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Compare the frequency of respiratory adverse events between patients who received intramuscular (IM) versus intravenous ketamine.Case control study from 1997 to 2005 at a large urban pediatric emergency department. Adverse events were defined as apnea, hypoxemia (oximetry93%), hypoventilation, laryngospasm, and other upper airway obstruction. Serious adverse events were defined by the level of intervention and included those cases that required positive pressure ventilation, insertion of oral or nasal airway, or endotracheal intubation. Minor adverse events were respiratory events requiring minimal intervention (stimulation, supplemental O2, airway repositioning). Controls (2:1) were selected by the next chronological patient in the data set who received ketamine but had no respiratory adverse event.Four thousand two hundred fifty-two patients received ketamine; 102 cases (2.4%) had respiratory adverse events, including 38 patients with severe adverse events (0.9%). Interventions for the cases included supplemental O2 (59/102, 58%), airway repositioning (36/102, 35%), continuous positive airway pressure (7/102, 7%), positive pressure ventilation (33/102, 32%), nasal airway (2/102, 2%), oral airway (1/102, 1%), stimulation (11/102, 11%), and intubation (1/102, 1%). Overall, 33% of all subjects received IM ketamine including 47% of cases and 27% of controls. Intramuscular IM ketamine was associated with increased likelihood of adverse events (odds ratio [OR] 2.1, 95% CI, 1.3-3). Twenty (69%) of the 29 patients with laryngospasm received IM ketamine (OR, 5.2; 95% CI, 2.3-11.9) and 20 (53%) of the 38 patients who had severe events were administered IM (OR, 2.4; 95% CI, 1.2-4.9). Use of pre-sedation morphine or combined administration with midazolam and/or atropine was not associated with adverse events. Specific procedures were not associated with increased adverse events.Respiratory adverse events with ketamine are uncommon. Serious events, like laryngospasm, are rare but occur more commonly with IM administration. This increased risk associated with IM administration should be considered in the sedation plan.

OBJECTIVE. Identify clinical predictors of Lyme arthritis among patients with acute monoarticular arthritis. METHODS. A medical chart review was conducted of children ≤18 years of age with monoarticular arthritis who underwent arthrocentesis in a pediatric emergency department located in the northeast United States. Patients were classified into 3 categories of arthritis: septic, Lyme, or nonseptic non-Lyme arthritis. Historical, clinical, and laboratory data were compared to identify distinguishing features of Lyme arthritis. RESULTS. One hundred seventy-nine patients were studied: 46 (26%) patients with septic arthritis, 55 (31%) patients with Lyme arthritis, and 78 (43%) patients with nonseptic non-Lyme arthritis. Compared with those with septic arthritis, patients with Lyme disease were more likely to have a tick-bite history, knee involvement, and less likely to have a history of fever or elevated temperature at triage. Erythrocyte sedimentation rate, C-reactive protein, joint white blood cell count, and joint neutrophil percentage were also statistically lower. In comparison to nonseptic non-Lyme arthritis, knee involvement and tick-bite history were predictors of Lyme. Erythrocyte sedimentation rate, joint white blood cell count, and joint neutrophil percentage were also statistically different. Multivariate analysis comparing Lyme to septic arthritis demonstrated fever history and elevated C-reactive protein level to be negative predictors of Lyme arthritis and knee involvement to be a positive predictor (model sensitivity: 88%; specificity: 82%). CONCLUSIONS. Lyme arthritis shares features with both septic and nonseptic non-Lyme arthritis. This overlap prevents the creation of a clinically useful predictive model for Lyme arthritis. In endemic areas, Lyme testing should be performed on all patients presenting with acute monoarticular arthritis.

Concussions in sports typically arise from a hard blow to the head. In soccer, for example, head-to-head impacts carry a high risk for concussion (Withnall et al., Br J Sports Med 39(Suppl 1):i49–i57, 2005). In the National Football League (NFL), an injury reconstruction study revealed that a striking player often lines up his head, neck, and torso to deliver maximum force to the other player in helmet-to-helmet impacts that result in concussive injuries to the player being struck (Viano and Pellman, Neurosurgery 56(2):266–280, 2005). Fortunately, most injuries in sports fall on the milder end of the spectrum of mild traumatic brain injuries (MTBI). Occasionally, however, athletes experience complicated mild, moderate, or severe traumatic brain injuries. In equestrian and auto racing, for example, accidents can result in much more serious injuries to the brain.

Studies before the introduction of conjugate pneumococcal vaccine demonstrated a high rate of radiographic pneumonia among highly febrile young children with leukocytosis and no other identified source of infection. We sought to evaluate the impact of universal vaccination with Prevnar (pneumococcal conjugate vaccine [PCV]) on the incidence and characteristics of occult and nonoccult radiographic pneumonia among these children.Retrospective cohort study of children younger than 5 years seen in an urban pediatric emergency department with temperature 39 degrees C or higher, white blood cell count 20,000/microL or higher, and chest radiograph performed. Pneumonia was defined as focal infiltrate or consolidation on chest radiograph as read by an attending radiologist. Occult pneumonia was defined as radiographic pneumonia in the absence of lower respiratory tract signs or cough.Before universal pneumococcal vaccination, radiographic pneumonia was found in 190 (21%) of 889 (95% confidence interval [CI], 19-24) eligible children compared with 61 (18%) of 335 (95% CI: 14, 23) eligible children after universal vaccination (P = 0.27). Occult pneumonia was identified in 61 (15%) of 404 (95% CI, 12-19) pre-PCV compared with 13 (9%) of 147 (95% CI, 5-15) post-PCV (P = 0.07). In children younger than 2 years, radiographic pneumonia was identified in 121 (17%) of 709 (95% CI, 14-20) pre-PCV and 26 (10%) of 254 (95% CI, 7-15) post-PCV (P = 0.01).Clinicians should continue to consider chest radiography in young highly febrile children with leukocytosis and no other identified source of infection.

Design a triage assessment tool that predicts acidosis in children with vomiting, diarrhea, and dehydration.A convenience sample of patients aged 3 months to 7 years with vomiting and/or diarrhea were enrolled in the triage area of a pediatric hospital's emergency department (ED). Caretakers of the eligible children completed a parental questionnaire assessing the patient's history of presenting illness. The triage nurse completed a 4-point physical examination assessment form. Collected information from the parental questionnaire and examination findings from the nurses' assessment were analyzed for factors that predicted acidosis in patients which was defined as having a serum bicarbonate level of 16 mmol/L or less or, if unavailable, an end-tidal carbon dioxide of 31 mm Hg or less.One hundred eighteen of the 130 patients enrolled had either a documented serum bicarbonate level or an end-tidal carbon dioxide and were therefore used in the final analysis for the primary outcome. Twenty-nine patients (25%) had acidosis. Univariate predictors of acidosis were younger age (mean [SD], 1.7 [1.4] vs. 3.1 [2.2] years, P = 0.002), previous evaluation by the primary care physician (62% vs. 33%, P = 0.008), being sent in by the primary care physician (66% vs. 33%, P = 0.002), and a worse overall appearance based on the triage nurse's mark on a 0-cm ("alert/playful") to 10-cm ("lethargic/limp") visual analog scale (3.7 [2.8] vs. 2.4 [2.2] cm, P = 0.013). A regression tree analysis identified age younger than 2 years, dry mucous membranes, and duration of illness more than 2 days as sequential factors predictive of patients at risk for acidosis. This decision tree identified patients with acidosis with an 89.7% sensitivity (95% confidence interval, 71.5%-97.3%) and a 93.6% negative predictive value (95% confidence interval, 81.4%-98.3%).The stepwise regression tree triage assessment tool dichotomizing patients based on age younger than 2 years, dry mucous membranes, and days of illness more than 2 days was able to predict acidosis with 90% sensitivity in patients presenting to the ED for evaluation of gastroenteritis. Identifying patients with acidosis early in their ED course allows the treating ED physician to focus more attention and resources toward rehydrating this at-risk population of patients with gastroenteritis.

BACKGROUND Young infants with fever routinely undergo laboratory evaluation, and many are treated with empirical antibiotics even when the infant seems well. The requirement of a lumbar puncture (LP) as part of a routine evaluation is debated; however, administration of antibiotics without an LP can cause concerns for partially treated bacterial meningitis and make subsequent evaluation of the cerebrospinal fluid (CSF) confusing. The ability to predict which febrile infants have a CSF pleocytosis would assist in the decision to perform LP in febrile infants. OBJECTIVE To develop a model to predict which febrile infants have a CSF pleocytosis. METHODS We conducted a retrospective review of febrile children aged 90 days or younger seen in the emergency department. Electronic data sources provided the age of the infant, the triage temperature, and all laboratory values. After univariate analysis, recursive partitioning analysis was performed to develop a decision tree to predict febrile infants at increased risk for CSF pleocytosis, defined as a CSF white blood cell (WBC) count of 25/microL or greater in infants 28 days old or younger and 10/microL or greater in those 29 to 90 days old. RESULTS Two thousand three febrile infants were studied; 176 (8.8%; 95% confidence interval [CI], 7.6%-10.1%) had a CSF pleocytosis. Presentation during the summer season increased the risk of pleocytosis from 5.0% during nonsummer months to 17.4% (95% CI, 14.6%-20.6%). During the nonsummer season, 7.3% (95% CI, 5.6%-9.5%) of febrile infants with a temperature of greater than 38.4 degrees C and a WBC count of greater than 6100/microL had a CSF pleocytosis, as opposed to 2.9% (95% CI, 1.9%-4.4%) of those with lower temperature or lower WBC count. The decision tree has an overall sensitivity of 89% (95% CI, 83%-92%) and a negative predictive value of 97% (95% CI, 96%-98%). CONCLUSIONS A significant number of well-appearing febrile infants will have a CSF pleocytosis. A simple decision tree based on objective clinical information can help identify those at greatest risk for CSF pleocytosis.

We describe the clinical presentation of appendicitis in preadolescent children and differences in symptoms among age-stratified subgroups.This is a retrospective analysis of a prospectively collected de-identified data set of patients 3 years or older and patients younger than 12 years presenting to a pediatric emergency department during a 21-month period with symptoms suspicious for appendicitis. The rates of appendicitis, perforation, negative appendectomy, as well as sensitivities, specificities, and positive likelihood ratios for historical and clinical variables associated with appendicitis were calculated for the entire cohort and for 3 age-stratified subgroups.Of 379 children, 121 (32%) had appendicitis, 75 (62%) were male, 24 (20%) had a perforated appendix, and 16 (12%) had a negative appendectomy. The perforation rate was highest (53%) in the youngest subset of patients (3-5.99 years). Patients with appendicitis presented with inability to walk (82%), maximal right lower quadrant tenderness (82%), nausea (79%), pain with percussion, hopping, coughing (79%), and anorexia (75%). Fewer patients with appendicitis presented with a history of vomiting (66%), fever (47%), or diarrhea (16%), and these findings were not associated with the diagnosis. The youngest subset of patients (3-5.99 years) presented to the emergency department with fever; however, within this age subset, there was no significant difference in temperatures between patients with and without appendicitis. Fever was an indicator for perforation. Psoas, Rovsing, and obturator signs were infrequent but very specific for appendicitis (0.86-0.98 depending on age).Nausea, right lower quadrant tenderness, inability to walk, and elevated white blood cell and neutrophil counts are sensitive indicators of appendicitis in preadolescent children. Although peritoneal signs are infrequently elicited, when present, they substantially increase the likelihood of appendicitis. Fever, vomiting, and diarrhea are not associated with appendicitis in preadolescent children.

Stridor is a common presentation to the pediatric emergency department. The differential diagnosis is broad and includes conditions that range from benign to immediately life threatening. The evaluation and management of pediatric patients with stridor can vary, depending on the likely diagnoses and the acuity of the presentation. We report a case of an infant with known myelomeningocele who presented to the emergency department with stridor and the use of ultrasound to diagnose Chiari crisis as the etiology of her symptoms.

The outcome of acute osteomyelitis treated with sequential therapy consisting of a short course of parenteral antibiotics, followed by oral antibiotics, was studied. To be considered acute osteomyelitis, related symptoms must have been present for less than 2 weeks before diagnosis. Short-course parenteral antibiotics (therapy for 7 days or less) and then oral antibiotics were used to treat 29 patients (median age, 6.3 years). Pathogens were identified from blood cultures and bone aspirates. Staphylococcus aureus was isolated in 59%. Median duration of parenteral antibiotics and oral antibiotics was 4 days (range, 0-7 days) and 28 days (range, 14-42 days), respectively. Median duration of combined (parenteral and oral) therapy was 32 days (range, 20-49 days). No failures or complications were noted at the 6-month follow-up, which was available for 27 patients. Short-course parenteral antibiotic therapy followed by oral therapy appears to be effective for treatment of acute, uncomplicated osteomyelitis.

Advanced diagnostic imaging is commonly used in the evaluation of suspected appendicitis in children. Despite its inferior diagnostic performance, ultrasonography (US) is now preferred to computed tomography (CT) owing to concerns about ionizing radiation exposure. With changes in imaging modalities, the influence on outcomes should be assessed.To review trends in the use of US and CT for children with appendicitis and to investigate simultaneous changes in the proportions of negative appendectomy, appendiceal perforation, and emergency department (ED) revisits.We reviewed the Pediatric Health Information System administrative database for children who presented to the ED with the diagnosis of appendicitis or who underwent an appendectomy in 35 US pediatric institutions from January 1, 2010, through December 31, 2013.We studied the use of US and CT for trends and their association with negative appendectomy, appendiceal perforation, and 3-day ED revisits.Our investigation included 52,153 children with appendicitis. Use of US increased 46% (from 24.0% in 2010 to 35.3% in 2013; absolute difference, 11.3%; adjusted test for linear trend, P = .02), whereas use of CT decreased 48% (from 21.4% in 2010 to 11.6% in 2013; absolute difference, -9.8%; adjusted test for linear trend, P .001). The proportion of negative appendectomy declined during the 4-year study period from 4.7% in 2010 to 3.6% in 2013 (test for linear trend, P = .002), whereas the proportion of perforations (32.3% in 2010 to 31.9% in 2013) and ED revisits (5.6% in 2010 and 2013) did not change (adjusted tests for linear trend, P = .64 and P = .84, respectively).Among children with suspected appendicitis, the use of US imaging has increased substantially as the use of CT has declined. Despite the increased reliance on the diagnostically inferior US, important condition-specific quality measures, including the frequency of appendiceal perforation and ED revisits, remained stable, and the proportion of negative appendectomy declined slightly.

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.

OBJECTIVE. The purpose of this study was to determine the effect of a nominal 50% reduction in median absorbed radiation dose on sensitivity, specificity, and negative appendectomy rate of CT for acute appendicitis in children. MATERIALS AND METHODS. On the basis of a departmental practice quality improvement initiative using computer-generated gaussian noise for CT dose reduction, we applied a nominal dose reduction of 50% to abdominal CT techniques used for bowel imaging. This retrospective study consisted of 494 children who underwent a CT for suspected acute appendicitis before (n = 244; mean age, 133 months) and after (n = 250; mean age, 145 months) the nominal 50% dose reduction. Test performance characteristics of CT for acute appendicitis and impact on the negative appendectomy rate were compared for both time periods. Primary analyses were performed with histologic diagnosis as the outcome standard. Volume CT dose index and dose-length product were recorded from dose reports and size-specific dose estimates were calculated. RESULTS. The nominal 50% dose reduction resulted in an actual 39% decrease in median absorbed radiation dose. Sensitivity of CT for diagnosis of acute appendicitis was 98% (95% CI, 91-100%) versus 97% (91-100%), and specificity was 93% (88-96%) versus 94% (90-97%) before and after dose reduction, respectively. The negative appendectomy rate was 4.5% (0.8-10.25%) before dose reduction and 4.0% (0.4-7.6%) after dose reduction. CONCLUSION. The negative appendectomy rate and performance characteristics of the CT-based diagnosis of acute appendicitis were not affected by a 39% reduction in median absorbed radiation dose.

The acute management of concussion is an important area of investigation and an area of clinical importance to the pediatrician. Recent studies suggest that concussions account for more than 10% of all sport-related injuries sustained by high school athletes and reveal an increase in the number children with concussions being cared for in emergency departments.1–3 At present, the mainstay of concussion management calls for both cognitive and physical rest until the acute symptoms resolve, followed by a graded return to activity.4 As noted by several medical societies, the evidence on which the recommendations for rest are based is sparse.4–6 This relative lack of evidence is due, in part, to the difficult nature of quantifying and tracking levels of physical and, particularly, cognitive activity. In this issue of Pediatrics , Thomas et al7 take this challenge head on; they should be applauded for their efforts. The authors describe the results of a randomized trial of 88 patients … Address correspondence to William P. Meehan III, MD, The Micheli Center for Sports Injury Prevention, 9 Hope Ave, Ste 100, Waltham, MA 02453. E-mail: william.meehan{at}childrens.harvard.edu

BACKGROUND. Some children who present with fever and erythroderma have rapid clinical deterioration or progress to toxic shock syndrome. Our primary objective was to determine whether specific clinical features of those who present with fever and erythroderma can predict who will develop hypotension or progress to toxic shock syndrome. Our secondary objective was to describe the clinical presentation, course, and outcome of children with fever and erythroderma.METHODS. We conducted a medical chart review of children ≤19 years of age with fever and erythroderma who presented to an urban pediatric emergency department over 60 months. Historical, clinical, and laboratory data were abstracted from the medical chart.RESULTS. Fifty-six patients with fever and erythroderma were studied. Eighteen percent of patients presented with hypotension. Thirty-three percent of the remaining patients who were normotensive on arrival developed shock. Fifty-two percent of patients with hypotension required vasopressor support. The most important predictors of developing hypotension after presentation were: age ≥3 years, ill appearance, vomiting, glucose ≥110 mg/dL, calcium ≤8.6 mg/dL, platelets ≤300000/μL, elevated creatinine, polymorphonuclear leukocytes ≥80%, and presence of a focal infection. Among all patients studied, 4 variables were determined to be the most important predictors of developing toxic shock syndrome: age ≥3 years, ill appearance, elevated creatinine, and hypotension on arrival.CONCLUSIONS. Overall, 45% of patients with fever and erythroderma developed shock, including 33% of those who were normotensive on presentation. Older age, presence of vomiting, identification of a focal bacterial source, as well as specific laboratory parameters can be used to help predict which patients are likely to have hemodynamic deterioration. Given the high rate of clinical decompensation, all of the patients with fever and erythroderma should be hospitalized, closely monitored, and managed aggressively.

As part of the Outcome Project of the Accreditation Council for Graduate Medical Education, training programs are required to evaluate trainees across six general competencies. Assessment of the patient-care competency by direct observation can be supplemented with a quantification of overall experience through the use of case logs. However, manual entry of information into such registries frequently is incomplete. The authors report on the development of an automated electronic case log as a novel tool for evaluating the experience of individual trainees or an entire training program. Specific examples of use of the case log are provided. The authors use a pediatric emergency medicine fellowship as a paradigm to demonstrate the potential utility across all emergency medicine training programs. In addition, the authors discuss how additional information technologies might be incorporated to further these evaluative efforts in the future.

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.

Objective. Computed tomography (CT) has gained widespread acceptance in the evaluation of children with suspected appendicitis. Concern has been raised regarding the long-term effects of ionizing radiation. Other means of diagnosing appendicitis, such as clinical scores, are lacking in children. We sought to develop a clinical decision rule to predict which children with acute abdominal pain do not have appendicitis.Methods. Prospective cohort study was conducted of children and adolescents who aged 3 to 18 years, had signs and symptoms suspicious for appendicitis, and presented to the emergency department between April 2003 and July 2004. Standardized data-collection forms were completed on eligible patients. Two low-risk clinical decision rules were created and validated using logistic regression and recursive partitioning. The sensitivity, negative predictive value (NPV), and negative likelihood ratio of each clinical rule were compared.Results. A total of 601 patients were enrolled. Using logistic regression, we created a 6-part score that consisted of nausea (2 points), history of focal right lower quadrant pain (2 points), migration of pain (1 point), difficulty walking (1 point), rebound tenderness/pain with percussion (2 points), and absolute neutrophil count of >6.75 × 103/μL (6 points). A score ≤5 had a sensitivity of 96.3% (95% confidence interval [CI]: 87.5–99.0), NPV of 95.6% (95% CI: 90.8–99.0), and negative likelihood ratio of .102 (95% CI: 0.026–0.405) in the validation set. Using recursive partitioning, a second low-risk decision rule was developed consisting of absolute neutrophil count of Conclusions. Our low-risk decision rules can predict accurately which children are at low risk for appendicitis and could be treated safely with careful observation rather than CT examination.

Objective To determine the prevalence of serious bacterial infection in infants younger than 3 months with fever > or =40 degrees C. Methods We retrospectively identified all infants younger than 3 months with fever who presented to a pediatric emergency department. The medical records were reviewed. The prevalence of serious bacterial infection (SBI) among those patients with hyperpyrexia was compared with febrile infants with lower fever. Results 5279 infants younger than 3 months with fever were reviewed. Ninety-eight patients (1.7%) had triage temperature > or =40 degrees C rectally. Median age, temperature, and white blood count for those with hyperpyrexia were 58 days (interquartile range [IQR] 36-78 days), 40.2 degrees C (IQR, 40.0-40.4 degrees C), and 10,800/mm3 (IQR, 7900-14,600/mm3), respectively. Diagnostic studies included blood culture (100%), urine culture (100%), lumbar puncture (100%), chest radiographs (34%), and stool cultures (11%). SBI was found in 38% infants with hyperpyrexia: urinary tract infection was the most common SBI (71%). Among patients with hyperpyrexia, patients with SBI had similar mean white blood cell counts (14,000 vs. 10,200 cells/mm3) and age (54 vs. 53 days) as those with hyperpyrexia but no SBI. The prevalence of SBI among febrile infants with temperatures > or =40.0 degrees C was 38% (95% CI 27-48%) compared with those with fever Conclusion Hyperpyrexia is rare among febrile infants younger than 3 months. One-third of infants with temperature > or =40.0 degrees C had SBI. Future management algorithms might include hyperpyrexia as a risk factor for serious infection.

Urinary tract infections (UTI) are one of the most common and serious infections among pediatric patients in the emergency department. Detection of UTI requires a systematic approach to urine testing and an understanding of the limitations to common screening tests. Proper culturing techniques are essential to the diagnosis. Accurate diagnosis and prompt treatment can reduce morbidity associated with UTIs.

Importance Pneumonia is a leading cause of morbidity and mortality in children. It is important to identify the clinical symptoms and physical examination findings associated with pneumonia to improve timely diagnosis, prevent significant morbidity, and limit antibiotic overuse. Objective To systematically review the accuracy of symptoms and physical examination findings in identifying children with radiographic pneumonia. Data Sources and Study Selection MEDLINE and Embase (1956 to May 2017) were searched, along with reference lists from retrieved articles, to identify diagnostic studies of pediatric pneumonia across a broad age range that had to include children younger than age 5 years (although some studies enrolled children up to age 19 years); 3644 unique articles were identified, of which 23 met inclusion criteria. Data Extraction and Synthesis Two authors independently abstracted raw data and assessed methodological quality. A third author resolved disputes. Main Outcomes and Measures Likelihood ratios (LRs), sensitivity, and specificity were calculated for individual symptoms and physical examination findings for the diagnosis of pneumonia. An infiltrate on chest radiograph was considered the reference standard for the diagnosis of pneumonia. Results Twenty-three prospective cohort studies of children (N = 13 833) with possible pneumonia were included (8 from North America), with a range of 78 to 2829 patients per study. The prevalence of radiographic pneumonia in North American studies was 19% (95% CI, 11%-31%) and 37% (95% CI, 26%-50%) outside of North America. No single symptom was strongly associated with pneumonia; however, the presence of chest pain in 2 studies that included adolescents was associated with pneumonia (LR, 1.5-5.5; sensitivity, 8%-14%; specificity, 94%-97%). Vital sign abnormalities such as fever (temperature >37.5°C [LR range, 1.7-1.8]; sensitivity, 80%-92%; specificity, 47%-54%) and tachypnea (respiratory rate >40 breaths/min; LR, 1.5 [95% CI, 1.3-1.7]; sensitivity, 79%; specificity, 51%) were not strongly associated with pneumonia diagnosis. Similarly, auscultatory findings were not associated with pneumonia diagnosis. The presence of moderate hypoxemia (oxygen saturation ≤96%; LR, 2.8 [95% CI, 2.1-3.6]; sensitivity, 64%; specificity, 77%) and increased work of breathing (grunting, flaring, and retractions; positive LR, 2.1 [95% CI, 1.6-2.7]) were signs most associated with pneumonia. The presence of normal oxygenation (oxygen saturation >96%) decreased the likelihood of pneumonia (LR, 0.47 [95% CI, 0.32-0.67]). Conclusions and Relevance Although no single finding reliably differentiates pneumonia from other causes of childhood respiratory illness, hypoxia and increased work of breathing are more important than tachypnea and auscultatory findings.

Study objective The presence of leukocyte esterase by urine dipstick and microscopic pyuria are both indicators of possible urinary tract infection. The effect of urine concentration on the diagnostic performance of the urinalysis for pediatric urinary tract infection has not been studied. Our objective is to determine whether the urinalysis performance for detecting urinary tract infection varies by urine concentration as measured by specific gravity. Methods This was a retrospective cross-sectional study of the urine laboratory results of children younger than 13 years who presented to the emergency department during 68 months and had a paired urinalysis and urine culture obtained. Urinary tract infection was defined as pure growth of a uropathogen at standard culture thresholds. Test characteristics were calculated across 4 specific gravity groups (1.000 to 1.010, 1.011 to 1.020, 1.021 to 1.030, and >1.030). Results In total, 14,971 cases were studied. Median age was 1.5 years (interquartile range 0.4 to 5.5 years) and 60% were female patients. Prevalence of urinary tract infection was 7.7%. For the presence of leukocyte esterase and a range of pyuria cut points, the positive likelihood ratios decreased with increasing specific gravity. From most dilute to most concentrated urine, the positive likelihood ratio decreased from 12.1 (95% confidence interval [CI] 10.7 to 13.7) to 4.2 (95% CI 3.0 to 5.8) and 9.5 (95% CI 8.6 to 10.6) to 5.5 (95% CI 3.3 to 9.1) at a threshold of greater than or equal to 5 WBCs per high-power field and presence of leukocyte esterase, respectively. The negative likelihood ratios increased with increasing specific gravity for leukocyte esterase and microscopic pyuria. Conclusion For the detection of pediatric urinary tract infection, the diagnostic performance of both dipstick leukocyte esterase and microscopic pyuria varies by urine concentration, and therefore the specific gravity should be considered when the urinalysis is interpreted.

BACKGROUND AND OBJECTIVES: In patients with appendicitis, the risk of perforation increases with time from onset of symptoms. We sought to determine if time from emergency department (ED) physician evaluation until operative intervention is independently associated with appendiceal perforation (AP) in children. METHODS: We conducted a planned secondary analysis of children aged 3 to 18 years with appendicitis enrolled in a prospective, multicenter, cross-sectional study of patients with abdominal pain ( RESULTS: Of 955 children with appendicitis, 25.9% ( n = 247) had AP. The median time from ED physician evaluation to operation was 7.2 hours (interquartile range: 4.8–8.5). Adjusting for variables associated with perforation, duration of time (≤ 24 hours) between initial ED evaluation and operation did not significantly increase the odds of AP (odds ratio = 1.0, 95% confidence interval, 0.96–1.05), even among children without perforation on initial computed tomography (odds ratio = 0.95, 95% confidence interval, 0.89–1.02). CONCLUSIONS: Although duration of abdominal pain is associated with AP, short time delays from ED evaluation to operation did not independently increase the odds of perforation.

Objectives The objective was to determine the frequency of postreduction, hospital-level interventions among children with successful reduction of ileocolic intussusception and identify factors that predict the need for such interventions. Methods This was a retrospective cross-sectional study of children who underwent successful enema reduction for ileocolic intussusception at a single emergency department. Hospital-level interventions were included if they occurred within 24 hours of reduction and were further classified as either major (recurrence or possible perforation) or minor (imaging for suspected recurrence or administration of parenteral narcotics or antiemetics). Binary logistic regression was used to identify predictors for hospital-level interventions. Results A total of 464 children underwent enema reduction. The median age was 1.7 years (interquartile range [IQR] = 0.8 to 2.5 years), and 66% were male. A total of 435 (94%) were hospitalized with a median hospital stay of 25 hours (IQR = 19 to 34 hours). Nineteen percent (95% confidence interval [CI] = 15% to 22%) needed postreduction interventions, including 6% (95% CI = 4% to 9%) who required major interventions. The median time to any hospital intervention was 9.9 hours (IQR = 6.3 to 16.4 hours). We identified two independent predictors for hospital-level interventions: duration of symptoms > 24 hours (adjusted odds ratio [OR] = 2.1, 95% CI = 1.3 to 3.4) and location of the intussusception tip at (or proximal to) the hepatic flexure (adjusted OR = 1.9, 95% CI = 1.1 to 3.3); the latter factor was also a predictor of a major intervention. None of the children (95% CI = 0 to 1.0%) had an acute decompensation after an initially successful enema reduction. Conclusions Clinical decompensation is rare and recurrence is relatively low after an uncomplicated reduction of ileocolic intussusception. However, one in five children required hospital-level interventions after reduction. Children with the intussusception tip at (or proximal to) the hepatic flexure, and those with symptoms for longer than 24 hours, are more likely to require subsequent interventions. Although outpatient management appears safe after a period of observation, caregivers should be counseled about the risk of ongoing symptoms and recurrence.

Background.The reevaluation process for outpatients recalled for Streptococcus pneumoniae bacteremia has not been standardized. Children who return ill or with new serious focal infections require admission and parenteral antibiotic therapy. Limited data exist to guide the follow-up management of those patients identified as having occult pneumococcal bacteremia.Objectives.Characterize the outcomes of outpatients with pneumococcal bacteremia based on their evaluation at follow-up. For patients who are well-appearing without serious focal infection, propose a management scheme for reevaluation.Methods.Retrospective review of outpatients with pneumococcal bacteremia. Patients with immunocompromise, those identified with focal bacterial infection at the initial visit, or those admitted at the initial visit were excluded. Data were collected from the initial visit (when blood culture drawn) and follow-up visit with regard to clinical parameters, laboratory data, diagnoses, and any antibiotic treatment. Decision tree analysis was used to generate a model to predict children at high risk for persistent bacteremia (PB).Results.A total of 548 episodes of pneumococcal bacteremia were studied. Seventy-three children received no antibiotic, 239 oral antibiotic, and 236 parenteral antibiotic at the initial visit. Median age, temperature, and white blood cell (WBC) count were 13.5 months, 40.0°C, and 20 400/mm3. Forty-one patients had PB or new focal infections (15 with PB alone, 4 had focal infection and PB). Eight patients had meningitis at follow-up. Ninety-two percent returned because of notification of the positive blood culture result. A repeat blood culture was obtained in 92%, 23% had a lumbar puncture, 33% had a chest radiograph, and 12% were admitted. PB was associated with the antibiotic treatment group, elevation of temperature, and WBC count at follow-up. A simple management scheme using 2 sequential decision nodes of antibiotic treatment (none vs any) and then temperature at follow-up (>38.8°C) would have predicted 16/19 patients with PB (sensitivity = .84 and specificity = .86).Conclusions.All patients with pneumococcal bacteremia need prompt reevaluation. For well-appearing patients without new focal infection, the utility of diagnostic testing (specifically repeat blood cultures) and the need for admission may be determined by the use of antibiotics at the initial evaluation and the presence of fever at follow-up. The majority of patients can be managed as outpatients entirely. Patients who did not receive antibiotics at the initial evaluation and those treated with oral antibiotics but remain febrile are at the highest risk for persistent bacteremia.

To determine whether reduced penicillin or ceftriaxone susceptibility affects clinical presentation and outcome in children with pneumococcal bacteremia.Retrospective review of patients with Streptococcus pneumoniae bacteremia.We reviewed 922 cases of pneumococcal bacteremia. Of 744 isolates with known penicillin (PCN) susceptibilities 56 were PCN-nonsusceptible. The majority displayed intermediate resistance; 14 of 730 isolates with known ceftriaxone (CTX) susceptibilities were CTX-nonsusceptible. Neither the PCN- nor the CTX-nonsusceptible cohort displayed a difference from its susceptible counterpart in temperature, respiratory rate or white blood cell count on initial patient evaluation, although trend suggested they were more often admitted at the initial visit. At follow-up only children treated initially with antibiotic were evaluated. Children with PCN-nonsusceptible isolates were no more likely to be febrile than those with PCN-susceptible isolates (28% vs. 25%, P = 0.61) and were no more likely to have a positive repeat blood culture (0% vs. 1%, P = 0.59) or a new focal infection (10% vs. 6%, P = 0.79). Data concerning CTX-nonsusceptible organisms were limited by the low number of such isolates. Although patients with CTX-nonsusceptible pneumococci were more likely to be febrile at follow-up than those with CTX-susceptible organisms (67% vs. 24%, P = 0.04), we were unable to demonstrate a significant difference for other endpoints.Reduced antibiotic susceptibility does not alter the clinical presentation of pneumococcal bacteremia. With current practice intermediate resistance to PCN is of little clinical significance in nonmeningitic systemic pneumococcal infections.

Objective: To compare bag-mask ventilation performed by emergency department (ED) personnel using anesthesia bags (AB) and self-inflating bags (SIB). Setting: ED in a teaching children's hospital where the AB is the device used during resuscitations. Design: Experimental study. Bag-mask ventilation was evaluated with an infant resuscitation mannequin equipped to measure airway volumes and pressures. Pediatric residents, ED nurses, and pediatric emergency medicine fellows performed bag-mask ventilation with AB and SIB and rated their confidence using each device. Main outcome measure: Ventilation failure rates. Results: Seventy subjects participated (17 interns, 16 junior residents, 13 senior residents, 10 fellows, and 14 nurses). There were 13 failures with the AB (18.6%) versus 1 (1.4%) with the SIB (P < 0.01) [95% confidence interval: 5-29%], with a significant difference even after excluding the least experienced subjects. There was no difference in high pressure breaths delivered (SIB 19% vs AB 15%, P = 0.4) and a higher incidence of hyperventilation with the SIB (67 vs 25%, P < 0.01). While using the SIB, 19 (27%) of the subjects did not turn on the O 2 flow. There was no difference in pretest confidence rating, but the posttest confidence rating was higher for the SIB (P < 0.05). Conclusions: Compared to SIB use for bag-mask ventilation in an ED, AB use resulted in more ventilation failures, no advantage in preventing excessive airway pressures, and less confidence among operators. The SIB should be the first choice for bag-mask ventilation in the ED, with attention to maximize oxygen delivery.

Objective. To determine whether oral antibiotics prevent meningitis and serious bacterial infections in children with Streptococcus pneumoniae occult bacteremia. Data Sources. Using the Medline database, the English-language literature was searched for all publications concerning bacteremia, fever, or S pneumoniae from 1966 to April 1996. Study Selection. All studies that included a series of children with S pneumoniae occult bacteremia containing orally treated and untreated groups. Children were excluded from individual studies if they were immunocompromised, had a serious bacterial infection, underwent a lumbar puncture, or received parenteral antibiotics. Data Extraction. Three authors independently reviewed each article to determine the number of eligible children and the outcome of children meeting entry criteria. Data Synthesis. Eleven of 21 studies were excluded, leaving 10 evaluable studies with 656 total cases of S pneumoniae occult bacteremia identified. Patients who received oral antibiotics had fewer serious bacterial infections than untreated patients (3.3% vs 9.7%; pooled odds ratio, 0.35; 95% confidence interval, 0.17 to 0.73). Meningitis developed in 3 (0.8%) of 399 children in the oral antibiotic group and 7 (2.7%) of 257 untreated children (pooled odds ratio, 0.51; 95% confidence interval, 0.12 to 2.09). Conclusion. Although oral antibiotics modestly decreased the risk of serious bacterial infections in children with S pneumoniae occult bacteremia, there was insufficient evidence to conclude that oral antibiotics prevent meningitis. Published recommendations that oral antibiotics be administered to prevent serious bacterial infections in children with possible S pneumoniae occult bacteremia should be reevaluated in light of the lower risk of sequelae from S pneumoniae occult bacteremia and newer data concerning side effects from treatment.

July 1, 2002. Overnight shift in the pediatric emergency department. In 1 room, the fellow is attempting to place a central venous catheter in a 5-year-old boy with presumed septic shock but has been unable to locate the femoral vein with her finder needle. In the next room lies a 7-year-old trauma patient. He is tachycardic with poor perfusion and abrasions on his chest. The team calls for a portable chest radiograph and begins a secondary survey. The resident taps your shoulder. “Can I present a patient?” He describes a 15-year-old girl with lupus complaining of chest pain who is ill appearing, tachycardic, and short of breath. “I ordered labs and chest radiograph.” July 1, 2012. Overnight shift in the pediatric emergency department. In 1 room, the fellow is attempting to place a central venous catheter in a 5-year-old boy with presumed septic shock. Using bedside ultrasound, she makes adjustments with her finder needle until she sees it enter the femoral vein. In the next room lies a 7-year-old trauma patient. He is tachycardic with poor perfusion and abrasions on his chest. The team performs an extended focused assessment with sonography for trauma examination, which reveals free fluid in Morison’s pouch and no pneumothorax. A computed tomography scan of the abdomen is prioritized, and type O negative blood is ordered. The resident taps your shoulder. “Can I present a patient?” He describes a 15-year-old girl with lupus complaining of chest pain who is ill appearing, tachycardic, and short of breath. “I did a bedside ultrasound, and she has a pericardial effusion.” In 2002, many … Address correspondence to Rebecca Vieira, MD, RDMS, Division of Emergency Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail: rebecca.vieira{at}childrens.harvard.edu

Objective To determine the association between Hispanic ethnicity and limited English proficiency (LEP) and the rates of appendiceal perforation and advanced radiologic imaging (computed tomography and ultrasound) in children with abdominal pain. Study design We performed a secondary analysis of a prospective, cross-sectional, multicenter study of children aged 3-18 years presenting with abdominal pain concerning for appendicitis between March 2009 and April 2010 at 10 tertiary care pediatric emergency departments in the US. Appendiceal perforation and advanced imaging rates were compared between ethnic and language proficiency groups using simple and multivariate regression models. Results Of 2590 patients enrolled, 1001 (38%) had appendicitis, including 36% of non-Hispanics and 44% of Hispanics. In multivariate modeling, Hispanics with LEP had a significantly greater odds of appendiceal perforation (OR, 1.44; 95% CI, 1.20-1.74). Hispanics with LEP with appendiceal perforation of moderate clinical severity were less likely to undergo advanced imaging compared with English-speaking non-Hispanics (OR, 0.64; 95% CI, 0.43-0.95). Conclusion Hispanic ethnicity with LEP is an important risk factor for appendiceal perforation in pediatric patients brought to the emergency department with possible appendicitis. Among patients with moderate clinical severity, Hispanic ethnicity with LEP appears to be associated with lower imaging rates. This effect of English proficiency and Hispanic ethnicity warrants further investigation to understand and overcome barriers, which may lead to increased appendiceal perforation rates and differential diagnostic evaluation.

Objectives The objectives were to assess the test characteristics of ultrasound (US) in diagnosing appendicitis in children and to evaluate site-related variations based on the frequency of its use. Additionally, the authors assessed the test characteristics of US when the appendix was clearly visualized. Methods This was a secondary analysis of a prospective, 10-center observational study. Children aged 3 to 18 years with acute abdominal pain concerning for appendicitis were enrolled. US was performed at the discretion of the treating physician. Results Of 2,625 patients enrolled, 965 (36.8%) underwent abdominal US. US had an overall sensitivity of 72.5% (95% confidence interval [CI] = 58.8% to 86.3%) and specificity 97.0% (95% CI = 96.2% to 97.9%) in diagnosing appendicitis. US sensitivity was 77.7% at the three sites (combined) that used it in 90% of cases, 51.6% at a site that used it in 50% of cases, and 35% at the four remaining sites (combined) that used it in 9% of cases. US retained a high specificity of 96% to 99% at all sites. Of the 469 (48.6%) cases across sites where the appendix was clearly visualized on US, its sensitivity was 97.9% (95% CI = 95.2% to 99.9%), with a specificity of 91.7% (95% CI = 86.7% to 96.7%). Conclusions Ultrasound sensitivity and the rate of visualization of the appendix on US varied across sites and appeared to improve with more frequent use. US had universally high sensitivity and specificity when the appendix was clearly identified. Other diagnostic modalities should be considered when the appendix is not definitively visualized by US.

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.

Interfacility transfers occur frequently and often involve critically ill patients. Clear communication at the time of patient referral is essential for patient safety.The objective of this work was to study whether a standardized inter-emergency department (ED) transfer communication template for pediatric patients with respiratory complaints identifies patients that require intensive care unit (ICU) admission.We created a template to structure the communication between referring and receiving providers involved in inter-ED transfers of children with respiratory complaints. The template was designed for use by nonphysicians to prompt specific questions that would trigger notification of the ED attending based on signs of critical illness. The template was retrospectively applied to determine whether it would have properly triggered attending physician notification of a child ultimately requiring ICU admission.Of 285 transferred children, 61 (21%) were admitted to an ICU from the receiving ED. The sensitivity of the communication template in predicting the need for ICU admission was 84% (95% confidence interval [CI], 72%-92%), negative predictive value of 95% (95% CI, 90%-97%), specificity of 77% (95% CI, 71%-82%), positive predictive value of 50% (95% CI, 40%-60%). Of the 10 patients admitted to an ICU who were not identified by the tool, none were critically ill upon arrival. Of the individual communication elements, the sensitivity and negative predictive value ranged from 3% to 38% and from 79% to 86%, respectively.A standardized communication template for inter-ED transfers can identify children with respiratory complaints who require ICU admission. Next steps include real-time application to judge screening performance compared with current nonstandardized intake protocols.

These data characterize and illuminate an analysis of experiences about teaching during each year of a pediatric residency training program in a tertiary care center. The curriculum sought to introduce many concepts about teaching, and residents reported that they: 1. Used concepts introduced about feedback; 2. Began to appreciate that teaching is more than imparting knowledge; 3. Began to identify teaching opportunities in the context of patient care; and 4. Incorporated the practice of establishing goals and expectations for learning with their learners. These data suggest that as interns are exposed to concepts about teaching, they are able to identify what they can offer students, irrespective of the amount of knowledge and clinical experience they have about pediatric medicine. Helping interns appreciate that teaching stems from one's experiences and is much more than just "telling what one knows" was an explicit goal of the Teaching Program's curriculum design group. Another conclusion is that PGY-2 residents are aware that patient care responsibilities pose challenges to teaching. PGY-2 residents at CHB are transitioning from a relatively intense teaching experience as PGY-1 interns to becoming team leaders as PGY-3 residents. Thus, the issues about teaching in the PGY-2 year seem less defined. Helping PGY-2 residents better integrate teaching with patient care continues to be a challenge. Although the focus of the PGY-2 curriculum in the Teaching Program focused on developing skills to become teachers during the final year of residency, what emerged from PGY-2 residents were their concerns and insights about teaching better in situations in which patient care responsibilities were the priority. In addition to using concepts introduced in the sessions, residents in all three training years unanimously reported one impact of the Teaching Program: it made them more "aware" of the importance of teaching and of developing teaching skills. They also began to realize that they require feedback about their teaching from peers, attending physicians, and learner sources. By experiencing the Teaching Program, residents identified other useful approaches and resources to learning about teaching, mainly by observing their peers. Additionally, many residents were beginning to develop individualized approaches toward teaching based on their experiences in the clinical setting and their development as clinicians—the examples shared by interns about how they actually engaged learners—support this conclusion. Finally, the Teaching Program stimulated the process of reflection about teaching—mainly the importance of teaching, the challenges of performing as better teachers, and learning ways to understand how individuals learn. The importance of developing reflective practice skills about teaching has been stated by Schon28 and Boud et al,29 and as a result of the Teaching Program, residents identified situations and moments in which they thought more about their teaching. Assisting residents in developing reflective practice to improve their teaching and to understand their learners better remains a further challenge to resident-as-teacher programs. There was one unanimity: residents and faculty who taught in the program agreed to continue the Teaching Program. Residents became "co-owners" of the Teaching Program by becoming cofaculty with attending physicians. Residents replaced the medical educators as core teaching faculty. The educator's teaching role changed from direct contact to a consultant's role, allowing the resident-attending physician teams to teach the program. Finally, those resident-attending physician teaching teams meet to review and redesign the instructional formats and materials for each workshop. The chief resident assumed a more responsible role by getting the resident-faculty teams together to deliver their respective workshops. Potential for the Future In reviewing the 3-year experience with the Teaching Program—from conceptualization to realization to evaluation—several insights were gained, which may prove useful to other residency training program efforts. 1. Leadership was vital to implementing the Teaching Program. 2. Professional leaders from several levels of medical education were actively involved in the process: from the hospital, the CHB's associate physician-in-chief (also the residency training program director), the CHB's chief resident, and resident and faculty members of the planning group; and from the medical school, the HMS dean of medical education, the associate director for faculty development, and the HMS physician fellow in medical education. 3. Setting aside time simply to discuss teaching was an integral part of all processes, as were the opportunities for residents and attending faculty to share their experiences and perspectives on teaching as it related to their needs as developing physicians. 4. The workshop sessions were an integral aspect of the residents' work weeks. During these sessions, residents had opportunities to explore teaching and learning in relation to their concurrent experiences of residency training. 5. Educator and physician teams emerged as key and useful elements in collaborating to develop a strategy to develop residents as teachers. 6. Evaluation strategies and methods varied in their individual effectiveness in evaluating the Teaching Program; however, in combination they revealed useful insight into what residents think about their development as teachers and how they go about teaching based on their level of clinical training. This work provides one model for others to use in developing a curriculum on teaching. Given different circumstances—ie, if medical educators are not available, if the residency program is a small one, or if a hospital opts not to develop a separate, self-standing curriculum—faculty can elect to train themselves in the use of this curriculum and then implement the program. Copies of the curriculum are available on request from the corresponding author. In the end, the CHB experience with the Teaching Program can be looked at as an approach to how disciplines of education and medicine can merge to meet the teaching and learning needs of medical professionals as they develop as educators in a specialized training setting.

A retrospective analysis of 354 patients < or = 2 years of age with urinary tract infections (UTIs) was performed to characterize patients with bacteremia or meningitis and to identify any objective predictors of these complications. Thirty-three patients with bacteremia were identified. Blood culture isolates included Escherichia coli (25), Staphylococcus aureus (4), enterococcus (1), group B Streptococcus (2), and Enterobacter (1). Besides one patient with group B Streptococcus bacteremia at 1.5 months of age, all bacteremias after one month of age were with E. coli. Bacteremia was limited to those < 6 months old and inversely related to age (R = 0.24, P = 0.0008). Grouped by age, the incidence of bacteremia was 21% for 0 < or = 1 month, 13% for 1.1-2.0 months, 4% for 2.1-3.0 months, and 8% for 3.1-6.0 months. Mean white blood cell count, initial temperature, initial serum bicarbonate, and erythrocyte sedimentation rate were not statistically significant between bacteremic (B) and nonbacteremic (NB) patients. Statistically significant differences were noted for percentage of bands (6.2% [NB] vs. 12.3% [B] P < 0.001), total band count (1048 [NB] vs. 2252 [B] P < 0.001), and band-neutrophil ratio (0.16 [NB] vs. 0.36 [B] P = 0.01); however, no practical value for any of these measures would reliably discriminate between bacteremic and nonbacteremic patients. Four patients, all neonates, had meningitis; too few patients with meningitis were identified for analysis. In summary, bacteremia with UTIs was observed to be inversely related to age and limited to patients less than six months of age. No objective parameters were identified to distinguish patients with bacteremia at the time of presentation.

To validate and refine a clinical prediction rule to identify which children with acute abdominal pain are at low risk for appendicitis (Low-Risk Appendicitis Rule).Prospective, multicenter, cross-sectional study.Ten pediatric emergency departments.Children and adolescents aged 3 to 18 years who presented with suspected appendicitis from March 1, 2009, through April 30, 2010.The test performance of the Low-Risk Appendicitis Rule.Among 2625 patients enrolled, 1018 (38.8% [95% CI, 36.9%-40.7%]) had appendicitis. Validation of the rule resulted in a sensitivity of 95.5% (95% CI, 93.9%-96.7%), specificity of 36.3% (33.9%-38.9%), and negative predictive value of 92.7% (90.1%-94.6%). Theoretical application would have identified 573 (24.0%) as being at low risk, misclassifying 42 patients (4.5% [95% CI, 3.4%-6.1%]) with appendicitis. We refined the prediction rule, resulting in a model that identified patients at low risk with (1) an absolute neutrophil count of 6.75 × 103/μL or less and no maximal tenderness in the right lower quadrant or (2) an absolute neutrophil count of 6.75 × 103/μL or less with maximal tenderness in the right lower quadrant but no abdominal pain with walking/jumping or coughing. This refined rule had a sensitivity of 98.1% (95% CI, 97.0%-98.9%), specificity of 23.7% (21.7%-25.9%), and negative predictive value of 95.3% (92.3%-97.0%).We have validated and refined a simple clinical prediction rule for pediatric appendicitis. For patients identified as being at low risk, clinicians should consider alternative strategies, such as observation or ultrasonographic examination, rather than proceeding to immediate computed tomographic imaging.

Emergency department (ED) crowding may affect disposition decision-making. The objective was to measure the effect of ED crowding on probability of admission and return visit to the ED after discharge.The authors studied a historical cohort at a large pediatric ED over 40 months. Each patient was assigned a score on arrival based on the ED occupancy rate (the ratio of patients to beds). Patients were divided into quintiles by occupancy rate. The proportion admitted for each quintile was compared to the least crowded quintile adjusting for acuity, hospital occupancy, and time of arrival. The same analysis was performed for return visits to the ED within 48 hours. The analyses were repeated for the subsets of patients with asthma and with gastroenteritis and/or dehydration.From the 40 months of historical data, 198,778 visits were analyzed. The adjusted odds ratio (aOR) for admission among the whole cohort was 0.85 (95% confidence interval [CI]=0.81 to 0.89) comparing the highest to the lowest crowding quintiles (occupancy rate1.17 and0.54, respectively). For asthma patients, aOR=0.93 (95% CI=0.72 to 1.20), and for gastroenteritis patients, aOR=0.87 (95% CI=0.65 to 1.17). The aOR of return visits comparing the highest to the lowest crowding quintiles for all patients was aOR=0.87 (95% CI=0.79 to 0.97), for asthma patients was aOR=1.52 (95% CI=0.95 to 2.46), and for gastroenteritis patients was aOR=0.83 (95% CI=0.54 to 1.28).Increasing ED crowding is associated with a lower likelihood of hospital admission and lower frequency of return visits within 48 hours.

OBJECTIVES:We aimed to characterize the demographics, diagnoses, and management of transferred patients who were directly discharged from the emergency department (ED) or admitted less than 24 hours.METHODS:We conducted a retrospective, cross-sectional study of patients classified as interfacility ED transfers over a 12-month period in the Pediatric Health Information System database, an administrative database of 42 tertiary care pediatric US hospitals. The primary study outcomes were ED resource utilization at the receiving facility with a focus on children who were discharged directly from the ED or admitted less than 24 hours.RESULTS:Overall, 24 905 interfacility transfers were identified, accounting for 1.3% of the ED volume of these academic pediatric centers. Of these, 24.7% were discharged directly from the ED and 17.0% were admitted for less than 24 hours. Among those directly discharged from the ED, the 3 most common complaints were orthopedic problems, nonsurgical abdominal pain, and viral gastroenteritis; 20.7% received no medical or procedural intervention. Among those admitted for less than 24 hours, the 3 most common complaints were orthopedic problems, traumatic head injury, and gastrointestinal conditions.CONCLUSIONS:A significant proportion of interfacility transfers to academic pediatric EDs is discharged directly from the ED or is admitted for less than a day. These patients and their clinical outcomes provide insight into the educational needs and medical capabilities of referring hospitals and clinicians.

OBJECTIVE: Our objective was to determine the interrater reliability of clinical history and physical examination findings in children undergoing evaluation for possible appendicitis in a large, multicenter cohort. METHODS: We conducted a prospective, multicenter, cross-sectional study of children aged 3–18 years with possible appendicitis. Two clinicians independently evaluated patients and completed structured case report forms within 60 minutes of each other and without knowing the results of diagnostic imaging. We calculated raw agreement and assessed reliability by using the unweighted Cohen κ statistic with 2-sided 95% confidence intervals. RESULTS: A total of 811 patients had 2 assessments completed, and 599 (74%) had 2 assessments completed within 60 minutes. Seventy-five percent of paired assessments were completed by pediatric emergency physicians. Raw agreement ranged from 64.9% to 92.3% for history variables and 4 of 6 variables had moderate interrater reliability (κ > .4). The highest κ values were noted for duration of pain (κ = .56 [95% confidence intervals .51–.61]) and history of emesis (.84 [.80–.89]). For physical examination variables, raw agreement ranged from 60.9% to 98.7%, with 4 of 8 variables exhibiting moderate reliability. Among physical examination variables, the highest κ values were noted for abdominal pain with walking, jumping, or coughing (.54 [.45–.63]) and presence of any abdominal tenderness on examination (.49 [.19–.80]). CONCLUSIONS: Interrater reliability of patient history and physical examination variables was generally fair to moderate. Those variables with higher interrater reliability are more appropriate for inclusion in clinical prediction rules in children with possible appendicitis.

Study objective Advanced imaging with computed tomography (CT) or ultrasonography is frequently used to evaluate for appendicitis. The duration of the abdominal pain may be related to the stage of disease and therefore the interpretability of radiologic studies. Here, we investigate the influence of the duration of pain on the diagnostic accuracy of advanced imaging in children being evaluated for acute appendicitis. Methods A secondary analysis of a prospective multicenter observational cohort of children aged 3 to 18 years with suspected appendicitis who underwent CT or ultrasonography was studied. Outcome was based on histopathology or telephone follow-up. Treating physicians recorded the duration of pain. Imaging was coded as positive, negative, or equivocal according to an attending radiologist's interpretation. Results A total of 1,810 children were analyzed (49% boys, mean age 10.9 years [SD 3.8 years]); 1,216 (68%) were assessed by CT and 832 (46%) by ultrasonography (238 [13%] had both). The sensitivity of ultrasonography increased linearly with increasing pain duration (test for trend: odds ratio=1.39; 95% confidence interval 1.14 to 1.71). There was no association between the sensitivity of CT or specificity of either modality with pain duration. The proportion of equivocal CT readings significantly decreased with increasing pain duration (test for trend: odds ratio=0.76; 95% confidence interval 0.65 to 0.90). Conclusion The sensitivity of ultrasonography for appendicitis improves with a longer duration of abdominal pain, whereas CT demonstrated high sensitivity regardless of pain duration. Additionally, CT results (but not ultrasonographic results) were less likely to be equivocal with longer duration of abdominal pain.

Study objective We seek to determine whether an initial intravenous bolus of 5% dextrose in normal saline solution compared with normal saline solution will lead to a lower proportion of hospitalized patients and a greater reduction in serum ketone levels in children with gastroenteritis and dehydration. Methods We enrolled children aged 6 months to 6 years in a double-blind, randomized controlled trial of patients presenting to a pediatric emergency department. Subjects were randomized to receive a 20 mL/kg infusion of either 5% dextrose in normal saline solution or normal saline solution. Serum ketone levels were measured before and at 1- and 2-hour intervals after the initial study fluid bolus administration. Primary outcome was the proportion of children hospitalized. Secondary outcome was change in serum ketone levels over time. Results One hundred eighty-eight children were enrolled. The proportion of children hospitalized did not differ between groups (35% in the 5% dextrose in normal saline solution group versus 44% in the normal saline solution group; risk difference 9%; 95% confidence interval [CI] −5% to 22%). Compared with children who received normal saline solution, those who received 5% dextrose in normal saline solution had a greater reduction in mean serum ketone levels at both 1 hour (mean Δ 1.2 versus 0.1 mmol/L; mean difference 1.1 mmol/L; 95% CI 0.4 to 1.9 mmol/L) and 2 hours (mean Δ 1.9 versus 0.3 mmol/L; mean difference 1.6 mmol/L; 95% CI 0.9 to 2.3 mmol/L). Conclusion Administration of a dextrose-containing bolus compared with normal saline did not lead to a lower rate of hospitalization for children with gastroenteritis and dehydration. There was, however, a greater reduction in serum ketone levels in patients who received 5% dextrose in normal saline solution.

Study objective To compare interpreter errors and their potential consequences in encounters with professional versus ad hoc versus no interpreters. Methods This was a cross-sectional error analysis of audiotaped emergency department (ED) visits during 30 months in the 2 largest pediatric EDs in Massachusetts. Participants were Spanish-speaking limited-English-proficient patients, caregivers, and their interpreters. Outcome measures included interpreter error numbers, types, and potential consequences. Results The 57 encounters included 20 with professional interpreters, 27 with ad hoc interpreters, and 10 with no interpreters; 1,884 interpreter errors were noted, and 18% had potential clinical consequences. The proportion of errors of potential consequence was significantly lower for professional (12%) versus ad hoc (22%) versus no interpreters (20%). Among professional interpreters, previous hours of interpreter training, but not years of experience, were significantly associated with error numbers, types, and potential consequences. The median errors by professional interpreters with greater than or equal to 100 hours of training was significantly lower, at 12, versus 33 for those with fewer than 100 hours of training. Those with greater than or equal to 100 hours of training committed significantly lower proportions of errors of potential consequence overall (2% versus 12%) and in every error category. Conclusion Professional interpreters result in a significantly lower likelihood of errors of potential consequence than ad hoc and no interpreters. Among professional interpreters, hours of previous training, but not years of experience, are associated with error numbers, types, and consequences. These findings suggest that requiring at least 100 hours of training for interpreters might have a major impact on reducing interpreter errors and their consequences in health care while improving quality and patient safety.

Background: Urinary tract infections are the most common serious bacterial infection in febrile infants. Bladder catheterization is the preferred method of obtaining urine for culture in young children. Contamination of urine can be recognized when nonpathogens or multiple pathogens are isolated; preliminary culture results may lead to unnecessary antibiotics pending final identification. Some low-colony count (

The value of physical examination findings in the diagnosis of pneumonia in children may be limited, and the accuracy of physicians in predicting pneumonia is not known.We sought to determine the correlation between physicians' assessment of the likelihood of pneumonia and radiographic presence of pneumonia.Prospective observational study of children 21 years or younger presenting to a pediatric emergency department, who had a chest radiography performed for suspicion of pneumonia. Physicians recorded clinical findings and likelihood of pneumonia before obtaining the radiograph. Definite and probable pneumonia was defined by a radiologist's interpretation of the radiograph.Of 2071 children, 147 (7%) had definite radiographic pneumonia, whereas 321 (15%) had probable or definite pneumonia. Among patients perceived to be at lowest risk for pneumonia (5% prediction), 4.3% (95% confidence interval [CI], 2.9%-5.7%) had definite pneumonia, and 10.0% (95% CI, 8.3%-12.5%) had probable or definite pneumonia. Among children perceived to be at highest risk for pneumonia (75% prediction), 30.6% (95% CI, 15.5%-45.6%) had definite pneumonia, and 52.8% (95% CI, 37.7%-70.3%) had probable or definite pneumonia. Physicians' estimates of the likelihood of pneumonia were positively correlated with the rate of definite (Spearman ρ = 0.15, P0.001) and probable or definite radiographic pneumonia (Spearman ρ = 0.19, P0.001).With some overestimation, physicians' assessment of the likelihood of pneumonia correlates well with radiographic diagnosis of pneumonia.

Background: Many children undergo chest radiography (CXR) in their evaluation of a febrile illness. Pneumonia without signs of respiratory distress or ausculatory findings has been previously described (termed occult pneumonia [OP]). Objective: The objectives of this study were to determine the incidence of OP among children who have CXR performed and to identify clinical predictors of OP. Methods: A prospective observational study of children undergoing CXR for possible pneumonia was conducted. Standardized data forms were completed before the CXR. Univariate analysis and recursive partitioning were used to identify predictors of OP. Results: Of 1866 patients enrolled, 308 had no evidence of respiratory distress or lower respiratory tract findings and were studied for OP. Twenty-one patients had radiographic OP (6.8%; 95% confidence interval [CI], 4.0%-10.6%). Age, height of fever, duration or quality of cough, and pulse oximetry were not associated with OP. A decision rule based on fever for 1 day or longer or with a combination of fever for less than 1 day but worsening cough identifies patients at greater risk for OP (likelihood ratio, 1.47; 95% CI, 1.21-1.77). No patient with fever for less than 1 day and without any cough or without worsening cough had pneumonia (likelihood ratio, 0.40; 95% CI, 0.19-0.84). Conclusions: Occult pneumonia was identified in 1 of 15 patients undergoing CXR without respiratory distress or ausculatory findings. Obtaining a CXR for the detection of OP in children without cough and with fever for less than 1 day in duration should be discouraged.

The World Health Organization (WHO) recommends the use of tachypnea as a proxy to the diagnosis of pneumonia in resource poor settings.To assess the relation between tachypnea and radiographic pneumonia among children evaluated in a pediatric emergency department (ED).Prospective study of children less than 5 years of age undergoing chest radiography (CXR) for possible pneumonia was conducted in an academic pediatric ED. Tachypnea was defined using 3 different measurements: (1) mean triage respiratory rate (RR) by age group, (2) age-defined tachypnea based on WHO guidelines (2 months [RRor =60/min], 2 to 12 months [RRor =50], 1 to 5 years [RRor =40]), and (3) physician-assessed tachypnea based on clinical impression assessed before CXR. The presence of pneumonia on CXR was determined by an attending radiologist.A total of 1622 patients were studied, of whom, 235 (14.5%) had radiographic pneumonia. Mean triage RR among children with pneumonia (RR = 39/min) did not differ from children without pneumonia (RR = 38/min). Twenty percent of children with tachypnea as defined by WHO age-specific cut-points had pneumonia, compared with 12% of children without tachypnea (P0.001). Seventeen percent of children who were assessed to be tachypneic by the treating physician had pneumonia, compared with 13% of children without tachypnea (P = 0.07).Among an ED population of children who have a CXR performed to assess for pneumonia, RR alone, and subjective clinical impression of tachypnea did not discriminate children with and without radiographic pneumonia. However, children with tachypnea as defined by WHO RR thresholds were more likely to have pneumonia than children without tachypnea.

OBJECTIVE: The goal was to identify factors associated with radiographically confirmed pneumonia among children with wheezing in the emergency department (ED) setting. METHODS: A prospective cohort study was performed with children ≤21 years of age who were evaluated in the ED, were found to have wheezing on examination, and had chest radiography performed because of possible pneumonia. Historical features and examination findings were collected by treating physicians before knowledge of the chest radiograph results. Chest radiographs were read independently by 2 blinded radiologists. RESULTS: A total of 526 patients met the inclusion criteria; the median age was 1.9 years (interquartile range: 0.7–4.5 years), and 36% were hospitalized. A history of wheezing was present for 247 patients (47%). Twenty-six patients (4.9% [95% confidence interval [CI]: 3.3–7.3]) had radiographic pneumonia. History of fever at home (positive likelihood ratio [LR]: 1.39 [95% CI: 1.13–1.70]), history of abdominal pain (positive LR: 2.85 [95% CI: 1.08–7.54]), triage temperature of ≥38°C (positive LR: 2.03 [95% CI: 1.34–3.07]), maximal temperature in the ED of ≥38°C (positive LR: 1.92 [95% CI: 1.48–2.49]), and triage oxygen saturation of CONCLUSIONS: Radiographic pneumonia among children with wheezing is uncommon. Historical and clinical factors may be used to determine the need for chest radiography for wheezing children. The routine use of chest radiography for children with wheezing but without fever should be discouraged.

Background We have recently profiled inflammatory gene expression in acute appendicitis (AA) and identified a set of genes that are overexpressed in AA. The purpose of this study was to determine whether serum levels of a subset of proteins coded for by these overexpressed genes could differentiate patients with AA from those with other causes of abdominal pain and whether the serum levels of these proteins correlate with the histologic severity of appendicitis. Materials and Methods Serum samples were obtained from a convenience sample of children between 1 and 21 y of age who presented to the emergency department (ED) with symptoms/signs of AA. Patients were assigned to the proven appendicitis (AA) or nonappendicitis (control) group based on histologic findings, chart review, and follow-up phone calls. The serum levels of haptoglobin, granulocyte colony stimulating factor (GCSF), interleukin 8 (IL-8), and C-reactive protein (CRP) were compared between groups. For patients with histologically proven appendicitis, a histologic severity score was assigned and correlated with the levels of potential serum biomarkers. Results thirty-two patients were enrolled; 23 patients (72%) had AA. Serum levels of CRP and GCSF were significantly different between AA and control groups (7.0 versus 0.8, P = 0.01 and 104.2 versus 58.7, P = 0.03, respectively.) In patients with AA, there was significant correlation between GCSF serum levels and the appendicitis severity score [r = 0.537, P = 0.02]. Conclusions GCSF serum levels can distinguish between patients with AA and controls. GCSF may prove to be a useful adjunctive test in the diagnosis and staging of acute appendicitis.