AIMS:High-flow nasal cannula (HFNC) therapy is increasingly used outside paediatric intensive care units (PICUs) for children with acute respiratory distress, despite limited evidence beyond bronchiolitis and neonatal populations. No existing review has synthesised evidence in children over 1 year without bronchiolitis managed in emergency department and ward settings. This narrative review aims to address this gap. METHODS:PubMed, Scopus and Medline (OVID) were searched to October 2025 for studies of HFNC in children aged over 12 months with acute respiratory distress, managed in emergency department or ward settings and compared with conventional oxygen therapy or non-invasive ventilation. RESULTS:Eight studies (six randomised trials, one pilot RCT, one observational cohort) were included, covering asthma, pneumonia and mixed hypoxaemic respiratory failure. Small trials showed early physiological improvement without consistent benefit in length of stay or PICU admission. Flow rates were highly variable, with several studies delivering flow below thresholds considered necessary for a true high-flow effect. The largest trial reported longer hospital stay and higher PICU admission with early HFNC use compared to conventional oxygen therapy. CONCLUSION:Overall, while HFNC appears safe and well tolerated, current evidence does not support routine first-line use outside the PICU in children over 1 year. More prospective research is urgently needed to identify which populations will benefit from HFNC use. Until such data is available, HFNC should be implemented with clear institutional guidelines, defined escalation criteria and close clinical monitoring.
AIM:Evaluate whether outpatient ondansetron prescription or in-office administration during a primary care (PC) visit was associated with subsequent emergency department (ED) utilization and downstream healthcare recourse utilization among children with acute gastroenteritis (AGE). METHODS:We conducted a retrospective cohort study of children aged 6 months to < 18 years presenting to 39 PC clinics with vomiting, diarrhoea, or AGE between 2017 and 2023. Only the first eligible visit for each child was included. The primary outcome was an ED visit within 7 days of the index PC visit. Secondary outcomes included ED acuity, hospital admission, and ED healthcare resource utilization among children subsequently presenting to the ED. Associations were evaluated using logistic and negative binomial regression models. RESULTS:We included 11 343 unique children. Ondansetron was prescribed during 3789 (33.4%) index PC visits, including 782 (20.6%) children who also received an in-office dose. Overall, 63 children (0.6%) presented to the ED within 7 days. Outpatient ondansetron prescription was not associated with subsequent ED utilization (OR 1.07, 95% CI 0.63-1.78; p = 0.798). Among children subsequently presenting to the ED, prior ondansetron exposure was not associated with ED acuity, hospital admission, or overall healthcare resource utilization, although fewer laboratory tests were performed (IRR 0.45, 95% CI 0.22-0.89; p = 0.026). CONCLUSION:Outpatient ondansetron prescription during PC visits for paediatric AGE was not associated with reduced ED utilization within 7 days. These findings should not be interpreted as evidence that ondansetron lacks clinical benefit but rather that downstream healthcare utilization is influenced by factors beyond symptom control alone. Ondansetron should continue to be considered an adjunct to oral rehydration therapy in appropriately selected children with AGE.
INTRODUCTION:Lung ultrasound (LUS) is increasingly used in neonatal intensive care units (NICUs) as a bedside, radiation-free imaging tool for assessing respiratory conditions. Despite its advantages, data on current LUS practices in Australasian NICUs are limited. This study aimed to evaluate LUS use across NICUs in both countries. METHODS:A structured, anonymous survey was distributed via REDCap to NICU heads of departments in Australia (n = 29) and New Zealand (n = 6). The 45-item questionnaire examined LUS frequency, indications, clinical and research use, staff training, equipment and perceived barriers. It was based on previous surveys and refined through expert feedback. Data were collected anonymously between October 2024 and July 2025. RESULTS:Twenty-nine NICUs participated (82.9% response rate). Routine use of LUS was reported by 10.3% of units, occasional use by 65.6% and non-use by 24.1%. LUS was used primarily for clinical purposes in 65.5% of units, for both clinical and research purposes in 17.2%, and for neither in 17.2%. Common indications included pleural effusion (79.3%), pneumothorax (75.9%), respiratory distress syndrome (58.6%), pneumonia (51.7%), transient tachypnoea of the newborn (48.3%) and atelectasis (37.9%). LUS was considered the first-line imaging modality for pneumothorax in 79.3% of units. In 75.9% of units, at least one senior consultant had received training in LUS, and in 55.2%, fellows were trained and encouraged to perform LUS. Inconsistent use was not attributed to limited access to ultrasound equipment. CONCLUSION:Routine LUS use across Australasian NICUs remains limited. Broader adoption may be supported through targeted training, institutional protocols and quality management frameworks.
OBJECTIVE:To examine the effects of a parent-participatory (PP) physical activity (PA) program combined with psychoeducation (PE) incorporating psychological skills training (PST) components on anxiety, depression, and social skills in children with ADHD. METHODS:A total of 33 children with ADHD, aged 7-12 years, were allocated to one of three groups: PA combined with PE incorporating PST components (PA + PE, n = 12), PA only (n = 10), or a control group (n = 11). The intervention was delivered for 8 weeks. Anxiety, depression, and social skills were assessed at baseline, post-intervention, and 6-month follow-up using the RCMAS, the CDI, and the K-SSRS-P, respectively. A two-way mixed-design repeated-measures ANOVA was used to evaluate intervention effects. RESULTS:Significant time × group interaction effects were observed for anxiety (p < 0.001) and depression (p < 0.001), but not for social skills (p = 0.320). From baseline to post-intervention, the PA + PE group showed reductions in anxiety (d = -1.79) and depression (d = -2.99), while the PA-only group also showed reductions in anxiety (d = -1.29) and depression (d = -0.95). CONCLUSIONS:PP PA, with or without PE incorporating PST components, may contribute to improvements in anxiety and depression in children with ADHD. Although numerically greater improvements were observed in the PA + PE group, its additional benefit over PA alone was not statistically established. Further adequately powered studies are needed to clarify the potential added contribution of PE and its effects on social skills. TRIAL REGISTRATION:Clinical Research Information Service (CRIS) as KCT0010046.
OBJECTIVE:Isolated skull fractures (ISFs) in young children are a common reason for referral to hospital-based child protection teams for forensic medical assessment. The purpose of this study was to describe the injury opinion of simple ISFs determined by a child protection team, and to assess the utility of skeletal survey and ophthalmology examination in forming the injury opinion. METHODS:A retrospective study was performed for children under 2 years referred to the child protection team at a tertiary children's hospital with a simple ISF between July 2015 and December 2024. The primary outcome was the injury opinion determined by the child protection team: accidental, indeterminate or inflicted. Secondary outcomes included the rate and positive yield of skeletal survey and ophthalmology examination. RESULTS:Of the 81 children referred with a simple ISF, 4 (5%) were considered inflicted, 30 (37%) indeterminate and 47 (58%) accidental. History with statutory child protection services (p-value 0.042) and additional suspicious cutaneous injuries (p-value < 0.001) were significantly associated with inflicted injury. A skeletal survey was obtained for 43 children (53%). Four skeletal surveys identified additional injuries, giving a positive yield of 9%. Ophthalmology examination was performed for 38 children (47%), and none had retinal haemorrhages. CONCLUSION:ISFs in young children are rarely determined to be inflicted injuries. In cases of inflicted ISF, there are additional clinical factors prompting concern (age under 6 months, history with child protection services, or additional suspicious cutaneous injuries). Skeletal survey rarely adds additional information, and ophthalmology examination never adds additional information.
AIM:To clarify the aetiology and clinical relevance of markedly elevated total serum immunoglobulin E (IgE) levels (≥ 1000 IU/mL) in children and to characterise the longitudinal outcomes of patients with persistently elevated IgE levels in whom no underlying cause can be identified. METHODS:This retrospective cohort study included children aged 1-18 years evaluated between September 2019 and June 2025 with total serum IgE levels ≥ 1000 IU/mL. Patients with at least three outpatient visits and a minimum follow-up of 12 months were eligible for final analysis. Comprehensive clinical, allergic, immunologic and laboratory assessments were performed to identify aetiologies. Children without an identifiable cause were followed longitudinally and classified according to IgE trajectories and clinical evolution. RESULTS:Among 1840 children with markedly elevated IgE levels, 1508 were eligible for final analysis. An aetiologic diagnosis was established in 1449 patients (96.1%), predominantly allergic diseases (97.4%). Only 59 children (3.9%) had unexplained IgE elevation despite extensive evaluation. Over a median follow-up of 27 months, most of these children remained asymptomatic or demonstrated spontaneous declines in IgE levels. However, 13.6% developed new allergic diseases during follow-up. Persistently elevated IgE levels were associated with transient differences in eosinophil counts but not with consistent immunologic abnormalities or severe clinical outcomes. CONCLUSIONS:In childhood, markedly elevated total IgE levels almost always reflect an identifiable underlying condition, most commonly atopic disease. Truly unexplained IgE elevation is rare and typically follows a benign course. In the absence of clinical warning signs, careful longitudinal monitoring, rather than aggressive or invasive diagnostic testing, appears to be the most appropriate management strategy, since a minority of these children, particularly those with persistently elevated IgE, go on to develop atopic disease.
OBJECTIVE:Adolescents with atypical anorexia nervosa (AAN) experience cardiac complications at rates comparable to typical anorexia nervosa, despite remaining within or above a normal weight range. The physiological mechanisms underlying this paradox remain poorly understood. This study is the first to compare cardiac outcomes between adolescents with AAN and those who underwent bariatric surgery, a population experiencing similarly rapid and substantial weight loss within a medically supervised context. METHODS:A retrospective study compared adolescents with AAN (n = 102, 82% female, mean age 15.0 ± 1.6 years) and adolescents who underwent bariatric surgery (n = 90, 67% female, mean age 16.4 ± 1.1 years) on weight loss magnitude and pace, minimum heart rate, thyroid function, physical activity and laboratory indices. RESULTS:Despite losing more weight at a faster rate, the bariatric surgery group had significantly higher minimum heart rates (83.6 vs. 62.2 bpm, p < 0.001) and no cases of clinically significant bradycardia, compared with 22.5% in the AAN group. Rate of weight loss did not correlate with minimum heart rate in either group. Exploratory analyses suggested an association between T3 levels and minimum heart rate, warranting further investigation. CONCLUSION:Weight loss magnitude and rate alone do not determine cardiac risk in AAN. The nutritional context and physiological adaptations specific to eating disorders appear to have a role in the cardiac outcome. Adolescents with AAN require proactive cardiac monitoring regardless of current weight or pace of weight loss.
AIM:To describe the etiological spectrum and pathophysiological mechanisms of torticollis in a clinically selected paediatric cohort and to characterise clinical features associated with serious underlying pathology. METHODS:We conducted a retrospective observational study at a tertiary referral centre over 5 years. Only patients in whom torticollis led to advanced evaluation or intervention were included. Cases were retrospectively classified by dominant pathophysiological mechanism. RESULTS:Fifteen patients (9 boys, 6 girls; median age 4 years) were included. Aetiologies included intracranial tumours (n = 5), spinal dural arteriovenous fistula, myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), ADPRHL2-related neurodegeneration (CONDSIAS), atlantoaxial subluxation, cervical lymphadenitis, laryngomalacia, epilepsy, ocular disorders, and acute monocytic leukaemia (AML-M5). Seven dominant mechanisms were assigned: compensatory posturing (n = 7), pain-avoidance posturing (n = 3), vestibulocerebellar dysfunction (n = 1), cervical spine instability (n = 1), ocular compensation (n = 1), cortical irritability (n = 1), and paroxysmal neurodegeneration (n = 1). Torticollis resolved in 13 of 15 patients (86.7%) after definitive treatment. CONCLUSIONS:Torticollis developing after the neonatal period may be the presenting sign of conditions ranging from refractive error to leukaemia, MOGAD, and dural arteriovenous fistula in children. The mechanism-based interpretations presented here are hypothesis-generating and require prospective validation.
AIM:This study investigated the dynamic profile of stromal cell-derived factor 4 (SDF4), a hypoxia-inducible chemokine and S100B, an established astroglial injury marker, in neonates with hypoxic-ischemic encephalopathy (HIE) undergoing therapeutic hypothermia (TH). Its potential as a biomarker was assessed by examining its relationship with baseline severity, clinical trajectories and metabolic recovery. METHODS:In this prospective cohort study, 33 term neonates with moderate-to-severe HIE treated with TH and 20 healthy controls were enrolled. Serum levels of SDF4, S100B, total antioxidant status (TAS), total oxidant status (TOS), oxidative stress index (OSI) and thiol-disulphide homeostasis were measured before TH (baseline) and on Day 5 (after rewarming). Effect sizes (Cohen's d) were calculated for significant results. RESULTS:Before TH, HIE infants had significantly higher SDF4, S100B, OSI and disulphide levels and lower native thiol and TAS than controls (all p < 0.01). Following TH, all six biomarkers changed significantly in the anticipated direction across the total cohort (all p ≤ 0.020). In stage-specific sub-analysis, post-TH reductions in SDF4 and S100B were statistically significant only in Stage 2 HIE (p = 0.013 and p = 0.030, respectively), whereas oxidative stress parameters (OSI, native thiol, TAS) improved significantly in both severity groups. CONCLUSION:SDF4 appears to be a novel biomarker reflecting both HIE severity and the dynamic response to TH. The selective lack of SDF4 and S100B clearance in Stage 3 HIE highlights a more sustained pattern of neuroinflammatory injury, supporting SDF4's potential role in monitoring metabolic recovery and guiding individualised neuroprotective strategies.
AIM:To describe the clinical characteristics, timing, and long-term outcomes of idiopathic acute pancreatitis (AP) in paediatric inflammatory bowel disease (IBD) after systematic exclusion of secondary causes. METHODS:We conducted a retrospective single-centre cohort study of paediatric IBD patients followed between January 2018 and December 2024. AP diagnosis and severity were classified according to the North American Society for Paediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) criteria. Patients with drug-induced, metabolic, infectious, genetic, or structural causes were excluded. Clinical, laboratory, imaging, and outcome data were analysed. RESULTS:Among 395 paediatric IBD patients, 16 (4.1%) developed AP. After excluding four azathioprine-related cases, 12 patients (3%) were included (50% male; median age 10.6 years). Ulcerative colitis (UC) predominated (67%), with colonic involvement in all cases. Idiopathic AP occurred during active disease in 75% and after IBD-related surgery in 25%. All episodes were mild and resolved with supportive management without complications. Ultrasound showed focal pancreatic inflammatory changes in 58% of patients, predominantly involving the body and tail, while diffuse pancreatic enlargement was reported in 5 patients (42%). Over a median follow-up of 3.7 years, 8/12 patients (67%) developed acute recurrent pancreatitis (ARP), with a median time to recurrence of 9 months. No patients developed pancreatic insufficiency or diabetes. Serum IgG4 levels were negative in all patients. Among those who developed ARP, genetic testing revealed no pathogenic variants. CONCLUSIONS:Idiopathic AP in children with IBD appeared to be a mild but potentially relapsing condition associated with active intestinal inflammation and colonic disease. Pancreatic function remained preserved despite recurrence, which may be consistent with an immune-mediated gut-pancreas axis. Given the limited sample size, these findings should be considered hypothesis-generating, and prospective multicentre studies are required to confirm these observations and better characterise the underlying pathogenesis.
AIM:Meconium-related ileus (MRI) often mimics other surgical pathologies in extremely low birth weight infants (ELBWIs), leading to diagnostic difficulties. This study aimed to clarify the clinical presentation and management outcomes of enema therapy in ELBWIs with a specific focus on the clinical indicators of underlying non-MRI surgical pathologies. METHODS:A retrospective review was conducted of 31 ELBWIs (birth weight < 1000 g) who received enema therapy for suspected MRI at a single tertiary center between 2008 and 2024. Infants were categorized into Success (n = 20) and Failure (n = 11) groups. The clinical characteristics, timing of intervention, and underlying pathologies were compared. RESULTS:Underlying non-MRI surgical pathologies were identified only in the Failure group (36% [4/11] vs. 0% [0/20] in the Success group, p = 0.010), including Hirschsprung disease, necrotizing enterocolitis, meconium peritonitis, and ileal stenosis. The overall survival was significantly lower in the Failure group than in the Success group (55% vs. 95%, p = 0.013). A descriptive review of these non-MRI patients highlighted that an atypically late initial enema therapy or a high frequency of repetitive procedures was critical clinical features that masked the underlying pathologies. CONCLUSION:In ELBWIs with suspected MRI, the failure of enema therapy was significantly associated with underlying non-MRI surgical pathologies. Although these findings require validation in larger cohorts, delayed initiation of therapeutic enema or repeated procedures without sustained improvement should prompt reassessment for non-MRI surgical pathology and early surgical consultation.
OBJECTIVE:To evaluate the physiological response following vasopressin initiation and identify factors associated with mortality in extremely preterm infants with refractory cardiopulmonary instability. STUDY DESIGN:Retrospective cohort study of infants born at less than 29 weeks' gestation who received vasopressin. Physiological responses and mortality were evaluated using multivariate logistic regression and receiver operating characteristic analyses. RESULTS:The cohort included 87 infants, of whom 60 (69.0%) died before discharge. Prior to vasopressin initiation, non-survivors had lower pH (7.20 [7.07-7.26] vs. 7.25 [7.21-7.30]; p = 0.009), higher lactate concentrations (5.6 vs. 1.1 mmol/L; p = 0.001), and higher oxygen saturation index (14.7 vs. 12.0; p = 0.022). Following vasopressin initiation, mean blood pressure increased from 29.0 to 39.0 mmHg at 24 h (p < 0.001), while FiO2 requirements, oxygenation indices, and lactate concentrations decreased. Lower pre-treatment pH (adjusted OR 0.53, 95% CI 0.33-0.87; p = 0.012), higher oxygen saturation index (adjusted OR 1.10, 95% CI 1.02-1.19; p = 0.017), and higher lactate concentration (adjusted OR 1.62, 95% CI 1.04-2.54; p = 0.035) were independently associated with mortality. Lactate showed the strongest discrimination for mortality (AUC 0.85, 95% CI 0.69-0.97). CONCLUSION:Vasopressin initiation was associated with improved physiological markers. Mortality was associated more strongly with impaired perfusion and oxygenation severity than with blood pressure alone.
AIM:The aim of this research was to explore what makes (or would make) for good genomic care delivered wholly or in part by paediatricians. METHODS:An interpretive description, qualitative study with parents of children offered genomic testing as an outpatient for a condition other than cancer; general and subspecialist paediatricians; nurses; and genetic counsellors. Data were primarily collected retrospectively and analysed using inductive content analysis. Interpretation was enriched by the involvement of parent and paediatrician project advisors. RESULTS:Twenty-five parents and 20 health professionals participated. Most parents had received a genetic diagnosis for a child presenting with neurodevelopmental delay and/or epilepsy. Key aspects of good genomic care identified included: adopting a slow, multi-appointment approach to discussing genomic testing in certain instances; letting families know what to expect; signposting to information and psychosocial support services when disclosing results; communicating next steps; and adopting a team approach to aid sense-making. Paediatricians were not expected to do everything, with ongoing roles for genetic experts described. At different stages of the testing process, paediatricians existing and ongoing relationships with families were identified as an asset in helping promote good experiences. CONCLUSION:Genomic testing in usual paediatric outpatient care can be delivered well, with this research yielding practical guidance for paediatricians. Ongoing evaluation as models of care evolve will support the delivery of high-quality genomic care that best meets families' needs.
OBJECTIVE:Determine if high-dose intravenous magnesium with/without nebulized budesonide for children with acute severe asthma is safe and reduces time to medical readiness for discharge compared to standard intravenous magnesium. METHODS:Either 2 doses of intravenous magnesium or 1 dose and placebo, each with/without high-dose nebulized budesonide, were given in a double-blind randomized trial to study patients in addition to standard-of-care asthma treatment. Time to medical readiness for discharge was the primary outcome. The proportion of patients discharged at 12, 18, and 24 h, asthma severity scores at 4, 8, 12, and 24 h, and safety of high-dose magnesium were secondary outcomes. Follow-up was 1 week. RESULTS:Covid-19 intervened to stop recuitment at 70% of the estimated 218 children planned. Primary and secondary results were similar for the 4 groups. High-dose magnesium was safe on clinical and laboratory assessment. Exploratory analysis combining IV high-dose magnesium groups compared to standard magnesium showed improvement of discharge ratio at 12 h for the former. 40/78 patients (51.2%) in high-dose magnesium versus 26/75 patients (34.6%) in the standard magnesium arms ready for discharge, p = 0.038, absolute risk reduction 16.6%,95% CI, 0.93% to 31.1%. There was a trend toward improvement of PRAM score at 4 and 8 h in the nebulized budesonide groups compared to placebo and no significant difference in seeking post-discharge outpatient or need for inpatient care. CONCLUSIONS:High-dose magnesium appeared safe with only a modest possible benefit of medical readiness for discharge at 12 h. There was a reduction in asthma severity score at 4 and 8 h from nebulized budesonide. TRIAL REGISTRATION:clinicaltrials.gov, ID #NCT02455687.
