Pediatric Emergency Research Networks Research Articles

Presentations and Outcomes Among Infants ≤90 Days With and Without SARS-CoV-2.

To compare symptoms and outcomes among infants aged ≤90 days tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a broad, international sample of emergency departments (EDs). This was a secondary analysis of infants aged 0 to 90 days with suspected SARS-CoV-2 infections tested using molecular approaches and with 14-day follow-up. The parent studies were conducted at 41 EDs in 10 countries (the global Pediatric Emergency Research Network; March 2020-June 2021) and 14 EDs across Canada (Pediatric Emergency Research Canada network; August 2020-February 2022). Symptom profiles included presence and number of presenting symptoms. Clinical outcomes included hospitalization, ICU admission, and severe outcomes (a composite of intensive interventions, severe organ impairment, or death). Among 1048 infants tested for SARS-CoV-2, 1007 (96.1%) were symptomatic at presentation and 432 (41.2%) were SARS-CoV-2-positive. A systemic symptom (any of the following: Apnea, drowsiness, irritability, or lethargy) was most common and present in 646 (61.6%) infants, regardless of SARS-CoV-2 status. Although fever and upper respiratory symptoms were more common among SARS-CoV-2-positive infants, dehydration, gastrointestinal, skin, and oral symptoms, and the overall number of presenting symptoms did not differ between groups. Infants with SARS-CoV-2 infections were less likely to be hospitalized (32.9% vs 44.8%; difference -11.9% [95% confidence interval (CI) -17.9% to -6.0%]), require intensive care (1.4% vs 5.0%; difference -3.6% [95% CI -5.7% to -1.6%]), and experience severe outcomes (1.4% vs 5.4%; difference -4.0% [95% CI -6.1% to -1.9%]). SARS-CoV-2 infections may be difficult to differentiate from similar illnesses among the youngest infants but are generally milder. SARS-CoV-2 testing can help inform clinical management.

Analysis of guideline recommendations for treatment of asthma exacerbations in children: a Pediatric Emergency Research Networks (PERN) study

RationaleThere is significant practice variation in acute paediatric asthma, particularly severe exacerbations. It is unknown whether this is due to differences in clinical guidelines.ObjectivesTo describe and compare the content and...

Core outcomes and factors influencing the experience of care for children with severe acute exacerbations of asthma: a qualitative study

ObjectiveTo identify the outcomes considered important, and factors influencing the patient experience, for parents and caregivers of children presenting to hospital with a severe acute exacerbation of asthma. This work...

Liver transaminase concentrations in children with acute SARS-CoV-2 infection

ObjectiveTo evaluate the relationship between SARS-CoV-2 infection and liver injury by comparing transaminase concentrations among children tested for SARS-CoV-2 and other respiratory viruses in pediatric emergency departments. Design & methodsEligible children were <18 years with suspected SARS-CoV-2, tested using molecular approaches in emergency departments between March 7, 2020, and June 15, 2021 (Pediatric Emergency Research Network), and between August 6, 2020, and February 22, 2022 (Pediatric Emergency Research Canada). We compared aspartate (AST) and alanine aminotransferase (ALT) concentrations at presentation for SARS-CoV-2 and other respiratory viruses through a multivariate linear regression model, with the natural log of serum transaminase concentrations as dependent variables. ResultsOf 16,892 enrolled children, 2,462 (14.6%) had transaminase concentrations measured; 4318 (25.6%) were SARS-CoV-2 positive, and 3932 (23.3%) were tested for additional respiratory viruses. Among study participants who had additional respiratory virus testing performed, the most frequently identified viruses were enterovirus/rhinovirus [8.7% (343/3,932)], respiratory syncytial virus [4.6% (181/3,932)], and adenovirus [2.6% (103/3,932)]. Transaminase concentrations were elevated in 25.6% (54/211) of children with isolated SARS-CoV-2 detection and 21.6% (117/541) of those with no virus isolated; P = 0.25. In the multivariable model, isolated SARS-CoV-2 detection was not associated with elevated ALT (adjusted geometric mean ratio (IU/L): 0.96; 95%Confidence Interval (CI): 0.84, 1.08) or AST (adjusted geometric mean ratio (IU/L): 1.03; 95%CI: 0.92, 1.16) concentrations, with negative respiratory panel as the referent group. Ninety-day follow-up was completed in 82.2% (3,550/4,318) of SARS-CoV-2 positive children; no cases of new-onset liver disease were reported. ConclusionAmong those tested, transaminase concentrations did not vary between SARS-CoV-2-positive children and those with a negative respiratory viral panel. In multivariate analysis, SARS-CoV-2 infection was not associated with increased initial transaminase concentrations compared to other respiratory viruses.

Outcomes of SARS-CoV-2–Positive Youths Tested in Emergency Departments

The Global Pediatric Emergency Research Network (PERN)–COVID-19 Study sought to understand the risk factors for severe SARS-CoV-2 infections in youth by conducting a cohort study including children, with early or mild stages of disease, seeking emergency department (ED) care. The study identifed that risk factors such as age, underlying chronic illness, and symptom duration may be useful to consider when making clinical care decisions.

Remote, real-time expert elicitation to determine the prior probability distribution for Bayesian sample size determination in international randomised controlled trials: Bronchiolitis in Infants Placebo Versus Epinephrine and Dexamethasone (BIPED) study

BackgroundBayesian methods are increasing in popularity in clinical research. The design of Bayesian clinical trials requires a prior distribution, which can be elicited from experts. In diseases with international differences in management, the elicitation exercise should recruit internationally, making a face-to-face elicitation session expensive and more logistically challenging. Thus, we used a remote, real-time elicitation exercise to construct prior distributions. These elicited distributions were then used to determine the sample size of the Bronchiolitis in Infants with Placebo Versus Epinephrine and Dexamethasone (BIPED) study, an international randomised controlled trial in the Pediatric Emergency Research Network (PERN). The BIPED study aims to determine whether the combination of epinephrine and dexamethasone, compared to placebo, is effective in reducing hospital admission for infants presenting with bronchiolitis to the emergency department.MethodsWe developed a Web-based tool to support the elicitation of the probability of hospitalisation for infants with bronchiolitis. Experts participated in online workshops to specify their individual prior distributions, which were aggregated using the equal-weighted linear pooling method. Experts were then invited to provide their comments on the aggregated distribution. The average length criterion determined the BIPED sample size.ResultsFifteen paediatric emergency medicine clinicians from Canada, the USA, Australia and New Zealand participated in three workshops to provide their elicited prior distributions. The mean elicited probability of admission for infants with bronchiolitis was slightly lower for those receiving epinephrine and dexamethasone compared to supportive care in the aggregate distribution. There were substantial differences in the individual beliefs but limited differences between North America and Australasia. From this aggregate distribution, a sample size of 410 patients per arm results in an average 95% credible interval length of less than 9% and a relative predictive power of 90%.ConclusionRemote, real-time expert elicitation is a feasible, useful and practical tool to determine a prior distribution for international randomised controlled trials. Bayesian methods can then determine the trial sample size using these elicited prior distributions. The ease and low cost of remote expert elicitation mean that this approach is suitable for future international randomised controlled trials.Trial registrationClinicalTrials.govNCT03567473

The Pediatric Emergency Research Network: a decade old and growing.

Bressan, Silviaa,,b; Klassen, Terry P.c,,d,,e; Dalziel, Stuart R.f,,g,,h; Babl, Franz E.i,,j,,k,,h; Benito, Javierl,,m; Chamberlain, Jamesn,,o; Chang, Todd P.p,,q,,o; Freedman, Stephen B.e,,r; Kohn Loncarica, Guillermos,,t; Lyttle, Mark D.u,,v,,w; Mintegi, Santiagol,,m; Mistry, Rakesh D.q,,x; Nigrovic, Lise E.q,,y,,z; Plint, Amy C.e,,aa,,bb; Rino, Pedros,,t; Roland, Damianw,,cc; Van De Mosselaer, Gregorydd,,ee; Oostenbrink, Rianneff,,b; Kuppermann, Nathangg,,o Author Information

The Pediatric Emergency Research Network (PERN): A decade of global research cooperation in paediatric emergency care

AbstractObjectivesThe Pediatric Emergency Research Network (PERN) was launched in 2009 with the intent for existing national and regional research networks in paediatric emergency care to organise globally for the conduct of collaborative research across networks.MethodsPERN has grown from five to eight member networks over the past decade. With an executive committee comprising representatives from all member networks, PERN plays a supportive and collaborative rather than governing role. The full impact of PERN's facilitation of international collaborative research, although somewhat difficult to quantify empirically, can be measured indirectly by the observed growth of the field, the nature of the increasingly challenging research questions now being addressed and the collective capacity to generate and implement new knowledge in treating acutely ill and injured children.ResultsBeginning as a pandemic response studying H1N1 influenza risk factors in children, PERN research has progressed to multiple observational studies and ongoing global randomised controlled trials (RCTs). As a recent example, PERN has developed sufficient network infrastructure to enable the rapid initiation of a prospective observational study in response to the current COVID‐19 pandemic.ConclusionsFollowing its success with developing global research, the PERN goal now is to promote the implementation of scientific advances into everyday clinical practice by: (i) expanding the capacity for global RCTs; (ii) deepening the focus on implementation science; (iii) increasing attention to healthcare disparities; and (iv) expanding PERN's reach into resource‐restricted regions. Through these actions, PERN aims to meet the needs of acutely ill and injured children throughout the world.

The Pediatric Emergency Research Network: A Decade of Global Research Cooperation in Pediatric Emergency Care.

ObjectivesThe Pediatric Emergency Research Network (PERN) was launched in 2009 with the intent for existing national and regional research networks in pediatric emergency care to organize globally for the conduct of collaborative research across networks.MethodsThe Pediatric Emergency Research Network has grown from 5- to 8-member networks over the past decade. With an executive committee comprising representatives from all member networks, PERN plays a supportive and collaborative rather than governing role. The full impact of PERN's facilitation of international collaborative research, although somewhat difficult to quantify empirically, can be measured indirectly by the observed growth of the field, the nature of the increasingly challenging research questions now being addressed, and the collective capacity to generate and implement new knowledge in treating acutely ill and injured children.ResultsBeginning as a pandemic response with a high-quality retrospective case-controlled study of H1N1 influenza risk factors, PERN research has progressed to multiple observational studies and ongoing global randomized controlled trials. As a recent example, PERN has developed sufficient network infrastructure to enable the rapid initiation of a prospective observational study in response to the current coronavirus disease 2019 pandemic. In light of the ongoing need for translation of research knowledge into equitable clinical practice and to promote health equity, PERN is committed to a coordinated international effort to increase the uptake of evidence-based management of common and treatable acute conditions in all emergency department settings.ConclusionsThe Pediatric Emergency Research Network's successes with global research, measured by prospective observational and interventional studies, mean that the network can now move to improve its ability to promote the implementation of scientific advances into everyday clinical practice. Achieving this goal will involve focus in 4 areas: (1) expanding the capacity for global randomized controlled trials; (2) deepening the focus on implementation science; (3) increasing attention to healthcare disparities and their origins, with growing momentum toward equity; and (4) expanding PERN's global reach through addition of sites and networks from resource-restricted regions. Through these actions, PERN will be able to build on successes to face the challenges ahead and meet the needs of acutely ill and injured children throughout the world.

Exposure and confidence across critical airway procedures in pediatric emergency medicine: An international survey study.

Airway management procedures are critical for emergency medicine (EM) physicians, but rarely performed skills in pediatric patients. Worldwide experience with respect to frequency and confidence in performing airway management skills has not been previously described. Our aims were 1) to determine the frequency with which emergency medicine physicians perform airway procedures including: bag-mask ventilation (BMV), endotracheal intubation (ETI), laryngeal mask airway (LMA) insertion, tracheostomy tube change (TTC), and surgical airways, and 2) to investigate predictors of procedural confidence regarding advanced airway management in children. A web-based survey of senior emergency physicians was distributed through the six research networks associated with Pediatric Emergency Research Network (PERN). Senior physician was defined as anyone working without direct supervision at any point in a 24-hcycle. Physicians were queried regarding their most recent clinical experience performing or supervising airway procedures, as well as with hands on practice time or procedural teaching. Reponses were dichotomized to within the last year, or≥1year. Confidence was assessed using a Likert scale for each procedure, with results for ETI and LMA stratified by age. Response levels were dichotomized to "not confident" or "confident." Multivariate regression models were used to assess relevant associations. 1602 of 2446 (65%) eligible clinicians at 96 PERN sites responded. In the previous year, 1297 (85%) physicians reported having performed bag-mask ventilation, 900 (59%) had performed intubation, 248 (17%) had placed a laryngeal mask airway, 348 (23%) had changed a tracheostomy tube, and 18 (1%) had performed a surgical airway. Of respondents, 13% of physicians reported the opportunity to supervise but not provide ETI, 5% for LMA and 5% for BMV. The percentage of physicians reporting "confidence" in performing each procedure was: BMV (95%) TTC (43%), and surgical airway (16%). Clinician confidence in ETT and LMA varied by patient age. Supervision of an airway procedure was the strongest predictor of procedural confidence across airway procedures. BMV and ETI were the most commonly performed pediatric airway procedures by emergency medicine physicians, and surgical airways are very infrequent. Supervising airway procedures may serve to maintain procedural confidence for physicians despite infrequent opportunities as the primary proceduralist.

Predicting severe pneumonia in the emergency department: a global study of the Pediatric Emergency Research Networks (PERN)—study protocol

IntroductionPneumonia is a frequent and costly cause of emergency department (ED) visits and hospitalisations in children. There are no evidence-based, validated tools to assist physicians in management and disposition decisions...

International Practice Patterns of Antibiotic Therapy and Laboratory Testing in Bronchiolitis.

International patterns of antibiotic use and laboratory testing in bronchiolitis in emergency departments are unknown. Our objective is to evaluate variation in the use of antibiotics and nonindicated tests in infants with bronchiolitis in 38 emergency departments in Pediatric Emergency Research Networks in Canada, the United States, Australia and New Zealand, the United Kingdom and Ireland, and Spain and Portugal. We hypothesized there would be significant variation, adjusted for patient characteristics. We analyzed a retrospective cohort study of previously healthy infants aged 2 to 12 months with bronchiolitis. Variables examined included network, poor feeding, dehydration, nasal flaring, chest retractions, apnea, saturation, respiratory rate, fever, and suspected bacterial infection. Outcomes included systemic antibiotic administration and urine, blood, or viral testing or chest radiography (CXR). In total, 180 of 2359 (7.6%) infants received antibiotics, ranging from 3.5% in the United Kingdom and Ireland to 11.1% in the United States. CXR (adjusted odds ratio [aOR] 2.3; 95% confidence interval 1.6-3.2), apnea (aOR 2.2; 1.1-3.5), and fever (aOR 2.4; 1.7-3.4) were associated with antibiotic use, which did not vary across networks (P = .15). In total, 768 of 2359 infants (32.6%) had ≥1 nonindicated test, ranging from 12.7% in the United Kingdom and Ireland to 50% in Spain and Portugal. Compared to the United Kingdom and Ireland, the aOR (confidence interval) results for testing were Canada 5.75 (2.24-14.76), United States 4.14 (1.70-10.10), Australia and New Zealand 2.25 (0.86-5.74), and Spain and Portugal 3.96 (0.96-16.36). Testing varied across networks (P < .0001) and was associated with suspected bacterial infections (aOR 2.12; 1.30-2.39) and most respiratory distress parameters. Viral testing (591 of 768 [77%]) and CXR (507 of 768 [66%]) were obtained most frequently. The rate of antibiotic use in bronchiolitis was low across networks and was associated with CXR, fever, and apnea. Nonindicated testing was common outside of the United Kingdom and Ireland and varied across networks irrespective of patient characteristics.

Global Collaborative Research Informs Wise Use of Tests and Antibiotics for Bronchiolitis.

Bronchiolitis is a lower respiratory viral infection that is a leading cause of hospitalization for infants.1 Organizations around the world have published guidelines for bronchiolitis to address widely varying rates of tests and treatments within their countries.2 Specific recommendations vary, but research consistently shows that many of these interventions are unnecessary and may cause unwarranted cost and the potential for harm because of associated radiation, antibiotic exposure, and other effects. In this issue of Pediatrics, Zipursky et al3 analyze testing protocols at a higher level by comparing trends across countries using a retrospective data set from the Pediatric Emergency Research Network (PERN), which combines 6 multicenter networks including 38 emergency departments from 8 countries in North America, Europe, the United Kingdom, Australia, and New Zealand. Authors of previous analyses addressed respiratory treatments4 and prediction of severe disease,5 but in this study, the investigators focus on antibiotics and laboratory testing. They report that 32.6% of infants received a nonindicated test, with rates varying widely between networks. Antibiotic use was overall low (7.6%) and was associated with ordering a chest radiograph.Retrospective analysis of clinical practice has limitations, in particular for testing and antibiotic use for bronchiolitis. The authors reviewed charts based on diagnosis codes, which may be differentially assigned on the basis of the results of a test. For example, a bronchiolitis diagnosis may change to pneumonia on the basis of a chest radiograph result. Schuh et al6 demonstrated in a prospective cohort that routinely obtaining a radiograph led clinicians to make pneumonia diagnoses that radiology review did not support and to prescribe antibiotics that did not appear to benefit patients. Zipursky et al,3 in their multicenter study, similarly find that radiograph use was associated with antibiotic prescription, and the network in the United Kingdom and Ireland had the lowest rates for both laboratory testing and antibiotic use. Assignment of diagnosis codes may also vary because of different definitions of the condition. In the United Kingdom, the definition of bronchiolitis, as reflected in their national guidelines,7 has consistently included the presence of crackles as a specific sign, whereas in North America, the definition for research studies and clinical guidelines has typically focused on wheeze.8 Perhaps clinicians in the United Kingdom accept the presence of crackles as an expected finding in an infant with bronchiolitis and are less likely to order imaging. Further researchers could look at outcomes to follow the impact of international variation in practice, although quality improvement collaborative networks within the United States have already shown that radiography can be safely reduced for bronchiolitis without negatively impacting outcomes.9Despite these limitations, comparing trends across countries can help us to better evaluate practice and drive further research. In the PERN study, respiratory viral testing led the nonindicated laboratory list in frequency, despite practice guidelines recommending against its routine use, because identifying a specific virus rarely changes management.2 However, evolving recommendations for broad testing and treatment of influenza in febrile infants, which is a rare cause (<2%) in cohort studies of typical bronchiolitis,10 and the now evolving severe acute respiratory syndrome coronavirus 2 pandemic will require these questions to be re-examined. Coronaviruses have always been a cause of bronchiolitis hospitalizations, and the PERN network is currently conducting an international prospective study that will help assess pediatric disease related to the new viral strain.11 Among other tests, Zipursky et al3 also found that urinalysis and urine cultures were obtained at a measurable rate, even in afebrile infants, although recent reviews suggest that urinary tract infection is uncommon in bronchiolitis using updated guidelines for screening.12The PERN collaboration of international networks of pediatric emergency providers is an encouraging sign of potential opportunities to come, for bronchiolitis and other conditions. In addition to studying variation, the ability to leverage large populations across the globe will provide the ability to study evolving conditions, as occurred with the H1N1 influenza virus and now severe acute respiratory syndrome coronavirus 2, as well as uncommon conditions, as is planned with severe asthma.13,14 As clinical practice becomes more standardized within countries because of national guidelines and quality improvement initiatives, such as the Choosing Wisely campaign, the ability to compare across countries is an opportunity to evaluate variation that can lead to innovation.15,16 Building on these research networks to link data to other sources could allow further analysis of the impact of variation across countries, connect these practices to health outcomes, and help us to make the wisest choices as a global pediatric community.

Pediatric Intentional Self-poisoning Evaluated in the Emergency Department: An International Study.

Suicide is a growing public health problem during late childhood and adolescence. The leading method of suicide attempts in this age group is intentional self-poisoning. A first self-poisoning episode is a strong predictor of subsequent suicide and premature death. The objective of this study was to analyze the presentation and management of children younger than 18 years with intentional self-poisonings admitted to an emergency department (ED) in a global research network of pediatric EDs. We performed a secondary analysis of a large, international, multicenter, cross-sectional prospective registry of childhood poisoning presentations to 105 EDs in the Pediatric Emergency Research Networks (PERN) network. Data collection started at each ED between January and September 2013 and continued for 1 year. During the study period, we included 1688 poisoning exposures. Of these, 233 (13.8%) were intentional self-poisonings, with significant variation between regions. Female/male ratio was 4.7/1 and most occurred at home. The most common toxicants were therapeutic drugs, mainly psychotropics and analgesics. Ninety patients (38.6%) gave a history of a previous episode of intentional self-poisoning. Sixty-three children (27.0%) were not assessed by a psychiatric service nor transferred to a psychiatric inpatient facility. No patient died. There was significant variation in the involved toxicants and interventions among EDs in different global regions. Most intentional self-poisoning presentations to pediatric EDs globally are related to intentional ingestions of therapeutic drugs at home by females. Best practices have to be translated into care to guarantee the best outcomes of these patients.

Exposure and Confidence With Critical Nonairway Procedures: A Global Survey of Pediatric Emergency Medicine Physicians.

Children rarely experience critical illness, resulting in low exposure of emergency physicians (EPs) to critical procedures. Our primary objective was to describe senior EP confidence, most recent performance, and/or supervision of critical nonairway procedures. Secondary objectives were to compare responses between those who work exclusively in PEM and those who do not and to determine whether confidence changed for selected procedures according to increasing patient age. Survey of senior EPs working in 96 emergency departments (EDs) affiliated with the Pediatric Emergency Research Networks. Questions assessed training, performance, supervision, and confidence in 11 nonairway critical procedures, including cardiopulmonary resuscitation (CPR), vascular access, chest decompression, and cardiac procedures. Of 2446 physicians, 1503 (61%) responded to the survey. Within the previous year, only CPR and insertion of an intraosseous needle had been performed by at least 50% of respondents: over 20% had performed defibrillation/direct current cardioversion. More than 50% of respondents had never performed or supervised ED thoracotomy, pericardiocentesis, venous cutdown, or transcutaneous pacing. Self-reported confidence was high for all patient age groups for CPR, needle thoracocentesis, tube thoracostomy, intraosseous needle insertion, and defibrillation/DC cardioversion. Confidence levels increased with increasing patient age for central venous and arterial line insertion. Respondents working exclusively in PEM were more likely to report being at least somewhat confident in defibrillation/DC cardioversion, intraosseous needle insertion, and central venous line insertion in particular age groups; however, they were less likely to be at least somewhat confident in ED thoracotomy and transcutaneous pacing. Cardiopulmonary resuscitation and intraosseous needle insertion were the only critical nonairway procedures performed by at least half of EPs within the previous year. Confidence was higher for these procedures, and needle and tube thoracostomy. These data may inform the development of continuing medical education activities to maintain pediatric procedural skills for emergency physicians.

Acute severe paediatric asthma: study protocol for the development of a core outcome set, a Pediatric Emergency Research Networks (PERN) study

BackgroundAcute severe childhood asthma is an infrequent, but potentially life-threatening emergency condition. There is a wide range of different approaches to this condition, with very little supporting evidence, leading to significant variation in practice. To improve knowledge in this area, there must first be consensus on how to conduct clinical trials, so that valid comparisons can be made between future studies. We have formed an international working group comprising paediatricians and emergency physicians from North America, Europe, Asia, the Middle East, Africa, South America, Central America, Australasia and the United Kingdom.Methods/designA 5-stage approach will be used: (1) a comprehensive list of outcomes relevant to stakeholders will be compiled through systematic reviews and qualitative interviews with patients, families, and clinicians; (2) Delphi methodology will be applied to reduce the comprehensive list to a core outcome set; (3) we will review current clinical practice guidelines, existing clinical trials, and literature on bedside assessment of asthma severity. We will then identify practice differences in tne clinical assessment of asthma severity, and determine whether further prospective work is needed to achieve agreement on inclusion criteria for clinical trials in acute paediatric asthma in the emergency department (ED) setting; (4) a retrospective chart review in Australia and New Zealand will identify the incidence of serious clinical complications such as intubation, ICU admission, and death in children hospitalized with acute severe asthma. Understanding the incidence of such outcomes will allow us to understand how common (and therefore how feasible) particular outcomes are in asthma in the ED setting; and finally (5) a meeting of the Pediatric Emergency Research Networks (PERN) asthma working group will be held, with invitation of other clinicians interested in acute asthma research, and patients/families. The group will be asked to achieve consensus on a core set of outcomes and to make recommendations for the conduct of clinical trials in acute severe asthma. If this is not possible, the group will agree on a series of prioritized steps to achieve this aim.DiscussionThe development of an international consensus on core outcomes is an important first step towards the development of consensus guidelines and standardised protocols for randomized controlled trials (RCTs) in this population. This will enable us to better interpret and compare future studies, reduce risks of study heterogeneity and outcome reporting bias, and improve the evidence base for the management of this important condition.

Pharmacotherapy in bronchiolitis at discharge from emergency departments within the Pediatric Emergency Research Networks: a retrospective analysis

Clinical guidelines advise against pharmacotherapy in bronchiolitis. However, little is known about global variation in prescribing practices for bronchiolitis at discharge from emergency departments. We aimed to evaluate global variation in prescribing practice (ie, inhaled salbutamol, or oral or inhaled corticosteroids) for infants with bronchiolitis at discharge from emergency departments. We did a planned secondary analysis of a multinational, retrospective cohort study of the Pediatric Emergency Research Networks. Previously healthy infants (aged <12 months) who were discharged with bronchiolitis between Jan 1 and Dec 31, 2013 from 38 emergency departments in Australia and New Zealand, Canada, Spain and Portugal, the UK and Ireland, and the USA were included. The primary outcome was pharmacotherapy prescription at discharge from the emergency department. Secondary outcomes were revisits to the emergency department or hospitalisations for bronchiolitis within 21 days of discharge. Of 1566 infants discharged from the emergency department, 317 (20%) were prescribed pharmacotherapy. Corticosteroid prescriptions were infrequent, ranging from 0% (0 of 68 infants) in Spain and Portugal to 6% (25 of 452) in the USA. Salbutamol prescriptions ranged from 5% (22 of 432) in the UK and Ireland to 32% (146 of 452) in the USA. Compared with the UK and Ireland, the odds of prescription of pharmacotherapy were increased in Spain and Portugal (odds ratio [OR] 9·22, 95% CI 1·70-49·96), the USA (8·20, 2·79-24·11), Canada (5·17, 1·61-16·67), and Australia and New Zealand (1·21, 0·36-4·10). After adjustment for clustering by site, pharmacotherapy at discharge was associated with older age (per 1 month increase; OR 1·23, 95% CI 1·16-1·30), oxygen saturation (per 1% decrease from 100%; 1·09, 1·01-1·18), chest retractions (1·88, 1·26-2·79), network (p=0·00050), and site (p<0·00090). 303 (19%) of 1566 infants returned to the emergency department and 129 (43%) of 303 were hospitalised. Discharge pharmacotherapy was not associated with revisits (p=0·55) or subsequent hospitalisations (p=0·50). Use of ineffective medications in infants with bronchiolitis at discharge from emergency departments is common, with large differences in prescribing practices between countries and emergency departments. Enhanced knowledge translation and deprescribing efforts are needed to optimise and unify the management of bronchiolitis. None.

Pediatric Anaerobic Blood Culture Practices in Industrialized Countries.

Routine anaerobic blood culture collection in febrile children is controversial, as clinicians try to account for the severe but relative infrequency of anaerobic bacteremia. Furthermore, clinical and laboratory practice variation among institutions may lead to potentially inaccurate epidemiological data. Our goal was to assess blood culture practices in pediatric patients throughout an international network of hospitals in industrialized countries. We conducted a survey of current clinical and laboratory practice patterns in a convenience sample of international institutions participating in 6 pediatric emergency research networks in the US, Canada, Europe, Australia, and New Zealand. A lead clinician at each institution queried institutional practices from the emergency department, pediatric intensive care unit, and oncology medical directors. The microbiology director at each institution completed the laboratory survey. Sixty-five of 160 (41%) invited institutions participated in the survey. Routine anaerobic blood cultures are collected in 30% of emergency departments, 30% of intensive care units, and 48% of oncology wards. Reasons for restricting anaerobic culture collection included concerns regarding blood volume (51%), low pretest probability (22%), and cost-effectiveness (16%). The most common reasons institutions allow for selectively obtaining anaerobic cultures are clinical suspicion (64%) and patients who are immunosuppressed (50%). The microbiology survey showed variation in systems, although most use the BACTEC™ culture system and MALDI-TOF for organism identification. There is broad variation in anaerobic blood culture practices among a network of pediatric hospitals in industrialized countries.

Implementation of a CT scan practice guideline for pediatric trauma patients reduces unnecessary scans without impacting outcomes.

Computed tomography (CT) scans are useful in the evaluation of trauma patients, but are costly and pose risks from ionizing radiation in children. Recent literature has demonstrated the use of CT scan guidelines in the management of pediatric trauma. The study objective is to review our treatment of pediatric blunt trauma patients and evaluate CT use before and after CT-guideline implementation. Our Pediatric Level 2 Trauma Center (TC) implemented a CT scan practice guideline for pediatric trauma patients in March 2014. The guideline recommended for or against CT of the head and abdomen/pelvis using published criteria from the Pediatric Emergency Care and Research Network. There was no chest CT guideline. We reviewed all pediatric trauma patients for CT scans obtained during initial evaluation before and after guideline implementation, excluding inpatient scans. The Trauma Registry Database was queried to include all pediatric (age < 15) trauma patients seen in our TC from 2010 to 2016, excluding penetrating mechanism and deaths in the TC. Scans were considered positive if organ injury was detected. Primary outcome was the proportion of patients undergoing CT and percent positive CTs. Secondary outcomes were hospital length of stay, readmissions, and mortality. Categorical and continuous variables were analyzed with χ and Wilcoxon rank-sum tests, respectively. p < 0.05 was considered significant. We identified 1,934 patients: 1,106 pre- and 828 post-guideline. Absolute reductions in head, chest, and abdomen/pelvis CT scans were 17.7%, 11.5%, and 18.8%, respectively (p < 0.001). Percent positive head CTs were equivalent, but percent positive chest and abdomen CT increased after implementation. Secondary outcomes were unchanged. Implementation of a pediatric CT guideline significantly decreases CT use, reducing the radiation exposure without a difference in outcome. Trauma centers treating pediatric patients should adopt similar guidelines to decrease unnecessary CT scans in children. Therapeutic study, level IV.

Overcoming the Bronchiolitis Blues: Embracing Global Collaboration and Disease Heterogeneity.

* Abbreviation: RSV — : respiratory syncytial virus Although bronchiolitis is 1 of the most common conditions in infancy, no medicine has been proven to be consistently beneficial. As a result, the primary objective of frontline providers in primary care and emergency medicine is to triage infants to the appropriate level of care (ie, home, hospital ward, or intensive care) for their hydration and respiratory needs.1 However, prospectively validated risk-stratification tools for infants with bronchiolitis do not exist for frontline providers. Freire et al,2 as part of the Pediatric Emergency Research Networks, addressed this knowledge gap by analyzing data that were collected from 38 emergency departments across the globe to develop a bronchiolitis risk score. In the resulting article,2 the authors report that the usual suspects (ie, being ≤2 months of age; having apnea; oxygen saturation of <90%; signs of increased work of breathing [including nasal flaring, grunting, and retractions]; and dehydration and/or poor feeding) were all predictive of escalated care, which is defined as hospitalization with a high-flow nasal cannula, noninvasive or invasive ventilation, or intensive care admission. Although many clinicians feel comfortable triaging infants with bronchiolitis at either … Address correspondence to Jonathan M. Mansbach, MD, MPH, Department of Medicine, Boston Children’s Hospital, 300 Longwood Ave, 9 S. 9157, Boston, MA 02115. E-mail: jonathan.mansbach{at}childrens.harvard.edu