Features Associated With Radiographic Pneumonia in Children with SARS-CoV-2

14% of children with SARS-CoV-2 infections had radiographic pneumonia. Hypoxemia, cough, higher temperature, and older age were associated with pneumonias. In children tested, SARS-CoV-2 test results were not associated with radiographic pneumonia.

Pharmacologic Procedural Distress Management During Laceration Repair in Children: A Systematic Review

OBJECTIVES

To systematically appraise the literature on the relative effectiveness of pharmacologic procedural distress management agents for children undergoing laceration repair.

METHODS

Six databases were searched in August 2021, and the search was updated in January 2023. We included completed randomized or quasi-randomized trials involving ( a ) children younger than 15 years undergoing laceration repair in the emergency department; ( b ) randomization to at least one anxiolytic, sedative, and/or analgesic agent versus any comparator agent or placebo; ( c ) efficacy of procedural distress management measured on any scale. Secondary outcomes were pain during the procedure, administration acceptance, sedation duration, additional sedation, length of stay, and stakeholder satisfaction. Cochrane Collaboration's risk-of-bias tool assessed individual studies. Ranges and proportions summarized results where applicable.

RESULTS

Among 21 trials (n = 1621 participants), the most commonly studied anxiolytic agents were midazolam, ketamine, and N 2 O. Oral midazolam, oral ketamine, and N 2 O were found to reduce procedural distress more effectively than their comparators in 4, 3, and 2 studies, respectively. Eight studies comparing routes, doses, or volumes of administration of the same agent led to indeterminate results. Meta-analysis was not performed because of heterogeneity in comparators, routes, and outcome measures across studies.

CONCLUSIONS

Based on procedural distress reduction, this study favors oral midazolam and oral ketamine. However, this finding should be interpreted with caution because of heterogeneous comparators across studies and minor conflicting results. An optimal agent for procedural distress management cannot be recommended based on the limited evidence. Future research should seek to identify the minimal, essential measures of patient distress during pharmacologic anxiolysis and/or sedation in laceration repair to guide future trials and reviews.

Balanced crystalloids (RInger's lactate) versus normal Saline in adults with diabetic Ketoacidosis in the Emergency Department (BRISK-ED): a pilot randomised controlled trial

BACKGROUND

Current diabetic ketoacidosis (DKA) treatment guidelines recommend using normal saline (NS); however, NS may delay DKA resolution by causing more hyperchloremic metabolic acidosis compared with balanced crystalloids. This study's objective was to determine the feasibility of a future multicentred randomised controlled trial (RCT) comparing intravenous Ringer's lactate (RL) with NS in managing ED patients with DKA.

METHODS

We conducted a parallel-arm, triple-blind, pilot RCT of adults (≥18 years) with DKA at a Canadian academic tertiary care ED. The primary feasibility outcome was recruitment rate (target ≥41.3% of eligible participants over the 1-year study period); the primary efficacy outcome was time elapsed from ED presentation to DKA resolution. The superiority margin for a clinically significant difference was chosen to be a 40% time reduction to DKA resolution. We also assessed the need to break allocation concealment and loss to follow-up. Patients with clinical suspicion for DKA were screened for inclusion and enrolled patients were randomised 1:1 to receive RL or NS. Patients, clinicians and outcome assessors were blinded to allocation.

RESULTS

We enrolled 52 (25 RL, 27 NS) of 60 eligible patients (86.7%), exceeding our target recruitment rate. There were more patients in the NS group with type 1 diabetes, and more patients in the RL group had an admission co-diagnosis in addition to DKA. For the 44 participants with confirmed laboratory evidence of resolution, median (IQR) time to DKA resolution for RL versus NS was 15.7 (10.4-18.8) and 12.7 (7.9-19.2) hours, respectively. There were no cases where blinding was broken, and there was no loss to follow-up.

CONCLUSIONS

This pilot trial demonstrated our protocol's feasibility by exceeding our target recruitment rate. Our results may be used to inform future multicentre trials to compare the safety and efficacy of RL and NS in managing DKA in the ED.

TRIAL REGISTRATION NUMBER

NCT04926740.

Nitrous oxide use in Canadian pediatric emergency departments: a survey of physician's knowledge, attitudes, and practices

OBJECTIVES

Nitrous oxide (N2O) is an inhaled analgesic/ anxiolytic gas with evidence supporting its safety and efficacy for distressing procedures in children. Despite this, its use is not consistent across Canadian pediatric emergency departments (EDs). We aimed to characterize a) physicians' knowledge and practices with N2O and b) site-specific N2O protocols in Canadian pediatric EDs to help optimize its use nationally.

METHODS

This cross-sectional survey was distributed to physician members of Pediatric Emergency Research Canada (PERC) in early 2021. Survey items addressed practice patterns, clinician comfort, and perceived barriers/ facilitators to use. Further, a representative from each ED completed a site-specific inventory of N2O policies and procedures.

RESULTS

N2O was available in 40.0% of 15 pediatric EDs, with 83.3% of these sites having written policies in place. Of 230 distributed surveys, 67.8% were completed with mean (SD) attending experience of 14.7 (8.6) years and 70.1% having pediatric emergency subspecialty training. Of the 156 respondents, 48.7% used N2O in their clinical practice. The most common indications for use were digit fracture/ dislocation reduction (69.7%), wound closure (60.5%), and incision & drainage (59.2%). Commonly perceived facilitators were N2O equipment availability (73.0% of 156) and previous clinical experience (71.7% of 156). Of the 51.3% of physicians who reported not using N2O, 93.7% did not have availability at their site; importantly, the majority indicated a desire to acquire access. They identified concerns about ventilation/ scavenging systems (71.2% of 80) and unfamiliarity with equipment (52.5% of 80) as the most common barriers to use.

CONCLUSIONS

Despite evidence to support its use, only half of Canadian pediatric ED physicians surveyed use N2O in their clinical practice for treating procedure-related pain and distress. Increased availability of N2O equipment, protocols, and training may improve clinicians' abilities to better manage pediatric acute pain and distress in the ED.

Post-COVID-19 Condition in Children 6 and 12 Months After Infection

Importance

There is a need to understand the long-term outcomes among children infected with SARS-CoV-2.

Objective

To quantify the prevalence of post-COVID-19 condition (PCC) among children tested for SARS-CoV-2 infection in pediatric emergency departments (EDs).

Design, Setting, and Participants

Multicenter, prospective cohort study at 14 Canadian tertiary pediatric EDs that are members of the Pediatric Emergency Research Canada network with 90-day, 6-month, and 12-month follow-up. Participants were children younger than 18 years who were tested for SARS-CoV-2 infection between August 2020 and February 2022. Data were analyzed from May to November 2023.

Exposure

The presence of SARS-CoV-2 infection at or within 14 days of the index ED visit.

Main Outcomes and Measures

Presence of symptoms and QoL reductions that meet the PCC definition. This includes any symptom with onset within 3 months of infection that is ongoing at the time of follow-up and affects everyday functioning. The outcome was quantified at 6 and 12 months following the index ED visit.

Results

Among the 5147 children at 6 months (1152 with SARS-CoV-2 positive tests and 3995 with negative tests) and 5563 children at 12 months (1192 with SARS-CoV-2 positive tests and 4371 with negative tests) who had sufficient data regarding the primary outcome to enable PCC classification, the median (IQR) age was 2.0 (0.9-5.0) years, and 2956 of 5563 (53.1%) were male. At 6-month follow-up, symptoms and QoL changes consistent with the PCC definition were present in 6 of 1152 children with positive SARS-CoV-2 tests (0.52%) and 4 of 3995 children with negative SARS-CoV-2 tests (0.10%; absolute risk difference, 0.42%; 95% CI, 0.02% to 0.94%). The PCC definition was met at 12 months by 8 of 1192 children with positive SARS-CoV-2 tests (0.67%) and 7 of 4371 children with negative SARS-CoV-2 tests (0.16%; absolute risk difference, 0.51%; 95% CI, 0.06 to 1.08%). At 12 months, the median (IQR) PedsQL Generic Core Scale scores were 98.4 (90.0-100) among children with positive SARS-CoV-2 tests and 98.8 (91.7-100) among children with negative SARS-CoV-2 tests (difference, -0.3; 95% CI, -1.5 to 0.8; P = .56). Among the 8 children with SARS-CoV-2 positive tests and PCC at 12-month follow-up, children reported respiratory (7 of 8 patients [88%]), systemic (3 of 8 patients [38%]), and neurologic (1 of 8 patients [13%]) symptoms.

Conclusions and Relevance

In this cohort study of children tested for SARS-CoV-2 infection in Canadian pediatric EDs, although children infected with SARS-CoV-2 reported increased chronic symptoms, few of these children developed PCC, and overall QoL did not differ from children with negative SARS-CoV-2 tests.

Family caregivers' emotional and communication needs in Canadian pediatric emergency departments

OBJECTIVES

To describe the extent to which caregivers' emotional and communication needs were met during pediatric emergency department (PED) visits. Secondary objectives included describing the association of caregiver emotional needs, satisfaction with care, and comfort in caring for their child's illness at the time of discharge with demographic characteristics, caregiver experiences, and ED visit details.

STUDY DESIGN

Electronic surveys with medical record review were deployed at ten Canadian PEDs from October 2018 -March 2020. A convenience sample of families with children <18 years presenting to a PED were enrolled, for one week every three months, for one year per site. Caregivers completed one in-PED survey and a follow-up survey, up to seven days post-visit.

RESULTS

This study recruited 2005 caregivers who self-identified as mothers (74.3%, 1462/1969); mean age was 37.8 years (SD 7.7). 71.7% (1081/1507) of caregivers felt their emotional needs were met. 86.4% (1293/1496) identified communication with the doctor as good/very good and 83.4% (1249/1498) with their child's nurse. Caregiver involvement in their child's care was reported as good/very good 85.6% (1271/1485) of the time. 81.8% (1074/1313) of caregivers felt comfortable in caring for their child at home at the time of discharge. Lower caregiver anxiety scores, caregiver involvement in their child's care, satisfactory updates, and having questions adequately addressed positively impacted caregiver emotional needs and increased caregiver comfort in caring for their child's illness at home.

CONCLUSION

Approximately 30% of caregivers presenting to PEDs have unmet emotional needs, over 15% had unmet communication needs, and 15% felt inadequately involved in their child's care. Family caregiver involvement in care and good communication from PED staff are key elements in improving overall patient experience and satisfaction.

Nasal Suctioning Therapy Among Infants With Bronchiolitis Discharged Home From the Emergency Department: A Randomized Clinical Trial

Importance

Although nasal suctioning is the most frequently used supportive management for bronchiolitis, its benefit remains unknown.

Objective

To evaluate the effectiveness of enhanced vs minimal nasal suctioning in treating infants with bronchiolitis after discharge from the emergency department (ED).

Design, Setting, and Participants

This single-blind, parallel-group, randomized clinical trial was conducted from March 6, 2020, to December 15, 2022, at 4 tertiary-care Canadian pediatric EDs. Participants included otherwise healthy infants aged 1 to 11 months with a diagnosis of bronchiolitis who were discharged home from the ED.

Interventions

Participants were randomized to minimal suctioning via bulb or enhanced suctioning via a battery-operated device before feeding for 72 hours.

Main Outcomes and Measures

The primary outcome was additional resource use, a composite of unscheduled revisits for bronchiolitis or use of additional suctioning devices for feeding and/or breathing concerns. Secondary outcomes included health care utilization, feeding and sleeping adequacy, and satisfaction.

Results

Of 884 screened patients, 352 were excluded for criteria, 79 declined participation, 81 were otherwise excluded, 372 were randomized (185 to the minimal suction group and 187 to the enhanced suction group), and 367 (median [IQR] age, 4 [2-6] months; 221 boys [60.2%]) completed the trial (184 in the minimal suction and 183 in the enhanced suction group). Additional resource use occurred for 68 of 184 minimal suction participants (37.0%) vs 48 of 183 enhanced suction participants (26.2%) (absolute risk difference, 0.11; 95% CI, 0.01 to 0.20; P = .03). Unscheduled revisits occurred for 47 of 184 minimal suction participants (25.5%) vs 40 of 183 enhanced suction participants (21.9%) (absolute risk difference, 0.04; 95% CI, -0.05 to 0.12; P = .46). A total of 33 of 184 parents in the minimal suction group (17.9%) used additional suctioning devices vs 11 of 183 parents in the enhanced suction group (6.0%) (absolute risk difference, 0.12; 95% CI, 0.05 to 0.19; P < .001). No significant between-group differences were observed for all bronchiolitis revisits (absolute risk difference, 0.07; 95% CI, -0.02 to 0.16; P = .15), ED revisits (absolute risk difference, 0.04; 95% CI, -0.03 to 0.12; P = .30), parental care satisfaction (absolute risk difference, -0.02; 95% CI, -0.10 to 0.06; P = .70), and changes from baseline to 72 hours in normal feeding (difference in differences, 0.03; 95% CI, -0.10 to 0.17; P = .62), normal sleeping (difference in differences, 0.05; 95% CI, -0.08 to 0.18; P = .47), or normal parental sleeping (difference in differences, 0.10; 95% CI, -0.02 to 0.23; P = .09). Parents in the minimal suction group were less satisfied with the assigned device (62 of 184 [33.7%]) than parents in the enhanced suction group (145 of 183 [79.2%]) (risk difference, 0.45; 95% CI, 0.36 to 0.54; P < .001).

Conclusions and Relevance

Compared with minimal suctioning, enhanced suctioning after ED discharge with bronchiolitis did not alter the disease course because there were no group differences in revisits or feeding and sleeping adequacy. Minimal suctioning resulted in higher use of nonassigned suctioning devices and lower parental satisfaction with the assigned device.

Trial Registration

ClinicalTrials.gov Identifier: NCT03361371.

Impact of SARS-CoV-2 Infection on the Association Between Laboratory Tests and Severe Outcomes Among Hospitalized Children

Background

To assist clinicians with identifying children at risk of severe outcomes, we assessed the association between laboratory findings and severe outcomes among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected children and determined if SARS-CoV-2 test result status modified the associations.

Methods

We conducted a cross-sectional analysis of participants tested for SARS-CoV-2 infection in 41 pediatric emergency departments in 10 countries. Participants were hospitalized, had laboratory testing performed, and completed 14-day follow-up. The primary objective was to assess the associations between laboratory findings and severe outcomes. The secondary objective was to determine if the SARS-CoV-2 test result modified the associations.

Results

We included 1817 participants; 522 (28.7%) SARS-CoV-2 test-positive and 1295 (71.3%) test-negative. Seventy-five (14.4%) test-positive and 174 (13.4%) test-negative children experienced severe outcomes. In regression analysis, we found that among SARS-CoV-2-positive children, procalcitonin ≥0.5 ng/mL (adjusted odds ratio [aOR], 9.14; 95% CI, 2.90-28.80), ferritin >500 ng/mL (aOR, 7.95; 95% CI, 1.89-33.44), D-dimer ≥1500 ng/mL (aOR, 4.57; 95% CI, 1.12-18.68), serum glucose ≥120 mg/dL (aOR, 2.01; 95% CI, 1.06-3.81), lymphocyte count <1.0 × 109/L (aOR, 3.21; 95% CI, 1.34-7.69), and platelet count <150 × 109/L (aOR, 2.82; 95% CI, 1.31-6.07) were associated with severe outcomes. Evaluation of the interaction term revealed that a positive SARS-CoV-2 result increased the associations with severe outcomes for elevated procalcitonin, C-reactive protein (CRP), D-dimer, and for reduced lymphocyte and platelet counts.

Conclusions

Specific laboratory parameters are associated with severe outcomes in SARS-CoV-2-infected children, and elevated serum procalcitonin, CRP, and D-dimer and low absolute lymphocyte and platelet counts were more strongly associated with severe outcomes in children testing positive compared with those testing negative.

Emergency department visits and hospital admissions for suicidal ideation, self-poisoning and self-harm among adolescents in Canada during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic had profound effects on the mental wellbeing of adolescents. We sought to evaluate pandemic-related changes in health care use for suicidal ideation, self-poisoning and self-harm.

METHODS

We obtained data from the Canadian Institute for Health Information on emergency department visits and hospital admissions from April 2015 to March 2022 among adolescents aged 10-18 years in Canada. We calculated the quarterly percentage of emergency department visits and hospital admissions for a composite outcome comprising suicidal ideation, self-poisoning and self-harm relative to all-cause emergency department visits and hospital admissions. We used interrupted time-series methods to compare changes in levels and trends of these outcomes between the prepandemic (Apr. 1, 2015-Mar. 1, 2020) and pandemic (Apr. 1, 2020-Mar. 31, 2022) periods.

RESULTS

The average quarterly percentage of emergency department visits for suicidal ideation, self-poisoning and self-harm relative to all-cause emergency department visits was 2.30% during the prepandemic period and 3.52% during the pandemic period. The level (0.08%, 95% confidence interval [CI] -0.79% to 0.95%) or trend (0.07% per quarter, 95% CI -0.14% to 0.28%) of this percentage did not change significantly between periods. The average quarterly percentage of hospital admissions for the composite outcome relative to all-cause admissions was 7.18% during the prepandemic period and 8.96% during the pandemic period. This percentage showed no significant change in level (-0.70%, 95% CI -1.90% to 0.50%), but did show a significantly increasing trend (0.36% per quarter; 95% 0.07% to 0.65%) during the pandemic versus prepandemic periods, specifically among females aged 10-14 years (0.76% per quarter, 95% CI 0.22% to 1.30%) and females aged 15-18 years (0.56% per quarter, 95% CI 0.31% to 0.81%).

INTERPRETATION

The quarterly change in the percentage of hospital admissions for suicidal ideation, self-poisoning and self-harm increased among adolescent females in Canada during the first 2 years of the COVID-19 pandemic. This underscores the need to promote public health policies that mitigate the impact of the pandemic on adolescent mental health.

Significantly Longer Shedding of Norovirus Compared to Rotavirus and Adenovirus in Children with Acute Gastroenteritis

Worldwide, acute gastroenteritis (AGE) is a major cause of morbidity and mortality in children under 5 years of age. Viruses, including norovirus, rotavirus, and enteric adenovirus, are the leading causes of pediatric AGE. In this prospective cohort study, we investigated the viral load and duration of shedding of norovirus, rotavirus, and adenovirus in stool samples collected from 173 children (median age: 15 months) with AGE who presented to emergency departments (EDs) across Canada on Day 0 (day of enrollment), and 5 and 28 days after enrollment. Quantitative RT-qPCR was performed to assess the viral load. On Day 0, norovirus viral load was significantly lower compared to that of rotavirus and adenovirus (p < 0.001). However, on Days 5 and 28, the viral load of norovirus was higher than that of adenovirus and rotavirus (p < 0.05). On Day 28, norovirus was detected in 70% (35/50) of children who submitted stool specimens, while rotavirus and adenovirus were detected in 52.4% (11/24) and 13.6% (3/22) of children (p < 0.001), respectively. Overall, in stool samples of children with AGE who presented to EDs, rotavirus and adenovirus had higher viral loads at presentation compared to norovirus; however, norovirus was shed in stool for the longest duration.

Balanced crystalloids (RInger's lactate) versus normal Saline in adults with diabetic Ketoacidosis in the Emergency Department (BRISK-ED): a protocol for a pilot randomized controlled trial

BACKGROUND

Current guidelines for diabetic ketoacidosis (DKA) recommend treatment with normal saline (NS). However, NS, with its high chloride concentrations, may worsen acidosis and contribute to a hyperchloremic metabolic acidosis. Alternatives to NS are balanced crystalloids (e.g. Ringer's Lactate [RL]) which have chloride concentrations similar to human plasma; therefore, treatment with balanced crystalloids may lead to faster DKA resolution. A recent systematic review and meta-analysis by Catahay et al. (2022) demonstrated the need for more blinded, high-quality trials comparing NS versus RL in the treatment of DKA.

METHODS

We describe a protocol for BRISK-ED (Balanced crystalloids [RInger's lactate] versus normal Saline in adults with diabetic Ketoacidosis in the Emergency Department). Our study is a single-centre, triple-blind, pilot randomized controlled trial (RCT) of adults (≥ 18 years) with DKA presenting to an academic tertiary care ED in London, Canada. Patients with clinical suspicion for DKA will be screened and those found to not meet DKA criteria or have euglycemic DKA will be excluded. We will aim to recruit 52 patients with DKA and will randomize them 1:1 to receive intravenous RL or NS. The primary feasibility outcome will be recruitment rate, and the primary efficacy outcome will be time elapsed from ED presentation to DKA resolution. Secondary outcomes include time to insulin infusion discontinuation, intensive care unit admission, in-hospital death, and major adverse kidney events within 30 days, defined as a composite of: i) death, ii) new renal replacement therapy, or iii) final serum creatinine ≥ 200% baseline at the earliest of hospital discharge or 30 days after ED presentation. Patients, clinicians, and outcome assessors will be blinded to allocation group. We will follow an intention-to-treat analysis. Gehan-Wilcoxon, Mann-Whitney U, or chi-square tests will be used to compare groups as appropriate.

DISCUSSION

The results of this pilot study will inform the design and feasibility of a full-scale, multicentre RCT to assess fluid choice in adult ED patients with DKA. If proven to demonstrate faster resolution of DKA, administration of balanced crystalloids may replace NS in diabetes treatment guidelines and improve patient and health systems outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov, Registration # NCT04926740; Registered June 15, 2021.

Factors Influencing Parental Decision-Making Regarding Analgesia for Children with Musculoskeletal Injury-Related Pain: A Qualitative Study

OBJECTIVES

To explore and understand parental decision-making relating to acute pain management for their children presenting to the emergency department.

STUDY DESIGN

This study employed one-on-one semistructured interviews. Parents of children with acute musculoskeletal injuries were recruited from 3 Canadian pediatric emergency departments. Interviews were conducted via telephone from June 2019 to March 2021. Verbatim transcription and thematic analyses occurred concurrently with data collection, supporting data saturation and theory development considerations.

RESULTS

Twenty-seven interviews were completed. Five major themes regarding pain care emerged: (1) my child's comfort is a priority, (2) every situation is unique, (3) opioids only if necessary, (4) considerations when choosing opioids, and (5) pain research is important. Overall, parents were highly comfortable with their assessment of their child's pain. Participants' willingness to use opioid analgesia for their children was primarily dependent on perceptions of injury and pain severity. Opioid-averse and opioid-accepting families had similar considerations when making analgesic decisions but weighed risks and benefits differently.

CONCLUSIONS

Parents assess and manage their children's pain globally and multimodally, with comfort being prioritized. For most parents, the desire to relieve their children's pain outweighed concerns of substance use disorder, misuse, and adverse events when making decisions about opioid analgesia for short-term use. These results can inform evidence-based family-centered approaches to co-decision-making of analgesic plans for children with acute pain.

Sedation and Analgesia for Reduction of Pediatric Ileocolic Intussusception

Importance

Ileocolic intussusception is an important cause of intestinal obstruction in children. Reduction of ileocolic intussusception using air or fluid enema is the standard of care. This likely distressing procedure is usually performed without sedation or analgesia, but practice variation exists.

Objective

To characterize the prevalence of opioid analgesia and sedation and assess their association with intestinal perforation and failed reduction.

Design, Setting, and Participants

This cross-sectional study reviewed medical records of children aged 4 to 48 months with attempted reduction of ileocolic intussusception at 86 pediatric tertiary care institutions in 14 countries from January 2017 to December 2019. Of 3555 eligible medical records, 352 were excluded, and 3203 medical records were eligible. Data were analyzed in August 2022.

Exposures

Reduction of ileocolic intussusception.

Main outcomes and measures

The primary outcomes were opioid analgesia within 120 minutes of reduction based on the therapeutic window of IV morphine and sedation immediately before reduction of intussusception.

Results

We included 3203 patients (median [IQR] age, 17 [9-27] months; 2054 of 3203 [64.1%] males). Opioid use was documented in 395 of 3134 patients (12.6%), sedation 334 of 3161 patients (10.6%), and opioids plus sedation in 178 of 3134 patients (5.7%). Perforation was uncommon and occurred in 13 of 3203 patients (0.4%). In the unadjusted analysis, opioids plus sedation (odds ratio [OR], 5.92; 95% CI, 1.28-27.42; P = .02) and a greater number of reduction attempts (OR, 1.48; 95% CI, 1.03-2.11; P = .03) were significantly associated with perforation. In the adjusted analysis, neither of these covariates remained significant. Reductions were successful in 2700 of 3184 attempts (84.8%). In the unadjusted analysis, younger age, no pain assessment at triage, opioids, longer duration of symptoms, hydrostatic enema, and gastrointestinal anomaly were significantly associated with failed reduction. In the adjusted analysis, only younger age (OR, 1.05 per month; 95% CI, 1.03-1.06 per month; P < .001), shorter duration of symptoms (OR, 0.96 per hour; 95% CI, 0.94-0.99 per hour; P = .002), and gastrointestinal anomaly (OR, 6.50; 95% CI, 2.04-20.64; P = .002) remained significant.

Conclusions and Relevance

This cross-sectional study of pediatric ileocolic intussusception found that more than two-thirds of patients received neither analgesia nor sedation. Neither was associated with intestinal perforation or failed reduction, challenging the widespread practice of withholding analgesia and sedation for reduction of ileocolic intussusception in children.

Inhaled nitrous oxide for painful procedures in children and youth: a systematic review and meta-analysis

OBJECTIVES

The objective of this study was to synthesize indication-based evidence for N₂O for distress and pain in children.

STUDY DESIGN

We included trials of N₂O in participants 0-21 years, reporting distress or pain for emergency department procedures. The primary outcome was procedural distress. Where meta-analysis was not possible, we used Tricco et al.'s classification of "neutral" (p ≥ 0.05), "favorable," or "unfavorable" (p < 0.05, supporting N₂O or comparator, respectively). We used the Cochrane Collaboration's Risk of Bias tool and the Grading of Recommendations Assessment, Development, and Evaluation system to evaluate risk of bias and quality of evidence, respectively.

RESULTS

We included 30 trials. For pain using the Visual Analog Scale (0-100 mm) during IV insertion, 70% N₂O (delta:-16.5; 95%CI:-28.6 to -4.4; p = 0.008; three trials; I² = 0%) and 50% N₂O plus eutectic mixture of local anesthetics (EMLA) (delta:-1.2; 95%CI:-2.1 to -0.3; p = 0.007; two trials; I² = 43%) were superior to EMLA. 50% N₂O was not superior to EMLA (delta:-0.4; 95%CI:-1.2 to 0.3; p = 0.26; two trials; I² = 15%). For distress and pain during laceration repair, N₂O was "favorable" versus each of SC lidocaine, oxygen, and oral midazolam but "neutral" versus IV ketamine (five trials). For distress and pain during fracture reduction (three trials), N₂O was "neutral" versus each of IM meperidine plus promethazine, regional anesthesia, and IV ketamine plus midazolam. For distress and pain during lumbar puncture (one trial), N₂O was "favorable" versus oxygen. For distress and pain during urethral catheterization (one trial), N₂O was "neutral" versus oral midazolam. For pain during intramuscular injection (one trial), N₂O plus EMLA was "favorable" versus N₂O and EMLA alone. Common adverse effects of N₂O included nausea (4.4%), agitation (3.7%), and vomiting (3.6%) AEs were less frequent with N₂O alone (278/1147 (24.2%)) versus N₂O plus midazolam (48/52 (92.3%)) and N₂O plus fentanyl (123/201 (61.2%)).

CONCLUSIONS

There is sufficient evidence to recommend N₂O plus topical anesthetic for IV insertion and laceration repair. Adverse effects are greater when combined with other sedating agents.

Predictors of Adherence to Short-Course Probiotics Among Children with Gastroenteritis who are Enrolled in a Clinical Trial

BACKGROUND

To improve our understanding of adherence to discharge medications in the ED and within research trials, we sought to quantify medication adherence and identify predictors thereof in children with acute gastroenteritis (AGE).

METHODS

We conducted a secondary analysis of a randomized trial of twice daily probiotic for 5 days. The population included previously healthy children aged 3-47 months with AGE. The primary outcome was patient-reported adherence to the treatment regimen, defined a priori as having received >70% of the prescribed doses. Secondary outcomes included predictors of treatment adherence and concordance between patient-reported adherence and the returned medication sachet counts.

RESULTS

After excluding participants with missing data on adherence, 760 participants were included in this analysis: 383 in the probiotic arm (50.4%); and 377 in the placebo arm (49.6%). Self-reported adherence was similar in both groups (77.0% in probiotic versus 80.3% in placebo). There was good agreement between self-reported adherence and sachet counts (87% within limits of agreement (-2.9 to 3.5 sachets) on the Bland-Altman plots). In the multivariable regression model, covariates associated with adherence were greater number of days of diarrhea post-emergency department visit, and the study site; covariates negatively associated with adherence were age 12-23 months, severe dehydration and greater total number of vomiting and diarrhea episodes after enrolment.

CONCLUSIONS

Longer duration of diarrhea and study site were associated with higher probiotic adherence. Age 12-23 months, severe dehydration and greater number of vomiting and diarrhea episodes post enrolment negatively predicted treatment adherence.

Optimal Dose of Intranasal Dexmedetomidine for Laceration Repair in Children: A Phase II Dose-Ranging Study

STUDY OBJECTIVE

To determine the optimal sedative dose of intranasal dexmedetomidine for children undergoing laceration repair.

METHODS

This dose-ranging study employing the Bayesian Continual Reassessment Method enrolled children aged 0 to 10 years with a single laceration (<5 cm), requiring single-layer closure, who received topical anesthetic. Children were administered 1, 2, 3, or 4 mcg/kg intranasal dexmedetomidine. The primary outcome was the proportion with adequate sedation (Pediatric Sedation State Scale score of 2 or 3 for ≥90% of the time from sterile preparation to tying of the last suture). Secondary outcomes included the Observational Scale of Behavior Distress-Revised (range: 0 [no distress] to 23.5 [maximal distress]), postprocedure length of stay, and adverse events.

RESULTS

We enrolled 55 children (35/55 [64%] males; median [interquartile range {IQR}] age 4 [2, 6] years). At 1, 2, 3, and 4 mcg/kg intranasal dexmedetomidine, respectively, the proportion of participants "adequately" sedated was 1/3 (33%), 2/9 (22%), 13/21 (62%), and 12/21 (57%); the posterior mean (95% equitailed credible intervals) for the probability of adequate sedation was 0.38 (0.04, 0.82), 0.25 (0.05, 0.54), 0.61 (0.41, 0.80), and 0.57 (0.36, 0.76); the median (IQR) Observational Scale of Behavior Distress-Revised scores during suturing was 2.7 (0.3, 3), 0 (0, 3.8), 0.6 (0, 5), and 0 (0, 3.7); the median (IQR) postprocedure length of stay was 67 (60, 78), 76 (60, 100), 89 (76, 109), and 113 (76, 150) minutes. There was 1 adverse event, a decrease in oxygen saturation at 4 mcg/kg, which resolved with head repositioning.

CONCLUSION

Despite limitations, such as our limited sample size and subjectivity in Pediatric Sedation State Scale scoring, sedation efficacy for 3 and 4 mcg/kg were similarly based on equitailed credible intervals suggesting either could be considered optimal.

Comparison of Symptoms Associated With SARS-CoV-2 Variants Among Children in Canada

IMPORTANCE

Clinical manifestations of SARS-CoV-2 variants have not been systematically compared in children.

OBJECTIVE

To compare symptoms, emergency department (ED) chest radiography, treatments, and outcomes among children with different SARS-CoV-2 variants.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter cohort study was performed at 14 Canadian pediatric EDs. Participants included children and adolescents younger than 18 years (hereinafter referred to as children) tested for SARS-CoV-2 infection in an ED between August 4, 2020, and February 22, 2022, with 14 days of follow-up.

EXPOSURE(S)

SARS-CoV-2 variants detected on a specimen collected from the nasopharynx, nares, or throat.

MAIN OUTCOMES AND MEASURES

The primary outcome was presence and number of presenting symptoms. The secondary outcomes were presence of core COVID-19 symptoms, chest radiography findings, treatments, and 14-day outcomes.

RESULTS

Among 7272 participants presenting to an ED, 1440 (19.8%) had test results positive for SARS-CoV-2 infection. Of these, 801 (55.6%) were boys, with a median age of 2.0 (IQR, 0.6-7.0) years. Children with the Alpha variant reported the fewest core COVID-19 symptoms (195 of 237 [82.3%]), which were most often reported by participants with Omicron variant infection (434 of 468 [92.7%]; difference, 10.5% [95% CI, 5.1%-15.9%]). In a multivariable model with the original type as the referent, the Omicron and Delta variants were associated with fever (odds ratios [ORs], 2.00 [95% CI, 1.43-2.80] and 1.93 [95% CI, 1.33-2.78], respectively) and cough (ORs, 1.42 [95% CI, 1.06-1.91] and 1.57 [95% CI, 1.13-2.17], respectively). Upper respiratory tract symptoms were associated with Delta infection (OR, 1.96 [95% CI, 1.38-2.79]); lower respiratory tract and systemic symptoms were associated with Omicron variant infection (ORs, 1.42 [95% CI, 1.04-1.92] and 1.77 [95% CI, 1.24-2.52], respectively). Children with Omicron infection most often had chest radiography performed and received treatments; compared with those who had Delta infection, they were more likely to have chest radiography performed (difference, 9.7% [95% CI, 4.7%-14.8%]), to receive intravenous fluids (difference, 5.6% [95% CI, 1.0%-10.2%]) and corticosteroids (difference, 7.9% [95% CI, 3.2%-12.7%]), and to have an ED revisit (difference, 8.8% [95% CI, 3.5%-14.1%]). The proportions of children admitted to the hospital and intensive care unit did not differ between variants.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study of SARS-CoV-2 variants suggest that the Omicron and Delta variants were more strongly associated with fever and cough than the original-type virus and the Alpha variant. Children with Omicron variant infection were more likely to report lower respiratory tract symptoms and systemic manifestations, undergo chest radiography, and receive interventions. No differences were found in undesirable outcomes (ie, hospitalization, intensive care unit admission) across variants.

Characterizing the Pain Experience of Children With Acute Gastroenteritis Based on Identified Pathogens

OBJECTIVES

Pain is common with acute gastroenteritis (AGE) yet little is known about the severity associated with specific enteropathogens. We sought to explore the correlation of pain severity with specific enteropathogens in children with AGE.

METHODS

Participants were prospectively recruited by the Alberta Provincial Pediatric EnTeric Infection TEam at 2 pediatric emergency departments (EDs) (December 2014-August 2018). Pain was measured (by child and/or caregiver) using the 11-point Verbal Numerical Rating Scale.

RESULTS

We recruited 2686 participants; 46.8% (n = 1256) females, with median age 20.1 months (interquartile range 10.3, 45.3). The mean highest pain scores were 5.5 [standard deviation (SD) 3.0] and 4.2 (SD 2.9) in the 24 hours preceding the ED visit, and in the ED, respectively. Prior to ED visit, the mean highest pain scores with bacterial detection were 6.6 (SD 2.5), compared to 5.5 (SD 2.9) for single virus and 5.5 (SD 3.1) for negative stool tests. In the ED, the mean highest pain scores with bacterial detection were 5.5 (SD 2.7), compared to 4.1 (SD 2.9) for single virus and 4.2 (SD 3.0) for negative stool tests. Using multivariable modeling, factors associated with greater pain severity prior to ED visit included older age, fever, illness duration, number of diarrheal or vomiting episodes in the preceding 24 hours, and respiratory symptoms, but not enteropathogen type.

CONCLUSION

Children with AGE experience significant pain, particularly when the episode is associated with the presence of a bacterial enteric pathogen. However, older age and fever appear to influence children's pain experiences more than etiologic pathogens.

Provision of immobilization or ice by paramedics in Southwestern Ontario

OBJECTIVES

Pain is the most common reason for prehospital transport. As emergency wait times increase, timely pain management is essential. In children, there is abundant evidence that prehospital pharmacologic analgesia is suboptimal, but little is known about non-pharmacologic therapies. We sought to characterize documentation by paramedics of non-pharmacologic (immobilization and ice) and pharmacologic analgesia in children with musculoskeletal injuries.

METHODS

We reviewed all ambulance call reports for children 0-17 years transported to Southwestern Ontario regional hospitals from January 1, 2017, to December 31, 2019, with a musculoskeletal injury (Ontario Ministry of Health and Long-Term Care problem codes 66 and 67). Primary and secondary outcomes were documented immobilization or ice and pharmacologic analgesia, respectively. In a multivariable analysis, we explored the relationship between immobilization or ice and the following a priori covariates: age, sex, visible deformity, crew type, pain severity, and analgesia.

RESULTS

Of 40,692 ambulance call reports reviewed, 4445 met inclusion criteria. There were 2584/4441 (58.2%) males, with a median (IQR) age of 14 (10, 16) years. In ambulance call reports with documented pain scores, 2106/3048 (69.1%) ambulance call reports reported "moderate or severe" pain. Immobilization or ice were documented in 1605/4445 (36.1%) and 385/4445 (8.7%) of ambulance call reports. Pharmacologic analgesia was documented in 275/1983 (13.9%) and 125/991 (12.6%) of ambulance call reports for primary care paramedics and advanced care paramedics, respectively. An increased odds of documented immobilization or ice was associated with moderate or severe pain [OR: 2.4; 95% CI 1.84-3.17; p < 0.01] and visible deformity [OR: 2.5; 95% CI 1.97-3.12; p < 0.01].

CONCLUSIONS

Documented immobilization and ice and pharmacologic analgesia to children by paramedics is suboptimal. Our findings underscore an important need for enhanced education surrounding the benefits of non-pharmacologic options for children with musculoskeletal injuries.

What influences physician opioid prescribing for children with acute pain?

Background

Pain is one of the most common symptoms encountered in the healthcare system, and opioids are among the top three medications used to treat it. Understanding the reasoning behind physicians’ opioid prescribing practices is vital to safe practice. The primary objective of our study was to describe pediatric emergency physicians’ decision-making process when prescribing opioids for children’s acute pain management.

Methods

This study employed qualitative methodology, using one-on-one semi-structured interviews within a grounded theory analytic framework. We employed purposeful sampling to recruit pediatric emergency physicians from across Canada. Interviews were conducted by telephone (December 2019–January 2021). Transcript analysis occurred concurrently with data collection, supporting data saturation and theory development considerations.

Results

Eleven interviews were completed with participants representing each of Canada’s geographic regions. Nine major themes emerged: (1) practice setting and outpatient opioid use, (2) condition-specific considerations, (3) physician confidence in medical evidence, (4) pain assessment challenges, (5) patient and family perspectives, (6) opioid safety concerns, (7) personal biases and experiences, (8) personal practice context, and (9) the Opioid Crisis/media influence. Most clinicians felt that they limited opioid use to those who needed it most; all participants described challenges managing acute pain, emphasizing the need for accurate pain measurement and better guidelines, evidence-based data, and knowledge translation. Clinicians were more comfortable treating pain in the emergency department, compared to discharge prescribing. They recognized the importance of co-therapy with non-opioids and the need for opioid risk assessment when prescribing. A family centered approach was recognized as the goal of practice.

Conclusion

Clinicians are less comfortable prescribing opioids to children for at-home use and find pain assessment and lack of clear guidelines to be barriers to pain care. Knowledge translation strategies for safer practice and optimal acute pain management could support responsible and judicious opioid use.

Canadian Anaphylaxis Network-Predicting Recurrence after Emergency Presentation for Allergic REaction (CAN-PREPARE): a prospective, cohort study protocol

INTRODUCTION

Anaphylaxis is a severe, potentially fatal multiorgan system manifestation of an allergic reaction. The highest incidence of anaphylaxis is in children and adolescents. Biphasic anaphylaxis (BA) is defined as the recurrence of allergic symptoms after resolution of an initial reaction. It has been reported to occur in 10%-20% of cases within 1-48 hours from the onset of the initial reaction. The dilemma for physicians is determining which patients with resolved anaphylaxis should be observed for BA and for how long. Guidelines for duration of postanaphylaxis monitoring vary, are based on limited evidence and can have unintended negative impacts on patient safety, quality of life and healthcare resources. The objectives of this study are to derive a prognostic model for BA and to develop a risk-scoring system that informs disposition decisions of children who present to emergency departments (ED) with anaphylaxis.

METHODS AND ANALYSIS

This prospective multicentre cohort study will enrol 1682 patients from seven paediatric EDs that are members of the Paediatric Emergency Research Canada network. We will enrol patients younger than 18 years of age with an allergic reaction meeting anaphylaxis diagnostic criteria. Trained ED research assistants will screen, obtain consent and prospectively collect study data. Research assistants will follow patients during their ED visit and ascertain, in conjunction with the medical team, if the patient develops BA. A standardised follow-up survey conducted following study enrolment will determine if a biphasic reaction occurred after ED disposition. Model development will conform to the broad principles of the PROGRESS (Prognosis Research Strategy) framework and reporting will follow the Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis Statement.

ETHICS AND DISSEMINATION

Ethics approval has been received from all participating centres. Our dissemination plan focuses on informing clinicians, policy makers and parents of the results through publication in peer-reviewed journals and broadcasting on multiple media platforms.

TRIAL REGISTRATION NUMBER

NCT05135377.

64 A Canadian multicentre survey of family needs when attending the pediatric emergency department

Background

Parents/caregivers strongly influence their child’s experience in the pediatric emergency department (PED). Understanding their needs can improve families’ PED experience and care.

Objectives

To describe caregivers’ perceived emotional, practical, and informational needs in the PED and how well these needs were met

Design/Methods

This descriptive, cross-sectional survey with medical record review was conducted at 10 Canadian PEDs from October 2018 to March 2020, over a 1-week period every season, for a total of 4 weeks per site. Digital surveys available in English or French were completed by caregivers in the PED and 7 days after their visit. Health literacy was evaluated by the Newest Vital Sign tool.

Results

A total of 2005 caregivers participated; mean age was 37.8 (SD 7.7) years, and 74.3% (1462/1969) were mothers. The mean child age was 5.9 (5.1) years and 51.9 % (1040/2003) were male. Caregivers’ main spoken language was mostly English [72.6% (1425/1964)] or French [10.5% (206/1964)]. Over half of caregivers had a university/professional degree [51.0% (997/1956)]; 37.4% (746/1998) had possible/probable limited health literacy. 77.9% (1132/1454) of caregivers reported that their overall care needs were met. 71.7% (1081/1507) of caregivers reported that their emotional needs were met; they reported most emotional support by doctors [(35.6%, 535/1510)] and bedside nurses [(24.2%, 364/1507)]. The median (IQR) length of stay was 3.9 (2.6, 6.1) hours; 36.7% (546/1487) of caregivers felt they waited ‘too long’, and 77.8% (1158/1489) did not know how long they would have to wait. 11.7% of families were dissatisfied with the care updates provided. A safe PED was the top overall identified practical need [(45.1%, 602/1336)]. Internet access was the most important practical need throughout the visit [(28.1%, 378/1345)], while more space was the most reported [(49.8%, 696/1398)] need in the waiting room. The most desired improvements in the PED were better communication of wait times and delays [(41.1%, 745/1812)], shorter wait times [(38.8%, 699/1801)] and faster diagnosis [(24.9%, 449/1803)].

Conclusion

Almost one quarter of Canadian caregivers report that their overall needs were not fully met when attending the PED. Safety during the PED visit was of utmost importance. Nationally, caregivers value shorter wait times, rapid diagnosis, and better communication about perceived delays. Top practical needs included internet access and more waiting room space. Creating innovative waiting systems, better methods to share wait time information, free internet access, and improved physical spaces could better address identified caregiver needs in the PED.

1 Ambulatory care visits and admissions for suicidal ideation and self-harm in Canadian adolescents during the COVID-19 pandemic: a population-based analysis

Background

The COVID-19 pandemic has challenged the resiliency of Canada’s adolescent population. Understanding changes in mental healthcare utilization can shed light on the impact the pandemic has had on Canada’s youth.

Objectives

To assess if during the pandemic there has been an increase in the proportion of ambulatory care visits and admissions for suicidal ideation and self-harm among adolescents.

Design/Methods

This was a population-based, interrupted time-series analysis of adolescents 10-18 years presenting to an ambulatory care facility (including emergency department) or admitted to a healthcare facility with R458 (suicidal ideation and emotional symptoms), X60-69 (intentional self-poisoning), and X70-84 (intentional self-harm) codes based on the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Canada (ICD-10-CA). We used the National Ambulatory Care Reporting System, Discharge Abstract Database, and Hospital Morbidity Database. The primary outcome was ambulatory care visits for a composite of suicidal ideation, intentional self-poisoning, and intentional self-harm. Results were stratified by age and sex and expressed as a rate (proportion of encounters with an outcome per 100 encounters). We compared the differences (delta) in slopes (average increase in outcomes) between April 1, 2015, to March 31, 2020, and April 1, 2020 to March 31, 2021 to determine if the expected rate (pre-pandemic) differed significantly from the observed rate (pandemic).

Results

From April 1, 2020, to March 31, 2021, compared to April 1, 2015, to March 31, 2020, the rate of ambulatory care visits and admissions for all conditions decreased. The average quarterly rate of ambulatory care visits for the composite among males 10-14 years, increased by 40.3%, from 0.57 to 0.8 (slope delta=0.1; 95% CI: 0.02, 0.18; p=0.012). Among females 10-14 years, the rate increased by 85.1%, from 1.81 to 3.35 (slope delta=0.7; 95% CI: 0.43, 0.97; p<0.001). Among males 15-18 years, the rate increased by 29.5%, from 1.56 to 2.02 (slope delta=0.13; 95% CI: -0.02, 0.28; p=0.078). Among females 15-18 years, the rate increased by 33.6%, from 3.18 to 4.25 (slope delta=0.26; 95% CI: -0.16, 0.68; p=0.192). The average quarterly rate of admissions was significant for females 10-14 years and increased by 27.7%, from 8.59 to 10.97 (slope delta=1.99; 95% CI: 0.57, 3.41; p=0.017).

Conclusion

The proportion of ambulatory care visits and admissions for emotional symptoms, suicidal ideation, and self-harm during the first year of the COVID-19 pandemic increased compared to pre-pandemic rates among adolescents 10-14 years in Canada. Our findings underscore the importance of promoting public health policies that mitigate the impact of pandemics on adolescent mental health.

60 Inhaled nitrous oxide for distressing procedures in children: a systematic review

Background

Inhaled nitrous oxide (N₂O) is a potentially effective agent for pain and procedural distress in children but questions remain regarding indication specific effectiveness.

Objectives

Our objective was to synthesize the evidence for N₂O in children and youth regarding procedural distress, pain, and adverse events (AEs).

Design/Methods

We performed electronic searches of MEDLINE, EMBASE, Google Scholar, CINAHL, conference proceedings, and trial registries. We included randomized trials of N₂O in children and youth 0-21.99 years that reported procedural distress or pain. Methodological rigor and quality of evidence were evaluated using the Cochrane Collaboration’s Risk of Bias tool and the Grading of Recommendations Assessment, Development, and Evaluation system, respectively. Where meta-analysis wasn’t possible, we summarized results using Tricco et al.’s classification system of “favorable” or “unfavorable” (p<0.05), or “neutral” (p>0.05).

Results

We included 29 trials, involving 2,404 children aged 3 weeks-21 years. The overall quality of evidence for distress and pain was “low” and “moderate”, respectively. For venous cannulation (n=12), three meta-analyses were possible: A) pain was significantly lower with 70% N₂O versus eutectic mixture of local anesthetics (EMLA) (mean difference: -16.5; 95% CI: -28.6 to -4.4; p=0.008; 85 participants; 3 trials; I²= 0%); B) pain was not significantly different with 50% N₂O alone versus EMLA (mean difference: -0.4; 95% CI: -1.2 to 0.3; p=0.26; 65 participants; 2 trials; I²= 15%); C) combination 50% N₂O plus EMLA was significantly better than EMLA alone (mean difference: -1.2; 95% CI: -2.1 to -0.3; p=0.007; 65 participants; 2 trials; I²= 43%). For pain and distress during laceration repair (n=5), N₂O was deemed “favorable” versus subcutaneous lidocaine, oxygen, or oral midazolam, but “neutral” versus intravenous ketamine. For pain and distress during fracture reduction (n=3), N₂O was deemed “neutral” versus combination intramuscular meperidine plus promethazine, intravenous lidocaine, or combination intravenous ketamine plus midazolam. For pain and distress during lumbar puncture (n=1), N₂O was deemed “favorable” versus oxygen. Higher concentrations of N₂0 were associated with more AEs per participant: 6.7% (1/15), 13.7% (64/468), and 25.3% (56/221) with 30%, 50%, and 70% N₂O, respectively. The most common AEs were nausea and agitation (both 3.5% [40/1128]). There were no AEs requiring resuscitative measures.

Conclusion

N₂O is a potentially effective agent for reducing procedural distress and pain in children, although high quality evidence is lacking. Most data exist for venous cannulation where safety and efficacy at reducing pain are optimized with combining 50% N₂O and topical anesthetic cream. For laceration repair, there is considerably less data. Still, N₂O appears to be superior to oral midazolam but equivalent to intravenous ketamine.

Pathogen-Specific Effects of Probiotics in Children With Acute Gastroenteritis Seeking Emergency Care: A Randomized Trial

BACKGROUND

It is unknown if probiotics exert pathogen-specific effects in children with diarrhea secondary to acute gastroenteritis.

METHODS

Analysis of patient-level data from 2 multicenter randomized, placebo controlled trials conducted in pediatric emergency departments in Canada and the United States. Participants were 3-48 months with >3 diarrheal episodes in the preceding 24 hours and were symptomatic for <72 hours and <7 days in the Canadian and US studies, respectively. Participants received either placebo or a probiotic preparation (Canada-Lactobacillus rhamnosus R0011/Lactobacillus helveticus R0052; US-L. rhamnosus GG). The primary outcome was post-intervention moderate-to-severe disease (ie, ≥9 on the Modified Vesikari Scale [MVS] score).

RESULTS

Pathogens were identified in specimens from 59.3% of children (928/1565). No pathogen groups were less likely to experience an MVS score ≥9 based on treatment allocation (test for interaction = 0.35). No differences between groups were identified for adenovirus (adjusted relative risk [aRR]: 1.42; 95% confidence interval [CI]: .62, 3.23), norovirus (aRR: 0.98; 95% CI: .56, 1.74), rotavirus (aRR: 0.86; 95% CI: .43, 1.71) or bacteria (aRR: 1.19; 95% CI: .41, 3.43). At pathogen-group and among individual pathogens there were no differences in diarrhea duration or the total number of diarrheal stools between treatment groups, regardless of intervention allocation or among probiotic sub-groups. Among adenovirus-infected children, those administered the L. rhamnosus R0011/L. helveticus R0052 product experienced fewer diarrheal episodes (aRR: 0.65; 95% CI: .47, .90).

CONCLUSIONS

Neither probiotic product resulted in less severe disease compared to placebo across a range of the most common etiologic pathogens. The preponderance of evidence does not support the notion that there are pathogen specific benefits associated with probiotic use in children with acute gastroenteritis.

CLINICAL TRIALS REGISTRATION

NCT01773967 and NCT01853124.

Post-COVID-19 Conditions Among Children 90 Days After SARS-CoV-2 Infection

IMPORTANCE

Little is known about the risk factors for, and the risk of, developing post-COVID-19 conditions (PCCs) among children.

OBJECTIVES

To estimate the proportion of SARS-CoV-2-positive children with PCCs 90 days after a positive test result, to compare this proportion with SARS-CoV-2-negative children, and to assess factors associated with PCCs.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study, conducted in 36 emergency departments (EDs) in 8 countries between March 7, 2020, and January 20, 2021, included 1884 SARS-CoV-2-positive children who completed 90-day follow-up; 1686 of these children were frequency matched by hospitalization status, country, and recruitment date with 1701 SARS-CoV-2-negative controls.

EXPOSURE

SARS-CoV-2 detected via nucleic acid testing.

MAIN OUTCOMES AND MEASURES

Post-COVID-19 conditions, defined as any persistent, new, or recurrent health problems reported in the 90-day follow-up survey.

RESULTS

Of 8642 enrolled children, 2368 (27.4%) were SARS-CoV-2 positive, among whom 2365 (99.9%) had index ED visit disposition data available; among the 1884 children (79.7%) who completed follow-up, the median age was 3 years (IQR, 0-10 years) and 994 (52.8%) were boys. A total of 110 SARS-CoV-2-positive children (5.8%; 95% CI, 4.8%-7.0%) reported PCCs, including 44 of 447 children (9.8%; 95% CI, 7.4%-13.0%) hospitalized during the acute illness and 66 of 1437 children (4.6%; 95% CI, 3.6%-5.8%) not hospitalized during the acute illness (difference, 5.3%; 95% CI, 2.5%-8.5%). Among SARS-CoV-2-positive children, the most common symptom was fatigue or weakness (21 [1.1%]). Characteristics associated with reporting at least 1 PCC at 90 days included being hospitalized 48 hours or more compared with no hospitalization (adjusted odds ratio [aOR], 2.67 [95% CI, 1.63-4.38]); having 4 or more symptoms reported at the index ED visit compared with 1 to 3 symptoms (4-6 symptoms: aOR, 2.35 [95% CI, 1.28-4.31]; ≥7 symptoms: aOR, 4.59 [95% CI, 2.50-8.44]); and being 14 years of age or older compared with younger than 1 year (aOR, 2.67 [95% CI, 1.43-4.99]). SARS-CoV-2-positive children were more likely to report PCCs at 90 days compared with those who tested negative, both among those who were not hospitalized (55 of 1295 [4.2%; 95% CI, 3.2%-5.5%] vs 35 of 1321 [2.7%; 95% CI, 1.9%-3.7%]; difference, 1.6% [95% CI, 0.2%-3.0%]) and those who were hospitalized (40 of 391 [10.2%; 95% CI, 7.4%-13.7%] vs 19 of 380 [5.0%; 95% CI, 3.0%-7.7%]; difference, 5.2% [95% CI, 1.5%-9.1%]). In addition, SARS-CoV-2 positivity was associated with reporting PCCs 90 days after the index ED visit (aOR, 1.63 [95% CI, 1.14-2.35]), specifically systemic health problems (eg, fatigue, weakness, fever; aOR, 2.44 [95% CI, 1.19-5.00]).

CONCLUSIONS AND RELEVANCE

In this cohort study, SARS-CoV-2 infection was associated with reporting PCCs at 90 days in children. Guidance and follow-up are particularly necessary for hospitalized children who have numerous acute symptoms and are older.

Intestinal Microbial Composition of Children in a Randomized Controlled Trial of Probiotics to Treat Acute Gastroenteritis

Compositional analysis of the intestinal microbiome in pre-schoolers is understudied. Effects of probiotics on the gut microbiota were evaluated in children under 4-years-old presenting to an emergency department with acute gastroenteritis. Included were 70 study participants (n=32 placebo, n=38 probiotics) with stool specimens at baseline (day 0), day 5, and after a washout period (day 28). Microbiota composition and deduced functions were profiled using 16S ribosomal RNA sequencing and predictive metagenomics, respectively. Probiotics were detected at day 5 of administration but otherwise had no discernable effects, whereas detection of bacterial infection (P<0.001) and participant age (P<0.001) had the largest effects on microbiota composition, microbial diversity, and deduced bacterial functions. Participants under 1 year had lower bacterial diversity than older aged pre-schoolers; compositional changes of individual bacterial taxa were associated with maturation of the gut microbiota. Advances in age were associated with differences in gut microbiota composition and deduced microbial functions, which have the potential to impact health later in life.

Derivation of the Pediatric Acute Gastroenteritis Risk Score to Predict Moderate-to-Severe Acute Gastroenteritis

OBJECTIVES

Although most acute gastroenteritis (AGE) episodes in children rapidly self-resolve, some children go on to experience more significant and prolonged illness. We sought to develop a prognostic score to identify children at risk of experiencing moderate-to-severe disease after an index emergency department (ED) visit.

METHODS

Data were collected from a cohort of children 3 to 48 months of age diagnosed with AGE in 16 North American pediatric EDs. Moderate-to-severe AGE was defined as a Modified Vesikari Scale (MVS) score ≥9 during the 14-day post-ED visit. A clinical prognostic model was derived using multivariable logistic regression and converted into a simple risk score. The model's accuracy was assessed for moderate-to-severe AGE and several secondary outcomes.

RESULTS

After their index ED visit, 19% (336/1770) of participants developed moderate-to-severe AGE. Patient age, number of vomiting episodes, dehydration status, prior ED visits, and intravenous rehydration were associated with MVS ≥9 in multivariable regression. Calibration of the prognostic model was strong with a P value of 0.77 by the Hosmer-Lemenshow goodness-of-fit test, and discrimination was moderate with an area under the receiver operator characteristic curve of 0.68 (95% confidence interval [CI] 0.65-0.72). Similarly, the model was shown to have good calibration when fit to the secondary outcomes of subsequent ED revisit, intravenous rehydration, or hospitalization within 72 hours after the index visit.

CONCLUSIONS

After external validation, this new risk score may provide clinicians with accurate prognostic insight into the likely disease course of children with AGE, informing disposition decisions, anticipatory guidance, and follow-up care.

Hematochezia in children with acute diarrhea seeking emergency department care - a prospective cohort study

OBJECTIVES

Although the passage of blood in stools in children represents a medical emergency, children seeking emergency department (ED) care remain poorly characterized. Our primary objective was to compare clinical characteristics and etiologic pathogens in children with acute diarrhea with and without caregiver-reported hematochezia. Secondary objectives were to characterize interventions and resource utilization.

METHODS

We conducted a secondary analysis of the Alberta Provincial Pediatric EnTeric Infection TEam (APPETITE) database. Children <18 years presenting to two pediatric EDs within a 24-hour period and <7 days of symptoms were consecutively recruited.

RESULTS

Of 1,061 participants, 115 (10.8%) reported hematochezia at the enrollment visit at which time those with hematochezia, compared to those without, had more diarrheal episodes/24-hour period (9 vs. 6; difference: 2; 95% confidence interval [CI]: 2.0, 4.0; p < 0.001), and were less likely to have experienced vomiting (54.8% vs. 80.2%; difference: -25.4; 95% CI: -34.9, -16.0; p < 0.001). They were more likely to receive intravenous fluids (33.0% vs. 17.9%; difference: 15.2; 95% CI: 6.2, 24.1; p < 0.001) and require repeat health care visits (45.5% vs. 34.7%; difference: 10.7; 95% CI: 0.9, 20.6; p = 0.03). A bacterial pathogen was identified in 33.0% of children with hematochezia versus 7.9% without (difference: 25.1; 95% CI: 16.3, 33.9; p < 0.001); viruses were detected in 31.3% of children with hematochezia compared to 72.3% in those without (difference: -41.0%, 95% CI: -49.9, -32.1; p < 0.001).

CONCLUSION

In children with acute diarrhea, caregiver report of hematochezia, compared to the absence of hematochezia, was associated with more diarrheal but fewer vomiting episodes, and greater resource consumption. The former group of children was also more likely to have bacteria detected in their stool.

Parental Perspectives on Children's Functional Experiences After Limb Fracture: A Qualitative Study

BACKGROUND

Fractures are a common childhood injury. Although the pain associated with fractures is well described, the related functional impact is less understood. When a child's function is impaired, his or her ability to participate in day-to-day life is restricted. Eighty percent of children with fractures experience compromise in daily function. An in-depth understanding of function can guide emergency department (ED) providers' discharge instructions.

OBJECTIVES

Our aim was to report caregivers' perspectives of the functional impact of limb fractures on their children's day-to-day life activities.

METHODS

We performed a qualitative study using interviews of caregivers of children (aged 5 to 11 years) who received care for acute, nonoperative long bone fractures in a pediatric ED. Audio-recorded, semistructured telephone interviews were completed 7 to 14 days after the ED visit. Interviews were primarily open ended, including questions targeting areas of function from existing pediatric fracture literature. Qualitative analysis was completed using content analysis.

RESULTS

Twenty-five interviews were included in the final analysis. Most of the children were diagnosed with upper extremity fractures, and most participants were mothers. All parents reported a change in their child's function. The most commonly affected areas were sleep, activities of daily living, and play. Play was either self-limited by the child or restricted by the parent. Pain was worse in the first days after discharge. Many children struggled emotionally with functional limitations. All children required help from their parents to perform daily tasks; this required adaptive strategies such as planning, changes to household routine, and missed work. Key concerns from parents included regression in the child's independence and fracture healing and complications.

CONCLUSIONS

Function is universally impaired in young children with fractures, significantly affecting family life after discharge. Discharge conversations with families should include pain management, changes to activities of daily living, family routines and play, and expectations for fracture healing.

Outcomes of SARS-CoV-2-Positive Youths Tested in Emergency Departments: The Global PERN-COVID-19 Study

IMPORTANCE

Severe outcomes among youths with SARS-CoV-2 infections are poorly characterized.

OBJECTIVE

To estimate the proportion of children with severe outcomes within 14 days of testing positive for SARS-CoV-2 in an emergency department (ED).

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study with 14-day follow-up enrolled participants between March 2020 and June 2021. Participants were youths aged younger than 18 years who were tested for SARS-CoV-2 infection at one of 41 EDs across 10 countries including Argentina, Australia, Canada, Costa Rica, Italy, New Zealand, Paraguay, Singapore, Spain, and the United States. Statistical analysis was performed from September to October 2021.

EXPOSURES

Acute SARS-CoV-2 infection was determined by nucleic acid (eg, polymerase chain reaction) testing.

MAIN OUTCOMES AND MEASURES

Severe outcomes, a composite measure defined as intensive interventions during hospitalization (eg, inotropic support, positive pressure ventilation), diagnoses indicating severe organ impairment, or death.

RESULTS

Among 3222 enrolled youths who tested positive for SARS-CoV-2 infection, 3221 (>99.9%) had index visit outcome data available, 2007 (62.3%) were from the United States, 1694 (52.6%) were male, and 484 (15.0%) had a self-reported chronic illness; the median (IQR) age was 3 (0-10) years. After 14 days of follow-up, 735 children (22.8% [95% CI, 21.4%-24.3%]) were hospitalized, 107 (3.3% [95% CI, 2.7%-4.0%]) had severe outcomes, and 4 children (0.12% [95% CI, 0.03%-0.32%]) died. Characteristics associated with severe outcomes included being aged 5 to 18 years (age 5 to <10 years vs <1 year: odds ratio [OR], 1.60 [95% CI, 1.09-2.34]; age 10 to <18 years vs <1 year: OR, 2.39 [95% CI 1.38-4.14]), having a self-reported chronic illness (OR, 2.34 [95% CI, 1.59-3.44]), prior episode of pneumonia (OR, 3.15 [95% CI, 1.83-5.42]), symptoms starting 4 to 7 days prior to seeking ED care (vs starting 0-3 days before seeking care: OR, 2.22 [95% CI, 1.29-3.82]), and country (eg, Canada vs US: OR, 0.11 [95% CI, 0.05-0.23]; Costa Rica vs US: OR, 1.76 [95% CI, 1.05-2.96]; Spain vs US: OR, 0.51 [95% CI, 0.27-0.98]). Among a subgroup of 2510 participants discharged home from the ED after initial testing and who had complete follow-up, 50 (2.0%; 95% CI, 1.5%-2.6%) were eventually hospitalized and 12 (0.5%; 95% CI, 0.3%-0.8%) had severe outcomes. Compared with hospitalized SARS-CoV-2-negative youths, the risk of severe outcomes was higher among hospitalized SARS-CoV-2-positive youths (risk difference, 3.9%; 95% CI, 1.1%-6.9%).

CONCLUSIONS AND RELEVANCE

In this study, approximately 3% of SARS-CoV-2-positive youths tested in EDs experienced severe outcomes within 2 weeks of their ED visit. Among children discharged home from the ED, the risk was much lower. Risk factors such as age, underlying chronic illness, and symptom duration may be useful to consider when making clinical care decisions.

Oral Ondansetron Administration in Children Seeking Emergency Department Care for Acute Gastroenteritis: A Patient-Level Propensity-Matched Analysis

STUDY OBJECTIVE

This study aimed to explore oral ondansetron usage and impact on outcomes in clinical practice.

METHODS

This observational study was a planned secondary analysis of 2 trials conducted in 10 US and 6 Canadian institutions between 2014 and 2017. Children 3 to 48 months old with gastroenteritis and ≥3 episodes of vomiting in the 24 hours preceding emergency department (ED) presentation were included. Oral ondansetron was administered at the discretion of the provider. The principal outcomes were intravenous fluid administration and hospitalization at the index visit and during the subsequent 72 hours and diarrhea and vomiting frequency during the 24 hours following the ED visit.

RESULTS

In total, 794 children were included. The median age was 16.0 months (interquartile range 10.0 to 26.0), and 50.1% (398/794) received oral ondansetron. In propensity-adjusted analysis (n=528), children administered oral ondansetron were less likely to receive intravenous fluids at the index visit (adjusted odds ratio [aOR] 0.50; 95% confidence interval [CI] 0.29 to 0.88). There were no differences in the frequencies of intravenous fluid administration within the first 72 hours (aOR 0.65; 95% CI 0.39 to 1.10) or hospitalization at the index visit (aOR 0.31; 95% CI 0.09 to 1.10) or the subsequent 72 hours (aOR 0.52; 95% CI 0.21 to 1.28). Episodes of vomiting (aRR 0.86; 95% CI 0.63 to 1.19) and diarrhea (aRR 1.11; 95% CI 0.93 to 1.32) during the 24 hours following ED discharge also did not differ.

CONCLUSION

Among preschool-aged children with gastroenteritis seeking ED care, oral ondansetron administration was associated with a reduction in index ED visit intravenous fluid administration; it was not associated with intravenous fluids administered within 72 hours, hospitalization, or vomiting and diarrhea in the 24 hours following discharge.

Anxiolysis for laceration repair in children: a survey of pediatric emergency providers in Canada

OBJECTIVES

Intranasal dexmedetomidine is a potentially effective anxiolytic but its role in pediatric laceration repair is only emerging. Future trials and clinical adoption of intranasal dexmedetomidine depend on understanding pediatric emergency providers' practice patterns surrounding anxiolysis and perceived barriers to intranasal dexmedetomidine for anxiolysis during suture repair in children. Our objectives were to characterize these parameters to inform future research and facilitate clinical adoption.

METHODS

We conducted an online survey of pediatric emergency physician members of Pediatric Emergency Research Canada from September to December 2020. Questions pertained to perceptions of anxiolysis for suture repair, with a focus on intranasal dexmedetomidine. The primary outcome was anxiolysis for suture repair. Data were reported using descriptive statistics.

RESULTS

The response rate was 155/225 (68.9%). During suture repair, 127/148 (86%) believed that > 25% of young children experience distress requiring physical restraint. 116/148 (78%) would provide anxiolysis, mainly intranasal benzodiazepines (100/148, 68%). Only 6/148 (4%) would provide intranasal dexmedetomidine but 95/148 (64%) would consider it if there was evidence of benefit. The most common perceived barriers to intranasal dexmedetomidine included inadequate personal experience (114/145, 79%) and lack of access (60/145, 41%).

CONCLUSIONS

Most Canadian pediatric emergency providers believe that laceration repair in a young child is distressing. Despite questionable efficacy, most would provide intranasal benzodiazepines, but would consider intranasal dexmedetomidine if there was evidence of benefit.

144 Characterizing the Pain Experience of Children with Acute Gastroenteritis Based on Identified Pathogens

Primary Subject area

Emergency Medicine - Paediatric

Background

Many children with acute gastroenteritis (AGE) experience moderate-to-severe pain. To date, the relationship between specific enteropathogens and pain intensity in children with AGE is poorly characterized.

Objectives

To describe pain severity experienced by children with AGE, by enteropathogen type (i.e., bacteria, virus, co-detection) during the 24 hours prior to emergency department (ED) presentation and while in the ED. We also sought to describe analgesic medication use in AGE.

Design/Methods

Children 0 to under 18 years with symptoms of AGE (vomiting and/or diarrhea, less than 7 days duration) were prospectively recruited in two pediatric EDs from December 2014 to August 2018. Rectal swabs and stool specimens were analyzed with a commercial enteric panel, an in-house viral panel, and standard enteric bacterial culture. Pain severity was reported by caregivers, with input from the child whenever possible, using a validated 11-point Verbal Numerical Rating Scale from 0 (no pain) to 10 (maximum pain).

Results

2686 children with AGE participated in the study. The overall maximal mean pain score was 5.50 (SD 3.00) during the 24 hours preceding the ED visit. Children with bacteria detected in their stool had a significantly higher mean pain score (difference: 1.10 [95% CI: 0.36, 1.84]) prior to ED visit and 1.32 (95% CI: 0.54, 2.10) while in the ED, compared to those with no pathogen identified. They also had significantly higher mean pain scores (difference: 1.10 [95%CI: 0.39, 1.81]) prior to ED visit and 1.44 (95%CI: 0.69, 2.20) while in the ED when compared to AGE caused by a single virus. Using a multivariable regression model, the association between pain severity and enteropathogen type was no longer demonstrated; however, longer illness duration (p=0.01), fever (p &lt; 0.0001), increased number of diarrheal (p &lt; 0.0001) and vomiting (p=0.03) episodes, and respiratory symptoms (p=0.03) were all associated with greater pain at home. Overall, analgesic use was low, with 41.6% (1117/2686) and 20.0% (538/2686) of participants receiving an analgesic at home and in the ED, respectively.

Conclusion

Enteropathogen type was not predictive of greater pain severity after adjustment for clinical symptoms (i.e., vomiting and diarrhea). The clinical constellation of symptoms accompanying any particular pathogen may differ between pathogens, and this clinical picture may play the greater role in pain experience. Analgesic use was low in children with this painful condition.

35 Implementation of a quality improvement initiative to reduce pain and anxiety associated with needle-related procedures in a Canadian paediatric emergency department

Primary Subject area

Emergency Medicine - Paediatric

Background

Needle-related procedures such as intravenous (IV) insertion, venipuncture, and lumbar puncture (LP) are commonly performed in children, particularly in the emergency department (ED). Children consistently rate these needle-related procedures as very distressing. While topical anesthetics have been shown to be highly effective and are available, they are inconsistently used. The Children’s Comfort Promise was originally developed at the Minnesota Children’s Hospital. It requires nursing staff to use four strategies for children undergoing needle-related procedures: (1) topical anesthetic, (2) sucrose or breastfeeding if ≤ 12 months, (3) Comfort positioning (swaddling, skin-to-skin, or facilitated tucking if ≤ 12 months and sitting upright for children &gt; 12 months), and (4) age-appropriate distraction.

Objectives

We sought to evaluate compliance with all 4 Comfort Promise strategies for managing children’s pain and anxiety during needle-related procedures in a Canadian paediatric ED.

Design/Methods

Implementation of The Comfort Promise in March 2020 included a focus group to perform a root cause analysis, designation of nurse champions, monthly steering committee and ED working group meetings, and didactic education sessions. Our institution’s decision support unit identified all encounters of children 0-17 years who underwent at least one needle-related procedure at our paediatric ED from January 1 to November 30, 2020. The outcome was compliance with all 4 Comfort Promise strategies. Balancing measures included adverse drug reactions and vasoconstriction. We used statistical process control to analyze the outcome from 2 months preceding and 7 months following implementation.

Results

From January 1 to November 30, 2020, 21,600 encounters were identified, of which 10,294/21,600 (47.7%) were female. Age ranged from 0-17 years with a mean (SD) of 6.9 (5.5) years. Needle-related procedures were performed in 730/21,600 (3.4%) encounters, most commonly IV insertion (289/730, 39.6%) and venipuncture for blood sampling (232/730, 31.8%). Half of all encounters had no compliance strategies electronically recorded (363/730, 49.7%). Compliance with all Comfort Promise strategies increased over the study period (Figure 1). Topical anesthetic increased from 3/35 (8.6%) to 35/83 (42.2%). Sucrose or breastfeeding increased from 0/6 (0%) to 2/16 (12.5%). Comfort positioning increased from 0/35 (0%) to 26/83 (31.3%). Distraction increased from 0/35 (0%) to 22/83 (26.5%). There were no adverse drug reactions or vasoconstriction.

Conclusion

Implementation of The Comfort Promise in a Canadian paediatric ED resulted in greater use of strategies, particularly topical anesthetic, to reduce needle-related distress in children. Ongoing compliance will depend on consistent electronic recording and provider education.

20 Adolescent and caregiver perspectives on living with a limb fracture: A qualitative study

Primary Subject area

Emergency Medicine - Paediatric

Background

Fractures occur in up to half of children by age 16 years. After initial emergency care for a fracture, function is universally impaired in children, and impacts extend to the immediate family. Knowledge of expected functional limitations is key to providing proper discharge instructions and anticipatory guidance to families.

Objectives

Our study objectives were to understand: 1) how adolescents (12-17 years) describe the functional impact of fractures on their lives; 2) how adolescents’ reports of their experiences compare to those of their caregivers; and 3) the impact of the fracture on the family unit.

Design/Methods

We conducted individual, semi-structured interviews from June 2019 to November 2020 with adolescents and their caregivers, 7-14 days following their initial visit to a pediatric emergency department. We utilized qualitative content analysis methodology. Recruitment proceeded until thematic saturation was achieved. Coding and analysis were concurrent with recruitment and interviews. A secondary coder reviewed 40% of the transcripts, and the coding team met regularly to discuss the coding framework and key themes. The interview script was modified in an iterative process, to reflect emerging themes.

Results

We completed a total of 29 interviews. The most commonly affected functions were: a) showering and hygiene (which required the most caregiver support); b) sleep variability (due to pain and cast-related discomfort); and c) exclusion from sports/activities. Many adolescents experienced disruptions to social activities and gatherings. Adolescents valued independence and often chose to take more time to complete a task to preserve this, regardless of inconvenience. Both adolescents and caregivers reported feelings of frustration as a result of day-to-day impacts imposed by the injury. Generally, caregivers’ perspectives were in keeping with the experiences that adolescents described for themselves. Notable family impacts included what we described as ‘sibling burden’ or conflicts that arose when a sibling had to take on extra chores/tasks.

Conclusion

These themes highlight an opportunity to better tailor discharge instructions for adolescents with fractures. Key messages include: 1) expect pain and impaired sleep, especially in the first few days; 2) allow extra time to complete tasks independently, especially for grooming and hygiene; 3) consider family impact, especially sibling burden; 4) prepare for changes in activities and social dynamics; and 5) frustration is normal, for both adolescents and caregivers. Future work can focus on developing a novel, family-informed tool to assess functional outcomes following injury.

19 Anxiolysis for laceration repair in children: A survey of pediatric emergency providers in Canada

Primary Subject area

Emergency Medicine - Paediatric

Background

Laceration repair accounts for half of procedures performed in pediatric emergency departments. Although commonly used, topical anesthetics do little to alleviate emotional distress, particularly in young children. Intranasal midazolam is frequently used but is not consistently effective. Intranasal dexmedetomidine (IND) is a new and potentially effective anxiolytic but clinical uptake is limited by a lack of pediatric data.

Objectives

Our objective was to understand pediatric emergency providers’ willingness, preferences, and perceived barriers surrounding anxiolysis for laceration repair in children, to inform the design of a future clinical trial of IND.

Design/Methods

This was an online survey of Canadian pediatric emergency providers listed in the Pediatric Emergency Research Canada database. The survey was developed according to published guidelines and featured a vignette of a 3-year-old distressed child requiring laceration repair. It was hosted on the Research Electronic Data Capture platform in English and French, and was disseminated from September to December 2020. The primary outcome was the proportion of respondents that would provide anxiolysis. Secondary outcomes included perceived barriers to IND use. Data were reported using summary statistics.

Results

The response rate was 155/225 (68.9%), of which 98/141 (70%) were Royal College accredited pediatric emergency physicians. For 129/147 (88%) of respondents, 80-100% of their patients were children. 123/146 (84%) had &gt; 6 years independent practice experience and 126/146 (86%) performed &gt; 4 laceration repairs per month. 127/148 (86%) believed that &gt; 25% of children experienced distress significant enough to require physical restraint during laceration repair. 116/148 (78%) indicated they would provide anxiolysis, mainly as intranasal benzodiazepines, such as midazolam (100/109, 92%). 95/148 (64%) indicated that they would consider IND if evidence suggested it was effective. Common perceived barriers included inadequate personal (114/145, 79%) and nursing (109/145, 75%) experience with IND, and lack of formulary access to IND (60/145, 41%).

Conclusion

Most pediatric emergency providers believe that laceration repair in a young child is distressing and would provide anxiolysis. Most providers would consider IND if there was evidence of benefit, suggesting that favourable findings from a clinical trial would have good clinical uptake.

28 Assessment of Pain and Provision of Non-Pharmacologic Analgesia to Children by Prehospital Providers in Southwestern Ontario: A Cross-Sectional Study

Primary Subject area

Emergency Medicine - Paediatric

Background

There is abundant evidence that provision of pharmacologic analgesia by prehospital providers to children is suboptimal. Most paediatric calls are performed by primary care paramedics (PCPs) who are unable to administer pharmacologic analgesia to children but can administer non-pharmacologic therapies.

Objectives

Our objective was to describe the provision of non-pharmacologic analgesia to children by prehospital providers.

Design/Methods

We reviewed all ambulance call reports (ACRs) of children 0-17 years with acutely painful conditions (headache, abdominal pain, injury, head/ears/eyes/nose/throat pain, and back pain) who were transported to a paediatric tertiary referral centre serving a catchment of &gt; 1 million from 2017-2019. Data collection was recorded by two blinded assessors using a study-specific Excel™ sheet. The primary outcome was the proportion of children offered non-pharmacologic analgesia. We performed a stepwise logistic regression on the primary outcome using covariates defined a priori: age, sex, visible deformity, type of crew, complaint, pain score, call time, and prior analgesia.

Results

All 11,084 ACRs from January 1, 2017 to December 31, 2019 were reviewed. The sample included 5887/11084 (53.1%) males, ranging from 1 month to 17 years, with a mean (SD) age of 10.5 (5.6) years. Calls involved mainly PCPs [8576/11084 (77.4%)]. Non-trauma-related musculoskeletal injuries were most common, comprising 2743/11,084 (24.7%) of calls. Pain scores were documented in 6947/11084 (62.7%) of calls. The verbal numeric rating scale (0-10) was used in 5022/6947 (72.3%) of calls, with a mean (SD) score of 5.2 (3.2). Non-pharmacologic analgesia was provided in 2926/11084 (26.4%) of calls, most commonly splint (1115/2926, 38.1%) and ice (931/2926, 31.8%). Pharmacologic analgesia was provided in 458/11084 (4.1%) of calls. In the multivariate model, mild (OR: 3.2; 95% CI 2.3-4.4; p &lt; 0 .001) and moderate pain (OR: 1.7; 95% CI 1.3-2.2) (versus no pain) were significant predictors of non-pharmacologic analgesia, whereas visible deformity (OR: 0.5; 95% CI 0.3-0.6; p &lt; 0 .001) was a significant negative predictor.

Conclusion

The provision of non-pharmacologic analgesia to children in Southwestern Ontario by prehospital providers is suboptimal, despite moderate to severe pain. There is a clear need for education surrounding approaches to non-pharmacologic analgesia in children among prehospital providers.

Comparing Pediatric Gastroenteritis Emergency Department Care in Canada and the United States

BACKGROUND

Between-country variation in health care resource use and its impact on outcomes in acute care settings have been challenging to disentangle from illness severity by using administrative data.

METHODS

We conducted a preplanned analysis employing patient-level emergency department (ED) data from children enrolled in 2 previously conducted clinical trials. Participants aged 3 to <48 months with <72 hours of gastroenteritis were recruited in pediatric EDs in the United States (N = 10 sites; 588 participants) and Canada (N = 6 sites; 827 participants). The primary outcome was an unscheduled health care provider visit within 7 days; the secondary outcomes were intravenous fluid administration and hospitalization at or within 7 days of the index visit.

RESULTS

In adjusted analysis, unscheduled revisits within 7 days did not differ (adjusted odds ratio [aOR]: 0.72; 95% confidence interval (CI): 0.50 to 1.02). At the index ED visit, although participants in Canada were assessed as being more dehydrated, intravenous fluids were administered more frequently in the United States (aOR: 4.6; 95% CI: 2.9 to 7.1). Intravenous fluid administration rates did not differ after enrollment (aOR: 1.4; 95% CI: 0.7 to 2.8; US cohort with Canadian as referent). Overall, intravenous rehydration was higher in the United States (aOR: 3.8; 95% CI: 2.5 to 5.7). Although hospitalization rates during the 7 days after enrollment (aOR: 1.1; 95% CI: 0.4 to 2.6) did not differ, hospitalization at the index visit was more common in the United States (3.9% vs 2.3%; aOR: 3.2; 95% CI: 1.6 to 6.8).

CONCLUSIONS

Among children with gastroenteritis and similar disease severity, revisit rates were similar in our 2 study cohorts, despite lower rates of intravenous rehydration and hospitalization in Canadian-based EDs.

Clinical Suspicion and Language Translation in the Pediatric Emergency Department

ABSTRACT

Elucidating a medical history and gaining patient consent and buy-in are difficult in any teenager presenting to a North American pediatric emergency department, but especially so when they present with limited English fluency. Translators can make this process easier, but both limited availability and impreciseness in translation can reduce their utility. We describe 2 teenage females who presented to our pediatric emergency department within 48 hours with similar presentations but no obvious organic cause or examination findings to suggest a specific diagnosis. We demonstrate how complex language translation issues in these adolescents contributed to prolonged diagnoses and advocate for independent interpreters to be available on first presentation to hospital.

Probiotic stool secretory immunoglobulin A modulation in children with gastroenteritis: a randomized clinical trial

BACKGROUND

We previously conducted the Probiotic Regimen for Outpatient Gastroenteritis Utility of Treatment (PROGUT) study, which identified no improvements in children with acute gastroenteritis (AGE) administered a probiotic. However, the aforementioned study did not evaluate immunomodulatory benefits.

OBJECTIVES

The object of this study was to determine if stool secretory immunoglobulin A (sIgA) concentrations in children with AGE increase more among participants administered a Lactobacillus rhamnosus/helveticus probiotic compared with those administered placebo.

METHODS

This a priori planned multicenter, randomized, double-blinded, placebo-controlled ancillary study enrolled children presenting for emergency care who received a 5-d probiotic or placebo course. Participants submitted stool specimens on days 0, 5, and 28. The primary endpoint was the change in stool sIgA concentrations on day 5 compared with baseline.

RESULTS

A total of 133 (n = 66 probiotic, 67 placebo) of 886 PROGUT participants (15.0%) provided all 3 specimens. Median stool sIgA concentrations did not differ between the probiotic and placebo groups at any of the study time points: day 0 median (IQR): 1999 (768, 4071) compared with 2198 (702, 5278) (P = 0.27, Cohen's d = 0.17); day 5: 2505 (1111, 5310) compared with 3207 (982, 7080) (P = 0.19, Cohen's d = 0.16); and day 28: 1377 (697, 2248) compared with 1779 (660, 3977) (P = 0.27, Cohen's d = 0.19), respectively. When comparing measured sIgA concentrations between days 0 and 5, we found no treatment allocation effects [β: -0.24 (-0.65, 0.18); P = 0.26] or interaction between treatment and specimen collection day [β: -0.003 (-0.09, 0.09); P = 0.95]. Although stool sIgA decreased between day 5 and day 28 within both groups (P < 0.001), there were no differences between the probiotic and placebo groups in the median changes in sIgA concentrations when comparing day 0 to day 5 median (IQR) [500 (-1135, 2362) compared with 362 (-1122, 4256); P = 0.77, Cohen's d = 0.075] and day 5 to day 28 [-1035 (-3130, 499) compared with -1260 (-4437, 843); P = 0.70, Cohen's d = 0.067], respectively.

CONCLUSIONS

We found no effect of an L. rhamnosus/helveticus probiotic, relative to placebo, on stool IgA concentrations. This trial was registered at clinicaltrials.gov as NCT01853124.

Variables Associated With Intravenous Rehydration and Hospitalization in Children With Acute Gastroenteritis: A Secondary Analysis of 2 Randomized Clinical Trials

IMPORTANCE

Despite guidelines endorsing oral rehydration therapy, intravenous fluids are commonly administered to children with acute gastroenteritis in high-income countries.

OBJECTIVE

To identify factors associated with intravenous fluid administration and hospitalization in children with acute gastroenteritis.

DESIGN, SETTING, AND PARTICIPANTS

This study is a planned secondary analysis of the Pediatric Emergency Research Canada (PERC) and Pediatric Emergency Care Applied Research Network (PECARN) probiotic trials. Participants include children aged 3 to 48 months with 3 or more watery stools in 24 hours between November 5, 2013, and April 7, 2017, for the PERC study and July 8, 2014, and June 23, 2017, for the PECARN Study. Children were from 16 pediatric emergency departments throughout Canada (6) and the US (10). Data were analyzed from November 2, 2018, to March 16, 2021.

EXPOSURES

Sex, age, preceding health care visit, distance between home and hospital, country (US vs Canada), frequency and duration of vomiting and diarrhea, presence of fever, Clinical Dehydration Scale score, oral ondansetron followed by oral rehydration therapy, and infectious agent.

MAIN OUTCOMES AND MEASURES

Intravenous fluid administration and hospitalization.

RESULTS

This secondary analysis of 2 randomized clinical trials included 1846 children (mean [SD] age, 19.1 [11.4] months; 1007 boys [54.6%]), of whom 534 of 1846 (28.9%) received oral ondansetron, 240 of 1846 (13.0%) received intravenous rehydration, and 67 of 1846 (3.6%) were hospitalized. The following were independently associated with intravenous rehydration: higher Clinical Dehydration Scale score (mild to moderate vs none, odds ratio [OR], 8.73; 95% CI, 5.81-13.13; and severe vs none, OR, 34.15; 95% CI, 13.45-86.73); country (US vs Canada, OR, 6.76; 95% CI, 3.15-14.49); prior health care visit with intravenous fluids (OR, 4.55; 95% CI, 1.32-15.72); and frequency of vomiting (per 5 episodes, OR, 1.66; 95% CI, 1.39-1.99). The following were independently associated with hospitalization: higher Clinical Dehydration Scale score (mild to moderate vs none, OR, 11.10; 95% CI, 5.05-24.38; and severe vs none, OR, 23.55; 95% CI, 7.09-78.25) and country (US vs Canada, OR, 3.37; 95% CI, 1.36-8.40). Oral ondansetron was associated with reduced odds of intravenous rehydration (OR, 0.21; 95% CI, 0.13-0.32) and hospitalization (OR, 0.44; 95% CI, 0.21-0.89).

CONCLUSIONS AND RELEVANCE

Intravenous rehydration and hospitalization were associated with clinical evidence of dehydration and lack of an oral ondansetron-supported oral rehydration period. Strategies focusing on oral ondansetron administration followed by oral rehydration therapy in children with dehydration may reduce the reliance on intravenous rehydration and hospitalization.

TRIAL REGISTRATION

ClinicalTrials.gov Identifiers: NCT01853124 (PERC) and NCT01773967 (PECARN).

Characterizing Pain in Children with Acute Gastroenteritis Who Present for Emergency Care

OBJECTIVE

To characterize the pain experienced by children with acute gastroenteritis (AGE) in the 24 hours before emergency department (ED) presentation. Secondary objectives included characterizing ED pain, discharge recommendations, overall analgesic use, and factors that influenced analgesic use and pain severity.

STUDY DESIGN

A prospective cohort was recruited from 2 pediatric EDs (December 2014 to September 2017). Eligibility criteria included <18 years of age, AGE (≥3 episodes of diarrhea or vomiting in the previous 24 hours), and symptom duration <7 days at presentation.

RESULTS

We recruited 2136 patients, median age 20.8 months (IQR 10.4, 47.4) and 45.8% (979/2136) female. In the 24 hours before enrollment, most caregivers reported moderate (28.6% [610/2136, 95% CI 26.7-30.5]) or severe (46.2% [986/2136, CI 44.0-48.3]) pain for their child. In the ED, they reported moderate (31.1% [664/2136, 95% CI 29.1-33.1]) or severe ([26.7% [571/2136, 95% CI 24.9-28.7]) pain; analgesia was provided to 21.2% (452/2131). The most common analgesics used in the ED were acetaminophen and ibuprofen. At discharge, these were also most commonly recommended. Factors associated with greater analgesia use in the ED were high pain scores during the index visit, having a primary care physician, earlier presentation to emergency care, fewer diarrheal episodes, presence of fever, and hospitalization at index visit.

CONCLUSIONS

Most caregivers of children presenting to the ED with AGE reported moderate or severe pain, both before and during their visit. Future research should focus on the development of effective, safe, and timely pain management plans.

A novel preference-informed complementary trial (PICT) design for clinical trial research influenced by strong patient preferences

Background

Patients and their families often have preferences for medical care that relate to wider considerations beyond the clinical effectiveness of the proposed interventions. Traditionally, these preferences have not been adequately considered in research. Research questions where patients and families have strong preferences may not be appropriate for traditional randomized controlled trials (RCTs) due to threats to internal and external validity, as there may be high levels of drop-out and non-adherence or recruitment of a sample that is not representative of the treatment population. Several preference-informed designs have been developed to address problems with traditional RCTs, but these designs have their own limitations and may not be suitable for many research questions where strong preferences and opinions are present.

Methods

In this paper, we propose a novel and innovative preference-informed complementary trial (PICT) design which addresses key weaknesses with both traditional RCTs and available preference-informed designs. In the PICT design, complementary trials would be operated within a single study, and patients and/or families would be given the opportunity to choose between a trial with all treatment options available and a trial with treatment options that exclude the option which is subject to strong preferences. This approach would allow those with strong preferences to take part in research and would improve external validity through recruiting more representative populations and internal validity. Here we discuss the strengths and limitations of the PICT design and considerations for analysis and present a motivating example for the design based on the use of opioids for pain management for children with musculoskeletal injuries.

Conclusions

PICTs provide a novel and innovative design for clinical trials with more than two arms, which can address problems with existing preference-informed trial designs and enhance the ability of researchers to reflect shared decision-making in research as well as improving the validity of trials of topics with strong preferences.

Starting, building and sustaining a program of research in emergency medicine in Canada

OBJECTIVE

To develop pragmatic recommendations for starting, building and sustaining a program of research in emergency medicine (EM) in Canada at sites with limited infrastructure and/or prior research experience.

METHODS

At the direction of the Canadian Association of Emergency Physicians (CAEP) academic section, we assembled an expert panel of 10 EM researchers with experience building programs of research. Using a modified Delphi approach, our panel developed initial recommendations for (1) starting, (2) building, and (3) sustaining a program of research in EM. These recommendations were peer-reviewed by emergency physicians and researchers from each of the panelist's home institutions and tested for face and construct validity, as well as ease of comprehension. The recommendations were then iteratively revised based on feedback and suggestions from peer review and amended again after being presented at the 2020 CAEP academic symposium.

RESULTS

Our panel created 15 pragmatic recommendations for those intending to start (formal research training, find mentors, local support, develop a niche, start small), build (funding, build a team, collaborate, publish, expect failure) and sustain (become a mentor, obtain leadership roles, lead national studies, gain influence, prioritize wellness) a program of EM research in centers without an established research culture. Additionally, we suggest four recommendations for department leads aiming to foster a program of research within their departments.

CONCLUSION

These recommendations serve as guidance for centres wanting to establish a program of research in EM.

The intranasal dexmedetomidine plus ketamine for procedural sedation in children, adaptive randomized controlled non-inferiority multicenter trial (Ketodex): a statistical analysis plan

Background

Procedural sedation and analgesia (PSA) is frequently required to perform closed reductions for fractures and dislocations in children. Intravenous (IV) ketamine is the most commonly used sedative agent for closed reductions. However, as children find IV insertion a distressing and painful procedure, there is need to identify a feasible alternative route of administration. There is evidence that a combination of dexmedetomidine and ketamine (ketodex), administered intranasally (IN), could provide adequate sedation for closed reductions while avoiding the need for IV insertion. However, there is uncertainty about the optimal combination dose for the two agents and whether it can provide adequate sedation for closed reductions. The Intranasal Dexmedetomidine Plus Ketamine for Procedural Sedation (Ketodex) study is a Bayesian phase II/III, non-inferiority trial in children undergoing PSA for closed reductions that aims to address both these research questions. This article presents in detail the statistical analysis plan for the Ketodex trial and was submitted before the outcomes of the trial were available for analysis.

Methods/design

The Ketodex trial is a multicenter, four-armed, randomized, double-dummy controlled, Bayesian response adaptive dose finding, non-inferiority, phase II/III trial designed to determine (i) whether IN ketodex is non-inferior to IV ketamine for adequate sedation in children undergoing a closed reduction of a fracture or dislocation in a pediatric emergency department and (ii) the combination dose for IN ketodex that provides optimal sedation. Adequate sedation will be primarily measured using the Pediatric Sedation State Scale. As secondary outcomes, the Ketodex trial will compare the length of stay in the emergency department, time to wakening, and adverse events between study arms.

Discussion

The Ketodex trial will provide evidence on the optimal dose for, and effectiveness of, IN ketodex as an alternative to IV ketamine providing sedation for patients undergoing a closed reduction. The data from the Ketodex trial will be analyzed from a Bayesian perspective according to this statistical analysis plan. This will reduce the risk of producing data-driven results introducing bias in our reported outcomes.

Trial registration

ClinicalTrials.gov NCT04195256. Registered on December 11, 2019.

Adaptive randomised controlled non-inferiority multicentre trial (the Ketodex Trial) on intranasal dexmedetomidine plus ketamine for procedural sedation in children: study protocol

INTRODUCTION

Up to 40% of orthopaedic injuries in children require a closed reduction, almost always necessitating procedural sedation. Intravenous ketamine is the most commonly used sedative agent. However, intravenous insertion is painful and can be technically difficult in children. We hypothesise that a combination of intranasal dexmedetomidine plus intranasal ketamine (Ketodex) will be non-inferior to intravenous ketamine for effective sedation in children undergoing a closed reduction.

METHODS AND ANALYSIS

This is a six-centre, four-arm, adaptive, randomised, blinded, controlled, non-inferiority trial. We will include children 4-17 years with a simple upper limb fracture or dislocation that requires sedation for a closed reduction. Participants will be randomised to receive either intranasal Ketodex (one of three dexmedetomidine and ketamine combinations) or intravenous ketamine. The primary outcome is adequate sedation as measured using the Paediatric Sedation State Scale. Secondary outcomes include length of stay, time to wakening and adverse effects. The results of both per protocol and intention-to-treat analyses will be reported for the primary outcome. All inferential analyses will be undertaken using a response-adaptive Bayesian design. Logistic regression will be used to model the dose-response relationship for the combinations of intranasal Ketodex. Using the Average Length Criterion for Bayesian sample size estimation, a survey-informed non-inferiority margin of 17.8% and priors from historical data, a sample size of 410 participants will be required. Simulations estimate a type II error rate of 0.08 and a type I error rate of 0.047.

ETHICS AND DISSEMINATION

Ethics approval was obtained from Clinical Trials Ontario for London Health Sciences Centre and McMaster Research Ethics Board. Other sites have yet to receive approval from their institutions. Informed consent will be obtained from guardians of all participants in addition to assent from participants. Study data will be submitted for publication regardless of results.

TRIAL REGISTRATION NUMBER

NCT0419525.

Hyoscine butylbromide versus acetaminophen for nonspecific colicky abdominal pain in children: a randomized controlled trial

BACKGROUND

Less than two-thirds of children with abdominal pain in the emergency department receive analgesia. We sought to determine whether hyoscine butylbromide was superior to acetaminophen for children with nonspecific colicky abdominal pain.

METHODS

We randomly allocated children aged 8-17 years with nonspecific colicky abdominal pain who presented to the pediatric emergency department of London Health Sciences Centre, London, Ontario to receive hyoscine butylbromide, 10 mg given orally, or acetaminophen, 15 mg/kg given orally (maximum 975 mg). We considered the minimal clinically important difference for the primary outcome (self-reported pain at 80 min) to be 13 mm on a 100 mm visual analogue scale. Secondary outcomes included administration of rescue analgesia, adverse effects and pain score less than 30 mm at 80 minutes.

RESULTS

A total of 236 participants (120 in the hyoscine butylbromide group and 116 in the acetaminophen group) were included in the trial. The mean visual analogue scale scores at 80 minutes were 29 mm (standard deviation [SD] 26 mm) and 30 mm (SD 29 mm) with hyoscine butylbromide and acetaminophen, respectively (adjusted difference 1, 95% confidence interval -7 to 7). Rescue analgesia was administered to 4 participants (3.3%) in the hyoscine butylbromide group and 1 participant (0.9%) in the acetaminophen groups (p = 0.2). We found no significant differences in rates of adverse effects between hyoscine butylbromide (32/116 [27.6%]) and acetaminophen (28/115 [24.3]) (p = 0.5); no serious adverse effects were observed. The proportion with a pain score less than 30 mm at 80 minutes was 66 (55.0%) with hyoscine butylbromide and 63 (54.3%) with acetaminophen (p = 0.9).

INTERPRETATION

Hyoscine butylbromide was not superior to acetaminophen in this setting. Both agents were associated with clinically important pain reduction, and either can be considered for children presenting to the emergency department with nonspecific colicky abdominal pain. Trial registration: Clinicaltrials.gov, no. NCT02582307.

A Bayesian response-adaptive dose-finding and comparative effectiveness trial

BACKGROUND/AIMS

Combinations of treatments that have already received regulatory approval can offer additional benefit over Each of the treatments individually. However, trials of these combinations are lower priority than those that develop novel therapies, which can restrict funding, timelines and patient availability. This article develops a novel trial design to facilitate the evaluation of New combination therapies. This trial design combines elements of phase II and phase III trials to reduce the burden of evaluating combination therapies, while also maintaining a feasible sample size. This design was developed for a randomised trial that compares the properties of three combination doses of ketamine and dexmedetomidine, given intranasally, to ketamine delivered intravenously for children undergoing a closed reduction for a fracture or dislocation.

METHODS

This trial design uses response-adaptive randomisation to evaluate different dose combinations and increase the information collected for successful novel drug combinations. The design then uses Bayesian dose-response modelling to undertake a comparative effectiveness analysis for the most successful dose combination against a relevant comparator. We used simulation methods determine the thresholds for adapting the trial and making conclusions. We also used simulations to evaluate the probability of selecting the dose combination with the highest true effectiveness the operating characteristics of the design and its Bayesian predictive power.

RESULTS

With 410 participants, five interim updates of the randomisation ratio and a probability of effectiveness of 0.93, 0.88 and 0.83 for the three dose combinations, we have an 83% chance of randomising the largest number of patients to the drug with the highest probability of effectiveness. Based on this adaptive randomisation procedure, the comparative effectiveness analysis has a type I error of less than 5% and a 93% chance of correcting concluding non-inferiority, when the probability of effectiveness for the optimal combination therapy is 0.9. In this case, the trial has a greater than 77% chance of meeting its dual aims of dose-finding and comparative effectiveness. Finally, the Bayesian predictive power of the trial is over 90%.

CONCLUSIONS

By simultaneously determining the optimal dose and collecting data on the relative effectiveness of an intervention, we can minimise administrative burden and recruitment time for a trial. This will minimise the time required to get effective, safe combination therapies to patients quickly. The proposed trial has high potential to meet the dual study objectives within a feasible overall sample size.