Out-of-Hospital Seizures in Children: A Population-Based Study.

OBJECTIVES: Seizures seem to represent a frequent cause for pediatric emergency medical (EM) and emergency room (ER) contacts, but few population-based data are available. Our aim was to study the incidence, prehospital and ER treatment, and outcomes of pediatric seizures necessitating out-of-hospital care. METHODS: We studied the out-of-hospital evaluation procedures, ER treatment, diagnostics and 2-year prognosis of all cases of pediatric (0-16 years) seizures encountered by the emergency medical services (EMS) in Helsinki, Finland, in 2012 (population 603,968, pediatric population 92,742); 251 patients were encountered by the EMS, of which 220 seen at the ER. RESULTS: The yearly incidence of pediatric seizures necessitating EMS activation was 2.8/1000 in the pediatric population. Febrile seizures were responsible for 97 (44.1%) of the cases transported to the ER. Only a minority of patients required advanced life support measures out-of-hospital or complex diagnostics in the ER. Still, of the 220 patients seen at ER, 68 (30.9%) were hospitalized, and 106 (48.2%) had follow-up contacts scheduled. CONCLUSIONS: Pediatric seizures were a common cause for EM and ER contacts. Advanced life support measures were seldom needed, and the prognosis was good, but seizures still required considerable resources. They often resulted in urgent EM dispatch and transport, hospitalization, follow-up visits, new medication, and complementary studies. This emphasizes the role the EMS plays in recognizing and terminating pediatric seizures and in referring these children to appropriate care.

Intermittent Tiotropium Bromide for Episodic Wheezing: A Randomized Trial.

BACKGROUND AND OBJECTIVES: Options to treat and prevent episodic wheezing in children are scarce. Our objective was to assess the efficacy of intermittent tiotropium bromide treatment in early childhood episodic wheezing. METHODS: This 48-week, randomized, open-label, controlled, parallel-group trial was conducted at 4 hospitals in Finland. Children aged 6 to 35 months with 2 to 4 physician-confirmed episodes of wheeze and/or shortness of breath were considered eligible. Study participants were randomly allocated to receive 1 of 3 treatments: once-daily tiotropium bromide 5 µg for 7 to 14 days during respiratory tract infections and as-needed albuterol sulfate 0.2 mg (n = 27), twice-daily fluticasone propionate 125 µg for 7 to 14 days during respiratory tract infections and as-needed albuterol sulfate 0.2 mg (n = 25), or as-needed albuterol sulfate 0.2 mg alone (n = 28). The primary outcome was efficacy, assessed as intention-to-treat by comparing the proportion of episode-free days (the days lacking symptoms or treatments) between the treatment groups. RESULTS: The proportion of episode-free days was higher in those receiving intermittent tiotropium bromide (median 97% [interquartile range, 93% to 99%]) than in those receiving intermittent fluticasone propionate (87% [78% to 93%], P = .002), or with as-needed albuterol sulfate alone (88% [79% to 95%], P = .003). Adjustment with allergic sensitization, the baseline number of physician-confirmed episodes of wheeze and/or shortness of breath, or short-course glucocorticoid treatment in the 2 weeks before the enrollment, did not affect the result. Intervention-related adverse events were not seen. CONCLUSIONS: Intermittent tiotropium bromide treatment may be an effective alternative to current therapies for episodic wheezing. Before implementation of use, further research on safety and efficacy is indicated.

Outcomes in children evaluated but not transported by ambulance personnel: retrospective cohort study.

BACKGROUND: Not all children with an out-of-hospital emergency medical contact are transported by ambulance to the emergency department (ED). Non-transport means that after on-scene evaluation and possible treatment, ambulance personnel may advise the patient to monitor the situation at home or may refer the patient to seek medical attention by other means of transport. As selecting the right patients for ambulance transport is critical for optimising patient safety and resource use, we studied outcomes in non-transported children to identify possible risk groups that could benefit from ambulance transport. METHODS: In a population-based retrospective cohort study of all children aged 0-15 years encountered but not transported by ambulance in Helsinki, Finland, between 1 January 2014 and 31 December 2016, we evaluated (1) 12-month mortality, (2) intensive care admissions, (3) unscheduled ED contacts within the following 96 hours after the non-transport decision and (4) the clinical status of the child on presentation to ED in the case of a secondary ED visit. RESULTS: Of all children encountered by out-of-hospital emergency medical services, 3579/7765 (46%) were not transported to ED by ambulance. There was no mortality or intensive care admissions related to the non-transport. The risk factors for an unscheduled secondary ED visit after a non-transport decision were young age (p=0.001), non-transport decision during the early morning hours (p<0.001) and certain dispatch codes, including 'dyspnoea' (p<0.001), 'vomiting/diarrhoea' (p=0.030) and 'mental illness' (p=0.019). We did not detect deterioration in patients' clinical presentation at ED traceable to non-transport decisions. CONCLUSIONS: Not transporting all children by ambulance after an out-of-hospital emergency medical contact was not associated with deaths, intensive care admissions or significant deterioration in general condition in our study population and healthcare system. Special attention and a formal non-transport protocol are warranted in certain subgroups, including infants.

Children in disadvantaged neighbourhoods have more out-of-hospital emergencies: a population-based study.

OBJECTIVE: We wanted to study whether the socioeconomic status of a neighbourhood can predict the incidence of paediatric out-of-hospital emergencies. METHODS: We conducted a population-based prospective study with all paediatric (0-15 years) out-of-hospital emergencies in Helsinki, Finland, in 2012-2013. We compared the geographical distribution of the emergencies in the paediatric population with those of mean income, unemployment level and educational level. The comparison was made both by the scene of the emergency and by the domicile of the patient. We also separately analysed the distribution of emergency medical (EM) contacts that were deemed medically unnecessary. RESULTS: The incidence of out-of-hospital emergencies was higher in areas with lower socioeconomic status and among children living inside those areas. Higher mean income was associated with lower incidence (risk ratio (RR) 0.970, 95% CI 0.957 to 0.983), and lower unemployment level to higher incidence (RR 1.046, 95% CI 1.002 to 1.092) of out-of-hospital emergencies inside a district. Higher mean income was associated with lower incidence of emergencies in the paediatric population living inside a district (RR 0.983, 95% CI 0.974 to 0.993). The distribution of medically unnecessary EM contacts was similar in all areas. CONCLUSIONS: The socioeconomic status of a neighbourhood was associated with the need for EM services (EMS) in the area, and in children living in the area. Overusing EMS for non-urgent or non-medical problems did not explain these findings. Instead, they seem to represent true differences in the incidence of paediatric emergencies.

Blood pressure, serum lipids, fasting insulin, and adrenal hormones in 12-year-old children born with maternal preeclampsia.

Women with prior preeclamptic pregnancies have an increased risk for metabolic syndrome and cardiovascular diseases. Maternal preeclampsia has been associated with elevated blood pressure (BP) in offspring during childhood. The aim of our study was to determine whether elevated BP pressure and metabolic changes, such as dyslipidemia, insulin resistance, and increased adrenal hormonal activity, are found in 12-yr-old children of preeclamptic mothers. Sixty children born after preeclamptic pregnancy (PRE) and 60 matched control subjects born after normotensive pregnancy (non-PRE) were studied at the age of 12 yr. The case-control pairs were matched for sex, gestational age (+/-1 wk), and size at birth. We measured BP and concentrations of blood glucose, serum fasting insulin, total and high density lipoprotein cholesterol, triglycerides, cortisol, dehydroepiandrosterone sulfate, and plasma epinephrine (E) and norepinephrine (NE). Low density lipoprotein cholesterol was calculated according to the Friedewald-Fredrickson formula. The PRE children had significantly higher mean systolic (116.4 vs. 113.2 mm Hg; P = 0.021) and diastolic (73.9 vs. 70.3 mm Hg; P = 0.022) BP than the non-PRE children, even when adjusted by current weight and height. At 12 yr of age, systolic BP values correlated inversely with birth weight (r = -0.459; P < 0.001) and length SD scores (r = -0.429; P = 0.001) in the PRE children. The mean concentrations of serum total, low density lipoprotein, and high density lipoprotein cholesterol; triglycerides; fasting insulin; blood glucose; serum cortisol; and dehydroepiandrosterone sulfate did not differ between the PRE and non-PRE groups. However, the mean plasma E concentration was higher in the PRE than in the non-PRE children (0.32 vs. 0.28 nmol/liter; P = 0.042), whereas the mean NE concentration did not differ between these two groups. In conclusion, 12-yr-old children born with maternal preeclampsia had elevated systolic and diastolic BPs and slightly increased E levels in the circulation. It is not known whether these changes are caused by genetic factors or by preeclampsia itself.

Maternal preeclampsia predicts elevated blood pressure in 12-year-old children: evaluation by ambulatory blood pressure monitoring.

Ambulatory blood pressure (ABP) monitoring offers a reliable method for determining blood pressure (BP) in children. The aim of this cohort study was to examine whether maternal preeclampsia is associated with elevated BP in an offspring. The study population consisted of 57 children born to preeclamptic mothers (PRE) and their 57 age- and sex-matched control subjects born to normotensive mothers (non-PRE). We examined the 24-h ABP at 12 y of age in the PRE and non-PRE children. Within the two groups, the association of anthropometric measures, plasma catecholamine (epinephrine [E], norepinephrine [NE]) concentrations, and ABP was examined. The PRE children had significantly higher mean 24-h systolic and diastolic ABPs than the non-PRE children. The same was true for the mean daytime and nighttime systolic and diastolic ABPs. The PRE boys had higher 24-h systolic ABP than the PRE girls. In the PRE children, high plasma E concentration and being born small for gestational age (SGA) predicted high systolic 24-h ABP in logistic regression analysis. In the non-PRE children, high current body mass index (BMI) and high plasma E concentration was associated with high systolic 24-h ABP. In conclusion, systolic and diastolic ABP values were elevated in the PRE children. High plasma E concentration and being born SGA were associated with high systolic 24-h ABP in the PRE children. Presumably maternal preeclampsia affects offspring via several mechanisms, including genetic ones and metabolic consequences of restricted intrauterine growth.

Increased adrenocortical and adrenomedullary hormonal activity in 12-year-old children born small for gestational age.

OBJECTIVES: To determine whether adrenal hormonal activity is altered in children born small for gestational age (SGA), and whether concentrations of adrenal hormones relate to those of serum lipids or to anthropometric measures. STUDY DESIGN: We studied 55 SGA children and 55 appropriate for gestational age (AGA) children at the age of 12 years in a case-control setting. The concentrations of fasting serum cortisol, dehydroepiandrosterone sulfate (DHEAS), plasma epinephrine (E), and norepinephrine (NE) were analyzed. RESULTS: The SGA children had significantly higher mean concentrations of serum DHEAS (3.53 vs 2.89 micromol/L, P =.009) and plasma E (0.33 vs 0.25 nmol/L, P =.005) than their age- and sex-matched control subjects. The mean serum cortisol and plasma NE concentrations did not differ significantly between the groups. However, the SGA children in the highest quartile for serum cortisol had significantly higher concentrations of plasma E (0.50 vs 0.28 nmol/L, P <.001), serum LDL (3.21 vs 2.73 mmol/L, P =.025) and total cholesterol (5.06 vs 4.42 mmol/L, P =.021) than the SGA children in the lower cortisol quartiles. The factors associating with high levels of plasma E in the SGA children were high level of serum cortisol [odds ratio (OR) = 3.8, 95% confidence interval (95% CI) = 1.5-10], LDL cholesterol (OR = 3.9, 95% CI = 1.3-12), male sex (OR = 8.3, 95% CI = 1.0-68) and low birth weight (OR = 1.4, 95% CI = 1.0-1.8) in multiple logistic regression analysis. CONCLUSIONS: Twelve-year-old children born SGA had increased DHEAS and epinephrine levels in circulation. High serum cortisol concentrations are associated with high epinephrine, LDL, and total cholesterol levels.

Ambulatory blood pressure in 12-year-old children born small for gestational age.

An association between low birth weight and subsequent elevated blood pressure has been demonstrated in a large number of studies, but the number of subjects born small for gestational age in these studies has been negligible. The inverse relationship between birth weight and blood pressure in children has been evaluated previously with an ambulatory blood pressure device, but only in children with normal birth weights. In this prospective case-control study from birth to the age of 12, we evaluated the ambulatory blood pressures in 50 children born at term but small for gestational age and in 50 full-term children born appropriate for gestational age. Children born small for gestational age had similar mean+/-SD systolic (117.5+/-8.5 mm Hg versus 115.3+/-7.4 mm Hg, P=0.221), and diastolic (69.2+/-5.3 mm Hg versus 67.3+/-4.4 mm Hg, P=0.075) 24-hour ambulatory blood pressure compared with the values of the children born appropriate for gestational age. However, 24-hour systolic blood pressure in the small-for-gestational-age children was higher (3.90 mm Hg; 95% confidence interval, 0.65 to 7.15) after adjusting for current body mass index. The difference in current body mass index was the only determinant for the difference in systolic blood pressure between the groups. Birth weight had no direct association with the blood pressure values. Impaired fetal growth may have a relationship with higher later blood pressure, but in 12-year-old children, blood pressure differences between small for gestational age and appropriate for gestational age children are much more dependent on current body size.