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Background During the initial phase of the Coronavirus Disease 2019 (COVID-19) pandemic, reduced numbers of acutely ill or injured children presented to emergency departments (EDs). Concerns were raised about the potential for delayed and more severe presentations and an increase in diagnoses such as diabetic ketoacidosis and mental health issues. This multinational observational study aimed to study the number of children presenting to EDs across Europe during the early COVID-19 pandemic and factors influencing this and to investigate changes in severity of illness and diagnoses. Methods and findings Routine health data were extracted retrospectively from electronic patient records of children aged 18 years and under, presenting to 38 EDs in 16 European countries for the period January 2018 to May 2020, using predefined and standardized data domains. Observed and predicted numbers of ED attendances were calculated for the period February 2020 to May 2020. Poisson models and incidence rate ratios (IRRs), using predicted counts for each site as offset to adjust for case-mix differences, were used to compare age groups, diagnoses, and outcomes. Reductions in pediatric ED attendances, hospital admissions, and high triage urgencies were seen in all participating sites. ED attendances were relatively higher in countries with lower SARS-CoV-2 prevalence (IRR 2·26, 95% CI 1·90 to 2·70, p < 0.001) and in children aged Conclusions Reductions in ED attendances were seen across Europe during the first COVID-19 lockdown period. More severely ill children continued to attend hospital more frequently compared to those with minor injuries and illnesses, although absolute numbers fell. Trial registration ISRCTN91495258 https://www.isrctn.com/ISRCTN91495258., Author(s): Ruud G. Nijman 1,2,3,*, Kate Honeyford 4, Ruth Farrugia 5, Katy Rose 1,6, Zsolt Bognar 7, Danilo Buonsenso 8,9, Liviana Da Dalt 10, Tisham De 2, Ian K. Maconochie [...]

Background: Complete avoidance of milk is the usual management for IgE‐mediated cow's milk protein allergy (CMPA). A baked milk ladder is a method of dietary advancement therapy in IgE‐mediated CMPA in Ireland, while in Spain, avoidance of milk awaiting natural tolerance acquisition through an oral food challenge (OFC) is employed. The aim of this study was to evaluate the use of dietary advancement therapy using a milk ladder compared with complete avoidance of milk for managing IgE‐mediated CMPA. Methods: This is a retrospective chart review of 371 pediatric patients from the population who have been treated for IgE‐mediated CMPA between 2011 and 2020, with the milk ladder (Ireland) or complete avoidance followed by an OFC (Spain). The main outcome was the introduction of cow's milk. Results: Milk ladder patients were 3.67 times more likely to succeed in comparison with milk avoidance (p <.001). Anaphylaxis during the treatment period occurred in 34 patients in the milk avoidance groups, while three patients in the milk ladder group experienced anaphylaxis due to accidental exposure to milk (p <.001). Failure to complete treatment was associated with a higher skin prick test in the milk avoidance group and a raised specific IgE in the milk ladder group. Conclusion: This is the first study that compares outcomes of dietary advancement therapy to complete avoidance for CMPA management, demonstrating that cow's milk can be successfully and safely reintroduced using dietary advancement therapy using a milk ladder. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To analyze the performance of commonly used blood tests in febrile infants ≤90 days of age to identify patients at low risk for invasive bacterial infection (bacterial pathogen in blood or cerebrospinal fluid) by duration of fever. METHODS: We conducted a secondary analysis of a prospective single-center registry that includes all consecutive infants #90 days of age with fever without a source evaluated at 1 pediatric emergency department between 2008 and 2021. We defined 3 groups based on caregiver-reported hours of fever (<2, 2-12, and ≥12) and analyzed the performance of the biomarkers and Pediatric Emergency Care Applied Research Network, American Academy of Pediatrics, and Step-by-Step clinical decision rules. RESULTS: We included 2411 infants; 76 (3.0%) were diagnosed with an invasive bacterial infection. The median duration of fever was 4 (interquartile range, 2-12) hours, with 633 (26.3%) patients with fever of <2 hours. The area under the curve was significantly lower in patients with <2 hours for absolute neutrophil count (0.562 vs 0.609 and 0.728) and C-reactive protein (0.568 vs 0.760 and 0.812), but not for procalcitonin (0.749 vs 0.780 and 0.773). Among well-appearing infants older than 21 days and negative urine dipstick with <2 hours of fever, procalcitonin ≥0.14 ng/mL showed a better sensitivity (100% with specificity 53.8%) than that of the combination of biomarkers of Step-by-Step (50.0% and 82.2%), and of the American Academy of Pediatrics and Pediatric Emergency Care Applied Research Network rules (83.3% and 58.3%), respectively. CONCLUSIONS: The performance of blood biomarkers, except for procalcitonin, in febrile young infants is lower in fever of very short duration, decreasing the accuracy of the clinical decision rules. [ABSTRACT FROM AUTHOR]

Febrile infants under three months of age pose a diagnostic challenge to clinicians. Unlike in older children, the rates of invasive bacterial infections (IBIs), such as bacteraemia or meningitis, are high. This greater risk of IBI combined with the practical challenges of assessing young infants results in a cautious approach with many febrile infants receiving parenteral antibiotics "just in case". However, there is a range of validated tailored care guidelines that support targeted investigation and management of febrile infants, with a cohort identified as lower risk suitable for fewer invasive procedures and observation without parenteral antibiotics. This manuscript outlines five common conundrums related to the safe application of tailored-care guidelines for the assessment and management of febrile infants under three months of age. It also explores future research which aims to further refine the management of febrile infants. [ABSTRACT FROM AUTHOR]

Purine nucleosides (adenosine) and nucleotides such as adenosine mono/di/triphosphate (AMP/ADP/ATP) may produce complex cardiovascular responses. For example, adenosine-5′-(β-thio)-diphosphate (ADPβS; a stable synthetic analogue of ADP) can induce vasodilatation/vasodepressor responses by endothelium-dependent and independent mechanisms involving purinergic P2Y receptors; however, the specific subtypes participating in these responses remain unknown. Therefore, this study investigated the receptor subtypes mediating the blood pressure changes induced by intravenous bolus of ADPβS in male Wistar rats in the absence and presence of central mechanisms with the antagonists MRS2500 (P2Y1), PSB0739 (P2Y12), and MRS2211 (P2Y13). For this purpose, 120 rats were divided into 60 anaesthetised rats and 60 pithed rats, and further subdivided into four groups (n = 30 each), namely: (a) anaesthetised rats, (b) anaesthetised rats with bilateral vagotomy, (c) pithed rats, and (d) pithed rats continuously infused (intravenously) with methoxamine (an α1-adrenergic agonist that restores systemic vascular tone). We observed, in all four groups, that the immediate decreases in diastolic blood pressure produced by ADPβS were exclusively mediated by peripheral activation of P2Y1 receptors. Nevertheless, the subsequent increases in systolic blood pressure elicited by ADPβS in pithed rats infused with methoxamine probably involved peripheral activation of P2Y1, P2Y12, and P2Y13 receptors. [ABSTRACT FROM AUTHOR]

Aim: Managing febrile infants has evolved without a generally accepted standard of care. We aimed to design quality indicators for managing infants ≤90 days old presenting to emergency departments (EDs) with fever without source. Methods: This multicentre Delphi study was carried out by the Febrile Infant Study Group of the Spanish Paediatric Emergency Research Network, from March 2021 to November 2021, and included paediatric emergency physicians from 24 Spanish EDs. A list of care standards was produced, following an extensive literature review and the involvement of all parties. Indicators were essential if they were voted by four panelists and also received a score of ≥4 from at least 95% of the 24 investigators. Results: We established 20 indicators, including one related to having a protocol, two to triage, nine to diagnostic processes, six to treatment and two to disposition. The following indicators were considered essential: having an ED management protocol, performing urinalysis on every infant, obtaining a blood culture from every infant and administering antibiotics in the ED to any febrile infant who did not appear well. Conclusion: The Delphi method resulted in a comprehensive list of quality indicators for managing febrile young infants in Spanish EDs. [ABSTRACT FROM AUTHOR]

Background: Anaphylaxis is rising in prevalence among children. The current recommendations on the effective transition of anaphylaxis management to adolescents and young adults suggest preparation for the transition may be considered at 11–13 years of age in accordance with the patient's developmental stage. However, there has been limited research conducted on the perspective of caregivers regarding the transition of anaphylaxis management to their children. This study aims to determine the age caregivers feel it is appropriate to begin to teach their child to recognize anaphylaxis and use their adrenaline auto‐injectors (AAI). Methods: Caregivers of pediatric allergy patients who have been diagnosed with IgE‐mediated food allergy and have an AAI prescription were contacted by phone and invited to complete a questionnaire about when they feel it is appropriate to begin to teach their child to recognize anaphylaxis and use their AAI. Results: Of the 123 responses to the questionnaire received, 44.7% indicated that 9–11 years was the appropriate time for teaching their children to self‐inject an AAI. History of severe anaphylaxis (94.3%), child's ability to describe reasons to inject adrenaline (87.8%), and demonstrate AAI use (82.1%) were "very important" readiness factors identified. Almost half of caregivers were "not confident" (8.94%) or "somewhat confident" (40.65%) in training their child to use AAI. Caregivers with higher household incomes more frequently identified themselves as the party responsible for training their children to use AAI (p =.04). Conclusion: Caregivers in this sample expressed different perspectives than the current guidelines regarding the timing to initiate the transition of anaphylaxis management to their child. Caregivers expressed suboptimal confidence in teaching their children to use AAI. Clinicians should be aware of the factors that may indicate caregivers' desire to initiate an earlier transition of anaphylaxis management to their child and ensure access to appropriate training, education and support is available. [ABSTRACT FROM AUTHOR]

A study published in the journal Clinical & Experimental Allergy examined the safety and effectiveness of a milk ladder for managing children with IgE-mediated milk allergy. The study found that 87% of infants with milk allergy successfully introduced milk using a home milk ladder. While allergic reactions were common, cases of anaphylaxis were triggered by accidental milk exposures, not the milk ladder itself. The study provides evidence for the efficacy and safety of the milk ladder in managing milk allergy in young children. However, it is important to note that no management strategy is without risk, and families should be informed of the potential benefits and risks of using a milk ladder. [Extracted from the article]

This document is a reply to a correspondence regarding a study on the management of cow's milk protein allergy in pediatric cohorts. The authors express gratitude for the correspondence and discuss the use of milk ladders in the Irish population as a treatment pathway. They emphasize the importance of involving parents in the home-based reintroduction of milk-containing foods and note that either preparing the food at home or using processed food with milk protein is acceptable. The authors acknowledge the limitations of their retrospective study and agree that a prospective study with randomization is needed to address questions about the effectiveness of milk ladder therapy. They also mention the need for long-term follow-up and respond to suggestions for subgroup analysis and age-specific initiation of milk oral immunotherapy. The authors conclude by stating that ladder-based dietary advancement therapy is a valuable tool that can coexist with other dietary advancement methods, and they acknowledge the importance of conducting definitive studies with oral food challenges and immunologic measurements to properly define tolerance. The document includes the contributions of the authors and a statement declaring no conflicts of interest. [Extracted from the article]

IgE-mediated cow's milk protein allergy (CMPA) is one of the most prevalent food allergies in early childhood. Though the cornerstone of management involves the strict avoidance of milk products while awaiting natural tolerance, research increasingly shows that the rates of resolution are slowing down. Therefore, there is a need to explore alternative pathways to promote tolerance to cow's milk in pediatric populations. This review aims to combine and appraise the scientific literature regarding the three CMPA management methods: avoidance, the milk ladder, and oral immunotherapy (OIT) and their outcomes in terms of efficacy, safety, and immunological effects. Cow's milk (CM) avoidance virtually protects against allergic reaction until natural tolerance occurs, with hypoallergenic substitutes available in the market, but accidental ingestion represents the main issue for this strategy. Introduction to baked milk using the milk ladder was designed, with most CMPA patients successfully completing the ladder. Similar to baked milk treatment, many OIT protocols also demonstrated decreased IgE and increased IgG4 levels post protocol, as well as a reduction in wheal size diameter. Though these strategies are shown to be safe and effective in CMPA, future clinical trials should compare the safety and effectiveness of these three management strategies. [ABSTRACT FROM AUTHOR]

Patients diagnosed with IgE-mediated CMPA between 2015 and 2021 who were treated with the iMAP milk ladder in a tertiary paediatric allergy clinic and in a local PC clinic in Ireland were included. Primary care as a setting for introducing milk using the milk ladder in children with IgE-mediated cow's milk protein allergy 2023; 15 (6): 1397. https://doi.org/10.3390/nu15061397 5 Ball HB, Luyt D. Home-based cow's milk reintroduction using a milk ladder in children less than 3 years old with IgE-mediated cow's milk allergy. [Extracted from the article]

Objective: To 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).Design: Secondary analysis of a prospective registry.Setting: Paediatric emergency department of a tertiary teaching hospital.Patients: Infants ≤60 days old with FWS between 2007 and 2018.Main Outcome Measures: Prevalence of serious bacterial infection (SBI) and invasive bacterial infection (IBI) in low-risk infants according to the PECARN rule.Results: Among 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).Conclusions: The 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. [ABSTRACT FROM AUTHOR]

Aim: This study analysed the association between a positive nitrite dipstick test and an invasive bacterial infection (IBI) in infants younger than 90 days of age with fever without source (FWS).Methods: We performed a secondary analysis of data from a prospective multicentre study of infants up to 90 days of age with FWS undergoing care in 19 paediatric EDs between October 2011 and September 2013. Invasive bacterial infection was defined as a positive blood or cerebrospinal fluid culture.Results: The dipstick urinalysis was positive for nitrite or leucocyte esterase in 766 (22.5%) of the 3401 infants we studied, and 270 (35.2%) had a dipstick test that was just positive for nitrite. Overall, 107 were diagnosed with an IBI (3.1%). The IBI prevalence was 2.2% among patients with a normal urine dipstick, 4.4% if they had positive leucocyte esterase test results, 8.3% where the nitrite test was positive and 10.6% when both tests were positive. After multivariate analysis, a positive nitrite test remained an independent risk factor for IBI (odds ratio 2.7, 95% confidence interval 1.4-4.9).Conclusion: In infants under 90 days of age with FWS, a positive nitrite urine dipstick test was an independent risk factor for IBI. [ABSTRACT FROM AUTHOR]

In conclusion, the blood culture extraction protocol proposed by several Spanish paediatric scientific societies seems effective, since greater adherence to it was associated with a lower rate of blood culture contamination. Patients with antibiotic treatment in the previous 7 days, those from whom the blood culture was obtained from any indwelling catheter, those whose blood culture result was missed and those whose parents or caregivers refused to participate were excluded. Abbreviations ED emergency department IQR interquartile range SD standard deviation The Clinical and Laboratory Standards Institute set the national benchmark for blood culture contamination at 3%.[1] Several interventions to avoid blood culture contamination have been reported to be effective. [Extracted from the article]

Background: Acute severe childhood asthma is an infrequent, but potentially life-threatening emergency condition. There is a wide range of different approaches to this condition, with very little supporting evidence, leading to significant variation in practice. To improve knowledge in this area, there must first be consensus on how to conduct clinical trials, so that valid comparisons can be made between future studies. We have formed an international working group comprising paediatricians and emergency physicians from North America, Europe, Asia, the Middle East, Africa, South America, Central America, Australasia and the United Kingdom.Methods/design: A 5-stage approach will be used: (1) a comprehensive list of outcomes relevant to stakeholders will be compiled through systematic reviews and qualitative interviews with patients, families, and clinicians; (2) Delphi methodology will be applied to reduce the comprehensive list to a core outcome set; (3) we will review current clinical practice guidelines, existing clinical trials, and literature on bedside assessment of asthma severity. We will then identify practice differences in tne clinical assessment of asthma severity, and determine whether further prospective work is needed to achieve agreement on inclusion criteria for clinical trials in acute paediatric asthma in the emergency department (ED) setting; (4) a retrospective chart review in Australia and New Zealand will identify the incidence of serious clinical complications such as intubation, ICU admission, and death in children hospitalized with acute severe asthma. Understanding the incidence of such outcomes will allow us to understand how common (and therefore how feasible) particular outcomes are in asthma in the ED setting; and finally (5) a meeting of the Pediatric Emergency Research Networks (PERN) asthma working group will be held, with invitation of other clinicians interested in acute asthma research, and patients/families. The group will be asked to achieve consensus on a core set of outcomes and to make recommendations for the conduct of clinical trials in acute severe asthma. If this is not possible, the group will agree on a series of prioritized steps to achieve this aim.Discussion: The development of an international consensus on core outcomes is an important first step towards the development of consensus guidelines and standardised protocols for randomized controlled trials (RCTs) in this population. This will enable us to better interpret and compare future studies, reduce risks of study heterogeneity and outcome reporting bias, and improve the evidence base for the management of this important condition. [ABSTRACT FROM AUTHOR]

Abstract: Aim: This study determined if blood levels of beta‐hydroxybutyrate were associated with the rate of failure in oral rehydration in paediatric patients with vomiting. Methods: This was a prospective observational study that was carried out from December 1, 2015 to November 30, 2016 in the Rio Hortega University Hospital, Valladolid, Spain. The study cohort were patients up to 14 years old who attended the emergency department with three or more vomiting episodes in the last four hours and glycaemia higher than 45 mg/dL. Blood was measured for beta‐hydroxybutyrate levels prior to the administration of oral rehydration solution for 90 minutes. Two or more vomiting episodes during this period were considered failed oral rehydration. Results: We analysed 248 patients, with a median age of four years and 7.5 months and 233 (94%) of the parents took part. The median number of vomiting episodes in the previous four hours was five and oral rehydration was successful in 183 (78.5%) patients. The multivariate analysis showed that the initial beta‐hydroxybutyrate blood level was not associated with the failure of oral rehydration. Conclusion: Blood levels of beta‐hydroxybutyrate had no predictive value for oral rehydration failure in young patients with vomiting and this routine measurement is unnecessary. [ABSTRACT FROM AUTHOR]

The genus Acacia spp belongs to the family Leguminosae, with more than 1300 species distributed naturally in all continents except Europe. In Mexico there are 85 species, of which 46 are endemic, most located in arid and semiarid regions, being Acacia coulteri and Acacia farnesiana the most widely distributed. The aim of this study was to determine the technological characteristics of the wood of Acacia schaffneri. To determine the anatomical characteristics, the methodology of Autonomous Chapingo University's wood anatomy laboratory was used; for the physical properties, standards NOM EE-117-1981 and NMX-EE-167-1983 were used, and in calculating the mechanical properties the mathematical formulas were employed. The wood is reddish brown and has interlocked grain with diffuse porosity, aliform confluent parenchyma and in confluent bands, and crystals and gums. The proportion of cells was 11,87% vessel elements, 50,65% fibers 27,76% axial parenchyma and 9,81% ray parenchyma. Basic density was 880 kg/m³, tangential, radial, axial and volumetric shrinkage values were 10,57%; 4,97%; 0,10% and 15,82 % respectively, and fiber saturation point was 19,97%. The mechanical properties were very high, so it can be used in the manufacture of floors and in building constructions. [ABSTRACT FROM AUTHOR]

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