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ObjectivesTo evaluate the appropriateness of the American Academy of Pediatrics’ (AAP) recommendation to no longer collect a urine culture (UC) in febrile infants ≥21 days old with negative urinalysis, and to identify predictors for having a positive UC in well-appearing febrile infants aged 22–90 days with a negative urinalysis.MethodsThis study was a subanalysis of a multicentre retrospective registry, including well-appearing febrile infants aged 22–90 days with a negative urinalysis between 2011 and 2022. We performed a multivariate regression analysis including the following variables: age, sex, duration of fever, maximum temperature, absolute neutrophil count (ANC), and C reactive protein and procalcitonin levels.ResultsWe included 2391 infants in the study. The UC was positive in 177 (7.4%; 13.5% in males vs 0.6% in females). The main isolated microorganisms were Escherichia coli (83, 46.9%), Enterococcus faecalis (40, 22.6%) and Klebsiella spp (24, 13.6%). Positive UCs were positively associated with male sex (OR 9.0; 95% CI 4.7 to 16.9) and ANC (OR 1.0001; 95% CI 1.00003 to 1.0002).ConclusionOur findings support the AAP’s recommendation to avoid obtaining a UC in female infants aged 22–90 days with a negative urinalysis. Blood tests demonstrated low performance in predicting a positive UC. This finding and the extremely low prevalence of circumcision in our setting suggest that most positive UCs in males with a negative urinalysis are more likely to represent contamination, as noted by the AAP.

Vital signs can help clinicians identify children at risk of serious illness. The NICE guideline for fever in under-fives recommends a routine measurement of temperature, heart rate, capillary refill and respiratory rate in all febrile children visiting the emergency department (ED). This study aims to evaluate the measurement of paediatric vital signs in European EDs, with specific attention to adherence to this NICE guideline recommendation. In a prospective observational study, we included 4560 febrile children under 16 years from the ED of 28 hospitals in 11 European countries (2014–2016). Hospitals were academic (n = 17), teaching (n = 10) and non-teaching (n = 1) and ranged in annual paediatric ED visits from 2700 to 88,000. Fifty-four percent were male, their median age was 2.4 years (IQR 1.1–4.7). Temperature was measured most frequently (97%), followed by capillary refill (86%), heart rate (73%), saturation (56%) and respiratory rate (51%). In children under five (n = 3505), a complete measurement of the four NICE-recommended vital signs was performed in 48% of patients. Children under 1 year of age, those with an urgent triage level and with respiratory infections had a higher likelihood of undergoing complete measurements. After adjustment for these factors, variability between countries remained.Conclusion: Measuring vital signs in children with fever in the ED occurs with a high degree of practice variation between different European hospitals, and adherence to the NICE recommendation is moderate. Our study is essential as a benchmark for current clinical practice, in order to tailor implementation strategies to different European settings.What is Known:• Vital signs can quickly provide information on disease severity in children in the emergency department (ED), and the NICE guideline for fever in under-fives recommends to routinely measure temperature, heart rate, capillary refill and respiratory rate.• Data regarding measurement of vital signs in routine practice across European EDs is currently unavailable.What is New:• Measurement of vital signs in febrile children is highly variable across European EDs and across patient subgroups, and compliance to the NICE recommendation is <50%.• Children under 1 year of age, those with an urgent triage level and with respiratory infections had a higher likelihood of undergoing complete measurements.

Background Globally, the COVID-19 pandemic had a huge impact on patients and healthcare systems. A decline in paediatric visits to healthcare settings was observed, which might have been due to lower incidence of injury and infectious illness, changes in healthcare services and parental concern. The aim of our study was to examine parental experiences of help-seeking for, and care of, a sick or injured child during COVID-19 lockdown periods in five European countries with different healthcare systems in place. Methods An online survey for parents with a child with any kind or illness of injury during COVID-19 lockdowns was circulated through social media in five European countries: Italy, Spain, Sweden, the Netherlands, and the United Kingdom. Parents living in one of these countries with self-identification of a sick or injured child during COVID-19 lockdown periods were eligible to fill in the survey. Descriptive statistics were used for the level of restrictions per country, children’s characteristics, family characteristics and reported help-seeking behaviour of parents prior to the lockdown and their real experience during the lockdown. The free text data was subjected to thematic analysis. Results The survey was fully completed by 598 parents, ranging from 50 to 198 parents per country, during varying lockdown periods from March 2020 until May 2022. Parents who completed the survey were not deterred from seeking medical help for their sick or injured child during the COVID-19 pandemic. This finding was comparable in five European countries with different healthcare systems in place. Thematic analysis identified three main areas: parental experiences of access to healthcare, changes in parents’ help-seeking behaviours for a sick or injured child during lockdowns, and the impact of caring for a sick or injured child during the lockdowns. Parents reported limited access to non-urgent care services and were anxious about either their child or themselves catching COVID-19. Conclusion This insight into parental perspectives of help-seeking behaviour and care for a sick or injured child during COVID-19 lockdowns could inform future strategies to improve access to healthcare, and to provide parents with adequate information concerning when and where to seek help and support during pandemics.

ObjectiveTo assess the diagnostic value of existing clinical prediction models (CPM; ie, statistically derived) in febrile young infants at risk for serious bacterial infections.MethodsA systematic literature review identified eight CPMs for predicting serious bacterial infections in febrile children. We validated these CPMs on four validation cohorts of febrile children in Spain (age <3 months), France (age <3 months) and two cohorts in the Netherlands (age 1–3 months and >3–12 months). We evaluated the performance of the CPMs by sensitivity/specificity, area under the receiver operating characteristic curve (AUC) and calibration studies.ResultsThe original cohorts in which the prediction rules were developed (derivation cohorts) ranged from 381 to 15 781 children, with a prevalence of serious bacterial infections varying from 0.8% to 27% and spanned an age range of 0–16 years. All CPMs originally performed moderately to very well (AUC 0.60–0.93). The four validation cohorts included 159–2204 febrile children, with a median age range of 1.8 (1.2–2.4) months for the three cohorts <3 months and 8.4 (6.0–9.6) months for the cohort >3–12 months of age. The prevalence of serious bacterial infections varied between 15.1% and 17.2% in the three cohorts <3 months and was 9.8% for the cohort >3–12 months of age. Although discriminative values varied greatly, best performance was observed for four CPMs including clinical signs and symptoms, urine dipstick analyses and laboratory markers with AUC ranging from 0.68 to 0.94 in the three cohorts <3 months (ranges sensitivity: 0.48–0.94 and specificity: 0.71–0.97). For the >3–12 months’ cohort AUC ranges from 0.80 to 0.89 (ranges sensitivity: 0.70–0.82 and specificity: 0.78–0.90). In general, the specificities exceeded sensitivities in our cohorts, in contrast to derivation cohorts with high sensitivities, although this effect was stronger in infants <3 months than in infants >3–12 months.ConclusionWe identified four CPMs, including clinical signs and symptoms, urine dipstick analysis and laboratory markers, which can aid clinicians in identifying serious bacterial infections. We suggest clinicians should use CPMs as an adjunctive clinical tool when assessing the risk of serious bacterial infections in febrile young infants.

[...]a large number of children with an invasive bacterial infection are not identified at first contact. 1 Different efforts have been made in order to identify children at low risk and high risk for serious bacterial infection. During the last decades, new blood tests such as C reactive protein (CRP) and, mainly, procalcitonin (PCT) have shown a better performance. [...]leucocyte indicators are less valuable than inflammatory markers for ruling in serious infection, and have no value for ruling out serious infection. 2 Nevertheless, these diagnostic tests are sometimes difficult to obtain for many physicians in different settings, are time-consuming and require a trained technician. 3 Verbakel et al analyse the value of point-of-care CRP to identify children with serious infections in a multicentre prospective study and propose a multivariable triage instrument. 4 Point-of-care tests have the advantage of obtaining the result in a very short time, making them suitable to be used when children are classified at the triage of an emergency department. [...]in populations with a low prevalence of serious infections CRP may have little clinically relevant value in discriminating febrile children in need of medical care from those who were not.

IntroductionRelatively limited data are available regarding paediatric COVID-19. Although most children appear to have mild or asymptomatic infections, infants and those with comorbidities are at increased risk of experiencing more severe illness and requiring hospitalisation due to COVID-19. The recent but uncommon association of SARS-CoV-2 infection with development of a multisystem inflammatory syndrome has heightened the importance of understanding paediatric SARS-CoV-2 infection.Methods and analysisThe Paediatric Emergency Research Network-COVID-19 cohort study is a rapid, global, prospective cohort study enrolling 12 500 children who are tested for acute SARS-CoV-2 infection. 47 emergency departments across 12 countries on four continents will participate. At enrolment, regardless of SARS-CoV-2 test results, all children will have the same information collected, including clinical, epidemiological, laboratory, imaging and outcome data. Interventions and outcome data will be collected for hospitalised children. For all children, follow-up at 14 and 90 days will collect information on further medical care received, and long-term sequelae, respectively. Statistical models will be designed to identify risk factors for infection and severe outcomes.Ethics and disseminationSites will seek ethical approval locally, and informed consent will be obtained. There is no direct risk or benefit of study participation. Weekly interim analysis will allow for real-time data sharing with regional, national, and international policy makers. Harmonisation and sharing of investigation materials with WHO, will contribute to synergising global efforts for the clinical characterisation of paediatric COVID-19. Our findings will enable the implementation of countermeasures to reduce viral transmission and severe COVID-19 outcomes in children.Trial registration number NCT04330261

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-h cycle. 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 ≥ 1 year. 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.

ObjectiveTo validate the Febrile Infant Working Group of the Pediatric Emergency Care Applied Research Network (PECARN) clinical prediction rule on an independent cohort of infants with fever without a source (FWS).DesignSecondary analysis of a prospective registry.SettingPaediatric emergency department of a tertiary teaching hospital.PatientsInfants ≤60 days old with FWS between 2007 and 2018.Main outcome measuresPrevalence of serious bacterial infection (SBI) and invasive bacterial infection (IBI) in low-risk infants according to the PECARN rule.ResultsAmong the 1247 infants included, 256 were diagnosed with an SBI (20.5%), including 38 IBIs (3.1%). Overall, 576 infants (46.0%; 95% CI 43.4% to 49.0%) would have been classified as low risk of SBI by the PECARN rule. Of them, 26 had an SBI (4.5%), including 5 with an IBI (2 (0.8%) diagnosed with bacterial meningitis). Sensitivity and specificity of the PECARN rule were 89.8% (95% CI 85.5% to 93.0%) and 55.5% (95% CI 52.4% to 58.6%) for SBI, with an area under the curve of 0.726 (95% CI 0.702 to 0.750). Its sensitivity to identify SBIs was 88.6% (95% CI 82.0% to 92.9%) among infants with a <6-hour history of fever (54.9% of the infants included).ConclusionsThe PECARN clinical rule for identifying SBI performed less well in our population than in the original study. This clinical rule should be applied cautiously in young infants with a short history of fever.

ObjectivesTo determine the performance of procalcitonin (PCT), C reactive protein (CRP) and absolute neutrophil count (ANC) in identifying invasive bacterial infection (IBI) among well-appearing infants ≤21 days old with fever without source and no leukocyturia. To compare this performance with that in those 22–90 days old.DesignSubstudy of a prospective single-centre registry performed between September 2008 and August 2017.SettingPaediatric emergency department of a tertiary teaching hospital.Patients196 infants ≤21 days old and 1331 infants 22–90 days old.Main outcome measuresSensitivity and negative likelihood ratio of blood tests for ruling out IBI (positive blood or cerebrospinal fluid culture). Abnormal blood test results: PCT ≥0.5 ng/mL, CRP >20 mg/L and ANC >10 000/µL.ResultsPrevalence of IBI in infants ≤21 days old with normal or any abnormal blood test result was 3.6% and 6.8%, respectively (OR 0.52 (95% CI 0.13 to 2.01)), compared with 0.2% and 4.5% in older infants (OR 0.03 (95% CI 0 to 0.17)). Sensitivity and negative likelihood ratio of the blood tests for ruling out IBI in infants ≤21 days were 44.4% (95% CI 18.9% to 73.3%) and 0.79 (95% CI 0.43 to 1.44), respectively (vs 84.6% (95% CI 57.8% to 95.7%)%) and 0.19 (95% CI 0.05 to 0.67) in older infants). The values improved in infants with fever ≥6 hours aged 22–90 days, but not in those ≤21 days.ConclusionsPCT, CRP and ANC are not useful for ruling out IBI in febrile infants ≤21 days old. It is still recommended that these patients are admitted and given empirical antibiotic therapy, regardless of their general appearance or blood test results.

ObjectiveTo determine the prevalence of invasive bacterial infections (IBI, pathogenic bacteria in blood or cerebrospinal fluid) in infants less than 90 days old with fever without a source related to the presence or absence of fever on arrival to the emergency department (ED).DesignProspective registry-based cohort study.SettingPaediatric ED of a tertiary teaching hospital.PatientsWe included infants less than 90 days old with a history of fever evaluated in the ED from 2003 to 2016.Main outcomes and measuresThe prevalence of IBI in patients with a history of fever who were febrile and afebrile on arrival to the ED.ResultsWe included 2470 infants: 678 afebrile and 1792 febrile when evaluated in the ED. Fifty-nine (2.4%) were diagnosed with an IBI (bacteraemia 46, meningitis 7 and sepsis 6): 16 in the group of afebrile infants with a history of fever (2.4%, 95% CI 1.4 to 3.8 vs 43 in the febrile group, 2.4%, 95% CI 1.8 to 3.2). Of the 16 afebrile infants with a history of fever diagnosed with an IBI, 14 were well appearing. The rate of non-IBI (pathogenic bacteria in urine or stools) was similar in both groups (15.5% and 16.7%).ConclusionsThe prevalence of IBI in infants ≤90 days with a history of fever is similar regardless of the presence of fever on the arrival at the ED. The approach to infants with a history of fever who are afebrile in the ED should not differ from that recommended for infants who are febrile in the ED.