Prediction Model for Croup Admission Need.

OBJECTIVES: This study aims to generate a predictive model stratifying the probability of requiring hospitalization and inpatient respiratory intervention for croup patients presenting to the emergency department (ED), and secondarily to compare the model's performance with that of ED providers. METHODS: Retrospective data was collected on croup patients presenting to the EDs of 2 pediatric and 1 community hospital from 2019 to 2020, including demographics, preexisting conditions, and history of croup. The ED length of stay, previous dexamethasone administration, time to ED dexamethasone, number of ED racemic epinephrine doses, viral testing, and ED revisits were also recorded. Westley croup scores were derived at ED presentation and final disposition. For admitted patients, any respiratory interventions were recorded. Admission need was defined as either admitted and required an inpatient intervention or not admitted with ED revisit. A prediction model for admission need was fit using L1-penalized logistic regression. RESULTS: We included 2951 patients in the study, 68 (2.3%) of which needed admission. The model's predictors were disposition Westley croup scores, number of ED racemic epinephrine doses, previous dexamethasone administration, and history of intubation. The model's sensitivity was 66%, specificity was 91%, positive predictive value was 15%, and negative predictive value was 99%. ED providers' performance had a sensitivity of 72%, a specificity of 94%, a positive predictive value of 23%, and a negative predictive value of 99%. CONCLUSIONS: The croup admission need predictive model appears to support clinical decision making in the ED, with the potential to improve decision making when pediatric expertise is limited.

Omphalitis and Concurrent Serious Bacterial Infection.

OBJECTIVE: Describe the clinical presentation, prevalence of concurrent serious bacterial infection (SBI), and outcomes among infants with omphalitis. METHODS: Within the Pediatric Emergency Medicine Collaborative Research Committee, 28 sites reviewed records of infants ≤90 days of age with omphalitis seen in the emergency department from January 1, 2008, to December 31, 2017. Demographic, clinical, laboratory, treatment, and outcome data were summarized. RESULTS: Among 566 infants (median age 16 days), 537 (95%) were well-appearing, 64 (11%) had fever at home or in the emergency department, and 143 (25%) had reported fussiness or poor feeding. Blood, urine, and cerebrospinal fluid cultures were collected in 472 (83%), 326 (58%), and 222 (39%) infants, respectively. Pathogens grew in 1.1% (95% confidence interval [CI], 0.3%-2.5%) of blood, 0.9% (95% CI, 0.2%-2.7%) of urine, and 0.9% (95% CI, 0.1%-3.2%) of cerebrospinal fluid cultures. Cultures from the site of infection were obtained in 320 (57%) infants, with 85% (95% CI, 80%-88%) growing a pathogen, most commonly methicillin-sensitive Staphylococcus aureus (62%), followed by methicillin-resistant Staphylococcus aureus (11%) and Escherichia coli (10%). Four hundred ninety-eight (88%) were hospitalized, 81 (16%) to an ICU. Twelve (2.1% [95% CI, 1.1%-3.7%]) had sepsis or shock, and 2 (0.4% [95% CI, 0.0%-1.3%]) had severe cellulitis or necrotizing soft tissue infection. There was 1 death. Serious complications occurred only in infants aged <28 days. CONCLUSIONS: In this multicenter cohort, mild, localized disease was typical of omphalitis. SBI and adverse outcomes were uncommon. Depending on age, routine testing for SBI is likely unnecessary in most afebrile, well-appearing infants with omphalitis.

Neonatal Mastitis and Concurrent Serious Bacterial Infection.

OBJECTIVES: Describe the clinical presentation, prevalence, and outcomes of concurrent serious bacterial infection (SBI) among infants with mastitis. METHODS: Within the Pediatric Emergency Medicine Collaborative Research Committee, 28 sites reviewed records of infants aged ≤90 days with mastitis who were seen in the emergency department between January 1, 2008, and December 31, 2017. Demographic, clinical, laboratory, treatment, and outcome data were summarized. RESULTS: Among 657 infants (median age 21 days), 641 (98%) were well appearing, 138 (21%) had history of fever at home or in the emergency department, and 63 (10%) had reported fussiness or poor feeding. Blood, urine, and cerebrospinal fluid cultures were collected in 581 (88%), 274 (42%), and 216 (33%) infants, respectively. Pathogens grew in 0.3% (95% confidence interval [CI] 0.04-1.2) of blood, 1.1% (95% CI 0.2-3.2) of urine, and 0.4% (95% CI 0.01-2.5) of cerebrospinal fluid cultures. Cultures from the site of infection were obtained in 335 (51%) infants, with 77% (95% CI 72-81) growing a pathogen, most commonly methicillin-resistant Staphylococcus aureus (54%), followed by methicillin-susceptible S aureus (29%), and unspecified S aureus (8%). A total of 591 (90%) infants were admitted to the hospital, with 22 (3.7%) admitted to an ICU. Overall, 10 (1.5% [95% CI 0.7-2.8]) had sepsis or shock, and 2 (0.3% [95% CI 0.04-1.1]) had severe cellulitis or necrotizing soft tissue infection. None received vasopressors or endotracheal intubation. There were no deaths. CONCLUSIONS: In this multicenter cohort, mild localized disease was typical of neonatal mastitis. SBI and adverse outcomes were rare. Evaluation for SBI is likely unnecessary in most afebrile, well-appearing infants with mastitis.

Invasive Bacterial Infections in Afebrile Infants Diagnosed With Acute Otitis Media.

OBJECTIVES: To determine the prevalence of invasive bacterial infections (IBIs) and adverse events in afebrile infants with acute otitis media (AOM). METHODS: We conducted a 33-site cross-sectional study of afebrile infants ≤90 days of age with AOM seen in emergency departments from 2007 to 2017. Eligible infants were identified using emergency department diagnosis codes and confirmed by chart review. IBIs (bacteremia and meningitis) were determined by the growth of pathogenic bacteria in blood or cerebrospinal fluid (CSF) culture. Adverse events were defined as substantial complications resulting from or potentially associated with AOM. We used generalized linear mixed-effects models to identify factors associated with IBI diagnostic testing, controlling for site-level clustering effect. RESULTS: Of 5270 infants screened, 1637 met study criteria. None of the 278 (0%; 95% confidence interval [CI]: 0%-1.4%) infants with blood cultures had bacteremia; 0 of 102 (0%; 95% CI: 0%-3.6%) with CSF cultures had bacterial meningitis; 2 of 645 (0.3%; 95% CI: 0.1%-1.1%) infants with 30-day follow-up had adverse events, including lymphadenitis (1) and culture-negative sepsis (1). Diagnostic testing for IBI varied across sites and by age; overall, 278 (17.0%) had blood cultures, and 102 (6.2%) had CSF cultures obtained. Compared with infants 0 to 28 days old, older infants were less likely to have blood cultures (P < .001) or CSF cultures (P < .001) obtained. CONCLUSION: Afebrile infants with clinician-diagnosed AOM have a low prevalence of IBIs and adverse events; therefore, outpatient management without diagnostic testing may be reasonable.

Emergency Endotracheal Intubation With a Rigid Stylet of an Infant With Severe Subglottic Stenosis.

BACKGROUND: Subglottic stenosis is a frequent complication of endotracheal intubation in children and can create a difficult airway situation for subsequent respiratory illnesses. Difficult airway algorithms are an essential aid when dealing with respiratory failure in clinical situations where ventilation or intubation is unsuccessful. CASE REPORT: A 4-month-old infant with a history of previous endotracheal intubation required endotracheal intubation for stridor and respiratory failure due to croup. There was difficulty intubating the trachea due to severe subglottic stenosis that developed following the previous episode of endotracheal intubation. Successful intubation was facilitated by the use of a rigid endotracheal tube stylet to facilitate passage of an endotracheal tube through the stenotic segment. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Difficult airway algorithms recommend the use of invasive airway access only as a last resort and noninvasive airway access should be explored prior to their use. The use of a readily available rigid stylet as an alternative method for tracheal intubation should be considered only after more conventional techniques and potential complications have been considered.

A Comparison of the Efficacy of Enema Solutions in Pediatric Emergency Department Patients.

BACKGROUND: Children presenting to pediatric emergency departments (EDs) are frequently given enemas for relief of constipation symptoms; there is very little literature guiding solution selection. OBJECTIVE: Our aim was to assess and compare the efficacy of the various enema solutions used in a pediatric ED, including the "pink lady," a previously unreported compounded combination of docusate, magnesium citrate, mineral oil, and sodium phosphate. METHODS: We identified all children who received any enema over a 5-year period in an urban, quaternary care pediatric ED for inclusion in the study via electronic record review. Physician investigators retrospectively reviewed routine visit documentation to confirm the type and dosage of enema and assess comorbidities, indications, efficacy, and side effects. Subjective descriptions of output were classified as none, small, medium, or large by reviewer consensus. RESULTS: There were 768 records included. Median age was 6.2 years (interquartile range 3.3-10.3 years). Solutions used were sodium phosphate (n = 396), pink lady (n = 198), soap suds (n = 160), and other (n = 14). There was no significant difference in output by solution type (p = 0.88). Volume delivered was highest for pink lady, with no significant association between volume delivered and output (p = 0.48). Four percent of patients had side effects. Soap suds had a significantly higher rate of side effects (10.6%; p = 0.0003), primarily abdominal pain. CONCLUSIONS: There was no significant difference in reported stool output produced by sodium phosphate, soap suds, and pink lady enemas in children treated in an ED. Further study via randomized controlled trials would be beneficial in guiding selection of enema solution.

Shock Index as a Predictor of Morbidity and Mortality in Pediatric Trauma Patients.

OBJECTIVES: Compared with unadjusted shock index (SI) (heart rate/systolic blood pressure), age-adjusted SI improves identification of negative outcomes after injury in pediatric patients. We aimed to further evaluate the utility of age-adjusted SI to predict negative outcomes in pediatric trauma. METHODS: We performed an analysis of patients younger than 15 years using the National Trauma Data Bank. Elevated SI was defined as high normal heart rate divided by low-normal blood pressure for age. Our primary outcome measure was mortality. Secondary outcomes included need for a blood transfusion, ventilation, any operating room/interventional radiology procedures, and intensive care unit stay. Multiple logistic regressions were performed. RESULTS: Twenty-eight thousand seven hundred forty-one cases met the study criteria. The overall mortality rate was 0.7%, and 1.7% had an elevated SI. Patients with an elevated SI were more likely (P < 0.001) to require blood transfusion, ventilation, an operating room/interventional radiology procedure, or an intensive care unit stay. An elevated SI was the strongest predictor for mortality (odds ratio [OR] 22.0) in pediatric trauma patients compared with hypotension (OR, 12.6) and tachycardia (OR, 2.6). CONCLUSIONS: Elevated SI is an accurate and specific predictor of morbidity and mortality in pediatric trauma patients and is superior to tachycardia or hypotension alone for predicting mortality.

Pediatric Chest Tubes And Pigtails: An Evidence-Based Approach To The Management Of Pleural Space Diseases.

Pediatric thoracostomy procedures are used in the emergency department to treat diseases of the pleural space. As children have unique thoracic anatomy and physiology, they may present with management challenges that the emergency clinician must consider. This issue reviews the use of chest tubes and pigtail catheters in pediatric patients, techniques and indications for placement, and possible complications. Diagnostic and treatment options for diseases of the pleural space, such as spontaneous pneumothorax, traumatic injury, and parapneumonic effusions/empyema, are examined. Additionally, this issue discusses the use of imaging modalities to aid in the diagnosis of pleural space diseases and the emerging practice of ambulatory management in certain cases.

Changes in children's perception-action tuning over short time scales: bicycling across traffic-filled intersections in a virtual environment.

This investigation examined short-term changes in child and adult cyclists' gap decisions and movement timing in response to general and specific road-crossing experiences. Children (10- and 12-year-olds) and adults rode a bicycle through a virtual environment with 12 intersections. Participants faced continuous cross traffic and waited for gaps they judged were adequate for crossing. In the control condition, participants encountered randomly ordered gaps ranging from 1.5 to 5.0s at all intersections. In the high-density condition, participants encountered high-density intersections sandwiched between sets of control intersections. These high-density intersections were designed to push participants toward taking tighter gaps. Participants in both conditions were more likely to accept 3.5-, 4.0-, 4.5-, and 5.0-s gaps at the last set of intersections than at the first set of intersections, whereas participants in the high-density condition were also more likely to accept very tight 3.0-s gaps at the last intersections than at the first intersections. Moreover, individuals in the high-density condition who waited less and took shorter gaps at the middle intersections were also more likely to take very tight 3.0-s gaps at the last intersections. The 10-year-olds in both conditions had more time to spare when they cleared the path of the oncoming car at the last intersections, whereas the 12-year-olds and adults showed no change in time to spare across intersections. The discussion focuses on linking short-term change in perceptual-motor functioning to longer term perceptual-motor development.