Natalie Phillips

Prevalence, codetection and seasonal distribution of upper airway viruses and bacteria in children with acute respiratory illnesses with cough as a symptom

n Abstractn n Most studies exploring the role of upper airway viruses and bacteria in paediatric acute respiratory infections (ARI) focus on specific clinical diagnoses and/or do not account for virus–bacteria interactions. We aimed to describe the frequency and predictors of virus and bacteria codetection in children with ARI and cough, irrespective of clinical diagnosis. Bilateral nasal swabs, demographic, clinical and risk factor data were collected at enrollment in children aged <15xa0years presenting to an emergency department with an ARI and where cough was a symptom. Swabs were tested by polymerase chain reaction for 17 respiratory viruses and seven respiratory bacteria. Logistic regression was used to investigate associations between child characteristics and codetection of the organisms of interest. Between December 2011 and August 2014, swabs were collected from 817 (93.3%) of 876 enrolled children, median age 27.7xa0months (interquartile range 13.9–60.3xa0months). Overall, 740 (90.6%) of 817 specimens were positive for any organism. Both viruses and bacteria were detected in 423 specimens (51.8%). Factors associated with codetection were age (adjusted odds ratio (aOR) for age <12xa0monthsxa0=xa04.9, 95% confidence interval (CI) 3.0, 7.9; age 12 to <24xa0monthsxa0=xa06.0, 95% CI 3.7, 9.8; age 24 to <60xa0monthsxa0=xa02.4, 95% CI 1.5, 3.9), male gender (aOR 1.46; 95% CI 1.1, 2.0), child care attendance (aOR 2.0; 95% CI 1.4, 2.8) and winter enrollment (aOR 2.0; 95% CI 1.3, 3.0). Haemophilus influenzae dominated the virus–bacteria pairs. Virus–H.xa0influenzae interactions in ARI should be investigated further, especially as the contribution of nontypeable H.xa0influenzae to acute and chronic respiratory diseases is being increasingly recognized.n n

Chronic cough postacute respiratory illness in children: a cohort study.

Objective Data on the aetiology of persistent cough at the transitional stage from subacute to chronic cough (>4 weeks duration) are scarce. We aimed to (1) identify the prevalence of chronic cough following acute respiratory illness (ARI) and (2) determine the diagnostic outcomes of children with chronic cough. Design Prospective cohort study. Setting A paediatric emergency department (ED) in Brisbane, Australia. Patients Children aged <15u2009years presenting with an ARI with cough. Interventions Children were followed weekly for 28u2009days;those with a persistent cough at day 28 were reviewed by a paediatric pulmonologist. Main outcome measures Cough persistence at day 28 and pulmonologist diagnosis. Results 2586 children were screened and 776 (30%) were ineligible; 839 children (median age=2.3u2009years, range=0.5u2009months to 14.7u2009years, 60% male) were enrolled over 2u2009years. Most children (n=627, 74.8%) had cough duration of <7 days at enrolment. At day 28, 171/839 (20.4%, 95%u2009CI 17.7 to 23.1) children had persistent cough irrespective of cough duration at enrolment. The cough was wet in 59/171 (34.5%), dry in 45/171 (26.4%) and variable in 28/171 (16.1%). Of these 117 children , 117 (68.4%) were reviewed by a paediatric pulmonologist. A new and serious chronic lung disease was diagnosed in 36/117 (30.8%) children; 55/117 (47.0%) were diagnosed with protracted bacterial bronchitis. Conclusions When chronic cough develops post-ARI, clinical review is warranted, particularly if parents report a history of prolonged or recurrent cough. Parents of children presenting acutely to ED with cough should be counselled about the development of chronic cough, as an underlying respiratory condition is not uncommon.

Upper airway viruses and bacteria and clinical outcomes in children with cough.

Background: Cough is symptomatic of a broad range of acute and chronic pediatric respiratory illnesses. No studies in children have tested for an extended panel of upper airway respiratory viruses and bacteria to identify whether they predict cough outcomes, irrespective of clinical diagnosis at the time of acute respiratory illness (ARI). We therefore determined whether upper airway microbes independently predicted hospitalization and persistent cough 28‐days later in children presenting with an ARI, including cough as a symptom. Methods: A cohort study of children aged <15‐years were followed for 28‐days after presenting to a pediatric emergency department with an ARI where cough was also a symptom. Socio‐demographic factors, presenting clinical features and a bilateral anterior nasal swab were collected at enrolment. Polymerase chain reaction assays tested for seven respiratory bacteria and 17 viruses. Predictors of hospitalization and persistent cough at day‐28 were evaluated in logistic regression models. Results: Eight hundred and seventeen children were included in the analysis; median age 27.7‐months. 116 (14.2%, 95%CI 11.8, 16.6) children were hospitalized and 163 (20.0%, 95%CI 17.2, 22.7) had persistent cough at day‐28. Hospitalized children were more likely to have RSV A or B detected on nasal swab than those not admitted (adjusted relative risk (aRR) 1.8, 95%CI 1.0, 3.3). M. catarrhalis was the only microbial difference between children with and without cough persistence (aRR for those with cough at day 28: 2.1, 95%CI 1.3, 3.1). Discussion: An etiologic role for M. catarrhalis in the pathogenesis of persistent cough post‐ARI is worth exploring, especially given the burden of chronic cough in children and its relationship with chronic lung disease. Pediatr Pulmonol. 2017;52:373–381.

A multicentre randomised controlled trial of levetiracetam versus phenytoin for convulsive status epilepticus in children (protocol): Convulsive Status Epilepticus Paediatric Trial (ConSEPT) - a PREDICT study

BackgroundConvulsive status epilepticus (CSE) is the most common life-threatening childhood neurological emergency. Despite this, there is a lack of high quality evidence supporting medication use after first line benzodiazepines, with current treatment protocols based solely on non-experimental evidence and expert opinion. The current standard of care, phenytoin, is only 60% effective, and associated with considerable adverse effects. A newer anti-convulsant, levetiracetam, can be given faster, is potentially more efficacious, with a more tolerable side effect profile. The primary aim of the study presented in this protocol is to determine whether intravenous (IV) levetiracetam or IV phenytoin is the better second line treatment for the emergency management of CSE in children.Methods/Design200 children aged between 3xa0months and 16xa0years presenting to 13 emergency departments in Australia and New Zealand with CSE, that has failed to stop with first line benzodiazepines, will be enrolled into this multicentre open randomised controlled trial. Participants will be randomised to 40xa0mg/kg IV levetiracetam infusion over 5xa0min or 20xa0mg/kg IV phenytoin infusion over 20xa0min. The primary outcome for the study is clinical cessation of seizure activity five minutes following the completion of the infusion of the study medication. Blinded confirmation of the primary outcome will occur with the primary outcome assessment being video recorded and assessed by a primary outcome assessment team blinded to treatment allocation. Secondary outcomes include: Clinical cessation of seizure activity at two hours; Time to clinical seizure cessation; Need for rapid sequence induction; Intensive care unit (ICU) admission; Serious adverse events; Length of Hospital/ICU stay; Health care costs; Seizure status/death at one-month post discharge.DiscussionThis paper presents the background, rationale, and design for a randomised controlled trial comparing levetiracetam to phenytoin in children presenting with CSE in whom benzodiazepines have failed. This study will provide the first high quality evidence for management of paediatric CSE post first-line benzodiazepines.Trial registrationProspectively registered with the Australian and New Zealand Clinical Trial Registry (ANZCTR): ACTRN12615000129583 (11/2/2015). UTN U1111–1144-5272. ConSEPT protocol version 4 (12/12/2014).

Qualitative evaluation of a deferred consent process in paediatric emergency research: a PREDICT study

Background A challenge of conducting research in critically ill children is that the therapeutic window for the intervention may be too short to seek informed consent prior to enrolment. In specific circumstances, most international ethical guidelines allow for children to be enrolled in research with informed consent obtained later, termed deferred consent (DC) or retrospective consent. There is a paucity of data on the attitudes of parents to this method of enrolment in paediatric emergency research. Objectives To explore the attitudes of parents to the concept of DC and to expand the knowledge of the limitations to informed consent and DC in these situations. Method Children presenting with uncomplicated febrile seizures or bronchiolitis were identified from three separate hospital emergency department databases. Parents were invited to participate in a semistructured telephone interview exploring themes of limitations of prospective informed consent, acceptability of the DC process and the most appropriate time to seek DC. Transcripts underwent inductive thematic analysis with intercoder agreement, using Nvivo 11 software. Results A total of 39 interviews were conducted. Participants comprehended the limitations of informed consent under emergency circumstances and were generally supportive of DC. However, they frequently confused concepts of clinical care and research, and support for participation was commonly linked to their belief of personal benefit. Conclusion Participants acknowledged the requirement for alternatives to prospective informed consent in emergency research, and were supportive of the concept of DC. Our results suggest that current research practice seems to align with community expectations.

Investigating the Variability in Mild Traumatic Brain Injury Definitions: A Prospective Cohort Study

OBJECTIVEnTo prospectively compare the proportion of traumatic brain injuries (TBIs) that would be classified as mild by applying different published definitions of mild TBI to a large prospectively collected dataset, and to examine the variability in the proportions included by various definitions.nnnDESIGNnProspective observational study.nnnSETTINGnHospital emergency departments.nnnPARTICIPANTSnChildren (N=11,907) aged 3 to 16 years (mean age, 8.2±3.9y). Of the participants, 3868 (32.5%) were girls, and 7374 (61.9%) of the TBIs were the result of a fall. Median Glasgow Coma Scale score wasxa015.nnnMAIN OUTCOME MEASURESnWe applied 17 different definitions of mild TBI, identified through a published systematic review, to children aged 3 to 16 years. Adjustments and clarifications were made to some definitions. The number and percentage identified for each definition is presented.nnnRESULTSnAdjustments had to be made to the 17 definitions to apply to the dataset: none in 7, minor to substantial in 10. The percentage classified as mild TBI across definitions varied from 7.1% (n=841) to 98.7% (n=11,756) and varied by age group.nnnCONCLUSIONSnWhen applying the 17 definitions of mild TBI to a large prospective multicenter dataset of TBI, there was wide variability in the number of cases classified. Clinicians and researchers need to be aware of this variability when examining literature concerning children with mild TBI.

Bell's palsy in children: Current treatment patterns in Australia and New Zealand. A PREDICT study

The aetiology and clinical course of Bells palsy may be different in paediatric and adult patients. There is no randomised placebo controlled trial (RCT) to show effectiveness of prednisolone for Bells palsy in children. The aim of the study was to assess current practice in paediatric Bells palsy in Australia and New Zealand Emergency Departments (ED) and determine the feasibility of conducting a multicentre RCT within the Paediatric Research in Emergency Departments International Collaborative (PREDICT).

G298(P) Paediatric intentional head injuriesin the emergency department. A predict multicentre prospective cohort study

Aims While the majority of head injuries (HIs) in children are non-intentional, there is limited information on intentional HIs outside abusive head trauma. The objective of this study was to describe epidemiology, demographics and severity of intentional HIs in childhood in a multicentre study in Australia and New Zealand. Methods Planned secondary analysis of a prospective multicentre cohort study of children aged <18 years across 10 centres in Australia and New Zealand between April 2011 and November 2014. Victorian state epidemiology codes (intent, activity, place, mechanism) were used to prospectively code the injuries. Clinical information including history of injury event and examination findings were collected and data were descriptively analysed. Results Intentional injuries were found in 372 of 20 137 (1.8%) head injured children. Injuries were caused by caregivers (103, 27.7%), by peers (97, 26.1%), by sibling (47, 12.6%), due to attack by stranger (35, 9.4%), by person with unknown relation to patient (21, 5.6%), intentional self-harm (7, 1.9%), legal intervention (1, 0.3%) or undetermined intent (61, 16.4%). 75.7% of victims of assault by caregiver were under 2 years old, whereas for other causes only 4.9% were under 2 years. Overall, 66.9% of victims were male. Rates for admission, CT scan and abnormal CT rates varied from 77.7%, 68.9% and 47.6% for assault by caregiver, 37.1%, 37.1% and 5.2% for attack by stranger, 23.7%, 18.6% and 5.2% for assault by peer and 8.5%, 2.1% and 2.1% for injuries caused by sibling respectively. Conclusion Intentional head injuries are infrequent in children. The most frequent cause is injury by caregiver or peer assault. HI due to assault by caregiver results in more abnormal findings on a CT scan than other mechanisms of intentional HI.

ANNUAL ACUTE HOSPITAL COST OF PAEDIATRIC HEAD INJURY IN AUSTRALIA – A PAEDIATRIC RESEARCH IN EMERGENCY DEPARTMENTS INTERNATIONAL COLLABORATIVE (PREDICT) STUDY

Objectives & Background Children with head injuries (HIs) frequently present to acute care settings. Most injuries are mild, but a small portion of patients have clinically significant intracranial injuries. An attempt to estimate the cost of paediatric HIs using prospectively collected data has never been attempted in Australia. We aimed to estimate the total cost paediatric HI in Australia and provide an understanding of the costs associated with different causative and presentation factors. Methods The study was embedded in a prospective observational study of 20,255 children <18u2005years designed to validate three published clinical decision rules. Each patients hospital presentation was micro-costed and then extrapolated to an annualised Australia-wide figure using Australian Independent Hospital Pricing Authority data. Results There were 109,729 cases of HI in children aged 0–18u2005years across Australia in the fiscal year 2012–2013 (1.67% of total emergency presentations). The average cost of each HI was

G273 Accuracy of Physician Practice as Compared with Pecarn, Catch and Chalice Head Injury Clinical Decision Rules in Children. A Predict Prospective Cohort Study

1348.21 [95%CI: 1173.02 to 1523.40]. The total cost of HI in Australia was