Q&A: Pediatric pneumonia severity risk tool aims to provide ‘safer, more effective care’

The lack of an established tool to predict disease severity among children with pneumonia may lead to ineffective management decisions, according to a press release from Ann & Robert H. Lurie Children’s Hospital of Chicago.

These management decisions can lead to unnecessary hospitalizations for those with milder disease or delayed care in those at risk for severe disease.

In order to improve conditions for children with community-acquired pneumonia (CAP) in the ED and treat those who are at an increased risk for severe disease in a timely manner, researchers are conducting a multicenter study, funded by a grant from the National Heart, Lung, and Blood Institute. The goal is to develop an ED-based pediatric CAP severity (PedCAPS) score.

To learn more about CAP and the up-and-coming PedCAPS score, Healio spoke with Todd A. Florin, MD, MSCE, director of research for the division of emergency medicine at Ann & Robert H. Lurie Children’s Hospital of Chicago.

Healio: How prevalent is CAP in children and how often do children present at the ED with this disease?

Florin: CAP is one of the most common potentially serious diseases in childhood. It leads to approximately 1.5 million pediatric health care visits annually, accounts for 1% to 4% of all ED visits in children and ranks among the top three reasons for pediatric hospitalization from the ED. CAP also ranks first in total days of antibiotic use in children’s hospitals.

Healio: What is the rationale behind developing a pediatric pneumonia severity prediction tool?

Florin: The decision to manage children as outpatients or inpatients is the most important decision in the management of CAP. Hospitalization poses substantial, and potentially unnecessary, burdens on children, families and the health care system.

In previously healthy children, outpatient treatment is preferable for children at low risk for severe illness. Yet, hospitalization rates vary widely by region and hospital, even after adjustment for illness severity, suggesting that admission criteria are not consistent across providers or institutions.

Hospitalization is likely unnecessary for many children, exposing them to nosocomial infections, medical errors, time lost from school/work, anxiety and cost. On the other hand, severe complications of CAP, although uncommon, can be devastating and may be preventable with earlier identification and targeted interventions. Management decisions, however, are currently based on nonspecific physical examination findings, radiographic images and conventional laboratory markers that do not reliably assess disease risk. An accurate clinical prediction rule for pediatric CAP severity will facilitate timely therapeutic interventions, standardize triage and site-of-care decisions, and enhance appropriate use of resources, including hospitalization. By identifying children at low risk for moderate or severe CAP, unnecessary hospitalizations can be avoided. By accurately identifying children at high risk for less frequent, but potentially devastating, outcomes, disease progression can be mitigated.

Healio: How does the CAP risk score function for adults, and why has there not yet been one developed for children?

Florin: The Infectious Diseases Society of America adult CAP guideline recommends use of the Pneumonia Severity Index as an adjunct to clinical judgment in guiding disposition decisions. These rules have been implemented into practice for adult care, including through clinical decision support, and their use has lowered mortality, decreased hospitalization rates and improved appropriate antibiotic selection, at both academic and rural critical access hospitals. Unfortunately, rules developed in adults perform poorly when extrapolated to children, and thus the need for risk stratification tools specific to children.

Healio: Can you briefly explain how this multicenter study will be conducted and how long it is projected to take?

Florin: This study will be conducted in 14 EDs that are part of the Pediatric Emergency Care Applied Research Network, which is funded by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of the Emergency Medical Services for Children Data Center, making it the first federally funded research network for pediatric emergency care research. We will enroll 2,000 children across seven EDs over 2 years to develop the severity score, and then we will enroll an additional 2,000 children in seven different EDs over the following 2 years to externally validate the rule.

Healio: What clinical factors and biomarkers do you plan to test for inclusion in the PedCAPS score?

Florin: We are including factors that have been shown to have some association with disease severity in children with pneumonia in prior studies, including symptom duration; symptoms such as difficulty breathing, vomiting or inability to tolerate oral intake; comorbidities; signs such as fever, heart rate, respiratory rate, work of breathing and abnormal auscultatory findings; oxygen saturation; and findings on chest radiography. We will examine how the use of biomarkers such as c-reactive protein, procalcitonin or proadrenomedullin improve risk stratification above using clinical features alone.

Healio: How will children who may have CAP and their parents benefit from the PedCAPS score?

Florin: At the end of this proposed study, we will have a fully validated risk prediction rule for pediatric CAP severity ready for widespread implementation. We anticipate that our rule can be converted into an online calculator to maximize ease of use at the point of care. As we anticipate that most, if not all, predictors will be readily available in the electronic health record, and we will also work to integrate our validated rule into the EHR as a decision support tool, providing an automated individualized risk assessment. Individualized risk estimates for children who present to the ED with CAP generated from this work will result in safer and more effective care, minimizing hospitalization and resource use in children who are at low risk for severe CAP, while targeting more intensive management to those at higher risk to prevent progression to severe outcomes.

For more information:

Todd A. Florin, MD, MSCE, can be reached at taflorin@luriechildrens.org.

Reference:

NIH-funded research to develop pneumonia severity prediction tool to improve emergency care of children. https://www.luriechildrens.org/en/news-stories/nih-funded-research-to-develop-pneumonia-severity-prediction-tool-to-improve-emergency-care-of-children/. Published Feb. 2, 2023. Accessed Feb. 6, 2023.