Validation of a Modified Triage Scale in a Norwegian Pediatric Emergency Department.

OBJECTIVE: Triage is a tool developed to identify patients who need immediate care and those who can safely wait. The aim of this study was to assess the validity and interrater reliability of a modified version of the pediatric South African triage scale (pSATS) in a single-center tertiary pediatric emergency department in Norway. METHODS: This prospective, observational study included all patients with medical conditions, referred to the pediatric emergency department of a tertiary hospital in Norway from September 1, 2015, to November 17, 2015. Their assigned triage priority was compared with rate of hospitalization and resource utilization. Validity parameters were sensitivity, specificity, positive and negative predictive value, and percentage of over- and undertriage. Interrater agreement and accuracy of the triage ratings were calculated from triage performed by nurses on written case scenarios. RESULTS: During the study period, 1171 patients arrived at the hospital for emergency assessment. A total of 790 patients (67 %) were triaged and included in the study. The percentage of hospital admission increased with increasing level of urgency, from 30 % of the patients triaged to priority green to 81 % of those triaged to priority red. The sensitivity was 74 %, the specificity was 48 %, the positive predictive value was 52 %, and the negative predictive value was 70 % for predicting hospitalization. The level of over- and undertriage was 52 % and 26 %, respectively. Resource utilization correlated with higher triage priority. The interrater agreement had an intraclass correlation coefficient of 0.99 by Cronbach's alpha, and the accuracy was 92 %. CONCLUSIONS: The modified pSATS had a moderate sensitivity and specificity but showed good correlation with resource utilization. The nurses demonstrated excellent interrater agreement and accuracy when triaging written case scenarios.

Parental anxiety related to referral of childhood heart murmur; an observational/interventional study.

BACKGROUND: Detection of a heart murmur in healthy children is common, but may generate anxiety among parents. Many parents believe a heart murmur is a sign of heart disease, although the majority of heart murmurs are innocent. The purpose of this study was to assess anxiety and concerns in parents of children referred for evaluation of a heart murmur and to evaluate the effect of receiving a fact sheet about heart murmurs before the cardiologic consultation. METHODS: Parents of children referred for evaluation of a heart murmur responded to questionnaires assessing family and patient characteristics, parental concerns and anxiety. Anxiety was measured using the State Trait Anxiety Index (STAI) before and two weeks after the consultation. One third of the parents received a fact sheet before the consultation. RESULTS: Two hundred fifty-eight parents of 178 children participated. About 60 % of the parents had an increased level of anxiety before the consultation. The majority of the parents (71 %) had at least one major concern about heart murmurs in children, and having a concern was related to higher anxiety levels (p = 0.02). Anxious personality and lower education predicted an increased anxiety level. Before the consultation, parents who received a fact sheet presented a lower mean STAI state anxiety level (33.2) than those who did not (35.3), but the difference was not significant (p = 0.09). Fewer parents in the intervention group believed their child would have increased risk of heart disease later in life (p = 0.04) or that heart murmurs in children represents valvular-or congenital heart disease (p = 0.02). After the consultation, parental anxiety decreased from a mean STAI state of 34.9 to 30.6 (p < 0.01), and the mean STAI state scores were similar for the control and intervention group. CONCLUSION: Parents with a child referred for a heart murmur presented a higher mean anxiety level than pre-school parents, and having an anxious personality, a major concern or low education predicted an increased anxiety level. After the consultation, parental anxiety decreased. Receiving a fact sheet about heart murmurs did not significantly reduce parental anxiety levels, but had a modest effect on concerns for the consequences of a heart murmur.

Associations of maternal atopic diseases with adverse pregnancy outcomes: a national cohort study.

BACKGROUND: Maternal asthma has been associated with adverse pregnancy outcomes. Little is known about the influence of other atopic diseases on pregnancy outcomes. We assessed how various maternal atopic diseases might affect preterm birth, stillbirth, and neonatal death. METHODS: By linking Norwegian national registries, we acquired information on maternal health, socio-demographic factors, pregnancy, birth, and neonatal outcome on all births in Norway from 1967 to 2003. RESULTS: A total of 1 974 226 births were included. Of these, 1.8% had a record of maternal asthma, 3.4% of maternal atopic dermatitis, and 0.4% of maternal allergic rhinoconjunctivitis. Overall rates of preterm birth, stillbirth, and neonatal death were 6.0%, 0.6%, and 0.5%, respectively. After adjustments for possible confounders, maternal asthma was associated with increased risk of preterm birth (relative risk (RR), 1.15, [95% confidence interval (CI) 1.10, 1.21]). In contrast, maternal atopic dermatitis was associated with decreased risk of preterm birth (RR 0.90, [95% CI 0.86, 0.93]), stillbirth (RR 0.70, [95% CI 0.62, 0.79]), and neonatal death (RR 0.76, [95% CI 0.65, 0.90]). Similarly, maternal allergic rhinoconjunctivitis was associated with decreased risk of preterm birth (RR 0.84, [95% CI 0.76, 0.94]) and stillbirth (RR 0.40, [95% CI 0.25, 0.66]). CONCLUSIONS: We confirmed the previously reported association of maternal asthma with increased risk for preterm birth. Unexpectedly, maternal atopic dermatitis and allergic rhinoconjunctivitis were associated with decreased risk of preterm birth and stillbirth. Mechanisms for these protective associations are unclear, and our findings require confirmation in further studies.

Risk of cerebral palsy in relation to pregnancy disorders and preterm birth: a national cohort study.

AIM: To assess the risk of developing cerebral palsy in relation to pregnancy disorders and preterm birth. METHOD: By linking the Medical Birth Registry of Norway to other national registries, we identified all live births in Norway from 1967 through to 2001. Risks of cerebral palsy (CP) after preterm delivery and pregnancy disorders were estimated in different gestational age groups. RESULT: In total, 1 764 509 children delivered at 23 to 43 weeks' gestation were included. The prevalence of CP was 1.8 per 1000 births. Absolute risk of CP was 8.5% among children born at 23 to 27 weeks' gestation, 5.6% at 28 to 30 weeks, 2.0% at 31 to 33 weeks, 0.4% at 34 to 36 weeks, and 0.1% thereafter. Placental abruption, chorioamnionitis, prolonged rupture of membranes, intrauterine growth restriction, pre-eclampsia, multiple births, placenta previa, bleeding, cervical conization, and congenital malformation were all associated with CP. Before 32 weeks' gestation, absolute risk of CP was highest with chorioamnionitis (9.1%) and lowest with pre-eclampsia (3.1%). Among those born after 31 weeks, the absolute risk of CP was more consistently (but also more slightly) increased with a recorded pregnancy disorder. INTERPRETATION: Early delivery and pregnancy disorders were both strong risk factors for CP. The added risks with recorded pregnancy disorders varied within categories of gestational age.

The association of preterm birth with severe asthma and atopic dermatitis: a national cohort study.

BACKGROUND: Asthma and atopic dermatitis are both regarded as atopic diseases. Being born too early is associated with increased risk of asthma, but some studies have indicated that the opposite might be true for atopic dermatitis. We explored in more detail the associations between preterm birth, asthma, and atopic dermatitis. METHODS: We analyzed data from Norwegian registries with prospectively collected data. All live births in Norway from 1967 through 2001 were followed through 2005 by linking the Medical Birth Registry of Norway to the National Insurance Scheme and to Statistics Norway. Only severe asthma and atopic dermatitis were registered in the National Insurance Scheme. RESULTS: Of a total of 1,760,821 children, we identified 9,349 cases (0.5%) with severe asthma and 6,930 cases (0.4%) with severe atopic dermatitis. Compared with children born at term (37-41 wk gestation), preterm birth was associated with increased odds for severe asthma (odds ratio (OR) 1.7 (95% confidence interval (CI): 1.6-1.8) for 32-36 wk gestation and OR 3.6 (95% CI: 3.1-4.2) for 23-31 wk) and decreased odds for severe atopic dermatitis (OR 0.9 (95% CI: 0.8-1.0) for 32-36 wk gestation and OR 0.7 (95% CI: 0.5-1.0) for 23-31 wk). Adjustment for perinatal and socio-demographic factors weakened the association between gestational age and severe asthma, while slightly strengthening the association between gestational age and severe atopic dermatitis. CONCLUSIONS: Preterm birth was associated with increased risk of severe asthma and decreased risk of severe atopic dermatitis.

[Cardiac arrest in a 10-month-old boy with spinal cord injury]. / Hjertestans hos en ti måneder gammel gutt med ryggmargsskade.

A 10-month-old boy with a previous upper spinal cord injury was admitted to hospital with acute respiratory and circulatory distress. Shortly after admission the boy had severe bradycardia leading to asystolia and pulseless electrical activity. He was successfully resuscitated, and the investigation that followed excluded infection, congenital heart defect, arrhythmia and cerebral haemorrhage. Over the following days the patient had several episodes of isolated bradycardia and combined bradycardia and hypotension. It was concluded that the patient suffered from autonomic dysreflexia, triggered by a distended urinary bladder. He was treated with intermittent catheterization and a permanent pacemaker, and after 12 months there have not been any symptomatic episodes or registered arrhythmias. Autonomic dysreflexia is a common and well known complication of spinal cord injury above Th6, but the literature on paediatric patients is scarce. Our case report presents an infant with an atypical and severe episode of autonomic dysreflexia. Patients with spinal cord injury, their caregivers and health-care personal should be aware of this complication of spinal cord injury, in order to prevent and treat autonomic dysreflexia properly and avoid potentially fatal episodes.

Small cell lung cancer in a 14-year-old girl.

Pediatric lung cancer is uncommon, and small cell lung cancer (SCLC) is exceptionally rare. A 14-year-old previously healthy girl was diagnosed with limited-stage SCLC, which was considered inoperable. She responded well to chemotherapy with carboplatin and etoposide, and surgical resection was performed after 2 cycles. High-dose thoracic radiotherapy in combination with etoposide and carboplatin was given as postoperative treatment. The patient died of relapsing disease 21 months after initial diagnosis. Only 1 single case report on SCLC has been published earlier. Additional reports on pediatric SCLC are needed to evaluate appropriate treatment.

[A 9-week-old boy with fever and diarrhoea]. / En gutt på ni uker med høy feber og diaré.

A 9-week-year-old boy was admitted to the pediatric clinic after 12 hours of fever and diarrhoea. On admission he had a fever of 40 degrees C, rhinitis and moderate diarrhoea. Blood tests were normal, except for elevated CRP (89 mg/L). The tentative diagnosis was viral gastroenteritis, and peroral rehydration with a hypertone glucose-salt-mixture was started. CRP reached a maximum of 199 mg/L, and the boy stayed febrile throughout the next days. Stool examination revealed Enterovirus. After several clinical examinations, findings included a reactive cervical glandular node and mild conjunctivitis. When the child had been febrile for five days, he was admitted to an echocardiography, which showed dilated coronary arteries with abnormal caliber variations and a small amount of pericardial fluid. Since he fulfilled only three of the five criteria of classical Kawasaki disease, he was diagnosed as having neonatal, incomplete Kawasaki disease. Kawasaki disease is an immunologic vasculitis that appears mainly in children between three months and 12 years of age. Only 2% of patients with Kawasaki disease are less than three months old. Neonates with Kawasaki disease often have an atypical presentation of symptoms and have a particular risk of developing coronary artery aneurysms with potentially fatal outcome. With this case-report we will stress the importance of considering Kawasaki disease in neonates with fever of unknown origin.