Surges of advanced medical support associated with influenza outbreaks.

We utilized de-identified data to evaluate increases in four outcomes during influenza outbreak periods (IOPs) including: hospitalization, intensive care unit admission, mechanical ventilation or death for adults aged 18 years or older with medically attended acute respiratory illnesses (MAARI) admitted to any of Maryland's 50 acute-care hospitals over 12 years. Weekly numbers of positive influenza tests in the Maryland area were obtained from the US Center for Disease Control and Prevention interactive website. The fewest consecutive weeks around the peak week containing at least 85% of the positive tests defined the IOP. Weekly counts of individual study outcomes were positively correlated with regional weekly counts of positive influenza tests during all the IOPs over 12 years. Also, rate ratios comparing daily occurrences of each study outcome between the IOP and non-IOP were significantly elevated. These results confirm conclusions of previous studies that influenza outbreaks are clearly associated with deaths and increased use of advanced medical resources by patients with MAARI. These data analyses suggest that increased efforts to develop more effective influenza vaccines and therapeutics should be a priority.

Acceptance of family member presence during pediatric resuscitations in the emergency department: effects of personal experience.

OBJECTIVE: Opinions remain polarized on allowing family member presence during pediatric resuscitations (FMP). Reluctance to adopt FMP may stem from preconceived notions on this practice. This study evaluates the effect of prior experience with FMP and on its acceptance by emergency department personnel (EDP). METHODS: EDP from three different EDs were surveyed concerning FMP. Study facilities included an urban teaching community ED with routine FMP (R-ED), a suburban community ED with occasional FMP (O-ED) and an urban university pediatric ED with virtually no FMP (N-ED) during pediatric resuscitations. Survey information included hospital of practice, position in ED, years in practice, opinions on FMP and personal experience with FMP for five clinical scenarios: laceration repair (LAC), intravenous access (IV), lumbar puncture (LP), endotracheal intubation (ETI), cardiopulmonary resuscitation (CPR), and critical resuscitation (CR). Statistical analysis was through chi square and regression analysis. RESULTS: Eighty-five emergency department personnel participated in the survey, 57 (67%) nurses, 22 (25%) physicians, 4 technicians (5%), and 2 nurses aids (2%). There was a significant correlation between a favorable opinion concerning family member presence during LP, ETI, CPR and CR and the type of Emergency Department in which the individual practiced (P<0.002). Regression analysis demonstrated a similar relation between personal experience with LAC, IV, ETI, CR, and CPR and a favorable opinion on FMP during that activity (P<0.03). CONCLUSION: Opinions on FMP are strongly influenced by experience with this practice. Emergency department personnel with prior exposure to family member presence during resuscitations favor this activity. Biases by EDP lacking experience with FMP may limit its introduction into unfamiliar institutions.

Nasal wash technique for nasal foreign body removal.

Nasal foreign bodies are seen commonly both in the office and pediatric emergency department setting. There have been a number of strategies described for their removal. We describe the "nasal wash" as a technique for nasal foreign body removal in the following three case reports. The "nasal wash" has been used in many pediatric vaccine studies as a method to collect mucus and relies on simple equipment readily available in the office setting.

Antibody titers eight months after three doses of a five-valent pneumococcal conjugate vaccine in HIV and non-HIV-infected children less than two years of age.

The objective of this study was to examine vaccine type-specific antibody titers eight months after a five-valent pneumococcal conjugate vaccine (PCV) in human immunodeficiency virus (HIV) and non-HIV-infected children under two years of age. Sixteen HIV-infected and 14 non-HIV-infected children under two years of age, and of similar age, race and sex distribution, received three doses (separated by two months each) of a five-valent oligosaccharide PCV (types 6B, 14, 18C, 19F, and 23F separately coupled to diphtheria CRM197). An additional 11 non-HIV-infected children, of similar demographic distribution to the PCV groups, received three doses of saline placebo. sera were collected just prior to, and at one and eight months after the three study drug doses. Serum vaccine type-specific pneumococcal IgG antibodies were measured by enzyme-linked immunoabsorbant assay (ELISA). There was an impressive rise in antibody titers pre- to one month post-third PCV in both the HIV (58-970-fold) and non-HIV-infected (19-553-fold) children. There was a rapid and similar drop in antibody titers eight months after the PCV series for both HIV (range 69-87% drop) and non-HIV-infected (range 57-79% drop) subjects respectively. However, 46% of the antibody titers from HIV-infected children and 62% of the titers from non-HIV-infected children were still > 1.0 microgram ml-1 compared to placebo recipients for whom only 5% of the titers were > 1.0 microgram ml-1 (p < 0.05). At the eight month post-PCV series blood draw, there were no significant differences in the GMTs, the percent drop in titers, or proportion of titers > 1.0 microgram ml-1 between the five HIV-infected children who had advanced (CDC class: N3, A3, B2-3, C1-3) compared to the 11 children with mild (CDC class: N1-2, A1-2, B1) HIV disease at the time of their first PCV dose. Eight months after the PCV series, the proportion of titers (combined all five serotypes) > 1.0 microgram ml-1 was slightly, but significantly, lower for HIV-infected subjects (46%) compared to non-HIV-infected subjects (62%) (p < 0.05). These data are helpful in describing the kinetics of antibody responses to pneumococcal conjugate vaccines in both HIV and non-HIV-infected young children.

Bacteremia in febrile human immunodeficiency virus-infected children presenting to ambulatory care settings.

BACKGROUND: Risk factors for bacteremia in febrile HIV-infected children are unknown. OBJECTIVE: To describe the frequency of bacteremia in febrile HIV-infected infants and young children in ambulatory settings and its association with clinical and laboratory factors. METHODS: In a birth cohort of 42 HIV-infected children, all febrile outpatient encounters at < or = 36 months of age were reviewed for HIV disease severity, presence of a central venous catheter (CVC) and the usage of antibiotics and/or intravenous immunoglobulin (IVIG). Blood culture results, highest temperature and white blood cell count (WBC) were noted. RESULTS: There was a mean of 1.8 febrile visits (210 visits/116.5 subject years) per child year of observation. Rapid HIV-disease progressors (n=14) were 4 times more likely to have a febrile visit than 28 non-rapid HIV disease progressors (P < 0.01). Blood cultures and WBCs were obtained for 87 and 89% of the febrile visits, respectively. Eleven of the 27 positive blood cultures grew Streptococcus pneumoniae and 16 grew CVC related organisms. The only pathogen identified (n=9) in 104 febrile visits in children without a CVC was S. pneumoniae, which was often (7 of 9) associated with mild illnesses. In children without a CVC temperature > or = 39 degrees C was significantly associated with S. pneumoniae bacteremia (P < 0.05). In 79 febrile visits by subjects with a CVC, temperature > or = 39 degrees C and WBC > or = 15000 cells/mm3 were frequently observed in the 16 bacteremic compared with the 63 nonbacteremic episodes (P < or = 0.05). There was a trend toward fewer S. pneumoniae bacteremias (3 of 11) in febrile subjects who were receiving antibiotics or IVIG. CONCLUSION: HIV-infected children younger than 36 months of age have a high incidence of S. pneumoniae and CVC-related bacteremias. Temperature > or = 39 degrees C, WBC > or = 15000 cells/mm3 and the presence of a CVC should be considered in the management of febrile HIV-infected children.

Safety and immunogenicity of three doses of a five-valent pneumococcal conjugate vaccine in children younger than two years with and without human immunodeficiency virus infection.

OBJECTIVE: To assess the safety and immunogenicity of three doses of a five-valent (types 6B, 23F, 14, 18C, and 19F) pneumococcal conjugate vaccine (PCV) among children younger than 2 years who are and are not infected with human immunodeficiency virus (HIV). METHODS: A convenience sample of 18 HIV-infected children 2 years and younger (mean, 12.9 months) received three doses (each separated by 2 months) of PCV. An additional convenience sample of 33 non-HIV-infected children of virtually identical age, race, and sex as the HIV-infected group were randomized in a double-blind fashion to receive three doses of PCV or saline placebo. Safety data were collected for 72 hours after each vaccination. Sera were obtained before each and 1 month after the third vaccination to determine vaccine type-specific immunoglobulin G pneumococcal antibody titers by an enzyme-linked immunosorbent assay. RESULTS: Seventeen HIV- and 30 non-HIV-infected children completed the study. The PCV was well tolerated by both HIV- and non-HIV-infected children. No significant differences in local or systemic reactions were noted between HIV- and non-HIV-infected PCV or placebo recipients. Three doses of PCV were immunogenic, as evidenced by 16- to 659-fold increases in type-specific geometric mean antibody titers over prevaccination levels in HIV- and non-HIV-infected children. With respect to an arbitrary protective level, 78% of the antibody titers from HIV-infected children and 88% of the titers from non-HIV-infected children were 1.0 microgram/mL or greater 1 month after the third PCV dose. HIV-infected children with milder disease (Centers for Disease Control and Prevention classes N1-2, A1-2, and B1) were more likely to have protective antibody titers after the first and second PCV doses than HIV-infected children with more advanced disease (Centers for Disease Control and Prevention classes N3, A3, B2-3, and C1-3). However, after the third PCV dose, these differences disappeared. CONCLUSION: Three doses of PCV seem safe and immunogenic in both HIV- and non-HIV-infected children younger than 2 years. This type of vaccine should result in a marked reduction in systemic pneumococcal disease in both HIV- and non-HIV-infected children. Given the high incidence of invasive pneumococcal disease in HIV-infected children, this vaccine may markedly improve the quality of life for this unfortunate group of children.

Lidocaine for lumbar punctures. A help not a hindrance.

OBJECTIVE: To determine whether premedication for lumbar puncture (LP) with lidocaine hinders collection of cerebrospinal fluid (CSF) through either increased number of attempts or increased incidence of traumatic punctures. DESIGN: A randomized controlled trial. SETTING: The pediatric emergency department of an innercity teaching hospital. PATIENTS: A convenience sample of 100 children, younger than 3 years, who required an LP as part of their diagnostic workup. INTERVENTION: Patients were randomized to receive either lidocaine or no local anesthetic before undergoing an LP. MAIN OUTCOME MEASURES: Comparison of the number of attempts needed to obtain CSF and the number of traumatic LPs between the lidocaine-treated and no local anesthetic groups. RESULTS: The 51 patients randomized to receive lidocaine did not differ markedly in age from the 49 patients randomized to receive no local anesthetic. Ease of obtaining CSF, as measured by number of attempts, did not differ with 59% of the patients in each group requiring 1 attempt. Defining a traumatic LP as more than 1000 x 10(6)/L red blood cells in the CSF showed notably more traumatic LPs in the lidocaine-treated group. Defining a traumatic LP as one with more than 10,000 x 10(6)/L red blood cells in the CSF showed no significant difference in the number of traumatic LPs whether or not the patient was premedicated with lidocaine. The level of experience of the physician performing the LP did not affect the outcome. CONCLUSIONS: Premedication with lidocaine for an LP does not binder the ease of obtaining CSF. The clinical relevance of a greater number of traumatic LPs in the lidocaine-treated group is questionable because this finding is negated when traumatic is defined as more than 10,000 x 10(6)/L CSF red blood cells. Based on these results, we advocate premedication with a local anesthetic when an LP is performed in the pediatric emergency department.

Family member presence during pediatric emergency department procedures.

OBJECTIVE: Exclusion of family members (FM) during pediatric procedures in the emergency department (ED) is an accepted practice. This study questions the validity of such a practice. SUBJECTS: FM of ED pediatric patients undergoing procedures and ED staff performing procedures. SITES: ED of a tertiary care university-affiliated community hospital and the pediatric ED of a university hospital. METHODS: Post-procedure surveys were obtained from FM remaining with their child during an ED procedure and from the ED personnel performing the procedures. FM activity during the procedure was also recorded. RESULTS: Ninety-six children (average age 20 months) underwent a total of 127 procedures. ED procedures included: vascular access 91, lumbar puncture 23, urethral catheterization 9, nasogastric tube placement 1, rapid sequence intubation 1, fluid resuscitation from shock 1, and removal of foreign body from eye 1. Three children were critically ill during performance of procedures. ED staff answered 98 surveys concerning the performance of the 127 procedures. FM ACTIVITIES INCLUDED: Stood at bedside 35 (31%), soothed child 21 (19%), and helped restrain child 55 (55%). In 55 (57%) cases the FM was the only adult present with the ED staff member performing the procedure(s). FM MEMBER OPINIONS OF PRESENCE DURING PROCEDURES WERE: Good idea 101 (91%), bad idea 6 (5%), and did not care 4 (4%). ED staff opinions were: good idea 92 (93%), bad idea 2 (2%), and did not care 4 (5%). FM presence made four (5%) members of the ED staff nervous. CONCLUSION: FM presence during ED procedures is a practice favored by both parents and ED staff at our institutions. This practice should not be limited to minimally invasive procedures in stable patients but should be considered for procedures such as lumbar punctures and intubations even in critically ill patients.

Comparison of the safety and immunogenicity of a pneumococcal conjugate with a licensed polysaccharide vaccine in human immunodeficiency virus and non-human immunodeficiency virus-infected children.

OBJECTIVE: To compare the safety and immunogenicity of a 5-valent pneumococcal conjugate vaccine to a licensed 23-valent polysaccharide pneumococcal vaccine in HIV-infected and non-HIV-infected children > or = 2 years old. METHODS: Thirty HIV-infected and 30 non-HIV-infected children > or = 2 years old were randomized to receive either a 5-valent pneumococcal conjugate vaccine (PCV) or a 23-valent pneumococcal polysaccharide vaccine (PPV) intramuscularly. Children who received PCV initially were given PPV after 6 weeks. Sera were obtained before and at 6 and 12 weeks after the first vaccination to determine IgG pneumococcal antibody titers by enzyme-linked immunosorbent assay to the 5 serotypes represented in the PCV. RESULTS: Both vaccines were well-tolerated with no significant differences in the rates of fever (0 to 14%) or local reactions (0 to 40%) noted between PCV and PPV recipients. Pre-first vaccination geometric mean antibody titers (combined PCV and PPV recipients) to 3 of the 5 pneumococcal types tested were significantly lower in HIV-infected than in non-HIV-infected children (in microgram/ml: type 6B, 0.179 vs. 0.565; type 14, 0.026 vs. 0.060; type 23F, 0.025 vs. 0.119, respectively; P < 0.05). Fewer > or = 4-fold titer rises were observed in HIV vs. non-HIV-infected children whether they received PCV initially (60% vs. 79%, P < 0.05) or PPV (31% vs. 59%, P < 0.05). Also PCV elicited more > or = 4-fold titer rises compared with PPV in HIV-infected (60% vs. 31%, P < 0.05) and non-HIV-infected (79% vs. 59%, P < 0.05) children. No consistent antibody-boosting effect was noted in subjects who received PPV after PCV. CONCLUSIONS: We conclude that antibody responses to natural infection, PCV and particularly PPV are poorer in HIV-infected than in non-HIV-infected children. PCV is as safe as and more immunogenic than the currently licensed PPV among HIV-infected and non-HIV-infected children.

Distribution of Streptococcus pneumoniae resistant to penicillin in the USA and in-vitro susceptibility to selected oral antibiotics.

Surveillance by 33 laboratories in 19 states during a 4 1/2 month period between December 1993 and April 1994 found that 263 of 1627 (16.2%) isolates of Streptococcus pneumoniae were resistant to penicillin. One hundred and seventy (10.4%) isolates were determined to be intermediately resistant to penicillin (MICs 0.1-1.0 mg/L and 93 (5.7%) were found to be highly resistant to penicillin (MICs > 2.0 mg/L). MIC90s for intermediately penicillin resistant strains were: amoxycillin/clavulanate 2.0 mg/L, cefaclor 64 mg/L, cefixime 32 mg/L, cefprozil 8 mg/L and loracarbef 128 mg/L. MIC90s for highly penicillin resistant strains were: amoxycillin/clavulanate 4.0 mg/L, cefaclor > or = 128 mg/L cefixime 64 mg/L, cefprozil 32 mg/L and loracarbef > or = 128 mg/L.

Hand-held metal detector identification of ingested foreign bodies.

The study purpose was to determine the ability of hand-held metal detectors (HHMDs) to identify the presence of ingested metallic foreign bodies (MFBs). Twenty-three children presenting to the emergency department with a complaint of MFBs ingested were enrolled. Sixteen of 23 patients had radiographically proven foreign bodies. The MFBs comprised coins (n = 11), a button battery (n = 1), a medallion (n = 1), a token (n = 1), a needle (n = 1), and a marble (leaded glass) (n = 1). The HHMD correctly detected 15 of 16 radiographically positive MFBs (93%) and correctly excluded a potential MFB in six of six radiographically negative cases. The only foreign body not detected was an ingested needle. One radiograph was equivocal. Radiographic localization of the ingested objects was as follows: esophagus, n = 4; stomach, n = 9; and intestines, n = 3. The HHMD correctly localized all detected MFBs. The HHMD had a sensitivity of 94%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 86%. HHMDs are effective screening devices for possible ingested MFBs. Positive studies localized to the stomach and lower gastrointestinal tract do not require confirmatory radiographic studies.

Efficacy of albuterol in the management of bronchiolitis.

OBJECTIVE: To examine the efficacy of albuterol (0.15 mg/kg per dose) in the management of bronchiolitis. DESIGN: Randomized, double-blind, placebo-controlled outpatient clinical trial utilizing four study groups: neubulized albuterol, nebulized saline, oral albuterol, and oral placebo. SETTING: Pediatric emergency department and outpatient clinic at University of Maryland in Baltimore. PATIENTS: Eighty-eight infants (median age 5.5 months) being treated for their first episode of wheezing were randomly assigned to nebulized albuterol (n = 22), nebulized saline (n = 23), oral albuterol (n = 19), oral placebo (n = 24). INTERVENTIONS: The nebulized groups received two nebulizations 30 minutes apart, whereas the oral groups received one oral dose. MAIN OUTCOME MEASURES: Respiratory and heart rates, clinical score, oxygen saturation (Spo2), and the infant's state, ie, asleep, awake, or feeding, were recorded at baseline and at 30 and 60 minutes after treatment. RESULTS: Randomization produced equivalent groups in terms of demographics and baseline measures. There were no statistically significant differences in any outcomes among the four treatments, except for oral albuterol, which produced an increase in heart rate (15 beats per minute, P = .005). No differences in the need for additional treatment or hospitalization were observed. Change in the state of the infant during the trial had significant effects on respiratory rate and clinical score. CONCLUSIONS: Albuterol is as effective as oral placebo in the management of bronchiolitis. Past studies supporting the use of albuterol did not control for effects of change in state of the infant and did not use a truly inactive placebo group. This study underscores the importance of these design components in measuring the efficacy of albuterol in infants.

Measles, mumps, and rubella antibodies in vaccinated Baltimore children.

OBJECTIVE: To determine quantitative measles, mumps, and rubella serum antibody levels as a function of time since vaccination in a sample of vaccinated Baltimore children. DESIGN: Cross-sectional serologic survey. SETTING: Pediatric outpatient departments at the University of Maryland Medical Center, Baltimore. PARTICIPANTS: One hundred seventy children, ranging in age from 1.5 through 16 years, who had measles, mumps, and rubella vaccination between ages 12 and 18 months. RESULTS: Serum antibody levels to measles and rubella declined with increasing time since vaccination. However, no such decline in antibody levels to mumps was observed. Children who were vaccinated between ages 12 and 14 months did not have lower antibody levels than children who were vaccinated at age 15 months or older. CONCLUSIONS: In areas free from natural disease, antibody levels resultant from measles, mumps, and rubella vaccine are likely to decline with advancing age. Revaccination with measles, mumps, and rubella vaccine may boost falling antibody titers.

The physical health of children in kinship care.

OBJECTIVE: The objectives of this study were to assess the current and chronic health problems and the adequacy of primary health care of children placed with a relative (kinship care) by a public agency. RESEARCH DESIGN: Population survey. SETTING: Children in kinship care in Baltimore, Md. PARTICIPANTS: Four hundred seven (78%) of 524 children in kinship care in 1989. INTERVENTIONS: None. MEASUREMENTS/MAIN RESULTS: Information on the child's health status and care was obtained via a review of medical records; questionnaires sent to primary care physicians, parents, care givers, and caseworkers; and clinical assessment of the child by a nurse, pediatrician, and child psychologist. The children were found to have health problems similar to those in foster and poor children, but more problems than American children in general. Frequent diagnoses included impaired visual acuity and hearing, obesity, dental caries, and asthma; often, these problems had not been identified or treated. Gaps in the medical records precluded firm conclusions concerning the children's primary care, but suggest an inadequate system for ensuring their health care. CONCLUSIONS: There is a need for improving the system of health care for children in kinship care. There is also a need for additional research on this high-risk group of children.

Retropharyngeal cellulitis: an unusual cause of respiratory distress in infancy.

The case of a 10-month-old infant who developed acute stridor, fever, and wheezing in the winter is presented. The ultimate diagnosis of retropharyngeal cellulitis was unsuspected. A review of this entity, along with differential diagnosis and management strategies, is included.