Inborn Errors of Immunity in Children With Invasive Pneumococcal Disease: A Multicenter Prospective Study.

BACKGROUND: In settings with universal conjugate pneumococcal vaccination, invasive pneumococcal disease (IPD) can be a marker of an underlying inborn error of immunity. The aim of this study was to determine the prevalence and characterize the types of immunodeficiencies in children presenting with IPD. METHODS: Multicenter prospective audit following the introduction of routinely recommended immunological screening in children presenting with IPD. The minimum immunological evaluation comprised a full blood examination and film, serum immunoglobulins (IgG, IgA and IgM), complement levels and function. Included participants were children in whom Streptococcus pneumoniae was isolated from a normally sterile site (cerebrospinal fluid, pleura, peritoneum and synovium). If isolated from blood, features of sepsis needed to be present. Children with predisposing factors for IPD (nephrotic syndrome, anatomical defect or malignancy) were excluded. RESULTS: Overall, there were 379 episodes of IPD of which 313 (83%) were eligible for inclusion and 143/313 (46%) had an immunologic evaluation. Of these, 17/143 (12%) were diagnosed with a clinically significant abnormality: hypogammaglobulinemia (n = 4), IgA deficiency (n = 3), common variable immunodeficiency (n = 2), asplenia (n = 2), specific antibody deficiency (n = 2), incontinentia pigmenti with immunologic dysfunction (n = 1), alternative complement deficiency (n = 1), complement factor H deficiency (n = 1) and congenital disorder of glycosylation (n = 1). The number needed to investigate to identify 1 child presenting with IPD with an immunologic abnormality was 7 for children under 2 years and 9 for those 2 years old and over. CONCLUSIONS: This study supports the routine immune evaluation of children presenting with IPD of any age, with consideration of referral to a pediatric immunologist.

Outcome of reduction of paediatric forearm fracture by emergency department clinicians.

OBJECTIVES: Paediatric forearm fractures are common. Anecdotally, there is a trend towards ED reduction of selected fractures under procedural sedation. We aimed to determine the rate of subsequent operative intervention for fracture re-displacement. METHODS: Retrospective observational study of children with a forearm/wrist fracture undergoing fracture reduction in ED. Outcome of interest was operative intervention for fracture re-displacement within 6 weeks. RESULTS: Among 176 patients studied, operative intervention occurred in nine patients (5.1%, 95% confidence interval 2.7-9.4%). CONCLUSION: Reduction of paediatric forearm fractures under procedural sedation by ED clinicians is increasingly common and results in a low rate of subsequent operative intervention.

Mid-Arm Point in PAEDiatrics (MAPPAED): An effective procedural aid for safe pleural decompression in trauma.

OBJECTIVE: Life-threatening thoracic trauma requires emergency pleural decompression and thoracostomy and chest drain insertion are core trauma procedures. Reliably determining a safe site for pleural decompression in children can be challenging. We assessed whether the Mid-Arm Point (MAP) technique, a procedural aid proposed for use with injured adults, would also identify a safe site for pleural decompression in children. METHODS: Children (0-18 years) attending four EDs were prospectively recruited. The MAP technique was performed, and chest wall skin marked bilaterally at the level of the MAP; no pleural decompression was performed. Radio-opaque markers were placed over the MAP-determined skin marks and corresponding intercostal space (ICS) reported using chest X-ray. RESULTS: A total of 392 children participated, and 712 markers sited using the MAP technique were analysed. Eighty-three percentage of markers were sited within the 'safe zone' for pleural decompression (4th to 6th ICSs). When sited outside the 'safe zone', MAP-determined markers were typically too caudal. However, if the site for pleural decompression was transposed one ICS cranially in children ≥4 years, the MAP technique performance improved significantly with 91% within the 'safe zone'. CONCLUSIONS: The MAP technique reliably determines a safe site for pleural decompression in children, albeit with an age-based adjustment, the Mid-Arm Point in PAEDiatrics (MAPPAED) rule: 'in children aged ≥4 years, use the MAP and go up one ICS to hit the safe zone. In children <4 years, use the MAP.' When together with this rule, the MAP technique will identify a site within the 'safe zone' in 9 out of 10 children.

Chlorhexidine skin cleaning to reduce clean-catch urine contamination in infants: A pilot study.

OBJECTIVE: Clean-catch urine (CCU) samples are frequently contaminated. Our aim was to determine if cleaning with 0.1% chlorhexidine before CCU is a safe and feasible method to reduce contamination. METHODS: Prospective interventional pilot study. Children 1-24 months underwent perigenital skin cleaning with 0.1% chlorhexidine. Primary outcome was contamination rate, and secondary outcomes were parent and clinician satisfaction with the procedure. RESULTS: Twelve of 54 urine samples were contaminated (22%, 95% CI 13-35). Over 90% of parents and clinicians were either 'satisfied' or 'very satisfied'. No adverse events were recorded. CONCLUSION: Cleaning with chlorhexidine solution before CCU is safe and feasible.

Epidemiology of Headache in Children in a Community Emergency Department: A Scoping Study.

OBJECTIVE: This study aimed to describe the epidemiology of headache in children attending a community mixed adult-pediatric emergency department (ED) in Australia with a view to providing scoping data for future headache-related projects for the pediatric ED research networks. METHODS: This is a retrospective cohort study by medical record review. Participants were children aged 2 to 16 years who presented to the ED between January 1, 2016, and December 31, 2016, with a major symptom of headache. Exclusion criteria were a history of recent head trauma, a ventriculoperitoneal shunt in situ, or known intracranial conditions associated with headache. Data collected included demographics, clinical features, investigations, diagnosis, disposition, and outcome. The primary outcomes of interest were the proportion of children with a serious ED diagnosis, the distribution of ED diagnoses, investigation ordering patterns, treatments provided, and clinical outcome. RESULTS: A total of 225 children were studied, with a median age of 9 years (interquartile range, 6-13 years). The most common associated symptoms were fever (47%) and vomiting (42%). The most common examination feature was fever (21%). Abnormal neurological findings were very uncommon. Few children underwent advanced neuroimaging (7 patients; 3%), and no intracranial abnormalities were detected. Seven children had a serious diagnosis (7/225 [3%]; 95% confidence interval, 2%-6%). Six of these 7 were viral meningitis, and there was 1 case of bacterial meningitis. CONCLUSIONS: In a community teaching hospital cohort of children with headache, intercurrent viral illness is the most common cause. Serious causes were very uncommon. The rate of bacterial meningitis, tumor, or abscess was <1%. This has implications for the planning of research projects.

Parent perspectives on children and young people's mental health services in Victoria - What's wrong and how to fix it: A multi-site qualitative study.

AIM: The number of children and young people presenting to emergency departments (EDs) with anxiety and depression is increasing. We aimed to determine parent perspectives on: (i) barriers to accessing non-ED mental health services; and (ii) improving access in the paediatric mental health service system. METHODS: Qualitative study with parents of children and young people aged 0-19 years who attended one of four EDs across Victoria between October 2017 and September 2018 and received a primary diagnosis of anxiety or depression. EXCLUSION CRITERIA: child or young person without a parent/guardian, or presented with self-harm or suicide attempt. Eligible participants completed semi-structured phone interviews. Interviews were recorded and transcripts were coded and analysed using content analysis. RESULTS: A total of 72 parents completed interviews. The average child age was 14 years (standard deviation 2.5) and two thirds identified as female (64%). A total of 57% of children and young people presented with a primary diagnosis of anxiety. Parents reported barriers in accessing care including: service shortages and inaccessibility, underresourced schools, lack of clinician mental health expertise, lack of child-clinician rapport, inconsistent care, financial constraints, lack of mental health awareness among parents, and stigma. Parents want expanded and improved access to services, more respite and support services, supportive schools, and improved mental health education for parents. CONCLUSIONS: Parents of children and young people attending the ED for anxiety and depression are generally dissatisfied with services for child mental health. Solutions that enable parents to better care for their child in the community are needed to improve care.

Understanding parent-reported factors that influence children and young people's anxiety and depression presentations to emergency departments: A multi-site study.

OBJECTIVE: Victorian ED data show increased presentations for anxiety and depression in children. We aimed to determine parent-reported factors contributing to these presentations. METHODS: Qualitative study with parents of children and young people aged 0-17 years who attended one of four EDs across Victoria between October 2017 and September 2018 and received a primary diagnosis of anxiety or depression (excluding self-harm or suicide attempt). Eligible parents completed semi-structured phone interviews, which were audio-recorded and transcribed. Transcripts were coded and qualitatively analysed using thematic analysis. RESULTS: Seventy parents completed interviews. The average age of children and young people was 14 years (standard deviation 2.4) and 63% (n = 44) identified as female. Thirty (43%) children received a primary diagnosis of depression, compared to 40 (57%) children who received a primary diagnosis of anxiety. The majority of respondents were mothers (n = 59; 84%). Key themes as to why families presented to EDs included: listening to trusted professionals, desperation, a feeling of no alternative, respecting their child's need to feel safe and to rule out a potentially serious medical condition. CONCLUSIONS: Parents bring their children to the ED for many reasons. Policy makers, managers and clinicians should work with parents to develop alternative approaches that provide families with community-based support, particularly for younger children and after hours, in order to provide an appropriate source of care for children and young people with anxiety and depression.

Postconcussive Symptoms Following Mild TBI and Extracranial Injury: What Are the Contributing Factors?

OBJECTIVES: Whether mild traumatic brain injury (mTBI) sustained by children results in persistent or recurrent symptoms, over and above those experienced by children who solely sustain mild extracranial injuries, remains debated. The current prospective longitudinal case-controlled study aimed to examine the relative influence of injury and noninjury factors on symptoms in preschool and primary school-aged children who sustained an mTBI or mild extracranial injury at least 8 month earlier. METHODS: Participants were 64 parents of children (31 mTBI, 33 trauma controls) who sustained injury between ages 2 and 12, whose postconcussive symptoms across the first 3-month postinjury have been previously described. The current study assessed postconcussive symptoms at 8 or more months postinjury (M = 24.3, SD = 8.4) and examined a range of injury and noninjury predictive factors. RESULTS: At or beyond 8-month postinjury, symptom numbers in the mTBI group were comparable with those of the group who sustained mild extracranial injury. Educational attainment of parents (below or above high-school attainment level) was the only predictor of symptoms at follow-up, with preexisting learning difficulties approaching significance as a predictor. CONCLUSIONS: While our earlier study found that mTBI was associated with symptoms at 3-month postinjury, follow-up at more than 8 months showed mTBI no longer predicted symptom reporting. While mTBI contributes significantly to the presence of symptoms in the first few months postinjury, researchers and healthcare practitioners in this field need to consider the potential impact of noninjury factors on persistent or recurrent symptoms after mTBI.

Sub-optimal treatment of paediatric migraine in an emergency department: An observational study.

OBJECTIVES: To describe treatment of children presenting to an Australian ED with a final ED diagnosis of migraine. METHODS: Planned substudy of a retrospective cohort study of the epidemiology of headache in children was done. Primary outcome of interest was treatment administered in the ED. RESULTS: Thirty-five children were studied. The most commonly used medications were non-steroidal anti-inflammatory drugs, paracetamol and ondansetron. Specific antimigraine therapy was used uncommonly. Fourteen percent of children received an opiate. CONCLUSION: Treatment of migraine in children was not consistent with the available evidence regarding agents' relative effectiveness. The use of opiates is concerningly high.

Medication use in infants admitted with bronchiolitis.

BACKGROUND: There are no medications known that improve the outcome of infants with bronchiolitis. Studies have shown the management of bronchiolitis to be varied. OBJECTIVES: To describe medication use at the seven study hospitals from a recent multi-centre randomised controlled trial on hydration in bronchiolitis (comparative rehydration in bronchiolitis [CRIB]). METHODS: A retrospective analysis of extant data of infants between 2 months (corrected for prematurity) and 12 months of age admitted with bronchiolitis identified through the CRIB trial. CRIB study records, medical records, pathology and radiology databases were used to collect data using a standardised form and entered in a single site database. Medications investigated included salbutamol, adrenaline, steroids, ipratropium bromide, normal saline, hypertonic saline, steroids and antibiotics. RESULTS: There were 3456 infants available for analysis, of which 42.0% received at least one medication during hospitalisation. Medication use varied by site between 27.0 and 48.7%. The most frequently used medication was salbutamol (25.5%). Medication use in general, and salbutamol use in particular, increased by 8.2 and 9.3%, respectively, per month after 4 months of age; from 22.9 and 3.6% at 4 months to 81.4 and 68.8% at 11 months. In infants admitted to the intensive care unit (ICU) compared with those not admitted to ICU 81.6 and 39.5%, respectively, received medication at one point during the hospital stay. CONCLUSIONS: Medication was used for infants with bronchiolitis frequently and variably in Australia and New Zealand. Medication use increased with age. Better strategies for translating evidence into practice are needed.

PREDICT prioritisation study: establishing the research priorities of paediatric emergency medicine physicians in Australia and New Zealand.

BACKGROUND: The Paediatric Research in Emergency Departments International Collaborative (PREDICT) performs multicentre research in Australia and New Zealand. Research priorities are difficult to determine, often relying on individual interests or prior work. OBJECTIVE: To identify the research priorities of paediatric emergency medicine (PEM) specialists working in Australia and New Zealand. METHODS: Online surveys were administered in a two-stage, modified Delphi study. Eligible participants were PEM specialists (consultants and senior advanced trainees in PEM from 14 PREDICT sites). Participants submitted up to 3 of their most important research questions (survey 1). Responses were collated and refined, then a shortlist of refined questions was returned to participants for prioritisation (survey 2). A further prioritisation exercise was carried out at a PREDICT meeting using the Hanlon Process of Prioritisation. This determined the priorities of active researchers in PEM including an emphasis on the feasibility of a research question. RESULTS: One hundred and six of 254 (42%) eligible participants responded to survey 1 and 142/245 (58%) to survey 2. One hundred and sixty-eight (66%) took part in either or both surveys. Two hundred forty-six individual research questions were submitted in survey 1. Survey 2 established a prioritised list of 35 research questions. Priority topics from both the Delphi and Hanlon process included high flow oxygenation in intubation, fluid volume resuscitation in sepsis, imaging in cervical spine injury, intravenous therapy for asthma and vasopressor use in sepsis. CONCLUSION: This prioritisation process has established a list of research questions, which will inform multicentre PEM research in Australia and New Zealand. It has also emphasised the importance of the translation of new knowledge.

Acute post-concussive symptoms in young children.

OBJECTIVES: Despite peaks of mild traumatic brain injury (mTBI) incidence in young children, few studies have examined the nature of post-concussive symptoms (PCSs) in children under the age of eight, whilst controlling for pre-injury symptoms and effects of trauma. The current study aimed to identify which PCSs differentiate children with mTBI from trauma controls early post-injury, and whether these differed among preschool and school-aged children. METHODS: The sample comprised 101 children aged 2-12 presenting to an emergency department, with concussion or other minor bodily injury (control). Groups were divided by age (preschool and school-aged). PCSs were assessed within 72 hours post-injury using a comprehensive PCS checklist, administered to their parents via structured interview. RESULTS: Parents of children with mTBI reported significantly more symptoms in their children than parents of children with other minor bodily trauma, p < 0.001, r = 0.84. Parents of preschool and school-aged children reported an equal number of symptoms. However, subtle differences were observed between symptom profiles of preschool and school-aged children. CONCLUSIONS: Primary care clinicians should be aware of post-concussive symptom presentations in children of varying ages, in order to provide optimal care, especially in younger children. Methods of eliciting symptoms may influence the identification of symptoms. This issue warrants further examination in the paediatric population. ABBREVIATIONS ED emergency department; GCS Glasgow coma scale; mTBI mild traumatic brain injury; PCS post-concussive symptoms; PTA post-traumatic amnesia; TC trauma control.

Influence of weather on incidence of bronchiolitis in Australia and New Zealand.

AIM: We aimed to examine the impact of weather on hospital admissions with bronchiolitis in Australia and New Zealand. METHODS: We collected data for inpatient admissions of infants aged 2-12 months to seven hospitals in four cities in Australia and New Zealand from 2009 until 2011. Correlation of hospital admissions with minimum daily temperature, wind speed, relative humidity and rainfall was examined using linear, Poisson and negative binomial regression analyses as well as general estimated equation models. To account for possible lag between exposure to weather and admission to hospital, analyses were conducted for time lags of 0-4 weeks. RESULTS: During the study period, 3876 patients were admitted to the study hospitals. Hospital admissions showed strong seasonality with peaks in wintertime, onset in autumn and offset in spring. The onset of peak incidence was preceded by a drop in temperature. Minimum temperature was inversely correlated with hospital admissions, whereas wind speed was directly correlated. These correlations were sustained for time lags of up to 4 weeks. Standardised correlation coefficients ranged from -0.14 to -0.54 for minimum temperature and from 0.18 to 0.39 for wind speed. Relative humidity and rainfall showed no correlation with hospital admissions in our study. CONCLUSION: A decrease in temperature and increasing wind speed are associated with increasing incidence of bronchiolitis hospital admissions in Australia and New Zealand.

Intensive care unit admissions and ventilation support in infants with bronchiolitis.

OBJECTIVES: To describe the rate of intensive care unit (ICU) admission, type of ventilation support provided and risk factors for ICU admission in infants with bronchiolitis. DESIGN: Retrospective review of hospital records and Australia and New Zealand Paediatric Intensive Care (ANZPIC) registry data for infants 2-12 months old admitted with bronchiolitis. SETTING: Seven Australian and New Zealand hospitals. These infants were prospectively identified through the comparative rehydration in bronchiolitis (CRIB) study between 2009 and 2011. RESULTS: Of 3884 infants identified, 3589 charts were available for analysis. Of 204 (5.7%) infants with bronchiolitis admitted to ICU, 162 (79.4%) received ventilation support. Of those 133 (82.1%) received non-invasive ventilation (high flow nasal cannula [HFNC] or continuous positive airway pressure [CPAP]) 7 (4.3%) received invasive ventilation alone and 21 (13.6%) received a combination of ventilation modes. Infants with comorbidities such as chronic lung disease (OR 1.6 [95% CI 1.0-2.6]), congenital heart disease (OR 2.3 [1.5-3.5]), neurological disease (OR 2.2 [1.2-4.1]) or prematurity (OR 1.5 [1.0-2.1]), and infants 2-6 months of age (OR 1.5 [1.1-2.0]) were more likely to be admitted to ICU. Respiratory syncitial virus positivity did not increase the likelihood of being admitted to ICU (OR 1.1 [95% CI 0.8-1.4]). HFNC use changed from 13/53 (24.5% [95% CI 13.7-38.3]) patient episodes in 2009 to 39/91 (42.9% [95% CI 32.5-53.7]) patient episodes in 2011. CONCLUSION: Admission to ICU is an uncommon occurrence in infants admitted with bronchiolitis, but more common in infants with comorbidities and prematurity. The majority are managed with non-invasive ventilation, with increasing use of HFNC.

Do Concussive Symptoms Really Resolve in Young Children?

OBJECTIVES: To examine the frequency and nature of postconcussive symptoms (PCSs) and behavioral outcomes in young children following mild traumatic brain injury (mTBI) or concussion. SETTING: Emergency department. PARTICIPANTS: Children aged 2 to 12 years presenting with either a concussion or minor bodily injury (control). OUTCOME MEASUREMENT: Parent ratings of PCS were obtained within 72 hours of injury, at 1 week, and 1, 2, and 3 months postinjury using a comprehensive PCS checklist. Preinjury behavior was examined at baseline using the Clinical Assessment of Behavior, which was readministered 1 and 3 months postinjury. RESULTS: PCS burden following mTBI peaked in the acute phase postinjury but reduced significantly from 1 week to 1 month postinjury. Parents of children with mTBI reported more persistent PCSs up to 3 months postinjury than trauma controls, characterized mostly by behavioral and sleep-related symptoms. Subtle increases in problematic behaviors were observed from baseline (preinjury) to 1 month postinjury and persisted at 3 months postinjury; however, scores were not classified as clinically "at risk." CONCLUSIONS: A significant minority of young children experienced persistent PCS and problematic behavior following mTBI. Care must be taken when assessing PCS in younger children as method of PCS assessment may influence parental reporting.

Computed tomography for head injuries in children: Change in Australian usage rates over time.

OBJECTIVE: Paediatric head injury is a common presentation to the ED. North American studies demonstrate increasing use of computed tomography (CT) brain scan (CTB) to investigate head injury. No such data exists for Australian EDs. The aim of this study was to describe CTB use in head injury over time in eight Australian EDs. METHODS: Retrospective ED electronic database and medical imaging database audit was undertaken for the years 2001-2010 by International Classification of Diseases (ICD) 9 or 10 code for head injury in children <16 years. EDs and medical imaging departments of eight hospitals in Australia (five tertiary referral and three mixed departments). Data for ED presentations with head injury, and all CTB performed by medical imaging were merged to obtain a data set of CTB performed within 24 h for head injury-related attendances to the ED. Descriptive and comparative analysis of CTB rates was performed. RESULTS: The rate of CTB over the decade was 10.2% (95% confidence interval (CI) 9.9-10.5). The annual rate varied from 9.5% (95% CI 8.2-10.9) to 12.5% (95% CI 11.2-13.9). CTB use did not increase over time. Median year of age at time of CT scan was 4 years, with an interquartile range of 1.5-9.4 years. Overall there was a 9.2% increase in the CTB scan rate for every additional year of age at presentation (95% CI 6.6-12.1; P < 0.001). CONCLUSION: CTB use in head injuries did not increase during the study period, and rates of CTB were less than reported for North America.

Bell's palsy in children: Current treatment patterns in Australia and New Zealand. A PREDICT study.

AIM: The aetiology and clinical course of Bell's palsy may be different in paediatric and adult patients. There is no randomised placebo controlled trial (RCT) to show effectiveness of prednisolone for Bell's palsy in children. The aim of the study was to assess current practice in paediatric Bell's palsy in Australia and New Zealand Emergency Departments (ED) and determine the feasibility of conducting a multicentre RCT within the Paediatric Research in Emergency Departments International Collaborative (PREDICT). METHODS: A retrospective analysis of ED medical records of children less than 18 years diagnosed with Bell's palsy between 1 January, 2012 and 31 December, 2013 was performed. Potential participants were identified from ED information systems using Bell's palsy related search terms. Repeat presentations during the same illness were excluded but relapses were not. Data on presentation, diagnosis and management were entered into an online data base (REDCap). RESULTS: Three hundred and twenty-three presentations were included from 14 PREDICT sites. Mean age at presentation was 9.0 (SD 5.0) years with 184 (57.0%) females. Most (238, 73.7%) presented to ED within 72 h of symptoms, 168 (52.0%) had seen a doctor prior. In ED, 218 (67.5%) were treated with steroids. Prednisolone was usually prescribed for 9 days at around 1 mg/kg/day, with tapering in 35.7%. CONCLUSION: Treatment of Bell's palsy in children presenting to Australasian EDs is varied. Prednisolone is commonly used in Australasian EDs, despite lack of high-level paediatric evidence. The study findings confirm the feasibility of an RCT of prednisolone for Bell's palsy in children.

Economic evaluation of nasogastric versus intravenous hydration in infants with bronchiolitis.

OBJECTIVE: Bronchiolitis is the most common lower respiratory tract infection in infants and the leading cause of hospitalisation. We aimed to assess whether intravenous hydration (IVH) was more cost-effective than nasogastric hydration (NGH) as a planned secondary economic analysis of a randomised trial involving 759 infants (aged 2-12 months) admitted to hospital with a clinical diagnosis of bronchiolitis and requiring non-oral hydration. No Australian cost data exist to aid clinicians in decision-making around interventions in bronchiolitis. METHODS: Cost data collections included hospital and intervention-specific costs. The economic analysis was reduced to a cost-minimisation study, focusing on intervention-specific costs of IVH versus NGH, as length of stay was equal between groups. All analyses are reported as intention to treat. RESULTS: Intervention costs were greater for IVH than NGH ($113 vs $74; cost difference of $39 per child). The intervention-specific cost advantage to NGH was robust to inter-site variation in unit prices and treatment activity. CONCLUSION: Intervention-specific costs account for <10% of total costs of bronchiolitis admissions, with NGH having a small cost saving across all sites.