Therapeutic plasma exchange in paediatric nephrology in Ireland.

BACKGROUND: Therapeutic plasma exchange (TPE) is utilised in the management of a limited number of paediatric renal conditions. Despite its widespread acceptance and advancements in the practice of apheresis, there remains a paucity of data pertaining to paediatrics. We present a large retrospective review of our cohort of paediatric patients undergoing TPE for renal indications, outlining their outcomes and complications. METHODS: A retrospective chart review was conducted for all patients (under 16 years) undergoing TPE for renal conditions between January 2002 and June 2019 in Ireland. Demographic and clinical data were extracted, with patients anonymised and stratified according to their pathology. RESULTS: A total of 58 patients were identified. A total of 1137 exchanges were performed using heparin sodium anticoagulation. The median age was 35.5 months (IQR 18-110 months). The leading indication was neurological involvement in Shiga toxin-producing Escherichia coli haemolytic uraemic syndrome (STEC-HUS) (n = 29). Complications (minor or major) occurred in 65.5% (n = 38) of patients, with most experiencing minor complications 58.6% (n = 34). Asymptomatic hypocalcaemia was the most common complication in 43.1% (n = 25). CONCLUSIONS: Our experience of TPE, spanning 1137 exchanges, proved a safe, well-tolerated therapy. Most complications were minor, and with therapy conducted in specialised centres, there are very low levels of adverse events.

Outpatient parenteral antimicrobial therapy: how young is too young?

OBJECTIVE: To report the use, and assess the efficacy and outcomes of outpatient parenteral antimicrobial therapy (OPAT) in neonates (≤28 days of age), compared with older infants (1-12 months of age). DESIGN: A prospective 8-year observational study from September 2012 to September 2020. SETTING: The Hospital-in-the-Home (HITH) programme of the Royal Children's Hospital Melbourne. PATIENTS: Neonatal patients (≤28 days of age) were compared with older infants (1-12 months of age) receiving OPAT. INTERVENTIONS: Data were collected including demographics, diagnosis, type of venous access and antibiotic choice. MAIN OUTCOME MEASURES: Success of OPAT, antibiotic appropriateness, complications and readmission rate. RESULTS: There were 76 episodes for which neonates were admitted to HITH for OPAT, and 405 episodes for older infants. Meningitis was the most common diagnosis in both groups (59% and 35%, respectively); the most frequently prescribed antibiotic was ceftriaxone for both groups (61% and 49%). A positive bacterial culture was less frequent in neonates (38% vs 53%, p=0.02). Vascular access complication rate was 19% in neonates compared with 13% in older infants (p=0.2) with no central line-associated bloodstream infection in either group. Rates of appropriate antibiotic prescribing were similarly high between groups (93% vs 90%, p=0.3). The OPAT course was successfully completed in 74 of 74 (100%) neonates and 380 of 396 (96%) older infants (p=0.09). The unplanned readmission rate was low: 4 of 76 (5%) neonates and 27 of 405 (7%) older infants. CONCLUSIONS: OPAT is a safe and effective way of providing antibiotics to selected clinically stable neonatal patients. While appropriate antibiotic use was common, improvements can still be made.

Policy of free GP care for children under 6 years: The impact on emergency department attendance.

Universal health coverage (UHC) aims to improve child health. Ireland, the only country in the European Union without universal access to primary care, introduced general practitioner (GP) care at no charge for children aged under six in 2015. This paper aims to evaluate the impact of this policy on attendance at the emergency department (ED). A difference-in-difference (DiD) analysis was applied to visit records of 367,000 paediatric patients at five hospitals over a period of five years, with treatment and control differentiated by age. DiD was also used to assess if GP referrals and the severity of presentations altered as a consequence of this policy. While existing research estimates that this policy increased attendance by children aged under six at general practice by over 25%, this policy did not lead to a reduction in ED attendance. Hospital level effects on attendance varied from no impact to increased attendance by children aged under six of 28.9%. While increased GP referrals, particularly for injury and medical reasons, indicated more patients presented to their GP prior to ED attendance, walk-ins without referral did not decrease. Attendance increased at both regional hospitals, which also had the highest proportion of GP referred visits. While the marginal probability of a visit being GP referred increased at four of the five hospitals in this study, only in two of these can the entire effect be attributed to the introduction of this policy (effects 1.4 and 1.8 percentage points). Previous unmet need, capacity constraints in general practice, regional variability in the GP to population ratio, restricted hours of access to GPs, coupled with faster access to diagnostics in the ED setting, may explain variability in the effect and why the expected reduction in ED attendances did not occur.

The impact of the COVID-19 pandemic on child health and the provision of Care in Paediatric Emergency Departments: a qualitative study of frontline emergency care staff.

BACKGROUND: The COVID-19 pandemic and subsequent public health guidance to reduce the spread of the disease have wide-reaching implications for children's health and wellbeing. Furthermore, paediatric emergency departments (EDs) have rapidly adapted provision of care in response to the pandemic. This qualitative study utilized insight from multidisciplinary frontline staff to understand 1) the changes in paediatric emergency healthcare utilization during COVID-19 2) the experiences of working within the restructured health system. METHODS: Fifteen semi-structured interviews were conducted with frontline staff working in two paediatric EDs and two mixed adult and children EDs. Participants included emergency medicine clinicians (n = 5), nursing managerial staff (n = 6), social workers (n = 2) and nursing staff (n = 2). Thematic Analysis (TA) was applied to the data to identify key themes. RESULTS: The pandemic and public health restrictions have had an adverse impact on children's health and psychosocial wellbeing, compounded by difficulty in accessing primary and community services. The impact may have been more acute for children with disabilities and chronic health conditions and has raised child protection issues for vulnerable children. EDs have shown innovation and agility in the structural and operational changes they have implemented to continue to deliver care to children, however resource limitations and other challenges must be addressed to ensure high quality care delivery and protect the wellbeing of those tasked with delivering this care. CONCLUSIONS: The spread of COVID-19 and subsequent policies to address the pandemic has had wide-reaching implications for children's health and wellbeing. The interruption to health and social care services is manifesting in myriad ways in the ED, such as a rise in psychosocial presentations. As the pandemic continues to progress, policy makers and service providers must ensure the continued provision of essential health and social services, including targeted responses for those with existing conditions.

Parental Hesitancy and Concerns around Accessing Paediatric Unscheduled Healthcare during COVID-19: A Cross-Sectional Survey.

A decrease in attendance at emergency departments among paediatric populations has been reported during the Coronavirus Disease 2019 (COVID-19) pandemic. The present study sought to understand parents' hesitancy and concerns around accessing healthcare during the pandemic using a cross-sectional survey of parents of children under the age of 16 (N = 1044) in Ireland. Multinomial and logistic regression analyses were used to determine the factors that influenced avoidance and hesitancy. In total, 34% of participants stated that their child required healthcare during the pandemic, of whom 22% decided against seeking healthcare. Parents who reported being much more hesitant about accessing healthcare were more likely to report mild-moderate (Relative Risk Ratio (RRR) = 2.31, CI: 1.54-3.47) and severe-extremely severe stress (RRR: 3.37, CI: 1.81-6.27). Parents who understood government advice to mean avoiding health services were more likely to be hesitant to attend (RRR: 1.71, CI; 1.10-2.67). These effects held when restrictions were beginning to be lifted. Higher levels of stress were associated with a parent believing that the government advice meant that they should not attend health services (OR: 1.66, CI: 1.14-2.41). Public health messaging must ensure parents are reassured on the accessibility and safety of paediatric healthcare services as this public health emergency continues.

Assessing the Impact of COVID-19 Public Health Stages on Paediatric Emergency Attendance.

This study outlines the impact of COVID-19 on paediatric emergency department (ED) utilisation and assesses the extent of healthcare avoidance during each stage of the public health response strategy. Records from five EDs and one urgent care centre in Ireland, representing approximately 48% of national annual public paediatric ED attendances, are analysed to determine changes in characteristics of attendance during the three month period following the first reported COVID-19 case in Ireland, with reference to specific national public health stages. ED attendance reduced by 27-62% across all categories of diagnosis in the Delay phase and remained significantly below prior year levels as the country began Phase One of Reopening, with an incident rate ratio (IRR) of 0.58. The decrease was predominantly attributable to reduced attendance for injury and viral/viral induced conditions resulting from changed living conditions imposed by the public health response. However, attendance for complex chronic conditions also reduced and had yet to return to pre-COVID levels as reopening began. Attendances referred by general practitioners (GPs) dropped by 13 percentage points in the Delay phase and remained at that level. While changes in living conditions explain much of the decrease in overall attendance and in GP referrals, reduced attendance for complex chronic conditions may indicate avoidance behaviour and continued surveillance is necessary.

Children's unscheduled primary and emergency care in Ireland: a multimethod approach to understanding decision making, trends, outcomes and parental perspectives (CUPID): project protocol.

INTRODUCTION: The aim of this project is to determine the patterns, decision-making processes and parental preferences associated with unscheduled paediatric healthcare utilisation in Ireland. Unscheduled paediatric healthcare is outpatient care provided within primary care settings by general practitioners (GPs), emergency departments (EDs) located in paediatric and general hospitals, and out-of-hours services provided by cooperatives of GPs operating on a regional basis. This project will take a multimethod approach to analysing the utilisation of unscheduled paediatric healthcare nationally within the context of a significant change to the provision of healthcare for young children in Ireland-the introduction of free at the point of delivery GP care for all children aged under 6. METHODS AND ANALYSIS: A multimethod approach consisting of three work packages will be employed. Using patient-level data, work package 1 will describe patterns of attendance at primary care, out-of-hours medical services and at EDs. Applying a difference-in-difference methodology, the impact of the introduction of free GP care for children under 6 on attendance will be assessed. Work package 2 will explore geospatial trends of attendance at EDs, identifying disparities in ED attendance by local area and demographic characteristics. Work package 3 will employ two discrete choice experiments to examine parental preferences for unscheduled paediatric healthcare and GP decision making when referring a child to the ED. The insights gained by each of the work packages individually and collectively will inform evidence-based health policy for the organisation of paediatric care and resource allocation. ETHICS AND DISSEMINATION: Ethical approval for this research has been granted by University College Dublin, The Irish College of General Practitioners and the five participating hospitals. Results will be disseminated via publication in peer-reviewed journals, national and international conferences, and to relevant stakeholders and interest groups.

CUPID COVID-19: emergency department attendance by paediatric patients during COVID-19 - project protocol.

Background: Measures introduced to delay the spread of COVID-19 may result in avoidance of emergency departments (EDs) for non-COVID related illness. Clinicians and medical representative bodies such as the Irish Association for Emergency Medicine (IAEM) have expressed concern that some patients may not seek timely urgent medical intervention. Evidence from previous epidemics found that hospital avoidance during outbreaks of MERS and SARS was common. While ED attendance returned to normal following SARS and MERS, both outbreaks lasted 2-3 months. As the COVID-19 pandemic is forecast to extend into 2021, little is known about the impact COVID-19 will have on paediatric attendance at EDs as the pandemic evolves. Aims: This project aims to assess the impact of COVID-19 on paediatric emergency healthcare utilisation, to understand how the health seeking behaviour of parents may have altered due to the pandemic, and to identify how any barriers to accessing care can be removed.   Methods: Administrative data records from five EDs across Ireland and one Urgent Care Centre will be analysed to identify temporal trends in attendances for emergency care. Qualitative inquiry will be utilised to capture the experience of staff providing emergency healthcare to paediatric patients during COVID-19, and their feedback on identified trends will inform the interpretation of findings. A cross-sectional survey of parents will capture experiences, concerns and decision-making on accessing healthcare for their children during the pandemic. Results and Conclusion: This information will help decision makers respond rapidly to meet the clinical needs of paediatric patients as the circumstances of the pandemic unfold and reduce the disruption to normal paediatric ED services during the onset of COVID-19. As the health of a child can deteriorate more rapidly than that of an adult, any delay in seeking care for an acutely ill child may have serious consequences.

A case report of multiple cerebral abscess formation complicating serogroup B Neisseria meningitidis meningitis.

BACKGROUND: Invasive meningococcal disease (IMD) presenting with meningitis causes significant mortality and morbidity. Suppurative complications of serogroup B meningococcal sepsis are rare and necessitate urgent multidisciplinary management to mitigate long-term morbidity or mortality. CASE PRESENTATION: We present a rare case of invasive meningococcal disease in a 28-month old boy complicated by multiple abscess formation within a pre-existing antenatal left middle cerebral artery territory infarct. Past history was also notable for cerebral palsy with right hemiplegia, global developmental delay and West syndrome (infantile spasms). Two craniotomies were performed to achieve source control and prolonged antimicrobial therapy was necessary. The patient was successfully discharged following extensive multidisciplinary rehabilitation. CONCLUSIONS: Longstanding areas of encephalomalacia in the left MCA distribution may have facilitated the development of multiple meningococcal serogroup B abscess cavities in the posterior left frontal, left parietal and left temporal lobes following an initial period of cerebritis and meningitis. A combination of chronic cerebral hypoperfusion and some degree of pre-existing necrosis in these areas, may also have facilitated growth of Neisseria meningitidis, leading ultimately to extensive cerebral abscess formation following haematogenous seeding during meningococcemia. In this case report we review similar cases of cerebral abscess or subdural empyema complicating serogroup B meningococcal meningitis.

Factors that influence family and parental preferences and decision making for unscheduled paediatric healthcare: a systematic review protocol.

There is a plethora of factors that dictate where parents and families choose to seek unscheduled healthcare for their child; and the complexity of these decisions can present a challenge for policy makers and healthcare planners as these behaviours can have a significant impact on resources in the health system. The systematic review will seek to identify the factors that influence parents' and families' preferences and decision making when seeking unscheduled paediatric healthcare.  Five databases will be searched for published studies (CINAHL, PubMed, SCOPUS, PsycInfo, EconLit) and grey literature will also be searched. Inclusion and exclusion criteria will be applied and articles assessed for quality. A narrative approach will be used to synthesise the evidence that emerges from the review. By collating the factors that influence decision-making and attendance at these services, the review can inform future health policies and strategies seeking to expand primary care to support the provision of accessible and responsive care. The systematic review will also inform the design of a discrete choice experiment (DCE) which will seek to determine parental and family preferences for unscheduled paediatric healthcare. Policies such as Sláintecare that seek to expand primary care and reduce hospital admissions from emergency departments need to be cognisant of the nuanced and complex factors that govern patients' behaviour.

A Comparison of Hospital Versus Outpatient Parenteral Antibiotic Therapy at Home for Pyelonephritis and Meningitis.

BACKGROUND: Despite the benefits of home treatment with outpatient parenteral antimicrobial therapy (OPAT), children with pyelonephritis and meningitis are rarely included. We aimed to compare clinical characteristics and outcomes between hospital and home treatment for these conditions and to identify factors influencing home treatment. METHODS: Children admitted to the hospital with pyelonephritis or proven and presumed bacterial meningitis from January 1, 2012, to December 31, 2013 were identified retrospectively. Patients who received any OPAT (home group) received daily visits via our Hospital-in-the-Home (HITH) program; inpatients (hospital group) received standard care. Clinical and demographic features, length of stay, readmission rate and cost were compared between hospital and home groups. RESULTS: One hundred thirty-nine children with pyelonephritis and 70 with meningitis were identified, of which 127 and 44 were potentially suitable for OPAT, respectively. Of these, 12 (9%) with pyelonephritis received OPAT, contrasting with 29 (66%) with meningitis. Clinical features did not differ between hospital- and home-treated patients for either condition. Patients with meningitis in the hospital group were younger than those transferred to HITH (1 vs. 2 months; P = 0.01). All patients were afebrile before transfer to HITH. Admissions for pyelonephritis were brief with inpatients having a shorter length of stay than home patients (median: 3 vs. 4.5 days; P = 0.002). Unplanned readmission rates were comparable across all groups. Transfer to HITH resulted in a saving of AU$178,180. CONCLUSIONS: Children with pyelonephritis and meningitis can feasibly receive OPAT. Age, treatment duration and fever influence this decision. None of these should be barriers to OPAT, and the cost savings support change in practice.

Requirement for age-specific peak cortisol responses to insulin-induced hypoglycaemia in children.

OBJECTIVE: Based on adult data, a peak cortisol response ≥500 nmol/l to insulin-induced hypoglycaemia constitutes a normal. Age-specific reference ranges for basal morning cortisol have been developed for clinical use in the paediatric population. Such reference ranges are not clearly established for peak cortisol responses to insulin-induced hypoglycaemia despite limited data suggesting an effect of age on peak cortisol. The aims of this study were to assess factors affecting the cortisol response to insulin-induced hypoglycaemia in children and to determine whether the peak cortisol response was related to age. DESIGN: The present study was a retrospective cohort study. METHODS: Retrospective analysis of children and adolescents aged ≤18 years undergoing the insulin tolerance test with adequate hypoglycaemia was undertaken. Patients with hypopituitarism or severe hypothalamic-pituitary-adrenal axis impairment (peak cortisol value <400 nmol/l) or using systemic glucocorticoids were excluded. RESULTS: Two hundred and twenty-three tests were analysed. Peak cortisol responses ≥500 nmol/l occurred in 183 (82%) tests. Age was negatively associated with peak cortisol responses (r=-0.15, P=0.03). A peak cortisol response <500 nmol/l was significantly less common in patients aged <12 years (9/97 (9%) vs 31/126 (25%); P=0.004). In children aged <12 years, the median (5th-95th centiles) peak cortisol values were 610 (480-806) nmol/l compared with 574 (442-789) nmol/l in children aged ≥12 years (P<0.004). Similarly, median cortisol increment was significantly higher in younger patients (301 nmol/l compared with 226 nmol/l (P=0.0004)). CONCLUSIONS: Use of a single peak cortisol threshold in children of all ages is not appropriate and will result in overdiagnosis of adrenal insufficiency in adolescents.

A randomised crossover study of low-flow air or oxygen via nasal cannulae to prevent desaturation in preterm infants.

OBJECTIVE: To compare the efficacy of low-flow oxygen, low-flow air and sham treatment given via nasal cannulae in preventing desaturation (falls in oxygen saturation (SpO2)) in preterm infants. STUDY DESIGN: Infants born at <33 weeks gestation receiving gas at flow rates <1 l/min via nasal cannulae were eligible for inclusion. Enrolled infants received three treatments-0.1 l/min 100% oxygen, 0.1 l/min air, (21% oxygen) and sham (tubing disconnected from flow-meter)-via nasal cannulae, each for 3 h. Treatments were given in a randomly assigned order and caregivers were masked to treatment. Infants were monitored with a pulse oximeter that recorded SpO2 and heart rate every 2 s. Treatment was stopped before 3 h if infants reached prespecified failure criteria. We compared the rates of failure and the frequency and duration of desaturation episodes that occurred during each treatment. RESULTS: Of 14 infants enrolled, 2 (14%) reached failure criteria during treatment with oxygen compared with 7 (50%) during treatment with air and sham. Among infants who completed the 3-h study periods, there were fewer episodes and shorter duration of desaturation with oxygen compared with air and sham. CONCLUSIONS: At a flow rate of 0.1 l/min via nasal cannulae, air is no better than sham treatment in preventing desaturation in preterm infants, while 100% oxygen is superior to both.

Lack of sensitivity of the 1-µg low-dose ACTH stimulation test in a paediatric population with suboptimal cortisol responses to insulin-induced hypoglycaemia.

CONTEXT: The insulin-tolerance test (ITT) is the gold standard for evaluation of the hypothalamic-pituitary-adrenal (HPA) axis. The low-dose ACTH stimulation test is increasingly used for evaluation of secondary adrenal insufficiency as several studies performed in adults have demonstrated high sensitivity and specificity when compared to the ITT. Whether the ACTH stimulation test demonstrates similar sensitivity in a paediatric and adolescent population compared with the gold standard is unclear. OBJECTIVE: To compare the sensitivity of the low-dose (1-µg) Synacthen(™) test (LDSST) and the gold-standard ITT in a paediatric and adolescent population. DESIGN AND PATIENTS: A retrospective review of 42 consecutive LDSSTs in children and adolescents with suboptimal cortisol responses (peak <500 nm) on ITT. RESULTS: Thirty-one patients (74%) had an adequate cortisol response to low-dose Synacthen(™) (sensitivity 26%). Patients had a higher cortisol increment with the LDSST than ITT (median Δ cortisol 294 vs 168 nm, P < 0.0001) and correspondingly a higher cortisol peak (median peak cortisol 572 vs 396 nm, P < 0.0001). Patients who had a suboptimal peak cortisol both on ITT and on LDSST had a lower baseline cortisol on ITT (median 178 vs 227 nm, P = 0.04). Peak cortisol on ITT was significantly higher in patients who had a subsequent normal LDSST than those that did not (median 417 vs 300 nm, P = 0.0005). CONCLUSIONS: The 1-µg LDSST lacks sensitivity in detection of secondary adrenal insufficiency in children when compared to the gold-standard ITT.