ObjectiveTo report the performance of clinical practice guidelines (CPG) in the diagnosis of serious/invasive bacterial infections (SBI/IBI) in infants presenting with a fever to emergency care in the UK and Ireland. Two CPGs were from the National Institutes for Health and Care Excellence (NICE guidelines NG51 and NG143) and one was from the British Society for Antimicrobial Chemotherapy (BSAC).DesignRetrospective multicentre cohort study.PatientsFebrile infants aged 90 days or less attending between the 31 August 2018 to 1 September 2019.Main outcome measuresThe sensitivity, specificity and predictive values of CPGs in identifying SBI and IBI.SettingSix paediatric Emergency Departments in the UK/Ireland.Results555 participants were included in the analysis. The median age was 53 days (IQR 32 to 70), 447 (81%) underwent blood testing and 421 (76%) received parenteral antibiotics. There were five participants with bacterial meningitis (1%), seven with bacteraemia (1%) and 66 (12%) with urinary tract infections. The NICE NG51 CPG was the most sensitive: 1.00 (95% CI 0.95 to 1.00). This was significantly more sensitive than NICE NG143: 0.91 (95% CI 0.82 to 0.96, p=0.0233) and BSAC: 0.82 (95% 0.72 to 0.90, p=0.0005). NICE NG51 was the least specific 0.0 (95% CI 0.0 to 0.01), and this was significantly lower than the NICE NG143: 0.09 (95% CI 0.07 to 0.12, p<0.0001) and BSAC: 0.14 (95% CI 0.1 to 0.17, p<0.0001).ConclusionNone of the studied CPGs demonstrated ideal performance characteristics. CPGs should be improved to guide initial clinical decision making.Trial registration numberNCT04196192.

Background During the initial phase of the Coronavirus Disease 2019 (COVID-19) pandemic, reduced numbers of acutely ill or injured children presented to emergency departments (EDs). Concerns were raised about the potential for delayed and more severe presentations and an increase in diagnoses such as diabetic ketoacidosis and mental health issues. This multinational observational study aimed to study the number of children presenting to EDs across Europe during the early COVID-19 pandemic and factors influencing this and to investigate changes in severity of illness and diagnoses. Methods and findings Routine health data were extracted retrospectively from electronic patient records of children aged 18 years and under, presenting to 38 EDs in 16 European countries for the period January 2018 to May 2020, using predefined and standardized data domains. Observed and predicted numbers of ED attendances were calculated for the period February 2020 to May 2020. Poisson models and incidence rate ratios (IRRs), using predicted counts for each site as offset to adjust for case-mix differences, were used to compare age groups, diagnoses, and outcomes. Reductions in pediatric ED attendances, hospital admissions, and high triage urgencies were seen in all participating sites. ED attendances were relatively higher in countries with lower SARS-CoV-2 prevalence (IRR 2·26, 95% CI 1·90 to 2·70, p < 0.001) and in children aged <12 months (12 to <24 months IRR 0·86, 95% CI 0·84 to 0·89; 2 to <5 years IRR 0·80, 95% CI 0·78 to 0·82; 5 to <12 years IRR 0·68, 95% CI 0·67 to 0·70; 12 to 18 years IRR 0·72, 95% CI 0·70 to 0·74; versus age <12 months as reference group, p < 0.001). The lowering of pediatric intensive care admissions was not as great as that of general admissions (IRR 1·30, 95% CI 1·16 to 1·45, p < 0.001). Lower triage urgencies were reduced more than higher triage urgencies (urgent triage IRR 1·10, 95% CI 1·08 to 1·12; emergent and very urgent triage IRR 1·53, 95% CI 1·49 to 1·57; versus nonurgent triage category, p < 0.001). Reductions were highest and sustained throughout the study period for children with communicable infectious diseases. The main limitation was the retrospective nature of the study, using routine clinical data from a wide range of European hospitals and health systems. Conclusions Reductions in ED attendances were seen across Europe during the first COVID-19 lockdown period. More severely ill children continued to attend hospital more frequently compared to those with minor injuries and illnesses, although absolute numbers fell. Trial registration ISRCTN91495258 https://www.isrctn.com/ISRCTN91495258.

BackgroundPain is very common in childhood emergency department (ED) attendances, but is under-recognised and undertreated. Sequential national paediatric analgesia audits demonstrate suboptimal outcomes in several domains. The Donabedian framework examines the structures, processes and outcomes to evaluate quality of care. To date there has been no network-level exploration of structures supporting analgesic practices or attempts to address failure to attain national standards.ObjectiveTo benchmark current variation in assessment and management of childhood pain at network level.MethodsOnline survey distributed between December 2016 and January 2017 exploring health system structures including pain score tools, pain assessment/protocols, training, practice guidelines and analgesic agent usage. We explored structures, processes and outcomes to identify interventions, and their potential effectiveness and feasibility.ResultsIn total 95% (38/40 sites) responded, including 25 tertiary (66%) and 13 secondary hospitals (34%), with a total annual paediatric ED census of 1 225 000 (range 11 500–65 000). Availability of analgesics varied included topical wound anaesthesia in 29/38 sites (76%), oral diclofenac sodium in 22/38 sites (58%) and tramadol in 16/38 sites (42%). Pain assessment was mandatory in initial assessment in 34/38 sites (89%), and 18/38 sites had a policy on frequency of pain assessment (47%). Local guidance aligned with national guidance in 21/38 sites (55%). There was no staff training at induction/orientation in 14/38 sites (37%) and no mandatory competencies in pain management in 23/38 sites (61%). Play specialist services were available in 21/38 sites (55%).ConclusionDespite national guidance and recommendations from multiple audits, there are substantial variations in structures relating to pain assessment and management across sites. The lack of uniformity is a likely root cause for the persistent suboptimal practices identified by serial national audits. A whole system and person-centred approach to improving pain outcomes by utilising effective interventions seeks to improve paediatric pain outcomes.

BackgroundBronchiolitis is a major source of morbimortality among young children worldwide. Non-pharmaceutical interventions (NPIs) implemented to reduce the spread of SARS-CoV-2 may have had an important impact on bronchiolitis outbreaks, as well as major societal consequences. Discriminating between their respective impacts would help define optimal public health strategies against bronchiolitis. We aimed to assess the respective impact of each NPI on bronchiolitis outbreaks in 14 European countries.MethodsWe conducted a quasi-experimental interrupted time-series analysis based on a multicentre international study. All children diagnosed with bronchiolitis presenting to the paediatric emergency department of one of the 27 centres from January 2018 to March 2021 were included. We assessed the association between each NPI and change in the bronchiolitis trend over time by seasonally adjusted multivariable quasi-Poisson regression modelling.ResultsIn total, 42 916 children were included. We observed an overall cumulative 78% reduction (95%CI [−100;−54], p<0.0001) in bronchiolitis cases following NPI implementation. The decrease varied between countries from −97% (95%CI [−100;−47], p=0.0005) to −36% (95%CI [−79;+07], p=0.105). Full lockdown (IRR 0.21, 95%CI [0.14;0.30], p<0.001), secondary-school closure (IRR 0.33, 95%CI [0.20;0.52], p<0.0001), wearing a mask indoors (IRR 0.49, 95%CI [0.25;0.94], p=0.034), and teleworking (IRR 0.55, 95%CI [0.31;0.97], p=0.038) were independently associated with reducing bronchiolitis.ConclusionSeveral NPIs were associated with a reduction of bronchiolitis outbreaks, including full lockdown, school closure, teleworking and facial masking. Some of these public health interventions may be considered to further reduce the global burden of bronchiolitis.