Archives of Disease in Childhood最新文献

Background: Elastomeric devices (EDs) allow infusion of antibiotic via an intravenous catheter over 24 hours, supporting outpatient parenteral antimicrobial therapy. We conducted a systematic review of these devices in a paediatric population.

Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was used to review studies assessing antibiotic delivery through EDs in a paediatric population (0-21 years). Medline, Embase, CINAHL, PubMed, The Cochrane Clinical Trials Library, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform were searched.

Results: After deduplication, 1789 titles and abstracts were screened; 45 underwent full-text review and nine were suitable for qualitative synthesis. 567 patients were treated in 657 episodes. 14 different antibiotics and aciclovir were delivered through EDs, primarily 24-hour infusions. Median treatment duration was 10 to 15 days. A variety of infections were treated (mostly infective exacerbations of cystic fibrosis (CF), bone/joint infection). Efficacy data were limited; two studies demonstrated non-inferiority of antibiotic therapy via ED for CF patients compared with conventional infusion pumps. In another study, only two patients (6%) experienced treatment failure. Few adverse events were reported: 1 of 34 patients (3%) experienced ED failure due to misplacement of the central line; one case of antibiotic crystallisation.

Conclusion: EDs have been used for a range of antimicrobial agents in children, in the treatment of a variety of infections, mostly in CF patients, and few adverse events were reported. Further studies should concentrate on new patient groups, and specific information about safety and cost effectiveness of ED in children is required.

Prospero registration number: CRD42021237146.

Background: High-flow nasal cannula (HFNC) therapy is increasingly used for lower respiratory tract infections (LRTIs) in infants and young children, but recommendations vary, and standardised practice is lacking.

Objective: To systematically review national or international guidelines on HFNC use in children aged 1-23 months with LRTIs, focusing on initiation, administration, monitoring, discontinuation and feeding.

Methods: We searched MEDLINE, EMBASE, CINAHL, Web of Science and professional society websites (2014-2025) for guidelines on HFNC use in this age group. Four reviewers independently screened, extracted data and assessed quality with the AGREE II tool. Interguideline concordance was calculated for all guidelines and separately for those addressing bronchiolitis and for evidence-based versus consensus-based guidelines. Recommendations were synthesised narratively.

Results: Fifteen guidelines were included, including nine bronchiolitis guidelines. All addressed HFNC initiation, with low oxygen saturation (73%) and respiratory distress (47%) as common indications. Initial flow recommendations varied; 2 L/kg/min was most frequent (57%), and all bronchiolitis guidelines reporting it advised weight-based settings. Only two guidelines included weaning or discontinuation protocols, and seven addressed failure criteria. Monitoring typically included pulse oximetry and clinical observation; pulse oximetry was endorsed by all bronchiolitis guidelines that reported it (8/9). Enteral feeding was supported by all reporting guidelines (6/15). Guideline quality was moderate to high, though applicability and updating were frequent gaps.

Conclusions: HFNC guideline recommendations for young children with LRTIs remain inconsistent, particularly regarding weaning, failure criteria and procedural details. Regular updates and greater standardisation are needed to improve care and optimise resource use.

Prospero registration number: CRD42024622544.

Objective: To evaluate whether a point-of-care decision rule could safely reduce antibiotic prescriptions in children presenting with fever without source in emergency departments.

Design: Open cluster randomised clinical trial (registered on ClinicalTrials.gov).

Setting: Twenty-five European paediatric emergency departments participated from November 2018 to October 2021.

Patients: Children aged 6 days to 36 months presenting with acute fever without source.

Interventions: During the first year, all centres (or clusters) followed their usual care protocols. In the second year, centres were randomised 1:1 to either continue usual care or to adopt the decision rule based on age, clinical symptoms, urine analysis and point-of-care procalcitonin measurements. In the third year, all centres applied the decision rule.

Main outcomes and measures: The primary outcome was antibiotic exposure within 15 days. Secondary outcomes included morbidity and mortality assessed at day 15.

Results: Among 4882 children (median age: 3 months, IQR 1-14), 2440 were in the usual care group and 2442 in the decision rule group. Serious bacterial infections occurred in 766 (15.7%) children, and invasive bacterial infections in 67 (1.4%). In the intention-to-treat analysis, 927 children (38.0%) received antibiotics within 15 days in the usual care group, compared with 641 (26.2%) in the decision rule group (OR 0.57; 95% CI 0.43 to 0.75; p<0.001). Morbidity and mortality rates were similar between groups (OR 0.83; 95% CI 0.57 to 1.22; p=0.34).

Conclusions: The decision rule safely reduced unnecessary antibiotic use in young children with fever without source in emergency departments.

Trial registration number: NCT03607162.