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Aim: To understand and evaluate the uptake and local adaptations of proven targeted implementation interventions that have effectively reduced unnecessary investigations and therapies in infants with bronchiolitis within emergency departments. Methods: A multi‐centred, mixed‐methods quality improvement study in four Australian hospitals that provide paediatric emergency and inpatient care from May to December 2021. All hospitals were provided with the same implementation intervention package and training. Real‐time tracking logs of adaptions were completed followed by semi‐structured interviews. Interviews were recorded, transcribed and subsequently coded using FRAME‐IS to further describe the adaptions made. Results: Tracking logs were summarised and data from 12 interviews were compared from participating sites. The intervention resulted in 116 education sessions and a total of 23 adaptations made to educational materials, both content and contextual. Shortening education presentations, addition of bronchiolitis definitions, formatting of materials and novel interventions were the most common modifications. Audit and feedback were completed across all sites with varying utilisation. Targeted teaching was noted to dictate adaptions prior to and during implementation. Conclusion: Quantitative and qualitative analysis of clinical 'real‐world' adaptations to proven targeted implementation interventions allows invaluable insight for future de‐implementation initiatives and national roll‐out of implementation packages in the ED setting. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the impact of locally adapted targeted implementation interventions on bronchiolitis management through reduction in ineffective investigation and therapies within emergency departments. Methods: A multi‐centred, quality improvement study in four different grades of hospitals in Western Australia that provide paediatric emergency and inpatient care. All hospitals incorporated an adapted implementation intervention package for infants under 1 year with bronchiolitis. The proportion whose care complied with guideline recommendations to not receive investigations and therapies of minimal benefit were compared to pre‐intervention care in a previous bronchiolitis season. Results: A total of 457 infants in 2019 (pre‐intervention) and 443 in 2021 (post‐intervention) were included, with mean age of 5.6 months (SD 3.2, 2019; SD 3.0, 2021). In 2019, compliance was 78.1% versus 85.6% in 2021, RD 7.4 (95% CI −0.6; 15.5). The strongest evidence was reduced salbutamol use (compliance improvement: 88.6% to 95.7%, RD 7.1 95% CI (1.7; 12.4)). Hospitals initially at <80% compliance demonstrated greatest improvements (Hospital 2: 95 (78.5%) to 108 (90.8%) RD 12.2 95% CI (3.3; 21.2); Hospital 3: 67 (62.6%) to 63 (76.8%) RD 14.2 95% CI (1.3; 27.2)). Conclusion: Targeted site‐adapted implementation interventions resulted in improvement in compliance with guideline recommendations, particularly for those hospitals with initial low compliance. Maximising benefits through guidance on how to adapt and effectively use interventions will enhance sustainable practice change. [ABSTRACT FROM AUTHOR]

Objectives: To assess (i) paediatric fever management practices among New Zealand ED doctors and nurses, including adherence to best practice guidelines; and (ii) the acceptability of a randomised controlled trial (RCT) of antipyretics for relief of discomfort in young children. Methods: A cross‐sectional survey of doctors and nurses across 11 New Zealand EDs. The primary outcome of adherence to paediatric fever management best practice guidelines was assessed with clinical vignettes and defined as single antipyretic use for the relief of fever‐related discomfort. Results: Out of 602 participants (243 doctors, 353 nurses and six unknown; response rate 47.5%), only 64 (10.6%, 95% confidence interval [CI] 8.3–13.4%) demonstrated adherence to best practice guidelines. In a febrile settled child with normal fluid intake, the percentage of participants that would use antipyretics doubled with abnormal vital signs (33.7% vs 72.9%, difference −39.2%, 95% CI –44.4% to −34.0%). Most participants would use antipyretics for reduced fluid intake (n = 494, 82.1%, 95% CI 78.8–85.0%) in a febrile settled child. Over half (n = 339, 57.1%, 95% CI 53.0–61.1%) would advise giving antipyretics to prevent febrile convulsions. Most (n = 467, 80.0%, 95% CI 76.5–83.1%) participants agreed that a RCT of antipyretics in febrile children <2 years of age with relief of discomfort as a primary outcome is needed. Conclusions: Just over 10% of New Zealand ED doctors and nurses demonstrated adherence to paediatric fever management best practice guidelines. A RCT of antipyretics in febrile children <2 years of age specifically addressing relief of discomfort as a primary outcome is strongly supported. [ABSTRACT FROM AUTHOR]

Objective: Paediatric status epilepticus (SE) has potential for long‐term sequelae. Existing data demonstrate delays to aspects of care. The objective of the present study was to examine the feasibility of collecting data on children with paediatric SE and describe current management strategies in pre‐hospital and in‐hospital settings. Methods: A pilot, prospective, observational cohort study of children 4 weeks to 16 years of age with SE, in four EDs in Australia. Clinical details including medications administered, duration of seizure and short‐term outcomes were collected. Follow up occurred by telephone at 1 month. Results: We enrolled 167 children with SE. Mean age was 5.4 years (standard deviation [SD] 4.1), and 81 (49%) male. Median seizure duration was 10 min (interquartile range 7–30). Midazolam was the first medication administered in 87/100 (87%) instances, mean dose of 0.21 mg/kg (SD 0.13). The dose of midazolam was adequate in 30 (35%), high (>0.2 mg/kg) in 44 (51%) and low (<0.1 mg/kg) in 13 (15%). For second‐line agents, levetiracetam was administered on 33/55 (60%) occasions, whereas phenytoin and phenobarbitone were administered on 11/55 (20%) occasions each. Mean dose of levetiracetam was 26.4 mg/kg (SD 13.5). One hundred and four (62%) patients were admitted to hospital, with 13 (8%) admitted to ICU and seven (4%) intubated. Conclusion: In children presenting with SE in Australia medical management differed from previous reports, with midazolam as the preferred benzodiazepine, and levetiracetam replacing phenytoin as the preferred second‐line agent. This pilot study indicates the feasibility of a paediatric SE registry and its utility to understand and optimise practice. [ABSTRACT FROM AUTHOR]

Aim: To explore factors influencing fever management practices and antipyretic use among New Zealand Emergency Department (ED) doctors and nurses using the Theoretical Domains Framework (TDF).Methods: Cross-sectional survey of doctors and nurses across 11 New Zealand EDs. The questionnaire examined eight of 12 TDF domains, based on a generic questionnaire validated to assess TDF-based determinants of health-care professional behaviour. Relevant domains were identified by the frequency of beliefs; the presence of conflicting beliefs within a domain; and the likely strength of impact of a belief on paediatric fever management in the ED.Results: About 602 participants (243 doctors, 353 nurses and 6 unknown) completed the survey (response rate 47.5%). Over half (351/591, 59.6%, 95% confidence interval (CI) 55.5-63.5%) knew the content of clinical practice guidelines regarding antipyretic use in febrile children (TDF Domain Knowledge), or had been trained to ensure antipyretics are given to febrile children only if they appear distressed (347/592, 58.6%, 95% CI 54.5-62.6%) (Skills). Over 40% (246/590, 95% CI 37.7-45.8%) aim to reduce the fever before discharge (Goals). Most (444/591, 75.1%, 95% CI 71.4-78.6%) participants felt capable of explaining appropriate antipyretic use to parents/care givers (Beliefs about Capabilities). Only a minority (155/584, 26.5%, 95% CI 23.0-30.3%) thought that they can ensure antipyretics are given to febrile children only if they appear distressed when the ED is busy (Environmental Context and Resources).Conclusions: Using the TDF, we identified factors influencing fever management practices and antipyretic use in the ED. These factors can guide the design of targeted, theory-informed knowledge translation strategies. [ABSTRACT FROM AUTHOR]

OBJECTIVE: We sought to determine if corticosteroid administration is associated with a SARS-CoV-2 nucleic acid test-positive result and to describe therapies administered to SARS- CoV-2 infected children. METHODS: We collected cross-sectional data from participants recruited in 41 pediatric emergency departments (ED) in 10 countries between March 2020 and June 2021. Participants were <18 years old, had signs or symptoms of, or risk factors for acute SARS-CoV-2 infection, and had nucleic acid testing performed. To determine if SARS-CoV-2 test status was independently associated with corticosteroid administration, we used a multivariable conditional logistic regression model matched by study site to compare treatments administered based on SARS-CoV-2 test and disposition status. This analysis was repeated for the subgroup of study participants who were hospitalized. RESULTS: 30.3% (3,121/10,315) of participants were SARS- CoV-2-positive. Although remdesivir was more commonly administered to SARS-CoV-2-positive children, use was infrequent (25/3120 [0.8%] vs 1/7188 [0.01%]; P = .001). Corticosteroid use was less common among SARS-CoV-2-positive children (219/3120 [7.0%] vs 759/7190 [10.6%]; P < .001). Among hospitalized children, there were no differences in provision of inotropes, respiratory support, chest drainage or extracorporeal membrane oxygenation between groups. Corticosteroid administration was associated with age, history of asthma, wheezing, study month, hospitalization and intensive care unit admission; it was not associated with a positive SARS-CoV-2 test result overall (aOR: 0.91; 95%CI: 0.74, 1.12) or among the subgroup of those hospitalized (aOR: 1.04; 95%C1: 0.75, 1.44). CONCLUSIONS: Few disease-specific treatments are provided to SARS-CoV-2-positive children; clinical trials evaluating therapies in children are urgently needed. [ABSTRACT FROM AUTHOR]

Aim: This study aimed to determine whether targeted interventions, proven to be effective at improving evidence‐based bronchiolitis management, changed factors previously found to influence variation in bronchiolitis management. Methods: This survey assessed change in factors influencing clinicians' (nurses and doctors) bronchiolitis management at baseline and post‐intervention in a cluster randomised controlled trial of targeted, theory‐informed interventions aiming to de‐implement non‐evidence‐based bronchiolitis management (no use of chest X‐ray, salbutamol, antibiotics, glucocorticoids and adrenaline). Survey questions addressed previously identified factors influencing bronchiolitis management from six Theoretical Domains Framework domains (knowledge; skills; beliefs about consequences; social/professional role and identity; environmental context and resources; social influences). Data analysis was descriptive. Results: A total of 1958 surveys (baseline = 996; post‐intervention = 962) were completed by clinicians from the emergency department and paediatric inpatient units from 26 hospitals (intervention = 13; control = 13). Targeted bronchiolitis interventions significantly increased knowledge of the Australasian Bronchiolitis Guideline (intervention clinicians = 74%, control = 39%, difference = 34.7%, 95% confidence interval (CI) = 25.6–43.8%), improved skills in diagnosing (intervention doctors = 89%, control = 76%, difference = 12.6%, 95% CI = 6.2–19%) and managing bronchiolitis (intervention doctors = 87%, control = 76%, difference = 9.9%, 95% CI = 3.7–16.1%), positively influenced both beliefs about consequences regarding salbutamol use (intervention clinicians = 49%, control = 29%, difference = 20.3%, 95% CI = 13.2–27.4%) and nurses questioning non‐evidence‐based bronchiolitis management (chest X‐ray: intervention = 71%, control = 51%, difference = 20.8%, 95% CI = 11.4–30.2%; glucocorticoids: intervention = 64%, control = 40%, difference = 21.9%, 95% CI = 10.4–33.5%) (social/professional role and identity). A 14% improvement in evidence‐based bronchiolitis management favouring intervention hospitals was demonstrated in the cluster randomised controlled trial. Conclusion: Targeted interventions positively changed factors influencing bronchiolitis management resulting in improved evidence‐based bronchiolitis care. This study has important implications for improving bronchiolitis management and future development of interventions to de‐implement low‐value care. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Decreasing unnecessary cranial computed tomography (CT) use in pediatric head trauma patients remains important for emergency departments (EDs) across the US. Our study evaluated CT use in children with minor blunt head trauma in 21 community EDs within an integrated health-care system. METHODS: We studied all children younger than 18 years old presenting to 21 community EDs between 2016 through 2018 with acute minor blunt head trauma, defined by an algorithm of ED chief complaints and diagnoses. We excluded patients with traumatic brain injuries diagnosed in the prior year, a CT within 24 hours prior to the ED visit, or an ED Glasgow Coma Scale score of less than 14. RESULTS: Among 39,792 pediatric minor head trauma ED visits, the aggregate CT use proportion across all EDs was 12.9% [95% confidence interval (CI), 12.6-13.3%; facility-level range, 5.4-21.6%]. The 7 facilities that had previously received a clinical decision support system intervention implementing the Pediatric Emergency Care Applied Research Network rules during 2013 through 2014 had an aggregate mean CT ordering rate of 11.2% (95% CI, 10.7-11.7%; facility-level range, 5.4-14.3%) compared to 14.1% (95% CI, 13.6-14.5%; facility-level range, 7.3-21.6%) for the nonintervention facilities. CONCLUSION: CT use for children with minor blunt head trauma in the community EDs of an integrated health-care system was low and stable across facilities from 2016 through 2018. This may be indicative of the safe stewardship of resources in the system, including the absence of financial or medicolegal incentives to scan very low-risk patients as well the availability of resources for close patient follow-up. [ABSTRACT FROM AUTHOR]

Objective: To determine the prevalence of fever phobia among caregivers of children presenting to New Zealand EDs. Methods: A cross‐sectional survey was administered to caregivers of children <5 years of age presenting to three New Zealand EDs. We defined fever phobia as caregivers having a high level of concern regarding fever or having incorrect beliefs regarding the consequences of fever. Results: A total of 502 caregivers completed the survey. Fever phobia was present in 365 (74.3% [95% confidence interval, CI 70.3–78.0%]) respondents, with 242 (49.3% [95% CI 44.9–53.7%]) caregivers reporting a high level of concern regarding fever, and 288 (61.8% [95% CI 57.3–66.1%]) caregivers reporting at least one incorrect belief regarding the consequences of fever. Majority of caregivers (n = 383, 87.6% [95% CI 84.2–90.4%]) knew the correct dosing interval for paracetamol, compared to less than half of caregivers (n = 179, 42.5% [95% CI 37.9–47.3%]) for ibuprofen. Caregivers reported non‐evidence‐based fever management practices such as sponging, always giving paracetamol and/or ibuprofen for fever, and waking children from sleep to give antipyretics. Over one‐third of caregivers identified ED doctors (n = 195, 40.2% [95% CI 34.7–43.2%]) and ED nurses (n = 173, 35.7% [95% CI 31.5–40.0%]) as sources of information regarding fever management. A higher level of education was associated with fever phobia (odds ratio 1.68 [95% CI 1.04–2.72], P = 0.04). Conclusions: Fever phobia is prevalent among caregivers of children presenting to New Zealand EDs. Opportunistic caregiver education in the ED in conjunction with public health strategies are needed to dispel undue fears and misconceptions about fever. [ABSTRACT FROM AUTHOR]

Objectives: The Pediatric Emergency Research Network (PERN) was launched in 2009 with the intent for existing national and regional research networks in paediatric emergency care to organise globally for the conduct of collaborative research across networks. Methods: PERN has grown from five to eight member networks over the past decade. With an executive committee comprising representatives from all member networks, PERN plays a supportive and collaborative rather than governing role. The full impact of PERN's facilitation of international collaborative research, although somewhat difficult to quantify empirically, can be measured indirectly by the observed growth of the field, the nature of the increasingly challenging research questions now being addressed and the collective capacity to generate and implement new knowledge in treating acutely ill and injured children. Results: Beginning as a pandemic response studying H1N1 influenza risk factors in children, PERN research has progressed to multiple observational studies and ongoing global randomised controlled trials (RCTs). As a recent example, PERN has developed sufficient network infrastructure to enable the rapid initiation of a prospective observational study in response to the current COVID‐19 pandemic. Conclusions: Following its success with developing global research, the PERN goal now is to promote the implementation of scientific advances into everyday clinical practice by: (i) expanding the capacity for global RCTs; (ii) deepening the focus on implementation science; (iii) increasing attention to healthcare disparities; and (iv) expanding PERN's reach into resource‐restricted regions. Through these actions, PERN aims to meet the needs of acutely ill and injured children throughout the world. [ABSTRACT FROM AUTHOR]

Objective: To determine if administration of oral prednisolone to preschool children with acute wheeze alters respiratory outcomes.Design: Double-blind, randomised, placebo-controlled equivalence trial.Setting: Three hospitals in New Zealand.Patients: 477 children aged 24-59 months with acute wheeze associated with respiratory illness.Interventions: 2 mg/kg (maximum 40 mg) oral prednisolone or similar placebo, once daily for 3 days.Main Outcome Measures: Primary outcome was change in Preschool Respiratory Assessment Measure (PRAM) score 24 hours after intervention. Secondary outcomes included PRAM score at 4 hours, length of emergency department and inpatient stays, admission and representation rates, time to return to normal activities and use of additional oral prednisolone or intravenous medications. Analysis was by intention-to-treat.Results: There was no difference between groups for change in PRAM score at 24 hours (difference between means -0.39, 95% CI -0.84 to 0.06, p=0.09). Absolute PRAM score was lower in the prednisolone group at 4 hours (median (IQR) 1 (0-2) vs 2 (0-3), p=0.01) and 24 hours (0 (0-1) vs 0 (0-1), p=0.01), when symptoms had resolved for most children regardless of initial treatment. Admission rate, requirement for additional oral prednisolone and use of intravenous medication were lower in the prednisolone group, although there were no differences between groups for time taken to return to normal activities or rates of representation within 7 days.Conclusion: Oral prednisolone does not alter respiratory outcomes at 24 hours or beyond in preschool children presenting with acute wheeze. [ABSTRACT FROM AUTHOR]

Objective: Intubation of children in the emergency setting is a high‐risk, low incidence event. Standardisation of clinical practice has been hampered by a lack of high‐quality evidence to support one technique over another. The aim of the present study is to determine clinician preference in intubation practice of children in EDs and ICUs in Australia and New Zealand to provide baseline information to allow future targeted research focused on improving the safety and efficacy of paediatric emergency airway management. Methods: The present study was a voluntary questionnaire undertaken by medical staff at registrar level or above in EDs and ICUs associated with the Paediatric Research in Emergency Departments International Collaborative (PREDICT) and Australia and New Zealand Intensive Care Society Paediatric Study Group (ANZICS PSG) research networks. Respondents reported on their individual intubation practices, with a focus on pre‐oxygenation and apnoeic oxygenation techniques, and the use of video laryngoscopy. Results: A total of 502 clinicians were invited to complete the survey between May and October 2018 with 336 (66.9%) responded. There was marked variation in practice between ED clinicians and ICU clinicians in the techniques used for pre‐oxygenation, the frequency of use of apnoeic oxygenation and the reported use of video laryngoscopy. Conclusions: Within Australia and New Zealand there is considerable variation in paediatric emergency airway clinical practice, in particular with respect to pre‐oxygenation, apnoeic oxygenation and use of video laryngoscopy. Definitive clinical trials are required to best inform clinical practice in this area. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Multicentre research provides advantages over single-centre research by maximising available patient numbers while pooling varied expertise and resources available across different participating investigators and sites. The increased complexity of multicentre regulatory approvals, communication and study management, can be mitigated by the formation of a research network where multicentre efforts move from ad hoc, single projects to formalised ongoing collaboration. Network research helps prioritise research efforts and importantly fosters the development of a collaborative track record in terms of research expertise, research capacity and grant success. It also has the potential to rapidly change patient care across many hospitals as research results will be more generalizable and definitive. This paper sets out the key elements of network research, its benefits and possible challenges drawing on the example of PREDICT (Paediatric Research in Emergency Departments International Collaborative) an established paediatric emergency research network in Australia and New Zealand. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Bronchiolitis is the most common reason for infants to be hospitalised. Over the past decade, the use of high-flow nasal cannulae (HFNC) therapy has increased markedly and it is now utilised not only in the intensive care unit setting but in general paediatric wards and emergency departments. The aim of this systematic review was to summarise and critique the current evidence-base for the use of HFNC in infants with bronchiolitis. We searched Ovid Medline, OvidEmbase, PubMed, Cinahl, Cochrane Library, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials for systematic reviews and randomised controlled trials of HFNC therapy in infants with bronchiolitis from 1 January 2000 to 27 June 2018. We identified four randomised controlled trials (n = 1891) of HFNC in infants with bronchiolitis: three of these studies involved infants treated in emergency departments and inpatient paediatric wards in Spain, Australia and New Zealand, and one study involved infants treated in paediatric intensive care units in France. The findings of this review suggest that HFNC should be used as a rescue treatment for hypoxaemic infants who have not responded to standard sub nasal oxygen therapy. The use of HFNC for work of breathing in the absence of hypoxaemia, and severe disease, is not currently supported by the evidence, and should only be considered in the context of an appropriate research trial. [ABSTRACT FROM AUTHOR]

The article discusses the Paediatric Research in Emergency Departments International Collaborative, has an Australian and New Zealand network of EDs with a mission to generate new knowledge and improve emergency care for children. Topics include why not use existing high-quality international guidelines; and knowledge translation includes adaption of knowledge to local context via guidelines.

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. [ABSTRACT FROM AUTHOR]

Background: Convulsive 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/design: 200 children aged between 3 months and 16 years 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 40 mg/kg IV levetiracetam infusion over 5 min or 20 mg/kg IV phenytoin infusion over 20 min. 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.Discussion: This 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 Registration: Prospectively 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). [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: International patterns of antibiotic use and laboratory testing in bronchiolitis in emergency departments are unknown. Our objective is to evaluate variation in the use of antibiotics and nonindicated tests in infants with bronchiolitis in 38 emergency departments in Pediatric Emergency Research Networks in Canada, the United States, Australia and New Zealand, the United Kingdom and Ireland, and Spain and Portugal. We hypothesized there would be significant variation, adjusted for patient characteristics. METHODS: We analyzed a retrospective cohort study of previously healthy infants aged 2 to 12 months with bronchiolitis. Variables examined included network, poor feeding, dehydration, nasal flaring, chest retractions, apnea, saturation, respiratory rate, fever, and suspected bacterial infection. Outcomes included systemic antibiotic administration and urine, blood, or viral testing or chest radiography (CXR). RESULTS: In total, 180 of 2359 (7.6%) infants received antibiotics, ranging from 3.5% in the United Kingdom and Ireland to 11.1% in the United States. CXR (adjusted odds ratio [aOR] 2.3; 95% confidence interval 1.6-3.2), apnea (aOR 2.2; 1.1-3.5), and fever (aOR 2.4; 1.7-3.4) were associated with antibiotic use, which did not vary across networks (P = .15). In total, 768 of 2359 infants (32.6%) had ≥1 nonindicated test, ranging from 12.7% in the United Kingdom and Ireland to 50% in Spain and Portugal. Compared to the United Kingdom and Ireland, the aOR (confidence interval) results for testing were Canada 5.75 (2.24-14.76), United States 4.14 (1.70-10.10), Australia and New Zealand 2.25 (0.86-5.74), and Spain and Portugal 3.96 (0.96-16.36). Testing varied across networks (P < .0001) and was associated with suspected bacterial infections (aOR 2.12; 1.30-2.39) and most respiratory distress parameters. Viral testing (591 of 768 [77%]) and CXR (507 of 768 [66%]) were obtained most frequently. CONCLUSIONS: The rate of antibiotic use in bronchiolitis was low across networks and was associated with CXR, fever, and apnea. Nonindicated testing was common outside of the United Kingdom and Ireland and varied across networks irrespective of patient characteristics. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Early risk stratification of infants with bronchiolitis receiving airway support is critical for focusing appropriate therapies, yet the tools to risk categorize this subpopulation do not exist. Our objective was to identify predictors of "escalated care" in bronchiolitis. We hypothesized there would be a significant association between escalated care and predictors in the emergency department. We subsequently developed a risk score for escalated care. METHODS: We conducted a retrospective cohort study of previously healthy infants aged <12 months with bronchiolitis. Our primary outcome was escalated care (ie, hospitalization with high-flow nasal cannula, noninvasive or invasive ventilation, or intensive care admission). The predictors evaluated were age, prematurity, day of illness, poor feeding, dehydration, apnea, nasal flaring and/or grunting, respiratory rate, oxygen saturation, and retractions. RESULTS: Of 2722 patients, 261 (9.6%) received escalated care. Multivariable predictors of escalated care were oxygen saturation <90% (odds ratio [OR]: 8.9 [95% confidence interval (CI) 5.1-15.7]), nasal flaring and/or grunting (OR: 3.8 [95% CI 2.6-5.4]), apnea (OR: 3.0 [95% CI 1.9-4.8]), retractions (OR: 3.0 [95% CI 1.6-5.7]), age ≤2 months (OR: 2.1 [95% CI 1.5-3.0]), dehydration (OR 2.1 [95% CI 1.4-3.3]), and poor feeding (OR: 1.9 [95% CI 1.3-2.7]). One of 217 (0.5%) infants without predictors received escalated care. The risk score ranged from 0 to 14 points, with the estimated risk of escalated care from 0.46% (0 points) to 96.9% (14 points). The area under the curve was 85%. CONCLUSIONS: We identified variables measured in the emergency department predictive of escalated care in bronchiolitis and derived a risk score to stratify risk of this outcome. This score may be used to aid management and disposition decisions. [ABSTRACT FROM AUTHOR]