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Early prediction of serious infections in febrile infants incorporating heart rate variability in an emergency department: a pilot study
  1. Shu-Ling Chong1,
  2. Gene Yong-Kwang Ong1,
  3. John Carson Allen2,
  4. Jan Hau Lee3,
  5. Rupini Piragasam4,
  6. Garion Zhi Xiong Koh5,
  7. Prashant Mahajan6,
  8. Nan Liu7,
  9. Marcus Eng Hock Ong5,8
  1. 1Department of Emergency Medicine, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
  2. 2Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
  3. 3Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
  4. 4KK Research Centre, KK Women's and Children's Hospital, Singapore
  5. 5Department of Emergency Medicine, Singapore General Hospital, Singapore
  6. 6Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
  7. 7Centre for Quantitative Medicine and Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore
  8. 8Health Services and Systems Research, Duke-NUS Medical School, Singapore
  1. Correspondence to Dr Shu-Ling Chong, Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore, Singapore; Chong.Shu-Ling{at}kkh.com.sg

Abstract

Background Early differentiation of febrile young infants with from those without serious infections (SIs) remains a diagnostic challenge. We sought to (1) compare vital signs and heart rate variability (HRV) parameters between febrile infants with versus without SIs, (2) assess the performance of HRV and vital signs with reference to current triage tools and (3) compare HRV and vital signs to HRV, vital signs and blood biomarkers, when predicting for the presence of SIs.

Methods Using a prospective observational design, we recruited patients <3 months old presenting to a tertiary paediatric ED in Singapore from December 2018 through November 2019. We obtained patient demographic characteristics, triage assessment (including the Severity Index Score (SIS)), HRV parameters (time, frequency and non-linear domains) and laboratory results. We performed multivariable logistic regression analyses to predict the presence of an SI, using area under the curve (AUC) with the corresponding 95% CI to assess predictive capability.

Results Among 203 infants with a mean age of 38.4 days (SD 27.6), 67 infants (33.0%) had an SI. There were significant differences in the time, frequency and non-linear domains of HRV parameters between infants with versus without SIs. In predicting SIs, gender, temperature and the HRV non-linear parameter Poincaré plot SD2 (AUC 0.78, 95% CI 0.71 to 0.84) performed better than SIS alone (AUC 0.61, 95% CI 0.53 to 0.68). Model performance improved with the addition of absolute neutrophil count and C reactive protein (AUC 0.82, 95% CI 0.76 to 0.89).

Conclusion An exploratory prediction model incorporating HRV and biomarkers improved prediction of SIs. Further research is needed to assess if HRV can identify which young febrile infants have an SI at ED triage.

Trial registration number NCT04103151.

  • paediatrics
  • paediatric emergency medicine
  • infection
  • ECG
  • clinical assessment
  • effectiveness

Data availability statement

Data are available upon reasonable request. Individual participant data that underlie the results reported in this article, after deidentification (text, tables, figures, and appendices) can be shared with researchers who provide a methodologically sound proposal. Proposals should be directed to Chong.Shu-Ling@kkh.com.sg.

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Data availability statement

Data are available upon reasonable request. Individual participant data that underlie the results reported in this article, after deidentification (text, tables, figures, and appendices) can be shared with researchers who provide a methodologically sound proposal. Proposals should be directed to Chong.Shu-Ling@kkh.com.sg.

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Footnotes

  • Handling editor Roland C Merchant

  • Presented at Prior abstract submission: 1567: Utility of Heart Rate Variability in the Triage of Febrile Infants, Critical Care Medicine: January 2020 - Volume 48 - Issue 1 - p 759 doi: 10.1097/01.ccm.0000648176.68927.0c

  • Contributors S-LC and GY-KO conceptualised and designed the study, coordinated and supervised data collection, drafted the initial manuscript and reviewed and revised the manuscript. JCA developed the analytical plan, carried out the analysis and reviewed and revised the manuscript. JHL, PM and NL reviewed and approved the design of the study, reviewed and revised the manuscript. RP and GZXK designed the data collection instruments, collected data, and reviewed and revised the manuscript. OM supervised the study, approved the design, reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

  • Funding Supported by National Medical Research Council (Singapore) <NMRC/MOH-000158-00> to S-LC.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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