Paediatrics (RCH) - Research Publications

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    Treatment patterns and frequency of key outcomes in acute severe asthma in children: a Paediatric Research in Emergency Departments International Collaborative (PREDICT) multicentre cohort study
    Craig, S ; Powell, CVE ; Nixon, GM ; Oakley, E ; Hort, J ; Armstrong, DS ; Ranganathan, S ; Kochar, A ; Wilson, C ; George, S ; Phillips, N ; Furyk, J ; Lawton, B ; Borland, ML ; O'Brien, S ; Neutze, J ; Lithgow, A ; Mitchell, C ; Watkins, N ; Brannigan, D ; Wood, J ; Gray, C ; Hearps, S ; Ramage, E ; Williams, A ; Lew, J ; Jones, L ; Graudins, A ; Dalziel, S ; Babl, FE (BMJ PUBLISHING GROUP, 2022-03-01)
    RATIONALE: Severe acute paediatric asthma may require treatment escalation beyond systemic corticosteroids, inhaled bronchodilators and low-flow oxygen. Current large asthma datasets report parenteral therapy only. OBJECTIVES: To identify the use and type of escalation of treatment in children presenting to hospital with acute severe asthma. METHODS: Retrospective cohort study of children with an emergency department diagnosis of asthma or wheeze at 18 Australian and New Zealand hospitals. The main outcomes were use and type of escalation treatment (defined as any of intensive care unit admission, nebulised magnesium, respiratory support or parenteral bronchodilator treatment) and hospital length of stay (LOS). MEASUREMENTS AND MAIN RESULTS: Of 14 029 children (median age 3 (IQR 1-3) years; 62.9% male), 1020 (7.3%, 95% CI 6.9% to 7.7%) had treatment escalation. Children with treatment escalation had a longer LOS (44.2 hours, IQR 27.3-63.2 hours) than children without escalation 6.7 hours, IQR 3.5-16.3 hours; p<0.001). The most common treatment escalations were respiratory support alone (400; 2.9%, 95% CI 2.6% to 3.1%), parenteral bronchodilator treatment alone (380; 2.7%, 95% CI 2.5% to 3.0%) and both respiratory support and parenteral bronchodilator treatment (209; 1.5%, 95% CI 1.3% to 1.7%). Respiratory support was predominantly nasal high-flow therapy (99.0%). The most common intravenous medication regimens were: magnesium alone (50.4%), magnesium and aminophylline (24.6%) and magnesium and salbutamol (10.0%). CONCLUSIONS: Overall, 7.3% children with acute severe asthma received some form of escalated treatment, with 4.2% receiving parenteral bronchodilators and 4.3% respiratory support. There is wide variation treatment escalation.
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    Neonatal head injuries: A prospective Paediatric Research in Emergency Departments International Collaborative cohort study
    Eapen, N ; Borland, ML ; Phillips, N ; Kochar, A ; Dalton, S ; Cheek, JA ; Gilhotra, Y ; Neutze, J ; Lyttle, MD ; Donath, S ; Crowe, L ; Dalziel, SR ; Oakley, E ; Williams, A ; Hearps, S ; Bressan, S ; Babl, FE (WILEY, 2019-12-23)
    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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    Paediatric abusive head trauma in the emergency department: A multicentre prospective cohort study
    Babl, FE ; Pfeiffer, H ; Kelly, P ; Dalziel, SR ; Oakley, E ; Borland, ML ; Kochar, A ; Dalton, S ; Cheek, JA ; Gilhotra, Y ; Furyk, J ; Lyttle, MD ; Bressan, S ; Donath, S ; Hearps, SJC ; Smith, A ; Crowe, L (WILEY, 2019-12-10)
    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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    Imaging and admission practices in paediatric head injury across emergency departments in Australia and New Zealand: A PREDICT study
    Phillips, N ; Dalziel, SR ; Borland, ML ; Dalton, S ; Lyttle, MD ; Bressan, S ; Oakley, E ; Hearps, SJC ; Kochar, A ; Furyk, J ; Cheek, JA ; Gilhotra, Y ; Neutze, J ; Babl, FE ; Phillips, N ; Dalziel, SR ; Borland, ML ; Dalton, S ; Lyttle, MD ; Bressan, S ; Oakley, E ; Hearps, SJC ; Kochar, A ; Furyk, J ; Cheek, JA ; Gilhotra, Y ; Neutze, J ; Babl, FE (WILEY, 2019-11-26)
    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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    Clinically important sport-related traumatic brain injuries in children
    Eapen, N ; Davis, GA ; Borland, ML ; Phillips, N ; Oakley, E ; Hearps, S ; Kochar, A ; Dalton, S ; Cheek, J ; Furyk, J ; Lyttle, MD ; Bressan, S ; Crowe, L ; Dalziel, S ; Tavender, E ; Babl, FE (WILEY, 2019-10-01)
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    Penetrating head injuries in children presenting to the emergency department in Australia and New Zealand: A PREDICT prospective study
    Babl, FE ; Lyttle, MD ; Bressan, S ; Borland, ML ; Phillips, N ; Kochar, A ; Dalton, S ; Cheek, JA ; Gilhotra, Y ; Furyk, J ; Neutze, J ; Donath, S ; Hearps, S ; Arpone, M ; Crowe, L ; Dalziel, SR ; Barker, R ; Oakley, E (WILEY, 2018-08-01)
    AIM: Penetrating head injuries (pHIs) are associated with high morbidity and mortality. Data on pHIs in children outside North America are limited. We describe the mechanism of injuries, neuroimaging findings, neurosurgery and mortality for pHIs in Australia and New Zealand. METHODS: This was a planned secondary analysis of a prospective observational study of children <18 years who presented with a head injury of any severity at any of 10 predominantly paediatric Australian/New Zealand emergency departments (EDs) between 2011 and 2014. We reviewed all cases where clinicians had clinically suspected pHI as well as all cases of clinically important traumatic brain injuries (death, neurosurgery, intubation >24 h, admission >2 days and abnormal computed tomography). RESULTS: Of 20 137 evaluable patients with a head injury, 21 (0.1%) were identified to have sustained a pHI. All injuries were of non-intentional nature, and there were no gunshot wounds. The mechanisms of injuries varied from falls, animal attack, motor vehicle crashes and impact with objects. Mean Glasgow Coma Scale on ED arrival was 10; 10 (48%) had a history of loss of consciousness, and 7 (33%) children were intubated pre-hospital or in the ED. Fourteen (67%) children underwent neurosurgery, two (10%) craniofacial surgery, and five (24%) were treated conservatively; four (19%) patients died. CONCLUSIONS: Paediatric pHIs are very rare in EDs in Australia and New Zealand but are associated with high morbidity and mortality. The absence of firearm-related injuries compared to North America is striking and may reflect Australian and New Zealand firearm regulations.
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    Paediatric intentional head injuries in the emergency department: A multicentre prospective cohort study
    Babl, FE ; Pfeiffer, H ; Dalziel, SR ; Oakley, E ; Anderson, V ; Borland, ML ; Phillips, N ; Kochar, A ; Dalton, S ; Cheek, JA ; Gilhotra, Y ; Furyk, J ; Neutze, J ; Lyttle, MD ; Bressan, S ; Donath, S ; Hearps, SJC ; Crowe, L (WILEY, 2019-08-01)
    OBJECTIVE: Although there is a large body of research on head injury (HI) inflicted by caregivers in young children, little is known about intentional HI in older children and inflicted HI by perpetrators other than carers. Therefore, we set out to describe epidemiology, demographics and severity of intentional HIs in childhood. METHODS: A planned secondary analysis of a prospective multicentre cohort study was conducted in 10 EDs in Australia and New Zealand, including children aged <18 years with HIs. Epidemiology codes were used to prospectively code the injuries. Demographic and clinical information including the rate of clinically important traumatic brain injury (ciTBI: HI leading to death, neurosurgery, intubation >1 day or admission ≥2 days with abnormal computed tomography [CT]) was descriptively analysed. RESULTS: Intentional injuries were identified in 372 of 20 137 (1.8%) head-injured children. Injuries were caused by caregivers (103, 27.7%), by peers (97, 26.1%), by siblings (47, 12.6%), by strangers (35, 9.4%), by persons with unknown relation to the patient (21, 5.6%), other intentional injuries (8, 2.2%) or undetermined intent (61, 16.4%). About 75.7% of victims of assault by caregivers were <2 years, whereas in other categories, only 4.9% were <2 years. Overall, 66.9% of victims were male. Rates of CT performance and abnormal CT varied: assault by caregivers 68.9%/47.6%, by peers 18.6%/27.8%, by strangers 37.1%/5.7%. ciTBI rate was 22.3% in assault by caregivers, 3.1% when caused by peers and 0.0% with other perpetrators. CONCLUSIONS: Intentional HI is infrequent in children. The most frequently identified perpetrators are caregivers and peers. Caregiver injuries are particularly severe.
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    Risk of traumatic intracranial haemorrhage in children with bleeding disorders
    Bressan, S ; Monagle, P ; Dalziel, SR ; Borland, ML ; Phillips, N ; Kochar, A ; Lyttle, MD ; Cheek, JA ; Neutze, J ; Oakley, E ; Dalton, S ; Gilhotra, Y ; Hearps, S ; Furyk, J ; Babl, FE (WILEY, 2020-08-18)
    AIM: To assess computerised tomography (CT) use and the risk of intracranial haemorrhage (ICH) in children with bleeding disorders following a head trauma. METHODS: Design: Multicentre prospective observational study. SETTING: 10 paediatric emergency departments (ED) in Australia and New Zealand. PATIENTS: Children <18 years with and without bleeding disorders assessed in ED following head trauma between April 2011 and November 2014. INTERVENTIONS: Data collection of patient characteristics, management and outcomes. MAIN OUTCOME MEASURES: Rate of CT use and frequency of ICH on CT. RESULTS: Of 20 137 patients overall, 103 (0.5%) had a congenital or acquired bleeding disorder. CT use was higher in these patients compared with children without bleeding disorders (30.1 vs. 10.4%; rate ratio 2.91 95% CI 2.16-3.91). Only one of 31 (3.2%) children who underwent CT in the ED had an ICH. This patient rapidly deteriorated in the ED on arrival and required neurosurgery. None of the patients with bleeding disorders who did not have a CT obtained in the ED or had an initial negative CT had evidence of ICH on follow up. CONCLUSIONS: Although children with a bleeding disorder and a head trauma more often received a CT scan in the ED, their risk of ICH seemed low and appeared associated with post-traumatic clinical findings. Selective CT use combined with observation may be cautiously considered in these children based on clinical presentation and severity of bleeding disorder.
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    Use of the sport concussion assessment tools in the emergency department to predict persistent post-concussive symptoms in children
    Bressan, S ; Clarke, CJ ; Anderson, V ; Takagi, M ; Hearps, SJC ; Rausa, V ; Anderson, N ; Doyle, M ; Dunne, K ; Oakley, E ; Davis, GA ; Babl, FE (WILEY, 2020-08)
    Aim The Sport Concussion Assessment Tool v3 (SCAT3) and its child version (ChildSCAT3) are composite tools including a symptom scale, a rapid cognitive assessment (standardised assessment of concussion (SAC)) and the modified Balance Error Scoring System (mBESS). It is unclear whether their use for the acute assessment of paediatric concussion in the emergency department (ED) may help predict persistent post‐concussive symptoms (PPCS). We aim to assess the predictive value of the main SCAT3/ChildSCAT3 components for PPCS when applied in the ED. Methods A single‐site, prospective longitudinal cohort study of children aged 5–18 years assessed within 48 h of their concussion at the ED of a state‐wide tertiary paediatric hospital and followed up at the affiliated concussion clinic, between November 2013 and August 2017. PPCS was defined as ≥2 new or worsening symptoms at 1 month post‐injury using the Post‐Concussive Symptom Inventory. Results Of the 370 children enrolled, 213 (57.7% <13 years old) provided complete data. Of these, 34.7% had PPCS at 1 month post‐injury (38.2% of children <13 years and 30.0% ≥13 years of age, P = 0.272). The adjusted ORs from multiple logistic regression models, for number and severity of symptoms, and for the SAC and mBESS performance in both the ChildSCAT3/SCAT3, were all not significant. The area under the curve of receiver operator characteristic curves for all analysed ChildSCAT3/SCAT3 components was below 0.6. Conclusions Although SCAT3 and ChildSCAT3 are recommended tools to assist with concussion diagnosis and monitoring of patient recovery, their use in the ED does not seem to help predict PPCS.
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    The Effect of Patient Observation on Cranial Computed Tomography Rates in Children With Minor Head Trauma
    Singh, S ; Hearps, SJC ; Borland, ML ; Dalziel, SR ; Neutze, J ; Donath, S ; Cheek, JA ; Kochar, A ; Gilhotra, Y ; Phillips, N ; Williams, A ; Lyttle, MD ; Bressan, S ; Hoch, JS ; Oakley, E ; Holmes, JF ; Kuppermann, N ; Babl, FE ; Cloutier, R (WILEY, 2020-03-26)
    BACKGROUND: Management of children with minor blunt head trauma often includes a period of observation to determine the need for cranial computed tomography (CT). Our objective was to estimate the effect of planned observation on CT use for each Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) risk group among children with minor head trauma. METHODS: This was a secondary analysis of a prospective observational study at 10 emergency departments (EDs) in Australia and New Zealand, including 18,471 children < 18 years old, presenting within 24 hours of blunt head trauma, with Glasgow Coma Scale scores of 14 to 15. The planned observation cohort was defined by those with planned observation and no immediate plan for cranial CT. The comparison cohort included the rest of the patients who were either not observed or for whom a decision to obtain a cranial CT was made immediately after ED assessment. The outcome clinically important TBI (ciTBI) was defined as death due to head trauma, neurosurgery, intubation for > 24 hours for head trauma, or hospitalization for ≥ 2 nights in association with a positive cranial CT scan. We estimated the odds of cranial CT use with planned observation, adjusting for patient characteristics, PECARN TBI risk group, history of seizure, time from injury, and hospital clustering, using a generalized linear model with mixed effects. RESULTS: The cranial CT rate in the total cohort was 8.6%, and 0.8% had ciTBI. The planned observation group had 4,945 (27%) children compared to 13,526 (73%) in the no planned observation group. Cranial CT use was significantly lower with planned observation (adjusted odds ratio [OR] = 0.2, 95% confidence interval [CI] = 0.1 to 0.1), with no difference in missed ciTBI rates. There was no difference in the odds of cranial CT use with planned observation for the group at very low risk for ciTBI (adjusted OR = 0.9, 95% CI = 0.5 to 1.4). Planned observation was associated with significantly lower cranial CT use in patients at intermediate risk (adjusted OR = 0.2, 95% CI = 0.2 to 0.3) and high risk (adjusted OR = 0.1, 95% CI = 0.0 to 0.1) for ciTBI. CONCLUSIONS: Even in a setting with low overall cranial CT rates in children with minor head trauma, planned observation was associated with decreased cranial CT use. This strategy can be safely implemented on selected patients in the PECARN intermediate- and higher-risk groups for ciTBI.