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Chong SL, Soo JSL, Allen JC, Ganapathy S, Lee KP, Tyebally A, Yung CF, Thoon KC, Ng YH, Oh JY, Teoh OH, Mok YH, Chan YH. Impact of COVID-19 on pediatric emergencies and hospitalizations in Singapore. BMC Pediatr 2020; 20:562. [PMID: 33353540 PMCID: PMC7755581 DOI: 10.1186/s12887-020-02469-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 12/11/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) has impacted the provision of health services in all specialties. We aim to study the impact of COVID-19 on the utilization of pediatric hospital services including emergency department (ED) attendances, hospitalizations, diagnostic categories and resource utilization in Singapore. METHODS We performed a retrospective review of ED attendances and hospital admissions among children < 18 years old from January 1st to August 8th 2020 in a major pediatric hospital in Singapore. Data were analyzed in the following time periods: Pre-lockdown (divided by the change in Disease Outbreak Response System Condition (DORSCON) level), during-lockdown and post-lockdown. We presented the data using proportions and percentage change in mean counts per day with the corresponding 95% confidence intervals (CIs). RESULTS We attended to 58,367 children with a mean age of 5.1 years (standard deviation, SD 4.6). The mean ED attendance decreased by 331 children/day during lockdown compared to baseline (p < 0.001), attributed largely to a drop in respiratory (% change - 87.9, 95% CI - 89.3 to - 86.3, p < 0.001) and gastrointestinal infections (% change - 72.4, 95%CI - 75.9 to - 68.4, p < 0.001). Trauma-related diagnoses decreased at a slower rate across the same periods (% change - 40.0, 95%CI - 44.3 to - 35.3, p < 0.001). We saw 226 children with child abuse, with a greater proportion of total attendance seen post-lockdown (79, 0.6%) compared to baseline (36, 0.2%) (p < 0.001). In terms of ED resource utilization, there was a decrease in the overall mean number of procedures performed per day during the lockdown compared to baseline, driven largely by a reduction in blood investigations (% change - 73.9, 95%CI - 75.9 to - 71.7, p < 0.001). CONCLUSIONS We highlighted a significant decrease in infection-related presentations likely attributed to the lockdown and showed that the relative proportion of trauma-related attendances increased. By describing the impact of COVID-19 on health services, we report important trends that may provide guidance when planning resources for future pandemics.
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Lee L, Mannix R, Guedj R, Chong SL, Sunwoo S, Woodward T, Fleegler E. Paediatric ED utilisation in the early phase of the COVID-19 pandemic. Emerg Med J 2020; 38:100-102. [PMID: 33273041 DOI: 10.1136/emermed-2020-210124] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 10/05/2020] [Accepted: 10/28/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Past epidemics, including influenza, have resulted in increased paediatric patient volume in EDs. During the early weeks of the COVID-19 pandemic, it was unclear how ED volume would be impacted in paediatric hospitals. The objective of this study was to examine differences in the international experience of paediatric ED utilisation and disposition at five different children's hospitals. METHODS We obtained data on ED volume, acuity level and disposition (hospitalisation and intensive care unit (ICU) admission) for the time period 1 December1-10 August for the years 2017-2020 from hospitals in five cities (Boston, Massachusetts, USA; Singapore; Melbourne, Australia; Seattle, Washington, USA; and Paris, France). Per cent change was analysed using paired t-tests or Wilcoxon signed rank test. RESULTS Overall ED volume dramatically decreased in all five hospitals during the early months of COVID-19 compared with prior years. There was a more varied response of decreases in ED volume by acuity level, hospitalisation and ICU admission among the five hospitals. The one exception was a 2% increase in ICU admissions in Paris. As of August 2020, all hospitals have demonstrated increases in ED volume; however, they are still below baseline. CONCLUSION Paediatric EDs in these five cities demonstrated differential decreases of ED volume by acuity and disposition during the early months of the COVID-19 pandemic.
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Chong SL, Dang TK, Loh TF, Mok YH, Bin Mohamed Atan MS, Montanez E, Lee JH, Feng M. Timing of tracheal intubation on mortality and duration of mechanical ventilation in critically ill children: A propensity score analysis. Pediatr Pulmonol 2020; 55:3126-3133. [PMID: 32797663 DOI: 10.1002/ppul.25026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 08/10/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We aimed to investigate whether early tracheal intubation (TI) is associated with a reduced risk of mortality and increased ventilator-free days (VFD). METHODS We performed a retrospective cohort study of children 0 to 18 years old in a pediatric intensive care unit (PICU), between 2008 and 2017. Patient demographics, vital signs, and laboratory findings were extracted. Using a time-dependent propensity score-matched algorithm, each patient was matched with another equally likely to be intubated within the same hour but was actually intubated with ≤2 hours, 2 to 4 hours, and 4 to 6 hours delays. Outcomes were mortality and VFD. RESULTS Among 333 patients, the median age was 1.72 years (interquartile range [IQR] 0.17-7.75). Thirty children died (9.0%) and the median PICU length of stay was 6.7 days (IQR 3.9-13.2). Early TI did not decrease mortality significantly when compared to a ≤2 hour delay (odds ratios [OR] 0.86; 95% CI, 0.40-1.85), a 2 to 4 hour delay (OR, 0.81; 95% CI, 0.39-1.69), or a 4 to 6 hour delay (OR, 0.87; 95% CI, 0.43-1.79). Similarly, early TI did not significantly increase VFD. Patients with early TI had 0.09 more VFD (95% CI -1.83 to 2.01) when compared to a delay within 2 hours, 0.23 more VFD (95% CI -1.66 to 2.13) when compared to a 2 to 4-hour delay and 0.56 more VFD (95% CI -1.49-2.61) when compared to a 4 to 6-hour delay. CONCLUSIONS We did not find a significant association between the timing of TI and mortality or VFD in critically ill children.
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Pek JH, Gan MY, Yap BJ, Seethor STT, Greenberg RG, Hornik CPV, Tan B, Lee JH, Chong SL. Contemporary trends in global mortality of sepsis among young infants less than 90 days old: protocol for a systematic review and meta-analysis. BMJ Open 2020; 10:e038815. [PMID: 32737098 PMCID: PMC7398098 DOI: 10.1136/bmjopen-2020-038815] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Neonatal sepsis has a high mortality rate that varies across different populations. We aim to perform a contemporary global evidence synthesis to determine the case fatality rates of neonatal sepsis, in order to better delineate this public health urgency and inform strategies to reduce fatality in this high-risk population. METHODS AND ANALYSIS We will search PubMed, Cochrane Central, Embase and Web of Science for articles in English language published between January 2010 and December 2019. All clinical trials and observational studies involving infants less than 90 days old with a clinical diagnosis of sepsis and reported case fatality rate will be included. Two independent reviewers will screen the studies and extract data on study variables chosen a priori. Quality of evidence and risk of bias will be assessed using Cochrane Collaboration's tool and ROBINS-I. Results will be synthesised qualitatively and pooled for meta-analysis. ETHICS AND DISSEMINATION No formal ethical approval is required as there is no collection of primary data. This systematic review and meta-analysis will be disseminated through conference meetings and peer-reviewed publications. PROSPERO REGISTRATION NUMBER CRD42020164321.
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Looi DSH, Goh MSL, Goh SSM, Goh JL, Sultana R, Lee JH, Chong SL. Protocol for a systematic review and meta-analysis of long-term neurocognitive outcomes in paediatric traumatic brain injury. BMJ Open 2020; 10:e035513. [PMID: 32554743 PMCID: PMC7304810 DOI: 10.1136/bmjopen-2019-035513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 03/24/2020] [Accepted: 05/21/2020] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Children who suffer from traumatic brain injury (TBI) are at risk of permanent brain damage and developmental deficits. Reports on neurodevelopmental outcomes in paediatric TBI suffer from small sample size and varying outcome definitions in the neurocognitive domains tested. This protocol describes a systematic review and meta-analysis of paediatric TBI in the following key neurocognitive domains: executive function, perceptual-motor function, language, learning and memory, social cognition and complex attention. METHODS A comprehensive search comprising studies from Medline, Cochrane, Embase and PsycINFO published from 1988 to 2019 will be conducted. We will include studies on children ≤18 years old who suffer from mild, moderate and severe TBI as determined by the Glasgow Coma Scale that report neurocognitive outcomes in domains predetermined by the Diagnostic and Statistical Manual of Mental Disorders fifth edition criteria. Systematic reviews, meta-analyses, randomised controlled trials, case-control, cohort and cross-sectional studies will be included. References from systematic reviews and meta-analyses will be hand-searched for relevant articles. A meta-analysis will be performed and effect sizes will be calculated to summarise the magnitude of change in each neurocognitive domain compared at different timepoints and stratified by severity of TBI. Included studies will be pooled using pooled standardised mean differences with a random effects model to determine an overall effect. In the scenario that we are unable to pool the studies, we will perform a narrative analysis. ETHICS AND DISSEMINATION Ethics approval is not required for this study.The authors of this study will publish and present the findings in a peer-reviewed journal as well as national and international conferences. The results of this study will provide understanding into the association between different severities of paediatric TBI and long-term neurocognitive outcomes. PROSPERO REGISTRATION NUMBER CRD42020152680.
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Pek JH, Yap BJ, Gan MY, Seethor STT, Greenberg R, Hornik CPV, Tan B, Lee JH, Chong SL. Neurocognitive impairment after neonatal sepsis: protocol for a systematic review and meta-analysis. BMJ Open 2020; 10:e038816. [PMID: 32532785 PMCID: PMC7295426 DOI: 10.1136/bmjopen-2020-038816] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/11/2020] [Accepted: 05/18/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION The effect of neonatal sepsis on the developing brain is not well documented. We aim to perform evidence synthesis to determine the outcome of neurodevelopmental impairment and intellectual disability among survivors of neonatal sepsis. The data gathered will inform on the long-term neurocognitive outcomes of neonates with sepsis and the measures used to document their developmental disability. METHODS AND ANALYSIS We will perform a search based on the following parameters: neonates and infants less than 90 days old diagnosed with sepsis who had neurocognitive outcomes or measures of developmental disability reported. We will search PubMed, Cochrane Central, Embase and Web of Science for articles in English language published between January 2010 and December 2019. Clinical trials and observational studies will be included. Two independent reviewers will screen studies for eligibility. Data extraction will then be performed using a standardised form. The quality of evidence and risk of bias will be assessed using Cochrane Collaboration's tool and Risk of Bias in Non-randomised Studies of Intervention (ROBINS-I). The results will be synthesised qualitatively and pooled for meta-analysis. ETHICS AND DISSEMINATION No formal ethical approval is required as there is no collection of primary data. This systematic review and meta-analysis will be disseminated through conference meetings and peer-reviewed publications. PROSPERO REGISTRATION NUMBER Registration submitted CRD42020164334.
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Wee BYH, Lee JH, Mok YH, Chong SL. A narrative review of heart rate and variability in sepsis. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:768. [PMID: 32647693 PMCID: PMC7333166 DOI: 10.21037/atm-20-148] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Clinicians face challenges in the timely diagnosis and management of pediatric sepsis. Pediatric heart rate has been incorporated into early warning systems and studied as a predictor for critical illness. We aim to review: (I) the role of heart rate in pediatric warning systems and (II) the role of heart rate variability (HRV) in adult and neonatal sepsis, with a focus on its potential applications in pediatrics. We conducted a literature search for papers published up to December 2019 on the utility of heart rate and HRV analysis in the diagnosis and management of sepsis, using four medical databases: PubMed, Google Scholar, EMBASE and Web of Science. This review demonstrates that the clinical utility of pediatric heart rate in predicting clinical deterioration is limited by the lack of consensus among warning systems, consensus-based guidelines, and evidence-based studies as to what constitutes abnormal heart rate in the pediatric age group. Current studies demonstrate that abnormal heart rate itself does not adequately discriminate children with sepsis from those without. HRV analysis provides a quick and non-invasive method of assessment and can provide more information than traditional heart rate. HRV analysis has the potential to add value in identification and prognostication of adult and neonatal sepsis. With further studies to explore its role, HRV analysis has the potential to add to current tools in the diagnosis and prognosis of pediatric sepsis.
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Tan RMR, Ong GYK, Chong SL, Ganapathy S, Tyebally A, Lee KP. Dynamic adaptation to COVID-19 in a Singapore paediatric emergency department. Emerg Med J 2020; 37:252-254. [PMID: 32321705 DOI: 10.1136/emermed-2020-209634] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 03/29/2020] [Accepted: 04/01/2020] [Indexed: 11/04/2022]
Abstract
Singapore was one of the earliest countries affected by the coronavirus disease 2019 (COVID-19) pandemic, with more laboratory-confirmed COVID-19 cases in early February 2020 than any other country outside China. This short report is a narrative review of our tertiary paediatric emergency department (ED) perspective and experience managing the evolving outbreak situation. Logistic considerations included the segregation of the ED into physically separate high-risk, intermediate-risk and low-risk areas, with risk-adapted use of personal protective equipment (PPE) for healthcare personnel in each ED area. Workflow considerations included the progressive introduction of outpatient COVID-19 testing in the ED for enhanced surveillance; adapting the admissions process particularly for high-risk and intermediate-risk cases; and the management of unwell accompanying adult caregivers. Manpower considerations included the reorganisation of medical manpower into modular teams to mitigate the risk of hospital transmission of COVID-19. Future plans for a tiered isolation facility should include structural modifications for the permanent isolation facility such as anterooms for PPE donning/doffing; replication of key ED functions in the tent facility such as a separate resuscitation room and portable X-ray room; and refresher PPE training. Dynamic reassessment of ED workflow processes, in conjunction with the hospital and national public health response, may help in managing this novel disease entity.
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Chong SL, Ong MEH. Advancing research in the exciting field of emergency medicine. Singapore Med J 2020; 61:58-59. [PMID: 32152641 DOI: 10.11622/smedj.2020012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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James V, Chong SL, Shetty SS, Ong GY. Early coagulopathy in children with isolated blunt head injury is associated with mortality and poor neurological outcomes. J Neurosurg Pediatr 2020; 25:663-669. [PMID: 32114542 DOI: 10.3171/2019.12.peds19531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 12/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is the leading cause of long-term disability and death in children and adolescents globally. Long-term adverse outcomes, including physical, cognitive, and behavioral sequelae, have been reported after TBI in a significant number of pediatric patients. In this study the authors sought to investigate the epidemiology of TBI-associated coagulopathy and its association with mortality and poor neurological outcome in a pediatric population with isolated moderate to severe blunt head injury treated at the authors' institution. METHODS This retrospective study was conducted in the children's emergency department between January 2010 and December 2016. Children < 18 years old who presented with isolated moderate to severe blunt head injury were included in the study. The authors collected data on patient demographics, clinical presentation, and TBI management. Outcomes studied were death and poor neurological outcome defined by a score of < 7 (death, moderate to severe neurological disability) at 6 months postinjury on the pediatric version of the Glasgow Outcome Scale-Extended (GOS-E Peds). RESULTS In 155 pediatric patients who presented with isolated moderate to severe blunt head injury, early coagulopathy was observed in 33 (21.3%) patients during the initial blood investigations done in the emergency department. The mean (SD) age of the study group was 7.03 (5.08) years and the predominant mechanism of injury was fall from height (65.2%). The median Abbreviated Injury Scale of the head (AIS head) score was 4 and the median GCS score was 13 (IQR 12-15). TBI-associated coagulopathy was independently associated with GOS-E Peds score < 7 (p = 0.02, adjusted OR 6.07, 95% CI 1.32-27.83). The overall mortality rate was 5.8%. After adjusting for confounders, only AIS head score and hypotension at triage remained significantly associated with TBI-associated coagulopathy. CONCLUSIONS TBI-associated coagulopathy was independently associated with GOS-E Peds score < 7 at 6 months postinjury. Larger prospective studies are needed to investigate the use of TBI-associated coagulopathy to prognosticate these critical clinical outcomes.
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Yao SHW, Chong SL, Ong GYK. Analysis of emergency department prediction tools in evaluating febrile young infants at risk for serious infections: reply. Arch Emerg Med 2020; 37:175-176. [DOI: 10.1136/emermed-2019-209399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2019] [Indexed: 11/03/2022]
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Craig S, Babl FE, Dalziel SR, Gray C, Powell C, Al Ansari K, Lyttle MD, Roland D, Benito J, Velasco R, Hoeffe J, Moldovan D, Thompson G, Schuh S, Zorc JJ, Kwok M, Mahajan P, Johnson MD, Sapien R, Khanna K, Rino P, Prego J, Yock A, Fernandes RM, Santhanam I, Cheema B, Ong G, Chong SL, Graudins A. Acute severe paediatric asthma: study protocol for the development of a core outcome set, a Pediatric Emergency Reserarch Networks (PERN) study. Trials 2020; 21:72. [PMID: 31931862 PMCID: PMC6956506 DOI: 10.1186/s13063-019-3785-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 10/09/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Acute severe childhood asthma is an infrequent, but potentially life-threatening emergency condition. There is a wide range of different approaches to this condition, with very little supporting evidence, leading to significant variation in practice. To improve knowledge in this area, there must first be consensus on how to conduct clinical trials, so that valid comparisons can be made between future studies. We have formed an international working group comprising paediatricians and emergency physicians from North America, Europe, Asia, the Middle East, Africa, South America, Central America, Australasia and the United Kingdom. METHODS/DESIGN A 5-stage approach will be used: (1) a comprehensive list of outcomes relevant to stakeholders will be compiled through systematic reviews and qualitative interviews with patients, families, and clinicians; (2) Delphi methodology will be applied to reduce the comprehensive list to a core outcome set; (3) we will review current clinical practice guidelines, existing clinical trials, and literature on bedside assessment of asthma severity. We will then identify practice differences in tne clinical assessment of asthma severity, and determine whether further prospective work is needed to achieve agreement on inclusion criteria for clinical trials in acute paediatric asthma in the emergency department (ED) setting; (4) a retrospective chart review in Australia and New Zealand will identify the incidence of serious clinical complications such as intubation, ICU admission, and death in children hospitalized with acute severe asthma. Understanding the incidence of such outcomes will allow us to understand how common (and therefore how feasible) particular outcomes are in asthma in the ED setting; and finally (5) a meeting of the Pediatric Emergency Research Networks (PERN) asthma working group will be held, with invitation of other clinicians interested in acute asthma research, and patients/families. The group will be asked to achieve consensus on a core set of outcomes and to make recommendations for the conduct of clinical trials in acute severe asthma. If this is not possible, the group will agree on a series of prioritized steps to achieve this aim. DISCUSSION The development of an international consensus on core outcomes is an important first step towards the development of consensus guidelines and standardised protocols for randomized controlled trials (RCTs) in this population. This will enable us to better interpret and compare future studies, reduce risks of study heterogeneity and outcome reporting bias, and improve the evidence base for the management of this important condition.
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Subramaniam A, Tan RMR, Chan D, Ng ZM, Dong CY, Feng JXY, Chong SL. Assessment of the Understanding of Concussion and Care Protocols Amongst Student Athletes and Coaches: A Qualitative Study. Front Pediatr 2020; 8:526986. [PMID: 33072670 PMCID: PMC7542181 DOI: 10.3389/fped.2020.526986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 08/21/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Pediatric sports-induced concussions have become a topic of interest and concern in the scientific community. Already, the literature is rich with studies that have identified numerous short-term and long-term consequences of childhood sports-induced concussions. However, there are very few studies that have identified how well the students who participate in concussion-prone sports and their coaches understand these consequences and how they can be avoided. This study aimed to explore student athletes' and their coaches' understanding of the concept of concussion and how it is managed both immediately after the injury occurs and during long-term recovery. Methods: This study utilized a qualitative design. The study was conducted in local and international schools in Singapore. Participants were recruited through purposive sampling. 42 student athletes aged 13-18 who participated in rugby, softball, football, cricket, volleyball, and/or water polo were recruited. Fourteen coaches who coached these same sports were also recruited. Four focus groups and three semi-structured interviews were conducted. Data collected were then analyzed with thematic analysis. Risk factors were assessed through four domains of focus: understanding of what concussion is; attitudes toward concussion; existing protocols for treating concussion; and return-to-school and return-to-play protocols. As this is a qualitative study, outcome measures were not identified. Results: Analysis of the data revealed four themes for each group. For student-athletes these included: limited understanding of concussion; non-reporting of injuries; variable supervision of athletes; and a lack of established return-to-school and return-to-play guidelines. For coaches these included: variable understanding of concussion; insufficient formal training in concussion management; limited medical support in managing injuries; and lack of understanding and adherence to return-to-school and return-to-play protocols. Conclusions: Of the themes identified, the most pressing was a lack of clearly defined return-to-play guidelines. This is an urgent issue that needs to be jointly addressed by healthcare professionals and schools with evidence-based guidelines.
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Wong PCY, Tripathi M, Warier A, Lim ZY, Chong SL. Parental presence during pediatric emergency procedures: finding answers in an Asian context. Clin Exp Emerg Med 2019; 6:340-344. [PMID: 31910505 PMCID: PMC6952637 DOI: 10.15441/ceem.18.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 12/11/2018] [Indexed: 12/03/2022] Open
Abstract
Objective The practice of allowing parental presence during invasive procedures in children varies depending on setting and individual provider preference. We aim to understand the attitudes, preferences, and practices of physicians and nurses with regard to parental presence during invasive pediatric emergency procedures in an Asian cultural context. Methods We surveyed physicians and nurses in the pediatric emergency department of a large tertiary hospital using separate self-administered questionnaires over three months. The data collected included the demographics and clinical experience of interview respondents. Each provider was asked about their attitude and preference regarding parental presence during specific invasive procedures. Results We surveyed 90 physicians and 107 nurses. Most physicians in our context preferred to perform pediatric emergency procedures without parental presence (82, 91.1%). Forty physicians (44.4%) reported that parental presence slowed down procedures, while 75 (83.3%) felt it increased provider stress. Most physicians made the decision to allow parents into the procedure room based on parental attitude (69, 76.7%) and the child’s level of cooperation (64, 71.1%). Most nurses concurred that parental presence would add to provider stress during procedures (69, 64.5%). We did not find a significant relationship between provider experience (P=0.26) or age (P=0.50) and preference for parental presence. Conclusion In our cultural context, most physicians and nurses prefer to perform procedures for children in the absence of parents. We propose that this can be changed by health professional training with role play and simulation, adequate supervision by experienced physicians, and clear communication with parents.
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Yao SHW, Ong GYK, Maconochie IK, Lee KP, Chong SL. Analysis of emergency department prediction tools in evaluating febrile young infants at risk for serious infections. Emerg Med J 2019; 36:729-735. [DOI: 10.1136/emermed-2018-208210] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 09/04/2019] [Accepted: 10/03/2019] [Indexed: 11/04/2022]
Abstract
ObjectiveFebrile infants≤3 months old constitute a vulnerable group at risk of serious infections (SI). We aimed to (1) study the test performance of two clinical assessment tools—the National Institute for Health and Care Excellence (NICE) Traffic Light System and Severity Index Score (SIS) in predicting SI among all febrile young infants and (2) evaluate the performance of three low-risk criteria—the Rochester Criteria (RC), Philadelphia Criteria (PC) and Boston Criteria (BC) among well-looking febrile infants.MethodsA retrospective validation study was conducted. Serious illness included both bacterial and serious viral illness such as meningitis and encephalitis. We included febrile infants≤3 months old presenting to a paediatric emergency department in Singapore between March 2015 and February 2016. Infants were assigned to high-risk and low-risk groups for SI according to each of the five tools. We compared the performance of the NICE guideline and SIS at initial clinical assessment for all infants and the low-risk criteria—RC, PC and BC—among well-looking infants. We presented their performance using sensitivity, specificity, positive, negative predictive values and likelihood ratios.ResultsOf 1057 infants analysed, 326 (30.8%) were diagnosed with SI. The NICE guideline had an overall sensitivity of 93.3% (95% CI 90.0 to 95.7), while the SIS had a sensitivity of 79.1% (95% CI 74.3 to 83.4). The incidence of SI was similar among infants who were well-looking and those who were not. Among the low-risk criteria, the RC performed with the highest sensitivity in infants aged 0–28 days (98.2%, 95% CI 90.3% to 100.0%) and 29–60 days (92.4%, 95% CI 86.0% to 96.5%), while the PC performed best in infants aged 61–90 days (100.0%, 95% CI 95.4% to 100.0%).ConclusionsThe NICE guideline achieved high sensitivity in our study population, and the RC had the highest sensitivity in predicting for SI among well-appearing febrile infants. Prospective validation is required.
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Pek JH, Ong YKG, Quek ECS, Feng XYJ, Allen JC, Chong SL. Evaluation of the criteria for trauma activation in the paediatric emergency department. Emerg Med J 2019; 36:529-534. [PMID: 31326954 DOI: 10.1136/emermed-2018-207857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 06/26/2019] [Accepted: 07/03/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Trauma team activation criteria have a variable performance in the paediatric population. We aimed to identify predictors for high-level resource utilisation during trauma resuscitation in the ED. METHODS A retrospective study was conducted in the ED of a tertiary paediatric hospital. Patient data were collected from trauma surveillance registry and analysis was performed to identify significant predictors. We then assessed the sensitivity and specificity of proposed models with respect to observed patient outcomes. RESULTS Among 11 282 cases, the mean age was 6.1±4.9 (SD) years old. Fall was the most common mechanism of injury in 7364 (65.3%) patients. Eighty-eight (0.8%) patients required at least one high-level resource. Significant predictors for high-resource utilisation were overall GCS of <14 (relative risk (RR) 38.841, 95% CI 21.328 to 70.739, p<0.001), high-risk mechanisms of fall from height and motor vehicle collision (RR 7.863, 95% CI 4.687 to 13.192, p<0.001), as well as age-specific tachycardia (RR 1.796, 95% CI 1.145 to 2.817, p=0.0108). A model consisting of GCS and high-risk mechanism would under-triage 21 (0.2%) patients and over-triage 681 (6.0%) patients. When age-specific tachycardia was added, 8 (0.1%) less patients would be under-triaged but an additional 3251 (28.9%) patients would be over-triaged. CONCLUSION As utilisation of high-level resources in paediatric trauma was rare, it was difficult to find an appropriate balance between under-triage and over-triage. Between the two, minimising the proportion of under-triage is more important as patient safety is paramount in paediatric trauma care.
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Hwang SY, Ong JW, Ng ZM, Foo CY, Chua SZ, Sri D, Lee JH, Chong SL. Long-term outcomes in children with moderate to severe traumatic brain injury: a single-centre retrospective study. Brain Inj 2019; 33:1420-1424. [PMID: 31314599 DOI: 10.1080/02699052.2019.1641625] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Traumatic brain injury (TBI) is a significant cause of mortality and disability in the pediatric population. Non-accidental trauma (NAT) has specifically been reported to result in more severe injury as compared to accidental mechanisms of injury. We aim to investigate the long-term neurological outcomes in children with moderate to severe traumatic brain injury. Our secondary aim is to evaluate the difference in outcomes between children presenting with NAT and non-NAT, in our study population. We performed a retrospective study in a tertiary pediatric hospital between January 2008 to October 2017 of all patients with TBI <16 years old with a Glasgow Coma Scale (GCS) ≤13. The dual primary outcomes were mortality and Paediatric Functional Independence Measure (WeeFIM) scores, recorded at the start of rehabilitation, discharge, 3 months and 6 months post-injury. The secondary outcome was the development of post-traumatic epilepsy. There were 68 patients with a median age of 4.5 [interquartile range (IQR) 1.0-9.0] years old. The most common presenting symptom was vomiting for children <2 years (11/20, 55.0%) while confusion and disorientation were common for those ≥2 years (27/48, 56.3%). WeeFIM scores at the start of rehabilitation [median 122.0, IQR 33.8-126.0] improved at 6 months post-injury (median 126.0, IQR 98.5-126.0). There was a greater incidence of post-traumatic epilepsy in age <2 years (6/20, 30.0%) compared to age ≥2 years (1/48, 2.1%) (p = .002). When comparing NAT versus non-NAT survivors, cognition WeeFIM scores were significantly different at the start of rehabilitation (p = .017) and at 3 months post-injury (p = .025). NAT predicts for poorer long-term outcomes, specifically in cognition, as measured by WeeFIM scores. Younger children <2 years had a higher incidence of post-traumatic epilepsy compared to older children.
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Tan RMR, Dong C, Shen GQ, Feng JXY, Piragasam R, Tyebally A, Chong SL. Parental knowledge and beliefs on the use of child car restraints in Singapore: a qualitative study. Singapore Med J 2019; 61:102-107. [PMID: 30773603 DOI: 10.11622/smedj.2019023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Road traffic injuries and fatalities represent a significant public health problem. In Singapore, compliance with appropriate child car restraints (CCRs) is poor. We aimed to understand parental knowledge, beliefs and barriers regarding the use of CCRs. METHODS In this qualitative study, we conducted five focus group discussions with parents who drive with their children in private cars. Participants were recruited using the KK Women's and Children's Hospital's social media page. Guiding questions were derived by consensus following literature review and adaptation to the Singapore context, exploring parental perceptions of CCR use. Focus group interviews were then transcribed and analysed. RESULTS 33 participants were recruited, with an age range of 28‒46 (mean age 35.5) years. They had a total of 46 children with ages ranging from 2.5 months to 14 years (mean age 4.2 years). Three key themes were identified: parental knowledge regarding CCRs, barriers to CCR use, and suggestions to increase CCR compliance. Barriers to compliance included lack of knowledge, difficult child behaviour and cultural norms. A multipronged approach was proposed to increase CCR use, including educating the public, reinforcing positive behaviour, legal enforcement as a deterrent to non-compliance, increasing CCR installation services, providing CCRs for taxi users and offering financial incentives. CONCLUSION Non-compliance to CCR use is multidimensional, including multiple potentially modifiable factors. This study could inform ongoing collaborative injury prevention efforts among healthcare professionals, industry partners and the traffic police, using public education and outreach to reduce the burden of road traffic injuries.
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Aeschlimann FA, Chong SL, Lyons TW, Beinvogl BC, Góez-Mogollón LM, Tan S, Laxer RM. Risk of Serious Infections Associated with Biologic Agents in Juvenile Idiopathic Arthritis: A Systematic Review and Meta-Analyses. J Pediatr 2019; 204:162-171.e3. [PMID: 30318371 DOI: 10.1016/j.jpeds.2018.08.065] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/20/2018] [Accepted: 08/24/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess whether treatment with biologic response modifying agents during clinical trial study periods increases the risk of serious infections in children with juvenile idiopathic arthritis (JIA). STUDY DESIGN A systematic literature review using Medline, Embase, Cochrane library, and the clinical trial registry was performed up to July 2017. Random effects meta-analyses were used to compare rates of serious infections in children with JIA given biologic agents compared with controls, and the pooled relative risk calculated. Subanalyses were performed for different biologic agent classes. RESULTS In total, 19 trials accounting for 21 individual studies were included (11 for tumor necrosis factor-alpha inhibitors [n = 814 patients], 3 for interleukin-6 inhibitors [n = 318], 6 for interleukin-1 inhibitors [n = 353], and 1 for selective T-lymphocyte costimulation modulators [n = 122]). Patients (68% female) had a mean age of 10.8 years. Seventeen serious infections were reported among 810 children receiving biologic agents and 15 among 797 controls. The most frequent infections were bronchopulmonary and varicella. No statistically significant difference in risk of serious infections was found between children receiving biologic agents compared with control groups (pooled relative risk = 1.13; 95% CI [0.63, 2.03]) during the trial study periods. The risk remained nonsignificant when evaluating the different classes of biologic agents separately. However, the analyses were underpowered to detect differences in the risk of serious infections overall or differences between classes of biologic agents. CONCLUSIONS In this systematic review and meta-analyses, serious infections were uncommon and not significantly increased among patients with JIA receiving biologic agents compared with controls. However, the analyses were underpowered and study periods were relatively short. Ongoing careful monitoring for serious infections remains necessary for all patients with JIA, and particularly those receiving biologic agents.
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Chong SL, Laerdal T, Cordero J, Khursheed M, Haedar A, Cai W, Nadarajan GD, Ho AFW, Pek PP, Chan SKT, Ong MEH. Global resuscitation alliance consensus recommendations for developing emergency care systems: Reducing perinatal mortality. Resuscitation 2018; 133:71-74. [DOI: 10.1016/j.resuscitation.2018.09.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 09/19/2018] [Accepted: 09/28/2018] [Indexed: 10/28/2022]
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Chong SL, Lai OF, Castillo L, Yeo JG, Nadkarni N, Teoh OH, Lee JH. Nasal high-mobility group box 1 and caspase in bronchiolitis. Pediatr Pulmonol 2018; 53:1627-1632. [PMID: 30362259 DOI: 10.1002/ppul.24183] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 09/19/2018] [Accepted: 10/07/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Nasal biomarkers have potential to add objectivity to the clinical assessment of the child with bronchiolitis. We aim to study, if nasal caspase and high-mobility group box 1 protein (HMGB1) levels differ between patients who were hospitalized and those discharged from the emergency department (ED), among patients with bronchiolitis. METHODS Using an observational cross-sectional study design, we recruited patients younger than 24 months presenting to the ED from September 1, 2015 to May 31, 2017 with a diagnosis of acute bronchiolitis. We described the patients' clinical severity measured by the modified respiratory index score (RIS), and performed standardized collection and analysis of nasal caspase and HMGB1 levels. RESULTS Among 85 patients recruited, the median age was 5.0 months (interquartile range, IQR 3.3-7.2) and the median modified RIS score was 3 (IQR 2-4). Hospitalized patients had a 2.4-fold higher HMGB1 level than patients who were discharged from the ED (2.558 μg/mL [IQR 1.038-5.125] vs 1.056 μg/mL [IQR 0.409-2.395], P = 0.0013). There was no difference in median caspase level between hospitalized and discharged patients. The Area Under the Receiver Operating Characteristics curve predicting hospitalization was 0.7021 for HMGB1 compared to 0.5709 for RIS in this bronchiolitis cohort. CONCLUSIONS Our study findings show that nasal HMGB1 levels significantly differentiate between young children with bronchiolitis who were hospitalized compared to those fit for discharge. This exploratory study holds potential for future research on nasal HMGB1 for severity stratification in young children with acute bronchiolitis.
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Wang J, Lee KP, Chong SL, Loi M, Lee JH. High flow nasal cannula in the emergency department: indications, safety and effectiveness. Expert Rev Med Devices 2018; 15:929-935. [PMID: 30426800 DOI: 10.1080/17434440.2018.1548276] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Heated humidified high flow nasal cannula therapy (HHHFNCT) is emerging as a popular non-invasive mode of respiratory support in adults and children. In recent years, its use has extended beyond the intensive care unit to other clinical areas. This review aims to explore the mechanism of action, indications, safety, and effectiveness of HHHFNCT use in the Emergency Department (ED). AREAS COVERED The mechanism of action of HHHFNCT, as well as its use in adult and pediatric ED will be discussed in this review. EXPERT COMMENTARY While there exists increasing enthusiasm in the use of HHHFNCT in the ED, constant monitoring of the patients and an experienced assessment of their response to treatment are critical and may require additional manpower deployment, which may be challenging, in the busy ED environment. Our experience with the use of HHHFNCT in children is still growing. Continual research in this area remains crucial in helping us better understand the patient types and conditions managed in ED that would most benefit from this device.
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Chong SL, Chiang LW, Allen JC, Fleegler EW, Lee LK. Epidemiology of Pedestrian-Motor Vehicle Fatalities and Injuries, 2006-2015. Am J Prev Med 2018; 55:98-105. [PMID: 29776783 DOI: 10.1016/j.amepre.2018.04.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 02/26/2018] [Accepted: 04/02/2018] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Pedestrian road safety remains a public health priority. The objective of this study is to describe trends in fatalities and injuries after pedestrian-motor vehicle collisions in the U.S. and identify associated risk factors for pedestrian fatalities. METHODS This is a cross-sectional study of U.S. pedestrian-motor vehicle collisions from 2006 to 2015 (performed in 2017). Pedestrian fatality and injury data were obtained from the National Highway Traffic Safety Administration's Fatality Analysis Reporting System and National Automotive Sampling System General Estimates System. Frequencies of fatalities, injuries, and associated characteristics were calculated. Multivariable logistic regression was performed for risk of fatality, controlling for demographic and crash-related factors. RESULTS There were 47,789 pedestrian fatalities and 674,414 injuries during the 10-year study period. Fatality rates were highest among the elderly aged 85 years and older (2.95/100,000 population), whereas injury rates were highest for those aged 15-19 years (35.23/100,000 population). Predictors associated with increased risk for death include the following: male sex (AOR=1.36, 95% CI=1.15, 1.62), age ≥65 years (AOR=3.44, 95% CI=2.62, 4.50), alcohol involvement (AOR=2.63, 95% CI=1.88, 3.67), collisions after midnight (AOR=5.21, 95% CI=3.20, 8.49), at non-intersections (AOR=2.76, 95% CI=2.21, 3.45), and involving trucks (AOR=2.15, 95% CI=1.16, 3.97) and buses (AOR=5.82, 95% CI=3.67, 9.21). CONCLUSIONS Potentially modifiable factors are associated with increased risk of death after pedestrian-motor vehicle collisions. Interventions including elder-friendly intersections and increasing visibility of pedestrians may aid in decreasing pedestrian injuries and deaths.
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Samsudin MI, Liu N, Prabhakar SM, Chong SL, Kit Lye W, Koh ZX, Guo D, Rajesh R, Ho AFW, Ong MEH. A novel heart rate variability based risk prediction model for septic patients presenting to the emergency department. Medicine (Baltimore) 2018; 97:e10866. [PMID: 29879021 PMCID: PMC5999455 DOI: 10.1097/md.0000000000010866] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
A quick, objective, non-invasive means of identifying high-risk septic patients in the emergency department (ED) can improve hospital outcomes through early, appropriate management. Heart rate variability (HRV) analysis has been correlated with mortality in critically ill patients. We aimed to develop a Singapore ED sepsis (SEDS) predictive model to assess the risk of 30-day in-hospital mortality in septic patients presenting to the ED. We used demographics, vital signs, and HRV parameters in model building and compared it with the modified early warning score (MEWS), national early warning score (NEWS), and quick sequential organ failure assessment (qSOFA) score.Adult patients clinically suspected to have sepsis in the ED and who met the systemic inflammatory response syndrome (SIRS) criteria were included. Routine triage electrocardiogram segments were used to obtain HRV variables. The primary endpoint was 30-day in-hospital mortality. Multivariate logistic regression was used to derive the SEDS model. MEWS, NEWS, and qSOFA (initial and worst measurements) scores were computed. Receiver operating characteristic (ROC) analysis was used to evaluate their predictive performances.Of the 214 patients included in this study, 40 (18.7%) met the primary endpoint. The SEDS model comprises of 5 components (age, respiratory rate, systolic blood pressure, mean RR interval, and detrended fluctuation analysis α2) and performed with an area under the ROC curve (AUC) of 0.78 (95% confidence interval [CI]: 0.72-0.86), compared with 0.65 (95% CI: 0.56-0.74), 0.70 (95% CI: 0.61-0.79), 0.70 (95% CI: 0.62-0.79), 0.56 (95% CI: 0.46-0.66) by qSOFA (initial), qSOFA (worst), NEWS, and MEWS, respectively.HRV analysis is a useful component in mortality risk prediction for septic patients presenting to the ED.
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Chong SL, Ong GYK, Chin WYW, Chua JM, Nair P, Ong ASZ, Ng KC, Maconochie I. A retrospective review of vital signs and clinical outcomes of febrile infants younger than 3 months old presenting to the emergency department. PLoS One 2018; 13:e0190649. [PMID: 29304160 PMCID: PMC5755800 DOI: 10.1371/journal.pone.0190649] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 12/18/2017] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Febrile infants younger than 3 months old present a diagnostic dilemma to the emergency physician. We aim to describe a large population of febrile infants less than 3 months old presenting to a pediatric emergency department (ED) and to assess the performance of current heart rate guidelines in the prediction of serious infections (SI). MATERIALS AND METHODS We performed a retrospective review of febrile infants younger than 3 months old, between March 2015 and Feb 2016, in a large tertiary pediatric ED. We documented the primary outcome of SI for each infant, as well as the clinical findings, vital signs, and Severity Index Score (SIS). We assessed the performance of the Paediatric Canadian Triage and Acuity Scale (PaedCTAS), Advanced Pediatric Life Support (APLS) guidelines and Fleming normal reference values, using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and area under receiver operating characteristics curve (AUC). RESULTS 1057 infants were analyzed, with 326 (30.6%) infants diagnosed with SI. High temperature, tachycardia, and low SIS score were significantly associated with SI. Item analysis showed that the SIS performance was driven by the presence of mottling (p = 0.003) and high temperature (p<0.001). The APLS guideline had the highest sensitivity (66.0%, 95% CI 60.5-71.1%), NPV (73.3%, 95% CI 69.7-76.5%) and AUC (0.538), while the PaedCTAS (2 standard deviation from normal) had the highest specificity (98.5%, 95% CI 97.3-99.3%) and PPV (55.2%, 95% CI 32.7-71.0%). CONCLUSIONS Current guidelines on infantile heart rates have a variable performance. In our study, the APLS heart rate guidelines performed with the highest sensitivity, but no individual guideline predicted for SIs satisfactorily.
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