Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old.

This guideline addresses the evaluation and management of well-appearing, term infants, 8 to 60 days of age, with fever ≥38.0°C. Exclusions are noted. After a commissioned evidence-based review by the Agency for Healthcare Research and Quality, an additional extensive and ongoing review of the literature, and supplemental data from published, peer-reviewed studies provided by active investigators, 21 key action statements were derived. For each key action statement, the quality of evidence and benefit-harm relationship were assessed and graded to determine the strength of recommendations. When appropriate, parents' values and preferences should be incorporated as part of shared decision-making. For diagnostic testing, the committee has attempted to develop numbers needed to test, and for antimicrobial administration, the committee provided numbers needed to treat. Three algorithms summarize the recommendations for infants 8 to 21 days of age, 22 to 28 days of age, and 29 to 60 days of age. The recommendations in this guideline do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

Chlamydia and Gonorrhea Prevalence and Treatment in Detained Youths: Strategies for Improvement.

PURPOSE: Adolescents and young adults have the highest prevalence of sexually transmitted infections (STIs), accounting for more than 50% of all reported infections. An especially high-risk group includes adolescents in juvenile or correctional facilities. METHODS: This retrospective analysis was conducted at the only juvenile detention facility in the State of Hawai'i from 2014 to 2017. Adolescents aged 12-17 years were offered STI screening and/or presumptive treatment at the time of medical evaluation. RESULTS: Of 2,208 adolescents offered voluntary testing, 461 males and 372 females agreed to be tested for Chlamydia trachomatis and Neisseria Gonorrhea. Acceptance did not vary by age; females chose testing more often than males (67.4% vs. 27.8%; p < .0001). Females were also more likely to accept presumptive treatment (22.8% vs. 8.8%; p < .0001). In tested youth, STIs were prevalent in 24% of females and 10% of males. Before leaving the detention facility, only half the STIs in females and only 39% of male STI infections had been treated. CONCLUSIONS: There was a high prevalence of STIs in both males and females admitted to this juvenile detention facility, with fewer than half the documented infections being treated before discharge. This indicates a need for universal and timely testing to allow the treatment of those infected. If for whatever reason rapid testing cannot be obtained, presumptive treatment offers a pragmatic approach to treatment and infection control.

The Child Witness in the Courtroom.

Beginning in the 1980s, children have increasingly served as witnesses in the criminal, civil, and family courts; currently, >100 000 children appear in court each year. This statement updates the 1992 American Academy of Pediatrics (AAP) policy statement "The Child as a Witness" and the subsequent 1999 "The Child in Court: A Subject Review." It also builds on existing AAP policy on adverse life events affecting children and resources developed to understand and address childhood trauma. The purpose of this policy statement is to provide background information on some of the legal issues involving children testifying in court, including the accuracy and psychological impact of child testimony; to provide suggestions for how pediatricians can support patients who will testify in court; and to make recommendations for policy improvements to minimize the adverse psychological consequences for child witnesses. These recommendations are, for the most part, based on studies on the psychological and physiologic consequences of children witnessing and experiencing violence, as well as appearing in court, that have emerged since the previous AAP publications on the subject. The goal is to reduce the secondary traumatization of and long-term consequences for children providing testimony about violence they have experienced or witnessed. This statement primarily addresses children appearing in court as victims of physical or sexual abuse or as witnesses of violent acts; most of the scientific literature addresses these specific situations. It may apply, in certain situations, to children required to provide testimony in custody disputes, child welfare proceedings, or immigration court. It does not address children appearing in court as offenders or as part of juvenile justice proceedings.

Management and Outcomes of Previously Healthy, Full-Term, Febrile Infants Ages 7 to 90 Days.

BACKGROUND: There is considerable variation in the approach to infants presenting to the emergency department and outpatient clinics with fever without a source. We set out to describe the current clinical practice regarding culture acquisition on febrile young infants and review the outcomes of infants with and without cultures obtained. METHODS: This study analyzed Kaiser Permanente Northern California's electronic medical record to identify all febrile, full term, previously healthy infants born between July 1, 2010, and June 30, 2013, presenting for care between 7 and 90 days of age. RESULTS: During this 3-year study, 96 156 full-term infants were born at Kaiser Permanente Northern California. A total of 1380 infants presented for care with a fever with an incidence rate of 14.4 (95% confidence interval: 13.6-15.1) per 1000 full term births. Fifty-nine percent of infants 7 to 28 days old had a full evaluation compared with 25% of infants 29 to 60 days old and 5% of infants 61 to 90 days old. Older infants with lower febrile temperatures presenting to an office setting were less likely to have a culture. In the 30 days after fevers, 1% of infants returned with a urinary tract infection. No infants returned with bacteremia or meningitis. CONCLUSIONS: Fever in a medical setting occurred in 1.4% of infants in this large cohort. Forty-one percent of febrile infants did not have any cultures including 24% less than 28 days. One percent returned in the following month with a urinary tract infection. There was no delayed identification of bacteremia or meningitis.

The changing epidemiology of serious bacterial infections in young infants.

BACKGROUND: Management of febrile young infants suspected of having serious bacterial infections has been a challenge for decades. The impact of changes in prenatal screening for Group B Streptococcus and of infant immunizations has received little attention in population-based studies. METHODS: This study analyzed all cultures of blood, urine and cerebrospinal fluid obtained from full-term infants 1 week to 3 months of age, who presented for care at Kaiser Permanente Northern California during a 7-year period utilizing electronic medical records. RESULTS: A total of 224,553 full-term infants were born during the study period. Of 5396 blood cultures, 129 bacteremic infants were identified (2%). Of 4599 urine cultures, 823 episodes of urinary tract infection (UTI) were documented in 778 infants (17%). Of 1796 CSF cultures, 16 infants had bacterial meningitis (0.9%). The incidence rate of serious bacterial infections (bacteremia, UTI and meningitis) and febrile serious bacterial infections was 3.75 and 3.1/1000 full-term births, respectively. Escherichia coli was the leading cause of bacteremia (78), UTI (719) and bacterial meningitis (7). There were 23 infants with Group B Streptococcus bacteremia including 6 cases of meningitis and no cases of Listeria infection. Nine percentage of infants had multiple sites of infection; 10% of UTIs were associated with bacteremia and 52% of bacteremia was associated with UTI. CONCLUSIONS: Compared with earlier studies, UTIs now are found significantly more often than bacteremia and meningitis with 92% of occult infections associated with UTIs. These data emphasize the importance of an urinalysis in febrile infants.

Office-based treatment and outcomes for febrile infants with clinically diagnosed bronchiolitis.

OBJECTIVES: The goals were to describe the (1) frequency of sepsis evaluation and empiric antibiotic treatment, (2) clinical predictors of management, and (3) serious bacterial illness frequency for febrile infants with clinically diagnosed bronchiolitis seen in office settings. METHODS: The Pediatric Research in Office Settings network conducted a prospective cohort study of 3066 febrile infants (<3 months of age with temperatures >or=38 degrees C) in 219 practices in 44 states. We compared the frequency of sepsis evaluation, parenteral antibiotic treatment, and serious bacterial illness in infants with and without clinically diagnosed bronchiolitis. We identified predictors of sepsis evaluation and parenteral antibiotic treatment in infants with bronchiolitis by using logistic regression models. RESULTS: Practitioners were less likely to perform a complete sepsis evaluation, urine testing, and cerebrospinal fluid culture and to administer parenteral antibiotic treatment for infants with bronchiolitis, compared with those without bronchiolitis. Significant predictors of sepsis evaluation in infants with bronchiolitis included younger age, higher maximal temperature, and respiratory syncytial virus testing. Predictors of parenteral antibiotic use included initial ill appearance, age of <30 days, higher maximal temperature, and general signs of infant distress. Among infants with bronchiolitis (N = 218), none had serious bacterial illness and those with respiratory distress signs were less likely to receive parenteral antibiotic treatment. Diagnoses among 2848 febrile infants without bronchiolitis included bacterial meningitis (n = 14), bacteremia (n = 49), and urinary tract infection (n = 167). CONCLUSIONS: In office settings, serious bacterial illness in young febrile infants with clinically diagnosed bronchiolitis is uncommon. Limited testing for bacterial infections seems to be an appropriate management strategy.

Forgone health care among U.S. adolescents: associations between risk characteristics and confidentiality concern.

PURPOSE: To examine risk characteristics associated with citing confidentiality concern as a reason for forgone health care, among a sample of U.S. adolescents who reported having forgone health care they believed was necessary in the past year. METHODS: The study used data from Wave I home interviews of the National Longitudinal Study of Adolescent Health. The generalized estimating equations method was used to account for the clustered nature of the data. RESULTS: Prevalence of several risk characteristics was significantly higher among boys and girls who reported confidentiality concern, as compared with those who did not report this concern. Regression analyses for boys (n = 1123), which adjusted for age, race/ethnicity, parental education and insurance type showed that high depressive symptoms, suicidal ideation, and suicide attempt were each associated with increased odds of reporting confidentiality concern as a reason for forgone health care. In multivariate analyses for girls (n = 1315), having ever had sexual intercourse, birth control nonuse at last sex, prior sexually transmitted infection, past-year alcohol use, high and moderate depressive symptoms, suicidal ideation, suicide attempt, and unsatisfactory parental communication were each associated with increased odds of citing confidentiality concern as a reason for forgone care. CONCLUSION: The population of U.S. adolescents who forgo health care due to confidentiality concern is particularly vulnerable and in need of health care services. Adolescents who report health risk behaviors, psychological distress and/or unsatisfactory communication with parents have an increased likelihood of citing confidentiality concern as a reason for forgone health care, as compared with adolescents who do not report these factors. Findings of this study suggest that if restrictions to confidentiality are increased, health care use may decrease among adolescents at high risk of adverse health outcomes.

Does clinical presentation explain practice variability in the treatment of febrile infants?

BACKGROUND: Previous studies documented considerable variability in the treatment of febrile infants, despite the existence of practice guidelines for this condition. None of those studies documented the extent to which this variability is accounted for by differences in clinical severity. OBJECTIVE: To quantify the individual effects of the patient's clinical presentation, demographic, provider, and practice characteristics, and regional variables on practice variability in the evaluation and treatment of febrile infants. METHODS: With data collected through the Pediatric Research in Office Settings network, we analyzed data on the treatment of 2712 febrile infants examined by 484 pediatricians located in 194 practices. We analyzed hospitalization, lumbar puncture, urinalysis and/or urine culture, blood work, and initial antibiotic administration. We obtained a summary score for evaluation and treatment intensity (ranging from no tests or treatments to comprehensive testing, hospitalization, and antibiotic therapy) by performing principal-components analysis with these 5 variables. This summary score was regressed with respect to patients' clinical presentation, demographic and practice/practitioner features, and geographic region. Provider fixed effects were also included in the model. RESULTS: Although the overall model explained 46.5% of the variance, the clinical characteristics of the patient alone explained 29.7% of the overall variance. Practice site fixed effects explained nearly 15% of the overall variance. Provider and practitioner characteristics and geographic region had minimal explanatory power. CONCLUSIONS: Our results show that measures of the patient's clinical presentation account for nearly one third of the variability that our model explains. This suggests that differences in clinical presentation and severity of illness underlie much of the observed practice variability among pediatricians evaluating and treating febrile infants. These findings demonstrate that the management of this common and potentially serious condition depends more on the clinical presentation of the patient than on the characteristics of the provider/practice and the residential region.

Examination of the treatment and follow-up care for adolescents who test positive for Chlamydia trachomatis infection.

OBJECTIVE: To document the comprehensive management of Chlamydia trachomatis infections in sexually active 14- to 19-year-old adolescents. DESIGN: A chart review of both paper and electronic records to examine documentation of treatment and follow-up of adolescents who tested positive for C. trachomatis infection. SETTING: Five pediatric clinics of a large northern California health maintenance organization. PARTICIPANTS: Consecutive sample of 122 adolescent girls and boys aged 14 to 19 years who tested positive for C. trachomatis infection beginning May 1, 2001, for 20-month (4 sites) or 4-month (1 site) study periods. MAIN OUTCOME MEASURES: Antibiotic treatment, counseling regarding safer sex, management of patients' partners, screening for other sexually transmitted infections, and retesting for C. trachomatis infection. RESULTS: The median age of participants was 16.9 years. All but 4 teenagers (97%) were treated with appropriate antibiotics. During follow-up, safer-sex counseling was documented for 79% of the patients. Partner management was addressed for 52% of the patients. Only 36% of the patients were tested for other sexually transmitted infections, and 10% received C. trachomatis retesting during the Centers for Disease Control and Prevention-recommended time frame of 3 to 12 months after treatment. Significantly fewer boys than girls received safer-sex counseling (P = .02) and partner management (P = .02). CONCLUSIONS: Most teenagers received appropriate antibiotics, but fewer received other recommended care. The current study highlights important "missed-opportunity" clinical encounters for counseling to address high-risk behaviors, management of partners, detection of other sexually transmitted infections, and retesting for reinfections. Systems to address these gaps in care should be incorporated into the clinical management of adolescents infected with C. trachomatis.

Choice of urine collection methods for the diagnosis of urinary tract infection in young, febrile infants.

BACKGROUND: The optimal method of urine collection in febrile infants is debatable; catheterization, considered more accurate, is technically difficult and invasive. OBJECTIVES: To determine predictors of urethral catheterization in febrile infants and to compare bag and catheterized urine test performance characteristics. DESIGN: Prospective analysis of infants enrolled in the Pediatric Research in Office Settings' Febrile Infant Study. SETTING: A total of 219 practices from within the Pediatric Research in Office Settings' network, including 44 states, the District of Columbia, and Puerto Rico. PATIENTS: A total of 3066 infants aged 0 to 3 months with temperatures of 38 degrees C or higher. MAIN OUTCOME MEASURES: We calculated adjusted odds ratios for predictors of catheterization. Diagnostic test characteristics were compared between bag and catheterization. Urinary tract infection was defined as pure growth of 100 000 CFU/mL or more (bag) and 20 000 CFU/mL or more (catheterization). RESULTS: Seventy percent of urine samples were obtained by catheterization. Predictors of catheterization included female sex, practitioner older than 40 years, Medicaid, Hispanic ethnicity, nighttime evaluation, and severe dehydration. For leukocyte esterase levels, bag specimens demonstrated no difference in sensitivity but somewhat lower specificity (84% [bag] vs 94% [catheterization], P<.001) and a lower area under the receiver operating characteristic curve for white blood cells (0.71 [bag] vs 0.86 [catheterization], P = .01). Infection rates were similar in bag and catheterized specimens (8.5% vs 10.8%). Ambiguous cultures were more common in bag specimens (7.4% vs 2.7%, P<.001), but 21 catheterized specimens are needed to avoid each ambiguous bag result. CONCLUSIONS: Most practitioners obtain urine from febrile infants via catheterization, but choice of method is not related to the risk of urinary tract infection. Although both urine cultures and urinalyses are more accurate in catheterized specimens, the magnitude of difference is small but should be factored into clinical decision making.

Screening sexually active adolescents for Chlamydia trachomatis: what about the boys?

OBJECTIVES: We sought to determine the effectiveness of a systems-based intervention designed to increase Chlamydia trachomatis (CT) screening among adolescent boys. METHODS: An intervention aimed at increasing CT screening among adolescent girls was extended to adolescent boys (14-18 years). Ten pediatric clinics in a health maintenance organization with an ethnically diverse population were randomized. Experimental clinics participated in a clinical practice improvement intervention; control clinics received traditional information on screening. RESULTS: The intervention significantly increased CT screening at the experimental sites from 0% (baseline) to 60% (18-month posttest); control sites evidenced a change only from 0% to 5%. The overall prevalence of CT was 4%. CONCLUSIONS: Although routine CT screening is currently recommended only for young sexually active women, the present results show that screening interventions can be successful in the case of adolescent boys, among whom CT is a moderate problem.

Impact of pulse oximetry and oxygen therapy on length of stay in bronchiolitis hospitalizations.

BACKGROUND: Infants hospitalized with bronchiolitis are frequently monitored with a pulse oximeter. However, there is little consensus on an acceptable lower limit of oxygenation. No previous studies have examined how the use of pulse oximetry and supplemental oxygen therapy affects length of stay. OBJECTIVE: To determine the extent to which bronchiolitis hospitalizations are prolonged by a perceived need for supplemental oxygen based on pulse oximetry readings. Design and Patients Retrospective case series of subjects younger than 2 years who were hospitalized with bronchiolitis at an academic medical center. Two investigators independently reviewed the hospitalization records of 73 infants and determined at what point an infant met all discharge criteria except oxygenation. We then calculated the extent to which hospitalizations were prolonged by a perceived need for supplemental oxygen therapy based on pulse oximetry readings alone. RESULTS: Sixty-two infants met inclusion criteria. There was high interrater reliability in determining whether hospitalizations were prolonged (kappa = 0.75). In 16 (26%) of 62 patients (95% confidence interval, 15%-37%), the hospitalization was prolonged because of oxygenation concerns. Length of stay was prolonged an average of 1.6 days (range, 1.1-2.0 days) per hospitalization for these 16 patients, or 0.4 day (range, 0.2-0.6 day) per hospitalization for all 62 patients. CONCLUSIONS: Hospitalizations of some infants with bronchiolitis are prolonged by a perceived need for supplemental oxygen therapy based on pulse oximetry readings. Further investigation into outcomes of different levels and durations of oxygen desaturation is needed and would have the potential to reduce practice variability and shorten the length of stay.

Management and outcomes of care of fever in early infancy.

CONTEXT: Fever in infants challenges clinicians in distinguishing between serious conditions, such as bacteremia or bacterial meningitis, and minor illnesses. To date, the practice patterns of office-based pediatricians in treating febrile infants and the clinical outcomes resulting from their care have not been systematically studied. OBJECTIVES: To characterize the management and clinical outcomes of fever in infants, develop a clinical prediction model for the identification of bacteremia/bacterial meningitis, and compare the accuracy of various strategies. DESIGN: Prospective cohort study. SETTING: Offices of 573 practitioners from the Pediatric Research in Office Settings (PROS) network of the American Academy of Pediatrics in 44 states, the District of Columbia, and Puerto Rico. PATIENTS: Consecutive sample of 3066 infants aged 3 months or younger with temperatures of at least 38 degrees C seen by PROS practitioners from February 28, 1995, through April 25, 1998. MAIN OUTCOME MEASURES: Management strategies, illness frequency, and rates and accuracy of treating bacteremia/bacterial meningitis. RESULTS: The PROS clinicians hospitalized 36% of the infants, performed laboratory testing in 75%, and initially treated 57% with antibiotics. The majority (64%) were treated exclusively outside of the hospital. Bacteremia was detected in 1.8% of infants (2.4% of those tested) and bacterial meningitis in 0.5%. Well-appearing infants aged 25 days or older with fever of less than 38.6 degrees C had a rate of 0.4% for bacteremia/bacterial meningitis. Frequency of other illnesses included urinary tract infection, 5.4%; otitis media, 12.2%; upper respiratory tract infection, 25.6%; bronchiolitis, 7.8%; and gastroenteritis, 7.2%. Practitioners followed current guidelines in 42% of episodes. However, in the initial visit, they treated 61 of the 63 cases of bacteremia/bacterial meningitis with antibiotics. Neither current guidelines nor the model developed in this study performed with greater accuracy than observed practitioner management. CONCLUSIONS: Pediatric clinicians in the United States use individualized clinical judgment in treating febrile infants. In this study, relying on current clinical guidelines would not have improved care but would have resulted in more hospitalizations and laboratory testing.

To screen or not to screen: prevalence of C. trachomatis among sexually active asymptomatic male adolescents attending health maintenance pediatric visits.

This study estimated the prevalence of Chlamydia trachomatis (CT) among sexually active, asymptomatic, multiethnic adolescent males attending preventive health maintenance visits at pediatric clinics within a large health maintenance organization. First-void urines of sexually active 14-18-year-old males were screened for CT. The CT infection rate was 4% (27/711), 95% CI = 2.5%, 5.5%.