Abstract Background To assist clinicians with identifying children at risk of severe outcomes, we assessed the association between laboratory findings and severe outcomes among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)–infected children and determined if SARS-CoV-2 test result status modified the associations. Methods We conducted a cross-sectional analysis of participants tested for SARS-CoV-2 infection in 41 pediatric emergency departments in 10 countries. Participants were hospitalized, had laboratory testing performed, and completed 14-day follow-up. The primary objective was to assess the associations between laboratory findings and severe outcomes. The secondary objective was to determine if the SARS-CoV-2 test result modified the associations. Results We included 1817 participants; 522 (28.7%) SARS-CoV-2 test-positive and 1295 (71.3%) test-negative. Seventy-five (14.4%) test-positive and 174 (13.4%) test-negative children experienced severe outcomes. In regression analysis, we found that among SARS-CoV-2-positive children, procalcitonin ≥0.5 ng/mL (adjusted odds ratio [aOR], 9.14; 95% CI, 2.90–28.80), ferritin >500 ng/mL (aOR, 7.95; 95% CI, 1.89–33.44), D-dimer ≥1500 ng/mL (aOR, 4.57; 95% CI, 1.12–18.68), serum glucose ≥120 mg/dL (aOR, 2.01; 95% CI, 1.06–3.81), lymphocyte count <1.0 × 109/L (aOR, 3.21; 95% CI, 1.34–7.69), and platelet count <150 × 109/L (aOR, 2.82; 95% CI, 1.31–6.07) were associated with severe outcomes. Evaluation of the interaction term revealed that a positive SARS-CoV-2 result increased the associations with severe outcomes for elevated procalcitonin, C-reactive protein (CRP), D-dimer, and for reduced lymphocyte and platelet counts. Conclusions Specific laboratory parameters are associated with severe outcomes in SARS-CoV-2-infected children, and elevated serum procalcitonin, CRP, and D-dimer and low absolute lymphocyte and platelet counts were more strongly associated with severe outcomes in children testing positive compared with those testing negative.
To estimate rates of critical medical and neurosurgical interventions and resource utilization for children with traumatic intracranial hemorrhage (ICH).This was a retrospective study of children younger than 18 years hospitalized in 1 of 35 hospitals in the Pediatric Health Information System from 2009 to 2019 for ICH. We defined critical intervention as a critical medical (hyperosmotic agents and intubation) or neurosurgical intervention. We determined rates of critical interventions, intensive care unit (ICU) admission, and repeat neuroimaging. We used hierarchical logistic regression to identify high-level factors associated with undergoing critical interventions, controlling for hospital-level effects.There were 12,714 children with ICH included in the study. Median (interquartile range) age was 4.3 (0.7-11.0) years. Twelve percent (n = 1470) of children underwent a critical clinical intervention. Critical medical interventions occurred in 10% (n = 1219), and neurosurgical interventions occurred in 3% (n = 419). Intensive care unit admission occurred in 44% (n = 5565), whereas repeat neuroimaging occurred in 40% (n = 5072). Among ICU patients, 79% (n = 4366) did not undergo a critical intervention. Of the 11,244 children with no critical interventions, 39% (n = 4366) underwent ICU admission, and 37% (n = 4099) repeat neuroimaging. After controlling for hospital, children with isolated subdural (P = 0.013) and isolated subarachnoid (P < 0.001) hemorrhage were less likely to receive critical interventions.Critical medical interventions occurred in 10% of children with ICH, and neurosurgical interventions occurred in 3%. Intensive care unit admission and repeat neuroimaging are common, even among those who did not undergo critical interventions. Selective utilization of ICU admission and repeat neuroimaging in children who are at low risk of requiring critical interventions could improve overall quality of care and decrease unnecessary resource utilization.
Abstract Objective The Pediatric Emergency Care Applied Research Network (PECARN) derived and externally validated a clinical prediction rule to identify children with blunt torso trauma at low risk for intraabdominal injuries undergoing acute intervention (IAI AI ). Little is known about the risk for IAI AI when only one or two prediction rule variables are positive. We sought to determine the risk for IAI AI when either one or two PECARN intraabdominal injury rule variables are positive. Methods We performed a planned secondary analysis of a prospective, multicenter study that included 7542 children (<18 years old) with blunt torso trauma evaluated in six emergency departments from December 2016 to August 2021. Patients with only one or two PECARN rule variables positive were included. The outcome was IAI AI (IAI undergoing therapeutic laparotomy, angiographic embolization, blood transfusion, or two or more nights of intravenous fluids). Results Among the 7542 children enrolled, 2986 (39.6%, 95% confidence interval [CI] 38.5%–40.7%) had one or two PECARN variables positive and were included. Of this subpopulation, 227 (7.6%, 95% CI 6.7%–8.6%) had intraabdominal injuries. In the 1639 patients with only one rule variable positive, 21 (1.3%, 95% CI 0.8%–2.0%) had IAI AI . In the 1347 patients with two rule variables positive, 27 (2.0%, 95% CI 1.3%–2.9%) had IAI AI . Risk for IAI AI for each variable was highest for Glasgow Coma Scale (GCS) score <14 (16/291, 5.5%, 95% CI 3.2%–8.8%) and abdominal wall trauma (three of 321, 0.9%, 95% CI 0.2%–2.7%). Risk for IAI AI when two variables were present was highest when decreased breath sounds (three of 44, 6.8%, 95% CI 1.4%–18.7%) and GCS <14 (10/207, 4.8%, 95% CI 2.3%–8.7%) were present with one other variable. Conclusions Few children with blunt torso trauma and one or two PECARN predictor variables present have IAI AI . Those with GCS score <14, however, are at highest risk for IAI AI .
When head injured children undergo head computed tomography (CT), radiation dosing can vary considerably between institutions, potentially exposing children to excess radiation, increasing risk for malignancies later in life. We compared radiation delivery from head CTs at a level 1 pediatric trauma center (PTC) versus scans performed at referring adult general hospitals (AGHs). We hypothesized that children at our PTC receive a significantly lower radiation dose than children who underwent CT at AGHs for similar injury profiles.We retrospectively reviewed the charts of all patients younger than 18 years who underwent CT for head injury at our PTC or at an AGH before transfer between January 1 and December 31, 2019. We analyzed demographic and clinical data. Our primary outcome was head CT radiation dose, as calculated by volumetric CT dose index (CTDIvol) and dose-length product (DLP; the product of CTDIvol and scan length). We used unadjusted bivariate and multivariable linear regression (adjusting for age, weight, sex) to compare doses between Children's Hospital Los Angeles and AGHs.Of 429 scans reviewed, 193 were performed at our PTC, while 236 were performed at AGHs. Mean radiation dose administered was significantly lower at our PTC compared with AGHs (CTDIvol 20.3/DLP 408.7 vs. CTDIvol 30.6/DLP 533, p < 0.0001). This was true whether the AGH was a trauma center or not. After adjusting for covariates, findings were similar for both CTDIvol and DLP. Patients who underwent initial CT at an AGH and then underwent a second CT at our PTC received less radiation for the second CT (CTDIvol 25.6 vs. 36.5, p < 0.0001).Head-injured children consistently receive a lower radiation dose when undergoing initial head CT at a PTC compared with AGHs. This provides a basis for programs aimed at establishing protocols to deliver only as much radiation as necessary to children undergoing head CT.Care Management/Therapeutic, level IV.
Background: Neonatal mastitis and omphalitis are uncommon but potentially serious infections in neonates. Clinical findings may range from localized soft tissue infection to more invasive necrotizing local infection or systemic illness with other concurrent serious bacterial infections. Modern literature on these diseases is scant, and there is very little evidence available to guide evaluation and treatment decisions. Objective: Describe the clinical presentation, prevalence of concurrent serious bacterial infection (SBI), and outcomes among infants with neonatal mastitis and omphalitis. Design/Methods: Utilizing the framework of the Pediatric Emergency Medicine Collaborative …
There is increased awareness of radiation risks from computed tomography (CT) in pediatric patients. In emergency departments (EDs), evidence-based guidelines, improvements in imaging technology, and availability of nonradiating modalities have potentially reduced CT use.To evaluate changes over time and hospital variation in advanced imaging use.This cross-sectional study assessed 26 082 062 ED visits by children younger than 18 years from the Pediatric Health Information System administrative database from January 1, 2009, through December 31, 2018.Imaging.The primary outcome was the change in CT, ultrasonography, and magnetic resonance imaging (MRI) rates from January 1, 2009, to December 31, 2018. Imaging for specific diagnoses was examined using all patient-refined diagnosis related groups. Secondary outcomes were hospital admission and 3-day ED revisit rates and ED length of stay.There were a total of 26 082 062 visits by 9 868 406 children (mean [SD] age, 5.59 [5.15] years; 13 842 567 [53.1%] male; 9 273 181 [35.6%] non-Hispanic white) to 32 US pediatric EDs during the 10-year study period, with 1 or more advanced imaging studies used in 1 919 283 encounters (7.4%). The proportion of ED encounters with any advanced imaging increased from 6.4% (95% CI, 6.2%-6.2%) in 2009 to 8.7% (95% CI, 8.7%-8.8%) in 2018. The proportion of ED encounters with CT decreased from 3.9% (95% CI, 3.9%-3.9%) to 2.9% (95% CI, 2.9%-3.0%) (P < .001 for trend), with ultrasonography increased from 2.5% (95% CI, 2.5%-2.6%) to 5.8% (95% CI, 5.8%-5.9%) (P < .001 for trend), and with MRI increased from 0.3% (95% CI, 0.3%-0.4%) to 0.6% (95% CI, 0.6%-0.6%) (P < .001 for trend). The largest decreases in CT rates were for concussion (-23.0%), appendectomy (-14.9%), ventricular shunt procedures (-13.3%), and headaches (-12.4%). Factors associated with increased use of nonradiating imaging modalities included ultrasonography for abdominal pain (20.3%) and appendectomy (42.5%) and MRI for ventricular shunt procedures (17.9%) (P < .001 for trend). Across the study period, EDs varied widely in the use of ultrasonography for appendectomy (median, 57.5%; interquartile range [IQR], 40.4%-69.8%) and MRI (median, 15.8%; IQR, 8.3%-35.1%) and CT (median, 69.5%; IQR, 54.5%-76.4%) for ventricular shunt procedures. Overall, ED length of stay did not change, and hospitalization and 3-day ED revisit rates decreased during the study period.This study found that use of advanced imaging increased from 2009 to 2018. Although CT use decreased, this decrease was accompanied by a greater increase in the use of ultrasonography and MRI. There appears to be substantial variation in practice and a need to standardize imaging practices.
Background: Cervical spine injuries (CSIs) in children are uncommon but potentially devastating; however, indiscriminate neck imaging after trauma unnecessarily exposes children to ionizing radiation. A robust pediatric CSI prediction rule is needed. Methods: Children <18 years experiencing blunt trauma evaluated at 18 emergency departments (EDs) were eligible for enrollment into derivation or validation cohorts. CSI risk factors were prospectively collected by ED clinicians. CSIs were determined by imaging reports and telephone follow-up. We identified factors with high CSI risk, performed a classification and regression tree (CART) analysis to identify other CSI risk factors in children without high-risk factors, and combined both sets of factors to create a CSI prediction rule. Test performance measures were calculated for both derivation and validation cohorts. Findings: Of 22,430 children enrolled, 433 (1.9%) had CSIs. Glasgow Coma Scale scores of 3-8 or unresponsiveness to pain; abnormal airway, breathing, or circulation findings; and focal neurologic deficits were associated with high CSI risk on bivariable analysis. Of 928 in the derivation cohort with >1 of these findings, 118 (12.7%) had CSIs. CART analysis on the remaining children identified neck pain, altered mentation, substantial torso injury, and midline neck tenderness as associated with CSI. The prediction rule, combining high-risk and CART-identified factors, had >92% sensitivity and near perfect NPV (99.9%). If applied to all participants, CT and plain radiograph use would have decreased from 17.2% to 6.9% and 39.7% to 34.2%, respectively.Interpretation: We derived and validated a highly accurate CSI prediction rule for children after blunt trauma.Trial Registration: ClinicalTrials.gov Identifier - NCT05049330.Funding: Eunice Kennedy Shriver National Institute of Child Health & Human Development 5R01HD091347 Development and Testing of a Pediatric Cervical Spine Injury Risk Assessment Tool, Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS), in the Maternal and Child Health Bureau (MCHB), under the Emergency Medical Services for Children (EMSC) program through the following cooperative agreements: Data Coordinating Center-University of Utah (UJ5MC30824), GLEMSCRN Nationwide Children’s Hospital (U03MC28844), HOMERUN-Cincinnati Children’s Hospital Medical Center (U03MC22684), PEMNEWS- Columbia University Medical Center (U03MC00007), PRIME-University of California at Davis Medical Center (U03MC00001), CHaMP node- State University of New York at Buffalo (U03MC33154), WPEMR- Seattle Children’s Hospital (U03MC33156), and SPARC- Rhode Island Hospital/Hasbro Children’s Hospital (U03MC33155). Declaration of Interests: We declare no competing interests. Ethics Approval: PECARN’s single Institutional Review Board at the University of Utah approved this study with a waiver of informed consent for prospective observational data collection and medical record review and verbal consent or mail notification for parental telephone follow-up.
