Short-term outcomes of pediatric emergency department febrile illnesses

Emergency Department Sepsis Triage Scoring Tool Elements Associated With Hypotension Within 24 Hours in Children With Fever and Tachycardia

OBJECTIVE

Pediatric sepsis screening is becoming the standard of care for children presenting to the emergency department (ED) and has been shown to improve recognition of severe sepsis, but it is unknown if these screening tools can predict progression of disease. The objective of this study was to determine if any elements of a sepsis triage trigger tool were predictive of progression to hypotensive shock in children presenting to the ED with fever and tachycardia.

METHODS

This study is a retrospective case-control study of children ≤18 years presenting to an ED with fever and tachycardia, comparing those who went on to develop hypotensive shock in the subsequent 24 hours (case) to those who did not (control). Primary outcome was the proportion of encounters where the patient had specific abnormal vital signs or clinical signs as components of the sepsis triage score. The secondary outcomes were the proportion of encounters where the patient had a sepsis risk factor.

RESULTS

During the study period, there were 94 patients who met case criteria and 186 controls selected. In the adjusted multivariable model, the 2 components of the sepsis triage score that were more common in case patients were the presence of severe cerebral palsy (adjusted odds ratio, 9.4 [3.7, 23.9]) and abnormal capillary refill at triage (adjusted odds ratio, 3.1 [1.4, 6.9]).

CONCLUSIONS

Among children who present to a pediatric ED with fever and tachycardia, those with prolonged capillary refill at triage or severe cerebral palsy were more likely to progress to decompensated septic shock, despite routine ED care.

Youth victim perspective: optimizing presentation of patient-reported outcomes in a violence intervention program

INTRODUCTION

The health, well-being and psychological development of children in urban areas is threatened by exposure to interpersonal violence. Violence intervention programs, such as Project Ujima, provide children with comprehensive treatment following exposure to violence. Services focus on the interruption of the violence cycle, mental health, and developing resiliency. The collection of patient-reported outcomes (PROs) from youth victims of violence informs community-based, programmatic, and individual participant interventions. Although the collection of PROs throughout treatment has been demonstrated to be feasible, youth and crime victim specialist preferences for data presentation is unknown. We sought to determine patient and crime victim specialist preferences regarding which PROs are of interest and how best to visually display them for optimal engagement.

RESULTS

Fifteen youth and nine crime victim specialists consented to participate. Both preferred visuals with the highest level of color-shading and descriptions. The domains with the highest level of interest among both youth and case workers were social, anger, emotional, school, physical, peer relations, and psychosocial well-being. Youth and crime victim specialists expressed low interest in positive affect, meaning/purpose, physical stress experience, and depression domains. Youth wanted to see their scores compared to others in the program, while crime victim specialists did not think such comparisons would be beneficial. In contrast to youth, crime victim specialists believed youth should see their physical functioning and PTSD scores.

CONCLUSION

Youth participants and their crime victim specialists in a violence intervention program desired to see their PROs in a graphical form and agreed on their preference for many of the domains except for PTSD and physical functioning. Both groups preferred visuals with the highest level of shading and descriptions. Further investigation is needed to determine how to implement PRO visuals with the desired domains into regular violence intervention programming.

METHODS

Participants in Project Ujima's 8-week summer camp, ages 7-18 years, who were either a victim of violent injury, a direct relative of a violent injury victim, or a homicide survivor were recruited for this qualitative study. Crime victim specialists, who work directly with these youth throughout the year, were also recruited to participate. We conducted structured interviews to determine which parameters and visual formats were of highest interest and best understood by youth participants and crime victim specialists.

Respiratory viral coinfection in a birth cohort of infants in rural Nepal

BACKGROUND

Acute respiratory illnesses are a leading cause of global morbidity and mortality in children. Coinfection with multiple respiratory viruses is common. Although the effects of each virus have been studied individually, the impacts of coinfection on disease severity are less understood.

METHODS

A secondary analysis was performed of a maternal influenza vaccine trial conducted between 2011 and 2014 in Nepal. Prospective weekly household-based active surveillance of infants was conducted from birth to 180 days of age. Mid-nasal swabs were collected and tested for respiratory syncytial virus (RSV), rhinovirus, influenza, human metapneumovirus (HMPV), coronavirus, parainfluenza (HPIV), and bocavirus by RT-PCR. Coinfection was defined as the presence of two or more respiratory viruses detected as part of the same illness episode.

RESULTS

Of 1730 infants with a respiratory illness, 327 (19%) had at least two respiratory viruses detected in their primary illness episode. Of 113 infants with influenza, 23 (20%) had coinfection. Of 214 infants with RSV, 87 (41%) had coinfection. The cohort of infants with coinfection had increased occurrence of fever lasting ≥ 4 days (OR 1.4, 95% CI: 1.1, 2.0), and so did the subset of coinfected infants with influenza (OR 5.8, 95% CI: 1.8, 18.7). Coinfection was not associated with seeking further care (OR 1.1, 95% CI: 0.8, 1.5) or pneumonia (OR 1.2, 95% CI: 0.96, 1.6).

CONCLUSION

A high proportion of infants had multiple viruses detected. Coinfection was associated with greater odds of fever lasting for four or more days, but not with increased illness severity by other measures.

Youth Victims of Violence Report Worse Quality of Life Than Youth With Chronic Diseases

OBJECTIVES

Measuring health-related quality of life (HRQOL) provides the patient's perspective of his/her well-being and offers a unique outcome measure to demonstrate the impact of violence on the victim. To date, no study has described HRQOL in youth victims of violence in the United States. The purpose of this study was to describe HRQOL in youth victims of violence as compared with healthy youth and youth with chronic disease.

METHODS

We conducted an exploratory cross-sectional study of the HRQOL of victims of violence aged 8 to 18 years. Descriptive statistics were reported for participant and injury demographics. One sample t tests were used to compare the sample population's HRQOL to known HRQOL of healthy populations and specific disease populations.

RESULTS

Fifty-eight victims of violence participated in the study. Youth victims of violence had significantly worse mean HRQOL scores (mean, 71.4) compared with healthy youth in overall functioning (mean, 83.9), P < 0.001. Youth victims of violence reported worse psychosocial (mean, 67.6), emotional (mean, 62.9), and school (mean, 63.8) functioning than youth with obesity (mean, 72.1, 68.6, 75.0, respectively) and cancer (mean, 72.1, 72.2, 68.3, respectively). Mean Patient-Reported Outcomes Measurement Information System T scores for youth victims of violence were significantly worse in anxiety (T = 51.9) and depression (T = 52.4) compared with youth with obesity (T = 48.3, 49.2), cancer (T = 47.7, 47.6), and sickle cell disease (T = 43, 44).

CONCLUSIONS

Youth victims of violence suffer significant impairment in HRQOL compared with healthy populations and youth with specific disease burdens. Future studies into violence prevention effectiveness should use HRQOL as a comparative outcome measure to better tailor post injury management and interventions.

Comparison of Antipyretic Efficacy of Intravenous (IV) Acetaminophen versus Oral (PO) Acetaminophen in the Management of Fever in Children

OBJECTIVE

To assess the dynamics of the onset of antipyretic efficacy of intravenous (IV) acetaminophen vs. oral (PO) acetaminophen in the management of fever in children.

METHODS

This observational single-dose study was conducted at Department of Pedriatrics, Army Hospital (Research and Referral), a multispecialty tertiary care center in New Delhi in fever patients to assess the antipyretic efficacy of IV acetaminophen 15 mg/kg/dose vs. PO acetaminophen 15 mg/kg/dose over 6 h. Subjects were randomly assigned to receive either IV acetaminophen (n = 200) or PO acetaminophen (n = 200).

RESULTS

Demographics and baseline characteristics were similar between the two groups and were normally distributed. Allergic reaction was found in 7 (3.5%) patients in IV acetaminophen group and was absent in PO acetaminophen group. Onset of constipation and dry mouth was found in 8 patients (4%) in IV acetaminophen group and was absent in PO acetaminophen group. Additional dose was required in 6 patients (3%) in intravenous acetaminophen group and 10 patients (5%) in oral acetaminophen group respectively. Statistically significant differences in the rate of fall in temperature through 180 min were observed in favor of the IV acetaminophen group when compared to those receiving PO acetaminophen.

CONCLUSIONS

A single dose of intravenous acetaminophen is safe and effective in reducing fever where patients are unable to tolerate oral administration or when rapid reduction of temperature is desirable.

Parental Language and Return Visits to the Emergency Department After Discharge

OBJECTIVE

Return visits to the emergency department (ED) are used as a marker of quality of care. Limited English proficiency, along with other demographic and disease-specific factors, has been associated with increased risk of return visit, but the relationship between language, short-term return visits, and overall ED use has not been well characterized.

METHODS

This is a planned secondary analysis of a prospective cohort examining the ED discharge process for English- or Spanish-speaking parents of children aged 2 months to 2 years with fever and/or respiratory illness. At 1 year after the index visit, a standardized chart review was performed. The primary outcome was the number of ED visits within 72 hours of the index visit. Multivariable logistic regression was used to examine the relative importance of predictor variables and adjust for confounders.

RESULTS

There were 202 parents eligible for inclusion, of whom 23% were Spanish speaking. In addition, 6.9% of the sample had a return visit within 72 hours. After adjustment for confounders, Spanish language was associated with return visit within 72 hours (odds ratio, 3.49; 95% confidence interval, 1.02-11.90) but decreased risk of a second visit within the year (odds ratio, 0.28; 95% confidence interval, 0.12-0.66).

CONCLUSION

Spanish-speaking parents are at an increased risk of 72-hour return ED visit but do not seem to be at increased risk of ED use during the year after their ED visit.

Tools for 'safety netting' in common paediatric illnesses: a systematic review in emergency care

CONTEXT

Follow-up strategies after emergency department (ED) discharge, alias safety netting, is often based on the gut feeling of the attending physician.

OBJECTIVE

To systematically identify evaluated safety-netting strategies after ED discharge and to describe determinants of paediatric ED revisits.

DATA SOURCES

MEDLINE, Embase, CINAHL, Cochrane central, OvidSP, Web of Science, Google Scholar, PubMed.

STUDY SELECTION

Studies of any design reporting on safety netting/follow-up after ED discharge and/or determinants of ED revisits for the total paediatric population or specifically for children with fever, dyspnoea and/or gastroenteritis. Outcomes included complicated course of disease after initial ED visit (eg, revisits, hospitalisation).

DATA EXTRACTION

Two reviewers independently assessed studies for eligibility and study quality. As meta-analysis was not possible due to heterogeneity of studies, we performed a narrative synthesis of study results. A best-evidence synthesis was used to identify the level of evidence.

RESULTS

We summarised 58 studies, 36% (21/58) were assessed as having low risk of bias. Limited evidence was observed for different strategies of safety netting, with educational interventions being mostly studied. Young children, a relevant medical history, infectious/respiratory symptoms or seizures and progression/persistence of symptoms were strongly associated with ED revisits. Gender, emergency crowding, physicians' characteristics and diagnostic tests and/or therapeutic interventions at the index visit were not associated with revisits.

CONCLUSIONS

Within the heterogeneous available evidence, we identified a set of strong determinants of revisits that identify high-risk groups in need for safety netting in paediatric emergency care being related to age and clinical symptoms. Gaps remain on intervention studies concerning specific application of a uniform safety-netting strategy and its included time frame.

Predicting prolonged duration of fever in children: a cohort study in primary care

BACKGROUND

Fever in children in primary care is commonly caused by benign infections, but often worries parents. Information about the duration of fever and its predictors may help in reassuring parents, leading to diminished consultation of health care.

AIM

To determine which signs and symptoms predict a prolonged duration of fever in febrile children in primary care and evaluate whether C-reactive protein (CRP) measurement has an additive predictive value for these symptoms.

DESIGN AND SETTING

A prospective cohort study at a GPs' cooperative (GPC) out-of-hours service.

METHOD

Children (aged 3 months to 6 years) presenting with fever as stated by the parents were included. Exclusion criteria were no communication in Dutch possible, previous enrolment in the study within 2 weeks, referral to the hospital directly after visiting the GPC, or no informed consent. The main outcome measure was prolonged duration of fever (>3 days) after initial contact.

RESULTS

Four-hundred and eighty children were analysed, and the overall risk of prolonged duration was 13% (63/480). Multivariate analysis combined model of patient history and physical examination showed that 'sore throat' (OR 2.8; 95% CI = 1.30 to 6.01) and 'lymph nodes palpable' (OR 1.87; 95% CI = 1.01 to 3.49) are predictive for prolonged duration of fever. The discriminative value of the model was low (AUC 0.64). CRP had no additive value in the prediction of prolonged duration of fever (OR 1.00; 95% CI = 0.99 to 1.01).

CONCLUSION

The derived prediction model indicates that only a few signs and symptoms are related to prolonged duration of fever. CRP has no additional value in this model. Overall, because the discriminative value of the model was low, the duration of fever cannot be accurately predicted.

Multiple health care visits related to a pediatric emergency visit for young children with common illnesses

We aim to describe the number of health care visits before and after pediatric emergency department (PED) visits for common illnesses in a French tertiary pediatric hospital. This was a prospective cohort study with 501 children under 6 years of age who were evaluated and discharged from a tertiary care PED. Enrollment occurred on eight randomly selected study days between November 2010 and June 2011. The caregivers were then contacted via telephone 8 days later to obtain follow-up data, including information about return visits to health care facilities. Multiple visits were made by 206 (41 %) children, previous visits had occurred for 139 (28 %) children, and return visits had occurred for 94 (19 %) children. Previous and return visits were made at the PED as well as in general practitioners' offices and private pediatric offices. The median age of the subjects was 18 months. Fever was the most common complaint and was associated with more frequent multiple heath care visits.

CONCLUSION

Multiple heath care visits for the same illness are frequent, especially for febrile children. Interestingly, this phenomenon concerns every type of health care facility, including the PED, general practitioners' offices, and private pediatric offices. Further studies should be performed to achieve a better understanding of this phenomenon and to test specific interventions, such as parental education and improvement of the information system.

Fever and antipyretic use in children

Fever in a child is one of the most common clinical symptoms managed by pediatricians and other health care providers and a frequent cause of parental concern. Many parents administer antipyretics even when there is minimal or no fever, because they are concerned that the child must maintain a "normal" temperature. Fever, however, is not the primary illness but is a physiologic mechanism that has beneficial effects in fighting infection. There is no evidence that fever itself worsens the course of an illness or that it causes long-term neurologic complications. Thus, the primary goal of treating the febrile child should be to improve the child's overall comfort rather than focus on the normalization of body temperature. When counseling the parents or caregivers of a febrile child, the general well-being of the child, the importance of monitoring activity, observing for signs of serious illness, encouraging appropriate fluid intake, and the safe storage of antipyretics should be emphasized. Current evidence suggests that there is no substantial difference in the safety and effectiveness of acetaminophen and ibuprofen in the care of a generally healthy child with fever. There is evidence that combining these 2 products is more effective than the use of a single agent alone; however, there are concerns that combined treatment may be more complicated and contribute to the unsafe use of these drugs. Pediatricians should also promote patient safety by advocating for simplified formulations, dosing instructions, and dosing devices.

Health-related quality of life for pediatric emergency department febrile illnesses: an evaluation of the Pediatric Quality of Life Inventory 4.0 Generic Core Scales

OBJECTIVE

We sought to assess the validity and short-term responsiveness of the Pediatric Quality of Life Inventory 4.0 Generic Core Scales (PedsQL) for febrile illnesses evaluated in the pediatric emergency department (ED).

DESIGN

Prospective cohort study of children 2-18 years discharged after ED evaluation for fever (>or= 38 degrees C). Self-administered, parent-report of health-related quality of life (HRQOL) was assessed using the PedsQL Acute Version, a validated HRQOL instrument. HRQOL was measured on ED presentation and at 7-10 day follow-up. At follow-up, duration of fever, child functional impairment, missed daycare/school, and disrupted family unit functioning, were assessed.

RESULTS

Of 160 subjects enrolled, 97 (61%) completed the study; mean follow-up was 8.7 days. Mean total HRQOL score on ED presentation was 76.4; mean follow-up score was 86.3. Compared to subjects that returned to baseline, statistically significant differences in HRQOL were noted for those with prolonged fever, child functional impairment, and relapse. Significant correlation was observed between HRQOL at follow-up and days of daycare/school missed (r = -0.35, p = .003) and days of family disruption (r = -0.43, p < .001). Mean change in HRQOL within subjects, from ED visit to follow-up, was +9.8 (95% CI: 5.6-14.6). Effect size was 0.53, indicating moderate responsiveness.

CONCLUSION

The PedsQL appears to be a valid and responsive indicator of HRQOL for short-term febrile illnesses evaluated in the ED.

Postdischarge pain, functional limitations and impact on caregivers of children with sickle cell disease treated for painful events

This study aimed to describe the outcomes of children with sickle cell disease (SCD) after discharge from medical care for vaso-occlusive painful events and to test the hypothesis that older age, longer length of hospital stay, and a history of frequent vaso-occlusive painful events will be associated with poor outcomes. Children aged 2-18 years with SCD treated in the emergency department or inpatient unit for a painful event were contacted after discharge to assess: days of pain, days of functional limitations for the child, and days of work/school absenteeism for the caregiver. Descriptive statistics were applied and multivariate logistic regression examined the association between the predictors and outcomes. Fifty-eight children were enrolled (mean age 10.8 +/- 4.8 years, 53.5% female). Postdischarge, 46.5% of children reported three or more days of pain, 54.3% had two or more days of functional limitations, and 24.3% of caregivers missed two or more days of work/school. Children with three or more prior painful events had increased odds of a poor outcome postdischarge (OR 1.79; 95% CI = 1.026, 3.096). In conclusion, acute vaso-occlusive painful events impact the lives of children with SCD and their caregivers, even after discharge to home.