Search

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.

BACKGROUND. Procalcitonin has been identified as a useful blood marker of serious bacterial infection in febrile infants. Many infants present with a febrile reaction after receiving immunizations. The effects of immunization on procalcitonin have not been investigated. METHODS. We performed a prospective observational cohort study at a large, urban pediatric emergency department. Infants ≤90 days of age with fever of ≥38°C were enrolled. Subjects were divided into 3 groups: infants with serious bacterial infection; subjects without serious bacterial infection who received recent ( RESULTS. Over 13 months, procalcitonin was measured for 271 infants. There were 44 (16%) patients with serious bacterial infection, 35 in the recent-immunization group, and 192 in the no-recent-immunization group. The median procalcitonin level for serious bacterial infection was 0.53 ng/mL, for recent immunization was 0.29 ng/mL, and for no recent immunizations was 0.17 ng/mL. Procalcitonin values were elevated for patients with serious bacterial infection compared with patients both with and without recent immunizations. Compared with patients who had no recent immunizations, procalcitonin levels were elevated in patients with recent immunization. Using a cut point of 0.12 ng/mL, the sensitivity of procalcitonin for serious bacterial infection was 96%, specificity was 23%, and negative predictive value was 96%. Two patients with recent immunization who had serious bacterial infection were identified with this cut point. CONCLUSIONS. Among febrile infants with recent immunization, procalcitonin levels are increased compared with patients with fever and no identified bacterial infection. Despite this increase, procalcitonin can still reliably discriminate infants with serious bacterial infection.

OBJECTIVES. The objectives of the study were (1) to study the test performance of procalcitonin for identifying serious bacterial infections in febrile infants ≤90 days of age without an identifiable bacterial source and (2) to determine an optimal cutoff value to identify infants at low risk for serious bacterial infections.METHODS. A prospective observational study was performed with febrile infants ≤90 days of age presenting to an urban, pediatric, emergency department. Serum procalcitonin levels were measured by using an automated high-sensitivity assay. An optimal procalcitonin cutoff value was selected to maximize sensitivity and negative predictive value for the detection of serious bacterial infections. Infants were classified as having definite, possible, or no serious bacterial infections.RESULTS. A total of 234 infants (median age: 51 days) were studied. Thirty infants (12.8%) had definite serious bacterial infections (bacteremia: n = 4; bacteremia with urinary tract infections: n = 2; urinary tract infections: n = 24), and 12 infants (5.1%) had possible serious bacterial infections (pneumonia: n = 5; urinary tract infections: n = 7). Mean procalcitonin levels for definite serious bacterial infections (2.21 ± 3.9 ng/mL) and definite plus possible serious bacterial infections (2.48 ± 4.6 ng/mL) were significantly higher than that for no serious bacterial infection (0.38 ± 1.0 ng/mL). The area under the receiver operating characteristic curve was 0.82 for definite serious bacterial infections and 0.76 for definite and possible serious bacterial infections. For identifying definite and possible serious bacterial infections, a cutoff value of 0.12 ng/mL had sensitivity of 95.2%, specificity of 25.5%, negative predictive value of 96.1%, and negative likelihood ratio of 0.19; all cases of bacteremia were identified accurately with this cutoff value.CONCLUSIONS. Procalcitonin has favorable test characteristics for detecting serious bacterial infections in young febrile infants. Procalcitonin measurements performed especially well in detecting the most serious occult infections.

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 Accreditation Council for Graduate Medical Education has mandated the assessment of medical training across 6 core competencies. The patient care competency is at the core of medical training. With the introduction of patient tracking systems used in emergency departments, patient-physician encounters can be systematically studied. The combination of tracking data with other clinical information systems can be used to create an electronic case log to quantify the experience of fellows, thereby offering a summative measure of the patient care competency. We used an automated case log to assess clinical exposure in our pediatric emergency medicine fellowship.

Objectives: To compare the interexaminer reliability and ability to predict appendicitis between pediatric emergency physicians (EPs) and senior surgical residents. Methods: The authors conducted a prospective cohort study of children aged 3 to 18 years of age with signs and symptoms suspicious for appendicitis. Patients were initially examined by a pediatric EP attending and then by a consulting senior surgical resident. Physicians reported the presence or absence of specific historical and physical exam findings and predicted the likelihood the patient had appendicitis. Interexaminer reliability of historical and physical exam findings was compared (kappa statistic). Distributions and median probabilities of appendicitis were calculated for pediatric EP and surgeon predictions. Results: The authors evaluated 350 patients with acute abdominal pain. Historical questions revealed slight to very good agreement (kappa statistic range 0.33–0.82) between physician types, whereas physical examination findings exhibited poor to fair agreement (range 0.14–0.48). Physicians predicted similar median probabilities of appendicitis for patients who were ultimately diagnosed with appendicitis (75% vs. 70%; p = 0.73) and patients without appendicitis (25% vs. 30%; p = 0.59). For a subset of patients given a ‡ 90% predicted probability of appendicitis, pediatric EPs and senior surgical residents had similar accuracy (80% vs. 79%; p = 0.92). Similarly, among patients with £ 10% predicted probability, pediatric EPs were correct in 95% and senior surgical residents correct in 94% of patients (p = 0.63). Conclusions: Pediatric EPs and senior surgical residents elicit historical findings from patients with suspected appendicitis with a greater degree of similarity than physical examination findings, which exhibit a wide degree of variability. Pediatric EPs and senior surgical residents do not differ in their ability to clinically predict appendicitis. These findings may be helpful in developing institutional management protocols. ACADEMIC EMERGENCY MEDICINE 2008; 15:119–125 a 2008 by the Society for Academic Emergency

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.

To retrospectively compare the diagnostic performance of intravenous contrast material-enhanced computed tomography (CT) with that of intravenous and rectal contrast-enhanced CT in the evaluation of children suspected of having appendicitis by using pathologic findings, surgical findings, or a follow-up telephone call as the reference standard.This HIPAA-compliant study was approved by the committee on clinical investigations. As part of a larger study, informed consent was obtained from all parents and from all children older than 7 years. Consecutive patients aged 5-21 years who presented to the emergency department and were suspected of having appendicitis were studied with CT. From April 2003 until February 2004, patients underwent intravenous and rectal contrast-enhanced CT. From March 2004 until December 2004, patients underwent intravenous contrast-enhanced CT. Demographic data, clinical outcomes, and test performance characteristics--including sensitivity, specificity, accuracy, and negative and positive predictive values--were compared.Of the 416 patients who met inclusion criteria, 223 underwent intravenous and rectal contrast-enhanced CT and 193 underwent intravenous contrast-enhanced CT. There were no differences in sex distribution (55% vs 52% male patients), frequency of appendicitis (36% vs 32%), or frequency of equivocal CT findings (4%) between the groups. Intravenous and rectal contrast-enhanced CT had a sensitivity of 92% (95% confidence interval [CI]: 85%, 97%), a specificity of 87% (95% CI: 79%, 92%), a negative predictive value of 94% (95% CI: 90%, 98%), and an accuracy of 89% (95% CI: 85%, 93%). Intravenous contrast-enhanced CT had a sensitivity of 93% (95% CI: 84%, 97%), a specificity of 92% (95% CI: 85%, 96%), a negative predictive value of 95% (95% CI: 90%, 99%), and an accuracy of 92% (95% CI: 88%, 96%) (P.2 for all comparisons).There was no significant difference between the performance of intravenous contrast-enhanced CT and that of rectal and intravenous contrast-enhanced CT in children suspected of having appendicitis.

Background: Rapid intravenous (IV) rehydration in the emergency department (ED) is required for certain children with acute gastroenteritis (AGE). Objectives: To determine whether the amount of IV dextrose administered is related to a return visit with admission (RVA) in children with AGE and dehydration, and to determine which clinical, laboratory, and treatment parameters are associated with an RVA. Methods: The investigators performed a case control study of children aged 6 months to 6 years who presented to an urban ED with AGE and dehydration and who received IV rehydration before discharge from the ED. Dehydration was defined a priori on the basis of parameters used in prior studies. Cases were defined as those patients who had an RVA within 72 hours of an original visit for ongoing symptoms. Controls were defined as those patients who met inclusion criteria who did not have an RVA. The authors studied whether the amount of IV dextrose administered at the initial visit was related to an RVA as well as which other clinical and treatment parameters were associated with an RVA. Results: A total of 56 cases and 112 controls were studied. Patients who had an RVA received significantly less IV dextrose (mean: 399 mg/kg vs. 747 mg/kg, p < 0.001) than those who did not have an RVA. Patients who received no IV dextrose had 3.9 times greater odds of having a return visit with admission than those who received some dextrose. Controlling for fluid volume, the amount of dextrose administered remained statistically significant by logistic regression; for every 500 mg/kg of IV dextrose administered, the patient was 1.9 times less likely to have an RVA. Patients with length of symptoms less than or equal to one day were more likely to have an RVA than were those with symptom length of two or more days. No other historical or physical exam findings or laboratory parameters (including mean serum bicarbonate) were associated with a return visit requiring admission. Conclusions: Administration of larger amounts of IV dextrose is associated with reduced return visits requiring admission in children with gastroenteritis and dehydration.

Background: The utility of chest radiographs (CXRs) for detecting occult pneumonia (OP) among pediatric patients without lower respiratory tract signs has been previously studied, but no predictors other than white blood cell count (WBC) and height of fever have been investigated. Objectives: To identify predictors of OP in pediatric patients in the postconjugate pneumococcal vaccination era. Methods: This was a retrospective cross sectional study that was conducted in a large urban pediatric hospital. Physician records of emergency department (ED) patients of age 10 years or less who presented with fever (≥38°C) and had a CXR obtained for suspected pneumonia were reviewed. Patients were classified into two groups: “signs of pneumonia” and “no signs of pneumonia” on the basis of the presence or absence of respiratory distress, tachypnea, or lower respiratory tract findings. Occult pneumonia was defined as radiographic pneumonia in a patient without signs of pneumonia. Results: Two thousand one hundred twenty-eight patients were studied. Among patients categorized as having no signs of pneumonia (n = 1,084), 5.3% (95% CI = 4.0% to 6.8%) had OP. Presence of cough and longer duration of cough (greater than 10 days) had positive likelihood ratios (LR+) of 1.24 (95% CI = 1.15 to 1.33) and 2.25 (95% CI = 1.21 to 4.20), respectively. Absence of cough had a negative likelihood ratio (LR−) of 0.19 (95% CI = 0.05 to 0.75). The likelihood of OP increased with increasing duration of fever (LR+ for more than three days and more than five days of fever, respectively: 1.62; 95% CI = 1.13 to 2.31 and 2.24; 95% CI = 1.35 to 3.71). When obtained (56% of patients), WBC was a predictor of OP, with a LR+ of 1.76 (95% CI = 1.40 to 2.22) and 2.17 (95% CI = 1.58 to 2.96) for WBC of >15,000/mm3 and >20,000/mm3, respectively. Conclusions: Occult pneumonia was found in 5.3% of patients with fever and no lower respiratory tract findings, tachypnea, or respiratory distress. There is limited utility in obtaining a CXR in febrile children without cough. The likelihood of pneumonia increased with longer duration of cough or fever or in the presence of leukocytosis.

Objectives To estimate the prevalence of Lyme infection among children presenting with acute, nontraumatic hip pain in a Lyme endemic region and to investigate predictors of Lyme disease among children with suspected transient synovitis. Study design Retrospective cross-sectional study of children with unilateral hip pain who were brought to an academic pediatric emergency department. Cases were identified by specific discharge diagnoses or radiologic imaging. Lyme infection was determined by serologic criteria, and a minimum prevalence was estimated for the entire study population; maximum estimate was determined for those who had Lyme testing. Multivariate regression was used to identify discriminating clinical findings for Lyme disease among those with nonseptic arthritis. Results Three hundred eighty-five children with a median age of 5.4 years were studied; 15% of children had fever ≥38.0°C and 40% had pain for less than 24 hours at evaluation. Lyme infection was identified in 5.2% (95% CI 3.2%-7.9%). A maximum estimate of Lyme disease was calculated to be 8.0% (95% CI 4.9%-12.0%). Regression analysis did not identify any practical clinical predictors of Lyme infection. Conclusions Lyme infection occurred in approximately 5% of children with acute, nontraumatic hip pain who were evaluated in a pediatric emergency department in a Lyme endemic region. Based on this estimate, we do not recommend routine Lyme testing when transient synovitis is suspected; however, Lyme testing should be considered in children having laboratory studies obtained for alternative diagnoses such as septic/pyogenic arthritis and for those with an atypical clinical course for transient synovitis.

Background The diagnosis of appendicitis remains challenging in children. Delays in diagnosis, or misdiagnosis, have important medical and legal implications. The typical, or classic, presentation of pediatric appendicitis has been modeled after adult disease; however, many children present atypically with subtle findings or unusual signs. Objectives To determine the frequency of atypical clinical features among pediatric patients with appendicitis and to investigate which atypical features are the strongest negative predictors for appendicitis among patients being evaluated for appendicitis. Methods Children and adolescents with suspected appendicitis were enrolled over 20 consecutive months. Pediatric emergency physicians completed standardized data collection forms on eligible patients. Final diagnosis was determined by pathology or follow-up telephone call. Typical and atypical findings were defined strictly a priori. Results Seven hundred fifty-five patients were enrolled. The median age was 11.9 years (interquartile range [IQR]: 8.5, 14.9 yr); 36% of patients were diagnosed with appendicitis. Among patients with appendicitis, the most common atypical features included absence of pyrexia (83%), absence of Rovsing's sign (68%), normal or increased bowel sounds (64%), absence of rebound pain (52%), lack of migration of pain (50%), lack of guarding (47%), abrupt onset of pain (45%), lack of anorexia (40%), absence of maximal pain in the right lower quadrant (32%), and absence of percussive tenderness (31%). Forty-four percent of patients with proven appendicitis had six or more atypical characteristics. The median number of atypical features for patients with proven appendicitis was five (IQR: 4.0, 7.0). The greatest negative predictors, on the basis of likelihood ratios, were as follows: white blood cell count (WBC) of

Objective.To develop a data-derived model for predicting serious bacterial infection (SBI) among febrile infants Methods.All infants ≤90 days old with a temperature ≥38.0°C seen in an urban emergency department (ED) were retrospectively identified. SBI was defined as a positive culture of urine, blood, or cerebrospinal fluid. Tree-structured analysis via recursive partitioning was used to develop the model. SBI or No-SBI was the dichotomous outcome variable, and age, temperature, urinalysis (UA), white blood cell (WBC) count, absolute neutrophil count, and cerebrospinal fluid WBC were entered as potential predictors. The model was tested by V-fold cross-validation.Results.Of 5279 febrile infants studied, SBI was diagnosed in 373 patients (7%): 316 urinary tract infections (UTIs), 17 meningitis, and 59 bacteremia (8 with meningitis, 11 with UTIs). The model sequentially used 4 clinical parameters to define high-risk patients: positive UA, WBC count ≥20 000/mm3 or ≤4100/mm3, temperature ≥39.6°C, and age Conclusions.Decision-tree analysis using common clinical variables can reasonably predict febrile infants at high-risk for SBI. Sequential use of UA, WBC count, temperature, and age can identify infants who are at high risk of SBI with a relative risk of 12.1 compared with lower-risk infants.

Background Urinary tract infections (UTIs) are a common source of bacterial infection among young febrile children. Clinical variables affecting the sensitivity of the urinalysis (UA) as a screen for UTI have not been previously investigated. The limited sensitivity of the UA for detecting a UTI requires that a urine culture be obtained in some children regardless of the UA result; however, a proper urine culture requires an invasive procedure, so the criteria for its use should be optimized. Objectives To determine how the sensitivity of the standard UA as a screening test for UTI varies with age, and to determine the clinical situation that necessitates the collection of a urine culture regardless of the UA result. Methods Retrospective medical record review of patients younger than 2 years with fever (≥38°C) seen in the emergency department during a period of 65 months. All urine cultures were reviewed for the collection method, isolates, and colony counts. A UA result was considered positive if the presence of 1 of the following was detected: leukocyte esterase, nitrite, or pyuria (≥5 white blood cells per high power field). Patients who had a paired UA and urine culture were used to calculate the sensitivity, specificity, and likelihood ratios of the UA. The prevalence of UTIs was also subcategorized by age, race, sex, and fever. Results Medical records of 37 450 febrile children younger than 2 years were reviewed. Forty-four percent were girls. Median age and temperature were 10.6 months and 38.8°C. A total of 11 089 patients (30%) had urine cultures obtained. The sensitivity of the UA was 82% (95% confidence interval [CI], 79%-84%) and did not vary by age subgroups. The specificity of UA was 92% (95% CI, 91%-92%). The likelihood ratios for a positive UA and negative UA were 10.6 (95% CI, 10.0-11.2) and 0.19 (95% CI, 0.18-0.20), respectively. Prevalence of UTI was 2.1% overall (2.9% for girls and 1.5% for boys, respectively). Among girls, the prevalence of UTI was 5.0% in white patients, 2.1% in Hispanic patients, and 1.0% in black patients. Among boys, the prevalence was 2.2% in Hispanic patients, 1.4% in white patients, and 0.8% in black patients. Higher prevalence was also seen among patients with a temperature at or above 39°C compared with those whose temperature was between 38.0°C and 38.9°C. The greatest prevalence of UTI (13%) was found among white girls younger than 6 months with a temperature at or greater than 39°C. The posttest probability of a UTI in the presence of a negative UA can be calculated using the negative likelihood ratio and the patient-specific prevalence of UTI. When the prevalence of UTI is 2%, 1 UA among 250 will produce a false-negative test result. Conclusions The sensitivity of the standard UA is 82% (95% CI, 79%-84%) and does not vary with age in febrile children younger than 2 years. The prevalence of UTI varies by age, race, sex, and temperature. A negative likelihood ratio and estimates of prevalence can be used to calculate the risk of missing a UTI due to a false-negative UA result.

Background. Non-typhi Salmonella (NTS) infections are a frequent cause of self-limited diarrheal illness in healthy children. Bacteremia is a known complication of NTS infection, but the management of children with bacteremia has been based on limited data. Objective. To study the outcomes of pediatric patients with NTS bacteremia. Methods. Retrospective review of patients with NTS bacteremia covering a 16-year period at an urban pediatric hospital. Clinical data from the initial visits and any follow-up visits or hospitalizations were abstracted from the medical record. Results. We studied 144 patients. Median age was 10.5 months. Fifty-four patients were hospitalized at the initial visit including all the patients with immunodeficiency (n = 12). Of the 90 patients initially managed as outpatients, 79 were subsequently admitted; only 1 of these patients developed a focal complication. Persistent bacteremia was found in 51 (41%) patients. Among nonimmunocompromised patients, persistent bacteremia was noted in 34% [95% confidence interval (CI), 20 to 52%] of those initially treated with oral antibiotics, 52% (CI 30 to 74%) of those initially treated with a parenteral dose of antibiotics and in 31% (CI 22 to 43%) of those who were not initially given antibiotics. No laboratory or clinical factors predicted persistent bacteremia. Twelve patients developed focal infections : 3 of 119 previously healthy children (2.5%, CI 0.5 to 7%); and 9 of 25 children with underlying medical conditions (36%, CI 19 to 57%). Focal infections included meningitis (3), osteomyelitis (4), septic arthritis (2), pneumonia (2) and cholangitis (1). Conclusions. NTS bacteremia occurs in otherwise healthy children, although the risk of focal infections is small. Patients with NTS bacteremia frequently have persistent bacteremia at follow-up regardless of initial antibiotic treatment.

Study objective: We sought to determine the incidence of radiographic findings of pneumonia in highly febrile children with leukocytosis and no clinical evidence of pneumonia or other major infectious source. Methods: We conducted a prospective cohort study at a large urban pediatric hospital. Clinical practice guidelines for the use of chest radiography in febrile children were established by the emergency medicine attending staff. All records of emergency department patients with leukocytosis (WBC count ≥ 20,000/mm 3 ), triage temperature 39.0°C or higher, age 5 years or less were reviewed daily for 12 months. Physicians completed a questionnaire to note the diagnosis, the presence of respiratory symptoms and signs, and the reason for the chest radiograph (if one was obtained). Patients were excluded for immunodeficiency, chronic lung disease, or major bacterial sources of infection other than pneumonia. Pneumonia was defined by an attending radiologist's reading of the radiograph. Results: We studied 278 patients. Chest radiographs were obtained in 225 for the following reasons: 79 because of respiratory findings suggestive of pneumonia and 146 because of leukocytosis and no identifiable major source of infection. Fifty-three patients did not undergo radiography. Pneumonia was found in 32 of 79 (40%; 95% confidence interval, 20% to 52%) of those with findings suggestive of pneumonia and in 38 of 146 (26%; 95% confidence interval, 19% to 34%) of those without clinical evidence of pneumonia. If patients who did not have a radiograph are assumed to not have pneumonia, the minimum estimate of occult pneumonia was 38 of 199 patients (19%; 95% confidence interval, 14% to 25%). Conclusion: Empiric chest radiographs in highly febrile children with leukocytosis and no findings of pneumonia frequently reveal occult pneumonias. Chest radiography should be considered a routine diagnostic test in children with a temperature of 39°C or greater and WBC count of 20,000/mm 3 or greater without an alternative major source of infection. [Bachur R, Perry H, Harper MB: Occult pneumonias: Empiric chest radiographs in febrile children with leukocytosis. Ann Emerg Med February 1999;33:166-173.]

Objective: To determine whether parenteral antibiotics are superior to oral antibiotics in preventing serious bacterial infections in children with Streptococcus pneumoniae occult bacteremia. Methods: Using the MEDLINE database, the English language literature was searched for all publications concerning bacteremia, fever, or Streptococcus pneumoniae from 1966 to January 1, 1997. All nondupli-cative studies with a series of children with S. pneumoniae occult bacteremia having both orally treated and parenterally treated groups were reviewed. Children were excluded from individual studies if at the time of their initial evaluation they were immuno-compromised, had a serious bacterial infection, underwent a lumbar puncture, or did not receive antibiotics. Results: Only 4 studies met study criteria. From these studies, 511 total cases of S. pneumoniae occult bacteremia were identified. Ten of 290 (3.4%) in the oral group and 5 of 221 (2.3%) in the parenteral antibiotic group developed serious bacterial infections (pooled p-value = 0.467, pooled OR = 1.48; 95% CI, 0.5–4.3). Two patients in the oral group (0.7%) and 2 patients in the parenteral group (0.9%) developed meningitis (pooled p-value = 0.699, pooled OR = 0.67; 95% CI, 0.1–5.1). Conclusion: The rates of serious bacterial infections and meningitis did not differ between children who were treated with oral and parenteral antibiotics. The extremely low rate of complications observed in both groups suggests no clinically significant difference between therapies. A study with > 7,500 bacteremic children (or >300,000 febrile children) would be needed to have 80% power to prove parenteral antibiotics are superior to oral antibiotics in preventing serious bacterial infections.

The records of 559 consecutive outpatient children with unsuspected bacteremia (467 Streptococcus pneumoniae) were reviewed. When compared with patients receiving oral or parenteral antibiotics, those patients who received no antibiotics at the initial visit were in follow-up : (1) less likely to be improved (32% vs. 86%, P < 0.01) ; (2) more likely to be febrile (75% vs. 28%, P < 0.01) ; (3) more likely to be hospitalized (67% vs. 22%, P < 0.01) ; (4) more likely to have persistent bacteremia (28% vs. 3%, P < 0.01) ; and (5) more likely to have new focal infections (13% vs. 5%, P < 0.01). Compared with patients receiving parenteral antibiotics at the initial visit, patients receiving oral antibiotics were in follow-up : (1) less likely to be improved (81% vs. 89%, P < 0.05) ; and (2) more likely to have persistent bacteremia (5% vs. 0%, P < 0.05). There was no statistical difference between patients receiving parenteral or oral therapy in the development of focal infections, although children with new focal infections receiving oral antibiotics more often had persistent or new positive cultures. No patients receiving parenteral antibiotics at the initial visit had positive blood or spinal fluid cultures at the follow-up visit. Analyses of the subgroups with (1) occult bacteremia with all organisms, (2) unsuspected bacteremia S. pneumoniae and (3) occult bacteremia with S. pneumoniae show results similar to those for the entire group. These findings extend earlier observations that antibiotic therapy improves the outcome of children with unsuspected bacteremia, particularly with parenteral administration, and point to the continued importance of treatment even in the absence of cases caused by Haemophilus influenzae type b.

To investigate the variation and trends in neuroimaging in children examined for minor head injury at major US pediatric emergency departments.We conducted a retrospective study of children19 years of age with mild head injury who were examined and discharged home from the emergency department at 40 pediatric hospitals from 2005 to 2009 by using the Pediatric Health Information Systems database. Variation in computed tomography (CT) rates between hospitals was assessed for correlation with hospital-specific rates of intracranial hemorrhage, admission, and return visits. Age-adjusted trends in CT use were calculated for the 5 years.In the 5 years, the median rate of imaging for minor head injured patients was 36% (IQR, 29%-42%; range, 19%-58%). There was no correlation between institution-specific rates of CT imaging and intracranial hemorrhage, admission, or return-visit rates. Age-adjusted rates of CT use decreased in the 5-year period (OR, 0.94; 95% CI, 0.92-0.97; P.001).In this study, we found significant practice variation in CT use at pediatric hospitals examining children with minor head injury. These data may help guide national benchmarks for the appropriate use of CT imaging in pediatric patients with minor head injury.

Study objective Molecular definition of disease has been changing all aspects of medical practice, from diagnosis and screening to understanding and treatment. Acute appendicitis is among many human conditions that are complicated by the heterogeneity of clinical presentation and shortage of diagnostic markers. Here, we sought to profile the urine of patients with appendicitis, with the goal of identifying new diagnostic markers. Methods Candidate markers were identified from the urine of children with histologically proven appendicitis by using high-accuracy mass spectrometry proteome profiling. These systemic and local markers were used to assess the probability of appendicitis in a blinded, prospective study of children being evaluated for acute abdominal pain in our emergency department. Tests of performance of the markers were evaluated against the pathologic diagnosis and histologic grade of appendicitis. Results Test performance of 57 identified candidate markers was studied in 67 patients, with median age of 11 years, 37% of whom had appendicitis. Several exhibited favorable diagnostic performance, including calgranulin A (S100-A8), α-1-acid glycoprotein 1 (orosomucoid), and leucine-rich α-2-glycoprotein (LRG), with the receiver operating characteristic area under the curve and values of 0.84 (95% confidence interval [CI] 0.72 to 0.95), 0.84 (95% CI 0.72 to 0.95), and 0.97 (95% CI 0.93 to 1.0), respectively. LRG was enriched in diseased appendices, and its abundance correlated with severity of appendicitis. Conclusion High-accuracy mass spectrometry urine proteome profiling allowed identification of diagnostic markers of acute appendicitis. Usage of LRG and other identified biomarkers may improve the diagnostic accuracy of clinical evaluations of appendicitis.

Study objective This article evaluates the performance of the previously published Alvarado and Samuel appendicitis scoring systems in a prospectively identified pediatric cohort. Methods A prospective cohort of patients, aged 3 to 21 years, being evaluated for appendicitis was enrolled during 20 consecutive months at a large, urban, pediatric hospital. Study forms were completed by pediatric emergency medicine attending physicians before imaging or surgery. Final diagnosis was determined by pathology or follow-up telephone call. Each score was tested as proposed by the original authors. Sensitivity, specificity, and predictive values were calculated for all patients and prepubertal patients younger than 10 years. Results Five hundred eighty-eight patients were studied. The median age was 11.9 years (interquartile range [IQR] 8.5; 14.9 years). Thirty-four percent of patients had appendicitis. An Alvarado score greater than or equal to 7 yielded a sensitivity of 72% (95% confidence interval [CI] 66% to 78%), specificity 81% (76% to 84%), negative predictive value (NPV) 85% (81% to 89%), and positive predictive value (PPV) 65% (59% to 72%). A Samuel score greater than or equal to 6 yielded a sensitivity of 82% (77% to 87%), specificity 65% (60% to 70%), NPV 88% (84% to 91%), and PPV 54% (48% to 60%). When analysis was limited to patients younger than 10 years, n=206, an Alvarado score greater than or equal to 7 yielded a sensitivity of 73% (62% to 84%), specificity 80% (73% to 86%), NPV 89% (83% to 94%), and PPV 58% (45% to 69%). A Samuel score greater than or equal to 6, when patients younger than 10 years were considered, yielded a sensitivity of 77% (66% to 87%), specificity 65% (56% to 72%), NPV 88% (82% to 94%), and PPV 45% (35% to 55%). Receiver operator characteristic curves had an area under the curve of 0.83 (95% CI 0.79 to 0.86) (Alvarado) and 0.81 (95% CI 0.78 to 0.85) (Samuel). Conclusion Although the Alvarado and Samuel scores provide measurably useful diagnostic information in evaluating children with suspected appendicitis, neither method provides sufficient PPV to be used in clinical practice as the sole method for determination of the need for surgery.

Background. The majority of young children with fever and urinary tract infections (UTIs) have evidence of pyelonephritis based on renal scans. Resolution of fever during treatment is 1 clinical marker of adequate treatment. Theoretically, prolonged fever may be a clue to complications, such as urinary obstruction or renal abscess. Objective. Describe the pattern of fever in febrile children undergoing treatment of a UTI. Compare the clinical characteristics of those patients with prolonged fever to those who respond faster to therapy. Setting. An urban pediatric hospital. Design. Medical record review. Methods. All children ≤2 years old admitted to the pediatric service with a primary discharge diagnosis of pyelonephritis or UTI were reviewed for 65 consecutive months. Patients with previous UTI, known urologic problems, or immunodeficiency were excluded. Only patients with an admitting temperature ≥38°C and those who met standard culture criteria were studied. Temperatures are not recorded hourly on the inpatient unit; therefore, they were assigned to blocks of time. Nonresponders were defined as those above the 90th percentile for the time to defervesce. Nonresponders were then compared with the balance of the study patients, termed responders. Results. Of 288 patients studied, the median age was 5.6 months (interquartile range: 1.3–7.9 months old). Median admission temperature was 39.3°C (interquartile range: 38.5°C–40.1°C). Median time to defervesce ranged in the time block 13 to 16 hours. Sixty-eight percent were afebrile by 24 hours and 89% by 48 hours. Thirty-one patients had fever >48 hours (nonresponders). Nonresponders were older than responders (9.4 vs 4.1 months old) but had similar initial temperatures (39.8 vs 39.2°C), white blood cell counts (18.4 vs 17.1 ×1000/mm3), and band counts (1.4 vs 1.2 ×1000/mm3). Nonresponders had similar urinalyses with regard to leukocyte esterase positive (23/29 vs 211/246), nitrite-positive (8/28 vs 88/221], and the number of patients with “too numerous to count” white blood cell counts per high power field (12/28 vs 77/220). Nonresponders were as likely as responders to have bacteremia (3/31 vs 21/256), hydronephrosis by renal ultrasound (1/31 vs 12/232), and significant vesicoureteral reflux (more than or equal to grade 3; 5/26 vs 30/219). Eschericia coli was the pathogen in cultures of 28 of 31 (nonresponders) and 225 of 257 (responders) cultures. The number of cultures with ≥100 colony-forming units/mL was similar (25/31 nonresponders vs 206/257 responders). Repeat urine cultures were performed in 93% of patients during the admission; all culture results were negative. No renal abscesses or pyo-hydronephrosis was diagnosed. Conclusions. Eighty-nine percent of young children with febrile UTIs were afebrile within 48 hours of initiating parenteral antibiotics. The patients who took longer than 48 hours to defervesce were clinically similar to those whose fevers responded faster to therapy. If antibiotic sensitivities are known, additional diagnostic studies or prolonged hospitalizations may not be justified solely based on persistent fever beyond 48 hours of therapy.