Paediatrics (RCH) - Research Publications
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ItemCommunity use of paracetamol and ibuprofen in children with fever(WILEY, 2021-10)OBJECTIVE: To establish, in children aged from 3 months to less than 13 years with a febrile illness, caregiver medication usage patterns and drivers. Secondary objectives assessed caregiver knowledge and concern about fever. METHODOLOGY: This was a prospective, observational study of a convenience sample of 147 children presenting to a tertiary Paediatric Emergency Department, where the caregivers reported a concern of fever within the preceding 48 h. A paper-based survey was completed by the caregivers, and the results analysed both qualitatively and quantitatively. RESULTS: Caregivers of 92.4% had administered medication for fever in the 48 h prior to presentation. Dual therapy of paracetamol and ibuprofen was used by 45.8%, with paracetamol used more frequently as monotherapy (35.4%). Almost one-third of caregivers woke their child to administer medication. Just over one-third of respondents stated that a temperature of less than 38.0°C is a fever. The majority of caregivers (67.6%) said that fever is bad for their child, with 97.9% being concerned by fever. Almost half the children (46.8%) were given medication purely to treat the degree of the temperature. General practitioners were reported as the strongest influence on medication decision (60%). CONCLUSIONS: This study provides insight into current knowledge and practices of parents regarding fever and its treatment. The results of this study may be used to direct future interventions to educate caregivers on this topic.
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ItemLignocaine/phenylephrine nasal spray vs. placebo for the pain and distress of nasogastric tube insertion in children: a study protocol for a randomized controlled trial.(Springer Science and Business Media LLC, 2015-01-27)BACKGROUND: Patients and clinicians consistently rate insertion of a nasogastric tube (NGT) as one of the most painful and distressing emergency department procedures. Despite this, surveys of emergency clinicians suggest that provision of adequate procedural analgesia is often inconsistent and suboptimal. While many studies have demonstrated the effectiveness of various interventions to reduce pain and distress in adults, there have been few studies in the pediatric population. There are currently no studies comparing the effectiveness of a local anesthetic nasal spray for the prevention of the pain and distress associated with NGT insertion in children. This study aims to compare the analgesic efficacy of a proprietary preparation of lignocaine/phenylephrine nasal spray and placebo for this indication. METHODS/DESIGN: This is a prospective, randomized, controlled, double-blind superiority trial of 100 children aged 6 months to 5 years weighing at least 6 kg in whom a nasogastric tube is planned to be inserted. These children will be randomized to either intranasal lignocaine/phenylephrine or placebo. Pain severity is the primary outcome measure and will be measured utilizing the Face, Legs, Arms, Cry and Consolability (FLACC) pain severity rating scale. An independent staff member not involved in inserting the NGT and the child's parents or carer will also record pain and distress on a visual analog scale (VAS). FLACC scores and VAS scores will be presented as median and interquartile range (IQR). Non-normally distributed scores will be compared using a Wilcoxon rank-sum test. Categorical data will be analyzed using Fisher's exact test. Adverse events will be described as type and incidence. DISCUSSION: Previous studies on NGT insertion have not focused on the pediatric population. This study aims to establish the effectiveness of a simple intranasal spray of lignocaine/phenylephrine in children undergoing NGT insertion. A positive result of this study would provide evidence of an effective intervention in a procedure considered by many to be very painful and distressing. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR). ACTRN12614000092695 , registered on 23 January 2014.
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ItemObservational study of alternative therapies among paediatric emergency department patients(WILEY, 2017-04)OBJECTIVE: While complementary medicine use among ED paediatric patients is common, the use of alternative therapies (ATs; physical or spiritual therapies) is unknown. We aimed to determine the 12 month period prevalence and nature of AT use among paediatric patients and parent perceptions of AT use. METHODS: We undertook a cross-sectional survey of a convenience sample of parents of paediatric patients in three EDs in metropolitan Melbourne, Australia (January-June, 2015). Parents were invited to complete a validated, anonymous, self-administered questionnaire. The main outcomes were AT use by the patient and parent perceptions of ATs. RESULTS: A total of 806 parents were enrolled. In the previous 12 months, 393 (48.8%) patients had received at least one AT. There were no gender or ethnicity differences between AT users and non-users. AT use was more common among older patients (P < 0.05). Patients with chronic illness tended to use more ATs (P = 0.12). A total of 1091 courses of 43 different ATs had been provided. The most common were massage (16% of patients), chiropractic therapy (9.8%), relaxation (7.2%), meditation (6.2%) and aromatherapy (6.1%). ATs were generally used for musculoskeletal problems, health maintenance, stress and anxiety. Parents who arranged the ATs were significantly more likely to report that ATs are safe, prevent and treat illness, assist prescription medicines and offer a more holistic approach to healthcare (P < 0.001). CONCLUSION: AT use is common among paediatric ED patients. Parents who arrange AT have differing perceptions of AT usefulness and safety from those who do not.
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ItemBell's palsy in children: Current treatment patterns in Australia and New Zealand. A PREDICT study(WILEY, 2017-04)AIM: The aetiology and clinical course of Bell's palsy may be different in paediatric and adult patients. There is no randomised placebo controlled trial (RCT) to show effectiveness of prednisolone for Bell's palsy in children. The aim of the study was to assess current practice in paediatric Bell's 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). METHODS: A retrospective analysis of ED medical records of children less than 18 years diagnosed with Bell's palsy between 1 January, 2012 and 31 December, 2013 was performed. Potential participants were identified from ED information systems using Bell's palsy related search terms. Repeat presentations during the same illness were excluded but relapses were not. Data on presentation, diagnosis and management were entered into an online data base (REDCap). RESULTS: Three hundred and twenty-three presentations were included from 14 PREDICT sites. Mean age at presentation was 9.0 (SD 5.0) years with 184 (57.0%) females. Most (238, 73.7%) presented to ED within 72 h of symptoms, 168 (52.0%) had seen a doctor prior. In ED, 218 (67.5%) were treated with steroids. Prednisolone was usually prescribed for 9 days at around 1 mg/kg/day, with tapering in 35.7%. CONCLUSION: Treatment of Bell's palsy in children presenting to Australasian EDs is varied. Prednisolone is commonly used in Australasian EDs, despite lack of high-level paediatric evidence. The study findings confirm the feasibility of an RCT of prednisolone for Bell's palsy in children.
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ItemWalk them or no leg to stand on! Diagnostic delay of neurologic conditions in young children(WILEY-BLACKWELL, 2016-10)Diagnosis of low incidence neurological conditions can be a challenge in paediatric emergency medicine. Neurological examination in young children can be very difficult, and medical staff may not previously have encountered conditions like acute demyelinating encephalomyelitis. We propose that the simple process of walking a child (provided they were previously ambulant) is the crucial step in the neurological examination. We present three cases to demonstrate this important part of the examination.
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ItemNeonatal head injuries: A prospective Paediatric Research in Emergency Departments International Collaborative cohort study(WILEY, 2020-05)AIM: To characterise the causes, clinical characteristics and short-term outcomes of neonates who presented to paediatric emergency departments with a head injury. METHODS: Secondary analysis of a prospective data set of paediatric head injuries at 10 emergency departments in Australia and New Zealand. Patients without neuroimaging were followed up by telephone call. We extracted epidemiological information, clinical findings and outcomes in neonates (≤28 days). RESULTS: Of 20 137 children with head injuries, 93 (0.5%) occurred in neonates. These were mostly fall-related (75.2%), commonly from a care giver's arms, or due to being accidentally struck by a person/object (20.4%). There were three cases of non-accidental head injuries (3.2%). Most neonates were asymptomatic (67.7%) and many had no findings on examination (47.3%). Most neonates had a Glasgow Coma Scale 15 (89.2%) or 14 (7.5%). A total of 15.1% presented with vomiting and 5.4% were abnormally drowsy. None had experienced a loss of consciousness. The most common findings on examination were scalp haematoma (28.0%) and possible palpable skull fracture (6.5%); 8.6% underwent computed tomography brain scan and 4.3% received an ultrasound. Five of eight computed tomography scan (5.4% of neonates overall) showed traumatic brain injury and two of four (2.2% overall) had traumatic brain injury on ultrasound. Thirty-seven percent were admitted, one patient was intubated and none had neurosurgery or died. CONCLUSIONS: Neonatal head injuries are rare with a mostly benign short-term outcome and are appropriate for observation. However, non-accidental injuries need to be considered.
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ItemPaediatric abusive head trauma in the emergency department: A multicentre prospective cohort study(WILEY, 2020-04)AIM: Abusive head trauma (AHT) is associated with high morbidity and mortality. We aimed to describe characteristics of cases where clinicians suspected AHT and confirmed AHT cases and describe how they differed. METHODS: This was a planned secondary analysis of a prospective multicentre cohort study of head injured children aged <18 years across five centres in Australia and New Zealand. We identified cases of suspected AHT when emergency department clinicians raised suspicion on a clinical report form or based on research assistant-assigned epidemiology codes. Cases were categorised as AHT positive, negative and indeterminate after multidisciplinary review. Suspected and confirmed AHT and non-AHT cases were compared using odds ratios with 95% confidence intervals. RESULTS: AHT was suspected in 70 of 13 371 (0.5%) head-injured children. Of these, 23 (32.9%) were categorised AHT positive, 18 (25.7%) AHT indeterminate and 29 (27.1%) AHT negative. Median age was 0.8 years in suspected, 1.4 years in confirmed AHT and 4.1 years in non-AHT cases. Odds ratios (95% confidence interval) for presenting features and outcomes in confirmed AHT versus non-AHT were: loss of consciousness 2.8 (1.2-6.9), scalp haematoma 3.9 (1.7-9.0), seizures 12.0 (4.0-35.5), Glasgow coma scale ≤12 30.3 (11.8-78.0), abnormal neuroimaging 38.3 (16.8-87.5), intensive care admission 53.4 (21.6-132.5) and mortality 105.5 (22.2-500.4). CONCLUSIONS: Emergency department presentations of children with suspected and confirmed AHT had higher rates of loss of consciousness, scalp haematomas, seizures and low Glasgow coma scale. These cases were at increased risk of abnormal computed tomography scans, need for intensive care and death.
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ItemImaging and admission practices in paediatric head injury across emergency departments in Australia and New Zealand: A PREDICT study(WILEY, 2020-04)OBJECTIVES: Variation in the management of paediatric head injury has been identified worldwide. This prospective study describes imaging and admission practices of children presenting with head injury across 10 hospital EDs in Australia and New Zealand. METHODS: Prospective observational multicentre study of 20 137 children (under 18 years) as a planned secondary analysis of the Australasian Paediatric Head Injury Rules Study. All presentations with head injury without prior imaging were eligible for inclusion. Variations in rates of computed tomography of the brain (CTB) and admission practices between sites, ED type and country were investigated, as were clinically important traumatic brain injuries (ciTBIs) and abnormal CTBs within CTBs. RESULTS: Among the 20 137 enrolled patients, the site adjusted CTB rate was 11.2% (95% confidence interval [CI] 7.8-14.6); individual sites ranged from 2.6 to 18.6%. ciTBI was found in 0.4-2.2%, with abnormal scans documented in 0.7-6.5%. As a percentage of CTBs undertaken, ciTBIs were found in 12.8% (95% CI 10.8-14.7) with individual site variation of 8.8-16.9%, and no statistically significant difference noted, and traumatic abnormalities in 29.3% (95% CI 26.2-32.3) with individual site variation between 19.4 and 35.6%. Among those under 2 years,traumatic abnormalities were found in greater than 50% of CTBs at 90% of sites. Admission rate overall was 24.0% (site adjusted) with wide variation between sites (5.0-48.9%). CONCLUSION: Across the 10 largely tertiary EDs included in this study, the overall CTB rate was low with no significant variation between sites when adjusted for ciTBIs.
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ItemRapid Assessment, Planning, Investigations and Discharge: Piloting the introduction of a senior doctor at triage model in an Australian paediatric emergency department(WILEY, 2020-02)OBJECTIVE: We implemented a senior doctor at triage (SDT) pilot programme at The Royal Children's Hospital, Melbourne. We examined the impact on ED length of stay, seen on time and fail to wait (FTW) rates. METHODS: A SDT model was piloted on Monday and Tuesday afternoons (pilot period) for 10 weeks, and compared with equivalent shifts for the preceding 10 weeks (pre-pilot period). We determined the differences between the proportions of patients seen on time, length of stay in the ED of less than 4 h and FTW rate, as well as the medians of time to clinician and length of stay in ED. RESULTS: A total of 2736 patients presented in the pilot period, and 2889 in the pre-pilot. The percentage of patients who were seen on time improved from 52.3% to 68.7% (absolute difference 16.4%, 95% confidence interval [CI] 13.6-19.2%, P < 0.001), the percentage of patients who had an ED length of stay of <4 h improved from 58.2% to 72.0% (absolute difference 13.8%, 95% CI 11.1-16.5%, P < 0.001) and the FTW rate reduced from 12.5% to 7.1% (absolute difference 5.4%, 95% CI 3.8-7.0%, P < 0.001) when the SDT model was operational. CONCLUSION: Implementation of a SDT model in a tertiary paediatric ED resulted in an increased proportion of patients being seen on time, having shorter length of stays in the ED and reduced the number of patients who FTW. Further studies are required to determine whether these improvements are sustained over time.
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