Building Blocks-A Block-by-Block Approach to Better Emergency Care in Children.

OBJECTIVE: We describe a case series of regional nerve blocks, which comprise an adapted framework for the pediatric emergency setting and were performed by pediatric emergency medicine physicians. METHODS: A case series of 8 different ultrasound-guided nerve blocks and 1 anatomical block, performed in 11 pediatric patients, aged 7 weeks to 17 years. RESULTS: All blocks resulted in adequate analgesia. No procedural complications were observed. CONCLUSION: We describe a set of nerve blocks performed by emergency medicine physicians in the pediatric population in an ED setting. In suitable settings, this is a safe and effective tool for procedural analgesia or for pain management. In such cases, performing an ultrasound-guided nerve block in the ED is a viable alternative for repeated doses of opiates, deep procedural sedation, or the operating theater. We propose this set of regional anesthesia procedures as a pediatric-adapted toolkit for the emergency physician to be performed in children in the ED setting. Adopting this set of procedures ensures better and safer care for children and provides a training framework for pediatric ED physicians.

Respective roles of non-pharmaceutical interventions in bronchiolitis outbreaks: an interrupted time-series analysis based on a multinational surveillance system.

BACKGROUND: Bronchiolitis is a major source of morbimortality among young children worldwide. Non-pharmaceutical interventions (NPIs) implemented to reduce the spread of severe acute respiratory syndrome coronavirus 2 may have had an important impact on bronchiolitis outbreaks, as well as major societal consequences. Discriminating between their respective impacts would help define optimal public health strategies against bronchiolitis. We aimed to assess the respective impact of each NPI on bronchiolitis outbreaks in 14 European countries. METHODS: We conducted a quasi-experimental interrupted time-series analysis based on a multicentre international study. All children diagnosed with bronchiolitis presenting to the paediatric emergency department of one of 27 centres from January 2018 to March 2021 were included. We assessed the association between each NPI and change in the bronchiolitis trend over time by seasonally adjusted multivariable quasi-Poisson regression modelling. RESULTS: In total, 42 916 children were included. We observed an overall cumulative 78% (95% CI -100- -54%; p<0.0001) reduction in bronchiolitis cases following NPI implementation. The decrease varied between countries from -97% (95% CI -100- -47%; p=0.0005) to -36% (95% CI -79-7%; p=0.105). Full lockdown (incidence rate ratio (IRR) 0.21 (95% CI 0.14-0.30); p<0.001), secondary school closure (IRR 0.33 (95% CI 0.20-0.52); p<0.0001), wearing a mask indoors (IRR 0.49 (95% CI 0.25-0.94); p=0.034) and teleworking (IRR 0.55 (95% CI 0.31-0.97); p=0.038) were independently associated with reducing bronchiolitis. CONCLUSIONS: Several NPIs were associated with a reduction of bronchiolitis outbreaks, including full lockdown, school closure, teleworking and facial masking. Some of these public health interventions may be considered to further reduce the global burden of bronchiolitis.

Ultrasound-Guided Supraclavicular Brachial Plexus Blocks Performed by Pediatric Emergency Medicine Physicians for Painful Orthopedic Procedures in a Pediatric Emergency Department-A Case Series.

OBJECTIVE: The aim of this study was to describe our experience with ultrasound-guided supraclavicular brachial plexus blocks performed by pediatric emergency physicians for the purpose of forearm fracture reductions in the emergency department. METHODS: We present a case series of 15 pediatric patients aged 7 to 17 years undergoing ultrasound-guided supraclavicular blocks. RESULTS: All blocks resulted in adequate analgesia. No procedural complications were observed. CONCLUSIONS: We conclude that in select pediatric cases ultrasound-guided brachial plexus blocks can be a safe, swift, and efficient means of pain management and procedural analgesia. This approach obviates the need for sedation, thus shortening the time lag between presentation and the reduction procedure, as well as overall length of stay.

Accuracy and Interrater Reliability of Point-of-Care Ultrasonography Image Interpretation for Intussusception.

OBJECTIVES: The aim of this study was to determine the accuracy and interrater reliability of (1) point-of-care ultrasound (POCUS) image interpretation for identification of intussusception and (2) reliability of secondary signs associated with intussusception among experts compared with novice POCUS reviewers. METHODS: We conducted a planned secondary analysis of a prospective, convenience sample of children aged 3 months to 6 years who were evaluated with POCUS for intussusception across 17 international pediatric emergency departments between October 2018 and December 2020. A random sample of 100 POCUS examinations was reviewed by novice and expert POCUS reviewers. The primary outcome was identification of the presence or absence of intussusception. Secondary outcomes included intussusception size and the presence of trapped free fluid or echogenic foci. Accuracy was summarized using sensitivity and specificity, which were estimated via generalized mixed effects logistic regression. Interrater reliability was summarized via Light's κ statistics with bootstrapped standard errors (SEs). Accuracy and reliability of expert and novice POCUS reviewers were compared. RESULTS: Eighteen expert and 16 novice POCUS reviewers completed the reviews. The average expert sensitivity was 94.5% (95% confidence interval [CI], 88.6-97.5), and the specificity was 94.3% (95% CI, 90.3-96.7), significantly higher than the average novice sensitivity of 84.7% (95% CI, 74.3-91.4) and specificity of 80.4% (95% CI, 72.4, 86.7). κ was significantly greater for expert (0.679, SE 0.039) compared with novice POCUS reviewers (0.424, SE 0.044; difference 0.256, SE 0.033). For our secondary outcome measure of intussusception size, κ was significantly greater for experts (0.661, SE 0.038) compared with novices (0.397, SE 0.041; difference 0.264, SE 0.029). Interrater reliability was weak for expert and minimal for novice reviewers regarding the detection of trapped free fluid and echogenic foci. CONCLUSIONS: Expert POCUS reviewers demonstrate high accuracy and moderate interrater reliability when identifying intussusception via image interpretation and perform better than novice reviewers.

Management of intraorbital infections in the pediatric emergency department.

Intraorbital infections may lead to severe complications, necessitating rapid diagnosis and intervention. The decision process regarding the need for emergent imaging and possible surgical intervention is unclear in the literature. This retrospective cohort study included two major pediatric emergency departments in Israel between 2010 and 2020. Patients arriving at the emergency department with an admission diagnosis of intraorbital infection and at least one high-risk symptom for orbital involvement were included in the study. The main outcome measures were the computerized tomography (CT) timing and results, whether the case was managed surgically or conservatively and whether the patient returned to the same hospital with significant complications. Ninety-five patients were included; 70 underwent a CT scan in the first 24 h, and of those 21 were managed surgically; 16 were treated based on clinical findings alone, with no imaging performed. When comparing groups based on management, we found no significant differences based on presenting symptoms, duration of complaints, or severity of CT findings. However, having three or more high-risk presenting symptoms was associated with a greater likelihood of surgical intervention (multivariate logistic regression p = 0.069, odds ratio 1.73, 95% confidence interval 0.96-3.11; one-way ANOVA and Fisher's exact test p < 0.05). CONCLUSION: The decision to treat intraorbital infections at our institutions appears to be based on clinical impression of disease severity rather than radiologic findings. This suggests a need for further interdisciplinary studies to clarify optimal management. WHAT IS KNOWN: • Orbital c ellulitis is associated with significant potential complications, necessitating rapid diagnosis and treatment. • Present literature provides insufficiently clear guidance on emergency department management. WHAT IS NEW: • Consideration of all relevant factors (clinical features, laboratory findings, timing of imaging, and conservative vs. surgical management) in a single retrospective cohort. • Our findings suggest that decision-making in practice may be guided by clinical impression rather than imaging.

Point-of-Care Ultrasound-Guided Aspiration of the Hip Joint by an Emergency Medicine Physician: A Pediatric Retrospective Case Series.

OBJECTIVES: Early administration of antibiotics is crucial to treating septic hip. This study aimed to describe the clinical course and outcomes of children with septic hip diagnosed using point-of-care ultrasound (POCUS)-guided hip aspirations performed by an emergency medicine physician. METHODS: A retrospective case series analysis. RESULTS: Between January 1, 2014, and December 31, 2019, 10 children with septic hip were diagnosed by emergency physicians using POCUS-guided hip aspirations. Six of them were female; the mean age was 4.2 ± 4.5 years, and the mean time from onset of symptoms to diagnosis was 2.9 ± 1.7 days. Seven patients (70%) had a history of fever. All the patients had elevated inflammatory blood markers (white blood cell count >12 K/µL, erythrocyte sedimentation rate >40 mm/h, or a C-reactive protein >2 mg/dL). The mean time from hospital arrival to the first antibiotic dose was 5.2 + 4.0 hours. All the children were discharged fully ambulatory and did not require rehospitalization or repeat aspiration after discharge. CONCLUSIONS: This case series shows that POCUS-guided hip aspiration is both safe and feasible in diagnosing septic hip in the pediatric emergency department. The procedure enables rapid diagnosis and early initiation of antibiotic treatment, thus reducing the risk for complications related to delayed initiation of therapy.

Diagnostic Accuracy of Point-of-Care Ultrasound for Intussusception: A Multicenter, Noninferiority Study of Paired Diagnostic Tests.

STUDY OBJECTIVE: To determine the diagnostic accuracy of point-of-care ultrasound (POCUS) performed by experienced clinician sonologists compared to radiology-performed ultrasound (RADUS) for detection of clinically important intussusception, defined as intussusception requiring radiographic or surgical reduction. METHODS: We conducted a multicenter, noninferiority, observational study among a convenience sample of children aged 3 months to 6 years treated in tertiary care emergency departments across North and Central America, Europe, and Australia. The primary outcome was diagnostic accuracy of POCUS and RADUS with respect to clinically important intussusception. Sample size was determined using a 4-percentage-point noninferiority margin for the absolute difference in accuracy. Secondary outcomes included agreement between POCUS and RADUS for identification of secondary sonographic findings. RESULTS: The analysis included 256 children across 17 sites (35 sonologists). Of the 256 children, 58 (22.7%) had clinically important intussusception. POCUS identified 60 (23.4%) children with clinically important intussusception. The diagnostic accuracy of POCUS was 97.7% (95% confidence interval [CI] 94.9% to 99.0%), compared to 99.3% (95% CI 96.8% to 99.9%) for RADUS. The absolute difference between the accuracy of RADUS and that of POCUS was 1.5 percentage points (95% CI -0.6 to 3.6). Sensitivity for POCUS was 96.6% (95% CI 87.2% to 99.1%), and specificity was 98.0% (95% CI 94.7% to 99.2%). Agreement was high between POCUS and RADUS for identification of trapped free fluid (83.3%, n=40/48) and decreased color Doppler signal (95.7%, n=22/23). CONCLUSION: Our findings suggest that the diagnostic accuracy of POCUS performed by experienced clinician sonologists may be noninferior to that of RADUS for detection of clinically important intussusception. Given the limitations of convenience sampling and spectrum bias, a larger randomized controlled trial is warranted.

Valaciclovir to prevent vertical transmission of cytomegalovirus after maternal primary infection during pregnancy: a randomised, double-blind, placebo-controlled trial.

BACKGROUND: Cytomegalovirus is a common congenital infection, with high morbidity after an early primary maternal infection. No effective means exist to prevent viral transmission to the fetus. We aimed to investigate whether valaciclovir can prevent vertical transmission of cytomegalovirus to the fetus in pregnant women with a primary infection acquired early in pregnancy. METHODS: This prospective, randomised, double-blind, placebo-controlled trial was done at the Infectious Feto-Maternal Clinic of Rabin Medical Center (Petach Tikvah, Israel). Pregnant women aged 18 years or older, with serological evidence of a primary cytomegalovirus infection acquired either periconceptionally or during the first trimester of pregnancy, were randomly assigned to oral valaciclovir (8 g per day, twice daily) or placebo from enrolment until amniocentesis at 21 or 22 gestational weeks. Randomisation was done separately for participants infected periconceptionally or during the first trimester and was done in blocks of four. Patients and researchers were masked to participant allocation throughout the entire study period. The primary endpoint was the rate of vertical transmission of cytomegalovirus. Statistical analyses were done according to per-protocol principles. The study was registered at ClinicalTrials.gov, NCT02351102. FINDINGS: Between Nov 15, 2015, and Oct 8, 2018, we enrolled and randomly assigned 100 patients to receive valaciclovir or placebo. Ten patients were excluded, five from each study group; therefore, the final analysis included 45 patients (all singletons) in the valaciclovir group and 45 patients (43 singletons and two sets of twins) in the placebo group. In the valaciclovir group, including both first trimester and periconceptional infections, five (11%) of 45 amniocenteses were positive for cytomegalovirus, compared with 14 (30%) of 47 amniocenteses in the placebo group (p=0·027; odds ratio 0·29, 95% CI 0·09-0·90 for vertical cytomegalovirus transmission). Among participants with a primary cytomegalovirus infection during the first trimester, a positive amniocentesis for cytomegalovirus was significantly less likely in the valaciclovir group (two [11%] of 19 amniocenteses) compared with the placebo group (11 [48%] of 23 amniocenteses; p=0·020. No clinically significant adverse events were reported. INTERPRETATION: Valaciclovir is effective in reducing the rate of fetal cytomegalovirus infection after maternal primary infection acquired early in pregnancy. Early treatment of pregnant women with primary infection might prevent termination of pregnancies or delivery of infants with congenital cytomegalovirus. FUNDING: None.

Acute hemorrhagic edema of infancy: the experience of a large tertiary pediatric center in Israel.

BACKGROUND: Acute hemorrhagic edema of infancy (AHEI) is a rare leukocytoclastic vasculitis of the small vessels occurring at a young age and considered as a benign self-limited disease. Due to its low prevalence, there are limited data on the presentation and complications of this disease. METHODS: All computerized files of children who were hospitalized at a tertiary pediatric center due to AHEI over a 10 year period were reviewed. Clinical, laboratory and histopathological data were collected. RESULTS: Twenty-six patients were included in our study, accounting for 0.7 cases per 1000 admissions of children aged 2 years or less. Mean age was 12.9 months. More than two thirds of the children had preceding symptoms compatible with a viral infection. Upon admission, all patients presented with typical findings of a rash and edema. Edema was most profound over the lower extremities (73%). Concomitant viral or bacterial infections were found in six children. Skin biopsy was performed in six patients revealing leukocytoclastic vasculitis. Thirteen children (50%) had systemic involvement including joint involvement (n=9), gastrointestinal hemorrhage (n=4), microscopic hematuria (n=1) and compartment syndrome of the limb (n=1). The latter was diagnosed in a patient with familial Mediterranean fever. CONCLUSIONS: Our largest data series highlighted what is known regarding clinical and histological findings in children with AHEI. However, contrary to what was previously reported, we found a higher rate of systemic involvement. Although AHEI is a rare entity, pediatricians should be familiar with its presentation, management and our reported complications.

[INSPIRATORY STRIDOR OF A NON-TRADITIONAL CAUSE].

INTRODUCTION: Stridor is a respiratory sound caused by turbulent air flow through narrow airways. The most common cause for acute inspiratory stridor is a viral infection of the upper airways, causing laryngotracheitis (Croup). Other common causes include an allergic reaction, foreign body aspiration and trauma. BACKGROUND: A nine week old infant with a history of meningomyelocele repair perinatally presented to the emergency room with alternating inspiratory stridor. The infant did not have a history of a recent febrile illness, and he did not suffer from cough or any other symptoms suggesting a foreign body aspiration. After the common causes of stridor were ruled out, an MRI was performed - demonstrating Chiari malformation Type 2, with herniation of the cerebellar tonsils and medullary compression. Bronchoscopy demonstrated the rare cause of the intermittent stridor - intermittent vocal cord paralysis, caused by the raised intracranial pressure and medullary compression. Due to rapid clinical deterioration, emergent surgical decompression was performed with complete recovery. CONCLUSIONS: This case report raises a rare and important cause of inspiratory stridor. Physicians should be alert to the symptoms suggesting a Chiari malformation in every child with a relevant medical history presenting with stridor. DISCUSSION: Intermittent stridor is mostly caused by an upper respiratory infection in a child with narrowed airways, allergic laryngotracheitis, or laryngomalacia. A less common cause of stidor of this kind is vocal cord paralysis, which may be caused by a symptomatic Chiari malformation.

Hearing outcome of infants with congenital cytomegalovirus and hearing impairment.

BACKGROUND: Congenital cytomegalovirus (cCMV) is the most common non-genetic cause of childhood sensorineural hearing loss. Antiviral treatment has been shown to prevent hearing deterioration in these infants. However, studies focused on infants with hearing impairment at birth and on the specific degree of impairment and further improvement or deterioration are lacking. OBJECTIVE: To investigate the relationship between hearing status at birth and any change in hearing status at the end of a prolonged follow-up period, after receiving 12 months of antiviral treatment in children born with hearing impairment due to congenital cCMV. METHODS: Clinical, laboratory, radiological and audiological data of all infants with cCMV infection followed in our centre between 2005 and 2013 were reviewed. Treatment with antiviral medication for hearing impairment found during the neonatal period was12 months of gan/valganciclovir. Hearing studies were performed only on infants who had been followed up for more than 1 year after treatment. RESULTS: Hearing impairment at birth was found in 54 (36.2%) of the 149 infants diagnosed with symptomatic cCMV, and found in 77 affected ears; unilateral in 31 (57.4%) and bilateral in 23 (42.6%). After 1 year of antiviral treatment and a long-term follow-up of the 77 affected ears at baseline, 50 (64.9%) had improved, 22 (28.6%) remained unchanged and 5 (6.5%) had deteriorated. Most improved ears (38/50=76%) returned to normal hearing. Improvement was most likely to occur in infants born with mild or moderate hearing loss and less in those with severe impairment. CONCLUSIONS: We found that infants born with cCMV and hearing impairment, receiving 12 months of antiviral treatment, showed significant improvement in hearing status. The probability of hearing improvement seems inversely related to the severity of the impairment at birth.

Cholestatic Hepatitis Induced by Epstein-Barr Virus in a Pediatric Population.

OBJECTIVE: We present 5 cases of Epstein-Barr virus (EBV)-induced cholestatic hepatitis (CH) and review all additional pediatric cases from the literature. DESIGN: The medical records of 5 patients with EBV-induced CH were reviewed. A comprehensive review of the literature was performed. RESULTS: Including our patients, a total of 17 patients with EBV-induced CH were reviewed. The average age was 11 years (range 1-18 years); male to female ratio was 0.9:1. The most common presenting symptoms included fever, jaundice, and cervical lymphadenopathy. However, a significant number of patients presented with jaundice alone, without other suggestive signs of an EBV infection. Hepatocellular enzyme levels were significantly higher than in classical infectious mononucleosis. In many cases, serum alkaline phosphatase was also elevated, accompanied by direct hyperbilirubinemia. CONCLUSION: EBV infection should be included in the differential diagnosis of CH in all age groups. In the vast majority, full recovery is expected.