The most common neonatal presentations to the pediatric emergency department

Introduction

The emergency department is the base of any hospital providing urgent medical services to treat patients with a restricted workforce and resources. Over the past few decades, there has been an annual increase in the number of Emergency department (ED) visitors from 96.5 million to 119.2 million between 1995 and 2006. The leading consequences were significantly negative on the quality of urgent remediation by ER physicians, duration of patient waiting, and eventually poorer overall outcomes, such as increasing rates of mortality.¹ Approximately 4-10% of all ED visitors are children with common complaints related to injuries and poisoning. More than 41% of children had visited the ER within their first year^2–4 and 25-50% had visited more than once,^5–7 and about 49-70% presenting with non-urgent matter.⁵ Many studies have linked a shorter neonatal hospital stay (less than 48 hours after birth) with the rate of neonates visiting the emergency department. The result showed wavering between increasing, decreasing, or no significant effects.

A retrospective study that evaluated all neonates’ arrivals at a tertiary urban children’s ED showed that breathing difficulty was the most common chief complaint. Vomiting and poor feeding were defined as follows: No apparent medical problems were repeatedly diagnosed, and the most common pathological diagnoses were bronchiolitis and sepsis. Fifty percent of the visitors were self-referrals by their parents. Most of them do not require pharmacological management.⁸ Another retrospective study was conducted on neonate visitors to the PED of the Central de Faro Hospital in 2005. Jaundice, excessive crying, rash, nasal congestion, and cough were the common complaints. Only jaundice, fever, cough, failure to thrive, and choking preceded diagnostic tests. No medical issues, infant colics, physiological jaundice, upper respiratory infection, or pathologic hyperbilirubinemia were the top diagnoses on the list. Birth weight less than 2500 g, and TG level of less than 37 weeks are both related to more serious neonatal disease and higher admission rates. There was no apparent relationship between hospital admission and delivery mode of delivery.⁹

A comprehensive understanding of both physiological and pathological neonatal changes, especially conditions related to jaundice and feeding difficulties, is significant for all ER providers. Additionally, Understanding the features of frequent pediatric presentations in the emergency department can help take appropriate steps to address these issues and improve the quality of healthcare.

Methods

Results

A total of 649 neonates attended the study hospital over a 1-year period. Neonate ages ranged from less than 1 d to 28 days, with a mean age of 15.5 ± 7.4 days. A total of 342 (52.7%) neonates were male, 330 (50.8%) were delivered at hospitals, and 319 (49.2%) were delivered at home (Table 1).

Clinical diagnosis of neonates who visited the ED. The most common diagnoses were upper respiratory tract infection (URTI) (26.8%), jaundice (20.2%), colic (14%), sepsis (8.6%), conjunctivitis (7.1%), acute gastroenteritis (4.8%), acute bronchitis (4.2%), and constipation (4%). UTI (0.5%), bleeding (0.5%), acute otitis media (0.3%), and clubfoot (0.2%) were the least reported diagnoses (Figure 1).

Figure 1. Clinical diagnosis of neonates who attended ED.

Distribution of clinical diagnoses of neonates who attended the ED by their age. The most reported diagnoses among the early neonates were jaundice (70.8%) and colic (5.6%). Among neonates aged 7-14 days, the most reported diagnoses were jaundice (24.7%) and colic (12.4%), in addition to URTIs (18%). Among the other neonates, URTIs and colic were the most common diagnoses (Table 2).

Laboratory findings among neonates who attended the ED. A total of 205 (31.6%) neonates who attended the ED had significant laboratory findings, while 443 (68.4%) had normal laboratory results (Figure 2).

Figure 2. Laboratory findings among neonates who attended ED.

Clinical outcome among neonates who attended the ED. Only 79 (12.2%) of the attended neonates required hospital admission, while most of them (87.8%; 570) were discharged after being managed (Figure 3).

Figure 3. Clinical outcome among neonates who attended ED.

Factors associated with laboratory findings among study neonates who attended the ED. Approximately 70.8% of neonates in their first week of life had significant laboratory findings versus 16.3% of others aged 21-28 days with statistically significant differences (P=.001). In addition, significant laboratory findings were reported among 35.8% of male neonates compared to 27% of female neonates (P=.017). A total of 83.2% of neonates diagnosed with jaundice had significant laboratory findings compared to 72.7% of those with seizures, 66.7% of neonates with bleeding, and 60.7% of those with sepsis, while 6.3% of neonates with URTI showed significant laboratory findings (P=.001) (Table 3) (extended data).

Factors associated with clinical outcomes among study neonates who attended the ED. A total of 25.8% of neonates below the age of 7 days required admission compared to 7.1% of older neonates (P=.001). In addition, 54.5% of neonates with seizures required admission compared to 40.7% of those with acute bronchiolitis (P=.001). A total of 38% of neonates with significant laboratory findings required hospital admission in comparison to only 1 (0.2%) with normal findings (P=.001) (Table 4) (Extended data).

Discussion

The first 28 days of a child’s life, also known as the neonatal period, is a crucial period for their health.¹⁰ While emergencies can occur during this time, many visits to the emergency department or urgent care can be avoided with proper preventive care during the newborn period and regular check-ups with primary care provider.¹¹ Using emergency departments for non-urgent issues can result in higher costs and inefficient use of healthcare resources.^11,12

Research has demonstrated that a significant percentage (up to 60%) of emergency department visits for infants in their first three months of life are non-urgent. This disproportionate use of emergency services is more common among younger and non-White mothers.¹³ Additionally, a study found that babies born to single mothers who did not attend prenatal classes were less likely to be admitted to the hospital after an ED visit, indicating that these visits may not have been necessary and could have been addressed in a primary care setting.¹⁴ However, most studies on ED use in infancy have been limited to single-center or healthcare system studies, except for a few state-based studies or those that cover a longer period than the first month of life.^15–19

The current study aimed to assess the main presentations in pediatric emergency, including characterizing the presenting features, management, and disposition of neonatal attendance to a tertiary children’s ED. The study revealed that most neonates with ED attendance were aged two weeks or more and a few percent were in their first week of life. Gender differences were not dominant among study neonates and the place of delivery, with a slight predominance for males who delivered at home. Similarly, Batu ED et al.²⁰ documented that the mean age for neonates who visited ED was 14.1 ± 8.3 days, with a slight predominance of males (57.3%). Additionally, Lim JM et al.²¹ found that 79.4% of patients presented at less than 15 days after birth. The length of stay in the PED was less than four hours in 94.0% of the neonates. There are conflicting results regarding the effects of early neonatal discharge on PED utilization reported in different studies.^22–27

With regard to the most reported clinical diagnoses for visiting the ED among neonates, the current study showed that upper respiratory tract infection (URTI), Jaundice, Colic, and Sepsis were the most dominant. UTI, Bleeding, Acute otitis media, and clubfoot were the least reported diagnoses. The study also showed that the most reported diagnoses among early neonates were jaundice and colic, which were also reported among older neonates in addition to URTIs. Similar findings were reported by Batu et al.²⁰ as the main complaints were jaundice, irritability, and vomiting, and the most common diagnoses were normal newborns, indirect hyperbilirubinemia, and colic. In addition, Calado et al.¹⁷ reported that the chief complaints were jaundice, excessive crying, and rashes. Diagnostic tests were requested in 27.2% of the cases. Millar et al.²⁸ found that the most common complaints were jaundice, difficulty breathing, feeding problems, and irritability. The most frequent diagnoses were normal physiology, jaundice, feeding problems, and query sepsis. In addition to many other studies, jaundice, irritability, and respiratory tract infections were the main causes of visiting PED.^27,29 Other causes have been reported, including feeding difficulties, mainly among older neonates.^30,31

The current study also showed that about one-third of the neonates who attended the ED had significant laboratory results, and those who needed hospital admission were infrequent. Early neonates, male sex, jaundice, infection, sepsis, and seizure were the most significant factors associated with the need for hospitalization.

Conclusions

In conclusion, the current study showed that PED visits were frequent among neonates. Jaundice was the dominant cause of PED visits and hospital admissions. The admission rate was higher during early life, mainly in male neonates. In addition, irrespective of high PED visits, only one out of three had significant laboratory findings, and most of the neonates were discharged. Providing better support for families to care for their babies at home or seeking alternative care may decrease non-urgent neonatal emergency department use.

Ethics and consent

The study design was approved by the Institutional Review Board of King Fisal University, Al Ahsa Saudi Araia on 08-11-2022, which waived the requirement for obtaining informed consent from the ethical No. KFU-REC-2022-NOV-ETHICS306. The participants’ information was kept confidential and anonymous.