Post-COVID-19 Conditions Among Children 90 Days After SARS-CoV-2 Infection

IMPORTANCE

Little is known about the risk factors for, and the risk of, developing post-COVID-19 conditions (PCCs) among children.

OBJECTIVES

To estimate the proportion of SARS-CoV-2-positive children with PCCs 90 days after a positive test result, to compare this proportion with SARS-CoV-2-negative children, and to assess factors associated with PCCs.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study, conducted in 36 emergency departments (EDs) in 8 countries between March 7, 2020, and January 20, 2021, included 1884 SARS-CoV-2-positive children who completed 90-day follow-up; 1686 of these children were frequency matched by hospitalization status, country, and recruitment date with 1701 SARS-CoV-2-negative controls.

EXPOSURE

SARS-CoV-2 detected via nucleic acid testing.

MAIN OUTCOMES AND MEASURES

Post-COVID-19 conditions, defined as any persistent, new, or recurrent health problems reported in the 90-day follow-up survey.

RESULTS

Of 8642 enrolled children, 2368 (27.4%) were SARS-CoV-2 positive, among whom 2365 (99.9%) had index ED visit disposition data available; among the 1884 children (79.7%) who completed follow-up, the median age was 3 years (IQR, 0-10 years) and 994 (52.8%) were boys. A total of 110 SARS-CoV-2-positive children (5.8%; 95% CI, 4.8%-7.0%) reported PCCs, including 44 of 447 children (9.8%; 95% CI, 7.4%-13.0%) hospitalized during the acute illness and 66 of 1437 children (4.6%; 95% CI, 3.6%-5.8%) not hospitalized during the acute illness (difference, 5.3%; 95% CI, 2.5%-8.5%). Among SARS-CoV-2-positive children, the most common symptom was fatigue or weakness (21 [1.1%]). Characteristics associated with reporting at least 1 PCC at 90 days included being hospitalized 48 hours or more compared with no hospitalization (adjusted odds ratio [aOR], 2.67 [95% CI, 1.63-4.38]); having 4 or more symptoms reported at the index ED visit compared with 1 to 3 symptoms (4-6 symptoms: aOR, 2.35 [95% CI, 1.28-4.31]; ≥7 symptoms: aOR, 4.59 [95% CI, 2.50-8.44]); and being 14 years of age or older compared with younger than 1 year (aOR, 2.67 [95% CI, 1.43-4.99]). SARS-CoV-2-positive children were more likely to report PCCs at 90 days compared with those who tested negative, both among those who were not hospitalized (55 of 1295 [4.2%; 95% CI, 3.2%-5.5%] vs 35 of 1321 [2.7%; 95% CI, 1.9%-3.7%]; difference, 1.6% [95% CI, 0.2%-3.0%]) and those who were hospitalized (40 of 391 [10.2%; 95% CI, 7.4%-13.7%] vs 19 of 380 [5.0%; 95% CI, 3.0%-7.7%]; difference, 5.2% [95% CI, 1.5%-9.1%]). In addition, SARS-CoV-2 positivity was associated with reporting PCCs 90 days after the index ED visit (aOR, 1.63 [95% CI, 1.14-2.35]), specifically systemic health problems (eg, fatigue, weakness, fever; aOR, 2.44 [95% CI, 1.19-5.00]).

CONCLUSIONS AND RELEVANCE

In this cohort study, SARS-CoV-2 infection was associated with reporting PCCs at 90 days in children. Guidance and follow-up are particularly necessary for hospitalized children who have numerous acute symptoms and are older.

Contemporary Trends in Global Mortality of Sepsis Among Young Infants Less Than 90 Days: A Systematic Review and Meta-Analysis

Objective

Current knowledge on the global burden of infant sepsis is limited to population-level data. We aimed to summarize global case fatality rates (CFRs) of young infants with sepsis, stratified by gross national income (GNI) status and patient-level risk factors.

Methods

We performed a systematic review and meta-analysis on CFRs among young infants < 90 days with sepsis. We searched PubMed, Cochrane Central, Embase, and Web of Science for studies published between January 2010 and September 2019. We obtained pooled CFRs estimates using the random effects model. We performed a univariate analysis at patient-level and a meta-regression to study the associations of gestational age, birth weight, onset of sepsis, GNI, age group and culture-proven sepsis with CFRs.

Results

The search yielded 6314 publications, of which 240 studies (N = 437,796 patients) from 77 countries were included. Of 240 studies, 99 were conducted in high-income countries, 44 in upper-middle-income countries, 82 in lower-middle-income countries, 6 in low-income countries and 9 in multiple income-level countries. Overall pooled CFR was 18% (95% CI, 17-19%). The CFR was highest for low-income countries [25% (95% CI, 7-43%)], followed by lower-middle [25% (95% CI, 7-43%)], upper-middle [21% (95% CI, 18-24%)] and lowest for high-income countries [12% (95% CI, 11-13%)]. Factors associated with high CFRs included prematurity, low birth weight, age less than 28 days, early onset sepsis, hospital acquired infections and sepsis in middle- and low-income countries. Study setting in middle-income countries was an independent predictor of high CFRs. We found a widening disparity in CFRs between countries of different GNI over time.

Conclusion

Young infant sepsis remains a major global health challenge. The widening disparity in young infant sepsis CFRs between GNI groups underscore the need to channel greater resources especially to the lower income regions.

Systematic Review Registration

[www.crd.york.ac.uk/prospero], identifier [CRD42020164321].

Comparative efficacy of anaesthetic methods for closed reduction of paediatric forearm fractures: a systematic review

BACKGROUND

Forearm fractures in children often require closed reduction in the emergency setting. The choice of anaesthesia influences the degree of pain relief, which determines the success of reduction. Main methods of anaesthesia include procedural sedation and analgesia, haematoma block, intravenous regional anaesthesia (IVRA) and regional nerve blocks. However, their comparative effectiveness is unclear. This study aims to synthesise peer-reviewed evidence and identify the most effective, in terms of pain reduction, and safest anaesthetic method.

METHODS

MEDLINE, Embase and the Cochrane Library were searched from inception to 15 June 2021. Randomised controlled trials comparing anaesthetic methods for the closed reduction of paediatric forearm fractures in the emergency setting were included. Two reviewers independently screened, collected data and assessed the risk of bias for the selected outcomes. The primary outcome was pain during reduction. Secondary outcomes included pain after reduction, adverse effects, satisfaction, adequacy of sedation/anaesthesia, success of reduction and resource use.

RESULTS

1288 records were screened and 9 trials, which studied 936 patients in total, were included. Four trials compared the main methods of anaesthesia. Within the same method of anaesthesia, one compared administrative routes, one compared procedural techniques, one compared different drugs, one compared the use of adjuncts and one compared different doses of the same drug. One study found better pain outcomes with infraclavicular blocks compared with procedural sedation and analgesia. Lidocaine was superior in analgesic effect to prilocaine in IVRA in one study. One study found lower pain scores with moderate-dose than low-dose lidocaine in IVRA.

CONCLUSION

Few randomised controlled trials compared anaesthetic methods in the closed reduction of paediatric forearm fractures. High heterogeneity precluded meta-analysis. Overall, current data are insufficient to guide the choice of anaesthetic method in emergency settings. More adequately powered trials, conducted using standardised methods, are required.

Early posttraumatic seizures in pediatric traumatic brain injury: a multicenter analysis

OBJECTIVE

Early posttraumatic seizures (EPTSs) in children after traumatic brain injury (TBI) increase metabolic stress on the injured brain. The authors sought to study the demographic and radiographic predictors for EPTS, and to investigate the association between EPTS and death, and between EPTS and poor functional outcomes among children with moderate to severe TBI in Asia.

METHODS

A secondary analysis of a retrospective TBI cohort among participating centers of the Pediatric Acute & Critical Care Medicine Asian Network was performed. Children < 16 years of age with a Glasgow Coma Scale (GCS) score ≤ 13 who were admitted to pediatric intensive care units between January 2014 and October 2017 were included. Logistic regression analysis was performed to study risk factors for EPTS and to investigate the association between EPTS and death, and between EPTS and poor functional outcomes. Poor functional outcomes were defined as moderate disability, severe disability, and coma as defined by the Pediatric Cerebral Performance Category scale.

RESULTS

Overall, 313 children were analyzed, with a median age of 4.3 years (IQR 1.8-8.9 years); 162 children (51.8%) had severe TBI (GCS score < 8), and 76 children (24.3%) had EPTS. After adjusting for age, sex, and the presence of nonaccidental trauma (NAT), only younger age was significantly associated with EPTS (adjusted odds ratio [aOR] 0.85, 95% CI 0.78-0.92; p < 0.001). Forty-nine children (15.6%) in the cohort died, and 87 (32.9%) of the 264 surviving patients had poor functional outcomes. EPTS did not increase the risk of death. After adjusting for age, sex, TBI due to NAT, multiple traumas, and a GCS score < 8, the presence of EPTS was associated with poor functional outcomes (aOR 2.08, 95% CI 1.05-4.10; p = 0.036).

CONCLUSIONS

EPTSs were common among children with moderate to severe TBI in Asia and were associated with poor functional outcomes among children who survived TBI.

Outcomes of SARS-CoV-2-Positive Youths Tested in Emergency Departments: The Global PERN-COVID-19 Study

IMPORTANCE

Severe outcomes among youths with SARS-CoV-2 infections are poorly characterized.

OBJECTIVE

To estimate the proportion of children with severe outcomes within 14 days of testing positive for SARS-CoV-2 in an emergency department (ED).

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study with 14-day follow-up enrolled participants between March 2020 and June 2021. Participants were youths aged younger than 18 years who were tested for SARS-CoV-2 infection at one of 41 EDs across 10 countries including Argentina, Australia, Canada, Costa Rica, Italy, New Zealand, Paraguay, Singapore, Spain, and the United States. Statistical analysis was performed from September to October 2021.

EXPOSURES

Acute SARS-CoV-2 infection was determined by nucleic acid (eg, polymerase chain reaction) testing.

MAIN OUTCOMES AND MEASURES

Severe outcomes, a composite measure defined as intensive interventions during hospitalization (eg, inotropic support, positive pressure ventilation), diagnoses indicating severe organ impairment, or death.

RESULTS

Among 3222 enrolled youths who tested positive for SARS-CoV-2 infection, 3221 (>99.9%) had index visit outcome data available, 2007 (62.3%) were from the United States, 1694 (52.6%) were male, and 484 (15.0%) had a self-reported chronic illness; the median (IQR) age was 3 (0-10) years. After 14 days of follow-up, 735 children (22.8% [95% CI, 21.4%-24.3%]) were hospitalized, 107 (3.3% [95% CI, 2.7%-4.0%]) had severe outcomes, and 4 children (0.12% [95% CI, 0.03%-0.32%]) died. Characteristics associated with severe outcomes included being aged 5 to 18 years (age 5 to <10 years vs <1 year: odds ratio [OR], 1.60 [95% CI, 1.09-2.34]; age 10 to <18 years vs <1 year: OR, 2.39 [95% CI 1.38-4.14]), having a self-reported chronic illness (OR, 2.34 [95% CI, 1.59-3.44]), prior episode of pneumonia (OR, 3.15 [95% CI, 1.83-5.42]), symptoms starting 4 to 7 days prior to seeking ED care (vs starting 0-3 days before seeking care: OR, 2.22 [95% CI, 1.29-3.82]), and country (eg, Canada vs US: OR, 0.11 [95% CI, 0.05-0.23]; Costa Rica vs US: OR, 1.76 [95% CI, 1.05-2.96]; Spain vs US: OR, 0.51 [95% CI, 0.27-0.98]). Among a subgroup of 2510 participants discharged home from the ED after initial testing and who had complete follow-up, 50 (2.0%; 95% CI, 1.5%-2.6%) were eventually hospitalized and 12 (0.5%; 95% CI, 0.3%-0.8%) had severe outcomes. Compared with hospitalized SARS-CoV-2-negative youths, the risk of severe outcomes was higher among hospitalized SARS-CoV-2-positive youths (risk difference, 3.9%; 95% CI, 1.1%-6.9%).

CONCLUSIONS AND RELEVANCE

In this study, approximately 3% of SARS-CoV-2-positive youths tested in EDs experienced severe outcomes within 2 weeks of their ED visit. Among children discharged home from the ED, the risk was much lower. Risk factors such as age, underlying chronic illness, and symptom duration may be useful to consider when making clinical care decisions.

Delays in Time-To-Antibiotics for Young Febrile Infants With Serious Bacterial Infections: A Prospective Single-Center Study

INTRODUCTION

Fear of missed serious bacterial infections (SBIs) results in many febrile young infants receiving antibiotics. We aimed to compare the time to antibiotics between infants with SBIs and those without.

MATERIALS AND METHODS

We recruited febrile infants ≤ 90 days old seen in the emergency department (ED) between December 2017 and April 2021. SBI was defined as (1) urinary tract infection, (2) bacteremia or (3) bacterial meningitis. We compared the total time (median with interquartile range, IQR) from ED arrival to infusion of antibiotics, divided into (i) time from triage to decision for antibiotics and (ii) time from decision for antibiotics to administration of antibiotics.

RESULTS

We analyzed 81 and 266 infants with and without SBIs. Median age of those with and without SBIs were 44 (IQR 19-72) and 29 (IQR 7-56) days, respectively (p = 0.002). All infants with SBIs and 168/266 (63.2%) infants without SBIs received antibiotics. Among 249 infants who received antibiotics, the median total time from ED arrival to infusion of antibiotics was 277.0 (IQR 236.0-385.0) mins for infants with SBIs and 304.5 (IQR 238.5-404.0) mins for those without (p = 0.561). The median time to decision for antibiotics was 156.0 (IQR 115.0-255.0) mins and 144.0 (IQR 105.5-211.0) mins, respectively (p = 0.175). Following decision for antibiotics, infants with SBIs received antibiotics much faster compared to those without [107.0 (IQR 83.0-168.0) vs. 141.0 (94.0-209.5) mins, p = 0.017].

CONCLUSION

There was no difference in total time taken to antibiotics between infants with SBIs and without SBIs. Both recognition and administration delays were observed. While all infants with SBIs were adequately treated, more than half of the infants without SBIs received unnecessary antibiotics. This highlights the challenge in managing young febrile infants at initial presentation, and demonstrates the need to examine various aspects of care to improve the overall timeliness to antibiotics.

Novel two-tiered developmental screening programme for Singaporean toddlers: a quality improvement report

Early identification of developmental delays with timely intervention, especially before the age of 3 years, can improve child development. In Singapore, however, diagnosis and intervention for developmental delays occur at a median age of 44 months. As early detection and intervention depends on an effective developmental screening programme, we aimed to improve the detection of developmental delays before the age of 3 years in a primary care setting. We did this by implementing a novel two-tiered screening programme which uses three standardised screening tools (Parents' Evaluation of Developmental Status, PEDS-Developmental Milestones and Ages and Stages Questionnaire-3). We used quality improvement methods to integrate and optimise this two-tiered programme into the existing 9-month and 18-month screening schedule, with an additional screening at 30 months to replace the pre-existing 36-month screening of the National Child Health Surveillance Programme. A total of three Plan-Do-Study-Act cycles were performed to ensure programme feasibility and sustainability. They focused on adequately training the primary care nurses, targeting an 80% screening rate and aiming for 20 min screening tool administration time per child. We assessed the proportion of children referred to the child development units after positive screening for developmental concerns under the new programme, with a pre-post and with-without intervention comparison, and reviewed the screening rates and screening tool administration time. The proportion of 18-month old children referred for developmental concerns improved from 3.5%-7.1% over a 6-month period. For those who received further assessment by developmental specialists after the two-tiered screening, 100% received a definitive diagnosis of developmental delays, similar to the situation before programme introduction. Our quality improvement efforts facilitated successful integration of the two-tiered programme into the pre-existing screening schedule with minimal impact to the clinic workflow. While we highlight challenges in implementation that need to be addressed, our findings support a potential nationwide adoption of the two-tiered programme.

Differences in radiation dose for computed tomography of the brain among pediatric patients at the emergency departments: an observational study

BACKGROUND

Computed tomography (CT) is associated with a risk of cancer development. Strategies to reduce radiation doses vary between centers. We compared radiation doses of CT brain studies between pediatric and general emergency departments (EDs), and determine the proportion studies performed within the reference levels recommended by the International Commission on Radiological Protection (ICRP).

METHODS

A retrospective review was carried out in a healthcare network consisting of one pediatric ED and three general hospital EDs. Pediatric patients less than 16 years old with CT brain studies performed between 1 January 2015 and 31 December 2018 were included. Information on demographic, diagnosis, volume-averaged computed-tomography dose index and dose length product (DLP) were collected. Effective dose was then calculated from DLP using conversion factors, termed k-coefficients which were derived using a 16 cm head CT dose phantom.

RESULTS

Four hundred and seventy-nine CT brain studies were performed - 379 (79.1%) at the pediatric ED. Seizure (149, 31.1%), head injury (147, 30.7%) and altered mental status (44, 9.2%) were the top three ED diagnoses. The median effective dose estimates were higher in general than pediatric EDs, particularly for those aged > 3 to ≤6 years old [1.57 mSv (IQR 1.42-1.79) versus 1.93 mSv (IQR 1.51-2.28), p = 0.047], > 6 to ≤10 years old [1.43 mSv (IQR 1.27-1.67) versus 1.94 mSv (IQR 1.61-2.59), p = 0.002) and > 10 years old (1.68 mSv (IQR 1.32-1.72) versus 2.03 mSv (IQR 1.58-2.88), p < 0.001). Overall, 233 (48.6%) and 13 (2.7%) studies were within the reference levels recommended by ICRP 60 and 103 respectively.

CONCLUSIONS

Radiation doses for CT brain studies were significantly higher at general EDs and less than half of the studies were within the reference levels recommended by ICRP. The development of diagnostic reference levels (DRLs) as a benchmark and clinical justification for performing CT studies can help reduce the radiation risks in the pediatric population.

Heart rate n-variability (HRnV) measures for prediction of mortality in sepsis patients presenting at the emergency department

Sepsis is a potentially life-threatening condition that requires prompt recognition and treatment. Recently, heart rate variability (HRV), a measure of the cardiac autonomic regulation derived from short electrocardiogram tracings, has been found to correlate with sepsis mortality. This paper presents using novel heart rate n-variability (HRnV) measures for sepsis mortality risk prediction and comparing against current mortality prediction scores. This study was a retrospective cohort study on patients presenting to the emergency department of a tertiary hospital in Singapore between September 2014 to April 2017. Patients were included if they were above 21 years old and were suspected of having sepsis by their attending physician. The primary outcome was 30-day in-hospital mortality. Stepwise multivariable logistic regression model was built to predict the outcome, and the results based on 10-fold cross-validation were presented using receiver operating curve analysis. The final predictive model comprised 21 variables, including four vital signs, two HRV parameters, and 15 HRnV parameters. The area under the curve of the model was 0.77 (95% confidence interval 0.70–0.84), outperforming several established clinical scores. The HRnV measures may have the potential to allow for a rapid, objective, and accurate means of patient risk stratification for sepsis severity and mortality. Our exploration of the use of wealthy inherent information obtained from novel HRnV measures could also create a new perspective for data scientists to develop innovative approaches for ECG analysis and risk monitoring.

Associations of initial haemodynamic profiles and neurological outcomes in children with traumatic brain injury: a secondary analysis

INTRODUCTION

Initial low systolic blood pressure (SBP) in paediatric traumatic brain injury (TBI) is associated with mortality. There is limited literature on how other haemodynamic parameters including heart rate (HR); diastolic blood pressure (DBP); mean arterial pressure (MAP); and shock index, paediatric age-adjusted (SIPA) affect not only mortality but also long-term neurological outcomes in paediatric TBI. We aimed to analyse the associations of these haemodynamic variables (HR, SBP, MAP, DBP and SIPA) with mortality and long-term neurological outcomes in isolated moderate-to-severe paediatric TBI.

METHODS

This was a secondary analysis of our primary study that analysed the association of TBI-associated coagulopathy with mortality and neurological outcome in isolated, moderate-to-severe paediatric head injury. A trauma registry-based, retrospective study of children <18 years old who presented to the emergency department with isolated, moderate-to-severe TBI from January 2010 to December 2016 was conducted. The association between initial haemodynamic variables and less favourable outcomes using Glasgow Outcome Scale-Extended Paediatric) at 6 months post injury was analysed using logistic regression.

RESULTS

Among 152 children analysed, initial systolic and diastolic hypotension (<5th percentile) (OR) for SBP 11.40, 95% CI 3.60 to 36.05, p<0.001; OR for DBP 15.75, 95% CI 3.09 to 80.21, p<0.001) and Glasgow Coma Scale scores <8 (OR 14.50, 95% CI 3.65 to 57.55, p<0.001) were associated with 'moderate-to-severe neurological disabilities', 'vegetative state' and 'death'. After adjusting for confounders, only SBP was significant (adjusted OR 5.68, 95% CI 1.40 to 23.08, p=0.015).

CONCLUSIONS

Initial systolic hypotension was independently associated with mortality and moderate-to-severe neurological deficits at 6 months post injury. Further work is required to understand if early correction of hypotension will improve long-term outcomes.

Singapore Paediatric Resuscitation Guidelines 2021

We present the 2021 Singapore Paediatric Resuscitation Guidelines. The International Liaison Committee on Resuscitation's Pediatric Taskforce Consensus Statements on Science and Treatment Recommendations, which was published in October 2020, and the updated resuscitation guidelines from the American Heart Association and European Resuscitation Council, were reviewed and discussed by the committee. These recommendations were derived after deliberation of peer-reviewed evidence updates on paediatric resuscitation and took into consideration the local setting and clinical practice.

Differences in intubation outcomes for pediatric patients between pediatric and general Emergency Departments

BACKGROUND

Intubation is a life-saving intervention at the Emergency Department (ED). However, general and pediatric EDs may vary in their preparedness to manage children with airway emergencies.

AIMS

We aimed to compare rates of first-pass intubation and adverse tracheal intubation-associated events between general and pediatric EDs.

METHODS

A retrospective review of medical records was conducted at a pediatric ED and three general EDs from January 1, 2015, to December 31, 2018. Information about the intubation process involving pediatric patients (less than 16 years old), as well as eventual outcomes of first-pass intubation and adverse tracheal intubation-associated events were collected and analyzed.

RESULTS

There were 180 pediatric intubations, of which 115 (63.9%) were performed in pediatric ED. The median age was 2 years old (interquartile range 0-6). Intubation was most commonly performed for patients with cardiac arrest (88, 48.9%). Direct laryngoscopy was used in 178 (98.9%) cases and uncuffed tube was used in 135 (75.0%) cases. Apneic oxygenation was performed in 26 (14.4%) cases-all in pediatric ED. Intubation was predominantly performed by senior clinicians (162, 90.0%). Overall, intubation was performed successfully in 175 (97.2%) cases, with a first-pass intubation rate of 82.2% which was similar between pediatric (96, 83.5%) and general EDs (52, 80%) (Odds ratio [OR] 1.26, 95% confidence interval [CI] 0.58 to 2.76, p = .558). There were 68 adverse tracheal intubation-associated events with right mainstem intubation being the most common (23, 12.8%). Pediatric EDs (44, 38.3%) had a higher rate of adverse tracheal intubation-associated events than general EDs (15, 23.1%) (OR 2.07, 95% CI 1.04 to 4.11; p = .037).

CONCLUSIONS

Differences exist in intubation outcomes between pediatric and general EDs. Quality improvement efforts should focus on standardizing intubation practices across both pediatric and general EDs.

Early Coagulopathy in Pediatric Traumatic Brain Injury: A Pediatric Acute and Critical Care Medicine Asian Network (PACCMAN) Retrospective Study

BACKGROUND

Although early coagulopathy increases mortality in adults with traumatic brain injury (TBI), less is known about pediatric TBI.

OBJECTIVE

To describe the prothrombin time (PT), activated partial thromboplastin time (APTT), and platelet levels of children with moderate to severe TBI to identify predictors of early coagulopathy and study the association with clinical outcomes.

METHODS

Using the Pediatric Acute and Critical Care Medicine Asian Network (PACCMAN) TBI retrospective cohort, we identified patients <16 yr old with a Glasgow Coma Scale (GCS) ≤13. We compared PT, APTT, platelets, and outcomes between children with isolated TBI and multiple trauma with TBI. We performed logistic regressions to identify predictors of early coagulopathy and study the association with mortality and poor functional outcomes.

RESULTS

Among 370 children analyzed, 53/370 (14.3%) died and 127/370 (34.3%) had poor functional outcomes. PT was commonly deranged in both isolated TBI (53/173, 30.6%) and multiple trauma (101/197, 51.3%). Predictors for early coagulopathy were young age (adjusted odds ratio [aOR] 0.94, 95% CI 0.88-0.99, P = .023), GCS < 8 (aOR 1.96, 95% CI 1.26-3.06, P = .003), and presence of multiple trauma (aOR 2.21, 95% confidence interval [CI] 1.37-3.60, P = .001). After adjusting for age, gender, GCS, multiple traumas, and presence of intracranial bleed, children with early coagulopathy were more likely to die (aOR 7.56, 95% CI 3.04-23.06, P < .001) and have poor functional outcomes (aOR 2.16, 95% CI 1.26-3.76, P = .006).

CONCLUSION

Early coagulopathy is common and independently associated with death and poor functional outcomes among children with TBI.

Early prediction of serious infections in febrile infants incorporating heart rate variability in an emergency department: a pilot study

BACKGROUND

Early differentiation of febrile young infants with from those without serious infections (SIs) remains a diagnostic challenge. We sought to (1) compare vital signs and heart rate variability (HRV) parameters between febrile infants with versus without SIs, (2) assess the performance of HRV and vital signs with reference to current triage tools and (3) compare HRV and vital signs to HRV, vital signs and blood biomarkers, when predicting for the presence of SIs.

METHODS

Using a prospective observational design, we recruited patients <3 months old presenting to a tertiary paediatric ED in Singapore from December 2018 through November 2019. We obtained patient demographic characteristics, triage assessment (including the Severity Index Score (SIS)), HRV parameters (time, frequency and non-linear domains) and laboratory results. We performed multivariable logistic regression analyses to predict the presence of an SI, using area under the curve (AUC) with the corresponding 95% CI to assess predictive capability.

RESULTS

Among 203 infants with a mean age of 38.4 days (SD 27.6), 67 infants (33.0%) had an SI. There were significant differences in the time, frequency and non-linear domains of HRV parameters between infants with versus without SIs. In predicting SIs, gender, temperature and the HRV non-linear parameter Poincaré plot SD2 (AUC 0.78, 95% CI 0.71 to 0.84) performed better than SIS alone (AUC 0.61, 95% CI 0.53 to 0.68). Model performance improved with the addition of absolute neutrophil count and C reactive protein (AUC 0.82, 95% CI 0.76 to 0.89).

CONCLUSION

An exploratory prediction model incorporating HRV and biomarkers improved prediction of SIs. Further research is needed to assess if HRV can identify which young febrile infants have an SI at ED triage.

TRIAL REGISTRATION NUMBER

NCT04103151.

Common diagnoses among pediatric attendances at emergency departments

BACKGROUND

Pediatric patients present to Emergency Departments (EDs) with a variety of medical conditions. An appreciation of the common presenting conditions can aid EDs in the provision of pediatric emergency care. In this study, we established the common pediatric diagnoses seen at the general EDs, with reference to a pediatric ED.

METHODS

A retrospective review of medical records was performed for patients less than 16 years old at a pediatric ED and two general EDs from 1 January to 31 December 2018. Information including patient demographics, triage category, case type and diagnoses were collected.

RESULTS

There were 159,040 pediatric attendances, of which 3477 (2.2%) were seen at the general EDs. Non-traumatic conditions were most prevalent at both general (N = 1933, 55.6%) and pediatric (N = 128,415, 82.5%) EDs. There was a higher proportion of trauma related conditions seen at the general EDs (N = 1544, 44.4%) compared to the pediatric ED (N = 27,148, 17.5%; p < 0.01). Across all EDs, upper respiratory tract infection, unspecified musculoskeletal pain and gastroenteritis were the three most common non-trauma related diagnoses, while fracture, wound and contusion were the three most common trauma related diagnoses. There was a greater proportion of emergent (P1) cases seen at the general EDs (N = 233, 6.7%) than the pediatric ED (N = 3821, 2.5%; p < 0.01). Respiratory conditions including bronchiolitis, asthma and bronchitis were the most common emergent (P1) diagnoses.

CONCLUSIONS

The common diagnoses among pediatric attendances varied between pediatric and general EDs. Therefore, general EDs should focus their efforts on these common diagnoses, especially the emergent (P1) ones, so that they can enhance their preparedness and work towards providing quality pediatric emergency care.

Traumatic Brain Injury Outcomes in 10 Asian Pediatric ICUs: A Pediatric Acute and Critical Care Medicine Asian Network Retrospective Study

OBJECTIVES

Traumatic brain injury remains an important cause of death and disability. We aim to report the epidemiology and management of moderate to severe traumatic brain injury in Asian PICUs and identify risk factors for mortality and poor functional outcomes.

DESIGN

A retrospective study of the Pediatric Acute and Critical Care Medicine Asian Network moderate to severe traumatic brain injury dataset collected between 2014 and 2017.

SETTING

Patients were from the participating PICUs of Pediatric Acute and Critical Care Medicine Asian Network.

PATIENTS

We included children less than 16 years old with a Glasgow Coma Scale less than or equal to 13.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We obtained data on patient demographics, injury circumstances, and PICU management. We performed a multivariate logistic regression predicting for mortality and poor functional outcomes. We analyzed 380 children with moderate to severe traumatic brain injury. Most injuries were a result of road traffic injuries (174 [45.8%]) and falls (160 [42.1%]). There were important differences in temperature control, use of antiepileptic drugs, and hyperosmolar agents between the sites. Fifty-six children died (14.7%), and 104 of 324 survivors (32.1%) had poor functional outcomes. Poor functional outcomes were associated with non-high-income sites (adjusted odds ratio, 1.90; 95% CI, 1.11-3.29), Glasgow Coma Scale less than 8 (adjusted odds ratio, 4.24; 95% CI, 2.44-7.63), involvement in a road traffic collision (adjusted odds ratio, 1.83; 95% CI, 1.04-3.26), and presence of child abuse (adjusted odds ratio, 2.75; 95% CI, 1.01-7.46).

CONCLUSIONS

Poor functional outcomes are prevalent after pediatric traumatic brain injury in Asia. There is an urgent need for further research in these high-risk groups.

Psychosocial impact of the COVID-19 pandemic on paediatric healthcare workers

Introduction: Frontline healthcare workers (HCWs) exposed to coronavirus disease 2019 (COVID-19) are at risk of psychological distress. This study evaluates the psychological impact of COVID-19 pandemic on HCWs in a national paediatric referral centre. Methods: This was a survey-based study that collected demographic, work environment and mental health data from paediatric HCWs in the emergency, intensive care and infectious disease units. Psychological impact was measured using the Depression, Anxiety, Stress Scale-21. Multivariate regression analysis was performed to identify risk factors associated with psychological distress. Results: The survey achieved a response rate of 93.9% (430 of 458). Of the 430 respondents, symptoms of depression, anxiety and stress were reported in 168 (39.1%), 205 (47.7%) and 106 (24.7%), respectively. Depression was reported in the mild (47, 10.9%), moderate (76, 17.7%), severe (23, 5.3%) and extremely severe (22, 5.1%) categories. Anxiety (205, 47.7%) and stress (106, 24.7%) were reported in the mild category only. Collectively, regression analysis identified female sex, a perceived lack of choice in work scope/environment, lack of protection from COVID-19, lack of access to physical activities and rest, the need to perform additional tasks, and the experience of stigma from the community as risk factors for poor psychological outcome. Conclusion: A high prevalence of depression, anxiety and stress was reported among frontline paediatric HCWs during the COVID-19 pandemic. Personal psychoneuroimmunity and organisational prevention measures can be implemented to lessen psychiatric symptoms. At the national level, involving mental health professionals to plan and coordinate psychological intervention for the country should be considered.

The Impact of Traumatic Brain Injury on Neurocognitive Outcomes in Children: a Systematic Review and Meta-Analysis

OBJECTIVE

To assess the burden of paediatric traumatic brain injury (TBI) on neurocognition via a systematic review and meta-analysis.

METHODS

Studies that compared neurocognitive outcomes of paediatric patients with TBI and controls were searched using Medline, Embase, PsycINFO and Cochrane Central Register of Controlled Trials, between January 1988 and August 2019. We presented a random-effects model, stratified by TBI severity, time of assessment post injury and age.

RESULTS

Of 5919 studies, 41 (patients=3717) and 33 (patients=3118) studies were included for the systematic review and meta-analysis, respectively. Studies mostly measured mild TBI (n=26, patients=2888) at 0-3 months postinjury (n=17, patients=2502). At 0-3 months postinjury, standardised mean differences between TBI and controls for executive function were -0.04 (95% CI -0.14 to 0.07; I2=0.00%), -0.18 (95% CI -0.29 to -0.06; I2=26.1%) and -0.95 (95% CI -1.12 to -0.77; I2=10.1%) for mild, moderate and severe TBI, respectively; a similar effect was demonstrated for learning and memory. Severe TBI had the worst outcomes across all domains and persisted >24 months postinjury. Commonly used domains differed largely from workgroup recommendations. Risk of bias was acceptable for all included studies.

CONCLUSION

A dose-dependent relationship between TBI severity and neurocognitive outcomes was evident in executive function and in learning and memory. Cognitive deficits were present for TBIs of all severity but persisted among children with severe TBI. The heterogeneity of neurocognitive scales makes direct comparison between studies difficult. Future research into lesser explored domains and a more detailed assessment of neurocognitive deficits in young children are required to better understand the true burden of paediatric TBI.

Paediatric emergency department attendances during COVID-19 and SARS in Singapore

Introduction: We evaluated the impact of public health measures on paediatric emergency department attendances during the COVID-19 and severe acute respiratory syndrome (SARS) outbreaks in Singapore. Methods: Between 1 January 2020 and 31 July 2020, we retrospectively reviewed paediatric emergency department attendances and admissions in a tertiary paediatric hospital in Singapore before and after a national lockdown to combat the spread of COVID-19 in Singapore. Hospital attendances and admissions were compared with data from a corresponding period in 2019 (1 January 2019 to 31 July 2019), as well as during and after the SARS outbreak (1 January 2003 to 31 December 2004). Results: Compared with a corresponding non-outbreak period, emergency department attendances decreased in line with nationwide public health measures during the COVID-19 and SARS outbreaks (2020 and 2003 respectively), before increasing gradually following lifting of restrictions, albeit not to recorded levels before these outbreaks. During the COVID-19 outbreak, mean daily attendances decreased by 40%, from 458 per day in January–July 2019, to 274 per day in January–July 2020. The absolute number of hospital inpatient admissions decreased by 37% from January–July 2019 (19,629) to January–July 2020 (12,304). The proportion of emergency department attendances requiring admission remained similar: 20% in January–July 2019 and 21% in January–July 2020. Conclusion: Nationwide public health measures in Singapore have had an impact on paediatric emergency department attendances and hospital inpatient admissions. Data from this study could inform planning and resource allocation for emergency departments in Singapore and internationally. Keywords: COVID-19, paediatric emergency department, public health measures, SARS

Predictors of serious bacterial infections using serum biomarkers in an infant population aged 0 to 90 days: a prospective cohort study

OBJECTIVE

Young febrile infants represent a vulnerable population at risk for serious bacterial infections (SBI). We aimed to evaluate the diagnostic accuracy of components of the complete blood count in comparison with C-reactive protein (CRP) to predict SBI among febrile infants.

DESIGN AND SETTING

Prospective cohort study conducted in a tertiary emergency department between December 2018 and November 2019.

PATIENTS

We included febrile infants ≤3 months old with complete blood count results. We analysed their white blood cell count (WBC), absolute neutrophil ratio (ANC), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio, mean platelet volume to platelet count ratio, and compared these to the performance of CRP.

MAIN OUTCOME MEASURES

SBIs were defined as urinary tract infection, bacteraemia, bacterial meningitis, sepsis, pneumonia, skin and soft tissue infection, bacterial enteritis, septic arthritis or osteomyelitis.

RESULTS

Of the 187 infants analysed, 54 (28.9%) were diagnosed with SBI. Median values of WBC, ANC, NLR and CRP were significantly higher in infants with SBI: WBC (13.8 vs 11.4×10⁹/L, p=0.004), ANC (6.7 vs 4.1×10⁹/L, p<0.001), NLR (1.3 vs 0.9, p=0.001) and CRP (21.0 vs 2.3 mg/L, p<0.001), compared with those without. CRP had the best discriminatory values for SBI, with area under the curve (AUC) of 0.815 (95% CI 0.747 to 0.883), compared with WBC, ANC and NLR. A predictive model consisting of WBC, ANC and NLR in combination with clinical parameters, had an AUC of 0.814 (95% CI 0.746 to 0.883). There was increased discriminative performance when this predictive model was combined with CRP, (AUC of 0.844, 95% CI 0.782 to 0.906).

CONCLUSION

In young febrile infants, CRP was the best discriminatory biomarker for SBI. WBC, ANC and NLR when used in combination have potential diagnostic utility in this population.

Cost of inpatient rehabilitation for children with moderate to severe traumatic brain injury

AIM

To evaluate the cost of inpatient rehabilitation for children with moderate to severe traumatic brain injury (TBI). Secondary aim was to identify factors associated with high inpatient rehabilitation cost.

METHOD

Retrospective review of a tertiary hospital's trauma registry was performed from 2011-2017. All patients aged 16 years or younger who sustained TBI with Glasgow Coma Scale ≤13 were included. Data on patient demographics, mechanism and severity of injury, hospital duration and inpatient rehabilitation cost were collected. We performed a regression analysis to identify factors associated with high rehabilitation cost.

RESULTS

There were a total of 51 patients. The median duration of inpatient rehabilitation was 13.5 days (interquartile range [IQR] 4-35), amounting to a median cost of SGD8,361 (IQR 3,543-25,232). Daily ward costs contributed the most to total inpatient rehabilitation cost. Those with severe TBI had longer duration of inpatient rehabilitation that resulted in higher cost of inpatient rehabilitation. Presence of polytrauma, medical complications, post-traumatic amnesia and TBI post-non-accidental injury (NAI) were associated with higher cost of inpatient rehabilitation.

CONCLUSION

The cost of inpatient rehabilitation for paediatric patients post-TBI is significant in Singapore. Patients with TBI secondary to NAI had significantly higher cost of inpatient rehabilitation. Ways to reduce duration of hospitalisation post-TBI and early step-down care or outpatient rehabilitation should be explored to reduce cost.