Prevalence of invasive bacterial infection in febrile infants ≤90 days with a COVID-19 positive test: a systematic review and meta-analysis.

BACKGROUND: Febrile infants with an infection by influenza or enterovirus are at low risk of invasive bacterial infection (IBI). OBJECTIVE: To determine the prevalence of IBI among febrile infants ≤90 days old with a positive COVID-19 test. METHODS: MEDLINE, Embase, Cochrane Central Register databases, Web of Science, ClinicalTrials.gov and grey literature were searched for articles published from February 2020 to May 2023. INCLUSION CRITERIA: researches reporting on infants ≤90 days of age with fever and a positive test for SARS-CoV-2 (antigen test/PCR). Case reports with <3 patients, articles written in a language other than English, French or Spanish, editorials and other narrative studies were excluded. Preferred Reposting Items for Systematic Reviews and Meta-analysis guidelines were followed, and the National Institutes of Health Quality Assessment Tool was used to assess study quality. The main outcome was the prevalence of IBI (a pathogen bacterium identified in blood and/or cerebrospinal fluid (CSF)). Forest plots of prevalence estimates were constructed for each study. Heterogeneity was assessed and data were pooled by meta-analysis using a random effects model. A fixed continuity correction of 0.01 was added when a study had zero events. RESULTS: From the 1023 studies and 3 databases provided by the literature search, 33 were included in the meta-analysis, reporting 3943 febrile infants with a COVID-19 positive test and blood or CSF culture obtained. The pooled prevalence of IBI was 0.14% (95% CI, 0.02% to 0.27%). By age, the prevalence of IBI was 0.56% (95% CI, 0.0% to 1.27%) in those 0-21 days old, 0.53% (95% CI, 0.0% to 1.22%) in those 22-28 days old and 0.11% (95% CI, 0.0% to 0.24%) in those 29-60 days old. CONCLUSION: COVID-19-positive febrile infants ≤90 days old are at low risk of IBI, especially infants >28 days old, suggesting this subgroup of patients can be managed without blood tests. PROSPERO REGISTRATION NUMBER: CRD42022356507.

Predictive values of indirect ultrasound signs for low risk of acute appendicitis in paediatric patients without visualisation of the appendix on ultrasound.

BACKGROUND AND OBJECTIVES: The ability to rule appendicitis in or out using ultrasound is limited by studies where the appendix is not visualised. We determined whether the absence of indirect ultrasound signs can rule out appendicitis in children undergoing a radiology-performed ultrasound in which the appendix is not visualised METHODS: This was a single-centre retrospective observational study of patients aged 3-13 with a clinical suspicion of acute appendicitis evaluated in a Paediatric Emergency Department in Spain from 1 January 2013 to 31 December 2019. For those patients who had formal ultrasound, direct and indirect findings of ultrasound were abstracted from the ultrasound report. The surgical pathology report was established as the gold standard in patients who underwent an appendectomy. In those who did not, appendicitis was considered not to be present if there was no evidence in their charts that they had undergone an appendectomy or conservative therapy for appendicitis during the episode. The main outcome variable was the diagnosis of acute appendicitis. For patients undergoing ultrasound, the independent association of each indirect ultrasound sign with the diagnosis of appendicitis in patients without a visualised appendix was analysed using logistic regression. RESULTS: We included 1756 encounters from 1609 different episodes. Median age at the first visit of each episode was 10.1 years (IQR, 7.7-11.9) and 921 (57.2%) patients were men. There were 730 (41.6%) encounters with an Alvarado score ≤3, 695 (39.6%) with a score 4-6 and 331 (18.9%) with a score ≥7. Appendicitis was diagnosed in 293 (17.8%) episodes. Ultrasonography was performed in 1115 (61.6%) encounters, with a visualised appendix in 592 (53.1%).The ultrasound findings independently associated with appendicitis in patients without a visualised appendix were the presence of free intra-abdominal fluid in a small quantity (OR:5.0 (95% CI 1.7 to 14.6)) or in an abundant quantity (OR:30.9 (95% CI 3.8 to 252.7)) and inflammation of the peri-appendiceal fat (OR:7.2 (95% CI 1.4 to 38.0)). The absence of free fluid and inflammation of the peri-appendiceal fat ruled out acute appendicitis in patients with an Alvarado score <7 with a sensitivity of 84.6% (95% CI 57.8 to 95.7) and a negative predictive value of 99.4% (95% CI 97.8 to 99.8). CONCLUSIONS: Patients with an Alvarado score <7 and without a visualised appendix on ultrasound but who lack free fluid and inflammation of the peri-appendiceal fat are at very low risk of acute appendicitis.

Respective roles of non-pharmaceutical interventions in bronchiolitis outbreaks: an interrupted time-series analysis based on a multinational surveillance system.

BACKGROUND: Bronchiolitis is a major source of morbimortality among young children worldwide. Non-pharmaceutical interventions (NPIs) implemented to reduce the spread of severe acute respiratory syndrome coronavirus 2 may have had an important impact on bronchiolitis outbreaks, as well as major societal consequences. Discriminating between their respective impacts would help define optimal public health strategies against bronchiolitis. We aimed to assess the respective impact of each NPI on bronchiolitis outbreaks in 14 European countries. METHODS: We conducted a quasi-experimental interrupted time-series analysis based on a multicentre international study. All children diagnosed with bronchiolitis presenting to the paediatric emergency department of one of 27 centres from January 2018 to March 2021 were included. We assessed the association between each NPI and change in the bronchiolitis trend over time by seasonally adjusted multivariable quasi-Poisson regression modelling. RESULTS: In total, 42 916 children were included. We observed an overall cumulative 78% (95% CI -100- -54%; p<0.0001) reduction in bronchiolitis cases following NPI implementation. The decrease varied between countries from -97% (95% CI -100- -47%; p=0.0005) to -36% (95% CI -79-7%; p=0.105). Full lockdown (incidence rate ratio (IRR) 0.21 (95% CI 0.14-0.30); p<0.001), secondary school closure (IRR 0.33 (95% CI 0.20-0.52); p<0.0001), wearing a mask indoors (IRR 0.49 (95% CI 0.25-0.94); p=0.034) and teleworking (IRR 0.55 (95% CI 0.31-0.97); p=0.038) were independently associated with reducing bronchiolitis. CONCLUSIONS: Several NPIs were associated with a reduction of bronchiolitis outbreaks, including full lockdown, school closure, teleworking and facial masking. Some of these public health interventions may be considered to further reduce the global burden of bronchiolitis.

Teaching children with food allergy to recognize anaphylaxis: The caregivers' perspectives.

BACKGROUND: Anaphylaxis is rising in prevalence among children. The current recommendations on the effective transition of anaphylaxis management to adolescents and young adults suggest preparation for the transition may be considered at 11-13 years of age in accordance with the patient's developmental stage. However, there has been limited research conducted on the perspective of caregivers regarding the transition of anaphylaxis management to their children. This study aims to determine the age caregivers feel it is appropriate to begin to teach their child to recognize anaphylaxis and use their adrenaline auto-injectors (AAI). METHODS: Caregivers of pediatric allergy patients who have been diagnosed with IgE-mediated food allergy and have an AAI prescription were contacted by phone and invited to complete a questionnaire about when they feel it is appropriate to begin to teach their child to recognize anaphylaxis and use their AAI. RESULTS: Of the 123 responses to the questionnaire received, 44.7% indicated that 9-11 years was the appropriate time for teaching their children to self-inject an AAI. History of severe anaphylaxis (94.3%), child's ability to describe reasons to inject adrenaline (87.8%), and demonstrate AAI use (82.1%) were "very important" readiness factors identified. Almost half of caregivers were "not confident" (8.94%) or "somewhat confident" (40.65%) in training their child to use AAI. Caregivers with higher household incomes more frequently identified themselves as the party responsible for training their children to use AAI (p = .04). CONCLUSION: Caregivers in this sample expressed different perspectives than the current guidelines regarding the timing to initiate the transition of anaphylaxis management to their child. Caregivers expressed suboptimal confidence in teaching their children to use AAI. Clinicians should be aware of the factors that may indicate caregivers' desire to initiate an earlier transition of anaphylaxis management to their child and ensure access to appropriate training, education and support is available.

Comparison of severity scales for acute bronchiolitis in real clinical practice.

Several clinical scales have been developed to assess the severity of bronchiolitis as well as the probability of needing in-hospital care. A recent systematic review of 32 validated clinical scores for bronchiolitis concluded that 6 of them (Wood-Downes, M-WCAS, Respiratory Severity Score, Respiratory Clinical Score, Respiratory Score and Bronchiolitis risk of admission score) were the best ones regarding reliability, sensitivity, validity, and usability. However, to the best of our knowledge, no study has compared all of them in a clinical scenario. Also, after this review, three more scales were published: BROSJOD, Tal modified, and one score developed by PERN. Our main aim was to compare the ability of different clinical scales for bronchiolitis to predict any relevant outcome. A prospective observational study was conducted that included patients of up to 12 months old attended to, due to bronchiolitis, in the paediatric Emergency Department of a secondary university hospital from October 2019 to January 2022. For each patient, the attending clinician filled in a form with the items of the scales, decomposed, in order to prevent the clinician from knowing the score of each scale. Then, the patient was managed according to the protocol of our Emergency Department. A phone call was made to each patient in order to check whether the patient ended up being admitted in the next 48 h. In the case of those that were impossible to contact by phone, the clinical history was reviewed. For the purpose of the study, any of the following were considered to be a relevant outcome: admission to ward and need for supplementary oxygen, non-invasive ventilation (NIV) or intravenous fluids, and admission to the paediatric intensive care unit (PICU) within the next 48 h or death. For the aim of the study, the area under the curve (AUC) and the odds ratio (OR) for a relevant outcome were calculated in each scale. Also, the best cut-off point was estimated according to the Youden index, and its sensitivity (Sn) and specificity (Sp) for a relevant outcome were calculated. We included 265 patients (52.1% male) with a median age of 5.3 months (P25-P75 2.6-7.4). Among them, 46 (17.4%) had some kind of relevant outcome. AUC for prediction of a relevant outcome ranged from 0.705 (Respiratory Score) to 0.786 (BRAS), although no scale performed significantly better than others. A score ≤ 2 in the PERN scale showed a sensitivity of 91.3% (CI95% 79.7-96.6) for a relevant outcome, with only 4 misdiagnosed patients (only 2 of them needed NIV).   Conclusions: There were no differences in the performance of the nine scales to predict relevant outcomes in patients with bronchiolitis. However, the PERN scale might be more useful to select patients at low risk of a severe outcome. What is Known: • Several clinical scales are used to assess the severity of bronchiolitis. Nevertheless, none of them seems to be better than others. What is New: • This is the first study comparing different bronchiolitis scales in a real clinical scenario. None of the nine scales compared performed better than the other. However, the PERN scale might be more useful to select patients at low risk of relevant outcomes.

Setting priorities for an agenda within the Spanish pediatric emergency medicine research network.

The research network of the Spanish Pediatric Emergency Society (RISeuP-SPERG Network) needs to establish its research agenda relevant to pediatric emergency medicine (PEM) to guide the development of future projects, as other networks have done before. The aim of our study was to identify priority areas in PEM for a collaborative network of pediatric emergency research in Spain. A multicenter study was developed including pediatric emergency physicians from 54 Spanish emergency departments, endorsed by the RISeuP-SPERG Network. Initially, a group of seven PEM experts was selected among the members of the RISeuP-SPERG. In the first phase, these experts elaborated a list of research topics. Then, using a Delphi method, we sent a questionnaire with that list to all RISeuP-SPERG members, to rank each item using a 7-point Likert scale. Finally, the seven PEM experts, using a modified Hanlon Process of Prioritization, weighted prevalence (A), seriousness of the condition (B), and feasibility of conducting research projects (C) on that condition to prioritize the selected items. Once the list of topics was chosen, the seven experts selected a list of research questions for each of the selected items. The Delphi questionnaire was answered by 74/122 (60.7%) members of RISeuP-SPERG. We established a list of 38 research priorities related to quality improvement (11), infectious diseases (8), psychiatric/social emergencies (5), sedoanalgesia (3), critical care (2), respiratory emergencies (2), trauma (2), neurologic emergencies (1), and miscellanea (4).   Conclusion: The RISeuP-SPERG prioritization process identified high-priority PEM topics specific to multicenter research that may help guide further collaborative research efforts within the RISeuP-SPERG network to improve PEM care in Spain. What is Known: • Some pediatric emergency medicine networks have established their priorities for research. What is New: • After a structured process, we have set the research agenda for pediatric emergency medicine in Spain. By identifying high-priority pediatric emergency medicine research topics specific to multicenter research, we may guide further collaborative research efforts within our network.

Multicentre Delphi study of physicians resulted in quality indicators for young infants with fever without source in emergency departments.

AIM: Managing febrile infants has evolved without a generally accepted standard of care. We aimed to design quality indicators for managing infants ≤90 days old presenting to emergency departments (EDs) with fever without source. METHODS: This multicentre Delphi study was carried out by the Febrile Infant Study Group of the Spanish Paediatric Emergency Research Network, from March 2021 to November 2021, and included paediatric emergency physicians from 24 Spanish EDs. A list of care standards was produced, following an extensive literature review and the involvement of all parties. Indicators were essential if they were voted by four panelists and also received a score of ≥4 from at least 95% of the 24 investigators. RESULTS: We established 20 indicators, including one related to having a protocol, two to triage, nine to diagnostic processes, six to treatment and two to disposition. The following indicators were considered essential: having an ED management protocol, performing urinalysis on every infant, obtaining a blood culture from every infant and administering antibiotics in the ED to any febrile infant who did not appear well. CONCLUSION: The Delphi method resulted in a comprehensive list of quality indicators for managing febrile young infants in Spanish EDs.

Presentations of children to emergency departments across Europe and the COVID-19 pandemic: A multinational observational study.

BACKGROUND: During the initial phase of the Coronavirus Disease 2019 (COVID-19) pandemic, reduced numbers of acutely ill or injured children presented to emergency departments (EDs). Concerns were raised about the potential for delayed and more severe presentations and an increase in diagnoses such as diabetic ketoacidosis and mental health issues. This multinational observational study aimed to study the number of children presenting to EDs across Europe during the early COVID-19 pandemic and factors influencing this and to investigate changes in severity of illness and diagnoses. METHODS AND FINDINGS: Routine health data were extracted retrospectively from electronic patient records of children aged 18 years and under, presenting to 38 EDs in 16 European countries for the period January 2018 to May 2020, using predefined and standardized data domains. Observed and predicted numbers of ED attendances were calculated for the period February 2020 to May 2020. Poisson models and incidence rate ratios (IRRs), using predicted counts for each site as offset to adjust for case-mix differences, were used to compare age groups, diagnoses, and outcomes. Reductions in pediatric ED attendances, hospital admissions, and high triage urgencies were seen in all participating sites. ED attendances were relatively higher in countries with lower SARS-CoV-2 prevalence (IRR 2.26, 95% CI 1.90 to 2.70, p < 0.001) and in children aged <12 months (12 to <24 months IRR 0.86, 95% CI 0.84 to 0.89; 2 to <5 years IRR 0.80, 95% CI 0.78 to 0.82; 5 to <12 years IRR 0.68, 95% CI 0.67 to 0.70; 12 to 18 years IRR 0.72, 95% CI 0.70 to 0.74; versus age <12 months as reference group, p < 0.001). The lowering of pediatric intensive care admissions was not as great as that of general admissions (IRR 1.30, 95% CI 1.16 to 1.45, p < 0.001). Lower triage urgencies were reduced more than higher triage urgencies (urgent triage IRR 1.10, 95% CI 1.08 to 1.12; emergent and very urgent triage IRR 1.53, 95% CI 1.49 to 1.57; versus nonurgent triage category, p < 0.001). Reductions were highest and sustained throughout the study period for children with communicable infectious diseases. The main limitation was the retrospective nature of the study, using routine clinical data from a wide range of European hospitals and health systems. CONCLUSIONS: Reductions in ED attendances were seen across Europe during the first COVID-19 lockdown period. More severely ill children continued to attend hospital more frequently compared to those with minor injuries and illnesses, although absolute numbers fell. TRIAL REGISTRATION: ISRCTN91495258 https://www.isrctn.com/ISRCTN91495258.

Value of Temperature for Predicting Invasive Bacterial Infection in Febrile Infants: A Spanish Pediatric Emergency Research Group (RISeuP-SPERG) Study.

OBJECTIVE: This study aimed to analyze the prevalence of invasive bacterial infection (IBI) among infants younger than 90 days with fever without source according to the degree of fever. METHODS: We performed a secondary analysis of a multicenter study with 19 participating Spanish pediatric emergency departments that included 3401 febrile infants 90 days or younger. RESULTS: Prevalence of IBI was 3.2% (5.3% among infants <29 days old, 2.5% among those 29-60 days old, and 2.2% among those 61-90 days old). Prevalence of bacteremia increased with the degree of fever, meanwhile the prevalence of bacterial meningitis did not. No cutoff point was useful for ruling out an IBI safely. Overall, 46.7% of the IBIs were diagnosed in patients with temperature <38.6° (sensitivity, 53.3%; negative likelihood ratio, 0.81). CONCLUSIONS: Performing blood tests should be recommended in infants 90 days or younger with temperature ≥38°C without source regardless of the degree of fever.

A positive nitrite test was an independent risk factor for invasive bacterial infections in infants under 90 days of age with fever without source.

AIM: This study analysed the association between a positive nitrite dipstick test and an invasive bacterial infection (IBI) in infants younger than 90 days of age with fever without source (FWS). METHODS: We performed a secondary analysis of data from a prospective multicentre study of infants up to 90 days of age with FWS undergoing care in 19 paediatric EDs between October 2011 and September 2013. Invasive bacterial infection was defined as a positive blood or cerebrospinal fluid culture. RESULTS: The dipstick urinalysis was positive for nitrite or leucocyte esterase in 766 (22.5%) of the 3401 infants we studied, and 270 (35.2%) had a dipstick test that was just positive for nitrite. Overall, 107 were diagnosed with an IBI (3.1%). The IBI prevalence was 2.2% among patients with a normal urine dipstick, 4.4% if they had positive leucocyte esterase test results, 8.3% where the nitrite test was positive and 10.6% when both tests were positive. After multivariate analysis, a positive nitrite test remained an independent risk factor for IBI (odds ratio 2.7, 95% confidence interval 1.4-4.9). CONCLUSION: In infants under 90 days of age with FWS, a positive nitrite urine dipstick test was an independent risk factor for IBI.

Bacterial meningitis in febrile young infants acutely assessed for presumed urinary tract infection: a systematic review.

Urinary tract infections, the most common severe bacterial infections in young infants, may be associated with co-existing meningitis. There is no consensus on when to perform a lumbar puncture in these infants. Our aim was to quantify the frequency of co-existing bacterial meningitis in febrile young infants acutely assessed for presumed urinary tract infections. We systematically reviewed PubMed, EMBASE, and the Cochrane Library for studies including infants ≤ 3 months with suspected/confirmed urinary tract infections, who underwent a lumbar puncture. Two investigators independently reviewed articles for inclusion and extracted relevant data. Our outcomes were culture-confirmed meningitis and identification of low-/high-risk criteria of meningitis. Overall 20/2079 studies, including 4191 infants, met inclusion criteria. A total of 11 infants had bacterial meningitis (frequency between 0 and 2.1% across studies) and were mostly neonates. Of 253 infants meeting the low-risk criteria (well-appearing, age > 21 days, procalcitonin ≤ 0.5 ng/ml, and C reactive protein ≤ 20 mg/L) none developed meningitis, but only 15 underwent lumbar puncture.Conclusion: Co-existing bacterial meningitis in febrile young infants with urinary tract infection is rare. In those meeting low-risk criteria, a lumbar puncture may not be indicated. A case by case assessment should be made in infants not meeting low-risk criteria.Trial registration: CRD42018105339 What is known: • When caring for febrile infants ≤ 3 months with urinary tract infections, clinicians may have uncertainty on whether to perform a lumbar puncture (LP) for possible co-existing meningitis What is new: • An up-to-date systematic review of 20 studies found the frequency of co-existing meningitis in this population to be between 0 and 2.1% • Despite limited data, an LP may not be indicated in infants meeting low-risk criteria (being well-appearing, age > 21 days, procalcitonin ≤ 0.5 ng/ml, C reactive protein ≤ 20 mg/L). Ill-appearance and neonatal age appear to be significant risk factors of co-existing meningitis.

A higher level of ketonaemia does not predict oral rehydration failure in vomiting paediatric patients and routine measurement is unnecessary.

AIM: This study determined if blood levels of beta-hydroxybutyrate were associated with the rate of failure in oral rehydration in paediatric patients with vomiting. METHODS: This was a prospective observational study that was carried out from December 1, 2015 to November 30, 2016 in the Rio Hortega University Hospital, Valladolid, Spain. The study cohort were patients up to 14 years old who attended the emergency department with three or more vomiting episodes in the last four hours and glycaemia higher than 45 mg/dL. Blood was measured for beta-hydroxybutyrate levels prior to the administration of oral rehydration solution for 90 minutes. Two or more vomiting episodes during this period were considered failed oral rehydration. RESULTS: We analysed 248 patients, with a median age of four years and 7.5 months and 233 (94%) of the parents took part. The median number of vomiting episodes in the previous four hours was five and oral rehydration was successful in 183 (78.5%) patients. The multivariate analysis showed that the initial beta-hydroxybutyrate blood level was not associated with the failure of oral rehydration. CONCLUSION: Blood levels of beta-hydroxybutyrate had no predictive value for oral rehydration failure in young patients with vomiting and this routine measurement is unnecessary.

Importance of Urine Dipstick in Evaluation of Young Febrile Infants With Positive Urine Culture: A Spanish Pediatric Emergency Research Group Study.

BACKGROUND AND OBJECTIVES: Guidelines from the American Academy of Pediatrics define urinary tract infection (UTI) as the growth of greater than 50,000 ufc/mL of a single bacterium in a urine culture with a positive urine dipstick or with a urinalysis associated. Our objective was to evaluate the adequacy of this cutoff point for the diagnosis of UTI in young febrile infants. METHODS: Subanalysis of a prospective multicenter study developed in RISeuP-SPERG Network between October 11 and September 13. To carry out the study, it was performed a comparison of analytical and microbiological characteristics of patients younger than 90 days with fever without focus, taking into account the results of urine dipstick and urine culture. RESULTS: Of a total of 3333 infants younger than 90 days with fever without focus which were included in the study, 538 were classified as UTI in accordance with American Academy of Pediatrics' guidelines. These patients were similar to those who had a positive urine dipstick and a urine culture yielding of 10,000 to 50,000 ufc/mL, and they were different from those who had a normal urine dipstick and a urine culture >50,000 ufc/mL, being focused on the isolated bacteria and blood biomarkers values. Forty-five invasive bacterial infections were diagnosed (5.9% of the 756 with a urine culture >10,000 ufc/mL). Half of the infants with a normal urine dipstick diagnosed with invasive bacterial infections were younger than 15 days. CONCLUSIONS: It might be inadequate to use a threshold of 50,000 cfu/mL to consider a urine culture as positive in young febrile infants given the fact that it would misdiagnose several UTIs.

Using a urine dipstick to identify a positive urine culture in young febrile infants is as effective as in older patients.

AIM: There is limited evidence about the diagnostic value of urine dipsticks in young febrile infants. The aim of this study was to determine whether urine dipsticks would identify positive urine cultures in febrile infants of less than 90 days of age. METHODS: This study was a subanalysis of a prospective multicentre study developed in 19 Spanish paediatric emergency departments belonging to the Spanish Paediatric Emergency Research Network. It focused on febrile infants of less than 90 days of age admitted between October 2011 and September 2013. A positive urine culture was defined as the growth of ≥ 50,000 cfu/mL of a single pathogen collected by a sterile method. RESULTS: We included 3401 patients, and 176 (12.8%) female patients and 473 (23.3%) males had a positive urine culture. The leucocyte esterase test showed a mean sensitivity of 82.1% and a mean specificity of 92.4%, with a greater mean negative predictive value for females than males (97.8 versus 94.1%) and a greater mean positive predictive value for males than females (79.4% versus 58%). CONCLUSION: The leucocyte esterase test showed the same accuracy in young febrile infants as previously reported findings for older children. It predicted positive urine cultures and also revealed important gender differences.

Evaluation of hemoculture extraction technique in an emergency department: nursing staff self-perception and reality.

INTRODUCTION: Between 2009 and 2010, the rate of contamination of hemocultures drawn in our emergency department was much higher than the quality standards recommended, so we decided to check the extraction procedure of the samples to detect possible faults. We also wanted to study the perception of the nursing staff about the quality of their practice. METHODS: This is a prospective study developed in 2 phases. In the first phase, medical staff observed the extraction of hemocultures. In the second phase, an anonymous test was sent to the nursing staff of the emergency department. RESULTS: We observed major faults in the extraction procedure. Of the 10 items checked, only 2 had a compliance rate greater than 50%. There were significant differences between test answers and data recovered from observation in 7 items. DISCUSSION: Several technical deficiencies were observed in the procedure for extraction of blood cultures. This fact partly explains the high rate of contamination found in our emergency department.

Conundrums in the Management of Febrile Infants under Three Months of Age and Future Research.

Febrile infants under three months of age pose a diagnostic challenge to clinicians. Unlike in older children, the rates of invasive bacterial infections (IBIs), such as bacteraemia or meningitis, are high. This greater risk of IBI combined with the practical challenges of assessing young infants results in a cautious approach with many febrile infants receiving parenteral antibiotics "just in case". However, there is a range of validated tailored care guidelines that support targeted investigation and management of febrile infants, with a cohort identified as lower risk suitable for fewer invasive procedures and observation without parenteral antibiotics. This manuscript outlines five common conundrums related to the safe application of tailored-care guidelines for the assessment and management of febrile infants under three months of age. It also explores future research which aims to further refine the management of febrile infants.

Performance of Febrile Infant Algorithms by Duration of Fever.

OBJECTIVES: To analyze the performance of commonly used blood tests in febrile infants ≤90 days of age to identify patients at low risk for invasive bacterial infection (bacterial pathogen in blood or cerebrospinal fluid) by duration of fever. METHODS: We conducted a secondary analysis of a prospective single-center registry that includes all consecutive infants ≤90 days of age with fever without a source evaluated at 1 pediatric emergency department between 2008 and 2021. We defined 3 groups based on caregiver-reported hours of fever (<2, 2-12, and ≥12) and analyzed the performance of the biomarkers and Pediatric Emergency Care Applied Research Network, American Academy of Pediatrics, and Step-by-Step clinical decision rules. RESULTS: We included 2411 infants; 76 (3.0%) were diagnosed with an invasive bacterial infection. The median duration of fever was 4 (interquartile range, 2-12) hours, with 633 (26.3%) patients with fever of <2 hours. The area under the curve was significantly lower in patients with <2 hours for absolute neutrophil count (0.562 vs 0.609 and 0.728) and C-reactive protein (0.568 vs 0.760 and 0.812), but not for procalcitonin (0.749 vs 0.780 and 0.773). Among well-appearing infants older than 21 days and negative urine dipstick with <2 hours of fever, procalcitonin ≥0.14 ng/mL showed a better sensitivity (100% with specificity 53.8%) than that of the combination of biomarkers of Step-by-Step (50.0% and 82.2%), and of the American Academy of Pediatrics and Pediatric Emergency Care Applied Research Network rules (83.3% and 58.3%), respectively. CONCLUSIONS: The performance of blood biomarkers, except for procalcitonin, in febrile young infants is lower in fever of very short duration, decreasing the accuracy of the clinical decision rules.

Dietary Advancement Therapy Using Milk and Egg Ladders Among Children With a History of Anaphylaxis.

BACKGROUND: Anaphylaxis has been increasing in recent years, with common triggers in infants being milk and eggs. Currently, the mainstay of treatment for milk and/or egg allergy is strict avoidance. Recently, new therapies have emerged including stepwise introduction of allergens via a ladder approach. The suitability of infants for the ladders is debated. OBJECTIVE: This study aims to focus on the use of food ladders in children with anaphylaxis to egg or milk. METHODS: Retrospective review of pediatric patients diagnosed with immunoglobulin E-mediated milk and/or egg allergy between 2011 and 2021. Inclusion and exclusion criteria were applied. Anaphylaxis was defined as per the World Allergy Organization-amended criteria 2020. Data analysis utilized SPSS Version 28. RESULTS: We reviewed 1,552 patient charts, and excluded 1,094, leaving a total sample size of 458. Seventy infants had anaphylaxis at diagnosis (milk n = 36; egg n = 34). A range of 77.8% to 85.2% of infants with anaphylaxis successfully completed the ladder, 88.9% to 92.9% without anaphylaxis were successful. Children who successfully completed the ladder did so at similar rates. A range of 20.6% to 50% children presenting with anaphylaxis at diagnosis experienced allergic symptoms during treatment, compared with 17.3% to 40.7% without anaphylaxis. Reactions were mild, mostly cutaneous and not requiring medical attention. Patients experiencing allergic symptoms while on the ladder were less likely to successfully complete treatment. CONCLUSIONS: Milk and egg ladders are a safe and effective way of inducing tolerance in infants, including those with a history of anaphylaxis at diagnosis. There are no obvious predictors for who will experience allergic reactions while on the ladder; however, these children are less likely to complete the ladder, so parents should be educated in management of mild allergic reactions at home.