Pre-school wheeze hospital presentations: A demographic profile and review of clinical management.

AIM: Pre-school wheeze is a common hospital presentation in Australasia. The aim of this study was to describe the regional hospital presentation and cost of pre-school wheeze. METHODS: Audit of children diagnosed with pre-school wheeze at two hospitals in Auckland, New Zealand from October 2017 to September 2019. Guideline adherence was determined. RESULTS: One hundred and ninety-two children made 247 pre-school wheeze hospital presentations. Pre-school wheeze accounted for a larger proportion of acute hospital presentations for Maori versus non-Maori children (rate ratio 1.76, 95% confidence intervals 1.32-2.31). Hospital representations with pre-school wheeze occurred in 38/192 (20%) children. The proportion with a pre-school wheeze representation was larger for Maori than non-Maori (30% vs. 16%, P = 0.02). Pre-school wheeze event median length of stay increased as household deprivation increased (P = 0.01). Clinical severity of 247 pre-school wheeze episodes was mild (n = 64, 26%), moderate (n = 153, 62%) and severe (n = 30, 12%). Of 244 episodes, inhaled bronchodilators only were given for 149 (61%), oxygen for 54 (22%) and intravenous treatment for 41 (17%). Hospital guideline use was evident in 164/247 (66%) episodes. Neither clinical severity nor treatment intensity varied with child sex, age or ethnicity or household deprivation. The estimated median (interquartile range) direct medical costs of each pre-school wheeze episode were NZ$1279 (NZ$774-2158). CONCLUSIONS: In Auckland, pre-school wheeze accounts for a larger proportion of acute hospital presentations for Maori compared with non-Maori and Maori children have increased odds of pre-school wheeze readmissions. Length of hospital stay for pre-school wheeze episodes increased with household deprivation. In this audit pre-school wheeze guideline adherence was poor.

Delayed access to care and late presentations in children during the COVID-19 pandemic New Zealand-wide lockdown: A New Zealand Paediatric Surveillance Unit study.

AIM: Describe paediatricians' experience of adverse health outcomes for children during the New Zealand-wide level 4 lockdown in response to the COVID-19 pandemic. METHODS: Weekly national survey of paediatricians with an open-ended questionnaire. RESULTS: During the 6-week study survey period, the New Zealand Paediatric Surveillance Unit received 33 reports about 55 instances where paediatricians believed care may have been compromised, about half (56%) relating to infants aged from birth to 6 weeks. Compromised care was for acute presentations in 75%, acute complications of a chronic illness in 14%, with 11% for chronic conditions. Paediatricians reported the outcome as moderately severe (short-term morbidity, increased length of stay, higher level of care) in 38 cases (69%) and in a further 4 (7%) as severe (potential to be life-threatening or result in permanent disability). CONCLUSION: Despite clear messaging, hospital avoidance and reduced access to primary and secondary care were associated with significant potential harm for children in New Zealand during a strict lockdown, with newborn infants disproportionately affected. During the implementation of interventions to eliminate community transmission of COVID-19, New Zealand paediatricians note the importance of face-to-face post-natal visits for newborns and primary care services for children with acute illness, to avoid preventable harm.

Do data from child protective services and the police enhance modelling of perinatal risk for paediatric abusive head trauma? A retrospective case-control study.

OBJECTIVES: First, to investigate whether there is a relationship between a family being known to child protective services or police at the time of birth and the risk of abusive head trauma (AHT, formerly known as shaken baby syndrome). Second, to investigate whether data from child protective services or police improve a predictive risk model derived from health records. DESIGN: Retrospective case control study of child protective service and police records. SETTING: Nine maternity hospitals. PARTICIPANTS: 142 consecutive cases of AHT admitted to a tertiary children's hospital from 1991 to 2010 and born in one of the nine participating maternity hospitals. 550 controls matched by the date and hospital of birth. OUTCOME MEASURE: Abusive head trauma. RESULTS: There is a relationship between families known to child protective services or police and the risk of AHT. Notification to child protective services: univariable OR 7.24 (95% CI 4.70 to 11.14). Involvement with youth justice: univariable OR 8.94 (95% CI 4.71 to 16.95). Police call-out for partner violence: univariable OR 3.85 (95% CI 2.51 to 5.91). Other violence offence: univariable OR 2.73 (95% CI 1.69 to 4.40). Drug offence: univariable OR 2.82 (95% CI 1.63 to 4.89). However, in multi-variable analysis with data from perinatal health records, notification to child protective services was the only one of these variables to remain in the final model (OR 4.84; 95% CI 2.61 to 8.97) and had little effect on overall predictive power. The area under the receiver operating characteristic curve was 89.5% (95% CI 86.6 to 92.5) using variables from health data alone and 90.9% (95% CI 88.0 to 93.7) when notification was added. CONCLUSIONS: Family involvement with child protective services or police is associated with increased risk of AHT. However, accessing such data at the time of birth would add little predictive power to a risk model derived from routine health information.

Is a rheumatic fever register the best surveillance tool to evaluate rheumatic fever control in the Auckland region?

AIM: To determine the most accurate data source for acute rheumatic fever (ARF) epidemiology in the Auckland region. METHOD: To assess coverage of the Auckland Regional Rheumatic Fever Register (ARRFR), (1998-2010) for children <15 years and resident in Auckland at the time of illness, register, hospitalisation and notification data were compared. A consistent definition was applied to determine definite and probable cases of ARF using clinical records. (www.heartfoundation.org.nz) RESULTS: Of 559 confirmed (definite and probable) RF cases <15 years (median age 10 years), seven were recurrences. Of 552 first episodes, the ARRFR identified 548 (99%), hospitalisations identified 501 (91%) including four not on the register, and public health notifications identified 384 (70%). Of hospitalisation cases, 33% (245/746), and of notifications 20% (94/478) did not meet the case definition and were therefore excluded. Between 1998-2010, eight cases, initially entered as ARF on the ARRFR, were later removed once further clinical detail was available. CONCLUSION: The ARRFR produced the most accurate information surrounding new cases of ARF (for children <15 years) for the years 1998-2010 in Auckland. This was significantly more accurate than medical officer of health notification and hospitalisation data.

Perinatal Risk and Protective Factors for Pediatric Abusive Head Trauma: A Multicenter Case-Control Study.

OBJECTIVE: To estimate associations between factors recorded in pregnancy and the first week of life and subsequent abusive head trauma. STUDY DESIGN: Multicenter, retrospective case-control study of perinatal records from 142 cases of abusive head trauma and 550 controls, matched by date and hospital of birth from 1991 to 2010. Multiple logistic regression assessed the relationship between perinatal exposures and abusive head trauma. RESULTS: The risk of abusive head trauma decreased with increasing maternal age (OR, 0.91 per year; 95% CI 0.85-0.97) and increasing gestational age at birth (OR 0.79 per week; 95% CI 0.69-0.91). Mothers of cases were more likely to be Maori (OR 4.61; 95% CI 1.98-10.78), to be single (OR 5.10; 95% CI 1.83-14.23), have recorded social concerns (OR 4.29; 95% CI 1.32-13.91), and have missing data for antenatal care, partner status, social concerns, and substance abuse (OR 13.53; 95% CI 2.39-76.47). Case mothers were more likely not to take supplements in pregnancy (OR 3.53; 95% CI 1.30-9.54), to have membrane rupture longer than 48 hours before delivery (OR 13.01; 95% CI 2.84-59.68), and to formula feed (OR for mixed breast and formula feeding 6.06; 95% CI 2.39-15.36) before postnatal discharge (median 3 days). CONCLUSIONS: Factors associated with subsequent abusive head trauma can be identified from routine perinatal records. Targeted interventions initiated perinatally could possibly prevent some cases of abusive head trauma. However, any plans for targeted prevention strategies should consider not only those with identified risk factors but also those for which data are missing.

Carotenemia and hepatomegaly in an atopic child on an exclusion diet for a food allergy.

Eczema is a frequent childhood manifestation and a few atopic children are allergic to certain foods or aeroallergens. Anxious parents of atopic children often have a fear of topical steroid-related side-effects, and some may try a range of elimination diets to avoid allergies. Elimination diets increase the risk of anaphylaxis on re-exposure to previously tolerated foods from the loss of oral tolerance. Unbalanced diets together with an inadvertent excessive consumption of fruits and vegetables may lead to carotenemia from the carotenoids in the plant foods. Carotenemia is benign but unusual diets and the consumption of preformed vitamin A in health supplements can lead to vitamin A toxicity. We discuss a child with eczema on an exclusion diet presenting with anaphylaxis to dairy food. He had carotenemia with hepatomegaly, which resolved on dietary management.

An evaluation of a pictorial asthma medication plan for Pacific children.

BACKGROUND: The burden of asthma falls disproportionately on children from New Zealand's Pacific communities. Guidelines recommend pictorial resources but these have not been evaluated in this population. AIMS: Evaluate a pictorial asthma medication plan focusing on regular 'everyday' inhaler use and a signs and symptoms sheet for Pacific children; the primary outcome measure was continued use of resources after 6 months. METHODS: Resources were provided to families with face-to-face education at a general practice or inpatient setting in West Auckland. A questionnaire about the resources was completed after 6 weeks, and an audit regarding use after 6 months. RESULTS: Data from 48 children were analysed (Samoan, n=31); 45 English and 22 first language versions (Samoan, Tongan, Tuvaluan) were used; median time to questionnaire completion was 48 days. The pictorial asthma medication plan was acceptable to families, effective at reinforcing the importance of 'everyday' inhalers, and a reminder for regular use; the signs and symptoms sheets were informative and improved self-efficacy; 93% of families were using the resources after 6 months. An increase in 'everyday' inhaler use was observed after education. CONCLUSION: The resources were effective at improving inhaler knowledge and supporting symptom recognition. A 'less-is-more' approach, pictorial format, and first language availability are characteristics that may benefit other ethnicities.