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The approach to febrile young infants remains challenging. This review serves as an update on the care of febrile infants less than 90 days of age with a focus on the changing epidemiology of serious bacterial infection (SBI), refinement of management strategies based on biomarkers, and the development of novel diagnostics.There is high variability in the emergency department management of febrile young infants without significant differences in outcomes. C-reactive protein (CRP) and procalcitonin have emerged as valuable risk-stratification tests to identify high-risk infants. When interpreting automated urinalyses for suspected urinary tract infection (UTI), urine concentration influences the diagnostic value of pyuria. Novel diagnostics including RNA biosignatures and protein signatures show promise in better identifying young febrile infants at risk of serious infection.The majority of febrile infants with an SBI will have a UTI but the diagnosis of invasive bacterial infection in infants continues to be challenging. The use of procalcitonin and CRP as biomarkers in prediction algorithms facilitates identification of low-risk infants.

The review describes current evidence on the evaluation of febrile seizures in the acute setting, the need for further outpatient assessment, and predictors regarding long-term outcomes of these patients.New evidence has been added in support of limited assessment and intervention: evidence on low utility of lumbar puncture, emergent neuroimaging, and follow-up electroencephalography, as well as low yield for antipyretic prophylaxis and intermittent use of antiepileptic drugs. Finally, there is growing evidence regarding the genetic basis of both febrile seizures and vaccine-related seizures/febrile seizures.Routine diagnostic testing for simple febrile seizures is being discouraged, and clear evidence-based guidelines regarding complex febrile seizures are lacking. Thus, clinical acumen remains the most important tool for identifying children with seizures who are candidates for a more elaborate diagnostic evaluation. Similarly, evidence and guidelines regarding candidates for an emergent out-of-hospital diazepam treatment are lacking.

Purpose of review Although there is abundant literature detailing the impact of quality improvement in adult sepsis, the pediatric literature is lacking. Despite consensus definitions for sepsis, which patients along the sepsis spectrum should receive aggressive management and the exact onset of sepsis ('time zero') are not clearly established. In the adult emergency department (ED), sepsis onset is defined as the time of entry into the ED; however, this definition cannot be applied to hospitalized patients or patients who evolve during their ED course. Since the time of sepsis onset will dictate the timeliness of subsequent process measures, the variable definitions in the literature make it difficult to generalize findings among prior studies. Recent findings Despite the variation in defining time zero, aggressive fluid administration, timely antibiotics, and compliance with sepsis bundles have been shown to improve mortality and to reduce hospital and intensive care length of stay. In addition, early identification tools show promise in beginning to define sepsis onset and retrospective search tools may allow improved case finding of those children of concern for sepsis. Summary Quality improvement in pediatric sepsis is evolving. As we continue to define quality measures, we must standardize the definition of sepsis onset. This definition should be applicable to any treatment venue to ensure measures can be evaluated across all settings. In addition, we must delineate which patients along the sepsis spectrum should be candidates for timely interventions and standardize other outcome measures beyond mortality.

Purpose of review Sepsis requires prompt recognition and aggressive therapy; early goal-directed therapy decreases morbidity and mortality. Recommendations on the specific management of pediatric sepsis have historically been extrapolated from adult literature and from expert/consensus opinion. This review serves to appraise recent recommendations and determine the applicability of newly promoted adult guidelines for pediatric sepsis. Recent findings The first and most recent recommendations on the management of pediatric sepsis were published in 2002 by expert consensus with the recognition that there were few data from randomized controlled trials or meta-analysis. Previous to this, adult guidelines were used in the management of pediatric sepsis. New definitions for pediatric sepsis provided by expert consensus take into account the specific physiologic changes. Prompt correction of hemodynamic derangements has been shown to improve outcome through aggressive volume resuscitation and early initiation of vasopressor therapy. Frequent reassessment has been emphasized to ensure appropriate management. Summary Prompt recognition, institution of appropriate therapy, and continual assessment for children with sepsis and shock are essential for improved outcomes. The emerging new literature on early goal-directed therapy is most applicable to care in the emergency department.

To review the advances in the assessment, treatment, and evaluation of care for pediatric dehydration.Recent studies have added new information across the spectrum of care for dehydration. Advances in the assessment of dehydration allow more accurate clinical evaluation, but do not help predict the treatment outcomes. Antiemetics as an adjunct to oral rehydration therapy have been proven well tolerated, efficacious, and cost-effective. Rapid, large-volume intravenous rehydration for outpatients with dehydration did not show any benefit over more standard regimens. Clinical guidelines incorporate all these aspects of care; however, physicians show poor adherence to the guidelines despite the evidence that guidelines improve outcomes and reduce cost.Dehydration burdens the healthcare system worldwide. Through advances in its assessment, treatment with antiemetics and intravenous fluids, and standardization of practice with clinical guidelines, this burden could be reduced.

Advanced airway management in children can be challenging, and the potential for morbidity following failed attempts is high.Supraglottic rescue devices, including the laryngeal mask airway, esophageal-tracheal combination tube, and laryngeal tube have been shown to be suitable ventilation strategies following failed intubation and in arrest scenarios. In addition, a newly developed reversal agent for rocuronium is being investigated as a means of limiting the duration of neuromuscular blockade following rapid sequence induction. Finally, the advent of video laryngoscopy has been shown to have advantages over traditional direct laryngoscopy, in terms of both patient care and training.Pediatric providers are encouraged to develop familiarity with emerging rescue ventilation devices, as well as recent advances in the practice of rapid sequence induction and laryngoscopy.

Purpose of review Emergency bedside ultrasound has been used by emergency and critical care physicians for over two decades. Its use has grown rapidly in emergency medicine and the range of diagnostic and procedural applications has continued to expand; only recently, however, has this tool been embraced by pediatric emergency and critical care physicians. As this technology develops and becomes more available pediatricians should understand its uses and limitations. Recent findings Use of emergency bedside ultrasound for victims of trauma and for procedural applications such as central venous access are well established in adults. Recent published studies suggest that utilizing bedside ultrasound for these purposes may be beneficial in pediatric emergency medicine. Other reports portend future pediatric applications such as assessment of volume status and dehydration, fracture identification and reduction, and aiding in the performance of lumbar punctures. Summary In a review of the literature, it is clear that emergency bedside ultrasound has a role in pediatric emergency and critical care medicine. Much more research is needed, however, to determine which sonographic assessments are of the greatest value. Collaborative efforts will likely be needed to establish definitive applications.

The prevalence of severe asthma in children has risen in the past few decades. The present review explores our current understanding of epidemiology, pathophysiology and treatment of status asthmaticus in children.The pathophysiology of inflammation and airway hyperactivity continues to be a source of research. Early initiation of inhaled beta-agonists and oral or parenteral steroids remain the standard of care in the treatment of status asthmaticus. Other treatment modalities such as magnesium and intravenous beta-agonists show some benefit. There is a resurgence of interest in the use of methylxanthines. Alternatives to endotracheal intubation show some promise in preventing respiratory failure.Asthma remains the third leading cause of hospitalization in children younger than 15 years old. Researchers continue to explore the efficacy of old and new treatment modalities. Future research efforts targeting at-risk populations could dramatically decrease asthma morbidity and mortality.