Correction to: Hyperpyrexia and high fever as a predictor for serious bacterial infection (SBI) in children-a systematic review.

It has been identified that the data listed within the above article was incorrectly presented. This is now presented correctly in this article.

Hyperpyrexia and high fever as a predictor for serious bacterial infection (SBI) in children-a systematic review.

It is not clear if children with high fever are at increased risk for serious bacterial infection (SBI). Our aim was to systematically review if children suffering from high fever are at high risk for SBI. Our data sources were Embase, Medline, and Pubmed; from their inception until the last week of March 2017. The study selection were of cohort and case control studies comparing the incidence of SBI in children with hyperpyrexia with children with fever of 41 °C or less, and children with a temperature higher than 40 °C, with children with fever of 40 °C or less. Two reviewers independently pooled studies for detailed review using a structured data-collection form. We calculated the odds ratio and 95% confidence intervals (CI) for SBI, assuming a random-effects model. A sub-group analysis was conducted. In our results, 11 studies met the inclusion criteria. Two studies showed that children with hyperpyrexia are at higher risk for SBI (OR 1.96 95% CI 1.3-1.97). An increased risk for SBI in children with high fever (OR 3.21 95% CI 1.67; 6.22). SBI in infants with temperature over 40 °C was higher compared to infants with lower degree of fever (OR 6.3 95% CI 4.44; 8.95). On older children, the risk for SBI was only slightly higher in children with fever above 40 °C. The limitation of the study is the small amount of studies and that the heterogeneity of the studies was very high. CONCLUSION: Young infants with temperature higher than 400 °C are at increased risk for SBI. Risk of SBI in older children with temperature > 400C is minimal. What is known: • An association between high fever and increased risk for SBI was reported in young infants. • Based on only two studies from the 1970s and 1980s, hyperpyrexia is associated with increased risk for SBI. What is new: • Infants under the age of 3 months with fever > 40 °C were found to have increased risk for SBI. • Risk of SBI in older children with temperature > 40 °C is minimal.

[REFERRAL LETTERS TO THE PEDIATRIC EMERGENCY UNIT - COMMUNITY PHYSICIANS' INTENTIONS VERSUS EMERGENCY DEPARTMENT PHYSICIANS' AND PARENTS' COMPREHENSION].

BACKGROUND: Referral notes are the main communication method between primary physicians and hospital physicians. Therefore, the written referral, has great importance in explaining the patient's condition or complaint, and the additional steps or actions that may be required for their complete evaluation and diagnosis. In this research we evaluated the main reasons for child referral to the hospital and, whether both the hospital physician and the child's parents understood those reasons correctly. METHODS: All the children referred to the ED during four weeks in July 2013 were included. For all cases with referral notes three questionnaires were presented: One to the hospital physician, one to the child's parents and a third, (via phone conversation), to the referring physician. RESULTS: At least two questionnaires were completed for each of the 261 cases. When primary physicians' original goals were compared with the hospital physicians' interpretation, only 33.7% of cases were fully matched, in 24.8% of cases there was a partial match and in 41.6% there was no match at all. When primary physicians' original goals were compared with the parents' understanding only 35.5% showed that they were fully matched, 30.3% showed partial match and 34.2% show no match at all. When evaluating primary physicians' intention with hospital physicians' interpretation, we found that during on-call hours the probability for a match was lower. Matching was higher for more experienced primary physicians. CONCLUSIONS: This research reinforces the impression of many hospital physicians of misunderstanding referral goals. Over 65% of referrals were partially or totally misunderstood. These findings are of importance when evaluating a sick child, since the community doctor usually has a greater acquaintance with the patient's condition gathered over the years or during an acute illness.

A double-blind, randomised, placebo-controlled trial of oral midazolam plus oral ketamine for sedation of children during laceration repair.

OBJECTIVES: To compare the efficacy of oral midazolam alone with a combination of oral midazolam and ketamine in children requiring laceration repair. DESIGN: A randomised, double-blind, placebo-controlled study. SETTING: Paediatric emergency department. PARTICIPANTS: Children 1-10 years of age with lacerations requiring sedation. INTERVENTIONS: Using a computer-generated sequence, children were randomly assigned in blocks of four to one of two groups: oral midazolam (0.5 mg/kg) plus oral placebo and oral midazolam (0.5 mg/kg) plus oral ketamine (5 mg/kg). The allocation sequence was kept by the pharmacy staff, and the investigators were blinded to randomisation until statistical analysis of the study was completed. MAIN OUTCOME MEASURES: Visual Analogue Scale (VAS) assessment by a parent and Sedation Score assessment by an investigator. RESULTS: 60 children were recruited; 29 were assigned for treatment with midazolam and 31 for the combination of midazolam and ketamine. There were no differences in basic demographics and wound characteristics between the groups. VAS assessment by a parent was 4.5±3.3 mm in the midazolam+ketamine group versus 4.4±2.7 mm in the midazolam alone group (mean difference 0.1, CI -1.9 to 1.71). Sedation Score during procedure was lower in the midazolam+ketamine group (mean difference 1.14, 95% CI 0.67 to 1.6). Intravenous sedation was required in two (6%) of the children in the midazolam+ketamine group, and in eight (27%) in the midazolam alone group. p=0.039. No clinically significant adverse effects were documented in either group. CONCLUSIONS: No difference was found in pain assessment during local anaesthetic injection between the group treated with midazolam and ketamine, and the group treated with midazolam alone. The combination of oral midazolam and ketamine led to deeper sedation than midazolam alone, with less children requiring intravenous sedation. CLINICAL TRIAL REGISTRATION: The trial was registered in www.clinicaltrials.gov as NCT01470157.

Neonatal hyperthyrotropinemia: population characteristics, diagnosis, management and outcome after cessation of therapy.

INTRODUCTION: Neonatal hyperthyrotropinaemia (HT), defined by elevated TSH and normal T(4), is either transient or persistent. The eventual outcome of neonatal HT is unpredictable and the management of HT patients is controversial. We assessed perinatal parameters and diagnostic measures that may distinguish between transient and persistent HT, compared with congenital hypothyroidism (CH). We also aimed to recommend optimal treatment in these forms of thyroid impairment. DESIGN AND PATIENTS: A multi-centre, retrospective study was conducted in six paediatric endocrinology units. Forty-three HT patients and 83 CH patients were included in the study. Measurements We evaluated differences in birth weight (BW), gestational age (GA), modes of diagnosis, screening and confirmatory T(4) and TSH levels, thyroid imaging results and optimal thyroxine doses between HT and CH and between the two forms of HT. RESULTS: Newborns with HT had lower BW and GA than those with CH. Transient (n = 18) and persistent HT (n = 25) patients were indistinguishable by most parameters, but those with persistent HT had a higher prevalence of abnormal thyroid imaging (69%vs 8%; P = 0.005). During treatment, 79% and 55% of transient and persistent HT patients respectively experienced elevated levels of free T(4.) Although most HT patients were reevaluated after 2.5 years, six transient HT patients stopped therapy and showed full recovery within the first year of life. CONCLUSIONS: We recommend obtaining thyroid imaging to distinguish between the two forms of HT. Adherence to recommended doses of thyroxine and probably early cessation of therapy in transient HT can prevent iatrogenic hyperthyroidism in these patients.

Efficacy of oral ketamine compared to midazolam for sedation of children undergoing laceration repair: A double-blind, randomized, controlled trial.

OBJECTIVE: To assess the efficacy of oral ketamine versus oral midazolam for sedation during laceration repair at a pediatric emergency department. METHODS: Children between 1 and 10 years requiring laceration repair were randomly assigned to 2 groups, treated either with oral midazolam (0.7 mg/kg) or with oral ketamine (5 mg/kg).Main outcomes measured were level of pain during local anesthesia, as assessed by the parent on a 10-cm visual analog scale (VAS) and the number of children who required intravenous sedation. Secondary outcomes included VAS by physician, pain assessment by child, maximal sedation depth assessed by the University of Michigan Sedation Scale, time until University of Michigan Sedation Scale 2 or more, general satisfaction of a parent and treating physician, length of procedure, total sedation time, and the incidence of any adverse events. RESULTS: Sixty-eight children were recruited of which 33 were girls. Average age was 5.08 ±â€Š2.14 years. Thirty-seven children were treated with ketamine and 31 with midazolam. Parent-assessed VAS in ketamine treated patients was 5.07 ±â€Š0.75 compared with 3.68 ±â€Š0.7 in midazolam treated patients [mean difference = 1.39 95% confidence interval (CI) -0.47 to 3.26]. Twelve (32%) of the children treated with ketamine required the addition of IV sedation compared to only 2 children (6%) of the children treated with midazolam [odds ratio (adjusted for age and gender) 6.1, 95% CI: 1.2 to 30.5]. The rest of the measured variables were similar between the groups, with no statistical significance. DISCUSSION: No difference in the level of pain was found between ketamine and midazolam treated patients. Compared with oral midazolam (0.7 mg/kg), oral ketamine (5 mg/kg) was associated with higher rates of sedation failure, and thus is not recommended as a single agent for oral sedation in children requiring laceration repair.