Large Tertiary Children Research Articles

General emergency physician perceptions of caring for children: A qualitative interview study.

Emergency physicians care for most children presenting to U.S. emergency departments (EDs). Pediatric exposure during emergency medicine (EM) residency can be variable and critically ill children are rarely encountered. A recent needs assessment revealed that emergency physicians feel less prepared to manage various conditions in children and that infants, regardless of presenting complaint, pose particular challenges. Emergency physician perceptions of the experience of caring for pediatric patients have not been widely examined through a qualitative lens. We designed an interview-based qualitative study to explore emergency physician perspectives on pediatric patient care. We recruited emergency physicians who graduated from residency in 2015-2019 and all rotated through the same large tertiary children's hospital. Four trained interviewers conducted in-depth, one-on-one virtual interviews. An interdisciplinary team transcribed and then coded the interviews. The team performed a conventional content analysis for themes. Recruitment continued until thematic saturation was achieved. Twelve participants completed interviews. These participants trained in five diverse residency programs. Likewise, the participants now practice in a variety of settings. Three major themes emerged from the data: (1) experience and exposure are key to establishing comfort caring for children; (2) simulation, pathways, and the pediatric anesthesia rotation are educationally useful; and (3) caring for children poses unique emotional challenges. Participants shared many recommendations for future pediatric education for EM trainees, including increasing autonomy and exposure to neonates and considering how care might differ in a community setting. This interview-based qualitative study elucidates key themes in recently graduated emergency physicians' perceived experience of caring for children. Our findings have important educational implications for this group of emergency physicians and those who share similar experiences in training and practice.

Diabetic ketoacidosis in youth with diabetes mellitus during the COVID-19 pandemic.

We sought to determine if the early months of the coronavirus disease 2019 (COVID-19) pandemic influenced pediatric diabetic ketoacidosis (DKA) hospitalization characteristics. This is a cross-sectional study of youth with laboratory-confirmed DKA admitted to a large tertiary children's hospital in the USA. Data were collected from admissions in March through July 2019 and March through July 2020, respectively. We evaluated the clinical characteristics of hospitalization, including demographic data and DKA severity. We used univariable ordinal logistic regression followed by multiple ordinal logistic regression to adjust for potential confounders. We included 137 children with diabetes admitted for DKA in the relevant period in 2019 and 173 patients admitted for DKA in the same period in 2020. Hemoglobin A1C (HbA1c) upon admission was higher in 2020 (median=12.2 %) than in 2019 (11.5 %, p=0.018). Children who were admitted with DKA in 2020 were less likely to be autoantibody positive than those in 2019 (83 vs. 91 %, p=0.028). In the univariable model, being admitted in 2020 was significantly associated with more severe DKA (p=0.038), as was HbA1c (p=0.001). After adjusting for HbA1c upon admission, admission year was no longer significantly associated with more severe DKA. In this study of pediatric diabetes of any type and duration of diabetes, youth admitted for DKA at the start of the COVID-19 pandemic, compared with those admitted during the year before, were more likely to have autoantibody-negative diabetes and had significantly higher HbA1c. Additionally, higher HbA1c seemed to mediate more severe DKA during the pandemic.

Routine Postclinical Event Debriefings on Inpatient Pediatric Units.

Debriefings are an underutilized opportunity to enhance team performance and safety culture. Little is known about the impact of postclinical event debriefing programs in Pediatric Hospital Medicine (PHM). We sought to develop a standardized debriefing process with multidisciplinary involvement after all clinical events on PHM service lines. Our primary aim was to achieve 75% debriefing completion rate over 12 months with debriefing duration less than 10 minutes. A standardized postclinical event debriefing process was created at a large tertiary children's hospital. We aimed to debrief after clinical events on PHM services. The debriefing process was developed with key stakeholders and used a key driver diagram and Plan-Do-Study-Act cycles to refine the process. The project team reviewed the data monthly. During our 20-month study period, debriefing completion rate sustained a median of 66% with a median debriefing time of 7 minutes. Most debriefings (61%) had all core team members present with attending physicians (pediatric hospitalists) being absent most often. Barriers to debriefing with all core members present included service type, time of day, and shift change. Process changes were implemented based on concerns addressed in the debriefings. Multidisciplinary, postclinical event debriefings were successfully implemented on inpatient pediatric wards. Future steps include process implementation on non-PHM units in our hospital based on expressed interest and to further assess how debriefings optimize team performance and improve clinical outcomes.

Themes associated with uncollected paediatric prescriptions at a large tertiary children’s hospital: a retrospective, observational study

ObjectiveThis study aimed to assess the number of prescriptions that were uncollected by caregivers to identify any predisposing systemic themes that may act as barriers to children receiving medications.Study design...

Going Commando as Part of a Multifaceted Intervention to Reduce CAUTIs in Critically Ill Children

Background and Objectives: Catheter associated urinary tract infections (CAUTIs) are a source of preventable harm in children. Insertion and maintenance bundles have significantly reduced CAUTIs, but infections still occur. Starting in mid-2019, we experienced an increase in CAUTIs in our pediatric intensive care unit (PICU). The objective was to identify preventable causes of CAUTI and develop and test interventions to reduce them. Methods: This quality improvement project was initiated in the PICU of a large tertiary children’s hospital. Interdisciplinary rounds led by the hospital epidemiologist and unit nursing leader with the bedside nurse occurred weekly (starting October 2019) for patients with urinary catheters in place for greater than three days. Discussions included strategies to optimize maintenance of the urinary catheter and identify catheters that could be removed. Additional interventions included no diapers for patients with a urinary catheter (starting March 2021) and use of a urine collection device that prevented both urine stasis in the drainage tube and retrograde flow of urine into the bladder (starting August 2021). Hand hygiene and CAUTI prevention bundle compliance was measured by direct observation of staff. CAUTIs were identified by prospective surveillance by infection prevention using standard definitions. The rate of CAUTIs over time was analyzed using statistical process control charts. Results: The baseline CAUTI rate (January 2017 - June 2019) was 0.5 infections/1000 catheter days with an average of 349 days between CAUTIs. Between July 2019 and February 2021, the CAUTI rate increased to 3.3 with an average of 88 days between CAUTIs. Annual compliance with hand hygiene and the CAUTI prevention bundle elements remained above 90% throughout all time periods. No improvement was seen after the institution of weekly interdisciplinary rounds. Starting in March 2021 after removal of diapers and implementation of the urine collection device that prevented retrograde flow, the CAUTI rate decreased to 0.9 and an average of 200 days between CAUTIs. Currently, it has been 512 days since the last CAUTI. Conclusion: CAUTIs decreased after removing diapers in children with urinary catheters and use of the urine collection device. Removal of diapers likely reduced stool contamination around the catheter and urethral opening. The urine collection device prevented inadvertent retrograde flow of urine into the bladder. These interventions could augment current CAUTI prevention strategies.

Withstanding the COVID19 pandemic - A tertiary children’s hospital’s commitment to equitable care

Introduction: The COVID-19 pandemic led to perceived increases in the rates of complicated appendicitis. Multiple studies have shown, both in adults and children, higher rates of complicated appendicitis among patients with Medicaid insurance. At our institution, we previously found that, contrary to statewide and nationwide findings, no differences in complicated appendicitis rates existed based on age, sex, race, insurance status, socioeconomic status, and income level. The purpose of this study was to determine if the COVID-19 pandemic altered our previous findings. Methods: The electronic medical record of a large tertiary children’s hospital was queried for all patients with ICD 10 appendicitis codes from 1/1/2017-12/31/2020. Patient records were reviewed to determine complicated (defined as having either a hole in the appendix, extraluminal fecalith, well-formed abscess, or frank stool in the abdomen) vs. uncomplicated appendicitis. Demographic information including age, sex, race, ethnicity, and insurance type were collected. Rates of complicated appendicitis were compared across years. Correlation between rates of complicated appendicitis and demographic variables was determined both within and across years. Results: The rate of complicated appendicitis was not significantly different across years from 2017-2020. There was no significant difference in the rate of complicated appendicitis based on age, sex, race, ethnicity, or insurance type. Conclusion: While some U.S. centers and those abroad found a significantly higher rate of complicated appendicitis in 2020 compared to prior years, the rate of complicated appendicitis at a large tertiary children’s hospital did not change during the pandemic. No disparities exist based on age, sex, race, ethnicity, or insurance type.

Low Influenza Vaccine Uptake; What is the Impact in Hospitalised Children

Seasonal influenza is an RNA virus spread by droplets. The burden of disease is significant, particularly in children under five, and in those with underlying health conditions. Vaccination against influenza is effective and recommended for all children aged 2-16, and those from 6 months of age with underlying health conditions. We completed a retrospective study examining the notes of all patients presenting to a large tertiary children’s hospital in the UK with confirmed seasonal influenza over the 2022/2023 season. 238 children were included in this study. 88/238 (37.0%) children in our cohort were under 2. 112/238 (47.1%) were discharged from ED. 41/238 (17.2%) were admitted for observation for 24 hours. 41/238(17.2%) stayed 3 days or longer. 1 child passed away. Overall 73/238 (30.6%) had a significant comorbidity, in those under 2 13/88 (14.8%) had a comorbidity. 13/238 (5.4%) were admitted to PICU or HDU. 30/238 (12.6%) received Oseltamivir, 114/238 (47.8%) children were given antibiotic therapy at presentation for a presumed secondary bacterial infection. 13/238 (5.4%) were vaccinated 14 days or more prior to presentation. 0 children admitted to HDU or PICU were vaccinated. Due to delays and vaccine availability and hesitancy we had very low rates of vaccination. Our results show the impact of influenza on an unvaccinated cohort. Just under half of all children were given antibiotics for a presumed secondary bacterial infection. We highlight that a significant number did not have an underlying comorbidity. This is most notable in the under 2 cohort. This reinforces data supporting the importance of vaccination in children and raises the question of whether we should extend our vaccination program to cover all children over 6 months of age.

Quality and Diagnosis on the Lateral View of Pediatric Upper Gastro-Intestinal Series.

The standard imaging technique for the diagnosis of intestinal malrotation remains the upper gastro-intestinal series (UGIS). The lateral view is promoted as important for making a diagnosis. For this, the lateral view should be of adequate quality, and radiologists must know the normal appearance as well as the appearance of duodenal variants, as misdiagnosis may lead to unnecessary surgery. We aimed to evaluate the quality, findings including the prevalence of the "descending staircase" configuration and its correspondence to a diagnosis of duodenum redundum. This was a retrospective study and was conducted in a large tertiary children's hospital in the United States. A retrospective review of UGI fluoroscopy exams in children aged ≤ 18 years between January and December 2018 was performed by a pediatric radiologist. First, the lateral view images/cine-loops were assessed independently, followed by the anteroposterior (AP) view. The studies which were designated to have an adequate lateral view were evaluated for configuration of the duodenum and recorded as: normal, abnormal, or normal variant. Also, the presence of a descending staircase configuration was correlated with an AP view for a diagnosis of duodenum redundum. A total of 26 children (26%) (males:16; females:10) with age range 0 to 16 years had adequate lateral views during UGI exams for inclusion. Of the 26, 18 (69%) were reported as normal, 7 (27%) were reported as having a descending staircase and 1 (4%) was reported as abnormal. The AP view demonstrated 2 abnormal studies (1 malrotation and 1 non-rotation), 6 duodenum redundum and 18 normal exams. The one abnormal lateral duodenum was confirmed as a non-rotation on AP view; the second patient with an abnormal AP view had a normal appearance on the lateral view. A total of 26% of UGI studies had adequate lateral views for interpretation. Of these, nearly a quarter (23%) demonstrated the descending stair-case sign corresponding to a diagnosis of duodenum redundum on the AP view. If the lateral view had been used alone, there would have been a missed diagnosis in one patient.

A Review of Covered Abdominal Wall Defects: Cord Hernias Are Associated With Major Anomalies

IntroductionCovered abdominal wall defects (CAWD) can be categorized into giant omphaloceles (GOs), nongiant omphaloceles (NGOs), and umbilical cord hernias (UCHs). We sought to evaluate differences in management and outcomes of the different CAWD, treated at a large tertiary children's hospital, with regards to survival and association with other major congenital anomalies. MethodsA retrospective review of CAWD patients between January 2010 and January 2021 was conducted. GO was defined as a fascial defect >5 cm or >50% liver herniation. UCH were defined as fascial defects ≤ 2 cm. All others were classified as NGO. Type of repair, time to fascial closure, index hospitalization length of stay (LOS), and survival rates were compared. Four major anomaly categories were identified: cardiac, midline, Beckwith-Weidemann Syndrome, and other genetic anomalies. ResultsWe identified 105 CAWD patients (UCH n = 40; GO n = 34; and NGO n = 31). Ninety percent of UCH underwent primary repair, 10% were never repaired. NGOs were repaired by primary or staged methods in 92.9% of cases and 7.1% by delayed repair. Primary or staged repair occurred in 32.4% of GOs and delayed repair occurred in 67.6%. The median days to repair was 181 [24,427] GO, 1 [1,3] NGO, and 1 [0,1] UCHs (P < 0.01). Index hospitalization median LOS (days) was 90 [55,157] GO, 23 [10,48] NGO, 9 [5,22] UCH, (P < 0.01). There were no statistical differences in survival rates, number of patients with major anomalies (GO 35.4%, NGO 51.5%, UCH 50%), or types of anomalies. ConclusionsUCHs and omphaloceles have similar incidences of major associated anomalies. Thus, all patients with a covered abdominal wall defect should undergo workup for associated anomalies.

Management of Magnet Ingestions at a Large Tertiary Care Children's Hospital.

To review the clinical management and outcomes of magnet ingestions at a large tertiary children's hospital. To determine the association of frequency of high-powered magnet ingestion with the regulation of these magnets. Children <18 years who presented to the emergency room and were admitted to the Children's Hospital of Philadelphia for ingestion of single or multiple magnets from January 2008 to December 2020 were included. Demographics, symptoms, management, and outcomes were analyzed. The frequency of magnet ingestion was compared over 3 eras: (1) pre-ban (2008-2012), (2) intra-ban (2013-2016), and (3) post-ban (2017-2020). There were 167 magnet ingestions, including 99 with multiple magnets. Most patients (59%) were male and median age was 6 (interquartile range, 3-9) years. Most single magnet ingestions (86%) were discharged with outpatient monitoring, and none experienced severe outcomes. Multiple magnet ingestions led to significant morbidity including hospitalizations (68%), endoscopic procedures (48%), surgical procedures (14%), and severe outcomes (12%). Most patients (75%) were asymptomatic, however, there was a higher risk of surgery and severe complications based on the presence of symptoms ( P = 0.003). The rate of surgical intervention was higher with ≥3 magnets (31.7%) compared to 2 magnets (2.4%) ( P < 0.003). Additionally, we found an 160% increase in children with magnet ingestions in the post-ban period ( P = 0.021). Multiple magnet ingestion is associated with high morbidity and rate of severe outcomes. There is a relationship between public policy of magnet sale and frequency of magnet ingestion.

25. Using 3-D Printed Models as Educational Tools: A Randomized Controlled Trial Comparing Traditional Lectures to Hands-On Methods in Craniosynostosis education.

Background: Three-dimensional (3D) printed models have been described as a tool for medical education, surgical training, pre-operative planning, research, and innovation. This study analyzes the effectiveness of using such 3D printed skull models to teach concepts central to craniosynostosis (CS) in a medical student elective course Methods: Medical students in a Plastic Surgery elective were randomly assigned to receive a traditional lecture on craniosynostosis alone (control group), or receive the lecture plus participate in a hands-on session using 3D printed skull models demonstrating craniosynostosis (intervention group). Prior to this study, the senior author collaborated with the Department of Radiology at a large tertiary care urban children’s hospital to have 12 models 3D printed from computed tomography (CT) scans of representative craniosynostosis patients. Pathologies represented include sagittal, metopic, lambdoid, unicoronal, and bicoronal craniosynostosis as well as pansynostosis resulting in Kleeblattschadel skull. Three of the skulls demonstrate post-operative changes following surgery for craniosynostosis with reconstructive techniques including strip craniectomy, modified Pi procedure, and frontoorbital advancement. A 23-question test evaluating knowledge of CS was administered at three timepoints: prior to the course, after the lecture +/- the intervention, and three weeks later. Statistical analysis compared test performance between cohorts. Results: 21 students were enrolled; 11 were randomized to the control group, 10 to the intervention group. Test 1 (pre-intervention) showed no significant difference in the mean overall score (defined as total percent of correct answers) between groups (control=61%, intervention=57% correct; p=0.67). On Test 2 (post-intervention), both groups had significant increases in overall score. The control group improved by 21.3% (p=0.004) and the intervention group improved by 34.4% (p=0.002). Moreover, the mean score for the intervention group was significantly higher compared to that of the controls, with 92.1% correct versus 82.6% (p=0.041). Test 3 overall scores were not statistically different from test 2 scores, indicating little temporal decay. Students were highly satisfied with the quality and content of the intervention. Conclusion: 3D printed skull models are effective educational adjuncts in craniofacial surgery. 3D printing technology is an inexpensive tool with high satisfaction rates that can be increasingly applied to medical student and resident education.

Density map estimation with convolutional neural networks to count radiopaque markers on colonic transit studies.

A radiopaque marker study measures colonic transit time for work-up of primary constipation. It requires the patient to ingest multiple tiny radiopaque markers, which the radiologist must count manually on follow-up abdominal radiographs. Counting these markers is tedious but cognitively simple. To develop a convolutional neural network (CNN) capable of counting the number of radiopaque markers on abdominal radiographs. The image archive at a large tertiary children's hospital was searched to identify abdominal radiographs performed in children for the indication of a radiopaque marker study. To establish the ground truth, a radiologist manually labeled the coordinates of the radiopaque markers in each radiograph and thereby generated a density map for that radiograph. A CNN was trained to estimate this density map from its corresponding abdominal radiograph. Spatially integrating the output density map provided an estimate of the number of markers in the radiograph. To assess model accuracy, mean absolute error and root mean square error were calculated. The study cohort consisted of 436 radiographs (mean number of markers per radiograph: 34). This cohort was randomly divided into training, validation and testing sets consisting of 306, 65 and 65 radiographs, respectively. Based on the testing set, the CNN accurately estimated the number of markers in each radiograph with mean absolute error=2.6 markers and root mean square error=3.9 markers. The proposed CNN generated promising results in counting the number of radiopaque markers on abdominal radiographs and offers the potential of automating the interpretation of colonic transit studies.

Diagnostic challenges with central venous catheter studies.

A central venous catheter is typically made of silicone rubber or polyurethane and inserted into a large central vein to provide prolonged and direct access to central venous circulation. These catheters provide a safe and effective method to administer intravenous medications, nutritional supplements, fluids and blood products. However, a myriad of complications is associated with central venous catheters, including, but not limited to, mechanical malfunction or fracture, kinking, erroneous placement, line infection, fibrin sheath formation and venous thrombosis. Following clinical and radiographic evaluation, contrast-enhanced line studies constitute the next best diagnostic tool to assess the functionality of central venous catheters. However, there is a lack of standardization in the literature outlining how these studies should be performed. In addition, the interpretation of these studies can be problematic for general pediatric radiologists, many of whom are often not familiar with placement or manipulation of these catheters. In this pictorial review, we highlight the challenges associated with performing and interpreting fluoroscopically guided contrast injection studies, using case studies drawn from a large tertiary children's hospital database for illustration. Revealing these challenges and understanding their causative mechanisms can improve the performance of these line studies.

Pediatric appendicitis in the time of the COVID-19 pandemic: A retrospective chart review.

AimConduct a time trend analysis that describes 2 groups of patients admitted to a large tertiary children's hospital that presented with appendicitis and determine if there was an increase in complicated appendicitis when compared between 2 time periods before and during the early coronavirus disease 2019 (COVID‐19) pandemic of 2020.MethodsWe conducted a retrospective analysis of all children presenting to a single‐center site with appendicitis between March 23 and August 31, 2020, in the Central Texas region. We compared 507 patients presenting with appendicitis from the non‐COVID‐19 era in 2019 with n = 249 to patients presenting during the COVID time period with n = 258. All patients with appendicitis within those time periods were reviewed with analysis of various characteristics in regard to presentation, diagnosis of uncomplicated versus complicated appendicitis, and management outcomes.ResultsThere were no significant demographic differences or change in the number of appendicitis cases noted between the 2 time periods of comparison. There was no significant difference in rates of complicated appendicitis or presentation time following symptom onset between the 2 eras. There was no significant difference in intraoperative or postoperative complications. There was a statistically significant increase in the use of computed tomography (CT) scans (P‐value = 0.004) with patients 1.81 times more likely to have a CT scan in the pandemic era after adjusting for patient‐level factors. The effect of severe acute respiratory syndrome coronavirus 2 status on outcomes was not part of the data analysis.ConclusionOur study is the largest to date examining appendicitis complications in the era of COVID. In the time of the COVID‐19 pandemic, we found no delay in presentation in children presenting to the emergency department and no increase in complicated appendicitis. We did identify an increase in the use of CT scans for definitive diagnosis of appendicitis noted in the pandemic era. Although COVID‐19 status was not studied, the finding of increased CT use for a definitive diagnosis of appendicitis was a distinctive finding of this study showing a change in practice in pediatric emergency medicine.

Machine learning to identify distal tibial classic metaphyseal lesions of infant abuse: a pilot study.

The classic metaphyseal lesion (CML) is an injury that is highly specific for infant abuse, and the distal tibia is one of the most common sites of occurrence. A machine learning tool that identifies distal tibial CMLs on infant skeletal surveys could assist radiologists in the diagnosis of infant abuse. To develop and evaluate a machine learning-based classification algorithm to identify distal tibial CMLs on skeletal surveys performed for suspected infant abuse. We reviewed medical records of infants (≤1year old) who had skeletal surveys for suspected abuse at a large tertiary children's hospital over the past 13years to identify those at low and high risk for abuse. Normal distal tibial radiographs from the low-risk group formed the normal study cohort; radiographs with distal tibial CMLs from the high-risk group formed the abnormal study cohort. We used these two cohorts to train a machine learning algorithm to classify distal tibial radiographs as normal or abnormal. We systematically evaluated this algorithm using a fivefold cross-validation procedure and statistically analyzed the results. The normal study cohort consisted of 177 radiographs from 89 infants, and the abnormal study cohort consisted of 73 radiographs from 35 infants. Our machine learning algorithm showed an overall performance accuracy of 93% and Kappa of 0.84. The overall sensitivity and specificity of the model were 88% and 96%, respectively. Our developed machine learning model shows encouraging results as an automated tool to identify CMLs of the distal tibia on skeletal surveys performed for suspected infant abuse.

Postoperative respiratory adverse events in children after endoscopic laryngeal cleft repair

Due to the serious nature of respiratory adverse events, understanding their incidence can help in decisions regarding safe postoperative disposition. There have been no studies, however, evaluating the risk of postoperative respiratory adverse events (PRAEs) in children undergoing endoscopic laryngeal cleft (LC) repair, which is the primary objective of this study. We conducted a retrospective chart review of all patients who underwent LC repair at a large tertiary children's hospital from 2015 to 2020. PRAEs were defined as having at least one of the following: remained intubated, required reintubation, required positive pressure ventilation, required high flow O2 nasal cannula, or required more than one dose of racemic epinephrine. Univariate analyses compared demographic, preoperative characteristics, and intraoperative characteristics between those with and without a PRAE. Overall, 8/26 (31%) patients had a PRAE and there were no differences between patients who did and did not have a PRAE and most comorbidities. Younger age (p = 0.03), being male (p = 0.07), and being admitted preoperatively (p = 0.07) were potentially associated with PRAEs. Need for intraoperative intubation for any reason or duration was associated with increased incidence of PRAEs (p = 0.02). The overall 31% incidence of postoperative respiratory adverse events reaffirms the appropriateness of PICU disposition for a large proportion of children undergoing endoscopic LC repair. Further studies with increased sample sizes are needed to tease apart patient or procedure-specific factors that significantly increase the risk of respiratory adverse events to have more definitive evidence regarding safe postoperative disposition.

Increased paediatric emergency mental health and suicidality presentations during COVID-19 stay at home restrictions.

ObjectiveAnecdotal reports indicate an increase in mental health presentations and acuity to EDs during the COVID‐19 pandemic and associated stay at home restrictions. Paediatric and adolescent data to confirm this are unavailable in the Australian setting.MethodsRetrospective electronic medical record review of all ED patients with mental health discharge codes at a large tertiary children's hospital in Australia during the period of stay at home restrictions from 1 April to 30 September 2020 compared with the same dates in 2019.ResultsWe found a 40% decrease in ED presentations (18 935–11 235) with a concurrent 47% increase in mental health presentations (809–1190) to ED during the study periods between 2019 and 2020. This resulted in an increase of 100 mental health admissions from ED. Diagnoses with greatest percentage increases were eating disorders, social issues and suicidality. We found suicidality presentation numbers were highest in June to September 2020 compared with 2019. Patients with a diagnosis of suicidality had a higher rate of re‐presentation in 2020 (1.83 presentations per patient) compared to 2019 (1.38 presentations per patient).ConclusionsDespite an overall decrease in ED presentations, the absolute increase in mental health presentations for children and adolescents during the stay at home restriction period was pronounced. It is unclear how sustained this change and the impact on mental health resource use will be post‐pandemic.

Bicycle injuries presenting to the emergency department during COVID-19 lockdown.

AimSince the start of the COVID‐19 pandemic, there have been many changes in the presenting complaints in paediatric emergency departments (EDs). We sought to characterise the impact of the COVID‐19 pandemic on bicycle‐related injuries in children presenting to a tertiary care paediatric ED.MethodsWe conducted a descriptive, cross‐sectional study of ED visits to a large urban tertiary children's hospital, comparing March to October 2020 (the study period) to the same date range 2 years prior (i.e. March to October 2018–2019). We included children 0–17.99 years presenting for a bicycle‐related injury. We compared absolute visit counts of bike injuries per month, demographics, triage acuity, injury type and disposition.ResultsA total of 1215 bike‐related visits were analysed. There were 234 presentations in 2018 (March to October), 305 in 2019, and 676 in 2020. Overall, the mean age was 9.5 years (standard deviation 5.5–13.5), there were 67% males, median Canadian Emergency Department Triage and Acuity Scale score was 3 (interquartile range 3–4) and the most common injuries were fractures (n = 471, 38.8%). There were significantly more bike injuries presenting to the ED per month in the COVID group, 33.7(17.9) versus 84.5(61.4) (two‐tailed P value = 0.041). There was no statistical difference in ‘severe injuries’ pre‐ versus post‐COVID (odds ratio 0.815 (95% confidence interval 0.611–1.088), P = 0.165).ConclusionThere was a significant increase in bicycle‐related injuries presenting to our ED during the pandemic, compared to previous years. Evaluating these trends will allow for the exploration of harm reduction strategies for preventing future bicycle‐related injuries.

Repeat tympanostomy tubes in children with Down syndrome

ObjectivesChildren with Down syndrome (DS) have a higher incidence of tympanostomy tube insertion (TTI) than children in the general population. As there were no studies investigating factors that are associated with multiple TTIs in children with DS, we sought to determine what factors increase or decrease the likelihood of repeat TTI in children with DS. MethodsA retrospective case-control study was performed on consecutive children with DS from 2007 to 2018 with first TTI at a large tertiary children's hospital and follow-up duration at least 27 months since first TTI. Results277 patients met the inclusion criteria. Repeat TTI rate was 61.4%. Having an indication of chronic otitis media with effusion (COME) at first TTI was an adjusted risk factor for increased rate of repeat TTI (OR: 2.01, 95%CI: 1.15–3.51, p = .014), while being older at first TTI was an adjusted protective factor for decreased rate of repeat TTI (OR: 0.84, 95%CI: 0.74–0.95, p = .004). Adenotonsillectomy at or before first TTI was not an adjusted protective factor for decreased rate of repeat TTI (OR: 0.915, 95%CI: 0.448–1.872, p = .809) and bilateral intra-operative fluid was not an adjusted risk factor for repeat TTI (OR: 1.97, 95%CI: 0.99–3.90, p = .054). ConclusionChildren with DS were more likely to undergo repeat TTI if they were of younger age and if the indication for surgery was COME. The repeat TTI rate for children with DS was high at 61.4%. Prospective studies are warranted to more precisely investigate factors associated with repeat TTIs in this unique patient population.

Urinary Tract Infection in Children With Bronchiolitis: Is It Worth Testing Everyone?

ObjectiveThe current study aims to determine the prevalence of urinary tract infection (UTI) and the need to perform urine analysis and cultures in children admitted with bronchiolitis in a large tertiary children’s hospital in Riyadh, Saudi Arabia.MethodsWe conducted a retrospective chart review of pediatric patients 0-2 years of age who were admitted with bronchiolitis from November 2016 till April 2017. All charts were analyzed to identify the children investigated for UTI, and their results were then reviewed.ResultsThere were 407 children admitted with bronchiolitis during the study period. Two-thirds of them were investigated for UTI. Only 2.6% of the patients tested positive for urine culture, and only 0.96% were found to have a true UTI.ConclusionThe prevalence of UTI in children with bronchiolitis is too low to justify routine screening. Therefore, only children with a high risk of having UTI should be investigated.