BACKGROUND:The ability of paediatric asthma scores to predict admission following initial bronchodilator therapy has not been comprehensively evaluated. METHODS:A multicentre observational study including children aged 2-18 years who received at least a single dose of bronchodilator following presentation to four Australian emergency departments (EDs). Observations were obtained by trained research nurses before and after initial treatment to calculate ten common asthma scores (Pediatric Respiratory Assessment Measure (PRAM), Siriraj Clinical Asthma Score (SiCAS), Clinical Asthma Score (CAS), Acute Asthma Intensity Research Score (AAIRS), Modified Pulmonary Index Score (MPIS), Pulmonary Index Score (PIS), Pediatric Asthma Score (PAS), Pediatric Asthma Severity Score (PASS), Woods and Downs and Pulmonary Score (WDCAS)). Primary outcome was determining the global ability of scores to discriminate between those admitted and discharged, assessed by an area under receiver operating curve (AUC ROC) ≥0.80. Secondary outcomes included adjusted ORs and the ability to provide an adequate balance between sensitivity and specificity (defined as Youden Index ≥50%). RESULTS:Of the 1238 patients enrolled, 792 (64.0%) were male, median age was 3 years (IQR 2-6), and 513 (41.4%) met the admission criteria. None of the asthma scores demonstrated an AUC ROC ≥0.80, with the four best performing (MPIS, SCAS, PIS and PAS) scoring between 0. 70 and 0.73. Results for adjusted OR analysis indicated that each one-point increase was associated with increased odds of admission for all 10 asthma scores (p=<0.001). No asthma score achieved a Youden Index ≥50%. CONCLUSION:None of the asthma scores assessed in this study met the predetermined primary outcome of an AUC ROC ≥0.80.

Background and aims:To identify the practice variations in the management of acute viral bronchiolitis (AVB) in different healthcare settings across India. Methods:This online survey was conducted over 2½ months (May-July 2025) involving healthcare professionals (pediatricians, emergency physicians, and pediatric intensivists) working in different healthcare settings in India. Questions were related to demographic profile, caseload and seasonal variations, diagnosis, admission/discharge criteria, and treatment. Results:Among 100 respondents across 21 states/union territories, the majority were pediatric intensivists (n = 55) and pediatricians (n = 30) working in tertiary-level hospitals (n = 90). The pediatric intensive care unit (PICU) was available to 88 respondents. Most respondents diagnose AVB in children <2 years (n = 66) based on clinical history and examination alone (n = 41) and the addition of chest radiograph (n = 44). Common investigations performed among admitted children were chest radiograph (n = 76), sepsis screen (n = 64), and viral polymerase chain reaction (n = 47). Common admission criteria were high-risk babies (n = 94), severe respiratory distress (n = 91), doubtful follow-up (n = 72), and SpO2 <94% (n = 50). Once admitted, most respondents measure SpO2 intermittently (n = 59), start oxygen therapy if SpO2 <94% (n = 52), and maintain SpO2 >92% during treatment (n = 49). Once off oxygen, SpO2 >94% was used as a threshold to discharge (n = 58). Common modes to start oxygen were simple nasal prongs (n = 75) and high-flow nasal cannula (n = 58). The majority (n = 96) use nebulizations, including 3% saline (n = 86) and adrenaline (n = 52). Antibiotic use was reported by most as sometimes or rarely (n = 87). Most respondents use either the Indian Academy of Pediatrics (n = 48) or the American Academy of Pediatrics (n = 25) guidelines, and only 36 have a written policy/flowchart in the unit for management of AVB. Conclusion:We noted wide variations in the diagnosis, severity assessment, investigations, treatment, and adherence to guidelines for AVB. However, the majority of respondents use antibiotics sometimes or rarely.

Objective:Abdominal pain is a common pediatric presentation in the emergency department (ED), and acute appendicitis (AA) is the most common surgical diagnosis. This study describes the management of suspected AA in a tertiary Australian pediatric ED.Methods:A single-center prospective observational study was performed between November 2022 and May 2023. Children aged 5 to 15 years presenting to the ED with acute abdominal pain and clinician suspicion of AA were included. Clinical gestalt was measured using a 5-point Likert Scale before and after blood tests. Diagnosis of AA was confirmed on histopathology, and non-AA was confirmed with follow-up at 30 to 60 days.Results:The study enrolled 481 children; AA was diagnosed in 146 (30.6%). Patients with AA were older (11.1 vs. 10.0 y) and more likely to be male (69.2% vs. 48.1%) compared with those without AA. Blood tests were performed in 449 (93.3%) children, with higher rates in AA cases (100% vs. 90.4%). Gestalt improved with blood test results, with overall diagnostic accuracy increasing from 65.9% pre-blood tests to 88.5% post-blood tests. Ultrasound (US) was performed in 361 (75.1%) children with a diagnostic accuracy of 90.6% and was frequently used even in patients deemed low-risk post-blood tests (65.7%). One hundred and fifty (31.2%) of suspected AA cases underwent surgery, with 3 negative appendectomies and 1 ovarian cystectomy without appendectomy. Median (IQR) hospital length of stay was significantly longer for AA cases than non-AA cases [50.8 (35.3 to 95.0) h vs. 7.1 (4.6 to 16.8) h].Conclusions:This study reviews the management and outcomes of suspected AA in a high-volume Australian ED. It shows the importance of blood tests in improving diagnostic accuracy of clinician gestalt and highlights the potential overuse of US in low-risk patients. Future research should explore a more structured diagnostic approach to increase diagnostic accuracy, optimize resource utilization, and improve patient outcomes.

BACKGROUND:Paediatric patients requiring a medical discharge generally have to wait for daytime ward rounds before leaving hospital. This can lead to unnecessary discharge delays spanning hours, with impacts on hospital capacity and patient satisfaction. AIMS:To assess the impact of an early-morning discharge project on discharge by time of day, family satisfaction, and staff experience. METHODS:A novel approach ("Sunrise Discharges") was trialled and audited at a tertiary children's hospital, whereby appropriate patients were discharged by night medical staff prior to morning handover. The Sunrise Discharge project was piloted in the General Paediatric department for 3 months starting from 1 August 2024, with prior communication to clinical staff through multiple channels. Analysis of patient discharge time trends was performed to assess the impact of this initiative. In addition, "Plan, Do, Study, Act" quality improvement cycles were implemented throughout the 3-month audit period utilising feedback from staff surveys, a parent experience survey, and chart reviews to improve this process. RESULTS:The implementation of Sunrise Discharges resulted in a nearly seven-fold increase in the percentage of total general paediatric discharges prior to 09:00 a.m. (0.65%-4.46%, p < 0.0001) when compared to the 3 months prior. Parent feedback on the project was positive. Staff provided helpful feedback which guided project improvement and notably, night staff did not feel this added unmanageable workload to their shifts. CONCLUSION:The Sunrise Discharge project significantly improved discharge by time of day, with positive family experience of the process. With further refinement, it holds potential for hospital-wide implementation and broader use in other paediatric centres.

Objectives: To examine the factors influencing paediatric fever management practices among Australian Emergency Department (ED) doctors and nurses using the Theoretical Domains Framework (TDF). Methods: Cross-sectional survey of doctors and nurses across 22 Australian EDs. The survey assessed 8 of the 12 domains from the TDF using 13 questionnaire items. Results: A total of 472 participants [275 (58.3%) doctors, 197 (41.7%) nurses] completed the survey (overall response rate 57.7%). Of these, 286/470 (60.9%, 95% CI: 56.4%-65.2%) were familiar with clinical practice recommendations on antipyretic administration for paediatric fever (TDF domain: Knowledge). Similar proportions indicated they had been trained to ensure antipyretic use solely when febrile children appear distressed [TDF domain: Skills; 285/469 (60.8%, 95% CI: 56.3%-65.1%)] and agreed that only administering antipyretics to febrile children who seemed distressed aligned with their professional responsibilities as ED clinicians [TDF domain: Social/Professional Role and Identity; 294/467 (63.0%, 95% CI: 58.5%-67.2%)]. More than half (268/467, 57.4%, 95% CI: 52.8%-61.8%) of participants felt pressured by parents/caregivers to give antipyretics for fever reduction, irrespective of the child’s discomfort level [TDF domain: Social Influences]. Just under one-third of participants (137/470, 29.1%, 95% CI: 25.2%-33.4%) aimed to reduce fever before discharge (TDF domain: Goals). Conclusions: Overall, ED clinicians showed moderate knowledge, training, and agreement with clinical practice recommendations on antipyretic administration for paediatric fever. Notably, more than half of the respondents surveyed felt pressured by parents/caregivers to use antipyretics outside of guideline recommendations. Our findings highlight the significant emotion attached to fever management and the need for clinicians to foster trust and provide tailored evidence-based information to families.

OBJECTIVES:We set out to describe the amount of fluid administered within the first 24 hours of sepsis treatment with an exploratory analysis of associations. DESIGN:This prospective observational study used data from the Sepsis Epidemiology in Australian and New Zealand Emergency Departments Study, collected from 2021 to 2023. PATIENTS:Participants were children aged 0 years to <18 years with suspected community-acquired sepsis admitted to the hospital through 11 emergency departments in Australia and New Zealand. MAIN OUTCOMES:We describe the volumes of fluid administered and mortality rates associated with different fluid volumes. RESULTS:A total of 5352 patients were included in the analysis, with a median age of 2.6 years (IQR 0.4-7.5 years), in-hospital mortality of 58 (1.1%), and 293 (5.5%) of whom met Phoenix sepsis criteria. The median total volume of fluid administered over the initial 24 hours of hospitalisation was 40.0 mL/kg (IQR 20.6-61.5 mL/kg), including: bolus fluid 10.0 mL/kg (IQR 9.4-19.9 mL/kg), maintenance fluid 27.1 mL/kg (IQR 10.2-47.3 mL/kg) and medication carrier fluid 0.0 mL/kg (IQR 0.0-0.9 mL/kg). In-hospital mortality increased with increasing volume of bolus fluid but not with increasing volume of total fluid (unadjusted OR for in-hospital mortality for >55 mL/kg vs <15 mL/kg bolus fluid: 20.5, 95% CI 8.0 to 52.5; p<0.001). CONCLUSION:Although maintenance fluids accounted for the largest proportion of total fluid volume, bolus fluids showed the strongest association with in-hospital mortality in unadjusted analyses.

BACKGROUND:Airway management in the Emergency Department (ED) can be challenging, particularly in children. Difficult laryngoscopy reduces first-pass success and increases complications, but pediatric ED data remain limited. METHODS:We conducted a prospective, observational study of pediatric intubations recorded in the Australian and New Zealand Emergency Department Airway Registry (ANZEDAR) between 2012 and 2025, including 25 Pediatric Research in Emergency Departments International Collaborative (PREDICT) sites. The primary outcome was the incidence of difficult laryngoscopy. Secondary outcomes were the impact of difficult laryngoscopy on First-Pass Success (FPS) and adverse events. The main exposure variable was laryngoscopic grade, defined as difficult when a Cormack-Lehane Grade 3 or 4 view was encountered on the first attempt. Patient, procedural, and operator characteristics were assessed as potential confounders. RESULTS:Of 946 pediatric ED intubations recorded across 55 sites (including 25 PREDICT pediatric sites) between 2012 and 2025, 865 were included in the analysis after exclusion of cases with missing laryngoscopic grade. The median age was 3.5 years. Difficult laryngoscopy (Cormack-Lehane grade 3-4) was observed in 65 cases (7.5%). FPS was significantly lower in patients with a difficult view compared with those with a non-difficult view (41.5% vs. 87.9%; OR 0.10, 95% CI 0.06-0.17). Adverse events were more frequent in the difficult-view group, including hypoxaemia (38.5% vs. 11.5%; OR 4.81, 95% CI 2.79-8.29) and esophageal intubation (15.4% vs. 1.3%; OR 14.36, 95% CI 5.73-35.98). CONCLUSION:Difficult laryngoscopy in pediatric ED intubations is relatively infrequent but associated with reduced FPS and increased complications. These findings emphasize the importance of ongoing quality improvement and may help inform training and escalation strategies. Continued registry participation is valuable to capture these low-frequency events and better understand their consequences.

Objective To describe the frequency and nature of non-pharmacological de-escalation methods used for children and adolescents presenting to emergency departments (EDs) with acute severe behavioural disturbance (ASBD).Design Secondary analysis of a randomised, controlled, open-label, multicentre trial of oral olanzapine versus oral diazepam for the management of ASBD.Setting Nine EDs in Australia between October 2021 and November 2023.Participants Children aged 9-17 years, for whom information on non-pharmacological de-escalation attempts was recorded, who ultimately required oral sedative medication to manage their ASBD.Main outcome measures The frequency and nature of the use of non-pharmacological de-escalation methods for children and adolescents presenting to EDs in a state of ASBD.Results There were 348 participants enrolled in the randomised controlled trial. This study reports on the 337 of 348 participants (97%) for whom information was recorded regarding non-pharmacological de-escalation attempts during the trial period. Verbal de-escalation was the most commonly attempted technique (96%) followed by active listening (75%). The frequency and nature of de-escalation techniques used were similar across the nine participating sites.Conclusions A variety of non-pharmacological de-escalation strategies are used among patients who require oral sedative medication. There is a need for studies to investigate whether there are optimal first-line de-escalation strategies and to determine their effectiveness and order of use in children and adolescents presenting to EDs with ASBD.

OBJECTIVE:To explore care recipients (patients' and their caregivers) and care providers (healthcare providers' and law enforcement officers') perspectives on paediatric mental health presentations to emergency departments, to identify challenges to care. METHODS:Secondary qualitative analysis of free-text responses from a Delphi study conducted within the Paediatric Research in Emergency Departments International Collaborative (PREDICT) network in 2022. The original Delphi process aimed to identify research themes and key data points for child and adolescent mental health ED presentations; however, a large number of additional free-text responses were received. The primary aim of this specific study was to identify major categories using the General Inductive Approach (GIA) of these free-text responses to explore the experiences, service delivery and perceived challenges of care recipients and care providers. Patients were recruited from 12 EDs across three Australian states, and pre-hospital services (two police and three ambulance departments) across four Australian states. RESULTS:A total of 184 participants provided responses (36 care recipients and 148 care providers). Three main categories are described: (1) care continuity and communication gaps, (2) challenges in the ED environment and (3) need for improved training and education and behavioural support. CONCLUSIONS:Care recipients and care providers identified challenges in service coordination, clinician readiness and the ED environment. Strengthening communication, expanding training, reducing sensory overload and improving privacy in physical EDs and improving links to community care could enhance patient experiences and outcomes.

Objective To explore parental perceptions of nasogastric tube (NGT) insertion for adolescents who have received inpatient treatment for an eating disorder and to identify factors shaping a positive or negative experience.Design Qualitative observational study using semistructured interviews with parents of adolescent patients who underwent NGT insertion during eating disorder treatment.Setting Participants' children had received care in eight hospitals across Australia. Videoconferencing software was used, with all participants completing their interview from home. One participant's child was a hospital inpatient at the time of interview.Participants Sixteen interviews were conducted: 3 with young people, 12 with parents and 1 joint interview with parent and child. Due to the small sample of patients, only the 13 parent interviews were analysed (including the joint interview).Results Five key themes emerged: (1) inconsistencies in hospital protocols and rigidity in their application, (2) unit culture and staff attitudes, (3) perception of autonomy and consent, (4) the psychological impact of NGT insertion and (5) the physical discomfort and pain of NGT insertion. While no quantitative measures apply, the consistency across multiple hospitals and participants underscores the robustness of these findings.Conclusions Participants reported substantial variations in protocols and processes across hospitals, including discrepancies in indications for NGT insertion and removal, and approaches to group mealtimes. These differences had a marked impact on patient and parent experience. Our findings provide important insight into the physical and psychological experience of NGT insertion for young people and their parents and identify areas for improvement in future clinical practice.

BACKGROUND:Whether treatment with balanced crystalloid fluid leads to better outcomes than 0.9% saline in children treated for septic shock is debated. METHODS:In this pragmatic clinical trial conducted at 47 emergency departments in five countries, patients (2 months to <18 years of age) with suspected septic shock and abnormal perfusion were randomly assigned to receive fluid resuscitation with either balanced fluid or 0.9% saline for up to 48 hours. The primary outcome was a major adverse kidney event (a composite of death, new renal-replacement therapy, or persistent kidney dysfunction) at 30 days after enrollment or hospital discharge, whichever occurred first. RESULTS:Of 9041 enrolled patients, 277 (6.1%) in the balanced-fluid group and 282 (6.2%) in the 0.9%-saline group withdrew from the trial, leaving 4235 and 4247 patients, respectively, for analysis. A primary-outcome event occurred in 137 patients (3.4%) in the balanced-fluid group and in 124 (3.0%) in the 0.9%-saline group (difference, 0.4 percentage points; 95% confidence interval [CI], -0.5 to 1.3; risk ratio, 1.10; 95% CI, 0.88 to 1.40; P = 0.85). The median number of hospital-free days during 28 days after enrollment was 23 (interquartile range, 19 to 25) in both groups. Hyperchloremia occurred in 868 patients (31.4%) in the balanced-fluid group and in 1383 (49.0%) in the 0.9%-saline group; hypernatremia in 52 (1.8%) and 89 (3.1%), respectively; and hyperlactatemia in 260 (19.8%) and 228 (16.7%). No differences in other safety outcomes or adverse events were seen. CONCLUSIONS:Among children treated for septic shock, no significant difference was seen in the incidence of death, new renal-replacement therapy, or persistent kidney dysfunction when fluid resuscitation was administered with balanced fluid as compared with 0.9% saline. (Funded by Eunice Kennedy Shriver National Institute of Child Health and Human Development and others; PRoMPT BOLUS ClinicalTrials.gov number, NCT04102371.).

COVID-19 pandemic-related ‘lockdowns’ (i.e., measures to restrict movements) used to reduce the spread of the COVID-19 virus may have impacted how children and young people (CYP) utilised mental health services. The aim of this review was to synthesise research on COVID-19-related changes in mental health-related emergency department (ED) presentations by CYP in Australia, with reference to lockdown stringency. We searched five databases for observational studies published after 31/12/2019 examining ED mental health-related presentations by CYP (aged 0–24 years) before and after onset of COVID-19 lockdowns. Studies were stratified by location and the relative restriction stringency, obtained via the Oxford COVID-19 Government Response Tracker. Region level variation was described, with pooled effects calculated using random effects models. Thirteen studies were included; five from New South Wales, four from Victoria (where lockdowns were most stringent), three from Queensland, and one including multiple Australian states. Outcome definitions and exposure periods were heterogeneous. Pooled estimates showed a moderate-to-large increase in monthly rates of eating disorder presentations, slight-to-moderate increases in overall mental health-related presentations and self-harm and suicide-related presentations, and inconclusive evidence for changes in substance-related and addictive disorder and behavioural/neurodevelopmental disorder-related presentations. Heterogeneity of pooled effects was extremely high (I2 = 84.8–99.5

OBJECTIVE:To develop a clearer understanding of what 'quality in emergency care' means from the perspective of patients and families to assist with the development of consumer-informed measures of quality for emergency care in an Australian setting. METHODS:Qualitative analysis of transcripts from three semi-structured focus groups, with 24 participants recruited using purposive sampling from a pre-existing consumer expert Safer Care Victoria (SCV) panel. The focus groups were audio-recorded, transcribed and de-identified. Thematic analysis was performed using NVivo software. RESULTS:Six major themes were identified: Staff-patient interactions, Provision of information, Time spent in the ED, Emotional experience, Needs of specific groups and Perception of the emergency care system. Patient and carer experiences of accessing emergency care are highly influenced by the nature of their interactions with staff and the ease and accessibility of information exchange. Prolonged ED wait times are a negative experience; however, this can be improved with attention to symptom management, comfort and privacy. The needs of priority patient groups (e.g., patients with disabilities or people of older age) may be frequently overlooked in ED settings. Participants in this study reported that many of the negative aspects of emergency care they experienced may be attributed to the system being overburdened/staff having insufficient time. CONCLUSIONS:Consumer-informed measures of quality in emergency care should address staff-patient interactions, emotional experience, information provision, time spent in the ED and be sensitive to the needs of priority groups.

OBJECTIVE:Abdominal pain is a common pediatric presentation in the emergency department (ED), and acute appendicitis (AA) is the most common surgical diagnosis. This study describes the management of suspected AA in a tertiary Australian pediatric ED. METHODS:A single-center prospective observational study was performed between November 2022 and May 2023. Children aged 5 to 15 years presenting to the ED with acute abdominal pain and clinician suspicion of AA were included. Clinical gestalt was measured using a 5-point Likert Scale before and after blood tests. Diagnosis of AA was confirmed on histopathology, and non-AA was confirmed with follow-up at 30 to 60 days. RESULTS:The study enrolled 481 children; AA was diagnosed in 146 (30.6%). Patients with AA were older (11.1 vs. 10.0 y) and more likely to be male (69.2% vs. 48.1%) compared with those without AA. Blood tests were performed in 449 (93.3%) children, with higher rates in AA cases (100% vs. 90.4%). Gestalt improved with blood test results, with overall diagnostic accuracy increasing from 65.9% pre-blood tests to 88.5% post-blood tests. Ultrasound (US) was performed in 361 (75.1%) children with a diagnostic accuracy of 90.6% and was frequently used even in patients deemed low-risk post-blood tests (65.7%). One hundred and fifty (31.2%) of suspected AA cases underwent surgery, with 3 negative appendectomies and 1 ovarian cystectomy without appendectomy. Median (IQR) hospital length of stay was significantly longer for AA cases than non-AA cases [50.8 (35.3 to 95.0) h vs. 7.1 (4.6 to 16.8) h]. CONCLUSIONS:This study reviews the management and outcomes of suspected AA in a high-volume Australian ED. It shows the importance of blood tests in improving diagnostic accuracy of clinician gestalt and highlights the potential overuse of US in low-risk patients. Future research should explore a more structured diagnostic approach to increase diagnostic accuracy, optimize resource utilization, and improve patient outcomes.

OBJECTIVE:To compare the total direct healthcare costs of nasal high flow (NHF) therapy and standard oxygen therapy (SOT) as first-line treatments for paediatric acute hypoxaemic respiratory failure (AHRF) and to identify what factors explain variations in these costs. DESIGN:Cost analysis following a randomised controlled trial. SETTING:14 hospitals across Australia and New Zealand. PATIENTS:1517 children aged 1-4 years admitted with AHRF between 18 December 2017 and 18 March 2020, enrolled in the Paediatric Acute Respiratory Intervention Study 2(PARIS-2) trial. INTERVENTIONS:Patients were randomised to receive either NHF or SOT. MAIN OUTCOME MEASURES:Total and average cost per patient admission for the two first-line treatments of AHRF. RESULTS:The total cost of treating the trial cohort was $A10 788 793 (US$7 660 143; €6 689 052; £6 041 724), corresponding to an average of $A7112 (US$5050; €4409; £3983) per patient. Average cost per patient admission was significantly higher in the NHF group at $A7815 (US$5549; €4845; £4376) compared with the SOT group at $A6419 (US$4557; €3980; £3595), with a mean difference of $A1396 (US$991; €866; £782, 95% CI $A419 to $A2372). Subgroup analyses showed that NHF non-responders, particularly those presenting with wheeze, incurred greater costs due to higher likelihood of intensive care admission and longer hospital stays. CONCLUSION:NHF costs more than SOT and does not lead to better clinical outcomes. Although NHF remains an important respiratory support modality for paediatric AHRF, its higher costs, particularly among those not responding to NHF, emphasise the need for more targeted use. TRIAL REGISTRATION NUMBER:ACTRN12618000210279.

Introduction Paediatric emergency medicine (PEM) in India is undergoing a period of rapid growth. A key step in the establishment of successful PEM research networks in high-income countries has been prioritisation of research questions. However, these may be less relevant to India due to differences in epidemiology (higher rates of infectious disease) and limited prehospital care. This gap highlights the importance of context-specific research priorities to address disparities in resource allocation and clinical outcomes.We report on a process to develop a prioritised list of research questions and topics aiming to improve the clinical care of children attending emergency departments across India.Methods A nominal group technique (NGT) approach was used to set research priorities within a 1-day workshop attached to the Society for Emergency Medicine in India conference (EMCON2023) in October 2023. The workshop, which included 30 participants, was facilitated by four members of an established PEM research network from Australia and New Zealand.The priority-setting process included idea generation and recording, open discussion and clarification of ideas and voting. The NGT method facilitated balanced participation and focused discussions, ensuring all participants’ input was equally considered. A final list of 48 prioritised research topics was generated.Results Top-ranking areas included prehospital care, septic shock, envenomation, timing of and physiological optimisation prior to intubation, point-of-care ultrasound, the role of structured clinical assessment and trauma.Conclusions This study has, for the first time, identified multicentre research priorities in PEM for India. The prioritisation of prehospital care reflects the urgent need to address delayed interventions, particularly in rural areas. The presented list of research questions will guide research efforts over the coming years and form the basis for the development of a multicentre research network. This initiative lays the groundwork for long-term collaboration and capacity building in PEM research across India.

OBJECTIVES:Research in critically ill children poses challenges in acquiring prospective informed consent. International ethical guidelines generally have provisions to perform research without prior consent (RWPC) in circumstances where consent is not feasible, but there is a paucity of data regarding the community acceptance of this process. The objectives of the current study were to explore the attitudes and experiences of parents of children enrolled into trials to determine understanding and acceptability of RWPC to parents of children involved. DESIGN:Qualitative study of semi-structured telephone interviews in 2017 exploring themes of medical research, trial participation in RWPC. Interview transcripts underwent inductive thematic analysis with intercoder agreement, using Nvivo 14 software. SETTING:Two clinical interventional trials in Australia conducted in critically ill children without prospective consent. SUBJECTS:Parents of children enrolled in critical care research. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:A total of 49 interviews were conducted and analyzed. Parents of participants were supportive of processes used in the trials and RWPC. Paperwork was often not thought to contribute to improved understanding, with verbal information more valued. There was no consensus on the optimal approach of RWPC in situations when clinical outcome was poor. CONCLUSIONS:Our study in 2017 shows that parent/carer supported RWPC in two pediatric trials involving critically ill children. Parents were satisfied with existing approval methods and safeguards. Parents valued brief verbal information at the time of randomization. These historical findings support the feasibility of conducting research on time-sensitive interventions in emergency settings with RWPC, aligning with community expectations.

OBJECTIVES:To examine variation in practice and adherence to international clinical guidelines for the management of fever among Australian Emergency Department (ED) clinicians. METHODS:Cross-sectional survey across 22 Australian EDs. Clinical vignettes were used to determine compliance with international best practice guidelines (use of antipyretic monotherapy to alleviate fever-associated child distress) for paediatric fever treatment. Comparisons were made between specialist paediatric EDs and general (non-specialist paediatric) EDs, and between medical and nursing staff. RESULTS:Of 539 survey respondents (300 doctors, 239 nurses; overall response rate 65.9%), only 9.3% (50/539, 95% confidence interval [CI] 7.1%-12.0%) adhered to evidence-based practice guidelines. Specialist paediatric ED clinicians demonstrated less than half the adherence of those from general EDs (5.4% [11/204] vs. 12.4% [38/307], difference -7.0%, 95% CI -11.7% to -1.9%). In a febrile settled child with normal hydration, the proportion of respondents who opted for antipyretics more than doubled in the context of elevated vital signs (40.4% [218/539] vs. 83.1% [44/539], difference -42.7%, 95% CI -46.8% to -38.2%). Nearly half of respondents (239/539, 46.8%, 95% CI 42.4%-51.2%) endorsed giving combined antipyretic therapy. In a febrile settled child, most participants would give antipyretics for temperature reduction (453/539, 84.0%, 95% CI 80.7%-86.9%) and for decreased fluid intake (468/539, 87.5%, 95% CI 84.4%-90.0%). Over one-third (192/539, 36.0%, 95% CI 32.1%-40.2%) recommended using antipyretics for febrile convulsion prevention during the current illness. CONCLUSIONS:Fewer than 10% of Australian ED clinicians self-report practice consistent with international consensus recommendations for paediatric fever management.

BACKGROUND:Acute limb pain in young children presenting to the emergency department (ED) can be a sign of serious pathology, with septic arthritis being the most important condition to rule out. Two clinical decision rules (CDRs) have been developed to assist with the diagnosis: Kocher's rule (which allocates points for fever, weight-bearing status, white cell count and erythrocyte sedimentation rate) and Caird's rule (which also includes C-reactive protein). This study aimed to determine (1) the diagnostic accuracy of the two rules for the identification of septic arthritis and (2) other clinical features most strongly associated with septic arthritis. METHODS:Prospective observational study of consecutive children aged <16 years with non-traumatic acute limp presenting to three EDs in Melbourne, Australia between July 2016 and September 2018. Data were prospectively collected on weight-bearing status, duration of symptoms, joint examination findings and signs of systemic disease. Structured chart reviews and telephone follow-up were used to adjudicate the presence/absence of septic arthritis. Area under the receiver operating characteristics curve (AUC) was calculated for each published CDR, and sensitivity, specificity and likelihood ratios were calculated for clinical findings. RESULTS:Of 583 patients presenting with atraumatic limp, 535 (91.8%) eligible patients had sufficient follow-up data. 14 (2.6%) were diagnosed with septic arthritis. Kocher's rule had an AUC of 0.72 (95% CI 0.42 to 1.00), while Caird's rule had an AUC of 0.78 (95% CI 0.52 to 1.00) for septic arthritis. Univariable analysis demonstrated strong associations between range of joint motion (unadjusted OR 13.9, 95% CI 5.0 to 38.5), signs of systemic disease (OR 20.5, 95% CI 6.2 to 67.7), hip pain (OR 3.8, 95% CI 1.2 to 11.7) and presence of fever (OR 5.1, 95% CI 1.0 to 25.1) with septic arthritis. Markedly reduced range of motion compared with the unaffected side had the highest positive likelihood ratio (12.1, 95% CI: 7.5 to 19.5), while inability to weight bear had a positive likelihood ratio of 3.85 (95% CI 2.49 to 5.95). None of the tested clinical findings had a negative likelihood ratio less than 0.3, or a positive predictive value of more than 25%. CONCLUSION:Septic arthritis is a relatively uncommon diagnosis in children presenting to the ED with an acute limp. Markedly reduced range of motion and inability to weight bear appear to be the strongest predictors of septic arthritis; however, their absence is insufficient to rule out the diagnosis.