Yield of Emergency Department Stool Culture Tests Among Children With Acute Gastroenteritis in Israel.

Previous studies have attempted to predict a positive stool culture in pediatric patients with acute gastroenteritis (AGE), but most of them are either from developing countries or are outdated. In all, 276 patients with AGE and 560 control patients were analyzed for differences in clinical factors including the presence of fever, highest recorded temperature, bloody diarrhea, number of bowel movements in 24 hours prior to presentation, and the presence of seizures, as well as laboratory parameters including leukocyte count and C-reactive protein (CRP). Positive stool sample rate was 13.7%. The most common bacterial pathogen was Campylobacter jejuni. Bacterial AGE was significantly associated with fever >37.9°C, bloody diarrhea, higher stool passing frequency, seizures, and CRP levels. For pediatric patients who present to the emergency department with AGE and present without bloody diarrhea, fever, frequent stool passing, or seizures, a stool culture test is of poor yield and may not be necessary.

The Effect of Medical Clowns on Blood Pressure Measurement in Children Presenting to the Emergency Department.

BACKGROUND: Blood pressure (BP) is routinely measured while triaging children presenting to the pediatric emergency department (PED). OBJECTIVES: To determine whether a medical clown shortens the time to acquire a BP measurement among children undergoing triage in the PED. METHODS: The study comprised 133 children. Patients were assigned to one of two groups: with a medical clown or without a medical clown. RESULTS: The presence of a medical clown led to a significantly shorter time to acquire a blood pressure measurement (60 ± 23 seconds vs. 81 ± 43.5 seconds, P < 0.001. Clowns had a significant effect on shortening total triage length among children of Jewish ethnicity compared to Arab ethnicity (113 ± 353.6 seconds vs. 154 ± 418 seconds, P = 0.012). CONCLUSIONS: Using medical clowns while measuring BP during triage when used in a culturally appropriate manner shortens time.

Pain management of upper limb fractures in pediatric emergency department versus general orthopedics emergency department.

Under treatment of pain is frequently reported in children even in conditions associated with severe pain such as fractures. Recent literature supports adequate and early pain treatment because extreme and uncontrolled pain can lead to hyperalgesia. Since 2017, the treatment of pediatric orthopedic cases in the "Meir" Medical Center was gradually shifted from the orthopedic general emergency department to the pediatric emergency department. The objective was to examine the differences in pain management between the orthopedic and pediatric emergency departments. Upper limb fractures were chosen as a representing case. This retrospective cohort study included children aged 0-18 years that suffered from an upper limb fracture and were admitted to the emergency department in the years 2016 and 2018. In our study, a total of 2520 children suffered from an upper limb fracture and were treated at the Meir Medical Center during the study period. 959 of these children were treated during 2016 in the general emergency department, and 1561 were treated in the pediatric emergency department during 2018. The group characteristics were similar. In the pediatric emergency department compared to general emergency department group, more children received analgesic treatment (47.85% versus 30.4%, p < .001), more opiates were given (13.9% versus 5.3%, p < .001), and the analgesic treatment was more adequate to pain severity. Additionally, sedation was performed more frequently in the pediatric emergency department (21.6% versus 9.5%, p < .001), especially for dislocated fractures (81.5% versus 31.4%, p < .001). COMPLICATIONS: Length of stay, surgery, hospitalization, and recurrent referral rates were similar between the two groups. CONCLUSIONS:  The transfer of orthopedic pediatric cases to the pediatric emergency department showed a notable improvement in pain management without an increase in complications or emergency department length of stay. WHAT IS KNOWN: • Pain management and control is a major issue to address in their treatment. • Traumatic injuries and especially fractures are common causes for ED admissions. WHAT IS NEW: • Comparing pain management and upper limb fractures treatment between general and pediatric ED. • Pain is better treated in the PED than in the GED, without an increased rate of complications.

Road accidents in children involving light electric vehicles cause more severe injuries than other similar vehicles.

Road accidents in Israel were responsible for 23% of injuries in pediatric population between 2013 and 2017. In recent years, the massive entrance of e-bike and other light electric vehicles (called collectively LEV) into the roads is significantly changing the epidemiology of road accidents among children. The study aims to describe the causes, injury types, and other epidemiological characteristics of children injured in road accident and compare injuries of LEV to regular bicycles and other light non-electric vehicles (called collectively LNEV). This retrospective study included all referrals to pediatric emergency department due to road accidents, from April 2015 through March 2017. The details of the accidents and injuries were retrieved, and the subjects' characteristics were compared based on vehicle type. A total of 1531 children met the inclusion criteria. The study found that LEV road accidents among children cause more severe injuries than other LNEV in terms of injury severity score (ISS) (mean ISS 5.8 ± 4.9 vs. 4.7 ± 3.6, P = 0.001), head and neck injuries (18.7% vs. 12.9%, respectively, P < 0.05), lower extremities (36.5% vs. 23.9%, P = 0.001), and multisystem injuries (58.6% vs. 31.8%, P < 0.001). The findings of the current study suggest that the use of LEVs is changing the epidemiology of road accidents, which requires adjustments in accident and injury prevention strategies.Conclusion: The study results should encourage authorities to provide appropriate community-based programs to promote helmet use, introduce mandatory training and licensing program for LEV riders, and enhance enforcement. What is Known: • Road accidents are the leading cause of death among children and young adults (5 to 29 years). • In recent years, there is a massive entrance of e-bikes and other light electric vehicles on the roads. What is New: • LEV (light electric vehicle) accidents among children impose more severe injuries than other LNEVs (light non-electric vehicles) in terms of ISS, hospitalizations, and multisystem injuries. • The use of LEV is changing the epidemiology of road accidents. This change requires enhancing accident and injury prevention strategies.

Bulging fontanelle in febrile infants as a predictor of bacterial meningitis.

It is common practice to perform a lumbar puncture in infants presenting with fever and a bulging fontanelle in order to rule out bacterial meningitis. However, most of these infants have benign, self-limiting diseases. The objective was to determine whether there is an association between bulging fontanelle and bacterial meningitis in febrile infants. This retrospective cohort study included febrile children with a bulging fontanelle who underwent lumbar puncture at Meir Medical Center from 2005 through 2015. A total of 764 children ages 2-18 months underwent lumbar puncture during the study period. Among them, 304 had a bulging fontanelle and fever on evaluation and cerebrospinal fluid pleocytosis was found in 115 (37.8%), including 1 case of bacterial meningitis (0.3%). None of the infants described on admission as appearing well on presentation was found to have bacterial meningitis. Of the 764 children who underwent lumbar puncture, 10 infants were diagnosed with bacterial meningitis, and only one (10%) presented with a bulging fontanelle.Conclusion: The finding of a bulging fontanelle has very low sensitivity and specificity for bacterial meningitis. Most causes of a bulging fontanelle in febrile infants are self-limiting diseases. The routine approach of performing a lumbar puncture in febrile infants with a bulging fontanelle should be reconsidered. What is Known: • It is common to perform a lumbar puncture in febrile infants with a bulging fontanelle, to rule out bacterial meningitis. • However, there are only few researches regarding the relationship between bulging fontanelle and bacterial meningitis. What is New: • The finding of a bulging fontanelle has very low sensitivity and specificity for bacterial meningitis • The need for routine lumbar puncture in these cases should be reconsidered.

A Cross-Sectional Study on Subjective Fever Assessment in Children by Palpation: Are Fathers as Reliable as Mothers?

BACKGROUND: Fever is common in pediatric patients. Often, parents rely solely on palpation when assessing their child's fever. The objective of the current study was to determine the accuracy of parents in detecting their child's fever by palpation. METHODS: A prospective cross-sectional study was conducted at the emergency department (ED) of a tertiary pediatric hospital. Infants and children, 0-4 years of age, presenting to the ED with both parents were included. Parents were separately asked if their child had a fever and, if so, were asked to assess the temperature by palpation. A nurse obtained the rectal temperature. The primary outcome measure was the accuracy of fathers and mothers in detecting fever. RESULTS: A total of 170 children with their parents were enrolled. The mean ages of the children, mothers, and fathers were 18.9 (SD 0.8) months, 31.1 (SD 6.4) years, and 33.7 (SD 6.9) years, respectively. No statistically significant difference was found between mothers and fathers in the ability to assess fever by palpation (OR 0.65, 95% CI 0.39,-1.08). Sensitivities for detecting fever by palpation for mothers and father were 86.4% and 88.2%, respectively (specificity among mothers: 54.2% and specificity among fathers: 43.1%). The overall negative and positive predictive values were 65.9% (95% CI 55%-75.7%) and 75.7% (95% CI 69.9%-80.8%), respectively. CONCLUSIONS: Mothers and fathers do not differ in their ability to accurately assess their child's fever by palpation. The low positive and negative predictive values indicate that if temperature was not measured, physicians cannot rely on parents' reports.

Levels of evidence: a comparison between top medical journals and general pediatric journals.

BACKGROUND: Given the large number of publications in all fields of practice, it is essential that clinicians focus on the resources that provide the highest level of evidence (LOE). We sought to determine the LOE that exists in the field of pediatrics, present in the general pediatric as well as high impact clinical literature. METHODS: Clinical pediatric literature, published between April 2011 and March 2012 inclusive in high-impact clinical journals (HICJ) (New England Journal of Medicine, Journal of the American Medical Association, & The Lancet) and the highest-impact general pediatric journals (GPJ) (Pediatrics, Journal of Pediatrics, & Archives of Pediatrics & Adolescent Medicine), was assessed. In addition to the LOE, articles were evaluated on criteria including subspecialty within pediatrics, number of authors, number of centers, and other parameters. Eligible level I randomized control trials were appraised using the Consolidated Standards of Reporting Trials (CONSORT) guidelines. RESULTS: Of 6511 articles screened, 804 met inclusion criteria (68 in HICJ and 736 in GPJ). On average, LOE in pediatrics-focused articles within The Lancet were significantly higher than all GPJ (p < 0.05). Average CONSORT scores were significantly higher in HICJ vs. GPJ (15.2 vs. 13.6, respectively, p < 0.001). CONCLUSIONS: LOE and quality of randomized control trials within the pediatric field is highest within HICJ, however, only represent a small proportion of data published. Following CONSORT criteria, and promoting studies of high LOE may allow authors and readers to turn to journals and articles of greater clinical impact.

Perinephric abscesses in the pediatric population: case presentation and review of the literature.

BACKGROUND: Perinephric abscesses in children are rare. Infection can come from various areas, and clinical signs overlap with more common etiologies, such as pyelonephritis. Imaging modalities and laboratory investigations help lead to a definitive diagnosis. CASE-DIAGNOSIS/TREATMENT: We present a case of a 5-month-old infant presenting with a febrile illness and eventual diagnosis of a perinephric abscess causing abdominal compartment syndrome. The infant had no known risk factors, i.e., congenital genitourinal abnormalities or immunosuppression, and was treated successfully following initial resuscitation, appropriate antibiotics, and open surgical drainage. Cultures obtained from the abscess and peritoneal fluid were positive for S. aureus, while blood and urine cultures were negative. CONCLUSIONS: A literature review found 13 studies looking at diagnosis and/or treatment of idiopathic perinephric abscess. With non-specific clinical signs and symptoms, diagnosis can be delayed and rests heavily on clinical suspicion and appropriate imaging. Treatment includes antibiotics alone, or in conjunction with percutaneous or open surgical drainage. In summarizing these studies, a suggestion for diagnosis and basic treatment approach is outlined.

Do antipyretics prevent the recurrence of febrile seizures in children? A systematic review of randomized controlled trials and meta-analysis.

OBJECTIVES: To determine the effectiveness of antipyretics use in prevention of subsequent febrile seizures in children. DATA SOURCES: A search for all available electronic databases (MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, ACP Journal Club, Database of Abstracts of Reviews of Effects (DARE), Cochrane Central Register of Controlled Trials, Cochrane Methodology Register) from 1950 to July 2011 was done. No language restrictions were applied, but English abstract required. STUDY SELECTION: We included randomized controlled trials comparing the efficacy of antipyretic drugs to placebo in reducing the recurrence rate of febrile seizures in children (6-72 months) with previous febrile seizures. We excluded reviews, letters, and uncontrolled or non-randomized studies. DATA EXTRACTION AND SYNTHESIS: The literature search was performed by a professional medical librarian. Based of the preliminary search, two reviewers independently pooled studies for detailed manual review per the inclusion criteria. We used the Cochrane Review Manager software (Revman 5) to calculate the odds ratio and 95% confidence intervals (CI) for seizure recurrence, assuming a random-effects model. RESULTS: Initial search identified 479 citations, five articles underwent further rigorous evaluation by two reviewers and three papers met the inclusion criteria. In these three studies, 540 children were included, of whom 348 received antipyretics (acetaminophen (15 mg/kg), ibuprofen (5-10mg/kg) or diclofenac (1.5mg/kg)) and 192 received placebo for prevention of subsequent febrile seizures during a 1-2 year follow-up period. Seventy-nine patients (22.7%) in the antipyretics group and forty-seven patients (24.4%) in the placebo group had febrile seizure recurrence during follow up. No statistically significant difference was found between the antipyretics and the placebo groups in the recurrence rate of febrile seizures (OR 0.9, 95% CI: 0.57-1.43). CONCLUSION: Antipyretics were ineffective in reducing the recurrence of febrile seizures.

Parental sex and age: their effect on pain assessment of young children.

OBJECTIVE: This study aimed to determine whether mothers and fathers assess pain in their offspring differently and to assess other variables that may affect the way parents assess their child's pain. METHODS: A prospective cohort study was conducted at a university-affiliated hospital in Israel. Children who were 0 to 4 years, who came to the emergency department with both parents and underwent a painful procedure, were included. The investigators provided instructions regarding the use of a visual analog scale (VAS) to both parents at the same time using a standard information kit. Both parents were asked to rank the child's pain on a 100-mm VAS. Parents were blinded to each other's score. RESULTS: A total of 61 couples were examined. There was no significant difference between mothers' VAS (59.1 ± 27.4) compared with father's VAS (57.9 ± 26.3) (P = 0.75).When analyses were stratified by mothers' age, the VAS declined from 67.4 ± 29 among mothers at the lowest age tertile to 48.4 ± 29 among mothers at the oldest age tertile. The fathers' VAS declined from 63.1 ± 25 among participants at the lowest age tertile to 51.3 ± 27 in the oldest age tertile. CONCLUSIONS: Fathers and mothers do not differ in their evaluation of their children's rating of pain. Younger parents, compared with older ones, tend to evaluate pain as more severe.

Sudden-onset tachypnea and confusion in a previously healthy teenager.

Acute intoxication with acetylsalicylic acid is a severe event commonly seen in children resulting from wide availability of this drug without prescription. Cases of self-poisoning resulting from overdose continue to occur and, although far less common, they are often severe and life-threatening. We report a 14-year-old girl who presented to the emergency department with tachypnea and altered mental status as a result of acetylsalicylic acid overdose in a suicide attempt. We discuss her presentation and the pathophysiological considerations leading to the management decisions taken during her emergency department stay, highlighting the role of the clinician and therapeutic drug monitoring consultant. The use of rapid decontamination with multiple doses of charcoal, even when more than 4 hours have passed since ingestion, and the use of urinary alkalinization are stressed. Timely management can obviate the need for dialysis. Published cases of acetylsalicylic acid intoxication are reviewed.

Hemorrhagic shock and encephalopathy syndrome: clinical course and neurological outcome.

The syndrome of hemorrhagic shock and encephalopathy is associated with an acute onset of diarrhea, followed by shock, disseminated intravascular coagulopathy, multiorgan failure, and encephalopathy. The etiology of this syndrome is unknown, and despite intensive treatment, the outcome is often fatal or associated with severe neurological sequelae. Two infants aged 6 and 9 months were admitted with this syndrome within a 24-hour time interval. The authors hereby present the clinical course and a prospective evaluation of the neurological outcome. A review of the literature regarding this infrequent syndrome is presented.

Pain in infants who are younger than 2 months during suprapubic aspiration and transurethral bladder catheterization: a randomized, controlled study.

OBJECTIVE: Proper diagnosis of urinary tract infections depends on obtaining an uncontaminated urine sample for culture. Suprapubic aspiration and transurethral catheterization are the 2 recommended procedures for obtaining specimens for urine culture from young infants. The objective of the current study was to compare the pain that is experienced during these 2 procedures when performed in young infants. METHODS: A prospective, single-blind, randomized, controlled study was conducted at a university-affiliated hospital in Israel. Institutional Research Ethics Board approved the study. Infants who were 0 to 2 months of age and presented to the emergency department with fever and therefore required urine collection for culture were randomly assigned evenly into 2 sample collection groups: suprapubic aspiration or transurethral catheterization. Patients were excluded when they were born prematurely or had had a previous sepsis workup or other painful procedures or an anomaly of the urogenital system or abdominal wall. Eutectic mixture of local anesthetic cream that contained lidocaine and prilocaine was applied 1 hour before the procedure. The urethra was catheterized using a 5-Fr latex-free feeding tube that was lubricated with sterile water-soluble jelly that contained 2% lidocaine hydrochloride. Pediatric residents who were experienced with the procedures performed both suprapubic aspiration and transurethral catheterization. The parents were instructed to use any comfort strategies that they wished, including verbal or physical comforting and pacifiers. Pain during collection was assessed on a 100-mm visual analog scale by a nurse and a parent. In addition, the infant's upper part of the body was videotaped during the procedure. An investigator, who was blinded to the procedure, assigned a point score according to the Douleur Aigue du Nouveaune neonatal acute pain scale. For ensuring a successful blinding process, the following steps were taken. First, camera recording started 30 seconds before the procedure to prevent the possibility of distinguishing between the procedures on the basis of their duration. Second, the physician and the nurse were asked not to speak during the procedure to avoid revealing the nature of the procedure. Third, the person who videotaped the procedure watched the tape before it was analyzed to ensure the impossibility of identifying the procedure from the tape. The Student's t test was used to compare the groups. The primary outcome was the mean Douleur Aigue du Nouveaune score. Secondary outcomes were the mean visual analogue scale for pain as estimated by the parents and by the nurse. We estimated that 25 patients would be needed in each group to detect a difference in the mean Douleur Aigue du Nouveaune score of at least 2 points with a power of 80% and alpha of .05. RESULTS: The study was conducted between April 1, 2004, and April 30, 2005. Fifty-eight infants were recruited; 29 were randomly assigned to suprapubic aspiration, and 29 were randomly assigned to transurethral catheterization. Seven infants were excluded because of consent withdrawal (3 patients), because of technical difficulties during videotaping (3 patients), or because the child voided during the procedure (1 patient). Twenty-seven infants in the suprapubic aspiration group and 24 in the transurethral catheterization group completed the study. All male infants were circumcised. An adequate urine sample was obtained in 18 (66%) of 27 patients in the suprapubic aspiration group and in 20 (83.3%) of 24 in the transurethral catheterization group. The mean Douleur Aigue du Nouveaune score was significantly higher in patients who were randomly assigned to suprapubic aspiration compared with patients who were randomly assigned to transurethral catheterization (7 and 4.5, respectively). The differences in Douleur Aigue du Nouveaune score also were significant in a subgroup analysis of boys and girls. Mean visual analogue scale scores by parents was higher in the suprapubic aspiration group compared with transurethral catheterization (63 +/- 27 mm vs 46 +/- 26, respectively). Similarly, mean visual analogue scale scores by nurses was higher in the suprapubic aspiration group compared with transurethral catheterization (3 +/- 18 mm vs 43 +/- 25 mm, respectively). CONCLUSIONS: In infants who are younger 2 months, suprapubic aspiration is more painful than transurethral catheterization. Health professionals should consider these differences when choosing a method for obtaining a urine sample from young infants.