Infrared thermometers and infants: The device is hot the baby maybe not.

AIM: The risk of serious illness in febrile infants (<60 days old) is high, and so fever often warrants aggressive management. Infrared thermometers are unreliable in young infants despite their ubiquity. We aim to describe the: (i) frequency of infrared thermometer usage; (ii) progression to documented fever in the emergency department (ED) and (iii) rate of serious illness (meningitis, urinary tract infection and bacteremia). METHODS: In this single-centre retrospective chart review at The Royal Children's Hospital, Melbourne, we audited medical records of infants (<60 days old) presenting to the ED with pre-hospital fever on history over a 12-month period. We described the type of thermometer used at home (tympanic or forehead, 'infrared' vs. axillary or rectal, 'direct') correlated to peak temperature in ED, investigations, treatment and diagnosis. The primary outcome was subsequent fever in ED. RESULTS: Of 159 infants, two of three had infrared temperature measurement at home. Fifty-one (32.1%) developed fever in ED (direct 28/54, 52% vs. infrared 23/105, 22% RR 2.36 (95% CI 1.52-3.69)). Investigations (75%) and admission (60%) were common. Pre-hospital fever alone was less likely to be associated with serious illness, with fever in ED a much stronger predictor. CONCLUSIONS: In young infants, infrared thermometer use is common and less likely to predict subsequent fever. Twenty-two percent of infants with fever via infrared measurement had fever in ED. History of fever without confirmation is less likely to signal serious illness. Education to public and health-care providers is required to avoid usage of infrared devices in this population.

Deformed pediatric forearm fractures: Predictors of successful reduction by emergency providers.

INTRODUCTION: Forearm fractures are common pediatric injuries. Most displaced or angulated fractures can be managed via closed reduction in the operating room or in the Emergency Department (ED). Previous research has shown that emergency physicians can successfully perform closed reduction within ED; however, the fracture morphology amendable to ED physician reduction is unclear. The aim of this study is to detail the fracture characteristics associated with successful reduction by ED physicians. METHODS: We conducted a retrospective study of children (aged <18 years) presenting to the ED of a tertiary care children's hospital (annual census 90,000) between January 2018 and December 2018 with closed distal and midshaft forearm fractures requiring reduction. Data collected included patient demographics, fracture morphology, management, and complications. Successful ED physician reduction was based on predefined criteria. Orthopedic referrals included those patients sent directly to the operating room, closed reductions performed by orthopedic trainees within the ED, and patients requiring orthopedic consultation after failed ED reduction. RESULTS: A total of 340 patients with forearm fractures were included in the study. ED clinicians attempted to reduce 274 (80.6%) of these fractures and were successful in 256/274 (93.4%) cases. Of the 84 orthopedic referrals, 18 were after failed ED clinician attempt, and 66 were ab initio managed by orthopedics (37 in the operating room and 29 in ED). Compared to the fractures with successful ED reduction (n = 256), factors associated with orthopedic referral (n = 84) included: increasing age, midshaft location, higher degree of angulation, and completely displaced fractures. Angulated distal greenstick fractures were most likely to be successfully reduced by ED clinicians. There were no difference in complication rates between the two groups. CONCLUSION: In this series, fractures most amenable to reduction by ED clinicians include distal greenstick fractures, whereas midshaft and completely displaced fractures are more likely to need treatment by orthopedics.

Oral Ondansetron to Reduce Vomiting in Children Receiving Intranasal Fentanyl and Inhaled Nitrous Oxide for Procedural Sedation and Analgesia: A Randomized Controlled Trial.

STUDY OBJECTIVE: Intranasal fentanyl and inhaled nitrous oxide are increasingly combined to provide procedural sedation and analgesia in the pediatric emergency setting. This regimen is attractive because of its nonparenteral administration, but is associated with a higher incidence of vomiting than nitrous oxide alone. We seek to assess whether prophylactic oral ondansetron use could reduce the incidence of vomiting associated with intranasal fentanyl and nitrous oxide for procedural sedation compared with placebo. METHODS: This was a double-blind, randomized controlled trial of oral ondansetron versus placebo conducted at a single tertiary care pediatric emergency department. Children aged 3 to 18 years with planned sedation with intranasal fentanyl and nitrous oxide were randomized to receive oral ondansetron or placebo 30 to 60 minutes before nitrous oxide administration. The primary outcome was early vomiting associated with procedural sedation, defined as occurring during or up to 1 hour after nitrous oxide administration. Secondary outcomes included vomiting 1 to 24 hours after procedural sedation, procedural sedation duration, adverse events, and quality of sedation across the 2 groups. RESULTS: We recruited 442 participants and 436 were included for analysis. There was no significant difference in the primary outcome, early vomiting associated with procedural sedation, between the groups: ondansetron 12% versus placebo 16%, with a difference in proportions of -4.6% (95% confidence interval -11% to 2.0%; P=.18). Most sedations were reported as optimal by treating clinicians (91%). Only 2 minor adverse events occurred, both in the placebo group. CONCLUSION: Oral ondansetron does not significantly reduce vomiting during or shortly after procedural sedation with combined intranasal fentanyl and inhaled nitrous oxide.

Retrospective chart review of minor tibial fractures in preschoolers: immobilisation and complications.

OBJECTIVE: To compare the treatment practices (immobilisation vs non-immobilisation) of toddler fractures and other minor tibial fractures (both proven and suspected) in preschoolers, aged 9 months-4 years, and examine rates of ED re-presentations and complications. METHODS: Retrospective chart review of presentations of minor tibial fractures, both proven (radiologically confirmed) or suspected (negative X-ray but clinical evidence of bony injury), in children aged 9 months-4 years presenting to a single tertiary level paediatric ED from May 2016 to April 2018. Data collected included treatment practices, subsequent unscheduled re-presentations (including reasons) and complications (defined as problems relating to the injury that required further active care). RESULTS: A search of medical records yielded 240 cases: 102 had proven fractures (spiral, buckle or Salter-Harris II) and 138 were diagnosed with a suspected fracture. 73.5% of proven fractures were immobilised, predominantly with backslabs. 79% of suspected fractures were treated with expectant observation without immobilisation. Patients treated with immobilisation were more likely to re-present to ED compared with non-immobilised patients (18/104, 17.3% vs 9/136, 6.6% RR 2.62, 95% CI 1.23 to 5.58). 21 complications were seen in 19/104 (18.3%) immobilised patients. There were eight skin complications (complication rate of 7.7%) and 11 cast issues (complication rate of 10.6%). Two (1.5%) of the 136 patients had complications related to pain or limp. Pain was uncommonly found, although follow-up was not universal. CONCLUSION: In our centre, proven minor tibial fractures were more likely to receive a backslab, whereas for suspected fractures, expectant observation without immobilisation was performed. Although there is potential bias in the identification of complications with immobilisation, the study suggests that non-immobilisation approach should be investigated.

Virtual Reality for Pediatric Needle Procedural Pain: Two Randomized Clinical Trials.

OBJECTIVE: To assess the efficacy and safety of a virtual reality distraction for needle pain in 2 common hospital settings: the emergency department (ED) and outpatient pathology (ie, outpatient laboratory). The control was standard of care (SOC) practice. STUDY DESIGN: In 2 clinical trials, we randomized children aged 4-11 years undergoing venous needle procedures to virtual reality or SOC at 2 tertiary Australian hospitals. In the first study, we enrolled children in the ED requiring intravenous cannulation or venipuncture. In the second, we enrolled children in outpatient pathology requiring venipuncture. In the ED, 64 children were assigned to virtual reality and 59 to SOC. In pathology, 63 children were assigned to virtual reality and 68 to SOC; 2 children withdrew assent in the SOC arm, leaving 66. The primary endpoint was change from baseline pain between virtual reality and SOC on child-rated Faces Pain Scale-Revised. RESULTS: In the ED, there was no change in pain from baseline with SOC, whereas virtual reality produced a significant reduction in pain (between-group difference, -1.78; 95% CI, -3.24 to -0.317; P = .018). In pathology, both groups experienced an increase in pain from baseline, but this was significantly less in the virtual reality group (between-group difference, -1.39; 95% CI, -2.68 to -0.11; P = .034). Across both studies, 10 participants experienced minor adverse events, equally distributed between virtual reality/SOC; none required pharmacotherapy. CONCLUSIONS: In children aged 4-11 years of age undergoing intravenous cannulation or venipuncture, virtual reality was efficacious in decreasing pain and was safe. TRIAL REGISTRATION: Australia and New Zealand Clinical Trial Registry: ACTRN12617000285358p.

Clean catch urine collection: Time taken and diagnostic implication. A prospective observational study.

AIM: Clean catch urine (CCU) collection is commonly used in pre-continent children. CCU can be time-consuming and specimens may be contaminated. Our aim was to determine the time taken for CCU attempts and to describe the success of this method in diagnosing or excluding urinary tract infection. METHODS: Prospective observational study of CCU in pre-continent children aged 2-48 months in the emergency department. Time taken until urine collection, 'successful' (voided and caught), 'missed' (voided not caught) or the procedure 'stopped', were recorded and urine culture results analysed. RESULTS: Two hundred and seventeen children (131 (60%) male) were enrolled. There were a total of 247 attempts at CCU. For the first attempt, the median collecting time was 30.5 min (interquartile range (IQR) 11-66). Outcome was 'successful' in 64% (95% confidence intervals (CI) 58-70%), 'missed' in 16% (95% CI 11-20%) and 'stopped' in 20% (95% CI 15-26%). Median time if 'successful' was 25 min (IQR 7-46.5), 'missed' 27 min (IQR 11.6-59) and 71 min (IQR 42.5-93) when 'stopped'. One hundred and sixty children had successful CCU collection, 129 were sent for culture. Fifty of 129 (39%) cultures were contaminated. If all urine specimens caught were sent for culture, the estimated yield of an uncontaminated urine specimen was 45%. Contamination was not related to time taken for CCU. CONCLUSIONS: CCU is time-consuming, frequently unsuccessful and contaminated, resulting in a low overall diagnostic yield. Clinicians could expect a 45% chance of obtaining a definitive urine sample from this method overall.

Evaluating an admission avoidance pathway for children in the emergency department: outpatient intravenous antibiotics for moderate/severe cellulitis.

OBJECTIVE: Children with moderate/severe cellulitis requiring intravenous antibiotics are usually admitted to hospital. Admission avoidance is attractive but there are few data in children. We implemented a new pathway for children to be treated with intravenous antibiotics at home and aimed to describe the characteristics of patients treated on this pathway and in hospital and to evaluate the outcomes. METHODS: This is a prospective, observational cohort study of children aged 6 months-18 years attending the ED with uncomplicated moderate/severe cellulitis in March 2014-January 2015. Patients received either intravenous ceftriaxone at home or intravenous flucloxacillin in hospital based on physician discretion. Primary outcome was treatment failure defined as antibiotic change within 48 hours due to inadequate clinical improvement or serious adverse events. Secondary outcomes include duration of intravenous antibiotics and complications. RESULTS: 115 children were included: 47 (41%) in the home group and 68 (59%) in the hospital group (59 hospital-only, 9 transferred home during treatment). The groups had similar clinical features. 2/47 (4%) of the children in the home group compared with 8/59 (14%) in the hospital group had treatment failure (P=0.10). Duration of intravenous antibiotics (median 1.9 vs 1.8 days, P=0.31) and complications (6% vs 10%, P=0.49) were no different between groups. Home treatment costs less, averaging $A1166 (£705) per episode compared with $A2594 (£1570) in hospital. CONCLUSIONS: Children with uncomplicated cellulitis may be able to avoid hospital admission via a home intravenous pathway. This approach has the potential to provide cost and other benefits of home treatment.

Quick-Wee: a novel non-invasive urine collection method.

BACKGROUND: Clean catch urine (CCU) collection in precontinent children is often time-consuming, with associated collection failure. We hypothesise that stimulating cutaneous reflexes hastens voiding for CCU. METHODS: 40 children aged 1-24 months in the ED. Standard CCU was augmented with gentle suprapubic cutaneous stimulation using saline-soaked gauze (Quick-Wee method). RESULTS: 12/40 (30%) children voided within 5 min for successful CCU. Parental and clinician satisfaction was high. CONCLUSIONS: Quick-Wee appears to be a simple method to speed CCU in young children.

What do Clinicians Perceive as a Successful "Trial of Fluids"?: A Secondary Assessment of a Randomized Controlled Trial.

OBJECTIVE: The aim of the study was to explore physician perceptions of the amount of fluid that demonstrates a successful "trial of fluids" (adequate fluid intake) in the emergency department in children who have had insufficient fluid intake at home. METHODS: This is a secondary analysis of a randomized placebo-controlled trial of viscous lidocaine versus placebo in children aged 6 months to 8 years with acute infectious ulcerative mouth conditions (gingivostomatitis, ulcerative pharyngitis, or hand foot and mouth disease) and poor oral fluid intake. We measured the amount of fluid ingested in 60 minutes after administration of the intervention and related physician perception of adequate intake to measured intake. Given that there was little difference in oral intake between the treatment groups, the 2 arms were pooled for this analysis. RESULTS: One hundred participants were recruited (50 per treatment group), all of whom completed the 60-minute trial period. At baseline, 72% were mildly dehydrated, 21% were not dehydrated, and 5% were moderately dehydrated. The participants drank a median of 8.6 mL/kg (interquartile range [IQR], 3.7-14). Clinicians perceived 58% of the participants to have an adequate intake within the first hour after intervention. The median consumption of those whose oral intake was deemed as adequate was 12.6 mL/kg (IQR, 9.4-18.4); for those whose oral intake was not deemed adequate, the median consumption was 2.7 mL/kg (IQR, 0.7-5.3) (rank sum, P < 0.001). CONCLUSIONS: In children undergoing trial of fluids, we found that most clinicians perceived a fluid intake greater than 9 mL/kg as adequate and lower than 5 mL/kg as inadequate.

Alternatives to ward admission from the emergency department.

There is ever-increasing pressure on hospital resources in general and emergency departments (ED) in particular. At the same time, there is increasing recognition that traditional inpatient ward-based care is not necessary for the majority of children presenting to the ED with acute illness, and that there are patient, family and hospital benefits to pursuing other options. Here, we describe alternative pathways for children presenting to the ED, including short stay and observational medicine, hospital-in-the-home and non-admission enhanced care, in other words, additional management practices or pathways for children who are discharged from the ED. We discuss the principles, models and practical considerations involved in each of these.

Topical lidocaine to improve oral intake in children with painful infectious mouth ulcers: a blinded, randomized, placebo-controlled trial.

STUDY OBJECTIVE: We establish the efficacy of 2% viscous lidocaine in increasing oral intake in children with painful infectious mouth conditions compared with placebo. METHODS: This was a randomized placebo-controlled trial of viscous lidocaine versus placebo at a single pediatric emergency department. Study staff, clinicians, nurses, caregivers, and participants were blinded to the group assignment. Children with acute infectious ulcerative mouth conditions (gingivostomatitis, ulcerative pharyngitis, or hand, foot, and mouth disease) and poor oral fluid intake were randomized to receive 0.15 mL/kg of either 2% viscous lidocaine or placebo with identical appearance and flavor. The primary outcome was the amount of fluid ingested in the 60 minutes after administration of the intervention, with a difference in intake of 4 mL/kg considered clinically important. Secondary outcomes were specific milliliter per kilogram fluid targets and incidence of adverse events. RESULTS: One hundred participants were recruited (50 per treatment group), all of whom completed the 60-minute fluid trial period. Oral intake 1 hour after drug administration was similar in both groups: lidocaine median 8.49 mL/kg (interquartile range 4.07, 13.84 mL/kg) versus placebo 9.31 mL/kg (interquartile range 3.06, 15.18 mL/kg); difference in medians 0.82 mL/kg (95% confidence interval -2.52 to 3.26); Mann-Whitney P=.90. Likewise, short-term secondary outcomes were similar between the groups and there were no adverse events in either group. CONCLUSION: Viscous lidocaine is not superior to a flavored gel placebo in improving oral intake in children with painful infectious mouth ulcers.

Defining complicated urinary tract infection and route of antibiotics in children presenting to the emergency department: a cohort study using the Melbourne RUPERT clinical score.

OBJECTIVES: Most children with uncomplicated urinary tract infections (UTI) can be managed with oral antibiotics. However, identifying those likely to fail oral and need intravenous antibiotics due to complicating features at presentation is challenging. We aimed to derive, validate and test a score to guide initial antibiotic route. DESIGN: This cohort study enrolled children both prospectively and retrospectively. Patients were divided into two groups based on whether they received intravenous or oral antibiotics after 24 hours, including those who switched between routes. Children diagnosed with confirmed UTI were used to derive then validate the score, comparing complicating clinical features between the two groups. Combinations of significantly differentiating features generated receiver operating characteristic curves and the optimal cut-off for intravenous antibiotic use was selected. SETTING: The emergency department of a tertiary paediatric hospital. PARTICIPANTS: All children aged 3 months-17 years with suspected UTI were eligible, and were included if they fulfilled the diagnostic criteria for UTI. OUTCOME MEASURES: The effectiveness of the derived clinical score to differentiate patients at presentation who had complicated UTI requiring ongoing intravenous antibiotics. RESULTS: There were 1240 patients, of whom 167 children aged 12 months-11 years with confirmed UTI comprised the derivation cohort. The combination of features that performed optimally (area under curve 0.85, 95% CI 0.79 to 0.91) were: rigors, urological abnormality, fever (≥38°C), emesis, recurrent (≥3) UTI, tachycardia: the RUPERT score (1 point each, maximum 6). A score ≥3 accurately classified route of antibiotics after 24 hours for 80% patients (sensitivity 77%, specificity 81%). For the 168 patients in the validation cohort, the score accurately classified 76% (sensitivity 67%, specificity 78%). The score tested well in 'probable' UTI and adolescents, and less well in infants. CONCLUSION: The Melbourne RUPERT score provides the first standardised, easy-to-use score to aid clinicians in deciding route of antibiotics for more complicated UTI in children. It now needs prospective validation.

Pain in children with Bell's palsy: secondary analysis of a randomised controlled trial.

OBJECTIVE: To describe the prevalence and severity of pain experienced by children with Bell's palsy over the first 6 months of illness and its association with the severity of facial paralysis. METHODS: This was a secondary analysis of data obtained in a phase III, triple-blinded, randomised, placebo-controlled trial of prednisolone for the treatment of Bell's palsy in children aged 6 months to <18 years conducted between 13 October 2015 and 23 August 2020 in Australia and New Zealand. Children were recruited within 72 hours of symptom onset and pain was assessed using a child-rated visual analogue scale (VAS), a child-rated Faces Pain Score-Revised (FPS-R) and/or a parent-rated VAS at baseline, and at 1, 3 and 6 months until recovered, and are reported combined across treatment groups. RESULTS: Data were available for 169 of the 187 children randomised from at least one study time point. Overall, 37% (62/169) of children reported any pain at least at one time point. The frequency of any pain reported using the child-rated VAS, child-rated FPS-R and parent-rated VAS was higher at the baseline assessment (30%, 23% and 27%, respectively) compared with 1-month (4%, 0% and 4%, respectively) and subsequent follow-up assessments. At all time points, the median pain score on all three scales was 0 (no pain). CONCLUSIONS: Pain in children with Bell's palsy was infrequent and primarily occurred early in the disease course and in more severe disease. The intensity of pain, if it occurs, is very low throughout the clinical course of disease. TRIAL REGISTRATION NUMBER: ACTRN12615000563561.

Facial Function in Bell Palsy in a Cohort of Children Randomized to Prednisolone or Placebo 12 Months After Diagnosis.

BACKGROUND: Information on the medium-term recovery of children with Bell palsy or acute idiopathic lower motor neuron facial paralysis is limited. METHODS: We followed up children aged 6 months to <18 years with Bell palsy for 12 months after completion of a randomized trial on the use of prednisolone. We assessed facial function using the clinician-administered House-Brackmann scale and the modified parent-administered House-Brackmann scale. RESULTS: One hundred eighty-seven children were randomized to prednisolone (n = 93) or placebo (n = 94). At six months, the proportion of patients who had recovered facial function based on the clinician-administered House-Brackmann scale was 98% (n = 78 of 80) in the prednisolone group and 93% (n = 76 of 82) in the placebo group. The proportion of patients who had recovered facial function based on the modified parent-administered House-Brackmann scale was 94% (n = 75 of 80) vs 89% (n = 72 of 81) at six months (OR 1.88; 95% CI 0.60, 5.86) and 96% (n = 75 of 78) vs 92% (n = 73 of 79) at 12 months (OR 3.12; 95% CI 0.61, 15.98). CONCLUSIONS: Although the vast majority had complete recovery of facial function at six months, there were some children without full recovery of facial function at 12 months, regardless of prednisolone use.

Changes in the epidemiology of gastroenteritis in a paediatric short stay unit following the introduction of rotavirus immunisation.

AIM: Acute gastroenteritis (AGE) has been a significant component of the clinical load in the short stay unit (SSU) at the Royal Children's Hospital (RCH) since its establishment in 2004. Since the introduction of routine rotavirus immunisation in Australia in 2007 there has been a clinical impression of a substantial reduction in AGE managed in the SSU. This study aimed to examine changes in the epidemiology of AGE in the SSU, and RCH overall, between 2005 and 2009 and explore whether this reflects a change specifically in AGE due to rotavirus. METHODS: Discharge coding data for AGE from all inpatient wards, the SSU and emergency department (ED) at the RCH were examined. Stool virology results for the same period were analysed. RESULTS: Since 2007 there has been a 58% reduction in AGE admissions to the SSU. The median age of patients admitted to the RCH with rotaviral enteritis has increased from 1.3 years to 3.8 years. Presentations to the ED for AGE have fallen from 53 to 34 cases per 1000 attendances between 2004 and 2009, and admission rates from the ED have fallen from 23 to 13% of AGE presentations. Detection rates of rotavirus fell from 13.1 to 6.7% between 2005 and 2009. CONCLUSION: A marked decrease in AGE-related clinical activity and reduction in rotavirus detection at the RCH has occurred since the introduction of routine rotavirus immunisation in Australia. This has significant resource planning implications for units based on short stay models of care.

Agreement of Clinician-Administered and Modified Parent-Administered House-Brackmann Scales in Children with Bell's Palsy.

Objective: Currently there is no parent administered scale for facial nerve function in children. We set out to assess the agreement between a newly developed parent-administered modified version of the House-Brackmann (HB) scale and the standard clinician-administered HB scale in children with Bell's palsy. Study Design: Secondary analysis of a triple-blind, randomized, placebo-controlled trial of corticosteroids to treat idiopathic facial paralysis (Bell's palsy) in children (6 months to <18 years). Setting: Multicenter study at pediatric hospitals with recruitment in emergency departments. Methods: Children were recruited within 72 hours of symptom onset and assessed using the clinician-administered and the parent-administered modified HB scales at baseline, and at 1, 3, and 6 months until recovered. Agreement between the 2 scales was assessed using intraclass coefficient (ICC) and a Bland-Altman plot. Results: Data were available for 174 of the 187 children randomized from at least 1 study time point. The mean ICC between clinician and parent HB scores across all time points was 0.88 (95% confidence interval, CI: 0.86, 0.90). The ICC for the data collected at baseline was 0.53 (95% CI: 0.43, 0.64), at 1 month was 0.88 (95% CI: 0.84, 0.91), at 3 months was 0.80 (95% CI: 0.71, 0.87) and at 6 months was 0.73 (95% CI: 0.47, 0.89). A Bland-Altman plot indicated a mean difference between the 2 scores (clinician-reported minus parent-reported) of only -0.07 (95% limits of agreement -1.37 to 1.23). Conclusion: There was good agreement between the modified parent-administered and the clinician-administered HB scales.

Aggression management in a children's hospital setting.

OBJECTIVES: To describe the development, structure and implementation of a formal system of aggression management, and to document its utilisation during the first year of operation. DESIGN AND SETTING: A prospective audit at the Royal Children's Hospital, a major children's hospital in Melbourne. MAIN OUTCOME MEASURES: Analysis of utilisation patterns from prospective data forms augmented by retrospective review of security logs and medical records for 14 months from launch in December 2006. RESULTS: Staff from four different clinical areas, led by an emergency consultant and a hospital administrator, made up the rostered multidisciplinary "code grey" team. Over 14 months, there were 104 incidents when the team was activated, involving patients in 75 cases and visitors in 29 cases. Incidents occurred at equal frequency on wards and in the emergency department. Patients involved were most commonly affected by a mental disorder, frustration and/or a developmental disability. The apparent cause of visitor aggression was mainly frustration and occasionally drugs. The majority of patient aggressors showed physical aggression towards people or objects or self-harming behaviour. Visitor aggressors were mostly verbally aggressive (and occasionally physically violent). For patients, the team used verbal de-escalation (56/75 events), physical restraint (34/75), sedation (23/75) and mechanical restraint (15/75). For visitors, verbal de-escalation occurred in 17/29 cases and 10/29 visitors left or were removed. Several patient and staff injuries were documented. CONCLUSIONS: An aggression management team can be established in a children's hospital setting. This team structure provides a useful response to concerns about staff safety and optimal patient care.

Pre-hospital intraosseous use in children: Indications and success rate.

OBJECTIVE: Intraosseous (IO) needle insertion is an effective method to obtain circulatory access in unwell children. METHODS: We conducted a 12-month retrospective record review of children aged less than 18 years who had a recorded IO attempt by Ambulance Victoria paramedics. RESULTS: Sixty-five children underwent IO attempt during pre-hospital care, 60 had IO outcome recorded and were included. 58/60 (96.7%) children had IO successfully placed, 35 were aged <5 years. Cardiorespiratory arrest (39/58, 67.2%) and status epilepticus (11/58, 19%) were the most common indications. CONCLUSION: While IO placement is uncommonly performed pre-hospital, in critical situations there is a high success rate.

Efficacy of Prednisolone for Bell Palsy in Children: A Randomized, Double-Blind, Placebo-Controlled, Multicenter Trial.

BACKGROUND AND OBJECTIVE: Corticosteroids are used to treat the early stages of idiopathic facial paralysis (Bell's palsy) in children, but their effectiveness is uncertain. We set out to determine if prednisolone improves the proportion of children with Bell's palsy with complete recovery at one month. METHODS: We conducted a double-blind, placebo-controlled, randomised trial of prednisolone in children presenting to emergency departments with Bell's palsy. Patients aged 6 months to less than 18 years, recruited within 72 hours after symptom onset, were randomly assigned to receive 10 days of treatment with oral prednisolone (approximately 1 mg/kg) or placebo. The primary outcome was complete recovery of facial function at 1 month rated on the House-Brackmann scale. Secondary outcomes included facial function, adverse events and pain up to 6 months. Target recruitment was n=540 (270 per group). RESULTS: Between 13 October 2015 to 23 August 2020, 187 children were randomised (94 to prednisolone and 93 to placebo) and included in the intention-to-treat analysis. At 1 month, the proportions of patients who had recovered facial function were 49% (n=43/87) in the prednisolone group compared with 57% (n=50/87) in the placebo group (risk difference -8.1%, 95% CI -22.8 to 6.7; adjusted odds ratio [aOR] 0.7, 95% CI 0.4 to 1.3). At 3 months these proportion were 90% (n=71/79) for the prednisolone group versus 85% (n=72/85) for the placebo group (risk difference 5.2%, 95%, CI -5.0 to 15.3; aOR 1.2, 95% CI 0.4 to 3.0) and at 6 months 99% (n=77/78) and 93% (n=76/82) respectively (risk difference 6.0%, 95% CI -0.1 to 12.2; aOR 3.0 95% CI 0.5 to 17.7) There were no serious adverse events and little evidence for group differences in secondary outcomes. DISCUSSION: In children with Bell's palsy the vast majority recover without treatment. The study, although underpowered, does not provide evidence that early treatment with prednisolone improves complete recovery. REGISTRATION: Registered with the Australian New Zealand Clinical Trials Registry ACTRN12615000563561, registered 1 June 2015, ://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368505&isReview=true CLASSIFICATION OF EVIDENCE: This study provides Class I evidence that for children with Bell's palsy, prednisolone does not significantly change recovery of complete facial function at one month. However, the study lacked the precision to exclude an important harm or benefit from prednisolone.

A double blind, randomised placebo controlled trial of topical 2% viscous lidocaine in improving oral intake in children with painful infectious mouth conditions.

BACKGROUND: Painful infectious mouth conditions are a common presentation to emergency departments. Although self limiting, painful ulcerative lesions and inflamed mucosa can decrease oral intake and can lead to dehydration. Oral analgesia is of limited efficacy and is often refused by the patient. Despite widespread use of oral 2% viscous lidocaine for many years, there is little evidence for its efficacy as an analgesic and in aiding oral intake in children with painful infectious mouth conditions. This study aims to establish the effectiveness of 2% viscous lidocaine in increasing oral intake in these children by comparing it with placebo. METHODS/DESIGN: This study is a randomised double-blind placebo controlled trial of children between 6 months and 8 years of age with painful infectious mouth conditions defined as gingivostomatitis (herpetic or non herpetic), ulcerative pharyngitis, herpangina and hand foot and mouth disease as assessed by the treating clinician in association with a history of poor oral fluid intake. It will be conducted at a single tertiary paediatric emergency department in Melbourne Australia.20 patients have already been randomised to receive 2% lidocaine or placebo in a pilot study to determine the sample size in a preplanned adaptive design. A further 80 patients will be randomised to receive either 2% lidocaine or placebo. The placebo agent is identical to lidocaine in terms of appearance, flavour and smell. All clinical and research staff involved, patients and their parents will be blinded to treatment allocation.The primary endpoint is the amount of fluid ingested by each child, expressed in ml/kg, within 60 minutes from the time of administration of the study mixture. Secondary endpoints are the proportion of patients ingesting 5 ml/kg and 10 ml/kg at 30 and 60 minutes after drug administration and the incidence of adverse events. Longer term outcomes will include the proportion of patients requiring hospital admission and length of emergency department stay. DISCUSSION: This trial will define the role of 2% lidocaine in the treatment of painful infectious mouth conditions. TRIAL REGISTRATION: The trial is registered with the Australian and New Zealand Clinical Trials Registry--ACTRN12609000566235.