Current variability of clinical practice management of pediatric diabetic ketoacidosis in Illinois pediatric emergency departments.

OBJECTIVE: This study aimed to investigate the management of pediatric patients with diabetic ketoacidosis (DKA) presenting to emergency departments (EDs) participating in the Illinois Emergency Medical Services for Children (EMSC) Facility Recognition program. METHODS: In 2010, Illinois EMSC conducted a survey (including case scenarios) and medical record review regarding management of pediatric patients with DKA. Data were submitted by 116 EDs. RESULTS: Survey response rate was 94%. Only 34% of EDs had a documented DKA guideline/policy; 37% reported that they did not have hospital adult or pediatric endocrinology services. Case scenarios identified a high percentage of respondents given an intravenous (IV) isotonic sodium chloride solution of 10 to 20 mL/kg during the first hour. However 17% to 21% would use an alternative choice such as administering initial IV solution of 0.45 sodium chloride, initiating an insulin drip before fluids, or waiting for more laboratory results before giving fluids or insulin. A total of 532 medical record reviews were submitted. In 87% of records, patients received an initial IV isotonic sodium chloride solution within the first hour. In 74%, patients received IV insulin infusion/drip (0.1 U/kg/h) after the initial fluid bolus. Of the patients, 51% were transferred to another facility; 22% were admitted to an intensive care unit. CONCLUSIONS: Best ED practice management of pediatric DKA includes establishing a specific guideline/protocol and ensuring access to a pediatric endocrinologist. Both were identified as improvement areas in this project. Illinois EMSC has developed an educational module and provided direct feedback to all participating EDs, to improve their management of pediatric patients with DKA.

Fetal Heart Tracing Patterns and the Outcomes of Newborns With Meconium-Stained Amniotic Fluid.

Objective To determine if the presence of meconium-stained amniotic fluid (MSAF) by itself or in combination with abnormal fetal heart tracing (FHT) (category II and III) is associated with poor neonatal outcomes in full-term newborns. Design/methods This is a retrospective cohort study. Cases included singleton and full-term neonates with MSAF. Cases were compared to matched controls (clear amniotic fluids) for the outcomes. SPSS (IBM SPSS Statistics for Windows, Version 22.0, Armonk, NY, USA) and SAS 9.4 (SAS Institute Inc., Cary, NC, USA) were used for data analysis. Results From 5512 deliveries, 210 cases (MSAF group) and 210 matched controls were identified. Cases and controls were similar in most maternal characteristics. Abnormal FHT was present in 43.2% of cases compared to 17.6% of controls (p<0.001). Low Apgar scores (<7) at one and five minutes were more common in the MSAF group (p=0.03 and 0.007, respectively). The neonatal intensive care unit (NICU) admission rate was also higher in the MSAF group (p=0.002). However, the mean hospital stay was similar in both groups (p=0.44). Twenty-two (10.5%) cases required resuscitation at birth compared to six (2.9%) controls (p=0.003). After applying the logistic regression model to adjust for the FHT pattern and Apgar scores at one minute, the association of MSAF with resuscitation lost significance. The factors associated with resuscitation requirement at birth were Apgar score at one minute (adjusted odds ratios (aOR) 4.1; 95% CI 2.8-5.1, p<0.001) and abnormal FHTs (aOR, 0.03; 95% CI 0.004-0.257, p=0.001). Conclusions Neonates born with MSAF were more likely to have abnormal FHT and require resuscitation at birth. However, after adjusting for confounding factors, abnormal FHT and one-minute Apgar scores were the only variables predictive of resuscitation needs at birth.

Congenital and Perinatal Tuberculosis.

This review discusses the recent literature (2006-2020) about the epidemiology, clinical presentation, diagnosis, and management of infants with congenital or perinatal tuberculosis (TB). While the incidence of childhood TB is declining in the United States and worldwide, many case reports describe how clinical suspicion for neonatal TB is raised only if an ill-appearing neonate does not improve with broad-spectrum antibiotics. Furthermore, the delay in initiating appropriate anti-TB therapy often results in the need for significant cardiopulmonary support and/or an increase in mortality. This review summarizes important clinical indications in the maternal and newborn history, the evaluation of an infant with possible TB exposure, and step-by-step recommendations for the treatment and follow-up of infants with TB.

Ureasplasma and Its Role in Adverse Perinatal Outcomes: A Review.

Human Ureaplasma species are the most common microbes found in amniotic fluid and in the placenta after preterm birth, and have previously been correlated with chorioamnionitis, preterm labor, and bronchopulmonary dysplasia, among other adverse birth and neonatal outcomes. Although these correlations exist, there still remains little explanation as to whether Ureaplasma plays a pathogenic role in the development of neonatal disease. In addition, Ureaplasma species are not usually identified on routine culture as they require special culture methods because of their fastidious growth requirements. Treatment of Ureaplasma with macrolides has been shown to effectively eradicate the bacteria in pregnant women and infants. However, it is unclear whether this leads to improved neonatal morbidity and mortality, or whether these generally represent commensal organisms. This review will synthesize the current perspectives about the proposed mechanisms of pathogenicity of Ureaplasma bacteria, its links to poor neonatal outcomes, and the role of screening and treatment in current clinical practice.

Hyperferritinemia: A Diagnostic Marker for Disseminated Neonatal Herpes Simplex Virus Infection?

Although the prognosis of neonatal herpes simplex virus (HSV) infection has improved with intravenous acyclovir, the morbidity and mortality of disseminated disease remains high. Transaminitis and thrombocytopenia have been reported to be sensitive markers of neonatal HSV disease; however, early diagnosis remains a challenge due to a lack of specific clinical and laboratory indicators for this disease process. Ferritin, an acute phase reactant known for its use in diagnosing hemophagocytic lymphohistiocytosis, has recently been reported as extremely elevated in neonates with disseminated HSV due to its high inflammatory nature. We report three cases of neonates at a single institution with hyperferritinemia in the setting of disseminated HSV. Based on this case series, we discuss whether ferritin can be used as an early diagnostic marker in the setting of suspected neonatal HSV disease. [Pediatric Annals. 2021;50(6):e264-e267.].

Pediatric Hypertension and End-Stage Renal Disease.

Pediatric hypertension is not an uncommon diagnosis, affecting about 3.5% of all children. Most childhood hypertension is associated with obesity, but elevated blood pressure can also be the presenting symptom of a secondary disease process. Moreover, no matter the cause of hypertension, early identification can improve long-term health outcomes as childhood hypertension predicts hypertension in adulthood. In 2017, the American Academy of Pediatrics revised their 2004 guidelines regarding blood pressure screening for all children. Here, we discuss an illustrative case of a 16-year-old girl with hypertension and underlying nephrotic syndrome whose diagnosis was delayed due to inadequate blood pressure screening. Given the varying practices regarding the interpretation of blood pressure data in the outpatient setting, it is important for primary care providers to understand the updated guidelines and the indications for referral. [Pediatr Ann. 2020;49(6):e258-e261.].

Kikuchi-Fujimoto Disease in Children: An Important Diagnostic Consideration for Cervical Lymphadenitis.

Kikuchi-Fujimoto disease (KFD), or histiocytic necrotizing lymphadenitis, is a rare, benign, and self-limited disease that causes lymphadenopathy and has a characteristic histological appearance. The etiology of this disease is unknown, but a possible infectious trigger has been hypothesized. In the adult population this disease is more common in females; however, in the pediatric population it is more common in males. Descriptions in the pediatric literature are lacking, particularly in the United States. The authors report three cases of pediatric KFD that presented at the same institution in a 9-month time period. All three patients were male and of non-Asian descent who were diagnosed with KFD by histopathologic specimen after presenting with unilateral cervical lymphadenitis. Each patient had additional laboratory evidence of a possible bacterial infection at the time of diagnosis. These three cases highlight the importance of considering KFD early when a pediatric patient presents with unilateral cervical lymphadenitis. The authors discuss the epidemiology, etiology, clinical manifestations, diagnostic approaches, and treatment of KFD. [Pediatr Ann. 2019;48(10):e406-e411.].