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13 Aug 2013

Predictors of severe H1N1 infection in children presenting within Pediatric Emergency Research Networks (PERN): retrospective case-control study (BMJ, abstract, edited)

[Source: British Medical Journal, full page: (LINK). Abstract, edited.]


Predictors of severe H1N1 infection in children presenting within Pediatric Emergency Research Networks (PERN): retrospective case-control study

BMJ 2013; 347 doi: (Published 12 August 2013)

Cite this as: BMJ 2013;347:f4836

Stuart R Dalziel, paediatrician 1 2, John MD Thompson, senior research fellow 2, Charles G Macias, associate professor 3, Ricardo M Fernandes, paediatricia 4, David W Johnson, professor 5, Yehezkel Waisman, professor 6, Nicholas Cheng, paediatrician 7, Jason Acworth, paediatrician 8, James M Chamberlain, professor 9, Martin H Osmond, professor 10, Amy Plint, associate professor 10, Paolo Valerio, paediatrician 11, Karen JL Black, paediatrician 12, Eleanor Fitzpatrick, research coordinator 12, Amanda S Newton, assistant professor 13, Nathan Kuppermann, professor 4, Terry P Klassen, professor 15 for the Pediatric Emergency Research Networks (PERN) H1N1 working group

Author Affiliations: 1Starship Children’s Hospital, Auckland, New Zealand 2University of Auckland, Auckland, New Zealand 3Baylor College of Medicine and Texas Children’s Hospital, Houston, TX, USA 4Department of Pediatrics, Hospital de Santa Maria, and Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Instituto de Medicina Molecular, Lisboa, Portugal 5Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB, Canada 6Schneider Children’s Medical Center of Israel, Petach Tikvah, Israel 7The Children’s Hospital at Westmead, Sydney, NSW, Australia 8Royal Children’s Hospital, Brisbane, Qld, Australia 9Children’s National Medical Center, Washington DC, USA 10University of Ottawa and Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada 11Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands 12IWK Health Centre, Halifax, NS, Canada 13University of Alberta, Edmonton, AB, Canada 14Departments of Emergency Medicine and Pediatrics, University of California, Davis School of Medicine, Davis, CA, USA 15Manitoba Institute of Child Health, University of Manitoba, Winnipeg, MB, Canada

Correspondence to: S R Dalziel

Accepted 22 July 2013




To identify historical and clinical findings at emergency department presentation associated with severe H1N1 outcome in children presenting with influenza-like illness.


Multicentre retrospective case-control study.


79 emergency departments of hospitals associated with the Pediatric Emergency Research Networks in 12 countries.


265 children (<16 years), presenting between 16 April and 31 December 2009, who fulfilled Centers for Disease Control and Prevention criteria for influenza-like illness and developed severe outcomes from laboratory confirmed H1N1 infection. For each case, two controls presenting with influenza-like illness but without severe outcomes were included: one random control and one age matched control.

Main outcome measures

Severe outcomes included death or admission to intensive care for assisted ventilation, inotropic support, or both. Multivariable conditional logistic regression was used to compare cases and controls, with effect sizes measured as adjusted odds ratios.


151 (57%) of the 265 cases were male, the median age was 6 (interquartile range 2.3-10.0) years, and 27 (10%) died. Six factors were associated with severe outcomes in children presenting with influenza-like illness: history of chronic lung disease (odds ratio 10.3, 95% confidence interval 1.5 to 69.8), history of cerebral palsy/developmental delay (10.2, 2.0 to 51.4), signs of chest retractions (9.6, 3.2 to 29.0), signs of dehydration (8.8, 1.6 to 49.3), requirement for oxygen (5.8, 2.0 to 16.2), and tachycardia relative to age).


These independent risk factors may alert clinicians to children at risk of severe outcomes when presenting with influenza-like illness during future pandemics.