Changes in pediatric emergency department visits during a COVID-19 lockdown period: an exhaustive single-center analysis

Background

In many countries, the restrictions related to the first period of lockdown during the coronavirus disease 2019 (COVID-19) pandemic led to widespread changes in health service usage in general and in emergency departments in particular. However, no comprehensive evaluation of changes has been published to date. The objective of the present study was to determine the precise impact of the 2020 lockdown on admissions to a pediatric emergency department (PED) compared to the same periods in 2018 and 2019.

Methods

This retrospective, observational study included all patients under the age of 183 months (15.25 years) admitted to our French university hospital's PED during the period from March 17 to May 11 in the years 2018, 2019, and 2020. The primary outcome was the change in PED admissions in 2020 compared to 2018 and 2019. The secondary outcomes were notably changes in the primary discharge diagnoses, the discharge destination, and unwarranted visits.

Results

A total of 10,479 PED visits were identified, of which 10,295 were analyzed. In 2020, the number of PED visits fell by 61% and 63% vs. 2018 and 2019, respectively. Although the number of discharges to other hospital departments decreased by 52% and 49%, the proportion of these discharges increased: 18% of 1579 in 2020 vs. 13% of 4232 in 2018 and of 4484 in 2019 (p<0.01). Discharge from the PED to the intensive care unit was significantly more frequent in 2020 (p<0.05). Unwarranted visits were significantly lower in 2020 (19%) as compared to 2018 (22%) and 2019 (24%). Surgical and injury-related discharge diagnoses increased by 6% in 2020 (p<0.001), with a significant rise in trauma and foreign-body injuries (p<0.05). With regard to disease-related discharge diagnoses, we observed a significant rise in mental, behavioral, and social issues (p<0.01). Conversely, there was a significant (p<0.01) drop in diagnoses of acute infectious diseases in 2020 compared with 2018 and 2019.

Conclusion

Lockdown was associated with a massive reduction in the number of PED visits, a significant change in primary discharge diagnoses, and a decrease in the proportion of unwarranted PED visits compared to the previous 2 years. This should encourage public health researchers to examine how to alleviate the burden of unnecessary PED visits.

[Should French pregnant women be vaccinated against pertussis during pregnancy?]

Many countries with a high perinatal level have started a policy of vaccination of pregnant women against pertussis. To date, France has not chosen this policy. The objective was to review knowledge on pertussis mortality in infants. Compare the strategies available to protect the infant before his first vaccination, scheduled for two months of age. We proceeded to a litterature analysis, from January 1998 to 2021. Search by the following keywords used ; "Whooping cough, vaccination, pregnancy, strategy, cocooning", on the scientific basis of "Pubmed", as well as French and foreign vaccination recommendations. Currently 90% of whooping cough deaths are concerning infants under six months of age and this mortality represents 2% of mortality in the first year of life. Vaccination at birth is not effective. The cocooning strategy, which consists of vaccinating those around the child, is expensive and difficult to implement. A systematic vaccination policy for pregnant women is effective and reasonably expensive when compared to the cocooning strategy. In England, it was recently accompanied by a 78% reduction in confirmed cases of pertussis in infants under six months of age. In conclusion, compared to cocooning strategy, pertussis vaccination of pregnant women appears more effective and cost-effective, and this with each pregnancy.

The position during urine sample collection from young precontinent children through a bag does not limit contamination rates: Results from a randomized controlled trial: Does infant position influence quality of urine collection?

AIM

Despite its limitation, bag collection is still widely used for a preliminary urine screening test in non-toilet-trained children suspected of febrile urinary tract infection. A previous study conducted by our group raised the hypothesis that the absence of direct contact between urine and the perinea during urine collection could limit urine contamination by perineal flora. The aim of this study was to evaluate the impact of the patient's position during urine collection (upright standing position versus free position) on the rate of contaminated urine samples in non-toilet-trained children with suspected febrile urinary tract infection.

METHODS

This prospective, randomized, controlled study took place in seven pediatric emergency departments. Two groups were compared: the intervention group (infants held in an upright standing position during urination) and the control group (free position during urination).

RESULTS

Among the 800 pediatric patients randomized to the study, 124 had a urine culture, 60 in the intervention group and 64 in the control group. Among the 124 urine cultures, 12 (9.7%) were contaminated: eight (13.3%) in the intervention group and four (6.3%) in the control group (p = 0.1824).

CONCLUSION

The results show that the patient's position does not have a significant impact on the quality of urine samples collected by bag.

Simulation-based pediatric training: A French national survey

INTRODUCTION

To have an overview of pediatric medical simulation within a country would be helpful to improve the offer and quality of teaching. The main objective of this study was to identify the scope for simulation-based teaching in pediatrics in France.

METHODS

An assessment of professional practices was conducted by means of a national survey conducted among all university hospitals between 20 May and 6 August 2018. A standardized GoogleForm® was created and sent to heads of simulation centers or persons responsible for pediatric simulation. Descriptive analyses and comparisons of centers with and without university trainers as well as with and without research activity were performed.

RESULTS

All 34 teaching hospitals or faculties of medicine responded to our survey. Of these, 31 had a simulation center. There was a median of nine trainers per center (interquartile range: 5-13). Most used simulation for communication and teamwork, as well as for technical and relational skills. These sessions were mainly dedicated to residents and health professionals. All centers reported working on high-fidelity newborn mannequins and 84% used low-fidelity newborn mannequins. Research activity was declared by 14 centers (45%), but only six of these had at least one publication. No difference was identified between centers with and without university trainers or with and without research activity.

CONCLUSION

Compared with the 2012 report, 19 new centers have emerged within 6 years in France (+158%). Pursuing research to evaluate the impact of simulation programs on physician skills and patient management would appear to be important.

Parental acceptance of an intranasal vaccine: Example of influenza vaccine

BACKGROUND

Influenza vaccination coverage of children with chronic disease is insufficient in France, although a nasal live attenuated influenza vaccine (LAIV) has been approved.

OBJECTIVE

We aimed to evaluate the acceptance of nasally administered vaccines by parents of children with chronic illness, by comparing LAIV vs. injectable inactivated influenza vaccine (IIV) acceptance.

METHODS

We performed a retrospective, observational study (December 2014 to April 2015) including parents of all children vaccinated with the LAIV during the 2013-2014 influenza vaccination campaign at our university hospital. It was an opinion survey on the tolerance and acceptance of the LAIV.

RESULTS

A standardized evaluation form was completed by 67/79 parents of all children who received the LAIV (mean age: 113±56 months; 64% with a chronic respiratory disease). The parents responded that vaccines in general were important (99%) but only 58% of them accepted the injectable route of administration. Of the 48 parents of children who had received both LAIV and IIV in the past, global opinion (P<0.0001) and tolerance (P<0.0001) were better for LAIV. For the future, 81% of parents would prefer LAIV, mainly because of needle absence and/or less painful character, and 18% IIV, mainly because of easier administration or habit.

CONCLUSION

The better acceptance of a nasally administrated vaccine could increase vaccination coverage in the future for nasal vaccines.

Impact of the Sofia® Influenza A+B FIA rapid diagnostic test in a pediatric emergency department

OBJECTIVE

The objective of this study was to evaluate the impact of a rapid diagnostic test for influenza (the Sofia^® Influenza A+B FIA rapid diagnostic test [RDT]) in a pediatric emergency department (PED).

METHODS

A retrospective, observational, cross-sectional study was conducted in the PED of the Lille University Hospital between 2013 and 2015. All patients under 18 years of age for whom influenza RDT was administered were included. Clinical data, management, and related hospitalizations were compared between positive and negative RDT groups. The length of stay in the PED (main outcome) and the number of additional tests (biological and radiographic tests) between the two groups were compared.

RESULTS

A total of 238 tests were reported: 119 positive, 110 negative, nine invalid. The mean length of stay in the PED was significantly lower in the positive RDT group: 4.0h vs. 7.4h (P<10^-6). Patients with positive RDT had significantly fewer biological tests (20% vs. 56%; P<10^-7) and radiographs (23% vs. 52%; P<10^-5). The prevalence of hospitalizations in a short-stay unit was significantly lower in patients with positive RDT (0.8% vs. 9.1%; P=0.009).

CONCLUSIONS

This study showed a significant medical impact of the use of Sofia^® Influenza RDT A+B FIA in a PED regarding the length of stay and the number of additional explorations.

Antibiotic treatment of lower respiratory tract infections

Lower respiratory tract infections, i.e., bronchitis, bronchiolitis, and pneumonia, are the second leading cause of antibiotic prescriptions. The vast majority of these infections are due to viruses and are self-limited diseases: most patients recover spontaneously. These two facts explain that antibiotic prescriptions must be limited to some clinical situations for which the diagnosis has to be done early. The first message of this manuscript is to strengthen non-antibiotic prescriptions in many situations such as bronchitis and bronchiolitis. Implementation of pneumococcal conjugate vaccines (PCVs) has reduced the incidence of pneumonia and empyema, and induced a dramatic decrease in the proportion of pneumococcus in these diseases. However, pneumococcus remains probably the leading cause of bacterial pneumonia and empyema and the main target of antibiotic treatment. Furthermore, the implementation of PCVs has reduced resistance to antibiotics including penicillins and macrolides antibiotics, explaining the de-escalation proposed in the last few years, with the reduction of the use if third generation cephalosporins and vancomycin. The therapeutic choices proposed in this article follow the previous official guidelines in France. Serious infections represented by empyema and severe pneumonia remain therapeutic emergencies, most often warranting hospitalization and IV antibiotics.

Clinical severity and molecular characteristics of circulating and emerging rotaviruses in young children attending hospital emergency departments in France

Group A rotavirus (RVA) is the leading cause of acute gastroenteritis in young children worldwide. A prospective surveillance network has been set up to investigate the virological and clinical features of RVA infections and to detect the emergence of potentially epidemic strains in France. From 2009 to 2014, RVA-positive stool samples were collected from 4800 children <5 years old attending the paediatric emergency units of 16 large hospitals. Rotaviruses were then genotyped by RT-PCR with regard to their outer capsid proteins VP4 and VP7. Genotyping of 4708 RVA showed that G1P[8] strains (62.2%) were predominant. The incidence of G9P[8] (11.5%), G3P[8] (10.4%) and G2P[4] (6.6%) strains varied considerably, whereas G4P[8] (2.7%) strains were circulating mostly locally. Of note, G12P[8] (1.6%) strains emerged during the seasons 2011-12 and 2012-13 with 4.1% and 3.0% prevalence, respectively. Overall, 40 possible zoonotic reassortants, such as G6 (33.3%) and G8 (15.4%) strains, were detected, and were mostly associated with P[6] (67.5%). Analysis of clinical records of 624 hospitalized children and severity scores from 282 of them showed no difference in clinical manifestations or severity in relation to the genotype. The relative stability of RVA genotypes currently co-circulating and the large predominance of P[8] type strains may ensure vaccine effectiveness in France. The surveillance will continue to monitor the emergence of new reassortants that might not respond to current vaccines, all the more so as all genotypes can cause severe infections in infants.

Survey of hospital procedures for parapneumonic effusion in children highlights need for standardised management

AIM

This study sought to evaluate the initial management of children with parapneumonic effusion admitted to all French university hospitals.

METHODS

A nationwide survey of all 35 university hospitals took place in 2011 to assess practices for children with parapneumonic effusion, using a hypothetical clinical vignette and a standardised questionnaire. Two to four paediatricians per hospital were interviewed and asked about their initial management, probabilistic antibiotic therapy and its adaptation to microbiological results and subsequent course. Answers from paediatricians working in emergency departments, intensive care units and conventional paediatric units were compared.

RESULTS

Of the 100 paediatricians contacted, 95 responded. Of these, 98% would order an initial blood test, 70% would order diagnostic thoracentesis, and all would start immediate antibiotic therapy: 31% with a single drug, 67% with two drugs and 2% with three drugs. The most frequent initial choices were third-generation cephalosporin alone (17%) or combined with rifampicin (34%) or vancomycin (24%). Adaptation varied according to drug used, dose and duration, especially when the microorganism was not Streptococcus pneumoniae. Practices did not differ significantly among the different groups of paediatricians.

CONCLUSION

Standardised management of parapneumonic effusion, including routine thoracentesis and more consistent prescription of antibiotics, is needed.

[Reasons for low usage of strep A rapid antigen detection tests for pharyngitis in private medical practice]

Rapid group A Streptococcus (GAS) antigen detection tests (RDT) have high diagnostic performance for the management of acute pharyngitis and are recommended before any antibiotic (ATB) prescription in France to reduce ATB use. The rate of general practitioners (GPs) using GAS RDT is low and decreasing. Our aims were to describe the reasons for pediatricians and GPs not using RDT or for prescribing ATB despite of a negative RDT.

METHODS

In 2011, a survey was conducted in a random sample of 368 GPs plus all ambulatory pediatricians (n=82) in the Nord-Pas-de-Calais region of France.

RESULTS

Response rates were 74% (n=61) for pediatricians and 18% (n=68) for GPs. RDTs for pharyngitis were used by 75% [95% CI: 63-85] of pediatricians and 53% [95% CI: 41-64] of GPs (P<0.001). RDTs were systematically used in children 3years of age and older by only 59% of all physicians using RDTs. An ATB was systematically prescribed in case of positive RDT by 96% of physicians and eventually prescribed in case of negative RDT by 74%. The main reasons for ATB prescription in case of negative RDT were association with otitis media (51%), second visit for the same pharyngitis (45%), and high clinical suspicion of GAS pharyngitis (36%). Forty percent of non-RDT users had used them in the past. The 3 main reasons for not using RDT were the lack of time (57%), high confidence in clinical data to discriminate GAS pharyngitis (48%), and low confidence in RDT (27%).

DISCUSSION

This survey highlights the lack of knowledge about low and high discriminant values of clinical data and RDT, respectively, especially the excellent negative predictive value of RDTs, and an erroneous assessment of the low risk of missing GAS pharyngitis compared to the consequences of inappropriate ATB use.

[Systemic adverse effects of topical ocular instillation of atropine in two children]

A medication-related cause must be sought when unusual symptoms occur. Topical treatments, including eye drops, whose side effects are more common in exposed children, need to be verified. We report here the cases of two children who developed systemic symptoms after the administration of atropine-based mydriatic eye drops. A 6-month-old boy was admitted to the emergency department with acute urine retention lasting 36h. Investigations identified only eye drop treatment 3h before the onset of symptoms, with 2 drops of homatropine 1 %, as a cause. No other urinary retention was observed during the 1-year follow-up. A 2-year-old boy was admitted to the emergency department for drowsiness, thirst, and dry mouth 30min after the administration of three eye drops of atropine 1 % instead of atropine 0.3 % (error made by the pharmacy). Symptoms disappeared after 6h. Both observations highlight the possible side effects related to mydriatic eye drops. Indeed, because of small penetration of such medications in the eye, a high concentration of the active part of the medication is contained in each drop. In young children, at least 20 to 40 % of the volume of a drop drains into the nasolacrimal duct and thereby into the systemic circulation, without passage through the liver. A close national pharmacologic vigilance follow-up has been set up for atropine-based mydriatic eye drops in young children, who are the most exposed to systemic and potentially severe complications of these medications. We emphasize the appropriate procedure for the use of eye drops in young children to limit systemic passage, with only a 0.3 % maximum atropine concentration in infants, compression of the internal angle of the eye for at least 1min, and at least a 15-mins interval between two eye drop administrations.

Detection of QTL controlling metabolism, meat quality, and liver quality traits of the overfed interspecific hybrid mule duck

The mule duck, an interspecific hybrid obtained by crossing common duck (Anas platyrhynchos) females with Muscovy (Cairina moschata) drakes, is widely used for fatty liver production. The purpose of the present study was to detect and map single and pleiotropic QTL that segregate in the common duck species, and influence the expression of traits in their overfed mule duck offspring. To this end, we generated a common duck backcross (BC) population by crossing Kaiya and heavy Pekin experimental lines, which differ notably in regard to the BW and overfeeding ability of their mule progeny. The BC females were mated to Muscovy drakes and, on average, 4 male mule ducks hatched per BC female (1600 in total) and were measured for growth, metabolism during growth and the overfeeding period, overfeeding ability, and the quality of their breast meat and fatty liver. The phenotypic value of BC females was estimated for each trait by assigning to each female the mean value of the phenotypes of her offspring. Estimations allowed for variance, which depended on the number of male offspring per BC and the heritability of the trait considered. The genetic map used for QTL detection consisted of 91 microsatellite markers aggregated into 16 linkage groups (LG) covering a total of 778 cM. Twenty-two QTL were found to be significant at the 1% chromosome-wide threshold level using the single-trait detection option of the QTLMap software. Most of the QTL detected were related to the quality of breast meat and fatty liver: QTL for meat pH 20 min post mortem were mapped to LG4 (at the 1% genome-wide significance level), and QTL for meat lipid content and cooking losses were mapped to LG2a. The QTL related to fatty liver weight and liver protein and lipid content were for the most part detected on LG2c and LG9. Multitrait analysis highlighted the pleiotropic effects of QTL in these chromosome regions. Apart from the strong QTL for plasma triglyceride content at the end of the overfeeding period mapped to chromosome Z using single-trait analysis, all metabolic trait QTL were detected with the multitrait approach: the QTL mapped to LG14 and LG21 affected the plasma cholesterol and triglyceride contents, whereas the QTL mapped to LG2a seemed to impact glycemia and the basal plasma corticosterone content. A greater density genetic map will be needed to further fine map the QTL.

Effectiveness of multifunction paediatric short-stay units: a French multicentre study

AIM

To describe the characteristics of the activities of multifunction paediatric 'short-stay units' (SSU) including observation unit (OU), medical assessment and planning unit (MAPU) and holding unit (HU), to evaluate their effectiveness and to explore predictors of inappropriate admissions for OU patients.

METHODS

Admissions to nine French paediatric SSUs were analysed. The main outcome measures were SSU length of stay with associated outcome for all patients and appropriate admission rate for OU patients.

RESULTS

Of 1084 patients included in the study, 66% were OU patients (n = 718), 21% MAPU patients (n = 225) and 13% HU patients (n = 141). The OU patients constituted the majority of the SSU admissions. The appropriate OU admission rates ranged from 52% to 86%. Head trauma and seizure were the conditions with the highest appropriate OU admission rates (82%). Age <1 year, and need for IV fluids or medications, CT-Scan or MRI and cardiorespiratory monitoring were associated with an increased risk of inappropriate OU admission. Eighteen per cent of the MAPU patients and 5% of the HU patients were discharged home within 24 h.

CONCLUSION

By providing extended and easily available facilities for diagnostics and early treatment for a wide range of sick children, the French paediatric SSU is an effective model for 'observation medicine' in emergency department-managed units. The experience and principles may be applicable to similar units in other health care systems.

Recognising haemorrhagic rash in children with fever: a survey of parents' knowledge

BACKGROUND

Early recognition and treatment of meningococcal disease improves its outcome. Haemorrhagic rash is one of the most specific signs that parents can learn to recognise.

OBJECTIVE

To determine the percentage of parents able to recognise a haemorrhagic rash and perform the tumbler test.

METHODS

123 parents of children consulting for mild injuries were interviewed about the significance and recognition of haemorrhagic rash in febrile children.

RESULTS

Although 88% of parents undressed their children when they were febrile, it was never to look specifically for a skin rash. Only 7% (95% CI 3% to 12%) were able to recognise a petechial rash and knew the tumbler test.

CONCLUSION

Information campaigns about the significance of haemorrhagic rash and about the tumbler test are needed.

[Thoracic actinomycosis: Thinking of it earlier?]

Thoracic actinomycosis is a rare disease, with high morbidity related to delayed diagnosis.

OBJECTIVES

To identify and analyse paediatric thoracic actinomycosis to promote earlier diagnosis.

DESIGN

A 10-year descriptive retrospective review (1999-2008). Clinical, biological, and radiological data were collected and compared to identify common signs.

RESULTS

Three patients were identified. The time to diagnosis varied from 4 months to 3 years. Fever, asthenia, pain, weight loss, and sweats were the most common complaints. A predisposing factor was systematically observed. Irregular subpleural nodules were revealed with an infiltrative aspect. Definitive diagnosis was always histological.

CONCLUSION

Actinomycosis should be sought in patients with asthenia and weight loss, local pain, when chest radiological evidence of distal nodules is observed with a non-specific biologic inflammatory syndrome. At this time, anaerobic bacteriological tests and histology should be performed.

Epidemiology and aetiology of paediatric malpractice claims in France

OBJECTIVE

To examine paediatric malpractice claims and identify common characteristics likely to result in malpractice in children in France.

DESIGN AND MATERIALS

First, the authors did a retrospective and descriptive analysis of all paediatric malpractice claims involving children aged 1 month to 18 years, in which the defendant was coded as paediatrician or general practitioner, reported to the Sou Médical-groupe MASCF insurance company during a 5-year period (2003-2007). Then, a comparison of these results with those from the USA was performed.

RESULTS

The average annual incidence of malpractice claims was 0.8/100 paediatricians. 228 malpractice claims were studied and were more frequent (41%) with more severe outcomes in children younger than 2 years of age (52% deaths or major injuries). Meningitis (n=14) and dehydration (n=13) were the leading causes of claims, with highest mortalities (93% and 92%, respectively). The most common alleged misadventures were diagnosis-related error (47%), and medication error (13%). Malignancy was the most common medical condition incorrectly diagnosed (14%).

CONCLUSIONS

Paediatric malpractice claims are less frequent in France than in the USA, but they share many similarities with those in the USA. These data would enhance the knowledge of high-risk areas in paediatric care that could be targeted to reduce the risk of medical malpractices and to improve patient safety.

Rebound in the incidence of pneumococcal meningitis in northern France: effect of serotype replacement

AIM

To determine whether the recent emergence of nonvaccine pneumococcal serotypes has affected the incidence of pneumococcal meningitis in children a few years after the introduction of the heptavalent pneumococcal conjugate vaccine.

METHODS

We conducted a multicentre retrospective cohort study from 2005 to 2008 in all hospitals with paediatric units in northern France. It included all patients < 18 years of age who were admitted for laboratory-confirmed pneumococcal meningitis during the study period. Data were collected from medical files and laboratory records at each hospital and compared with the regional hospital discharge codes. We assessed global and age-specific incidence rates of pneumococcal meningitis from 2005 through 2008, compared them with those from the prevaccine era (2000-2002) and evaluated pneumococcal serotypes.

RESULTS

In all, 41 cases were found during the study period. The incidence rate of pneumococcal meningitis varied from 0.8/100,000 children < 18 years in 2005 to 1.8/100,000 children in 2008 (2.2-fold increase, p = 0.06); and from 1.8 to 11.9/100,000 children < 2 years (6.5-fold increase, p = 0.004). This increase was caused by nonvaccine pneumococcal serotypes.

CONCLUSION

The incidence of pneumococcal meningitis in infants has rebounded in northern France during the pneumococcal conjugate vaccine programme, with the emergence of nonvaccine pneumococcal serotypes.