Vomiting, Pyloric Mass, and Point-of-Care Ultrasound: Diagnostic Test Accuracy for Hypertrophic Pyloric Stenosis-A Meta-Analysis.

BACKGROUND: Hypertrophic pyloric stenosis is a common cause of nonbilious vomiting in infants younger than 6 months. Its history, physical examination, and point-of-care ultrasound (POCUS) have not been compared for their diagnostic test accuracy. OBJECTIVE: The aim of this systematic review was to quantify and compare the diagnostic test accuracy of a history of vomiting, a pyloric mass on palpation, and POCUS. METHODS: We performed three searches of the literature from 1977 to March 2022. We evaluated bias using the QUADAS-2 (Quality Assessment Tool for Diagnostic Accuracy-2) tool. We performed a bivariate analysis. RESULTS: From 5369 citations, we identified 14 studies meeting our inclusion criteria. We quantified three diagnostic elements: POCUS, a pyloric mass on palpation, and vomiting. We identified five studies that analyzed POCUS, which included 329 patients. POCUS had a sensitivity of 97.7% (95% confidence interval (CI) 93.1-99.3%) and a specificity of 94.1% (95% CI 88.7-97.1%) for detecting pyloric stenosis. We identified six studies that analyzed the presence of a pyloric mass, which included 628 patients. The palpation of a pyloric mass had a sensitivity of 73.5% (95% CI 62.6-82.1%) and a specificity of 97.5% (95% CI 93.8-99.0%). We identified four studies that analyzed vomiting, which included 355 patients. Vomiting had a sensitivity of 91.3% (95% CI 82.1-96.0) and a specificity of 60.8% (95% CI 8.5-96.3). Both POCUS and palpation of a pyloric mass had a high positive likelihood ratio (LR+: 17 and 33, respectively). The LR+ for vomiting was 5.0. CONCLUSIONS: Both POCUS and palpable mass had high specificity and positive LR, whereas vomiting provided the lowest diagnostic test measures.

Evidence-Based Diagnostic Test Accuracy of History, Physical Examination, and Imaging for Intussusception: A Systematic Review and Meta-analysis.

INTRODUCTION: Intussusception is the most common cause of pediatric small bowel obstruction. Timely and accurate diagnosis may reduce the risk of bowel ischemia. We quantified the diagnostic test accuracy of history, physical examination, abdominal radiographs, and point-of-care ultrasound. METHOD: We conducted a systematic review for diagnostic test accuracy of history, physical examination, and imaging concerning for intussusception. Our literature search was completed in June 2019. Databases included Medline via Ovid, Embase, Scopus, and Wiley Cochrane Library. We conducted a second review of the literature up to June 2019 for any additional studies. Inclusion criteria were younger than 18 years and presenting to the emergency department for abdominal complaints, consistent with intussusception. We performed data analysis using mada, version 0.5.8. We conducted univariate and bivariate analysis (random effects model) with DerSimonian-Laird and Reitsma model, respectively. QUADAS-2 was used for bias assessment. RESULTS: The literature search identified 2639 articles, of which 13 primary studies met our inclusion criteria. Abdominal pain, vomiting, and bloody stools had positive likelihood ratios LR(+) between 1 and 2, whereas the negative likelihood ratio, LR(-), ranged between 0.4 and 0.8. Abnormal abdominal radiograph had LR(+) of 2.5 and LR(-) of 0.20, whereas its diagnostic odds ratio was 13. Lastly, point-of-care ultrasound had LR(+) of 19.7 and LR(-) of 0.10. The diagnostic odds ratio was 213. CONCLUSIONS: History and physical examination had low diagnostic test accuracy. Abdominal radiographs had low diagnostic test accuracy, despite moderate discriminatory characteristics. Point-of-care ultrasound had the highest diagnostic test accuracy to rule in or rule out intussusception.

Association of Delay in Appendectomy With Perforation in Children With Appendicitis.

OBJECTIVE: The aim of this study was to assess whether increased time from emergency department (ED) triage to appendectomy is associated with a greater risk of children developing appendiceal perforation. METHODS: We performed a multicenter retrospective cohort study of children younger than 18 years hospitalized with appendicitis. To avoid enrolling patients who had perforated prior to ED arrival, we included only children who had a computed tomography (CT) scan demonstrating nonperforated appendicitis. Time to appendectomy was measured as time from ED triage to incision. The main outcome was appendiceal perforation as documented in the surgical report. Variables associated with perforation in bivariate analysis (P < 0.05) were adjusted for using logistic regression. RESULTS: Overall, 857 patients had a CT scan that demonstrated nonperforated appendicitis. The median age was 12 years (interquartile range, 9-15 years), and 500 (58%) were male. The median time to appendectomy was 11 hours (interquartile range, 8-15 hours). In total, 111 patients (13%) had perforated appendicitis at operation. Children who developed perforation were more likely to require additional CT scans and return to the ED and had a significantly longer length of stay. After adjusting for potential confounders, every hour increase in the time from ED triage to incision was independently associated with a 2% increase in the odds of perforation (P = 0.03; adjusted odds ratio, 1.02; 95% confidence interval, 1.00-1.04). CONCLUSIONS: Delays in appendectomy were associated with an increase in the odds of perforation. These results suggest that prolonged delays to appendectomy might be harmful for children with appendicitis and should be minimized to prevent associated morbidity.

Calling 911! What role does the pediatrician play?

OBJECTIVE: The objective of this study was to compare admission rates and medical interventions among children whose caregivers called their child's primary care provider (PCP) before taking an ambulance to the pediatric emergency department (PED) versus those who did not. METHODS: This was a prospective cohort study of patients brought to an urban, public hospital PED via emergency medical system (EMS). Children were included if the caregiver called 911 to have them transported via EMS and was present in the PED. The main variable was whether the child's PCP was called before EMS utilization. Study outcomes were medical interventions, such as intravenous line insertion or laboratory tests, and hospital admission. χ Test and logistic regression were used to evaluate the relationship of the main variable to the study outcomes. RESULTS: Six hundred fourteen patients met inclusion criteria and were enrolled. Five hundred eighty-five patients (95.3%) were reported to have a PCP. Seventy-four caregivers (12.1%) called their child's PCP before calling EMS. Two hundred seventy-seven patients (45.1%) had medical interventions performed; of these, 42 (15.2%) called their PCP (P = 0.03). Forty-two patients (6.8%) were admitted; among these, 14 (33.3%) called their PCP (P < 0.01). Adjusting for triage level, patients whose caregiver called the PCP before calling EMS were 3.2 times (95% confidence interval, 1.9-5.2 times) more likely to be admitted and 1.7 times (95% confidence interval, 1.1-2.9 times) more likely to have a medical intervention compared with patients whose caregivers did not call their child's PCP. CONCLUSIONS: Children were more likely to be admitted or require a medical intervention if their caregiver called their PCP before calling EMS. The availability of a PCP for telephone triage may help to optimize EMS utilization.

The predictive value of a normal radiographic anterior fat pad sign following elbow trauma in children.

OBJECTIVE: The purposes of this study were to describe the characteristics of a normal anterior fat pad (AFP) and to determine the association between a normal AFP and the absence of fracture. METHODS: A prospective cohort of children aged 1 to 18 years with elbow trauma underwent radiographic examination. All patients received standard orthopedic management and follow-up 7 to 14 days after injury. A pediatric radiologist evaluated all radiographs for the presence or absence of fracture and documented whether the AFP was normal or abnormal on the lateral view. The radiologist also recorded specific measurements of the AFP including the apical angle, which is formed by the intersection of the humerus and the superior aspect of the AFP. The interpretation of the AFP on the initial lateral radiograph was compared with the final patient outcome (fracture/no fracture). RESULTS: Two hundred thirty-one patients had elbow radiographs; 34 patients (15%) were lost to follow-up. A total of 56 fractures were identified: 49 (87%) on the initial radiograph and an additional 7 (13%) on follow-up radiographs. This latter group was defined as occult fractures. Among the 197 patients available for analysis, 113 (57%) had a normal AFP on the initial radiograph. Of these, 2 children had a final diagnosis of fracture. The sensitivity of a normal AFP was 96.4% (95% confidence interval, 86.6%-99.4%), and the negative predictive value was 98.2% (95% confidence interval, 93.1%-99.7%). There was a significant difference in mean AFP angle when the AFP was read as normal (14.7 [SD, 3.3] degrees) compared with when it was read as abnormal (27.0 [SD, 6.8] degrees) (P < 0.01). CONCLUSIONS: Our data suggest that a normal AFP is highly associated with absence of elbow fracture and that the determination of a normal AFP can be aided by measuring the apical angle of the AFP.

Adherence and morbidity following emergency department care among inner-city children with asthma.

OBJECTIVES: To explore the utility of two measures, Risk for Nonadherence (RN) and Admitted Nonadherence (AN), developed in a national sample of children with chronic asthma, for predicting short-term morbidity among children following a pediatric emergency department (PED) visit for acute asthma and to compare verbal and self-completion of these measures. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of children 3 to 11 years of age presenting to a PED with an acute asthma exacerbation. Caretakers were randomized to self-completion of a questionnaire assessing RN and AN or to verbally respond to the same questionnaire administered by a research assistant. Five asthma morbidity indicators were collected at 2, 4, and 8 weeks following discharge from the PED. RESULTS: One hundred fifty-four patients were enrolled. There were no significant differences in asthma severity, RN, or AN, or the number of items missing on questionnaires between the self-completion and verbal administration groups. Patients with a RN score >4 had an adjusted odds of 3.67 (95% confidence interval [CI] 1.57-8.58) for waking >2 nights due to asthma symptoms. The adjusted odds of patients with any AN to report needing >4 days of rescue asthma medication was 3.16 (95% CI 1.37-7.26). CONCLUSION: RN and AN were both associated with morbidity indices following an acute asthma exacerbation and can identify children at risk for increased short-term morbidity regardless of the method of questionnaire administration. Assessment of RN and AN by self-administered questionnaire during an ED visit for asthma maybe feasible.

Does parental involvement in pediatric emergency department asthma treatment affect home management?

To determine whether parents who deliver albuterol treatments in a pediatric emergency department with a metered dose inhaler with a spacer device (MDIS) report better adherence to MDIS use at home compared to parents whose children undergo standard nebulizer therapy. Children aged 1-5 years were randomized by day to usual treatment with nebulized albuterol (40 children) or to treatment by the parent with albuterol with an MDIS (46 children). All caregivers received standard discharge instructions, a spacer and an MDI. Two weeks following the visit, a trained research assistant blinded to the child's group status, administered a brief telephone questionnaire to each caretaker. At follow-up, children in the MDIS group were 7.5 times more likely to be using the MDIS for their albuterol treatments (95%CI 1.6-35.6). Involving parents in treatment of asthma exacerbations in the emergency department using an MDIS may improve adherence to MDIS use at home.

Prospective Investigation of a Novel Ultrasound-assisted Lumbar Puncture Technique on Infants in the Pediatric Emergency Department.

OBJECTIVE: The objective was to describe a novel ultrasound-assisted lumbar puncture (UALP) technique and to compare it to standard lumbar puncture (SLP) technique in infants. METHODS: A prospective, randomized, controlled study in infants 60 days old and younger undergoing a lumbar puncture (LP) in a pediatric emergency department. Patients with a spinal anomaly or ventriculoperitoneal shunt were excluded. Eligible infants were randomized to UALP or SLP. A spinal sonogram was performed on all patients by an investigator not involved in performing the LP. Spinal landmarks and maximum safe depth were identified for the UALP providers. Providers in the SLP group were blinded to sonographic measurements. A successful LP was defined as the collection of cerebrospinal fluid (CSF) with a red blood cell count of less than 10,000 cells/mm3 . Statistical analysis included chi-square, Mann-Whitney U-test, and number needed to treat (NNT). RESULTS: Forty-three patients were enrolled, 21 in the UALP group and 22 in the SLP group. Prematurity, weight, length, provider experience, anesthesia use, stylet technique, and number of attempts were similar between groups. The median age in the UALP group was 38 days (interquartile range [IQR] = 33 days) versus 45 days (IQR = 19 days) in the SLP group (p = 0.02). CSF was obtained in all UALP subjects (100%) versus in 18 of 22 (82%) in the SLP group (p = 0.04); 20 (95%) UALP subjects versus 15 (68%) SLP subjects met our definition of success (p = 0.023). The odds ratio of successful LP using UALP technique was 9.33 (95% confidence interval [CI] = 1.034 to 84.026) and the NNT was 3.7 (95% CI = 2.02 to 24.18). CONCLUSION: The UALP technique increases the rate of a successful LP in infants compared to standard technique.

Predicting the need for hospitalization in acute childhood asthma using end-tidal capnography.

OBJECTIVE: To explore the utility of end-tidal capnography for predicting hospitalization in acute childhood asthma. DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort study of a convenience sample of children 5 to 17 years of age presenting to a pediatric emergency department with an acute asthma exacerbation. Capnography was performed at baseline. The length of the plateau portion of the baseline capnograph waveform was measured in millimeters and divided by the respiratory rate at the time of the measurement to create a ratio. The sensitivity and specificity of the baseline capnography ratio for predicting hospitalization were assessed. MAIN OUTCOME MEASURES: Hospitalization versus discharge from the pediatric emergency department. RESULTS: Thirty-seven patients were enrolled. The hospitalized (n = 12) and discharged (n = 25) groups did not differ in terms of any demographic or baseline characteristics except for pulmonary score and the median baseline capnography ratio. The median ratio was 0.15. Ten (83.3%) of 12 of patients who were hospitalized had a baseline ratio less than 0.15 compared with 8 (32%) of 25 of patients who were discharged from pediatric emergency department (P < 0.05). Controlling for baseline asthma severity, the odds of being hospitalized if the baseline capnography ratio was less than 0.15 were 18.77 (95% confidence interval, 1.91-184.69). CONCLUSION: This pilot study suggests that baseline capnography may be useful as an objective effort-independent tool for identifying children with an asthma exacerbation who are at risk for hospitalization.

Identifying children at low risk for bacterial conjunctivitis.

OBJECTIVE: To identify a population of children at low risk for bacterial conjunctivitis on the basis of history and physical examination findings. DESIGN: Prospective observational cohort study. SETTING: Urban pediatric emergency department. PARTICIPANTS: Children aged 6 months to 17 years with conjunctival erythema, eye discharge, or both. The exclusion criteria were eye trauma, exposure to a noxious chemical, contact lens use, and antibiotic drug use in the past 5 days. INTERVENTIONS: Clinicians completed a checklist of signs and symptoms and collected a conjunctival swab for bacterial culture. MAIN OUTCOME MEASURES: The chi(2) test, the Mann-Whitney test, and logistic regression were used to create a prediction model for a negative bacterial culture. RESULTS: Of 368 patients enrolled, 194 (52.7%) were males. The median patient age was 3 years (interquartile range, 1-5 years). Conjunctival cultures were negative in 130 patients (35.3%). Age 6 years or older, presentation in April through November, no or watery discharge, and no glued eye in the morning were the clinical factors found to be independently associated with a negative conjunctival culture. If 3 factors were present, 76.4% (95% confidence interval, 63.6%-85.6%) of patients had a negative culture. If all 4 factors were present, 92.3% (95% confidence interval, 66.1%-98.2%) of patients had a negative culture. CONCLUSION: The combination of 4 clinical factors may enable clinicians to identify children at low risk for bacterial conjunctivitis and may reduce routine antibiotic drug administration.

Comparison of two approaches to observation therapy for acute otitis media in the emergency department.

OBJECTIVE: This study compared parental adherence to delayed antibiotic therapy for acute otitis media with and without a written prescription in a pediatric emergency department. PATIENTS AND METHODS: Children aged 2 to 12 years who met criteria for delayed antibiotic treatment were randomly assigned to observation therapy with or without a prescription. Patients randomly assigned to observation therapy without prescription were instructed to seek follow-up care if symptoms persisted for 2 to 3 days. Patients assigned to observation therapy with a prescription were discharged with an antibiotic prescription, and instructed to fill it if their child's symptoms persisted 2 to 3 days. A research assistant who was blinded to group assignment called parents 7 to 10 days after the visit to assess adherence to observation therapy. RESULTS: Of 117 children assigned to the observation therapy group, 100 completed follow-up; of 115 assigned to the observation therapy with a prescription group, 106 completed follow-up. In the observation therapy group, 87 parents reported no antibiotic use within the 3-day observation period compared with 66 parents in the prescription group. During the entire study period, 81% of the observation therapy group reported no use of antibiotics compared with 53% in the prescription group. These groups did not differ in satisfaction with the visit; 91% and 95% were very or extremely satisfied, respectively. No complications were reported. CONCLUSIONS: Observation therapy with and without a prescription were both well accepted by parents of children diagnosed with acute otitis media in an urban pediatric emergency department. Adherence to delayed antibiotic therapy was better for those not offered a prescription. These data suggest that, in the pediatric emergency department setting, observation therapy reduces antibiotic use without compromising satisfaction with the visit.

The association of preprocedural anxiety and the success of procedural sedation in children.

PURPOSE: To investigate the association between a child's preprocedural state anxiety and the success of sedation. METHODS: A consecutive sample of children aged 2 through 17 years requiring sedation for a procedure was enrolled. Pain, preprocedural anxiety (range, 0-9), and success of sedation (10=most successful) were measured. RESULTS: Fifty-nine patients were enrolled. The median age was 7 years. The median anxiety score was 1.0 (interquartile ratio, 0-3). Pain and anxiety were weakly correlated (r=.21, P>.10). The mean sedation score was 7.8 (+/-2.2). Preprocedural anxiety and successful sedation were inversely correlated (r=-0.31, P=.002). Sedation was successful in 81% of children with anxiety scores below the median and 52% with anxiety scores above the median (P=.02). Children with low anxiety were 3.8 times more likely to be successfully sedated (95% confidence interval, 1.19-12.14). CONCLUSION: Our data suggest that preprocedural state anxiety is associated with the success of sedation in children.