Antibiotics for Clinical Dysentery in the Pediatric Emergency Department.

BACKGROUND: Clinical dysentery causes hundreds of thousands of deaths annually worldwide. However, current recommendations reserve antibiotics for those either clinically sick or with highly suspected cases of shigellosis. This treatment stems from rising antibiotic resistance. Children diagnosed with clinical dysentery in the pediatric emergency department (PED) are regarded more cautiously. OBJECTIVES: To explore the use of antibiotics in children diagnosed with clinical dysentery in the PED. METHODS: A retrospective case study of children with clinical dysentery at a single PED during the years 2015 and 2018. Demographics as well as clinical findings were compared to culture results and antibiotic treatment. RESULTS: The study included 281 children who were diagnosed with clinical dysentery during the study period; 234 (83%) were treated with antibiotics. However, cultures were positive in only 162 cases (58%). Only 32% were Shigella spp. Younger age, fever, and leukocytosis were related to antibiotic treatment. CONCLUSIONS: The diagnosis of clinical dysentery is misgiven commonly in the PED leading to widespread use of antibiotics when not indicated. This treatment may impact antibiotic resistance patterns. Further studies and interventions are necessary to create clear guidelines in the PED setting.

The risk of serious bacterial infections among young ex-premature infants with fever.

Background and Objectives: To determine the rate of serious-bacterial-infections (SBI) in young ex-premature infants with fever, and to develop a risk-stratification algorithm for these patients. Methods: A retrospective cohort study including all infants who presented to the pediatric emergency department (ED) of a tertiary-care university-hospital between 2010 and 2020 with fever (≥38°C), were born prematurely (<37-weeks), had post-conception age of <52-weeks, and had available blood, urine, or CSF cultures. The rates of SBI by age-of-birth and age-at-visit were calculated and compared to a cohort of matched full-term controls. Results: The study included a total of 290 ex-premature cases and 290 full-term controls. There were 11 cases (3.8%) with an invasive bacterial infection (IBI) of either bacteremia, meningitis or both and only six controls (2.1%) with IBI (p = 0.32). Over 28-days chronologic-age, there were 10 (3.6%) IBIs among cases and no IBIs among the controls (p = 0.02). There were eight (3%) cases and three (1%) controls with IBI who were well-appearing on physical examination (p = 0.19). All eight well-appearing ex-premature infants were under 60-days adjusted-age, seven of whom (88%) were also under 28-days adjusted-age. There were 28 (10.6%) cases and 34 (12%) controls with urinary tract infection (UTI) (p = 0.5). Among cases under 60-days adjusted-age, urinalysis was not reliable to exclude UTI (50% negative). Conclusions: Well-appearing ex-preterm infants have a significant risk for IBI until the adjusted age of 28-days and for UTI until the adjusted age of 60-days. Further studies are needed to evaluate the approach to fever in this unique population.

The ongoing indirect effect of the COVID-19 pandemic on a pediatric emergency department.

INTRODUCTION: The SARS-CoV-2 coronavirus pandemic may cause significant morbidity and mortality in adults, yet severe cases are rare among children. The indirect impact of the pandemic on health care delivery in general and pediatric emergency department (PED) visits in particular has been widely reported. AIMS: To assess the impact of the pandemic and the social restrictions imposed in its wake on PED visits and hospitalization rates in our Israeli medical center. We also sought to track these data in relation to the variation in pandemic severity and social restrictions over time. A comparison of this data with that of the adult emergency department was also performed. METHODS: Data for this study were drawn from the Shaare Zedek Medical Center (SZMC), Jerusalem, Israel computerized databank. The daily number of PED and adult ER visits as well as hospitalizations resulting from these visits during the months January-July during the years 2018, 2019, 2020 were recorded. We compared the risk ratio for hospitalization in 2019 and 2020, as well as the incidence rate ratio. RESULTS: During March and April there was a decrease in PED visits from 4,588 visits in 2019 to 2,527 visits in 2020 (ratio = .551, 95%CI [.52,.58]. Despite the drop in PED visits, the rate of hospitalizations rose with respect to 2019 (Risk Ratio = 1.31, p < .001, 95%CI [1.17,1.47]). Similar but more moderate trends were seen in the adult ED. From May-July 2020, after the lockdown was lifted, PED visits remained 30% below the same time period from 2018 and 2019, while the hospitalization rate returned to its pre-pandemic level. CONCLUSIONS: A significant drop in PED visits is seen to extend well beyond the peak of the pandemic and the lockdown period. This highlights the potential risk of children with serious emergencies becoming casualties of the pandemic by their not being brought to medical attention. Efforts should be made to raise public awareness among parents and other caretakers of children regarding this matter.

The rates of hospital admissions and return visits to a rapidly growing pediatric emergency department as measures of quality of care.

BACKGROUND: Return visits to the emergency department are viewed as a quality measure of patient management. Avoiding unnecessary admissions to the ward can potentially cause an increase in return visits, thus effecting quality assessment. METHODS: After implementing an educational process the relationship between admissions and return visits was assessed over time at a rapidly growing pediatric emergency department. RESULTS: There was a 264% increase in visits from 2004 to 2017. In the study period admission rates declined from 25 to 14%. This was achieved without a rise in return visits and with a stable percentage of admissions from return visits. CONCLUSIONS: Interventions aimed at decreasing unnecessary admissions do not lead to increased return visits and return visit admissions.

Hypernatremic Dehydration in Young Children: Is There a Solution?

BACKGROUND: Hypernatremic dehydration is a common and potentially life-threatening condition in children. There is currently no consensus as to the optimal strategy for fluid management. OBJECTIVES: To describe the relationship between the type, route and rate of fluids administered and the rate of decline in serum sodium (Na+) concentration. METHODS: We reviewed the medical records of all children under the age of 2 years who were hospitalized with hypernatremic dehydration (serum Na+ ≥ 155 mEq/L) in Shaare Zedek Medical Center during the period 2001-2010. Collected data of 62 subjects included initial and subsequent serum Na+ levels, and rate and Na+ concentration of all intravenous and oral fluids administered until the serum Na+ reached ≤ 150 mEq/L. RESULTS: Median initial serum Na+ was 159.5 mEq/L (IQR 157-163, maximal value 170). The median rate of decline in serum Na+ until serum Na+ reached 150 mEq/L was 0.65 mEq/L/hr (IQR 0.45-0.95). Forty-two children received hypotonic oral fluids which accounted for approximately one-quarter of all fluids they received. There was no significant difference in the rate of decline in serum Na+ between those who consumed oral fluids and those who did not. Neither was there a correlation between the rate of IV fluids, receipt of oral fluids or the degree of dehydration, with the rate of decline in serum Na+. No child experienced an apparent short-term adverse outcome. CONCLUSIONS: A cumulative rate of 5.9 mI/kg/hr of IV fluid administration may reduce the serum Na+ by an acceptable rate (0.65 mEq/L/hr). Fluid therapy comprising up to 25% hypotonic oral fluids and 75% IV fluids high in Na+ concentration was not associated with any short-term adverse outcome in our patient population.

Perforated peptic ulcer in an adolescent girl.

A perforated peptic ulcer in a child is a rare entity. Severe abdominal pain in an ill-appearing child with a rigid abdomen and possibly with signs of shock is the typical presenting feature of this life-threatening complication of peptic ulcer disease. We present a case of a 14.5-year-old adolescent girl who developed abdominal and shoulder pain that resolved after 1 day. She was then completely well for 2 days until the abdominal and shoulder pain recurred. On examination, she appeared well, but in pain. A chest radiograph revealed a large pneumoperitoneum. She underwent emergent laparoscopic omental patch repair of a perforated ulcer on the anterior wall of her stomach. Result of a urea breath test to detect Helicobacter pylori was negative. The differential diagnosis of pneumoperitoneum in children is discussed, as are childhood perforated peptic ulcer in general, and the unique clinical features present in this case in particular.

Infectious aortitis: a rare cause of chest pain in a child.

Infectious aortitis (IA) is a life-threatening bacterial infection that occurs almost exclusively in adults. Only 1 case of IA had been previously reported in a child. We present a case of IA that occurred in a 6.5-year-old previously healthy girl who was seen in our emergency department because of fever and chest pain of immediate onset. She underwent a thorough evaluation but died of aortic rupture before the correct diagnosis was established. The etiology, clinical presentation, diagnosis, and treatment of IA are discussed.

A costly covenant: ritual circumcision and urinary tract infection.

BACKGROUND: Ritual circumcision in neonates may cause a urinary tract infection within 2 weeks of the procedure. OBJECTIVES: To evaluate the prevalence of urinary tract infection among Jewish male circumcised neonates < or = 28 days old) evaluated for fever in the emergency room. METHODS: All available medical records of neonates presenting to the pediatric emergency room for evaluation of fever over a 10 year period were reviewed. Data included gender, ethnic background, age (in days) on presentation to the emergency room, age (in days) when circumcision was performed (in males > or = 8 days of age), and results of urine, blood and cerebrospinal fluid cultures. Families of males older than 8 days of age who had a UTI were contacted by telephone to verify the circumcision status when the infant presented to the ER, to ascertain whether the circumcision had been performed ritually by a mohel* or by a physician, and, if not recorded in the chart, to verify the day of life on which circumcision was performed. RESULTS: Among neonates older than 8 days of age, 60 (24.7%) of the 243 febrile Jewish males had a UTI, as compared to 12 (8.4%) of 143 females (P < 0.0001). In 39 of 54 male neonates (72%) for whom circumcision was performed ritually on the eighth day of life, UTI occurred within 9 days of the circumcision. For females, there was no such clustering of UTI cases in the second week of life, nor during any other time period. CONCLUSIONS: Febrile male neonates who have undergone ritual circumcision have a high prevalence of UTI and must be evaluated and treated accordingly.

Does sweat volume influence the sweat test result?

OBJECTIVE: Low volume sweat samples are considered unreliable for the diagnosis of cystic fibrosis, based on the assertion that sweat conductivity and chloride are reduced at lower sweating rates. We aimed to re-evaluate the relationship between sweat volume and test results. DESIGN: We reviewed all sweat tests performed in our institution to assess the relationship between sweat volume and conductivity, and between sweat volume and sweat chloride. We also compared results between pairs of sweat tests taken simultaneously from a single patient, one with sweat volume below and the other above the currently accepted minimum volume (15 microl). RESULTS: A weak inverse relationship between sweat volume and sweat conductivity was found (n=1500, R2=0.105, p<0.001). There was no correlation between sweat volume and sweat chloride (n=463, R2=0.002, p>0.05). In discordant pairs (one below and one exceeding the accepted minimum volume), the mean test result in the low volume sample was slightly higher than its counterpart. In 76 such pairs, mean conductivity was 41.1+/-14.6 mmol/l in the lower volume sample, compared with 36.8+/-16.0 mmol/l in the higher volume sample (p<0.001). Similarly, in 33 of the pairs, mean sweat chloride was 28.4+/-15.7 mmol/l in the lower volume sample compared with 25.1+/-15.2 mmol/l in the higher volume sample (p=0.004). CONCLUSION: A normal sweat conductivity and/or chloride value from a sweat volume <15 microl in a patient whose clinical symptoms are not very suggestive of cystic fibrosis, renders this diagnosis unlikely. In contrast, elevated sweat chloride or conductivity measured from a sample whose volume is <15 microl may represent an artefact related to the low volume.

The outcome of chronic dialysis in infants and toddlers--advantages and drawbacks of haemodialysis.

BACKGROUND: Improvements in dialysis technology allow replacement therapy for even the youngest of children with end stage renal disease. Nevertheless, the cumulative experience in this age group is limited. METHODS: We compared the outcome of 20 children who initiated chronic dialysis before the age of 1 year (weight 4.9 +/- 2 kg, Group 1), with a particular focus on those under the age of 1 month (eight children, weight 2.9 +/- 0.34), to that of 14 patients, aged 1.1-3 years when starting dialysis (weight 10.1 +/- 1.7, Group 2). RESULTS: The outcome was poor in the youngest age group; only 3/8 survived to 3 years. Of those who started dialysis between the ages of 0.3 and 3 years, 84% underwent kidney transplantation. One-, three-, five-, and eight-year patient survival was 96%, 88%, 84% and 84% respectively [corrected] Severe co-morbidities were present in almost half of those who died. Hospital stay was 3.5 times longer in Group 1 than in Group 2 during the first 3 months of dialysis. Permanent central venous catheters inserted under ultrasound guidance resulted in a 4.4-fold increase in catheter survival compared to non-cuffed catheters. Marked blood loss at beginning of haemodialysis (HD) is attributable to residual volume in the dialysis system (15.7 mL/kg/month) and frequent blood tests (12.1 +/- 5.9 mL/kg/month). These values decreased 2-fold after 8 months of treatment. CONCLUSIONS: The main factors determining the poor outcome of infants on dialysis are extremely young age at initiation and severe co-morbidities. Despite some disadvantages, HD may be successfully implemented in infants and toddlers, in highly specialized centres with a well-trained nursing staff.

Morgagni hernia mimicking pneumonia in Down syndrome.

Down syndrome patients are immunodeficient and commonly suffer from respiratory infections. Two children with Down syndrome were referred for evaluation of recurrent pneumonia accompanied by persistent infiltrate on chest radiographs. In both cases the radiographic abnormalities were actually found to be Morgagni hernia. When a child with Down syndrome has a persistent lower lobe infiltrate on chest radiograph, the possibility of a diaphragmatic defect should be entertained.

Asthma prevalence, family size, and birth order.

BACKGROUND: Asthma prevalence may be reduced in large families. The hygiene hypothesis suggests that older siblings protect their younger siblings from asthma through a modulating effect on the still-maturing immune system. If the hygiene hypothesis is correct, asthma prevalence should be inversely related to birth order. The objective of this study was to examine the relationship between asthma prevalence, and family size and birth order. METHODS: The medical records of 531,116 Israeli military conscripts were reviewed. The association between number of children in the family and the prevalence of asthma, and between birth order and the prevalence of asthma was assessed. Odds ratios for asthma by birth order and family size, adjusted for each other, were calculated. RESULTS: Asthma was diagnosed in 26,833 male subjects (8.6%) and 15,079 female subjects (6.9%). Asthma prevalence was inversely related to the number of children in the family (p < 0.001). Among subjects who were the only child in the family, the prevalence of asthma was 7.3%. The prevalence increased to 8.95% among subjects from families with three siblings, and then progressively decreased as the number of siblings increased, and reached a trough of 0.58% in conscripts from families of 15 to 20 siblings. Asthma prevalence was similar for all birth orders. CONCLUSIONS: In families with four or more children, asthma prevalence is inversely related to the number of children in the family. Asthma prevalence is similar for all birth orders. The similar asthma prevalence for all birth orders challenges the hygiene hypothesis as the mechanism for the decreased asthma prevalence in large families.

A single dose of dexamethasone to prevent postbronchoscopy fever in children: a randomized placebo-controlled trial.

STUDY OBJECTIVE: To assess the effectiveness of one dose of dexamethasone (0.5 mg/kg; maximum, 10 mg) to prevent fever after bronchoscopy with BAL. DESIGN: Randomized, placebo-controlled study. PATIENTS: Immunocompetent nonfebrile children undergoing fiberoptic bronchoscopy with BAL. MEASUREMENTS AND RESULTS: Sixty-nine children were included in the study. Thirty-eight children received saline solution, and 31 children received dexamethasone. The two groups were similar regarding the number of children < 2 years old, the percentage of abnormal bronchoscopic findings, the number of positive BAL culture findings, and the index of lipid-laden macrophages. Twenty-six children (68%) in the saline solution group (SG) had fever, compared to 3 children (9.6%) in the dexamethasone group (DG) [p < 0.001]. Fever after the procedure appeared later (12.3 +/- 5.5 h) in the DG compared to 5.4 +/- 2.7 h in the SG. CONCLUSIONS: One dose of dexamethasone administered prior to performing bronchoscopy with BAL may prevent fever subsequent to the procedure. Further studies are necessary in order to determine the optimal dosing regimen for dexamethasone when used for this purpose.

Investigation of unexplained infant deaths in Jerusalem, Israel 1996-2003.

BACKGROUND: Sudden infant death syndrome (SIDS) is a diagnosis of exclusion that may be assigned only after investigations including a forensic autopsy are performed to exclude possible organic and environmental causes of death. Israeli society is influenced by the Jewish and Islamic faiths, which permit autopsy only under selected circumstances. Against this background, we carried out a study to determine what examinations are performed to investigate unexplained infant deaths in Jerusalem, Israel. METHODS: We examined hospital, Ministry of Health and Ministry of Interior records of unexplained infant deaths in the Jerusalem district from the years 1996-2003. RESULTS: Ninety six cases were identified from all sources. Forty nine (51%) infants were brought to a hospital at or near the time of death. Studies to determine the cause of death were performed in 54% of cases for which medical records were available for review. These studies included bacterial cultures (44%), skeletal surveys (12%), computerised tomography (3%) and metabolic studies (3%). Only one forensic autopsy was performed, and in no instance was the death site examined by medical personnel. There was a high rate of retrospective review by district health physicians. The most frequently assigned cause of death was SIDS. CONCLUSIONS: : The capacity of public health officials and forensic pathologists to investigate unexplained infant deaths is strongly affected by the legal, religious and political milieu in which they work. Efforts should be made to develop socially acceptable methods of improving the quality of infant death investigations in Jerusalem.

Sensitivity of exercise testing for asthma in adolescents is halved in the summer.

STUDY OBJECTIVES: The exercise test is one of the most widely used challenge tests for asthma. It is not clear if the sensitivity of this test is lower when patients with asthma are not symptomatic. Since asthma activity is season dependent, with lower activity in the summer, we sought to determine if the percentage of positive exercise test results for asthma is lower in the summer as well. DESIGN: In this retrospective study, the proportion of positive exercise test results for asthma during each of the four seasons of the year, over a 5-year period, was compared. SETTING: The study was conducted at the pediatric respiratory clinic and pulmonary function laboratory of Shaare Zedek Medical Center. PARTICIPANTS: The study group consisted of 532 consecutive patients, all 17 years of age, who were referred for exercise testing for evaluation of suspected asthma. All had normal baseline FEV1 levels, and none received maintenance asthma treatment. MEASUREMENTS AND RESULTS: Spirometry was performed before and after a standard exercise regimen. A decrease of > or = 10% in FEV1 after exercise was considered positive; 141 patients (26%) had a positive test result. The percentage of positive results in the summer (July to September quartile) was 12.9%, less than half the percentage of positive results during any of the other three quartiles (January to March, 28.9%, p < 0.05; April to June, 30.6%, p < 0.05; October to December, 29.1%, p < 0.05). CONCLUSIONS: This study shows that the percentage of positive exercise challenge test results in the summer is half that of any other season. It is likely that the lower percentage of positive results for asthma in the summer reflects the lower sensitivity of the test during this season due to decreased asthma activity. We suggest performing exercise challenge testing only when patients are symptomatic. Physicians caring for patients with symptoms suggestive of exercise-induced asthma whose exercise test results are negative while asymptomatic should consider repeat exercise testing when their patients are symptomatic.

Childhood accidents: the relationship of family size to incidence, supervision, and rapidity of seeking medical care.

BACKGROUND: Large family size may be a risk factor for childhood accidents. A possible association with quality of child supervision and rapidity of seeking medical care has not been fully evaluated. OBJECTIVES: To determine whether children with multiple siblings are at increased risk for accidents, to assess whether quality of child supervision varies with family size, and to evaluate the relationship of family size with the rapidity of seeking medical care after an accident. METHODS: We prospectively studied 333 childhood accidents treated at TEREM (emergency care station) or the Shaare Zedek Medical Center. Details on family composition and the accident were obtained through parental interview. Family size of the study population was compared with that of the Jerusalem population. Families with one to three children (Group 1) and four or more children (Group 2) were compared with regard to type of supervision and different "Gap times" - the time interval from when the accident occurred until medical assistance was sought ("Gap 1"), the time from that medical contact until arrival at Shaare Zedek ("Gap 2"), and the time from the accident until arrival at Shaare Zedek for those children for whom interim medical assistance either was ("Gap 3A") or was not ("Gap 3B") sought. RESULTS: Children from families with 1, 2, 3, 4 and > or =5 children comprised 7.2%, 18.3%, 14.4%, 18.6% and 41.4% of our sample compared to 20.4%, 21.8%, 18.4%, 14.7% and 24.7% in the general population respectively. Children from Group 2 were less often attended to by an adult (44.5% vs. 62.0%) and more often were in the presence only of other children at the time of the accident (27.0% vs. 10.5%). Gaps 1, 2 and 3A in Group 2 (6.3 hours, 16.5 hours, 27.8 hours respectively) were longer than for Group 1 (2.7, 10.7, 13.3 hours respectively). CONCLUSIONS: The risk for accidents is increased among children from families with four or more children. The adequacy of child supervision in large families is impaired. There is a relative delay from the time of the accident until these children are brought for treatment.

Endoscopic findings in children with obstructive sleep apnea: effects of age and hypotonia.

Obstructive sleep apnea (OSA) syndrome is a common disorder among children and is often associated with significant morbidity. The causes of OSA are related to either fixed upper airway abnormalities such as adenotonsillar hypertrophy, or dynamic airway abnormalities such as laryngomalacia and pharyngeal wall collapse. The aim of the present study was to determine the prevalence of dynamic upper airway abnormalities, based on endoscopic findings, in normotonic and hypotonic children with polysomnographically documented OSA. The records of 39 consecutive children with OSA who underwent bronchoscopy (22 with normal tone, and 17 with hypotonia) were reviewed. The prevalence of dynamic defects among children with normal tone decreased with age. All 7 patients less than 1 year old had dynamic abnormalities (isolated or combined fixed/dynamic), compared to only 66% (6/9) of patients between 1-2 years old, and 17% (1/6) of children more than 2 years old. In contrast, dynamic abnormalities were very common among hypotonic children, independent of age. Since children with dynamic defects are less likely to respond to surgical treatments, it would be appropriate to identify these children prior to any intervention. Due to the higher frequency of dynamic defects in both infants (< 1 year) and hypotonic children, it may be appropriate to include endoscopy as part of the diagnostic evaluation of OSA in these subgroups.

Is noncompliance among adolescent renal transplant recipients inevitable?

OBJECTIVE: To evaluate the prevalence of noncompliance and factors that influence poor adherence to immunosuppressive drug regimens among kidney transplant recipients. METHODS: We reviewed immunosuppressive drug compliance in 79 posttransplant patients. Patient self-report and low plasma calcineurin inhibitor levels served as indicators of noncompliance. RESULTS: The prevalence of noncompliance was found to be highest in adolescents who were responsible for their own medications and who underwent cadaveric kidney transplantation (CTx; 45.5%) and lower after living related transplantation (28.6%). There were no documented cases of noncompliance among any recipient of living unrelated (commercial) transplantation. Among 13 noncompliant patients, the first indication of "drug holiday" was low plasma calcineurin inhibitor levels in 11 children. Two additional children presented with acute rejection. In 7 patients, repeated episodes of "drug holidays" led to acute rejection later: 21.4 +/- 13.2 months after the first decrease in plasma calcineurin inhibitor level had been recorded. All 9 patients who experienced acute rejection subsequently developed chronic rejection. In 4 patients, noncompliance did not influence graft function. Psychosocial factors that were associated with noncompliance included insufficient family support, low self-awareness caused by poor cognitive abilities, and denial. CONCLUSIONS: The absence of cases of noncompliance in adolescents who underwent commercial living unrelated kidney transplantation suggests that although noncompliance is prevalent, it is not inevitable. Strategies to decrease noncompliance in young patients with chronic illnesses can be learned from the experience with transplant recipients. The general pediatrician has a central role in identifying and addressing the problem of noncompliance in adolescents with chronic disease.

Automatic 3-dimensional visualization of peripheral blood slides: a new approach for the detection of infection/inflammation at the point of care.

CONTEXT: The identification and quantitation of the intensity of the acute-phase response at the point of care might be of clinical relevance. OBJECTIVE: To report the possibility of automatic screening of unstained peripheral blood slides by using a 3-dimensional image analysis system. DESIGN: Peripheral venous blood was obtained from children with acute inflammation/infection and examined by an automatic 3-dimensional image analyzer to detect the number of white blood cells as well as to reveal the degree of erythrocyte aggregation, a marker of the humoral phase response. RESULTS: We included 66 children with acute bacterial infections and 59 with nonbacterial inflammation/infection; mean ages of the 2 groups were 4.3 +/- 3.9 years and 4.2 +/- 3.7 years, respectively (P = .91). The percentages of correct classifications based on discriminant analysis in predicting between bacterial and nonbacterial inflammation/infection were 61.3% by using the white blood cell count, 64.5% by using the percentage of granulocytes, 61.6% by using the degree of erythrocyte aggregation, and 59.2% by using the number of leukocytes counted on the unstained slides. The results of the receiver-operated characteristic curve analysis yielded an area under the curve of 0.714 (P < .001) for the number of granulocytes, 0.699 (P < .001) for the white blood cell count, 0.685 (P < .001) for the number of leukocytes on the slides, and 0.685 (P = .001) for the degree of erythrocyte aggregation. The correlation between the number of leukocytes by the electronic cell analyzer and the number of cells counted on the slides was highly significant (r = 0.85, P < .001). CONCLUSIONS: It is feasible to use an automatic 3-dimensional image analyzer to reveal the different intensities of the acute-phase response between a group of children with an acute bacterial infection and another with nonbacterial inflammation/infection. These findings might be relevant for potential application at the point of care.