Resource utilization among children presenting with cannabis poisonings in the emergency department.

BACKGROUND: Exploratory pediatric cannabis poisonings are increasing. The aim of this study is to provide a national assessment of the frequency and trends of diagnostic testing and procedures in the evaluation of pediatric exploratory cannabis poisonings. METHODS: This is a retrospective cross-sectional study of the Pediatric Health Information Systems database involving all cases of cannabis poisoning for children age 0-10 years between 1/2016 and 12/2021. Cannabis poisoning trends were assessed using a negative binomial regression model. A new variable named "ancillary testing" was created to isolate testing that would not confirm the diagnosis of cannabis poisoning or be used to exclude co-ingestion of acetaminophen or aspirin. Ancillary testing was assessed with regression analyses, with ancillary testing as the outcomes and year as the predictor, to assess trends over time. RESULTS: A total of 2001 cannabis exposures among 1999 children were included. Cannabis exposures per 100,000 ED visits increased 68.7% (95% CI, 50.3, 89.3) annually. There was a median of 4 (IQR 2.0, 6.0) diagnostic tests performed per encounter. 64.5% of encounters received blood tests, 28.8% received a CT scan, and 2.4% received a lumbar puncture. Compared to White individuals, Black individuals were more likely to receive ancillary testing (OR 1.52 [95% CI, 1.23, 1.89]). Compared to those 2-6 years, those <2 years were more likely to receive ancillary testing (OR 1.55 [95% CI, 1.19, 2.02). We found no significant annual change in the odds of receiving ancillary testing (OR 1.04 [95% CI, 0.97, 1.12]). CONCLUSIONS: We found no change in the proportion of encounters associated with ancillary testing, despite increases in exploratory cannabis poisonings over the study period. Given the increasing rate of pediatric cannabis poisonings, emergency providers should consider this diagnosis early in the evaluation of a pediatric patient with acute change in mental status. While earlier use of urine drug screening may reduce ancillary testing and invasive procedures, even a positive urine drug screen does not rule out alternative pathologies and should not replace a thoughtful evaluation.

Systematic review and meta-analysis of the diagnostic value of four biomarkers in detecting neonatal sepsis in low- and middle-income countries.

BACKGROUND: Biomarkers may enhance diagnostic capability for common paediatric infections, especially in low- and middle-income countries (LMICs) where standard diagnostic modalities are frequently unavailable, but disease burden is high. A comprehensive understanding of the diagnostic capability of commonly available biomarkers for neonatal sepsis in LMICs is lacking. Our objective was to systematically review evidence on biomarkers to understand their diagnostic performance for neonatal sepsis in LMICs. METHODS: We conducted a systematic review and meta-analysis of studies published in English, Spanish, French, German, Dutch, and Arabic reporting the diagnostic performance of C reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell count (WBC) and procalcitonin (PCT) for neonatal sepsis. We calculated pooled test characteristics and the area under the curve (AUC) for each biomarker compared with the reference standards blood culture or clinical sepsis defined by each article. RESULTS: Of 6570 studies related to biomarkers in children, 134 met inclusion criteria and included 23 179 neonates. There were 80 (59.7%) studies conducted in LMICs. CRP of ≥60 mg/L (AUC 0.87, 95% CI 0.76 to 0.91) among 1339 neonates and PCT of ≥0.5 ng/mL (AUC 0.87, 95% CI 0.70 to 0.92) among 617 neonates demonstrated the greatest discriminatory value for the diagnosis of neonatal sepsis using blood culture as the reference standard in LMICs. CONCLUSIONS: PCT and CRP had good discriminatory value for neonatal sepsis in LMICs. ESR and WBC demonstrated poor discrimination for neonatal sepsis in LMICs. Future studies may incorporate biomarkers into clinical evaluation in LMICs to diagnose neonatal sepsis more accurately. PROSPERO REGISTRATION NUMBER: CRD42020188680.

Trends in the Use of Procalcitonin at US Children's Hospital Emergency Departments.

OBJECTIVES: Procalcitonin (PCT) was approved by the Food and Drug Administration in 2016. We assessed changes in PCT utilization over time in emergency departments (EDs) at US Children's Hospitals and identified the most common conditions associated with PCT testing. METHODS: We performed a cross-sectional study of children <18 years of age presenting to 1 of 33 EDs contributing data to the Pediatric Health Information System between 2016 and 2020. We examined trends in PCT utilization during an ED encounter between institutions and over the study period. Using All Patients Refined Diagnosis Related Groups, we identified the most common conditions for which PCT was obtained (overall, and relative to the performance of a complete blood count). RESULTS: The overall rate of PCT testing increased from 0.2% of all ED visits in 2016 to 1.8% in 2020. Across hospitals, the proportion of ED encounters with PCT obtained ranged from 0.0005% to 4.3% with marked variability in overall use. Among children who had PCT testing performed, the most common diagnoses were fever (10.7%), infections of the upper respiratory tract (9.2%), and pneumonia (5.9%). Relative to the performance of a complete blood count, rates of PCT testing were highest among children with sepsis (28.7%), fever (21.4%), pulmonary edema/respiratory failure (17.3%), and bronchiolitis/respiratory syncytial virus pneumonia (15.6%). CONCLUSIONS: PCT utilization in the ED has increased over the past 5 years with variation between hospitals. PCT is most frequently obtained for children with respiratory infections and febrile illnesses.

Boston Febrile Infant Algorithm 2.0: Improving Care of the Febrile Infant 1-2 Months of Age.

Significant variation exists in the management of febrile infants, particularly those between 1 and 2 months of age. An established algorithm for well-appearing febrile infants 1-2 months of age guided clinical care for three decades in our emergency department. With mounting evidence for procalcitonin (PCT) to detect invasive bacterial infection (IBI), we revised our algorithm intending to decrease lumbar punctures (LPs) and antibiotic administration without increasing hospitalizations, revisits, or missed IBI. Methods: The algorithm's risk stratification was revised based on the expert review of evidence regarding test performance of PCT for IBI in febrile infants. With the revision, routine LP and empiric antibiotics were not recommended for low-risk infants. We used quality improvement strategies to disseminate the revised algorithm and reinforce uptake. The primary outcomes were the proportion of infants undergoing lumbar punctures or receiving antibiotics. Admission rates, 72-hour revisits requiring admission, and missed IBI were monitored as balancing measures. Results: We studied 616 infants including 326 (52.9%), after the implementation of the revised algorithm. LP was performed in 66.2% prerevision and 31.9% postrevision (34.3% absolute reduction, P < 0.001). Antibiotic administration decreased by 26.2% (pre 62.4% to post 36.2%, P < 0.001) and hospitalization rates decreased by 8.1% (P = 0.03). There have been no missed IBIs. Adherence to the pathway led to a sustained reduction in LPs and antibiotic administration for 24 months. Conclusion: A revised pathway with the addition of PCT resulted in a safe, sustained reduction in LPs and reduced antibiotic administration in febrile infants 1-2 months of age.

A Statewide Collaboration to Deliver and Evaluate a Pediatric Critical Care Simulation Curriculum for Emergency Medical Services.

Objective: Care of the critically ill child is a rare but stressful event for emergency medical services (EMS) providers. Simulation training can improve resuscitation care and prehospital outcomes but limited access to experts, simulation equipment, and cost have limited adoption by EMS systems. Our objective was to form a statewide collaboration to develop, deliver, and evaluate a pediatric critical care simulation curriculum for EMS providers. Methods: We describe a statewide collaboration between five academic centers to develop a simulation curriculum and deliver it to EMS providers. Cases were developed by the collaborating PEM faculty, reviewed by EMS regional directors, and based on previously published EMS curricula, a statewide needs assessment, and updated state EMS protocols. The simulation curriculum was comprised of 3 scenarios requiring recognition and acute management of critically ill infants and children. The curriculum was implemented through 5 separate education sessions, led by a faculty lead at each site, over a 6 month time period. We evaluated curriculum effectiveness with a prospective, interventional, single-arm educational study using pre-post assessment design to assess the impact on EMS provider knowledge and confidence. To assess the intervention effect on knowledge scores while accounting for nested data, we estimated a mixed effects generalized regression model with random effects for region and participant. We assessed for knowledge retention and self-reported practice change at 6 months post-curriculum. Qualitative analysis of participants' written responses immediately following the curriculum and at 6 month follow-up was performed using the framework method. Results: Overall, 78 emergency medical technicians (EMTs) and 109 paramedics participated in the curriculum over five separate sessions. Most participants were male (69%) and paramedics (58%). One third had over 15 years of clinical experience. In the regression analysis, mean pediatric knowledge scores increased by 9.8% (95% CI: 7.2%, 12.4%). Most (93% [95% CI: 87.2%, 96.5%]) participants reported improved confidence caring for pediatric patients. Though follow-up responses were limited, participants who completed follow up surveys reported they had used skills acquired during the curriculum in clinical practice. Conclusion: Through statewide collaboration, we delivered a pediatric critical care simulation curriculum for EMS providers that impacted participant knowledge and confidence caring for pediatric patients. Follow-up data suggest that knowledge and skills obtained as part of the curriculum was translated into practice. This strategy could be used in future efforts to integrate simulation into EMS practice.

Application of Frequent, Spaced Multiple-choice Questions as an Educational Tool in the Pediatric Emergency Department.

OBJECTIVES: The objective was to assess the feasibility of using spaced multiple-choice questions (MCQs) to teach residents during their pediatric emergency department (PED) rotation and determine whether this teaching improves knowledge retention about pediatric rashes. METHODS: Residents rotating in the PED from four sites were randomized to four groups: pretest and intervention, pretest and no intervention, no pretest and intervention, and no pretest and no intervention. Residents in intervention groups were automatically e-mailed quizlets with two MCQs every other day over 4 weeks (20 questions total) via an automated e-mail service with answers e-mailed 2 days later. Retention of knowledge was assessed 70 days after enrollment with a posttest of 20 unique, content-matched questions. RESULTS: Between August 2015 and November 2016, a total 234 residents were enrolled. The completion rate of individual quizlets ranged from 93% on the first and 76% on the 10th quizlet. Sixty-six residents (55%) completed all 10 quizlets. One-hundred seventy-three residents (74%) completed the posttest. There was no difference in posttest scores between residents who received a pretest (61.0% ± 14.5%) and those who did not (64.6% ± 14.0%; mean difference = -3.7, 95% confidence interval [CI] = -8.0 to 0. 6) nor between residents who received the intervention (64.5% ± 13.3%) and those who did not receive the intervention (61.2% ± 15.2%; mean difference = 3.2, 95% CI = -1.1 to 7.5). For those who received a pretest, scores improved from the pretest to the posttest (46.4% vs. 60.1%, respectively; 95% CI = 9.7 to 19.5). CONCLUSION: Providing spaced MCQs every other day to residents rotating through the PED is a feasible teaching tool with a high participation rate. There was no difference in posttest scores regardless of pretest or intervention. Repeated exposure to the same MCQs and an increase in the number of questions sent to residents may increase the impact of this educational strategy.

Preventing injuries must be a priority to prevent disease in the twenty-first century.

Injuries continue to be the leading cause of morbidity and mortality for children, adolescents, and young adults aged 1-24 years in industrialized countries in the twenty-first century. In this age group, injuries cause more fatalities than all other causes combined in the United States (U.S.). Importantly, many of these injuries are preventable. Annually in the U.S. there are >9 million emergency department visits for injuries and >16,000 deaths in children and adolescents aged 0-19 years. Among injury mechanisms, motor vehicle crashes, firearm suicide, and firearm homicide remain the leading mechanisms of injury-related death. More recently, poisoning has become a rapidly rising cause of both intentional and unintentional death in teenagers and young adults aged 15-24 years. For young children aged 1-5 years, water submersion injuries are the leading cause of death. Sports and home-related injuries are important mechanisms of nonfatal injuries. Preventing injuries, which potentially cause lifelong morbidity, as well as preventing injury deaths, must be a priority. A multi-pronged approach using legislation, advancing safety technology, improving the built environment, anticipatory guidance by clinical providers, and education of caregivers will be necessary to decrease and prevent injuries in the twenty-first century.

Identifying a Disc-shaped Foreign Body.

A four-year-old girl presented to the emergency department vomiting after a foreign body ingestion. An anteroposterior plain radiograph demonstrated a disc-shaped foreign body. Ordinarily, a plain radiograph cannot conclusively identify an object as a coin rather than a button battery that requires emergent removal. However, this high-voltage radiograph, windowed to increase contrast, showed the visible face of George Washington to confirm the diagnosis of an ingested quarter.

Febrile infant update.

PURPOSE OF REVIEW: The approach to febrile young infants remains challenging. This review serves as an update on the care of febrile infants less than 90 days of age with a focus on the changing epidemiology of serious bacterial infection (SBI), refinement of management strategies based on biomarkers, and the development of novel diagnostics. RECENT FINDINGS: There is high variability in the emergency department management of febrile young infants without significant differences in outcomes. C-reactive protein (CRP) and procalcitonin have emerged as valuable risk-stratification tests to identify high-risk infants. When interpreting automated urinalyses for suspected urinary tract infection (UTI), urine concentration influences the diagnostic value of pyuria. Novel diagnostics including RNA biosignatures and protein signatures show promise in better identifying young febrile infants at risk of serious infection. SUMMARY: The majority of febrile infants with an SBI will have a UTI but the diagnosis of invasive bacterial infection in infants continues to be challenging. The use of procalcitonin and CRP as biomarkers in prediction algorithms facilitates identification of low-risk infants.

Outcomes of pediatric patients with persistent midline cervical spine tenderness and negative imaging result after trauma.

BACKGROUND: There is little evidence to guide management of pediatric patients with persistent cervical spine tenderness after trauma but with negative initial imaging study findings. Our objective was to determine the prevalence of clinically significant cervical spine injury among pediatric blunt trauma patients discharged from the emergency department with negative imaging study findings but persistent midline cervical spine tenderness. METHODS: We performed a single-center, retrospective study of subjects 1 year to 15 years of age discharged in a rigid cervical spine collar after blunt trauma over a 5-year period. We included patients with negative imaging results who were maintained in a collar because of persistent midline cervical spine tenderness. Primary outcome was clinically significant cervical spine injury. Secondary outcome was continued use of the collar after follow-up. Outcomes were ascertained from the medical record or self-report via telephone call. RESULTS: A total of 307 subjects met inclusion criteria, of whom 289 (94.1%) had follow-up information available (89.6% in chart, 10.4% via telephone call). Of those with follow-up information, 189 (65.4%) had subspecialty follow-up in the spine clinic. Of those with spine clinic follow-up, 84.6% had the hard collar discontinued at the first visit (median time to visit, 10 days). Of subjects with spine clinic follow-up, 10.1% were left in the collar for persistent tenderness without findings on imaging and 2.1% had imaging findings related to their injury; none required surgical intervention. CONCLUSION: A very small percentage of subjects with persistent midline cervical spine tenderness and normal radiographic study findings have a clinically significant cervical spine injury identified at follow-up. Referral for subspecialty evaluation may only be necessary in a small number of patients with persistent tenderness or concerning signs/symptoms. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Pediatric cervical spine injury evaluation after blunt trauma: a clinical decision analysis.

STUDY OBJECTIVE: Although many adult algorithms for evaluating cervical spine injury use computed tomography (CT) as the initial screening modality, this may not be appropriate in low-risk children, considering radiation risks. We determine the optimal initial evaluation strategy for cervical spine injury in pediatric blunt trauma. METHODS: We constructed a decision analysis tree for a hypothetical population of patients younger than 19 years with blunt trauma, using 3 strategies: clinical stratification, screening radiographs followed by focused CT if the radiograph result was positive, and CT. For the model inputs, we used the current literature to determine the probabilities of cervical spine injury and estimate the long-term risks of malignancy after CT, as well as test characteristics of radiographic imaging. We used published utilities and conducted 1- and 2-way sensitivity analyses to determine the optimal strategy for evaluation of pediatric cervical spine injury. RESULTS: In our model of a population with blunt trauma, the expected value of a clinical stratification strategy was the highest of the 3 strategies, making it the overall preferred management. One-way sensitivity analysis of several contributing factors revealed that the only independent factor that altered the dominant strategy was the sensitivity of clinical clearance criteria, lowering the threshold at which screening-radiograph strategy is optimal. Within the patient population considered as having non-negligible risk by clinical stratification and thus requiring imaging, the preferred imaging modality was screening radiograph/focused CT. The probability of cervical spine injury above which CT became the preferred strategy was 24.9%. CONCLUSION: The model highlights that clinical clearance and screening radiographs in a hypothetical trauma pediatric population are preferred strategies, whereas CT scanning is rarely the initial optimal evaluation.

Cardiac output assessed by non-invasive monitoring is associated with ECG changes in children with critical asthma.

The primary aim of this study was to determine changes in CI and SI, if any, in children hospitalized with status asthmatics during the course of treatment as measured by non-invasive EC monitoring. The secondary aim was to determine if there is an association between Abnormal CI (defined as <5 or >95 % tile adjusted for age) and Abnormal ECG (defined as ST waves changes) Non-invasive cardiac output (CO) recordings were obtained daily from admission (Initial) to discharge (Final). Changes in CI and SI measurements were compared using paired t tests or 1-way ANOVA. The association between Abnormal CI on Initial CO recording and Abnormal ECG was analyzed by Fischer's exact test. Data are presented as mean ± SEM with mean differences reported with 95 % confidence interval; p < 0.05 was considered significant. Thirty-five children with critical asthma were analyzed. CI decreased from 6.2 ± 0.2 to 4.5 ± 0.1 [-1.6 (-0.04 to -0.37)] L/min/m(2) during hospitalization. There was no change in SI. There was a significant association between Abnormal Initial CI and Abnormal ECG (p = 0.02). In 11 children requiring prolonged hospitalization CI significantly decreased from 7.2 ± 0.5 to 4.0 ± 0.2 [-3.2 (-4.0 to -2.3)] L/min/m(2) and SI decreased from 51.2 ± 3.8 to 40.3 ± 2.0 [-11.0 (-17.6 to -4.4)] ml/beat/m(2) There was a significant decrease in CI in all children treated for critical asthma. In children that required a prolonged course of treatment, there was also a significant decrease in SI. Abnormal CI at Initial CO recording was associated with ST waves changes on ECG during hospitalization. Future studies are required to determine whether non-invasive CO monitoring can predict which patients are at risk for developing abnormal ECG.