Facial Function in Bell Palsy in a Cohort of Children Randomized to Prednisolone or Placebo 12 Months After Diagnosis.

BACKGROUND: Information on the medium-term recovery of children with Bell palsy or acute idiopathic lower motor neuron facial paralysis is limited. METHODS: We followed up children aged 6 months to <18 years with Bell palsy for 12 months after completion of a randomized trial on the use of prednisolone. We assessed facial function using the clinician-administered House-Brackmann scale and the modified parent-administered House-Brackmann scale. RESULTS: One hundred eighty-seven children were randomized to prednisolone (n = 93) or placebo (n = 94). At six months, the proportion of patients who had recovered facial function based on the clinician-administered House-Brackmann scale was 98% (n = 78 of 80) in the prednisolone group and 93% (n = 76 of 82) in the placebo group. The proportion of patients who had recovered facial function based on the modified parent-administered House-Brackmann scale was 94% (n = 75 of 80) vs 89% (n = 72 of 81) at six months (OR 1.88; 95% CI 0.60, 5.86) and 96% (n = 75 of 78) vs 92% (n = 73 of 79) at 12 months (OR 3.12; 95% CI 0.61, 15.98). CONCLUSIONS: Although the vast majority had complete recovery of facial function at six months, there were some children without full recovery of facial function at 12 months, regardless of prednisolone use.

Pain in children with Bell's palsy: secondary analysis of a randomised controlled trial.

OBJECTIVE: To describe the prevalence and severity of pain experienced by children with Bell's palsy over the first 6 months of illness and its association with the severity of facial paralysis. METHODS: This was a secondary analysis of data obtained in a phase III, triple-blinded, randomised, placebo-controlled trial of prednisolone for the treatment of Bell's palsy in children aged 6 months to <18 years conducted between 13 October 2015 and 23 August 2020 in Australia and New Zealand. Children were recruited within 72 hours of symptom onset and pain was assessed using a child-rated visual analogue scale (VAS), a child-rated Faces Pain Score-Revised (FPS-R) and/or a parent-rated VAS at baseline, and at 1, 3 and 6 months until recovered, and are reported combined across treatment groups. RESULTS: Data were available for 169 of the 187 children randomised from at least one study time point. Overall, 37% (62/169) of children reported any pain at least at one time point. The frequency of any pain reported using the child-rated VAS, child-rated FPS-R and parent-rated VAS was higher at the baseline assessment (30%, 23% and 27%, respectively) compared with 1-month (4%, 0% and 4%, respectively) and subsequent follow-up assessments. At all time points, the median pain score on all three scales was 0 (no pain). CONCLUSIONS: Pain in children with Bell's palsy was infrequent and primarily occurred early in the disease course and in more severe disease. The intensity of pain, if it occurs, is very low throughout the clinical course of disease. TRIAL REGISTRATION NUMBER: ACTRN12615000563561.

Agreement Between House-Brackmann and Sunnybrook Facial Nerve Grading Systems in Bell's Palsy in Children: Secondary Analysis of a Randomized, Placebo-Controlled Multicenter Trial.

BACKGROUND: There is limited evidence on the use of facial nerve function grading scales in acute facial nerve paralysis in children. OBJECTIVE: To investigate the agreement between and the usability of the House-Brackmann and Sunnybrook scales in children with idiopathic facial paralysis (Bell's palsy) and to compare their ease of administration. METHODS: Data from a randomized controlled trial in children aged 6 months to <18 years with Bell's palsy was used. Children were recruited within 72 hours of symptom onset and assessed using the House-Brackmann and the Sunnybrook scales at baseline and at 1, 3, and 6 months until recovered. Agreement between the scales was assessed using the intraclass correlation coefficient (ICC) at each time point and using a Bland-Altman plot. Ease of administration was assessed using an 11-point Likert scale. RESULTS: Comparative data were available for 169 of the 187 children randomized. The ICC between the 2 scales across all time points was 0.92 (95% confidence interval [CI] 0.91-0.93), at baseline 0.37 (95% 0.25, 0.51), at 1 month 0.91 (95% CI 0.89-0.94), at 3 months 0.85 (95% CI 0.80-0.89), and at 6 months 0.96 (95% CI 0.95-0.97). The median score for the ease of administration for the House-Brackmann and Sunnybrook scales was 3 (interquartile range [IQR]: 1-5) and 7 (IQR: 4-8) respectively (P < .001, Wilcoxon signed-rank test). CONCLUSIONS: There was excellent agreement between House-Brackmann and Sunnybrook scales, with poorer agreement at baseline. Clinicians found the House-Brackmann scale easier to administer. These findings suggest that both scales can be applied in children.

Presentation design and delivery to improve knowledge translation in a remote world.

The practical dissemination of new knowledge is not given adequate attention despite large investment in undertaking high-quality research and the desire for evidence-based practice. It is important that those involved in knowledge translation and continuing medical education understand the fundamental principles of effective presentations, whether at scientific conferences, workshops or group teaching sessions. The switch to remote presentations has made this a more challenging endeavour. We describe established presentation techniques that improve knowledge translation and how to use them in both face-to-face and remote settings.

Efficacy of Prednisolone for Bell Palsy in Children: A Randomized, Double-Blind, Placebo-Controlled, Multicenter Trial.

BACKGROUND AND OBJECTIVE: Corticosteroids are used to treat the early stages of idiopathic facial paralysis (Bell's palsy) in children, but their effectiveness is uncertain. We set out to determine if prednisolone improves the proportion of children with Bell's palsy with complete recovery at one month. METHODS: We conducted a double-blind, placebo-controlled, randomised trial of prednisolone in children presenting to emergency departments with Bell's palsy. Patients aged 6 months to less than 18 years, recruited within 72 hours after symptom onset, were randomly assigned to receive 10 days of treatment with oral prednisolone (approximately 1 mg/kg) or placebo. The primary outcome was complete recovery of facial function at 1 month rated on the House-Brackmann scale. Secondary outcomes included facial function, adverse events and pain up to 6 months. Target recruitment was n=540 (270 per group). RESULTS: Between 13 October 2015 to 23 August 2020, 187 children were randomised (94 to prednisolone and 93 to placebo) and included in the intention-to-treat analysis. At 1 month, the proportions of patients who had recovered facial function were 49% (n=43/87) in the prednisolone group compared with 57% (n=50/87) in the placebo group (risk difference -8.1%, 95% CI -22.8 to 6.7; adjusted odds ratio [aOR] 0.7, 95% CI 0.4 to 1.3). At 3 months these proportion were 90% (n=71/79) for the prednisolone group versus 85% (n=72/85) for the placebo group (risk difference 5.2%, 95%, CI -5.0 to 15.3; aOR 1.2, 95% CI 0.4 to 3.0) and at 6 months 99% (n=77/78) and 93% (n=76/82) respectively (risk difference 6.0%, 95% CI -0.1 to 12.2; aOR 3.0 95% CI 0.5 to 17.7) There were no serious adverse events and little evidence for group differences in secondary outcomes. DISCUSSION: In children with Bell's palsy the vast majority recover without treatment. The study, although underpowered, does not provide evidence that early treatment with prednisolone improves complete recovery. REGISTRATION: Registered with the Australian New Zealand Clinical Trials Registry ACTRN12615000563561, registered 1 June 2015, ://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368505&isReview=true CLASSIFICATION OF EVIDENCE: This study provides Class I evidence that for children with Bell's palsy, prednisolone does not significantly change recovery of complete facial function at one month. However, the study lacked the precision to exclude an important harm or benefit from prednisolone.

PRE-scripted debriefing for Paediatric simulation Associated with Resuscitation EDucation (PREPARED): A multicentre, cluster randomised controlled trial.

Aim: Scripted debriefing tools may improve the performance of novices debriefing in resuscitation courses, but this has not previously been measured. The aim of this study was to determine the impact of a script on the quality of debriefs in a statewide paediatric resuscitation course. Methods: This cluster-randomised controlled trial compared scripted debriefing (intervention) versus non-scripted debriefing (control) for participants in a paediatric resuscitation course. The trial was conducted across participating sites in Queensland, Australia, from November 2017 to February 2020. Debriefing quality was measured using the Observational Structured Assessment of Debriefing (OSAD) tool. The OSAD tool rates 8 domains that comprise the elements of an ideal debrief. OSAD scores between scripted and non-scripted groups were compared, overall and after stratification by debriefer experience and site size. Results: Seventy debriefings occurred across 19 sites (intervention, n = 34, control n = 36). There was a statistically significant increase in total OSAD scores in the scripted group, compared to non-scripted (mean difference (MD) = 3.5, 95% confidence interval (CI) 0.7-6.2, p = 0.01). The categories of 'reflection' and 'analysis' had the greatest difference in OSAD scores in the scripted group (MD = 0.8, 95%CI 0.2-1.3, p = 0.005; MD = 0.6, 95%CI 0.2-1.0, p = 0.007). After stratification, overall OSAD scores improved for novices (MD = 4.1, 95%CI 0.5-7.7, p = 0.03) and large centres (MD = 5.2, 95%CI 1.1-9.2, p = 0.01). Conclusion: Providing debriefing scripts to faculty facilitating simulated paediatric resuscitation scenarios improved the quality of debriefing, especially for novices and those at large sites. The development and provision of debriefing scripts for large-scale paediatric resuscitation courses should be considered.

Treatment patterns and frequency of key outcomes in acute severe asthma in children: a Paediatric Research in Emergency Departments International Collaborative (PREDICT) multicentre cohort study.

RATIONALE: Severe acute paediatric asthma may require treatment escalation beyond systemic corticosteroids, inhaled bronchodilators and low-flow oxygen. Current large asthma datasets report parenteral therapy only. OBJECTIVES: To identify the use and type of escalation of treatment in children presenting to hospital with acute severe asthma. METHODS: Retrospective cohort study of children with an emergency department diagnosis of asthma or wheeze at 18 Australian and New Zealand hospitals. The main outcomes were use and type of escalation treatment (defined as any of intensive care unit admission, nebulised magnesium, respiratory support or parenteral bronchodilator treatment) and hospital length of stay (LOS). MEASUREMENTS AND MAIN RESULTS: Of 14 029 children (median age 3 (IQR 1-3) years; 62.9% male), 1020 (7.3%, 95% CI 6.9% to 7.7%) had treatment escalation. Children with treatment escalation had a longer LOS (44.2 hours, IQR 27.3-63.2 hours) than children without escalation 6.7 hours, IQR 3.5-16.3 hours; p<0.001). The most common treatment escalations were respiratory support alone (400; 2.9%, 95% CI 2.6% to 3.1%), parenteral bronchodilator treatment alone (380; 2.7%, 95% CI 2.5% to 3.0%) and both respiratory support and parenteral bronchodilator treatment (209; 1.5%, 95% CI 1.3% to 1.7%). Respiratory support was predominantly nasal high-flow therapy (99.0%). The most common intravenous medication regimens were: magnesium alone (50.4%), magnesium and aminophylline (24.6%) and magnesium and salbutamol (10.0%). CONCLUSIONS: Overall, 7.3% children with acute severe asthma received some form of escalated treatment, with 4.2% receiving parenteral bronchodilators and 4.3% respiratory support. There is wide variation treatment escalation.

Australian and New Zealand Guideline for Mild to Moderate Head Injuries in Children.

OBJECTIVE: Children frequently present with head injuries to acute care settings. Although international paediatric clinical practice guidelines for head injuries exist, they do not address all considerations related to triage, imaging, observation versus admission, transfer, discharge and follow-up of mild to moderate head injuries relevant to the Australian and New Zealand context. The Paediatric Research in Emergency Departments International Collaborative (PREDICT) set out to develop an evidence-based, locally applicable, practical clinical guideline for the care of children with mild to moderate head injuries presenting to acute care settings. METHODS: A multidisciplinary Guideline Working Group (GWG) developed 33 questions in three key areas - triage, imaging and discharge of children with mild to moderate head injuries presenting to acute care settings. We identified existing high-quality guidelines and from these guidelines recommendations were mapped to clinical questions. Updated literature searches were undertaken, and key new evidence identified. Recommendations were created through either adoption, adaptation or development of de novo recommendations. The guideline was revised after a period of public consultation. RESULTS: The GWG developed 71 recommendations (evidence-informed = 35, consensus-based = 17, practice points = 19), relevant to the Australian and New Zealand setting. The guideline is presented as three documents: (i) a detailed Full Guideline summarising the evidence underlying each recommendation; (ii) a Guideline Summary; and (iii) a clinical Algorithm: Imaging and Observation Decision-making for Children with Head Injuries. CONCLUSIONS: The PREDICT Australian and New Zealand Guideline for Mild to Moderate Head Injuries in Children provides high-level evidence and practical guidance for front line clinicians.

The Baby Shark (Songs Heard Affecting Resuscitation Kinetics) study.

Previous research has examined the utilisation of musical cues to improve the performance of cardiopulmonary resuscitation (CPR) delivered in training environments. We postulated a musical cue that is both contemporary and transcends cultures may improve CPR performance. Our aim was to establish whether chest compressions are performed with improved rate and depth if a song of a fixed beat (PinkFong's 'Baby Shark' with a tempo of 115 beats per minute (bpm) and 15 beats in each verse) is played to a healthcare professional immediately before undertaking CPR compared to whale noises (a non-metronomic rhythm). 58 Participants of a paediatric conference (majority doctors) were randomly assigned to listen to a minute of Baby Shark (28) or whale song (30) and then undertake a minute of CPR. There was no significant difference in the mean compression rate between the Baby Shark and control groups, with the groups achieving 121 and 125 bpm, respectively (p=0.18). In relation to compression depth within the target zone, the Baby Shark group had more compressions completed within the target zone (55%) than the control group (39%) although this difference was not significant (p=0.08). Listening to Baby Shark prior to undertaking simulated CPR does not improve overall performance, but there is a potential tendency to improve adequate compression depth which may be beneficial in training exercises.

Factors predictive for computed tomography use and abnormality in paediatric head injuries in Australia and New Zealand.

OBJECTIVES: To investigate patient-level factors predictive for computed tomography of the brain (CTB) use and abnormality in head injured children in Australia and New Zealand. METHODS: Retrospective data from tertiary, urban/suburban and regional/rural EDs including factors predictive for CTB use and abnormality. RESULTS: Of 3072 children at 31 EDs, 212 (6.9%) had a CTB scan, of which 66 (31%) were abnormal. Increasing age, serious mechanisms of injury and decreasing Glasgow Coma Score were predictive for ordering CTB. Decreasing age was predictive for CTB abnormalities. Other factors were not. CONCLUSION: Patient-level drivers of CTB use in children in Australia and New Zealand are consistent with international data.

Women and children first? Gender equity in paediatric medicine.

There has been an increased focus on diversity and inclusion in medicine in recent years-the field of medicine still has a long way to go to reach gender equity. We assess how paediatrics is performing by examining the role gender plays in our specialty; and we propose some practical solutions to reach an equitable state. Achieving gender equity is not a simple or easy option and will require an ongoing commitment from all facets of the profession.

Diagnosis of appendicitis in the paediatric emergency department: an update.

PURPOSE OF REVIEW: Concern regarding appendicitis is a common reason for presentation to the paediatric emergency department. We review recent progress in the use of biomarkers, imaging and clinical scoring systems in improving diagnostic accuracy in suspected appendicitis in children. RECENT FINDINGS: Use of ultrasound, often performed at the bedside, is becoming more widespread with a parallel reduction in computed tomography (CT) use. Protocols for image acquisition and interpretation have been shown to improve diagnostic accuracy. Novel biomarkers have been explored and clinical diagnostic algorithms refined but none have achieved the level of diagnostic accuracy required. SUMMARY: Appendicitis remains a clinical diagnosis. Point of care ultrasound is increasingly available and offers higher diagnostic accuracy than several routinely performed laboratory investigations. Recent publications provide support for increased use of clinician performed ultrasound, increased use of MRI, less use of CT, less emphasis on basic laboratory investigation and a renewed respect for the value of serial examination, particularly early in the course of illness.

An update in the initial management of paediatric status epilepticus.

PURPOSE OF REVIEW: Over the last 2 years, algorithms for the optimal management of status epilepticus have changed, as the medical community has recognized the need to terminate seizures in status in a timely manner. Recent research has evaluated the different choices of benzodiazepine and has given consideration to second-line treatment options. RECENT FINDINGS: There has been a move to examine alternatives to phenytoin (such as levetiracetam and lacosamide) as second-line agents. Valproate should be used cautiously in view of the potential side effects. Three ongoing trials [Established Staus Epilepticus Treatment Trial (ESETT), Convulsive Status Epilepticus Paediatric Trial (ConSEPT), and emergency treatment with levetiracetam or phenytoin in status epilepticus in children (EcLiPSE)] are comparing the efficacy of levetiracetam and phenytoin. SUMMARY: Benzodiazepines remain the first-line agent of choice, although there is ongoing discussion about the mode of administration and the best drug to choose. The results of ESETT, ConSEPT, and EcLiPSE will affect our future management of status, as we give consideration to levetiracetam as an alternative to phenytoin. Other medications such as lacosamide may emerge in future algorithms too.

Changing paediatric emergency department model of care is associated with improvements in the National Emergency Access Target and a decrease in inpatient admissions.

OBJECTIVE: To assess the impact on patient flow as noted by the National Emergency Access Target (NEAT), with the introduction of a new Paediatric ED (PEM ED) model of care. METHODS: This longitudinal observational study was conducted at the Logan Hospital, a 344 bed public hospital in metropolitan Brisbane, which opened a physically separate, dedicated PEM ED on 14 October 2014, incorporating approximately 30% more staff, limited changes in processes and no changes in governance. De-identified data of the entire clientele from the ED Information System were compared 365 days before and after the opening of the PEM ED. RESULTS: Although the number of children presenting to ED increased by 23% (pre 18 142, post 22 391), the median length of stay decreased substantially from 152 min to 138 min, resulting in a 7.75% rise in presentations that met the NEAT target (pre 77.41%, post 85.16%; P < 0.0001). Admission to the ED Short Stay Unit rose by 16.48% (pre 5.38%, post 21.86%; P < 0.0001), whereas final disposition to the inpatient paediatric unit fell by 2.30% (pre 11.43, post 9.13%; P < 0.0001). The clinical presentations were similar pre and post across age, sex, ethnicity, referral and arrival mode, Australasian Triage Scale category, presenting problem and discharge diagnosis. CONCLUSION: NEAT times improved after changing the PEM ED model of care. Further studies may assist identifying which of the specific features within the new model are most effective for improving patient flow.