Pediatrics 2015

Treatment


1. Pediatrics. 2015 Sep;136(3):542-53. doi: 10.1542/peds.2015-0738. Epub 2015 Aug
17.

Safety and Efficacy of High-Flow Nasal Cannula Therapy in Preterm Infants: A
Meta-analysis.

Kotecha SJ(1), Adappa R(2), Gupta N(2), Watkins WJ(1), Kotecha S(1), Chakraborty
M(3).

Author information: 
(1)Department of Child Health, Cardiff University, Cardiff, United Kingdom; and. 
(2)Department of Neonatology, University Hospital of Wales, Cardiff, United
Kingdom. (3)Department of Child Health, Cardiff University, Cardiff, United
Kingdom; and Department of Neonatology, University Hospital of Wales, Cardiff,
United Kingdom chakrabortym@cardiff.ac.uk.

BACKGROUND AND OBJECTIVE: High-flow therapy is the most recent, and popular, mode
of respiratory support in neonates. However, the evidence supporting its efficacy
and safety has not yet been established. We conducted a systematic review and
meta-analysis of clinical trials comparing efficacy and safety of high-flow
therapy compared with other modes of noninvasive ventilation (NIV) in preterm
infants.
METHODS: Articles were indexed by using Medline, Embase, Scopus, OpenSIGLE,
Health Management Information Consortium, and Cochrane Central Register of
Controlled Trials. Randomized or quasi-randomized clinical trials involving
preterm infants, comparing high-flow therapy with other modes of NIV, and
reporting extractable data on relevant outcomes, were selected. Data on efficacy,
safety, and other common neonatal outcomes were extracted on predesigned forms.
RESULTS: In this analysis, we included 1112 preterm infants, participating in 9
clinical trials. High-flow therapy was similar in efficacy to other modes of NIV
in preterm infants when used as primary support (odds ratio of failure of
therapy, 1.02 [95% confidence interval: 0.55 to 1.88]), as well as after
extubation (1.09 [0.58 to 2.02]). There were no significant differences in odds
of death (0.48 [0.18 to 1.24]) between the groups. Preterm infants supported on
high-flow had significantly lower odds of nasal trauma (0.13 [0.02 to 0.69]).
CONCLUSIONS: High-flow therapy appears to be similar in efficacy and safety to
other conventional modes of NIV in preterm infants. It is associated with
significantly lower odds of nasal trauma. Caution needs to be exercised in
extreme preterm infants because of the paucity of published data.

Copyright © 2015 by the American Academy of Pediatrics.

PMID: 26283781  [PubMed - in process]


2. Pediatrics. 2015 Oct;136(4):e879-86. doi: 10.1542/peds.2015-1852.

Intraurethral Lidocaine for Urethral Catheterization in Children: A Randomized
Controlled Trial.

Poonai N(1), Li J(2), Langford C(2), Lepore N(2), Taddio A(3), Gerges S(3), Stitt
L(4), Teefy J(2), Manji K(2), Castelo M(2), Rieder M(2), Qui T(2), Matsui D(2),
Ali S(5).

Author information: 
(1)Department of Pediatrics, Schulich School of Medicine and Dentistry, Western
University, London, Ontario, Canada; Children's Health Research Institute, and
naveen.poonai@lhsc.on.ca. (2)Department of Pediatrics, Schulich School of
Medicine and Dentistry, Western University, London, Ontario, Canada; (3)Leslie
Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada;
(4)Lawson Health Research Institute, London Health Sciences Centre, London,
Ontario, Canada; (5)Department of Pediatrics, University of Alberta, Edmonton,
Alberta, Canada; and Women and Children's Health Research Institute, Edmonton,
Alberta, Canada.

OBJECTIVES: To determine whether lidocaine is superior to nonanesthetic lubricant
(NAL) for relieving pain in children undergoing urethral catheterization (UC).
METHODS: Children 0 to 24 months requiring UC were randomized to NAL or topical
and intraurethral 2% lidocaine gel. Primary outcome was facial grimacing in the
pre to during drug administration and catheterization phases. Secondary outcome
was caregiver satisfaction by using a Visual Analog Scale.
RESULTS: There were 133 participants (n = 68 lidocaine, n = 65 NAL). There were
no significant differences in mean (SD) scores during UC between lidocaine and
NAL (86.4% [121.5%] vs 85.2% [126.6%]), respectively (Δ [confidence interval
(CI)] = -1.2 [-21.0 to 49.0], P = .4). There was a significantly greater
difference in mean (SD) scores during instillation of lidocaine versus NAL (61.8%
[105.6%] vs 3.2% [84.9%]), respectively (Δ [CI] -58.6 [-95.0 to -32.0], P <
.001). There were no significant differences in mean (SD) parental satisfaction
scores between lidocaine and NAL (4.8 [3.2] vs 5.9 [2.9]), respectively (CI-0.1
to 2.2; P = .06). In the subgroup analysis, age, gender, and positive urine
culture did not significantly influence between-group differences in facial
grimacing.
CONCLUSIONS: Compared with NAL, topical and intraurethral lidocaine is not
associated with significant pain reduction during UC, but significantly greater
pain during instillation. Therefore, clinicians may consider using noninvasive
pain-reducing strategies for young children who require UC.

Copyright © 2015 by the American Academy of Pediatrics.

PMID: 26416942  [PubMed - in process]


3. Pediatrics. 2015 Oct;136(4):687-701. doi: 10.1542/peds.2015-1914.

Nebulized Hypertonic Saline for Acute Bronchiolitis: A Systematic Review.

Zhang L(1), Mendoza-Sassi RA(2), Klassen TP(3), Wainwright C(4).

Author information: 
(1)Faculty of Medicine, Federal University of Rio Grande, Rio Grande, Brazil;
lzhang@furg.br linjie.zhang@pq.cnpq.br. (2)Faculty of Medicine, Federal
University of Rio Grande, Rio Grande, Brazil; (3)Manitoba Institute of Child
Health; Children's Hospital Research Institute of Manitoba; Department of
Pediatrics, University of Manitoba, Winnipeg, Canada; and. (4)Queensland
Children's Medical Research Institute; Department of Respiratory and Sleep
Medicine, Lady Cilento Children's Hospital; School of Medicine, University of
Queensland, Brisbane, Australia.

BACKGROUND AND OBJECTIVE: The mainstay of treatment for acute bronchiolitis
remains supportive care. The objective of this study was to assess the efficacy
and safety of nebulized hypertonic saline (HS) in infants with acute
bronchiolitis.
METHODS: Data sources included PubMed and the Virtual Health Library of the Latin
American and Caribbean Center on Health Sciences Information up to May 2015.
Studies selected were randomized or quasi-randomized controlled trials comparing
nebulized HS with 0.9% saline or standard treatment.
RESULTS: We included 24 trials involving 3209 patients, 1706 of whom received HS.
Hospitalized patients treated with nebulized HS had a significantly shorter
length of stay compared with those receiving 0.9% saline or standard care (15
trials involving 1956 patients; mean difference [MD] -0.45 days, 95% confidence
interval [CI] -0.82 to -0.08). The HS group also had a significantly lower
posttreatment clinical score in the first 3 days of admission (5 trials involving
404 inpatients; day 1: MD -0.99, 95% CI -1.48 to -0.50; day 2: MD -1.45, 95% CI
-2.06 to -0.85; day 3: MD -1.44, 95% CI -1.78 to -1.11). Nebulized HS reduced the
risk of hospitalization by 20% compared with 0.9% saline among outpatients (7
trials involving 951 patients; risk ratio 0.80, 95% CI 0.67-0.96). No significant
adverse events related to HS inhalation were reported. The quality of evidence is
moderate due to inconsistency in results between trials and study limitations
(risk of bias).
CONCLUSIONS: Nebulized HS is a safe and potentially effective treatment of
infants with acute bronchiolitis.

Copyright © 2015 by the American Academy of Pediatrics.

PMID: 26416925  [PubMed - in process]


4. Pediatrics. 2015 Nov;136(5):e1169-77. doi: 10.1542/peds.2015-1364.

Prescription Opioids in Adolescence and Future Opioid Misuse.

Miech R(1), Johnston L(2), O'Malley PM(2), Keyes KM(3), Heard K(4).

Author information: 
(1)Survey Research Center, University of Michigan, Ann Arbor, Michigan;
ramiech@umich.edu. (2)Survey Research Center, University of Michigan, Ann Arbor, 
Michigan; (3)Mailman School of Public Health, Columbia University, New York, New
York; and. (4)Department of Emergency Medicine, University of Colorado School of
Medicine, Aurora, Colorado.

BACKGROUND AND OBJECTIVE: Legitimate opioid use is associated with an increased
risk of long-term opioid use and possibly misuse in adults. The objective of this
study was to estimate the risk of future opioid misuse among adolescents who have
not yet graduated from high school.
METHODS: Prospective, panel data come from the Monitoring the Future study. The
analysis uses a nationally representative sample of 6220 individuals surveyed in
school in 12th grade and then followed up through age 23. Analyses are stratified
by predicted future opioid misuse as measured in 12th grade on the basis of known
risk factors. The main outcome is nonmedical use of a prescription opioid at ages
19 to 23. Predictors include use of a legitimate prescription by 12th grade, as
well as baseline history of drug use and baseline attitudes toward illegal drug
use.
RESULTS: Legitimate opioid use before high school graduation is independently
associated with a 33% increase in the risk of future opioid misuse after high
school. This association is concentrated among individuals who have little to no
history of drug use and, as well, strong disapproval of illegal drug use at
baseline.
CONCLUSIONS: Use of prescribed opioids before the 12th grade is independently
associated with future opioid misuse among patients with little drug experience
and who disapprove of illegal drug use. Clinic-based education and prevention
efforts have substantial potential to reduce future opioid misuse among these
individuals, who begin opioid use with strong attitudes against illegal drug use.

Copyright © 2015 by the American Academy of Pediatrics.

PMID: 26504126  [PubMed - in process]


5. Pediatrics. 2015 Nov;136(5):912-9. doi: 10.1542/peds.2015-1028. Epub 2015 Oct 19.

Videolaryngoscopy to Teach Neonatal Intubation: A Randomized Trial.

O'Shea JE(1), Thio M(2), Kamlin CO(3), McGrory L(4), Wong C(5), John J(5),
Roberts C(6), Kuschel C(6), Davis PG(3).

Author information: 
(1)Department of Newborn Research, Royal Women's Hospital, Melbourne, Australia; 
Department of Paediatrics, Royal Hospital for Children, Glasgow, Scotland;
University College Cork, Cork, Ireland; University of Glasgow, Glasgow, Scotland;
joyce.o'shea@ggc.scot.nhs.uk. (2)Department of Newborn Research, Royal Women's
Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia;
PIPER-Neonatal Transport, The Royal Children's Hospital Melbourne, Australia;
(3)Department of Newborn Research, Royal Women's Hospital, Melbourne, Australia; 
University of Melbourne, Melbourne, Australia; Murdoch Children's Research
Institute, Melbourne, Australia; and. (4)Department of Newborn Research, Royal
Women's Hospital, Melbourne, Australia; University of Dundee, Dundee, Scotland.
(5)Department of Newborn Research, Royal Women's Hospital, Melbourne, Australia; 
(6)Department of Newborn Research, Royal Women's Hospital, Melbourne, Australia; 
University of Melbourne, Melbourne, Australia;

BACKGROUND: Neonatal endotracheal intubation is a necessary skill. However,
success rates among junior doctors have fallen to <50%, largely owing to
declining opportunities to intubate. Videolaryngoscopy allows instructor and
trainee to share the view of the pharynx. We compared intubations guided by an
instructor watching a videolaryngoscope screen with the traditional method where
the instructor does not have this view.
METHODS: A randomized, controlled trial at a tertiary neonatal center recruited
newborns from February 2013 to May 2014. Eligible intubations were performed
orally on infants without facial or airway anomalies, in the delivery room or
neonatal intensive care, by doctors with <6 months' tertiary neonatal experience.
Intubations were randomized to having the videolaryngoscope screen visible to the
instructor or covered (control). The primary outcome was first-attempt intubation
success rate confirmed by colorimetric detection of expired carbon dioxide.
RESULTS: Two hundred six first-attempt intubations were analyzed. Median
(interquartile range) infant gestation was 29 (27 to 32) weeks, and weight was
1142 (816 to 1750) g. The success rate when the instructor was able to view the
videolaryngoscope screen was 66% (69/104) compared with 41% (42/102) when the
screen was covered (P < .001, OR 2.81, 95% CI 1.54 to 5.17). When premedication
was used, the success rate in the intervention group was 72% (56/78) compared
with 44% (35/79) in the control group (P < .001, OR 3.2, 95% CI 1.6 to 6.6).
CONCLUSIONS: Intubation success rates of inexperienced neonatal trainees
significantly improved when the instructor was able to share their view on a
videolaryngoscope screen.

Copyright © 2015 by the American Academy of Pediatrics.

PMID: 26482669  [PubMed - in process]


6. Pediatrics. 2015 Mar;135(3):e607-14. doi: 10.1542/peds.2014-1073. Epub 2015 Feb
16.

Sucrose and warmth for analgesia in healthy newborns: an RCT.

Gray L(1), Garza E(2), Zageris D(3), Heilman KJ(4), Porges SW(4).

Author information: 
(1)Department of Pediatrics, University of Chicago, Chicago, Illinois;
larrygray@uchicago.edu. (2)Pediatrics, Baylor College of Medicine, Houston,
Texas; (3)Philadelphia College of Osteopathic Medicine, Philadelphia,
Pennsylvania; and. (4)Department of Psychiatry, University of North Carolina at
Chapel Hill, Chapel Hill, North Carolina.

BACKGROUND AND OBJECTIVE: Increasing data suggest that neonatal pain has
long-term consequences. Nonpharmacologic techniques (sucrose taste, pacifier
suckling, breastfeeding) are effective and now widely used to combat minor
neonatal pain. This study examined the analgesic effect of sucrose combined with
radiant warmth compared with the taste of sucrose alone during a painful
procedure in healthy full-term newborns.
METHODS: A randomized, controlled trial included 29 healthy, full-term newborns
born at the University of Chicago Hospital. Both groups of infants were given 1.0
mL of 25% sucrose solution 2 minutes before the vaccination, and 1 group
additionally was given radiant warmth from an infant warmer before the
vaccination. We assessed pain by comparing differences in cry, grimace, heart
rate variability (ie, respiratory sinus arrhythmia), and heart rate between the
groups.
RESULTS: The sucrose plus warmer group cried and grimaced for 50% less time after
the vaccination than the sucrose alone group (P < .05, respectively). The sucrose
plus warmer group had lower heart rate and heart rate variability (ie,
respiratory sinus arrhythmia) responses compared with the sucrose alone group (P
< .01), reflecting a greater ability to physiologically regulate in response to
the painful vaccination.
CONCLUSIONS: The combination of sucrose and radiant warmth is an effective
analgesic in newborns and reduces pain better than sucrose alone. The ready
availability of this practical nonpharmacologic technique has the potential to
reduce the burden of newborn pain.

Copyright © 2015 by the American Academy of Pediatrics.

PMCID: PMC4338320 [Available on 2016-03-01]
PMID: 25687147  [PubMed - indexed for MEDLINE]


7. Pediatrics. 2015 Jun;135(6):965-71. doi: 10.1542/peds.2015-0012.

Diagnostic accuracy of the urinalysis for urinary tract infection in infants <3
months of age.

Schroeder AR(1), Chang PW(2), Shen MW(3), Biondi EA(4), Greenhow TL(2).

Author information: 
(1)Department of Pediatrics, Santa Clara Valley Medical Center, San Jose,
California; Alan.Schroeder@hhs.sccgov.org. (2)Department of Pediatrics, Kaiser
Permanente Northern California, Oakland, California; (3)Department of Pediatrics,
Dell Children's Medical Center, Austin, Texas; and. (4)Department of Pediatrics, 
University of Rochester, Rochester, New York.

Comment in
    Pediatrics. 2015 Jun;135(6):1126-7.

BACKGROUND: The 2011 American Academy of Pediatrics urinary tract infection (UTI)
guideline suggests incorporation of a positive urinalysis (UA) into the
definition of UTI. However, concerns linger over UA sensitivity in young infants.
Infants with the same pathogenic organism in the blood and urine (bacteremic UTI)
have true infections and represent a desirable population for examination of UA
sensitivity.
METHODS: We collected UA results on a cross-sectional sample of 276 infants <3
months of age with bacteremic UTI from 11 hospital systems. Sensitivity was
calculated on infants who had at least a partial UA performed and had ≥50 000
colony-forming units per milliliter from the urine culture. Specificity was
determined by using a random sample of infants from the central study site with
negative urine cultures.
RESULTS: The final sample included 245 infants with bacteremic UTI and 115
infants with negative urine cultures. The sensitivity of leukocyte esterase was
97.6% (95% confidence interval [CI] 94.5%-99.2%) and of pyuria (>3 white blood
cells/high-power field) was 96% (95% CI 92.5%-98.1%). Only 1 infant with
bacteremic UTI (Group B Streptococcus) and a complete UA had an entirely negative
UA. In infants with negative urine cultures, leukocyte esterase specificity was
93.9% (95% CI 87.9 - 97.5) and of pyuria was 91.3% (84.6%-95.6%).
CONCLUSIONS: In young infants with bacteremic UTI, UA sensitivity is higher than
previous reports in infants with UTI in general. This finding can be explained by
spectrum bias or by inclusion of faulty gold standards (contaminants or
asymptomatic bacteriuria) in previous studies.

Copyright © 2015 by the American Academy of Pediatrics.

PMID: 26009628  [PubMed - indexed for MEDLINE]


8. Pediatrics. 2015 Feb;135(2):213-23. doi: 10.1542/peds.2014-0966. Epub 2015 Jan 5.

Benefits of strict rest after acute concussion: a randomized controlled trial.

Thomas DG(1), Apps JN(2), Hoffmann RG(3), McCrea M(4), Hammeke T(2).

Author information: 
(1)Departments of Pediatrics, dthomas@mcw.edu. (2)Psychiatry and Behavioral
Medicine, and. (3)Departments of Pediatrics. (4)Neurology and Neurosurgery,
Medical College of Wisconsin, Milwaukee, Wisconsin.

Comment in
    Pediatrics. 2015 Feb;135(2):362-3.
    J Pediatr. 2015 Jul;167(1):209-10.

OBJECTIVES: To determine if recommending strict rest improved concussion recovery
and outcome after discharge from the pediatric emergency department (ED).
METHODS: Patients aged 11 to 22 years presenting to a pediatric ED within 24
hours of concussion were recruited. Participants underwent neurocognitive,
balance, and symptom assessment in the ED and were randomized to strict rest for
5 days versus usual care (1-2 days rest, followed by stepwise return to
activity). Patients completed a diary used to record physical and mental activity
level, calculate energy exertion, and record daily postconcussive symptoms.
Neurocognitive and balance assessments were performed at 3 and 10 days
postinjury. Sample size calculations were powered to detect clinically meaningful
differences in postconcussive symptom, neurocognitive, and balance scores between
treatment groups. Linear mixed modeling was used to detect contributions of group
assignment to individual recovery trajectory.
RESULTS: Ninety-nine patients were enrolled; 88 completed all study procedures
(45 intervention, 43 control). Postdischarge, both groups reported a 20% decrease
in energy exertion and physical activity levels. As expected, the intervention
group reported less school and after-school attendance for days 2 to 5
postconcussion (3.8 vs 6.7 hours total, P < .05). There was no clinically
significant difference in neurocognitive or balance outcomes. However, the
intervention group reported more daily postconcussive symptoms (total symptom
score over 10 days, 187.9 vs 131.9, P < .03) and slower symptom resolution.
CONCLUSIONS: Recommending strict rest for adolescents immediately after
concussion offered no added benefit over the usual care. Adolescents' symptom
reporting was influenced by recommending strict rest.

Copyright © 2015 by the American Academy of Pediatrics.

PMID: 25560444  [PubMed - indexed for MEDLINE]


9. Pediatrics. 2015 Dec;136(6):1036-43. doi: 10.1542/peds.2015-1037. Epub 2015 Nov
9.

3% Hypertonic Saline Versus Normal Saline in Inpatient Bronchiolitis: A
Randomized Controlled Trial.

Silver AH(1), Esteban-Cruciani N(2), Azzarone G(2), Douglas LC(2), Lee DS(2),
Liewehr S(3), Nazif JM(2), Agalliu I(4), Villegas S(5), Rhim HJ(2), Rinke ML(2), 
O'Connor K(2).

Author information: 
(1)Division of Pediatric Hospital Medicine, Department of Pediatrics,
alysilve@montefiore.org. (2)Division of Pediatric Hospital Medicine, Department
of Pediatrics. (3)Division of Pediatric Hospital Medicine, Department of
Pediatrics, Department of Pediatrics, Steven and Alexandra Cohen Children's
Medical Center at North Shore-LIJ Health System, New Hyde Park, New York; and.
(4)Department of Epidemiology and Population Health, Albert Einstein College of
Medicine, Bronx, New York; (5)Department of Pharmacy, Arnold and Marie Schwartz
College of Pharmacy, Long Island University, Brooklyn, New York Department of
Pharmacy, The Children's Hospital at Montefiore, and.

BACKGROUND AND OBJECTIVES: Bronchiolitis, the most common reason for
hospitalization in children younger than 1 year in the United States, has no
proven therapies effective beyond supportive care. We aimed to investigate the
effect of nebulized 3% hypertonic saline (HS) compared with nebulized normal
saline (NS) on length of stay (LOS) in infants hospitalized with bronchiolitis.
METHODS: We conducted a prospective, randomized, double-blind, controlled trial
in an urban tertiary care children's hospital in 227 infants younger than 12
months old admitted with a diagnosis of bronchiolitis (190 completed the study); 
113 infants were randomized to HS (93 completed the study), and 114 to NS (97
completed the study). Subjects received 4 mL nebulized 3% HS or 4 mL 0.9% NS
every 4 hours from enrollment until hospital discharge. The primary outcome was
median LOS. Secondary outcomes were total adverse events, subdivided as clinical
worsening and readmissions.
RESULTS: Patient characteristics were similar in groups. In intention-to-treat
analysis, median LOS (interquartile range) of HS and NS groups was 2.1 (1.2-4.6) 
vs 2.1 days (1.2-3.8), respectively, P = .73. We confirmed findings with
per-protocol analysis, HS and NS groups with 2.0 (1.3-3.3) and 2.0 days
(1.2-3.0), respectively, P = .96. Seven-day readmission rate for HS and NS groups
were 4.3% and 3.1%, respectively, P = .77. Clinical worsening events were similar
between groups (9% vs 8%, P = .97).
CONCLUSIONS: Among infants admitted to the hospital with bronchiolitis, treatment
with nebulized 3% HS compared with NS had no difference in LOS or 7-day
readmission rates.

Copyright © 2015 by the American Academy of Pediatrics.

PMID: 26553190  [PubMed - in process]


10. Pediatrics. 2014 Dec;134(6):e1537-44. doi: 10.1542/peds.2014-1329. Epub 2014 Nov
17.

Validation of a clinical prediction rule for pediatric abusive head trauma.

Hymel KP(1), Armijo-Garcia V(2), Foster R(3), Frazier TN(4), Stoiko M(5),
Christie LM(6), Harper NS(7), Weeks K(8), Carroll CL(9), Hyden P(10), Sirotnak
A(11), Truemper E(12), Ornstein AE(13), Wang M(14); Pediatric Brain Injury
Research Network (PediBIRN) Investigators.

Collaborators: Herman BE, Narang SK, Graf JM, Dias M, Pullen DA, Boos SC.

Author information: 
(1)Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, New
Hampshire; Departments of Pediatrics, and kphymel@gmail.com. (2)Department of
Pediatrics, University of Texas Health Science Center at San Antonio, San
Antonio, Texas; (3)Department of Emergency Medicine, Children's Hospital of
Richmond at Virginia Commonwealth University Health System, Richmond, Virginia;
(4)Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri;
(5)Department of Pediatrics, DeVos Children's Hospital, Grand Rapids, Michigan;
(6)Department of Critical Care, Dell Children's Medical Center of Central Texas, 
Austin, Texas; (7)Children's Physician Services of South Texas, Driscoll
Children's Hospital, Corpus Christi, Texas; Department of Pediatrics, University
of Minnesota Children's Hospital, Minneapolis, Minnesota; (8)Department of
Pediatrics, University of Kansas School of Medicine, Wichita, Kansas;
(9)Department of Pediatrics, Connecticut Children's Medical Center, Hartford,
Connecticut; (10)Department of Pediatrics, Children's Hospital of Central
California, Madera, California; (11)Department of Pediatrics, Children's Hospital
Colorado, Aurora, Colorado; (12)Department of Pediatrics, Children's Hospital of
Omaha, Omaha, Nebraska; and. (13)Department of Pediatrics, IWK Health Centre,
Halifax, Nova Scotia. (14)Health Sciences, Penn State College of Medicine,
Hershey, Pennsylvania;

BACKGROUND AND OBJECTIVE: To reduce missed cases of pediatric abusive head trauma
(AHT), Pediatric Brain Injury Research Network investigators derived a 4-variable
AHT clinical prediction rule (CPR) with sensitivity of .96. Our objective was to
validate the screening performance of this AHT CPR in a new, equivalent patient
population.
METHODS: We conducted a prospective, multicenter, observational, cross-sectional
study. Applying the same inclusion criteria, definitional criteria for AHT, and
methods used in the completed derivation study, Pediatric Brain Injury Research
Network investigators captured complete clinical, historical, and radiologic data
on 291 acutely head-injured children <3 years of age admitted to PICUs at 14
participating sites, sorted them into comparison groups of abusive and nonabusive
head trauma, and measured the screening performance of the AHT CPR.
RESULTS: In this new patient population, the 4-variable AHT CPR demonstrated
sensitivity of .96, specificity of .46, positive predictive value of .55,
negative predictive value of .93, positive likelihood ratio of 1.67, and negative
likelihood ratio of 0.09. Secondary analysis revealed that the AHT CPR identified
98% of study patients who were ultimately diagnosed with AHT.
CONCLUSIONS: Four readily available variables (acute respiratory compromise
before admission; bruising of the torso, ears, or neck; bilateral or
interhemispheric subdural hemorrhages or collections; and any skull fractures
other than an isolated, unilateral, nondiastatic, linear, parietal fracture)
identify AHT with high sensitivity in young, acutely head-injured children
admitted to the PICU.

Copyright © 2014 by the American Academy of Pediatrics.

PMID: 25404722  [PubMed - indexed for MEDLINE]

Diagnostic

None

Review

None

Clinical Prediction Rules

None