Thanks to everyone for joining the #CochraneChild Twitter journal club on May 27th, 2015 with TREKK's own Dr. Terry Klassen and Dr. Amanda Newton. The archived discussion is at: http://bit.ly/CrisisJC
What: Twitter journal club on crisis interventions for pediatric mental health in the emergency department
When: Wednesday, May 27th, 1:00pm PT Vancouver | 2:00pm MT Edmonton & Calgary | 3:00pm CT Winnipeg | 4:00pm ET Toronto
Where: Follow #CochraneChild on Twitter and join in the discussion by including #CochraneChild in all your posts. See these tips for participating in a Twitter chat.
Questions we will be addressing:
1. How often do Emergency Department (ED) clinicians see a patient for mental health care? Have visit trends changed over time?
2. Based on the 2010 review, what interventions have been tested for pediatric crisis care in the ED?
3. The studies included in the review were all observational studies. What are the challenges with this? Would other study designs have worked in this context?
4. What care do children and youth currently receiving in EDs for mental health emergencies?
5. Have new studies of ED-based crisis care been published since the 2010 review highlighted today?
Dr Terry Klassen Bio-sketch:
Dr. Klassen graduated from the Faculty of Medicine, University of Manitoba in 1982 and completed his Pediatric Residency training at the University of Manitoba in 1986. He completed M.Sc. in Epidemiology at McMaster University in 1994. He has served as CEO and Scientific Director for the Children’s Hospital Research Institute of Manitoba and Associate Dean, Academic in the College of Medicine, Faculty of Health Sciences at the University of Manitoba and Director of the George and Fay Yee Center for Healthcare Innovation since returning to Manitoba in September, 2010. Since the commencement of his new role as Head of the Department of Pediatrics, he has stepped down from the Associate Dean, Academic position but continues to serve both the Children’s Hospital Research Institute of Manitoba and CHI roles.
From 1999 to 2009 Dr. Klassen was Chair of the Department of Pediatrics, University of Alberta; Director of the Alberta Research Centre for Health Evidence and Director of the Evidence-based Practice Center at the University of Alberta. He is a clinician scientist focused on Pediatric Emergency Medicine, and has been active in Pediatric Emergency Research Canada collaborating on a national research program involving randomized controlled trials, systematic reviews and knowledge translation. He has a consistent record of national and international peer reviewed funding, along with a publication record that has included many articles in the highest impact medical journals.
In 2009, Dr. Klassen co-founded StaR Child Health, an international group aimed at improving the design, conduct and publication of randomized controlled trials in children. In recognition for his lifetime contributions, he was elected into the Institute of Medicine in 2010 in the foreign associate category. He is also a Fellow in the Canadian Academy of Health Sciences. Dr. Klassen’s research has had a large impact on the practice of Pediatric Emergency Medicine, which was recognized when he received a 2011 Canadian Institutes of Health Research – Canadian Medical Association Journal Top Achievements in Health Research Award. In 2011 he was also awarded the Networks of Centres of Excellence (NCE) grant, entitled TRanslating Emergency Knowledge for Kids (TREKK). In 2012 Dr. Klassen was appointed to the Governing Council of the Canadian Institutes of Health Research.
Dr. Amanda Newton Bio-sketch:
Dr. Newton is an Associate Professor in the Department of Pediatrics at the University of Alberta (Edmonton, Alberta, Canada) and clinician scientist affiliated with the Stollery Children’s Hospital in Edmonton. Her research aims to improve mental health care and outcomes for children and youth who are acutely mentally ill.
From team: News and Events
May 25, 2015 - This week's post is also available from the Cochrane Child Health blog.
Children’s Mental Health by the Numbers
Every year in Canada, 1.2 million children and youth experience mental health problems and illnesses . Fewer than 20% of them receive appropriate treatment . And from 2006-2007 to 2013-2014, the national rates of visits to the emergency department (ED) for mental disorders among children and youth between the ages of 5 and 24 increased by 45% .
Beyond the numbers, these statistics describe kids who are battling conditions like depression, harmful and hazardous substance use, and anxiety disorders. Kids who can present to the ED in acute crisis. Kids who often have nowhere else to go.
While ideally, children and youth with mental health needs would receive early intervention and community-based management, this doesn’t always align with service availability or the nature of the treatment need. Sometimes, a crisis can’t be avoided. In all these circumstances, the ED plays an important role in providing care.
Emergency Department-Based Management Interventions for Mental Health Presentations
A systematic review published in 2010 evaluated the effectiveness of different ED-based management strategies used when children and youth presented with mental health complaints . There were only three studies that focused on pediatric (≤18 years) populations, so nine additional studies in adult populations, or in populations where the age was unknown, were also included. In all cases, patients with a range of mental health conditions were represented.
The authors identified three main categories of interventions: specialized models of pediatric care, patient triage scales, and other ED mental health care.
Specialized Models of Pediatric Care: These interventions included referrals to a specialized psychiatric team, made up of at least a child psychiatrist, and possibly also other psychiatric professionals like a nurse specialist or social worker. In three studies, referrals to these teams were associated with reduced hospital admissions, length of stay in the ED, and a modest cost savings in the ED.
Patient Triage Scales: Five studies evaluated four different triage scales as they were applied to mental health presentations. The outcomes measured across studies were variable, limiting the conclusions that can be made.
Other ED Mental Health Care: While none were evaluated in pediatric populations, three other strategies were described in the systematic review. Changes in legislation allowing psychologists to recommend involuntary patient hospitalization did not lead to significant differences in disposition decisions made by psychologists, or between psychiatrists and psychologists. The use of crisis teams had no impact on patient distress in one study, but reduced hospitalization in another. A computerized reminder system for restraints reduced the time to renewal of restraint orders, as well as time spent in restraints.
Limited evidence on the best strategies to treat children and youth with mental health conditions was available, but this review did find some support for the use of specialized psychiatric teams, and identified gaps in the child health evidence where the adult literature may provide some direction, namely the use of triage scales and developing guidance for restraint.
Dr. Amanda Newton, the senior author of the review, commented “Recent statistics reinforce that addressing emergency mental health care is critical. What is clear from this review is that the pediatric evidence base requires development. Studies that evaluate the quality of care provided and patient reported outcomes are important. Evidence exists outside of this review for specialized care, such as care for intentional self-harm, but a focus on the quality of general emergency mental health care is also important as this is standard care provided in emergency departments.”
Please join the authors of the systematic review for a live discussion on Twitter this Wednesday May 17 @ 2 pm MT. Check out the journal club announcement here.
1. Mental Health Commission of Canada. (2013). School-based mental health and substance abuse project.
2. Mental Health Commission of Canada. (2015). Topics: Child and Youth.
3. Canadian Institute for Health Information. (2015). Care for Children and Youth with Mental Disorders.
4. Hamm, M. P., Osmond, M., Curran, J., Scott, S., Ali, S., Hartling, L., . . . Newton, A. S. (2010). A systematic review of crisis interventions used in the emergency department: recommendations for pediatric care and research. Pediatr Emerg Care, 26(12), 952-962. doi: 10.1097/PEC.0b013e3181fe9211
From team: News and Events
May 18, 2015 - This week's post is also available from the Cochrane Child Health blog.
I am sure you have heard. Type I diabetes is growing in both prevalence and incidence every year. This year alone, nearly 65,000 children and youth under the age of 15 will be diagnosed with type 1 diabetes worldwide . Next year, there will be a 3% increase in the incidence of diagnosis . Unfortunately, this trend is not expected to change in the near future.
Upon diagnosis, 10-70% of children will present with diabetic ketoacidosis (DKA) . Characterized by hyperglycemia, acidosis, and ketonuria, DKA is a very serious condition that carries substantial risk for life threatening complications, like cerebral edema. Moreover, in comparison to adults, children are at a high risk for severe complications. Because of this, DKA is the most common cause of diabetes related death in kids .
It remains unclear whether presenting in DKA at diagnosis is indicative of a more severe form of type 1 diabetes, or if it is linked to delayed diagnosis. However, we do know that children who present with DKA at diagnosis have a poorer long term prognosis, with diminished glycemic control, less residual β cell function for up to two years after diagnosis, and a decreased incidence of remission .
The mean duration between the onset of symptoms and development of DKA is 14 days, and over one third of children will have at least one medical consultation in this period prior to diagnosis . This represents an ideal time for identifying and triaging children at high risk for developing DKA. To do this, evidence-based risk factors for the development of DKA in children need to be identified.
Evidence-based factors associated with DKA at type 1 diabetes diagnosis
Usher-Smith et al. conducted a systematic review, including 46 studies with over 24,000 children and youth (ages 0-21 years) from 31 different countries, to determine factors associated with diabetic ketoacidosis at the diagnosis of type 1 diabetes in children and young adults. Together, 23 different factors were considered in this review. Here is the key evidence you need to know to identify a child at risk for presenting in DKA at type 1 diabetes diagnosis.
Age: Children less than 2 years old were three times more likely to present in DKA than children 2-5 years old.
Ethnicity: Because the populations included in the studies were too heterogeneous, the frequency of DKA could not be determined for specific ethnic groups. However, 5 studies compared differing pairs of ethnic groups, and consistently found the ethnic minority group experienced an increased risk of DKA.
Body mass index (BMI): Children with lower BMIs were at an increased risk for DKA.
Health insurance status: In the United States, children who had either no health insurance or Medicaid were three times more likely to present in DKA at diagnosis when compared to children with private health insurance.
Family income, parental employment, and social status: Children of low SES were at an increased risk for presenting in DKA.
Diagnostic error: Children who were not diagnosed with type 1 diabetes on their first medical consultation due to diagnostic error were three times more likely to present in DKA at diagnosis. Diagnostic error was significantly more likely in young children. The mean age of children presenting in DKA at diagnosis whose diagnosis was missed on the first medical consultation was 5.4 years, compared to mean age of 8.8 years in children whose diagnosis was not missed.
Delayed treatment and presence of structured diabetes team: One European multicenter study showed a greater than 24 hour delay between diagnosis and treatment led to a small increased risk of presenting in DKA at diagnosis. One Kuwaiti study showed that children diagnosed in hospitals without a structured diabetes team were more likely to present in DKA.
Preceding infection or febrile illness: Having a preceding infection or febrile illness increased the risk of presenting with DKA at diagnosis.
Family history of diabetes: Children who had a first-degree relative with type 1 diabetes were six times less likely to present in DKA on diagnosis.
Parental education: High parental education was protective against DKA, however, the definition of “high” education varied depending on the location of data collection in the included study.
Background incidence of type 1 diabetes: Children who lived in an area with a higher background incidence of type 1 diabetes were less likely to present in DKA.
Factors with no or an unclear effect on rate of presentation in DKA at diagnosis:
The following factors had no impact on the rates of presentation in DKA at diagnosis, or their impact could not be adequately assessed due to limitations of the data: sex, parental consanguinity (i.e., blood relation to a parent with type 1 diabetes), family structure, rural or urban residence, delayed diagnosis, and number of medical consultations before diagnosis.
Summarizing the evidence
The authors of the review concluded: “Younger age, diagnostic error, ethnic minority status, lack of health insurance in the US, lower body mass index, preceding infection, and delayed treatment were all associated with an increased risk of diabetic ketoacidosis, while having a first degree relative with type 1 diabetes at the time of diagnosis, higher parental education, and higher background incidence of type 1 diabetes appear to be protective.”
Implications for practicing clinicians
The authors of the review highlight: “As with other serious illnesses in children, differentiating the occasional child with a serious illness from the large number with minor undifferentiated illness is challenging. The relatively easy access to point of care tests for hyperglycemia, ketonemia, and glycosuria, however, means that diagnosis does not require access to specialist diagnostic services but, instead, a high index of suspicion. Our findings suggest that clinicians should be particularly alert for diabetic ketoacidosis in children under 5 years old, those from ethnic minority groups, and those from families with low education level or socioeconomic status.”
Translating Emergency Knowledge for Kids (TREKK):
1. Karvonen, M. (2006). Incidence and trends of childhood Type 1 diabetes worldwide 1990-1999. Diabetic Medicine, 23(8), 857-866. doi: 10.1111/j.1464-5491.2006.01925.x
2. Usher-Smith, J. A., Thompson, M. J., Sharp, S. J., & Walter, F. M. (2011). Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: A systematic review. BMJ, 343(7815). doi: 10.1136/bmj.d4092
From team: News and Events
tags: Diabetic ketoacidosis
May 11, 2015 - This week's post is also available from the Cochrane Child Health blog.
Head trauma. Headache. Nausea. Loss of balance. Dizziness. Difficulty concentrating. Confusion. Behavioural changes. Sleep changes.
It might be a concussion. What next?
With growing attention in research and the media, it is becoming clear that concussions are very serious injuries with sometimes lasting effects. As an emergency physician, the chances are good that you have treated many children with these symptoms – pediatric concussion is considered a silent epidemic . In the US, estimates suggest up to 3.8 million concussions occur every year, resulting in over 700,000 Emergency Department visits . Because of this, head trauma is one of the most common reasons for consultation in the Emergency Department .
Concussion symptoms typically alleviate within 72 hours, and completely resolve in 7 to 10 days . However, in many cases, children and youth experience ongoing or recurrent headache, behavioural changes, and other physical symptoms, requiring subsequent Emergency Department and primary care physician visits . It was estimated in one Canadian study that 58% of children with concussion remained symptomatic in the first month, 11% at 3 months, and 2% beyond one year . These findings reinforce that concussions are serious injuries that can last over time.
Considering the significant morbidity of concussion, and its impact on quality of life and school participation, identifying kids at risk for long-term consequences and those in need of neurosurgical intervention is crucial. There is an increasing tendency by physicians to perform early diagnostic imaging through CT scan for suspected concussion because it is linked to better outcomes, lower admission rates, and serves as the diagnostic standard for identifying intracranial injury . However, it isn’t feasible or necessary to conduct this scan with all children presenting with concussion symptoms. This makes a clinical decision rule for CT scans important. With summer around the corner, and team sports ramping up for the season, understanding and using effective and validated clinical decision rules is essential to identify children at risk for intracranial injury.
When to CT: The evidence
In a recent systematic review, Pickering et al. reviewed evidence from 16 RCTs (representing 14 cohorts and 79,740 patients) to determine which clinical decision tool is most accurate at predicting which pediatric patients will have an intracranial injury on CT or require neurosurgical intervention . Sensitivity and specificity were determined for 11 decision rules:
Of the 11 clinical decision rules published at the time of the review (2011), methodologically, PECARN was identified as the strongest rule with the greatest validity, largest study cohort, highest sensitivity and acceptable specificity for clinically significant intracranial injury.
PECARN is the recommended clinical decision rule for identifying children at risk for intracranial injury who require imaging in Canada . However, in the UK, because the CHALICE-derived National Institute for Health and Clinical Excellence (NICE) criteria for CT scan forms the basis for 85% of management decisions in the Emergency Department , the authors acknowledged its continued use as an acceptable and cost-effective alternative more in keeping with National Health Service-based practice.
The PECARN Management Algorithm for Children after Head Trauma was initially published in the Lancet in 2009, and was based on a derivation and validation study involving 42,412 children . The algorithm has separate considerations for children younger than 2 years and 2 years or older. It is available through trekk.ca or directly on the Ontario Neurotrauma Foundation website on page 53 of their Guidelines for Diagnosing and Managing Pediatric Concussion .
The authors concluded that the PECARN algorithm provides "highly accurate prediction rules for children at very low risk of clinically-important traumatic brain injuries for whom CT scans should be avoided. Application of these rules could limit CT use, protecting children from unnecessary radiation risks” .
The heterogeneity of the rules included in the review prevented any meta-analysis of the data. The authors noted that a shift in practice from identification of any lesion on a CT scan to focusing on clinically significant lesions has made results of studies difficult to compare. The authors suggested: “future research efforts in this field should concentrate on the universal application of definitions for patient populations, inclusion criteria, reference standards, and outcome criteria” .
Translating Emergency Knowledge for Kids (TREKK):
1. TREKK Bottom Line Recommendations: Concussion (English Version)
2. McCrory, P., Meeuwisse, W., Aubry, M., Cantu, B., Dvorak, J., Echemendia, R., . . . Turner, M. (2013). Consensus statement on Concussion in Sport - The 4th International Conference on Concussion in Sport held in Zurich, November 2012. Phys Ther Sport, 14(2), e1-e13. doi: 10.1016/j.ptsp.2013.03.002
3. Farrell, C. A. (2013). Management of the paediatric patient with acute head trauma. Paediatrics and Child Health (Canada), 18(5), 253-258.
4. Scorza, K. A., Raleigh, M. F., & O'Connor, F. G. (2012). Current concepts in concussion: Evaluation and management. American Family Physician, 85(2), 124-132.
5. Barlow, K. M., Crawford, S., Stevenson, A., Sandhu, S. S., Belanger, F., & Dewey, D. (2010). Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury. Pediatrics, 126(2), e374-381. doi: 10.1542/peds.2009-0925
6. Pickering, A., Harnan, S., Fitzgerald, P., Pandor, A., & Goodacre, S. (2011). Clinical decision rules for children with minor head injury: A systematic review. Archives of Disease in Childhood, 96(5), 414-421. doi: 10.1136/adc.2010.202820
7. Kuppermann, N., Holmes, J. F., Dayan, P. S., Hoyle, J. D., Jr., Atabaki, S. M., Holubkov, R., . . . Wootton-Gorges, S. L. (2009). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet, 374(9696), 1160-1170. doi: 10.1016/s0140-6736(09)61558-0
8. Zemek, R., Duval, S., Dematteo, C. et al. (2014). Guidelines for Diagnosing and Managing Pediatric Concussion. Toronto, ON: Ontario Neurotrauma Foundation
From team: News and Events
May 4, 2015 - This week's post is also available from the Cochrane Child Health blog.
"Michael's barky cough startled Valerie from her sleep. For the last few nights, Valerie had not slept well as her two-year-old son was fighting a cold and had been up off and on with a fever and cough...She desperately hoped the coughing would stop...More barky coughing roused her from her thoughts. This time the cough frightened her. As she ran into his room, Michael seemed to be fighting for breath."
Michael's barky cough is a hallmark sign of croup. The cough that often occurs in the middle of the night, rousing parents from their sleep, can be an intense and worrisome event for parents and their young children. However, croup is a well-defined condition with a strong evidence base supporting effective therapeutic management.
Croup, or laryngotracheobronchitis, is an illness that affects a child's breathing. It is caused by many different viruses and most often occurs in the cooler fall and winter months. Croup occurs most commonly in children between 6 months and 3 years of age, but can occur in children of all ages. Croup is characterized by a barky cough that can start quite suddenly. Often the child will have a hoarse voice and difficulty breathing. You may hear a high pitched sound when the child breathes in (stridor). Croup is worse at night or when the child is lying flat. The symptoms occur predominately at night with improvement during the day. The barky cough and difficulty breathing usually resolve after a few nights, though occasionally they can last up to a week. Viruses that trigger croup symptoms are picked up from others, and usually spread through coughing, sneezing or contact with the mucous on tissues, toys or hands.
Doctors assess the severity of the child's symptoms by simply watching and listening. If children have an occasional barky cough, but no stridor, they have a mild case. If they have a frequent barky cough and easily heard stridor even while calm, they have a moderate case. If a child’s chest caves in as they breathe, in addition to a frequent barky cough and easily heard stridor, they have a severe case. When the child has severe symptoms they are most commonly very distressed and agitated. In most cases, the illness is mild and lasts a short time; however, in the most severe cases, a small number of children may require hospitalization and intubation .
Antibiotics do not work on croup because the infection is caused by a virus. However, there are a number of other treatment strategies. An overview of reviews compiled evidence to determine which treatment strategies were most effective. The overview brought together evidence from four systematic reviews that included 54 studies involving 4,710 children. The authors made the following conclusions:
Dr. David Johnson of the Alberta Children's Hospital Research Institute has developed bottom line recommendations for treating croup in collaboration with Translating Emergency Knowledge for Kids (TREKK). The recommendations and other resources including clinical practice guidelines are available at trekk.ca. Dr. Johnson suggests:
“The vast majority of children with croup will resolve their barky cough and difficulty breathing within a few nights. While this will occur regardless of whether their child is treated or not, treatment with glucocorticoids helps reduce both children’s severity and duration of symptoms, allowing parents to relax and return to their normal daily routine sooner than they would otherwise.”
TRanslating Emergency Knowledge for Kids (TREKK):
Croup Storybooks for Caregivers:
University of Alberta, Capital Health, Stollery Children's Hospital. (2012). A Resourceful Father and His Internet Connections: Managing Croup at Home - Mild Croup [Brochure]. Edmonton, Canada.
University of Alberta, Capital Health, Stollery Children's Hospital. (2012). A Late Night Trip to the Emergency Department: Was It The Right Thing To Do? - Moderate Croup [Brochure]. Edmonton, Canada.
University of Alberta, Capital Health, Stollery Children's Hospital. (2012). Things We Take for Granted: A Mother’s Account of Her Child’s Struggle with Croup - Severe Croup [Brochure]. Edmonton, Canada.
1. Bjornson C, Russell K, Foisy M, Johnson DW. The Cochrane Library and the treatment of croup in children: an overview of reviews. Evidence-based Child Health: A Cochrane Review Journal 2010;5(4):1555-65.
From team: News and Events