The history and physical assessments of the febrile infant.

Grading patient clinical appearance using the Young Infant Observation Scale and the Yale Observation Scale can effectively classify approximately 75% of infants with a serious illness or infection as ill appearing and 95% who appear to be well as having low risk for serious illness or infection. Most children with invasive bacterial infections appear to be ill at the time of evaluation, although exceptions to this are not uncommon. Accuracy in distinguishing the etiology of fever in infants is an integrated evaluation including thorough assessment of historical data, clinical appearance, and physical findings.

Safe and effective method for application of tetracaine, adrenaline, and cocaine to oral lacerations.

STUDY OBJECTIVE: To evaluate the safety and efficacy of a technique for application of tetracaine, adrenaline, and cocaine (TAC) for minor oral lacerations. METHODS: Our study group comprised 22 consecutive children older than 5 years of age who presented to an urban pediatric emergency department with a minor oral laceration 2 cm or less in length requiring single-layer closure. The children were prospectively treated with a two-drop dose of TAC containing .5 mg tetracaine and 12 mg cocaine on a cotton-tipped applicator placed in contact with the wound for up to 5 minutes. RESULTS: Lacerations involved the labial mucosa (n = 12), tongue (n = 6), and buccal mucosa (n = 4); 41 (91%) of 45 sutures were placed without pain (95% confidence interval, 0% to 8.2%). No patient exhibited an adverse reaction related to TAC. CONCLUSION: This TAC application technique was safe and highly effective in providing anesthesia for minor oral lacerations.

Outpatient rapid intravenous rehydration to correct dehydration and resolve vomiting in children with acute gastroenteritis.

STUDY OBJECTIVE: To determine the efficacy of outpatient rapid i.v. rehydration in correcting dehydration and resolving vomiting in children with mild to moderate dehydration resulting from acute gastroenteritis. METHODS: We carried out a prospective cohort study in an urban children's hospital. A convenience sample of 58 children aged 6 months to 13 years, with acute gastroenteritis and clinically estimated dehydration of 5% to 10% body weight, was assembled. All patients had been vomiting for less than 48 hours, had vomited at least five times in the 24 hours preceding presentation, and had metabolic acidosis (serum bicarbonate concentration, 18 mEq/L or less). Each patient received an i.v. infusion of 20 to 30 mL/kg isotonic crystalloid solution over 1 to 2 hours, followed by the oral administration of 1 to 3 ounces of clear fluid. Patients who subsequently vomited were admitted for continued i.v. fluid therapy. Patients who tolerated oral fluid were discharged; their caregivers were contacted by telephone 24 to 48 hours after discharge. RESULTS: All patients had improved hydration status after rapid i.v. rehydration. Sixteen patients (28%) did not tolerate oral fluids after rapid i.v. rehydration and were admitted; 11 of these patients had a serum bicarbonate concentration of 13 mEq/L or less. The other 42 patients (72%) tolerated oral fluids after rapid i.v. rehydration and were discharged; 41 of these patients had a serum bicarbonate concentration greater than 13 mEq/L. The frequency of serum bicarbonate concentration of 13 mEq/L or less on presentation was significantly greater (P = .001) in patients requiring hospitalization than in those discharged from the emergency department after rapid i.v. rehydration. Of 40 patients whose caregivers were contacted after discharge, 34 (85%) required no further medical evaluation or treatment for any reason, including inadequate hydration; 29 of these patients vomited no more than once. Six of the discharged patients (15%) required further medical evaluation and were admitted; four had recurrent vomiting and dehydration, two had not vomited but were dehydrated as a result of diarrheal fluid loss or inadequate oral fluid intake. CONCLUSION: Outpatient rapid i.v. rehydration is safe and effective in correcting dehydration and resolving vomiting in selected children with acute gastroenteritis and mild to moderate dehydration. In our study, most children who presented with a serum bicarbonate concentration greater than 13 mEq/L tolerated oral fluids after rapid i.v. rehydration and were further managed as outpatients without complications. By contrast, most children with a serum bicarbonate concentration of 13 mEq/L or less usually did not tolerate oral fluids after rapid i.v. rehydration and required more prolonged i.v. fluid therapy. All discharged patients, regardless of their serum bicarbonate concentration, demonstrated the ability to tolerate orally administered fluid.

Adjunctive dexamethasone therapy for pediatric bacterial meningitis.

There have been numerous studies performed to assess the impact of adjunctive corticosteroid therapy on the outcome of pediatric bacterial meningitis. Much of these data are conflicting, which can result in confusion regarding therapeutic efficacy. The present article will review the pathophysiology of this disease, critique the body of medical literature on this aspect of therapy, and provide guidelines for the emergency physician on the use of dexamethasone therapy for bacterial meningitis in children.

Acute infectious enteritis in children. Emergency department diagnosis and management.

The approach to the child with acute infectious enteritis requires a clear diagnostic evaluation. The various common pathogens are reviewed. Treatment decisions are largely based on the clinical condition of the child. Oral rehydration therapy is addressed.

Efficacy of nurses suturing pediatric dermal lacerations in an emergency department.

STUDY OBJECTIVE: To assess the efficacy of nurses suturing pediatric dermal lacerations in an emergency department. DESIGN: Prospective study. SETTING: Pediatric ED. PARTICIPANTS: Suturing nurses completed a comprehensive training program provided by physicians at our institution and at a national wound management workshop; both included instruction in wound assessment, preparation, anesthesia, repair, and care after repair. A survey of physician and parent satisfaction with wound repair and for wound healing complications was performed at the time of suture removal in 61 children whose dermal laceration was repaired by suturing nurses. RESULTS: The laceration was located on the face in 40 patients, the scalp in 14, and an extremity in 7. A total of 343 sutures was required (18 lacerations required a layered closure). Pediatricians graded wound repair as "very good" in 32 cases (53%) and "excellent" in 29 cases (47%). Parents rated themselves as "very satisfied" with the wound repair procedure in 60 cases (98%) and with the wound repair outcome in 59 cases (97%). There were no wound-healing complications. Suturing nurses took a total of 72 hours to repair lacerations. In comparison, of 20 lacerations repaired by an ED attending physician, 11 (55%) were graded as "excellent" and 9 (45%) as "very good," with no wound-healing complications (P = NS). CONCLUSION: Nurses who complete a standardized training program in wound management and repair are capable of providing high-quality, definitive care for children with dermal lacerations, thus allowing physicians to use their time more effectively in managing general patient care in the ED.

Esophageal mucosal changes in children with an acutely ingested coin lodged in the esophagus.

An important factor in choosing the method to remove an ingested coin lodged in the esophagus (endoscopy with forceps extraction, Foley catheter extraction, or bougienage advancement) is the duration of the ingestion and the risk for compromise to the esophageal mucosal integrity. We reviewed 50 consecutive cases occurring during a five-year period of children with a witnessed acutely ingested coin (less than 24 hours duration) that was lodged in the esophagus to determine the degree of compromise of the esophageal mucosal integrity. All coins were removed by endoscopic forceps extraction, with direct inspection of esophageal mucosa. The duration of ingestion was less than eight hours in 22 patients, nine to 16 hours in 16 patients, and 17 to 24 hours in 12 patients. Endoscopy showed that the esophageal mucosa had no abnormalities in 42 patients, "minimal erythema" in six patients, and "minimal abrasion" in two patients. There were no symptoms or complications referable to the gastrointestinal tract reported subsequent to coin removal in any case. Ingested coins that are lodged in the esophagus for fewer than 24 hours do not cause significant compromise to the integrity of the esophageal mucosa. We discuss the implications of these findings in the context of choosing an appropriate method for removing esophageal coins.

The clinical characteristics and infectious outcomes of febrile infants aged 8 to 12 weeks.

We reviewed 356 consecutive cases of febrile infants aged 8 to 12 weeks who received outpatient evaluation for sepsis over 4 years. Thirty-three infants (9.3%) had a serious bacterial infection (SBI), including bacterial meningitis, bacteremia, urinary tract infection (UTI), and Salmonella enteritis. The SBI rate, which was directly proportional to fever height, was significantly greater for infants with hyperpyrexia (35%) than those with lesser degrees of fever (7.7%) and for infants with peripheral blood leukocytosis (total WBC count > or = 15,000/mm3; 25%) than those with lesser total WBC counts (5.8%). An attending-level physician judged that 67% of infants with SBI appeared to be "well," including five or eight cases (63%) of bacteremia, 14 of 17 cases (82%) of UTI, and all three cases of Salmonella enteritis, whereas all five patients with bacterial meningitis appeared to be "ill." Urinalysis abnormalities indicative of UTI were present in 15 of 17 infants (88%) who had this infection. SBIs are not uncommon in febrile infants aged 8 to 12 weeks and occur significantly more often in those with either hyperpyrexia or peripheral blood leukocytosis.

Efficacy of a protocol to distinguish risk of serious bacterial infection in the outpatient evaluation of febrile young infants.

A study of 534 febrile infants ages 4 to 8 weeks evaluated for sepsis assessed the efficacy of the Milwaukee Protocol (MP) for selecting patients at low risk for serious bacterial infection (SBI) who might benefit from outpatient management. Two groups were compared: 1) Infants with uncompromised presentation (UP) who met all MP criteria received ceftriaxone 50 mg/kg and were discharged, then reevaluated within 24 hours. 2) Infants with compromised presentation (CP) who did not meet MP criteria were hospitalized for antibiotic therapy pending culture results. Of 391 CP patients, 23 (5.9%) had SBI; of 143 UP patients, 1 (0.7%) had SBI (P < .02). The MP criteria had a sensitivity of 96% and a 99% negative predictive value for distinguishing SBI outcome. The only UP patient with SBI was afebrile and had a negative repeat blood culture after 24 hours, and recovered with no complications. Managing UP infants as outpatients avoided 48 to 72 hours of hospitalization, decreasing health-care costs by an estimated total of $465,170.

Correlating changes in body temperature with infectious outcome in febrile children who receive acetaminophen.

We reviewed the body-temperature patterns of 140 children ages 2 to 24 months who had fever > or = 39.0 degrees C, received acetaminophen 10 to 15 mg/kg, and had their temperatures remeasured 60 to 90 min later. The children comprised three groups: 22 had bacterial meningitis; 59, isolated bacteremia; and 59, nonbacterial febrile illness. Percentages of patients who became afebrile (temperature < 38.0 degrees C) after receiving acetaminophen were not significantly different among the three groups. Differences in mean temperature decrease after antipyretic was given were significant within each group but not between groups. An inverse relation (P < .004) between patient age and magnitude of temperature was revealed by the following formula: degrees C of defervescence = 1.66 - (0.028 x patient age in months). Thus, highly febrile young children with and without invasive bacterial infections who receive a therapeutic dose of acetaminophen experience a significant temperature drop after 60 to 90 min but do not commonly defervesce to an afebrile state. The degree of defervescence is age-dependent and does not distinguish between infectious outcomes.

Correlating infectious outcome with clinical parameters of 1130 consecutive febrile infants aged zero to eight weeks.

The study objectives were to characterize the infectious outcomes and associated clinical parameters of a large group of febrile young infants who received outpatient sepsis evaluation. This retrospective review of consecutive cases during a seven-year period was set in an urban pediatric emergency department. Febrile infants, aged zero to eight weeks, were the participants. All received a standard evaluation for sepsis, including complete blood count/blood culture, lumbar puncture/cerebrospinal fluid culture, and urinalysis/urine culture. Of 1130 patients, 447 (42%) were aged zero to four weeks, and 683 (58%) were aged four to eight weeks. In 96 cases (8.5%), a bacterial pathogen was isolated by culture of cerebrospinal fluid, blood, urine, or stool; 58% were aged zero to four weeks and 42% were aged four to eight weeks. The rate of positive cultures per patient age was doubled in those aged zero to four weeks (12%) compared with those aged four to eight weeks (6%). The 49 cases of invasive bacterial infections (bacterial meningitis/bacteremia) were most commonly associated with lower degrees of fever, as slightly over one half (25/49) had temperature < 39 degrees C. The most common pathogens of invasive bacterial infection were group B streptococcus and Escherichia coli, accounting for 33 of 49 cases (67%); the most common pathogens of invasive bacterial infection in older children (Haemophilus influenzae type b and Streptococcus pneumoniae) were relatively underrepresented, accounting for only five of these 49 (10%) cases.

Reliability of observation variables in distinguishing infectious outcome of febrile young infants.

We prospectively evaluated 7 observation variables (level of activity, level of alertness, respiratory status/effort, peripheral perfusion, muscle tone, affect, feeding pattern) which qualify patient clinical appearance in order to determine reliability in distinguishing the infectious outcome of 233 febrile infants ages 0 to 8 weeks. Each variable was graded either 1, 3, or 5, with a higher score indicative of a greater degree of compromise. All infants received physical examination and sepsis evaluation (lumbar puncture, complete blood count/blood culture, urinalysis/urine culture). The 3 outcome groups compared were 29 cases of serious bacterial infections, (+SBI; 10 with bacterial meningitis, 12 with bacteremia, 7 with urinary tract infection), 45 cases of aseptic meningitis (AM) and 159 cases culture-negative with normal cerebrospinal fluid (CN-NCSF). The mean score for each of the 7 variables was significantly greater in the +SBI group compared with both the AM and CN-NCSF groups (P < 0.05), whereas there was no significant difference in mean score for each of the 7 variables between the AM and CN-NCSF groups. Stepwise discriminant analysis identified 3 variables that best distinguished outcome: affect; respiratory status/effort; and peripheral perfusion, which constituted the Young Infant Observation Scale. The mean total Young Infant Observation Scale score generated from assessing these 3 variables was significantly greater (P = 0.0001) in the +SBI, group (9) compared with both the AM (5) and CN-NCSF (5) groups. A total Young Infant Observation Scale score > or = 7 had a sensitivity of 76%, specificity of 75% and negative-predictive value of 96% for outcome of +SBI.