The Factors Affecting Neonatal Presentations to the Pediatric Emergency Department

Reasons for Neonatal Presentations to Pediatric Emergency Departments in Catania: Multicentric Cross-Sectional Analysis and Exhaustive Review of the Literature

INTRODUCTION

This study aimed to characterize neonatal admissions to pediatric emergency departments (PEDs) in Catania, to analyze the primary pediatric conditions leading to these admissions, and to explore the association between the demographic characteristics of the population and the severity of their presentations.

MATERIALS AND METHODS

A retrospective analysis was conducted on neonates (aged <28 days) admitted to three PEDs in Catania between January 2015 and December 2019. Additionally, a comprehensive review of the literature on this topic was performed.

RESULTS

A total of 5183 neonates presented during the study period, with a median age of 14 days at admission. The top three diagnoses were neonatal jaundice (15%), abdominal discomfort (12%), and upper airway inflammation (11%). The majority of cases were classified as non-urgent (green) at triage (59%). Overall, 1296 patients (25%) required hospitalization; 95% of those assigned a yellow triage color at admission required hospitalization. Only 33% of hospitalized patients were referred by parents, while the majority were referred by primary care pediatricians. The highest number of admissions occurred in August, while the peak in hospitalizations was in February.

CONCLUSIONS

The majority of neonatal PED admissions are for non-acute conditions that do not require immediate medical attention. This concerning trend leads to increased workloads for PED staff, higher healthcare costs, and potential risks to neonates. Possible causes include insufficient caregiver knowledge, inadequate parental education, and suboptimal transition from hospital to primary care pediatric services.

Comparison between local and three validated triage systems in an emergency department for 2126 children under 3 months

AIM

Triage of patients less than 3 months old was not already studied. The aim was to evaluate Paediatric Emergency Department triage in patients less than 3 months old and newborns using a local system in comparison with three validated paediatric triage systems (Canadian Triage and Acuity Scale, Manchester Triage System and Emergency Severity Index) and to determine inter-system agreement.

METHODS

All admissions of patients less than 3 months old admitted to the Emergency Department of the Saint Vincent University Hospital between April 2018 and December 2019 were included. The local triage system level was determined prospectively for comparison with retrospectively calculated triage levels of the validated systems. Hospitalisation rates were compared and inter-system agreements determined.

RESULTS

Among emergency admissions, 2126 were included (55% males, mean age 45 days). Hospitalisation rate increased with priority severity as determined by all triage systems studied. Cohen's kappa showed slight agreement between the local triage system and the Canadian Triage and Acuity Scale, Emergency Severity Index and Manchester Triage System (weighted kappa = 0.133, 0.185 and 0.157 respectively).

CONCLUSION

Whether prospective or retrospective triage used, the systems studied exhibited good association with hospitalisation rate for patients aged less than 3 months and newborn infants.

Relationship between large and small for gestational age and hospital readmission after postpartum discharge: a population-based, data-linkage study

This study aims to determine the association of small for gestational age (SGA) and large for gestational age (LGA) at birth with hospital readmission after postpartum discharge for up to 28 days of delivery. This is a population-based, data-linkage study using the French National Uniform Hospital Discharge Database. "Healthy" singleton term infants born between January 1st, 2017, and November 30th, 2018, in the French South region were included. SGA and LGA were defined as birth weight < 10th and > 90th percentiles, respectively, according to sex and gestational age. A multivariable regression analysis was performed. Among 67,359 included infants, 2441 (3.6%) were readmitted, and 61% of them were hospitalized within 14 days postpartum. Hospitalized infants were more likely to be LGA at birth (10.3% vs. 8.6% in non-hospitalized infants, p < 0.01); the proportion of SGA infants did not differ between both groups. Compared to appropriate birth weight for GA (AGA) infants, LGA infants were more often hospitalized for infectious diseases (57.7% vs. 51.3%, p = 0.05). After regression analysis, LGA infants had a 20% higher odds of being hospitalized than those born AGA (aOR (95%CI) = 1.21 (1.06-1.39)), while aOR (95%CI) for SGA was 1.11 (0.96-1.28).

CONCLUSION

 In contrast to SGA, LGA was associated with hospital readmission during the first month of life. Follow-up protocols that include LGA should be evaluated.

WHAT IS KNOWN

• Newborns are at high risk of hospital readmission during the postpartum period. • However, the influence of appropriateness for gestational age at birth, i.e. being born small for gestational age (SGA) or large for gestational age (LGA), has been little evaluated.

WHAT IS NEW

• In contrast to SGA born infants, we found that infants born LGA were at high risk of hospital admission and the main cause was infectious diseases. • This population should be considered at risk of early adverse outcomes and should require attentive medical follow-up after postpartum discharge.

Patologías pediátricas no asociadas con cuadros respiratorios o infecciones por SARS-CoV-2 en Colombia durante el primer aislamiento social obligatorio

Objetivo: Describir el perfil epidemiológico en menores de 18 años atendidos en el Hospital Universitario San Ignacio (HUSI) por una etiología diferente a una infección respiratoria aguda o confirmada de COVID-19 durante el primer aislamiento social obligatorio. Metodología: Estudio observacional descriptivo retrospectivo de los registros de pacientes menores de 18 años atendidos en el HUSI por una patología diferente a infección respiratoria aguda o por COVID-19, desde el 24 de marzo hasta el 31 de agosto de 2020. Resultados: De 955 pacientes recolectados, 461 (48 %) consultaron por causas no respiratorias ni diagnóstico de infección por SARS-CoV-2. El 40,3 % tenía entre 0, y 3 años y el 33,2 %, de 12 a 17 años. El 25 % correspondió a una patología crónica agudizada y el 75 % de las atenciones requirieron hospitalización. Los principales diagnósticos globales fueron ictericia neonatal, apendicitis aguda, infección urinaria y patología de salud mental en adolescentes. Conclusiones: La mayoría de los pacientes cursaron con patologías agudas y no prevenibles. Se evidenciaron consultas tardías, cuadros clínicos de mayor severidad con mayor porcentaje de hospitalización y un número importante de problemas de salud mental en el grupo de adolescentes.

Effects of a Smartphone-Based Out-of-Hospital Screening App for Neonatal Hyperbilirubinemia on Neonatal Readmission Rates and Maternal Anxiety: Randomized Controlled Trial

Background

Neonatal hyperbilirubinemia is one of the leading causes of neonatal readmission—especially severe hyperbilirubinemia and its complications—and it influences disease burden as well as neonatal and maternal health. Smartphones have been shown to have satisfactory accuracy in screening neonatal bilirubin levels, but the impact of this technology on neonatal health care service and maternal health outcomes is still unknown.

Objective

The aim of this study was to evaluate the impact of a smartphone-based out-of-hospital neonatal jaundice screening program on neonatal readmission rates for jaundice and related maternal anxiety.

Methods

This was a 2-arm, unblinded, randomized controlled trial with 30 days of intervention and follow-up periods. From August 2019 to August 2020, healthy mother-infant dyads were recruited on-site from 3 public hospitals in Hainan, China. Intervention group mothers used the smartphone app to routinely monitor neonatal jaundice at home under the web-based guidance of pediatricians. Control group participants received routine care. The primary study outcome was the neonatal readmission rate due to jaundice within 30 days of the first hospital discharge. The secondary outcome was the maternal anxiety score associated with neonatal jaundice. The data were collected through a self-assessed questionnaire. All participants were included in the analysis (intention-to-treat).

Results

In this study, 1424 mother-infant dyads were recruited, comprising 1424 mothers and 1424 newborns. The median age of the mothers was 29 (IQR 26-32) years, and there were 714 (50.1%) male neonates. These mother-infant dyads were randomly assigned to the intervention group and the control group, with 712 dyads in each group; only 1187 of these dyads completed the follow-up. We found that the adjusted 30-day neonatal readmission rate due to jaundice reduced by 10.5% (71/605, 11.7% vs 141/582, 24.2%; 95% CI 5%-15.9%; odds ratio 0.4, 95% CI 0.3-0.5; P<.001) and the relevant maternal anxiety mean score decreased by 3.6 (95% CI –4.4 to –2.8; β=–3.6, 95% CI –4.5 to –2.8; P<.001) in the intervention group compared to those in the routine care group.

Conclusions

Our study shows that the smartphone-based out-of-hospital screening method for neonatal hyperbilirubinemia decreased the neonatal readmission rate within 30 days from the first discharge and improved maternal mental health to some degree, thus demonstrating the usefulness of this screening app for follow-up in pediatric care.

Trial Registration

China Clinical Trial Registration Center, ChiCTR2100049567; http://www.chictr.org.cn/showproj.aspx?proj=64245

Factors Affecting Nonurgent Pediatric Emergency Department Visits and Parental Emergency Overestimation

OBJECTIVES

Understanding the factors causing nonurgent visits to the pediatric emergency departments (PED) is essential for developing effective interventions. Sociodemographic factors might have a direct effect, or they might be associated with other potential causal factors such as access, perceived severity, and convenience. Therefore, we aimed to evaluate the factors that might have an effect on nonurgent PED visits and parental overestimation of emergency severity.

METHODS

Data of a total of 974 patients who have been administered to the PED of a district state hospital were collected with a cross-sectional, self-administered survey. Level 5 was accepted as nonurgent cases according to the Pediatric Canadian Triage and Acuity Scale. Parents' assessment of their child's emergency status was assessed along with the age and sex of the child, the number of children, presence of a chronic illness, presence of fever, admission time, parental age, education status and occupation, transportation method, and living distance to emergency department.

RESULTS

Sixty-eight percent of visits were nonurgent. Among these visits, 51.6% were perceived as urgent, and 11.5% as extremely urgent by the parents. We identified that infancy age group (P = 0.001), father's unemployment status (P = 0.038), presence of a chronic disease (P = 0.020), and a previous visit to the PED in the last week (P = 0.008) are associated with urgent visits. Having a fever (P = 0.002), younger mother (P = 0.046) and father age (P = 0.007), mother not having an income (P = 0.034), and father's lower level of education (P = 0.036) increased the likelihood of overestimating the emergency severity.

CONCLUSIONS

Nonurgent visits constitute most of the PED admissions. Several factors were found to be associated with nonurgent visits either by causing a direct effect or by indirectly impacting the perceived severity. Health literacy-based interventions targeting common symptoms like fever and especially younger parent groups might be beneficial in lowering the patient burden of PEDs.

Low-Resource Emergency Department Visits for Children With Complex Chronic Conditions

OBJECTIVE

Reducing emergency department (ED) use in children with complex chronic conditions (CCC) is a national health system priority. Emergency department visits with minimal clinical intervention may be the most avoidable. We assessed characteristics associated with experiencing such a low-resource ED visit among children with a CCC.

METHODS

A retrospective study of 271,806 ED visits between 2014 and 2017 among patients with a CCC in the Pediatric Health Information System database was performed. The main outcome was a low-resource ED visit, where no medications, laboratory, procedures, or diagnostic tests were administered and the patient was not admitted to the hospital. χ2 Tests and generalized linear models were used to assess bivariable and multivariable relationships of patients' demographic, clinical, and health service characteristics with the likelihood of a low- versus higher-resource ED visit.

RESULTS

Sixteen percent (n = 44,111) of ED visits among children with CCCs were low-resource. In multivariable analysis, the highest odds of experiencing a low- versus higher-resource ED visit occurred in patients aged 0 year (vs 16+ years; odds ratio [OR], 3.9 [95% confidence interval {CI}, 3.7-4.1]), living <5 (vs 20+) miles from the ED (OR, 1.7 [95% CI, 1.7-1.8]), and who presented to the ED in the day and evening versus overnight (1.5 [95% CI, 1.4-1.5]).

CONCLUSIONS

Infant age, living close to the ED, and day/evening-time visits were associated with the greatest likelihood of experiencing a low-resource ED visit in children with CCCs. Further investigation is needed to assess key drivers for ED use in these children and identify opportunities for diversion of ED care to outpatient and community settings.

Evaluation of compliance with early postbirth follow-up and unnecessary visits to the paediatric emergency department: a prospective observational study at the Lenval Children's Hospital in Nice

OBJECTIVE

To evaluate compliance with the French National Authority for Health's (Haute Autorité de Santé, HAS) postbirth follow-up recommendations for newborns attending our paediatric emergency department (PED) and identify risk factors associated with non-compliance and unnecessary emergency department utilisation.

DESIGN

Prospective, single centre.

SETTING

Fourth biggest PED in France in terms of attendance (CHU-Lenval).

PATIENTS

280 patients of whom 249 were included in the statistical analysis.

MAIN OUTCOME MEASURES

The primary outcome of this study was the evaluation of compliance of the care pathway for newborns consulting at the PED with respect to the French postbirth follow-up recommendations. Secondary outcome was the assessment of whether the visit to the PED was justified by means of PED reception software and two postconsultation interviews RESULTS: 77.5% (193) of the newborns had non-compliant care pathways and 43% (107) of PED visits were unnecessary. Risk factors associated with a non-compliance regarding the HAS's postbirth follow-up recommendations were: unnecessary visit to the PED (OR 2.0, 95% CI 1.1 to 3.9), precariousness (OR 2.8, 95% CI 1.4 to 6.2), birth in a public maternity hospital (OR 2.5, 95% CI 1.3 to 4.8) and no information about HAS's postbirth follow-up recommendations on discharge from maternity ward (OR 11.4, 95% CI 5.8 to 23.3). Risk factors for unnecessary PED visits were: non-compliant care pathway (OR 2.0, 95% CI 1.1 to 3.9) and a first medical visit at a PED (OR 1.8, 95% CI 1.1 to 3.1).

CONCLUSION

Postbirth follow-up may lead to decrease unnecessary emergency department visits unnecessary emergency department visits.

TRIAL REGISTRATION NUMBER

The study bears the clinical trial number NCT02863627.

Retrospective observational study of neonatal attendances to a children's emergency department

AIM

Attendances to emergency departments (EDs) in the UK are increasing, particularly for younger children. Community services are under increasing pressure and parents may preferentially bring their babies to the ED, even for non-urgent problems. This study aimed to characterise the presenting features, management and disposition of neonatal attendances to a children's ED (CED).

METHODS

Retrospective observational review of neonatal attendances (≤28 days) to the CED at Bristol Royal Hospital for Children (BRHC) from 01/01/2016 to 31/12/2016. Further information was obtained from investigation results and discharge summaries. Data abstracted included sex, age, referral method, presenting complaint, diagnosis, investigations and treatments.

RESULTS

Neonatal attendances increased from 655 to 1,205 from 2008 to 2016. The most common presenting complaints were breathing difficulty (18.1%) and vomiting (8.3%). The most common diagnoses were 'no significant medical problem' (41.9%) and bronchiolitis (10.5%). Half of neonatal attendances to the CED had no investigations performed and most (77.7%) needed advice or observation only.

CONCLUSION

Many neonates presenting to the CED were well and discharged with observation only. This suggests potential for improving community management and in supporting new parents. Drivers of health policy should consider developing enhanced models of out of hospital care which are acceptable to clinicians and families.

Risk factors for emergency room use and rehospitalization among opioid-exposed newborns in Massachusetts

OBJECTIVE

To determine the risk factors for receipt of emergency room (ER) care and rehospitalization among opioid-exposed newborns in Massachusetts.

DESIGN/METHODS

We analyzed two linked data sets from 2002 to 2010: (a) Massachusetts Pregnancy to Early Life Longitudinal Data System and (b) Massachusetts Bureau of Substance Abuse Services Management Information System. Generalized estimating equations were used to assess the independent association of maternal and infant characteristics with ER use and rehospitalization in the first year of life.

RESULTS

Four thousand and five hundred and twenty-four maternal-infant dyads affected by OUD were included in the analysis. In adjusted analysis, risk factors for receipt of ER care included Hispanic ethnicity (aOR 1.63 [95% CI 1.30-2.05]), lower education levels (aOR 1.54-1.69 [95% CI 1.12-2.31]), nonprivate insurance (aOR 1.44 [95% CI 1.11-1.86]), and presence of maternal chronic conditions (aOR 1.14 [95% CI 1.01-1.29]). Risk factors for rehospitalization included prematurity (aOR 1.44 [95% CI 1.14-1.82]), low birthweight (aOR 2.02 [95% CI 1.63-2.49]), and nonprivate insurance (aOR 1.58 [95% CI 1.13-2.22]). Prolonged infant birth hospitalization was protective against both ER use (aOR 0.84 [95% CI 0.73-0.96]) and rehospitalization (aOR 0.63 [95% CI 0.53-0.75]).

CONCLUSIONS

Clinical and sociodemographic characteristics are risk factors for receipt of ER care and rehospitalization among opioid-exposed newborns in Massachusetts.

Neighborhood Inequality and Emergency Department Use in Neonatal Intensive Care Unit Graduates

Neonatal intensive care unit graduates residing in high-risk neighborhoods were at increased risk of emergency department use and had higher rates of social/environmental risk factors. Distances to primary care provider and emergency department did not contribute to emergency department use. Knowledge of neighborhood risk is important for preventative service reform.

The consequences of having an excessively crying infant in the family: an integrative literature review

BACKGROUND

The consequences of having an excessively crying infant in the family are acknowledged in research, yet to our knowledge, no literature review has been made regarding the overall consequences to the family and infant. This integrative review fills the gap with the aim to review and synthesise current research.

AIMS

To identify, describe and synthesise previous studies on the consequences of having an excessively crying infant in the family.

DESIGN

An integrative review of literature published between January 2008 and April 2018. The search was conducted in the following databases: MEDLINE, CINAHL, PsycINFO, Medic and Journals@Ovid. Empirical literature reporting the consequences of having an excessively crying infant in the family was eligible for inclusion. Quality appraisal was performed using CASP tools and JBI checklists. The extracted data were analysed using thematic analysis.

FINDINGS

Thirty-one articles were included in the review. Ten themes were identified: The consequences of having an excessively crying infant in the family create desperation. It ruins everyday life, impairs breastfeeding, isolates and casts parents into loneliness, strains and breaks family relationships with feelings of failure as a parent. The excessively crying infant in the family brings a struggle that can lead to physical and mental exhaustion. The infant may have problems later in childhood. Parents are actively trying to solve the problem and to adjust. Time allows survival with traces of negative symptoms, feelings and memories.

CONCLUSIONS

The consequences of having an excessively crying infant in the family are harmful to relationships and health. Caring for the crying infant can lead to exhaustion, which might escalate into abuse. These findings help professionals understand this complex phenomenon and encourage actions for concrete support. Further research is required to explore evidence-based interventions that can help excessively crying infants and their families.

Non-urgent paediatric emergency department presentation: A systematic review

There has been an increase in the use of the emergency department (ED) for non-urgent presentations. The aim of this systematic review was to identify the proportion, criteria and predictors of non-urgent ED presentations in paediatric populations. A search of multiple databases was conducted for articles published from inception of the databases to 20 August 2018, which reported the proportion, criteria and predictors of non-urgent ED presentation in paediatric populations. Thirty-one articles met the inclusion criteria. The mean proportion of non-urgent paediatric ED presentations was 41.06 ± 15.16%. There appears to be a weak association between predisposing, enabling and needs factors and non-urgent ED use in paediatric populations. The findings of this review suggest that non-urgent ED use in paediatric populations is high. However, non-urgent ED use and the reasons for the visits in paediatric populations remain understudied.

Why Are Newborns Brought to the Emergency Department?

OBJECTIVES

Neonatal period is a peculiar life stage. This study aimed to characterize newborns' visits to the emergency department (ED) of a secondary care hospital.

METHODS

Retrospective analysis of infants up to 28 days, who resorted to the ED between January and December of 2014, was performed. The data included newborn and maternal demographic characteristics and characterization of visits in the ED.

RESULTS

From 378 newborns' visits in the ED, 77 were excluded because the visits did not meet the inclusion criteria. From the remaining 301 visits, corresponding to 266 newborns, 56 newborns were referred to hospital care by another doctor, and 34 returned to ED in the neonatal period. The majority of newborns were full term (94%), born by vaginal delivery (55.1%), and had an appropriate birth weight for gestational age (94%). The main reasons for ED visits were gastrointestinal symptoms (33.8%), mucocutaneous lesions (21.4%), and jaundice (16.2%). Half (53%) of the newborns' visits were considered nonurgent. Emergency department visits for reasons justifying medical evaluation were higher in those referred by another doctor (P < 0.001). The rate of hospitalization or guidance for consultation was higher in newborns referred by another doctor (P = 0.017), in those whose color attributed by Manchester Triage System was yellow or orange (P = 0.029) and in newborns older than 7 days (P = 0.035).

CONCLUSIONS

The majority of ED visits is owing to insufficient caretaker knowledge or benign symptoms without necessity of immediate medical evaluation. These results emphasize the need for parents' education by health professionals.

Parental characteristics and perspectives pertaining to neonatal visits to the emergency department: a multicentre survey

BACKGROUND

Parents take neonates to the emergency department for many reasons, often nonurgent, pressuring an already burdened system. We aimed to characterize these visits and families to identify potential strategies to decrease neonatal emergency department visits.

METHODS

We developed and implemented a survey that explored characteristics of neonates and parents/guardians evaluated in the emergency department, perspectives of parents and use of health care services. Parents presenting with a neonate to the emergency department in 5 large academic hospitals in Ontario were surveyed between December 2013 and June 2015. We used descriptive statistics to report survey data and explored correlations between factors.

RESULTS

A total of 1533 surveys were completed. The most common reasons for presenting were jaundice (441 [28.8%]) and feeding issues (251 [16.4%]). The majority of respondents (73.9% [1104/1494]) had received advice before going to the emergency department. In most cases (86.4% [954/1104]), this was from a health care provider, who frequently advised going to the emergency department. Although most parents (86.8% [1280/1475]) reported high confidence in caring for a sick or injured child, 42.3% (643/1519) were unsure of the severity, and most (90.4% [578/639]) of these parents felt that the infant required assessment immediately or the same day. Of parents who felt the condition was not serious, 83.2% (198/238) thought that same-day evaluation was required. Nearly half of respondents (44.4% [621/1400]) said they would have gone to their health care provider with a same-day appointment, and 28.1% (344/1225) would have gone to their care provider with a next-day appointment.

INTERPRETATION

Parents' reported confidence in caring for sick or injured infants does not match the perceived urgency of neonatal conditions, which likely contributes to emergency department overuse. Any system to decrease nonurgent emergency department use by neonates would need to be immediately responsive, providing same-day help.

The Clinical Differences between Urgent Visits and Non-Urgent Visits in Emergency Department During the Neonatal Period

As neonates are brought to the emergency department (ED) for various complaints, it is challenging for emergency physicians to clinically determine the urgency of the visit. We sought to explore clinical characteristics associated with urgent visits to the ED. We conducted a retrospective study by reviewing medical records of neonatal visits to a tertiary pediatric regional emergency center for 5 years. Cases of patients who were discharged after checking only chest or abdominal X-ray or discharged without workup, were classified as non-urgent visits. Cases where more examinations were performed, or when the patient was hospitalized, were classified as urgent visits. Various clinical features and process in the ED were compared between the groups. Of the 1,008 cases enrolled in this study, 856 (84.9%) were urgent and 152 (15.1%) were non-urgent visits. After adjustment by multiple logistic regression analysis, non-urgent visits were associated with self-referrals rather than physician-referrals (odds ratio [OR], 5.96), visits in the evening rather than at night or daytime (OR, 2.51), patient visits from home rather than from medical facilities (OR, 2.19; 95). Fever and jaundice were the most common complaints (25.7% and 24.5%, respectively), and their OR of non-urgent visit was relatively low (adjusted OR 0.03 and 0.03, respectively). However, other common complaints, such as vomiting and cough (7.4% and 7.1%, respectively), were more likely to be non-urgent visits (adjusted OR 2.96 and 9.83, respectively). For suspected non-urgent visits, emergency physicians need to try to reduce unnecessary workup and shorten length of stay in ED.