Contaminant Organism Growth in Febrile Infants at Low Risk for Invasive Bacterial Infection.

In this multicenter, cross-sectional, secondary analysis of 4042 low-risk febrile infants, nearly 10% had a contaminated culture obtained during their evaluation (4.9% of blood cultures, 5.0% of urine cultures, and 1.8% of cerebrospinal fluid cultures). Our findings have important implications for improving sterile technique and reducing unnecessary cultures.

Race, Ethnicity, Language, and the Treatment of Low-Risk Febrile Infants.

Importance: Febrile infants at low risk of invasive bacterial infections are unlikely to benefit from lumbar puncture, antibiotics, or hospitalization, yet these are commonly performed. It is not known if there are differences in management by race, ethnicity, or language. Objective: To investigate associations between race, ethnicity, and language and additional interventions (lumbar puncture, empirical antibiotics, and hospitalization) in well-appearing febrile infants at low risk of invasive bacterial infection. Design, Setting, and Participants: This was a multicenter retrospective cross-sectional analysis of infants receiving emergency department care between January 1, 2018, and December 31, 2019. Data were analyzed from December 2022 to July 2023. Pediatric emergency departments were determined through the Pediatric Emergency Medicine Collaborative Research Committee. Well-appearing febrile infants aged 29 to 60 days at low risk of invasive bacterial infection based on blood and urine testing were included. Data were available for 9847 infants, and 4042 were included following exclusions for ill appearance, medical history, and diagnosis of a focal infectious source. Exposures: Infant race and ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White, and other race or ethnicity) and language used for medical care (English and language other than English). Main Outcomes and Measures: The primary outcome was receipt of at least 1 of lumbar puncture, empirical antibiotics, or hospitalization. We performed bivariate and multivariable logistic regression with sum contrasts for comparisons. Individual components were assessed as secondary outcomes. Results: Across 34 sites, 4042 infants (median [IQR] age, 45 [38-53] days; 1561 [44.4% of the 3516 without missing sex] female; 612 [15.1%] non-Hispanic Black, 1054 [26.1%] Hispanic, 1741 [43.1%] non-Hispanic White, and 352 [9.1%] other race or ethnicity; 3555 [88.0%] English and 463 [12.0%] language other than English) met inclusion criteria. The primary outcome occurred in 969 infants (24%). Race and ethnicity were not associated with the primary composite outcome. Compared to the grand mean, infants of families that use a language other than English had higher odds of the primary outcome (adjusted odds ratio [aOR]; 1.16; 95% CI, 1.01-1.33). In secondary analyses, Hispanic infants, compared to the grand mean, had lower odds of hospital admission (aOR, 0.76; 95% CI, 0.63-0.93). Compared to the grand mean, infants of families that use a language other than English had higher odds of hospital admission (aOR, 1.08; 95% CI, 1.08-1.46). Conclusions and Relevance: Among low-risk febrile infants, language used for medical care was associated with the use of at least 1 nonindicated intervention, but race and ethnicity were not. Secondary analyses highlight the complex intersectionality of race, ethnicity, language, and health inequity. As inequitable care may be influenced by communication barriers, new guidelines that emphasize patient-centered communication may create disparities if not implemented with specific attention to equity.

Acute Pediatric Liquid Nicotine Ingestions.

Electronic cigarette and vaping device use in the household represents a possible source of unintentional nicotine exposure to pediatric patients. Although most ingestions of nicotine may be mild, there is a potential for significant toxicity. Nicotine toxicity can present similarly to many other types of ingestions, which makes the history an important piece of the encounter. Treatment of nicotine toxicity is primarily supportive care directed at the presenting signs and symptoms. There is no antidotal therapy for nicotine toxicity. This review covers information that can assist clinicians who might treat a pediatric patient presenting with significant nicotine toxicity after the accidental ingestion of liquid nicotine products. [Pediatr Ann. 2023;52(5):e187-e191.].

Skin to Intramuscular Compartment Thigh Measurement by Ultrasound in Pediatric Population.

INTRODUCTION: Pediatric obesity threatens the efficacy of medications given intramuscularly. In anaphylactic patients, epinephrine auto-injector needle lengths are potentially too short to reach the muscle compartment in patients with elevated body habitus. The objective of the study was to determine needle-length requirements for intramuscular injections in pediatric patients. METHODS: We used ultrasound to measure the distance from skin to muscle compartment of the thigh in 200 pediatric patients of various weight and body mass index who presented to the emergency department. RESULTS: Patients with higher body mass index had an increased distance to muscle and bone. If current recommendations were followed, 5% of patients within the EpiPen adult weight category and 11% of patients within the Centers for Disease Control and Prevention weight category would have potentially used a needle inadequate in length for intramuscular injections. CONCLUSION: With the increase in childhood obesity, needle lengths may be too short to effectively deliver medications to the intramuscular compartment. Needle length should be evaluated to accommodate pediatric patients with increased skin to muscle distance.

Consensus development of a pediatric emergency medicine clerkship curriculum.

INTRODUCTION: As emergency medicine (EM) has become a more prominent feature in the clinical years of medical school training, national EM clerkship curricula have been published to address the need to standardize students' experiences in the field. However, current national student curricula in EM do not include core pediatric emergency medicine (PEM) concepts. METHODS: A workgroup was formed by the Clerkship Directors in Emergency Medicine and the Pediatric Interest Group of the Society of Academic Emergency Medicine to develop a consensus on the content to be covered in EM and PEM student courses. RESULTS: The consensus is presented with the goal of outlining principles of pediatric emergency care and prioritizing students' exposure to the most common and life-threatening illnesses and injuries. CONCLUSION: This consensus curriculum can serve as a guide to directors of PEM and EM courses to optimize PEM knowledge and skills education.

Comparison of procedural sedation for the reduction of dislocated total hip arthroplasty.

INTRODUCTION: Various types of sedation can be used for the reduction of a dislocated total hip arthroplasty. Traditionally, an opiate/benzodiazepine combination has been employed. The use of other pharmacologic agents, such as etomidate and propofol, have more recently gained popularity. Currently no studies directly comparing these sedation agents have been carried out. The purpose of this study is to compare differences in reduction and sedation outcomes, including recovery times, of these 3 sedation agents. METHODS: We performed a retrospective chart review examining 198 patients who presented with dislocated total hip arthroplasty at 2 academic affiliated medical centers. The patients were grouped according to the type of sedation agent. We calculated percentages of reduction and sedation complications along with recovery times. Reduction complications included fracture, skin or neurovascular injury, and failure of reduction requiring general anesthesia. Sedation complications included use of bag-valve mask and artificial airway, intubation, prolonged recovery, use of a reversal agent, and inability to achieve sedation. We then compared the data for each sedation agent. RESULTS: We found reduction complications rates of 8.7% in the propofol, 24.7% in the etomidate, and 28.9% in the opiate/benzodiazepine groups. The propofol group was significantly different from the other 2agents (p ≤ 0.01). Sedation complications were found 7.3% of the time in the propofol , 11.7% in the etomidate , and 21.3% in the opiate/benzodiazepine group, (p=0.02 propofol vs. others) . Average recovery times were 25.2 minutes for propofol, 30.8 minutes for etomidate, and 44.4 minutes for opiate/benzodiazepine (p = 0.05 for propofol vs. other agents). CONCLUSION: For reduction of dislocated total hip arthroplasty under procedural sedation, propofol appears to have fewer complications and a trend toward more rapid recovery than both etomidate and opiate/benzodiazepine. These data support the use of propofol as first line agent for procedural sedation of dislocated total hip arthroplasty, with fewer complications and a shorter recovery period.

Serum lactate as a screening tool and predictor of outcome in pediatric patients presenting to the emergency department with suspected infection.

OBJECTIVES: No single reliable sepsis biomarker exists for risk stratification and prognostication in pediatric patients presenting to the emergency department (ED). Serum lactate (LA) predicts mortality in septic adults. We sought to determine if serum LA correlated with the diagnosis of sepsis, admission rates, and outcomes in pediatric patients presenting to the ED with suspected infection. METHODS: This retrospective study was performed in an ED with a sepsis protocol that included serum LA with every blood culture. Of 735 pediatric patients with blood cultures drawn, 289 had serum LA obtained concomitantly. Appropriate statistical analyses determined the relationship between serum LA and variables of interest. RESULTS: A significant positive correlation was found between serum LA and pulse, respiratory rate, white blood cell count, platelets, and length of stay, whereas a significant negative correlation was seen with temperature, HCO3, and blood urea nitrogen. Admitted patients had higher serum LA (2.36 mM) than did those not admitted (1.70 mM), P = 0.0001. Of patients discharged, there was no difference in serum LA between those who returned within 3 days (1.80 mM) and those who did not (1.72 mM), P = 0.6654. Mean serum LA for those with sepsis (2.03 mM) did not differ from those without sepsis (1.91 mM), P = 0.3364. CONCLUSIONS: Higher serum LA in pediatric patients presenting to the ED with suspected infection correlated with increased pulse, respiratory rate, white blood cell count, and platelets and decreased blood urea nitrogen, HCO3, and age. Serum LA may be predictive of hospitalization and length of stay and thus suggestive of disease severity, but not of return rates or pediatric sepsis screening in the ED.

Gastric volvulus complication in an infant with undiagnosed congenital diaphragmatic hernia presenting with acute respiratory distress.

INTRODUCTION: Congenital diaphragmatic hernia is an embryologic defect that creates a passage for herniation of abdominal structures into the thoracic cavity. This can lead to a variety of complications, including gastric volvulus that can present acutely with epigastric distention and vomiting. In cases of late-onset congenital diaphragmatic hernia, symptoms may be vague and often necessitate further investigation. CASE: Our patient is a 12-month-old previously healthy female infant who presented to the emergency department with a history of vomiting and acute onset respiratory distress. Her SaO(2) was 94% to 98% on room air, her respiratory rate was in the 80s breaths per minute, and she was noted to have severe retractions. Her chest examination revealed absent breath sounds on the left side. Her abdominal examination was unremarkable. The acute presentation of respiratory distress was initially concerning for a foreign body aspiration, but a chest radiograph demonstrated left-sided opacification and mediastinal shift to the right. The patient required intubation for respiratory decompensation and a subsequent computed tomographic scan showed diaphragmatic hernia with gastric volvulus. CONCLUSIONS: This patient's presentation highlights one of the complications that may occur owing to congenital diaphragmatic hernia. Computed tomographic scan is the confirmatory test for diaphragmatic hernia and, in this case, also uncovered a concomitant gastric volvulus. Treatment includes early resuscitation, a definitive airway, and emergent surgery to prevent ischemic necrosis of the stomach owing to strangulation, gastric perforation, and serious cardiorespiratory decompensation.

Randomized, controlled trial of antibiotics in the management of community-acquired skin abscesses in the pediatric patient.

STUDY OBJECTIVE: Emergency department visits for skin and soft tissue infections are increasing with the discovery of community-acquired methicillin-resistant Staphylococcus aureus. Whether abscesses treated surgically also require antibiotics is controversial. There are no published pediatric randomized controlled trials evaluating the need for antibiotics in skin abscess management. We determine the benefits of antibiotics in surgically managed pediatric skin abscesses. METHODS: This was a double-blind, randomized, controlled trial. Pediatric patients were randomized to receive 10 days of placebo or trimethoprim-sulfamethoxazole after incision and draining. Follow-up consisted of a visit/call at 10 to 14 days and a call at 90 days. Primary outcome was treatment failure at the 10-day follow-up. Secondary outcome was new lesion development at the 10- and 90-day follow-ups. Noninferiority of placebo relative to trimethoprim-sulfamethoxazole for primary and secondary outcomes was assessed. RESULTS: One hundred sixty-one patients were enrolled, with 12 lost to follow-up. The failure rates were 5.3% (n=4/76) and 4.1% (n=3/73) in the placebo and antibiotic groups, respectively, yielding a difference of 1.2%, with a 1-sided 95% confidence interval (CI) (-infinity to 6.8%). Noninferiority was established with an equivalence threshold of 7%. New lesions occurred at the 10-day follow-up: 19 on placebo (26.4%) and 9 on antibiotics (12.9%), yielding a difference of 13.5%, with 95% 1-sided CI (-infinity to 24.3%). At the 3-month follow-up, 15 of 52 (28.8%) in the placebo group and 13 of 46 (28.3%) in the antibiotic group developed new lesions. The difference was 0.5%, with 95% 1-sided CI (-infinity to 15.6%). CONCLUSION: Antibiotics are not required for pediatric skin abscess resolution. Antibiotics may help prevent new lesions in the short term, but further studies are required.

Lemierre syndrome.

Lemierre syndrome is characterized by pharyngitis followed by Fusobacterium necrobacillosis sepsis complicated by internal jugular vein thrombosis and infectious metastatic abscesses. It has been considered to be a rare disease until the last decade when a larger number of cases have been reported. We discuss a case of Lemierre syndrome in a 17-year-old girl and review the pathophysiology of Fusobacterium necrobacillosis and diagnosis and treatment of Lemierre syndrome.