Case Series of Children Admitted to Starship Children’s Hospital with Celluliti

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Exposures/Breaches of Skin

Frequency In order to assess whether breaches of the skin were associated with the development of cellulitis, caregivers were asked whether their child had a minor injury or breach to their skin in the week prior to the interview or development of the cellulitis. Such breaches were common among all children. Approximately three quarters of all children had some breach of the skin or minor injury reported in the week prior to being interviewed. The most common injuries were cuts or scratches (34%), insect bites (30%), nappy rash (22% of those who wore nappies), a bruise (22%), other skin problem (15%) and eczema (14%). Splinters (6%), animal or human bites (4%) and chicken pox (0.9%) were less common. Cases and controls had similar overall rates of breaches of the skin, however, the frequency of specific breaches varied between the groups (Table 17). Children with insect bites in the preceding week were 2.7 times more likely to develop cellulitis than children with no reported insect bites (1.8-4). There was a dose response with the higher the number of bites, the greater the risk of cellulitis (Table 18). Children who scratched their bites until they bled or wept were almost three times more likely to develop cellulitis than those that did not. More than 75% of bites were attributed to mosquitos and a smaller percentage to fleas (Table 19). There was no difference in type of insect bites between the groups.

Hand Washing

Parents were asked a series of questions relating to their child’s hand washing habits. Seventyone percent of cases usually washed their hands on their own compared to 61% of controls (p=0.02) (Table 22). Infants and children who were too young to wash their hands without help (either supervised or on their own) were at reduced risk of developing cellulitis. Among both case and control children who were considered old enough to wash their own hands, there were similar proportions of children who needed frequent reminders (Table 23, p=0.61). Both cases and controls were also similar with the proportion of children that ‘always or usually’ washed their hands before eating, after eating, after playing outside, after handling a pet, and if visibly dirty. Fewer case children ‘always or usually’ washed their hands after going to the toilet. Children who ‘sometimes, rarely or never washed’ their hands after going to the toilet were more than twice as likely to develop cellulitis as children who ‘always or usually’ washed their hands (Table 24). Hand washing at home was done under running water and using different forms of soap (Table 24). There were no differences in temperature of water or different types of soap used, although children who used shared family soap were at greater risk of developing cellulitis than those who used liquid soap.

Previous Cellulitis and Skin Sepsis

Previous episodes of cellulitis were more common among cases, other children in the household, as well as adults in the household (Table 28). Overall, more than 54% of cases had at least one family member with a past history of cellulitis compared to almost 16% of controls (p<0.001). A previous history of cellulitis in any household member increased the risk of developing cellulitis six fold. Children with a previous history of cellulitis were nine times more likely to develop cellulitis than those without (OR 9.0, 4.9-16.7). There was a dose response with the greater the number of previous episodes, the greater the risk of cellulitis (Table 29). Children who had cellulitis in the previous 3 months were almost 10 times more likely to develop cellulitis than those who had never had cellulitis (Table 30). An elevated risk remained even if the most recent episode was more distant, with children who had cellulitis more than 3 months prior to the interview having 7 times the risk of cellulitis than those with no prior episode (2.9-16.8). Eight case children and 2 control children had other children in the household who had cellulitis at the time of the interview. Thirty-four case and 7 control children had other children in the house that had cellulitis at the time of the interview or within the previous month. This increased the risk of developing cellulitis 7 fold (OR 7.5, 2.97-19.02)

Socioeconomic Status

The effect of socioeconomic status was examined by two different measures: that defined by the social deprivation score of the mesh block (NZDep Index)137 and that defined by the most recent occupation of the mother and father.138 The proportion of cases and controls in each of the social deprivation quintiles is noted in Table 32. There was a different distribution of socioeconomic status with approximately half the cases being in the highest two quintiles (most deprived) compared to 27% of the controls (p<0.001). Children in the most deprived quintiles (4-5) were 2.4 times more likely to develop cellulitis than those in the least deprived quintiles (1-3)(1.6-3.6). There was a dose response for deprivation with the more deprived the household the higher the risk of cellulitis (Table 32). Questions were asked re the current or last job of both mother and father as per the NZ Standard Classification of Occupations (1999).138 In view of a significant amount of missing data and uncertainty regarding the responses, this was not a reliable measure of socioeconomic status and was not reported further.

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Household Characteristics

Caregivers were asked to specify whether they lived in a house/townhouse, flat/unit, or other type of dwelling. Almost all families lived in houses, townhouses, or apartments with only 5% cases and 4% of controls living in other environments (including flat, unit, caravan, garage, and boarding house) (Table 35, p=0.53). Living in another environment was not associated with an increased risk of cellulitis. Overall, 67% of families owned their own home, however, significantly fewer cases lived in their own homes than controls (49% vs. 72%, p<0.001). Children living in rental property were at greater risk of developing cellulitis than those in their own homes, with the risk being greater for those in Housing New Zealand rental properties than private rental (Table 35). Household mobility had no effect on the risk of cellulitis with rates of those that moved in the previous two years the same for both cases (33%) and controls (31%, p=0.69). Neither moving house nor moving two or more times within the last two years were associated with an increased risk of cellulitis. Almost all families had access to a phone, although cases were more likely to either have no phone or rely on mobile phones compared to controls (6% case vs. 3% controls, p=0.03). Families with no landline were 2.5 times more likely to have a child with cellulitis (1.1-6.0).

Table of Contents :

Abstract
Acknowledgements
List of Figures
List of Tables (Volume 2)
Glossary
Chapter 1: Introduction
- 1.1 Research Journey
- 1.1.1 Epidemiological Investigation
- 1.1.2 Review of Risk Factor Literature
- 1.1.3 Initial Steps
- 1.1.4 Risk Factor Research
- 1.2 Research Group
- 1.2.1 Role of Candidate
- 1.3 Funding
- 1.4 Thesis Organisation
Chapter 2: Background
- 2.1 Introduction
- 2.2 Definitions
- 2.2.1 Clinical Definition
- 2.2.2 Epidemiological Definition
- 2.3 Etiology
- 2.4 Epidemiology
- 2.4.1 Local Paediatric Incidence
- 2.4.2 National Paediatric Incidence
- 2.4.3 International Paediatric Incidence
- 2.4.4 National Adult Incidence
- 2.4.5 International Adult Incidence
- 2.4.6 Ethnicity
- 2.4.7 Age
- 2.4.8 Gender
- 2.4.9 Socioeconomic Status
- 2.5 Costs
- 2.6 Morbidity and Mortality
- 2.7 Postulated Pathway to the Development of Cellulitis
- 2.8 Risk Factors
- 2.8.1 Host Susceptibility
- 2.8.2 Exposures/Breaches of the Skin
- 2.8.3 Host Behaviours
- 2.8.4 Past History
- 2.8.5 Social and Environmental Factors
- 2.8.6 Microbiology
- 2.8.7 Health Literacy and Healthcare
- 2.9 Conclusion
Chapter 3: Case Series of Children Admitted to Starship Children’s Hospital with Cellulitis
- 3.1 Introduction
- 3.2 Aims
- 3.3 Study Design
- 3.3.1 Rationale for Study Design
- 3.3.2 Case Definition
- 3.3.3 Selection of Cases
- 3.4 Study Period and Sample Size
- 3.5 Data Collection
- 3.5.1 Caregiver Questionnaire
- 3.5.2 Health Professional Questionnaire
- 3.5.3 Clinical Record Review
- 3.6 Data Management and Analysis
- 3.7 Staff Roles
- 3.8 Ethics Approval
- 3.9 Results
- 3.9.1 Study Numbers and Response Rate
- 3.9.2 Demographic Characteristics of Participants
- 3.9.3 Host Factors
- 3.9.4 Socioeconomic Factors
- 3.9.5 Pathways to Care
- 3.9.6 Clinical Information
- 3.10 Discussion
- 3.11 Conclusion
Chapter 4: Case-Control Study: Research Design
- 4.1 Introduction
- 4.2 Aims and Hypotheses
- 4.2.1 Specific Aims
- 4.2.2 Hypotheses
- 4.3 Study Design
- 4.3.1 Rationale for Study Design
- 4.3.2 Case Definition
- 4.3.3 Sampling Methodology
- 4.3.4 Sample Frame (Study Base)
- 4.3.5 Study Period
- 4.3.6 Sample Size and Power Calculations
- 4.4 Study Procedures, and Data Collection
- 4.4.1 Management and Conduct of the Study
- 4.5 Staff Roles and Study Manual
- 4.5.1 Project Manager/Hospital Co-ordinator
- 4.5.2 Primary Care Co-ordinator
- 4.5.3 Interviewers
- 4.5.4 Study Manual
- 4.5.5 Data Collection
- 4.5.6 Variables Considered But Not Collected
- 4.6 Data Management and Analysis
- 4.6.1 Data Entry and Checking
- 4.6.2 Data Analysis
- 4.7 Ethics Approval
- 4.8 Conclusion
Chapter 5: Case-Control Study: Study Base Description