Performance of Febrile Infant Decision Tools on Hypothermic Infants Evaluated for Infection.

BACKGROUND: Given the lack of evidence-based guidelines for hypothermic infants, providers may be inclined to use febrile infant decision-making tools to guide management decisions. Our objective was to assess the diagnostic performance of febrile infant decision tools for identifying hypothermic infants at low risk of bacterial infection. METHODS: We conducted a secondary analysis of a retrospective cohort study of hypothermic (≤36.0 C) infants ≤90 days of age presenting to the emergency department or inpatient unit among 9 participating sites between September 1, 2016 and May 5, 2021. Well-appearing infants evaluated for bacterial infections via laboratory testing were included. Infants with complex chronic conditions or premature birth were excluded. Performance characteristics for detecting serious bacterial infection (SBI; urinary tract infection, bacteremia, bacterial meningitis) and invasive bacterial infection (IBI; bacteremia, bacterial meningitis) were calculated for each tool. RESULTS: Overall, 314 infants met the general inclusion criteria, including 14 cases of SBI (4.5%) and 7 cases of IBI (2.2%). The median age was 5 days, and 68.1% of the infants (214/314) underwent a full sepsis evaluation. The Philadelphia, Boston, IBI Score, and American Academy of Pediatrics Clinical Practice Guideline did not misclassify any SBI or IBI as low risk; however, they had low specificity and positive predictive value. Rochester and Pediatric Emergency Care Applied Research Network tools misclassified infants with bacterial infections. CONCLUSIONS: Several febrile infant decision tools were highly sensitive, minimizing missed SBIs and IBIs in hypothermic infants. However, the low specificity of these decision tools may lead to unnecessary testing, antimicrobial exposure, and hospitalization.

Variation in Care of Well-Appearing Hypothermic Young Infants: A Multisite Study.

BACKGROUND AND OBJECTIVES: Numerous decision tools have emerged to guide management of febrile infants, but limited data exist to guide the care of young infants presenting with hypothermia. We evaluated the variation in care for well-appearing hypothermic young infants in the hospital and/or emergency department setting between participating sites. METHODS: This is a retrospective cohort study of well-appearing infants ≤90 days old across 9 academic medical centers from September 1, 2016 to May 5, 2021. Infants were identified via billing codes for hypothermia or an initial temperature ≤36.0°C with manual chart review performed. Primary outcomes included assessment of variation in diagnostic evaluation, disposition, empirical antimicrobial therapy, and length of stay. RESULTS: Of 14 278 infants originally identified, 739 met inclusion criteria. Significant interhospital variation occurred across all primary outcomes. Across sites, a full serious bacterial illness evaluation was done in 12% to 76% of hypothermic infants. Empirical antibiotics were administered 20% to 87% of the time. Performance of herpes simplex viral testing ranged from 7% to 84%, and acyclovir was empirically started 8% to 82% of the time. Hospital admission rates ranged from 45% to 100% of patients. CONCLUSIONS: Considerable variation across multiple aspects of care exists for well-appearing young infants presenting with hypothermia. An improved understanding of hypothermic young infants and their risk of infection can lead to the development of clinical decision tools to guide appropriate evaluation and management.

"SPORTS ARE FUN": A Guide for the Discussion of Sport-Related Films.

Sport participation is an important part of the development of children and adolescents in the United States. Due to the popularity of sport-related films, coaches, athletic trainers, and parents have used these films to both educate and motivate pediatric athletes. The objective of this study was to develop a discussion guide template based on common positive and negative themes depicted in sport-related films, and demonstrate the application of this discussion guide template to a select number of sport-related films released from 2014 to 2018. A discussion guide template ("SPORTS ARE FUN") was developed by the co-investigators, reflecting common themes of "Sportsmanship, Participation for All, Obstacles, Relationships, Teamwork, Setting Realistic Goals, Academics, Responsibility, Exercise/Nutrition/Rest/Drugs/Performance Enhancing Drugs, Fun, Unrelenting Spirit, and "No Pain, No Gain." The authors hope that pediatric health care providers, athletic coaches/staff, and parents can utilize this discussion guide template in the education and development of children and adolescents who participate in sports.

Neurodevelopmental Delay Diagnosis Rates Are Increased in a Region with Aerial Pesticide Application.

A number of studies have implicated pesticides in childhood developmental delay (DD) and autism spectrum disorder (ASD). The influence of the route of pesticide exposure on neurodevelopmental delay is not well defined. To study this factor, we examined ASD/DD diagnoses rates in an area near our regional medical center that employs yearly aerial pyrethroid pesticide applications to combat mosquito-borne encephalitis. The aim of this study was to determine if areas with aerial pesticide exposure had higher rates of ASD/DD diagnoses. This regional study identified higher rates of ASD/DD diagnoses in an area with aerial pesticides application. Zip codes with aerial pyrethroid exposure were 37% more likely to have higher rates of ASD/DD (adjusted RR = 1.37, 95% CI = 1.06-1.78, p = 0.02). A Poisson regression model controlling for regional characteristics (poverty, pesticide use, population density, and distance to medical center), subject characteristics (race and sex), and local birth characteristics (prematurity, low birthweight, and birth rates) identified a significant relationship between aerial pesticide use and ASD/DD rates. The relationship between pesticide application and human neurodevelopment deserves additional study to develop safe and effective methods of mosquito prevention, particularly as communities develop plans for Zika virus control.

Timing of single balloon enteroscopy: significant or not?

BACKGROUND: The development of balloon assisted enteroscopy (BAE) has revolutionized diagnostic and therapeutic modalities for small-bowel disorders. Although the role of emergent esophagogastroduodenoscopy and colonoscopy for upper and lower gastrointestinal bleeding is well defined, there is scarce data with regard to emergent BAE for gastrointestinal bleeding. STUDY: We performed a retrospective cohort study including 110 hospitalized patients with obscure gastrointestinal bleeding who underwent single balloon enteroscopy (SBE) between January 2010 and August 2013. Patients were divided into two groups based on procedures performed emergently (within 24 hours) versus non-emergently (greater than 24 hours). Data on patient demographics, hemodynamic characteristics, type of obscure bleed, lesions identified, location of lesions, endoscopic intervention performed, need for further surgical or radiological intervention, diagnostic and therapeutic yield, and adverse events were compared between groups. Independent samples t test and Fisher's exact test were used to assess the association between dependent and independent variables. For continuous data, the results were summarized as mean difference and 95 % confidence intervals (CI), and for binary as odds ratio and 95 %CI. RESULTS: Although patients in the group where enteroscopy was performed within 24 hours had a significantly higher incidence of radiological intervention (10.0 % vs. 0.0 %, P = 0.019), the diagnostic and therapeutic yields between the two groups were not significantly different. Additionally, there were no statistically significant differences between the groups for overt and occult bleeding, transfusion requirements, type and location of lesions, endoscopic intervention performed, or adverse events. Hospital stay was shorter in the patients who had SBE within 24 hours of admission (6.2 vs. 11.3 days, P < 0.001). CONCLUSIONS: Although the diagnostic and therapeutic yields of SBE were not significantly different between patients having the procedure within 24 hours and those having it later, the early SBE group required more interventional radiology procedures. While endoscopists may not necessarily have to perform emergent assessment within 24 hours in patients with obscure gastrointestinal bleeding (OGIB) for greater diagnostic or therapeutic yield, early intervention may allow for earlier stabilization and thus shorter hospital stays. Prospective studies further evaluating these findings are indicated.

The safety and efficacy of single balloon enteroscopy in the elderly.

BACKGROUND: Single balloon enteroscopy (SBE) is an important tool in the management of small bowel disease with limited data available on its performance in the elderly. We aimed to evaluate the safety, efficacy, diagnostic and therapeutic outcomes of SBE in the elderly. METHODS: A retrospective review was performed on 366 patients undergoing 428 SBEs from 2010 to 2014. Patients were divided into different age groups: control <55, 55-64, 65-74 and ⩾75 years. Data on comorbidities, complications, findings, diagnostic and therapeutic yield were compared between groups. RESULTS: Anterograde and retrograde SBE were performed in 340 and 49 patients, respectively, with 63 patients requiring more than 1 procedure. Diagnostic yield was significantly higher for age ⩾75 years compared with <55, 66.3% versus 50%, odds ratio (OR) 1.97 [95% confidence interval (CI) 1.14-3.41]. Therapeutic yield was significantly higher in all three older age groups compared with <55 years, 20.3%: 55-64 years, 44.4%, OR 3.13(95% CI 1.7-5.78); 65-74 years, 42%, OR 2.84 (95% CI 1.59-5.06); and >75 years, 47.5%, OR 3.55 (95% CI 1.96-6.43). No significant difference was seen between age groups in complications or failures. Our overall complication rate was 2.3% with 5 minor and 5 major complications. There was a higher yield of angioectasias in the elderly. Argon plasma coagulation (APC) and multipolar electrocoagulation were used more often in older age groups. CONCLUSION: SBE is safe in elderly patients and delivers higher diagnostic and therapeutic yields compared to younger patients. The elderly are more likely to have angioectasias and undergo APC and electrocoagulation.

Splenic Avulsion Following PEG Tube Placement: A Rare but Serious Complication.

Placement of a percutaneous endoscopic gastrostomy (PEG) tube is a common procedure to allow for enteral nutrition in patients with multiple indications. PEG tube placement is a safe procedure with minor complications such as site infection and irritation. One of the more severe complications is splenic laceration, which may result in intra-peritoneal bleeding and manifest as an acute abdomen. We present a rare case of intra-abdominal bleeding secondary to catastrophic splenic injury 12 hours after PEG tube placement resulting in hemodynamic compromise. The patient underwent splenectomy and had an uneventful recovery.