prior to seeking ED care (vs starting 0-3 days before seeking care: OR, 2.22 [95% CI, 1.29-3.82]), and country (eg, Canada vs US: OR, 0.11 [95% CI, 0.05-0.23]; Costa Rica vs US: OR, 1.76 [95% CI, 1.05-2.96]; Spain vs US: OR, 0.51 [95% CI, 0.27-0.98]). Among a subgroup of 2510 participants discharged home from the ED after initial testing and who had complete follow-up, 50 (2.0%; 95% CI, 1.5%-2.6%) were eventually hospitalized and 12 (0.5%; 95% CI, 0.3%-0.8%) had severe outcomes. Compared with hospitalized SARS-CoV-2-negative youths, the risk of severe outcomes was higher among hospitalized SARS-CoV-2-positive youths (risk difference, 3.9%; 95% CI, 1.1%-6.9%). Conclusions and Relevance: In this study, approximately 3% of SARS-CoV-2-positive youths tested in EDs experienced severe outcomes within 2 weeks of their ED visit. Among children discharged home from the ED, the risk was much lower. Risk factors such as age, underlying chronic illness, and symptom duration may be useful to consider when making clinical care decisions.

Anxiolysis for laceration repair in children: a survey of pediatric emergency providers in Canada.

OBJECTIVES: Intranasal dexmedetomidine is a potentially effective anxiolytic but its role in pediatric laceration repair is only emerging. Future trials and clinical adoption of intranasal dexmedetomidine depend on understanding pediatric emergency providers' practice patterns surrounding anxiolysis and perceived barriers to intranasal dexmedetomidine for anxiolysis during suture repair in children. Our objectives were to characterize these parameters to inform future research and facilitate clinical adoption. METHODS: We conducted an online survey of pediatric emergency physician members of Pediatric Emergency Research Canada from September to December 2020. Questions pertained to perceptions of anxiolysis for suture repair, with a focus on intranasal dexmedetomidine. The primary outcome was anxiolysis for suture repair. Data were reported using descriptive statistics. RESULTS: The response rate was 155/225 (68.9%). During suture repair, 127/148 (86%) believed that > 25% of young children experience distress requiring physical restraint. 116/148 (78%) would provide anxiolysis, mainly intranasal benzodiazepines (100/148, 68%). Only 6/148 (4%) would provide intranasal dexmedetomidine but 95/148 (64%) would consider it if there was evidence of benefit. The most common perceived barriers to intranasal dexmedetomidine included inadequate personal experience (114/145, 79%) and lack of access (60/145, 41%). CONCLUSIONS: Most Canadian pediatric emergency providers believe that laceration repair in a young child is distressing. Despite questionable efficacy, most would provide intranasal benzodiazepines, but would consider intranasal dexmedetomidine if there was evidence of benefit.

RéSUMé: OBJECTIFS: La dexmédétomidine intranasale est un anxiolytique potentiellement efficace mais son rôle dans la réparation des lacérations en pédiatrie n'est qu'émergent. Les futurs essais et l'adoption clinique de la dexmédétomidine intranasale dépendent de la compréhension des habitudes de pratique des urgentistes pédiatriques en matière d'anxiolyse et des obstacles perçus à la dexmédétomidine intranasale pour l'anxiolyse pendant la réparation des sutures chez les enfants. Nos objectifs étaient de caractériser ces paramètres pour éclairer les recherches futures et faciliter l'adoption clinique. MéTHODES: Nous avons mené un sondage en ligne auprès des médecins urgentistes pédiatriques membres de Recherche en urgence pédiatrique Canada (Pediatric Emergency Research Canada) de septembre à décembre 2020. Les questions portaient sur les perceptions de l'anxiolyse pour la réparation des sutures, en mettant l'accent sur la dexmédétomidine intranasale. Le résultat principal était l'anxiolyse pour la réparation des sutures. Les données ont été rapportées à l'aide de statistiques descriptives. RéSULTATS: Le taux de réponse était de 155/225 (68,9 %). Pendant la suture, 127/148 (86 %) ont estimé que > 25 % des jeunes enfants éprouvent une détresse nécessitant une contention physique. 116/148 (78 %) fourniraient une anxiolyse, principalement des benzodiazépines intranasales (100/148, 68 %). Seulement 6/148 (4 %) fourniraient de la dexmédétomidine intranasale, mais 95/148 (64 %) l'envisageraient s'il y avait une preuve de bénéfice. Les obstacles les plus fréquemment perçus à la dexmédétomidine intranasale étaient une expérience personnelle insuffisante (114/145, 79 %) et un manque d'accès (60/145, 41 %). CONCLUSIONS: La plupart des fournisseurs canadiens de services d'urgence pédiatriques croient que la réparation des lacérations chez un jeune enfant est pénible. En dépit d'une efficacité douteuse, la plupart d'entre eux fourniraient des benzodiazépines intranasales, mais envisageraient la dexmédétomidine intranasale s'il était prouvé qu'elle était bénéfique.

Improving research personnel's hand hygiene adherence in the pediatric acute care setting during the COVID-19 pandemic: a quality improvement initiative.

Introduction: Hand hygiene is critical in preventing the spread of healthcare-associated infections. Routine hand hygiene surveillance and education are common for clinical staff in pediatric acute care settings. However, nonclinical staff, including research personnel, are often excluded from these programs and therefore represent a gap in ongoing infection control efforts. This project aimed to evaluate the impact of evidence-based interventions on improving hand hygiene adherence among research personnel in the pediatric emergency department to meet provincial targets set for clinical staff. Methods: We used a Plan-Do-Study-Act approach to carry out a peer-driven, multimodal hand hygiene improvement strategy involving education, surveillance, and feedback targeted to research assistants working in a pediatric emergency department. Two anonymous peer evaluators observed hand hygiene practices in several specific instances (eg, before/after patient interactions) and determined adherence a priori. Results: In an open sample of clinical research assistants (Ntotal = 22), hand hygiene adherence increased from 12.5% to 89.1% over 11 months. Increases in adherence were particularly notable before entering the patient environment compared to exiting. Conclusions: Hand hygiene interventions targeting research personnel show potential success in acute care. Further quality improvement initiatives in larger research personnel samples must robustly evaluate the framework's effectiveness.

The physical examination is unreliable in determining the location of the distal fibular physis.

OBJECTIVES: Salter-Harris type 1 (SH1) fractures of the distal fibula are acute orthopedic injuries with tenderness over the physis without radiographic evidence of fracture. Our primary objective was to establish the accuracy of the physical examination performed by pediatric emergency medicine (PEM) physicians in determining the location of the distal fibular physis compared to a criterion standard of ultrasound. METHODS: This was a prospective, observational study at an urban academic pediatric emergency department of a convenience sample of children aged 4 to 10 years old between March 2019 and March 2020. A PEM physician or fellow examined the patient's distal fibula and marked the location of the physis with a marker. A study investigator scanned the distal fibula to establish the location of the physis on ultrasound and measured the distance between the clinician's estimated position and the actual sonographic position. We a priori defined a clinically accurate position as a distance of ≤5 mm. We compared the accuracy rate of physical examination to ultrasound landmarking using proportions with 95% confidence intervals (CI). RESULTS: We enrolled 71 patients, of whom 52 (73%) were male. The mean age was 6.7 years and the mean weight was 25.5 kg. Participating PEM physicians included 18 attending physicians and 2 fellows. The distal fibular physis was correctly identified in 24 patients, yielding an accuracy rate of 34% (95% CI 23%-46%). The mean distance between the physician's estimated position and the sonographic position was 7.4 mm (95% CI 6.4-8.4 mm). CONCLUSIONS: PEM physicians were unable to accurately identify the distal fibular physis on physical examination.

Prevalence of Bacterial Meningitis Among Febrile Infants Aged 29-60 Days With Positive Urinalysis Results: A Systematic Review and Meta-analysis.

Importance: Fever in the first months of life remains one of the most common pediatric problems. Urinary tract infections are the most frequent serious bacterial infections in this population. All published guidelines and quality initiatives for febrile young infants recommend lumbar puncture (LP) and cerebrospinal fluid (CSF) testing on the basis of a positive urinalysis result to exclude bacterial meningitis as a cause. For well infants older than 28 days with an abnormal urinalysis result, LP remains controversial. Objective: To assess the prevalence of bacterial meningitis among febrile infants 29 to 60 days of age with a positive urinalysis result to evaluate whether LP is routinely required. Data Sources: MEDLINE and Embase were searched for articles published from January 1, 2000, to July 25, 2018, with deliberate limitation to recent studies. Before analysis, the search was repeated (October 6, 2019) to ensure that new studies were included. Study Selection: Studies that reported on healthy, full-term, well-appearing febrile infants 29 to 60 days of age for whom patient-level data could be ascertained for urinalysis results and meningitis status were included. Data Extraction and Synthesis: Data were extracted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and used the Newcastle-Ottawa Scale to assess bias. Pooled prevalences and odds ratios (ORs) were estimated using random-effect models. Main Outcomes and Measures: The primary outcome was the prevalence of culture-proven bacterial meningitis among infants with positive urinalysis results. The secondary outcome was the prevalence of bacterial meningitis, defined by CSF testing or suggestive history at clinical follow-up. Results: The parent search yielded 3227 records; 48 studies were included (17 distinct data sets of 25 374 infants). The prevalence of culture-proven meningitis was 0.44% (95% CI, 0.25%-0.78%) among 2703 infants with positive urinalysis results compared with 0.50% (95% CI, 0.33%-0.76%) among 10 032 infants with negative urinalysis results (OR, 0.74; 95% CI, 0.39-1.38). The prevalence of bacterial meningitis was 0.25% (95% CI, 0.14%-0.45%) among 4737 infants with meningitis status ascertained by CSF testing or clinical follow-up and 0.28% (95% CI, 0.21%-0.36%) among 20 637 infants with positive and negative urinalysis results (OR, 0.89; 95% CI, 0.48-1.68). Conclusions and Relevance: In this systematic review and meta-analysis, the prevalence of bacterial meningitis in well-appearing febrile infants 29 to 60 days of age with positive urinalysis results ranged from 0.25% to 0.44% and was not higher than that in infants with negative urinalysis results. These results suggest that for these infants, the decision to use LP should not be guided by urinalysis results alone.

Adaptive randomised controlled non-inferiority multicentre trial (the Ketodex Trial) on intranasal dexmedetomidine plus ketamine for procedural sedation in children: study protocol.

INTRODUCTION: Up to 40% of orthopaedic injuries in children require a closed reduction, almost always necessitating procedural sedation. Intravenous ketamine is the most commonly used sedative agent. However, intravenous insertion is painful and can be technically difficult in children. We hypothesise that a combination of intranasal dexmedetomidine plus intranasal ketamine (Ketodex) will be non-inferior to intravenous ketamine for effective sedation in children undergoing a closed reduction. METHODS AND ANALYSIS: This is a six-centre, four-arm, adaptive, randomised, blinded, controlled, non-inferiority trial. We will include children 4-17 years with a simple upper limb fracture or dislocation that requires sedation for a closed reduction. Participants will be randomised to receive either intranasal Ketodex (one of three dexmedetomidine and ketamine combinations) or intravenous ketamine. The primary outcome is adequate sedation as measured using the Paediatric Sedation State Scale. Secondary outcomes include length of stay, time to wakening and adverse effects. The results of both per protocol and intention-to-treat analyses will be reported for the primary outcome. All inferential analyses will be undertaken using a response-adaptive Bayesian design. Logistic regression will be used to model the dose-response relationship for the combinations of intranasal Ketodex. Using the Average Length Criterion for Bayesian sample size estimation, a survey-informed non-inferiority margin of 17.8% and priors from historical data, a sample size of 410 participants will be required. Simulations estimate a type II error rate of 0.08 and a type I error rate of 0.047. ETHICS AND DISSEMINATION: Ethics approval was obtained from Clinical Trials Ontario for London Health Sciences Centre and McMaster Research Ethics Board. Other sites have yet to receive approval from their institutions. Informed consent will be obtained from guardians of all participants in addition to assent from participants. Study data will be submitted for publication regardless of results. TRIAL REGISTRATION NUMBER: NCT0419525.

Improving the diagnostic accuracy of appendicitis using a multidisciplinary pathway.

BACKGROUND/PURPOSE: Improvement opportunities exist in the accuracy and timeliness of the diagnosis of childhood appendicitis. The purpose of our study was to conduct a post-implementation audit of a diagnostic pathway for children with suspected appendicitis presenting to our pediatric emergency department. METHODS: We adopted a diagnostic pathway that utilized a validated risk of appendicitis stratification tool (Alvarado Score) with protocolized use of abdominal ultrasound for moderate risk patients. We conducted a 10% convenience sample audit of pathway patients treated over the subsequent 18-month period. Outcome measures included false negative and positive rates, sensitivity, specificity, and overall pathway accuracy. RESULTS: One hundred thirty-four pathway patients, of which 22 (16.4%) had appendicitis confirmed pathologically, were evaluated. The risk group distribution of patients was: low risk (29%), moderate risk (60%), and high risk (11%). The negative appendectomy rate was 4.4% (reduced from 14% pre-pathway), and the false negative (missed appendicitis) rate was 3.0%. No patients received CT scans. Pathway sensitivity was 81.8%% (95% CI 59.7% to 94.8%), specificity-92.9%% (95% CI 86.4%-96.9%), and overall accuracy-91.0% (95% CI 84.9%-95.3%). CONCLUSION: Implementation of a diagnostic pathway achieved a high level of accuracy and reduced our institutional negative appendectomy rate by 67%. The audit identified additional pathway improvement opportunities. LEVELS OF EVIDENCE: Level IV.

Intranasal Dexmedetomidine for Procedural Distress in Children: A Systematic Review.

CONTEXT: Intranasal dexmedetomidine (IND) is an emerging agent for procedural distress in children. OBJECTIVE: To explore the effectiveness of IND for procedural distress in children. DATA SOURCES: We performed electronic searches of Medline (1946-2019), Embase (1980-2019), Google Scholar (2019), Cumulative Index to Nursing and Allied Health Literature (1981-2019), and Cochrane Central Register. STUDY SELECTION: We included randomized trials of IND for procedures in children. DATA EXTRACTION: Methodologic quality of evidence was evaluated by using the Cochrane Collaboration's risk of bias tool and the Grading of Recommendations Assessment, Development, and Evaluation system, respectively. The primary outcome was the proportion of participants with adequate sedation. RESULTS: Among 19 trials (N = 2137), IND was superior to oral chloral hydrate (3 trials), oral midazolam (1 trial), intranasal midazolam (1 trial), and oral dexmedetomidine (1 trial). IND was equivalent to oral chloral hydrate (2 trials), intranasal midazolam (2 trials), and intranasal ketamine (3 trials). IND was inferior to oral ketamine and a combination of IND plus oral ketamine (1 trial). Higher doses of IND were superior to lower doses (4 trials). Adverse effects were reported in 67 of 727 (9.2%) participants in the IND versus 98 of 591 (16.6%) in the comparator group. There were no reports of adverse events requiring resuscitative measures. LIMITATIONS: The adequacy of sedation was subjective, which possibly led to biased outcome reporting. CONCLUSIONS: Given the methodologic limitations of included trials, IND is likely more effective at sedating children compared to oral chloral hydrate and oral midazolam. However, this must be weighed against the potential for adverse cardiovascular effects.

Bone fractures in children: is there an association with obesity?

OBJECTIVE: To determine the relationship between body mass index (BMI) and odds of extremity bone fractures in children. STUDY DESIGN: This was a prospective cross-sectional study conducted at 2 tertiary care pediatric emergency departments. A convenience sample of children 2-17 years of age with a nonpenetrating extremity injury was enrolled. Demographics, activity level, mechanism of injury, participant BMI, and presence of a fracture were recorded. The main outcome was the odds of an extremity bone fracture based on BMI category; logistic regression was used to estimate the odds of fracture by BMI category. RESULTS: We enrolled 2213 children, of whom 1078 (48.7%) sustained a fracture and 316 (14.3%) were classified as obese. The mean (SD) age was 9.5 (4.2) years, and percentage of male children was 56.8%. Compared with children with a normal BMI, the adjusted odds of fracture among obese, overweight, and underweight children were 0.75 (0.58, 0.97), 1.15 (0.89, 1.48), and 1.44 (1.00, 2.07) respectively. CONCLUSIONS: Obese children had a minor but statistically significant decreased odds of fracture relative to children with a normal BMI, but no association was observed in overweight children. However, underweight children were found to be at an increased odds of fracture. This study suggests that overweight and obese children do not have increased odds of extremity fracture.