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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.

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]

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]

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]