The relationship between nasopharyngeal CCL5 and microbiota on disease severity among infants with bronchiolitis.

Emerging evidence suggests that the airway microbiota plays an important role in viral bronchiolitis pathobiology. However, little is known about the combined role of airway microbiota and CCL5 in infants with bronchiolitis. In this multicenter prospective cohort study of 1005 infants (age <1 year) hospitalized for bronchiolitis during 2011-2014, we observed statistically significant interactions between nasopharyngeal airway CCL5 levels and microbiota profiles with regard to the risk of both intensive care use (Pinteraction =.02) and hospital length-of-stay ≥3 days (Pinteraction =.03). Among infants with lower CCL5 levels, the Haemophilus-dominant microbiota profile was associated with a higher risk of intensive care use (OR, 3.20; 95%CI, 1.18-8.68; P=.02) and hospital length-of-stay ≥3 days (OR, 4.14; 95%CI, 2.08-8.24; P<.001) compared to the Moraxella-dominant profile. Conversely, among those with higher CCL5 levels, there were no significant associations between the microbiota profiles and these severity outcomes (all P≥.10).

Allergen-specific IgE as a biomarker of exposure plus sensitization in inner-city adolescents with asthma.

BACKGROUND: Relationships among allergen-specific IgE levels, allergen exposure and asthma severity are poorly understood since sensitization has previously been evaluated as a dichotomous, rather than continuous characteristic. METHODS: Five hundred and forty-six inner-city adolescents enrolled in the Asthma Control Evaluation study underwent exhaled nitric oxide (FE(NO)) measurement, lung function testing, and completion of a questionnaire. Allergen-specific IgE levels and blood eosinophils were quantified. Dust samples were collected from the participants' bedrooms for quantification of allergen concentrations. Participants were followed for 12 months and clinical outcomes were tracked. RESULTS: Among sensitized participants, allergen-specific IgE levels were correlated with the corresponding settled dust allergen levels for cockroach, dust mite, and mouse (r = 0.38, 0.34, 0.19, respectively; P < 0.0001 for cockroach and dust mite and P = 0.03 for mouse), but not cat (r = -0.02, P = 0.71). Higher cockroach-, mite-, mouse-, and cat-specific IgE levels were associated with higher FE(NO) concentrations, poorer lung function, and higher blood eosinophils. Higher cat, dust mite, and mouse allergen-specific IgE levels were also associated with an increasing risk of exacerbations or hospitalization. CONCLUSIONS: Allergen-specific IgE levels were correlated with allergen exposure among sensitized participants, except for cat. Allergen-specific IgE levels were also associated with more severe asthma across a range of clinical and biologic markers. Adjusting for exposure did not provide additional predictive value, suggesting that higher allergen-specific IgE levels may be indicative of both higher exposure and a greater degree of sensitization, which in turn may result in greater asthma severity.

The associations among pediatricians' knowledge, attitudes, and practices regarding emergency contraception.

OBJECTIVES: To quantify practitioner administration of the emergency contraceptive pill (ECP) among adolescent patients, and to determine if such administration is associated with physician knowledge and attitudes regarding efficacy, side effects, and appropriate use. DESIGN: Survey of pediatricians. SETTING: The survey address list was generated from a database of active Fellows of the American Academy of Pediatrics in the District of Columbia metropolitan area. MAIN OUTCOMES MEASURES: Prescription of the ECP in the previous 12 months, or counseling of an adolescent patient about the ECP. RESULTS: Of the 236 questionnaires distributed, 143 (61%) were returned and 121 (51%) were usable. Twenty-four pediatricians (20%) reported prescribing the ECP, and 29 (24%) had counseled adolescent patients about the ECP. Of the practice-related variables surveyed, both the number of adolescents seen per week and the practice setting were significantly associated with these outcomes. Of the knowledge-related variables surveyed, knowledge of the timing and the Food and Drug Administration-labeled status of the ECP were significantly associated with outcomes. None of the attitude-related variables surveyed were associated with outcomes. CONCLUSIONS: This study demonstrates that knowledge deficits, not attitude-related variables, are significantly associated with the low level of ECP administration and counseling among District of Columbia pediatricians. Because knowledge deficits are amenable to educational interventions, our data suggest that informing pediatricians about the ECP may increase its administration among their adolescent patients.emergency contraceptive pill, pediatricians, adolescents.

Prospective study of recurrent radial head subluxation.

OBJECTIVES: To calculate a recurrence rate for radial head subluxation (RHS) and to identify risk factors for recurrence. DESIGN: Prospective cohort study. SETTING: Pediatric emergency department of an urban, tertiary care children's hospital. PATIENTS: Consecutive sample of 107 children younger than 6 years with definite (n = 94) or probable (n = 13) RHS enrolled during a 6-month period and followed up for at least 12 months. MAIN OUTCOME MEASURE: Recurrent episodes of RHS. RESULTS: Follow-up information was available on 86.9% (93/107) patients, with a mean +/- SD of 16.4 +/- 1.9 months (range, 12 to 20 months). Of these 93 patients, 22 (23.7%) had recurrent RHS. Among the patients who had their first episode of RHS during the study period (n = 76), those with recurrences were significantly younger than those without (21.7 +/- 9.9 months vs 29.2 +/- 13.5 months, respectively, P = .04, t test). Those 24 months or younger had a relative risk of 2.60 for one or more recurrences during the study period (95% confidence interval, 1.04 to 6.30) compared with those older than 24 months. No differences were observed in duration of follow-up, sex, elbow involved in the initial episode, or family history of RHS between those with and without recurrences. CONCLUSIONS: Recurrent RHS occurs in nearly one fourth of patients, and those 24 months or younger are at greatest risk. Sex, family history, and the elbow involved in the initial episode are not risk factors for recurrence.

Compliance with penicillin prophylaxis in patients with sickle cell disease.

OBJECTIVE: To assess factors related to compliance with penicillin prophylaxis among patients with sickle cell disease. DESIGN: Prospective case series. SETTING: Urban pediatric medical center where universal penicillin prophylaxis is recommended for all patients with any sickle cell hemoglobinopathy independent of age. PARTICIPANTS: Eligible patients with sickle cell hemoglobinopathies were enrolled in either the emergency department or the sickle cell clinic. MAIN OUTCOME MEASURES: Compliance was assessed by structured interview and by urine assay with an established method (Micrococcus luteus with disk diffusion) that detects excreted penicillin up to 15 hours after each dose administration. RESULTS: Of the 159 patients actively followed up at the sickle cell center, 123 (77.3%) eligible patients were enrolled. Reported compliance by structured interview (> or = 1 dose of penicillin V potassium within 15 hours of enrollment) was 83 of 123 patients (67.5%; 95% confidence interval, 59.2%-75.8%), whereas measured compliance as determined by urine assay was 53 of 123 patients (43.1%; 95% confidence interval, 31.3%-51.7%). Measured compliance was significantly greater in patients younger than 5 years than in those older than 5 years (25/41 [61%] vs 28/82 [34%], respectively; P = .004), and was significantly greater in patients with private insurance than in those with public insurance (17/28 [61%] vs 33/90 [37%], respectively; P = .02). Measured compliance was not significantly associated with sex, site of recruitment, hemoglobinopathy, or chief complaint in the emergency department. CONCLUSIONS: Measured compliance was poor, and patients and/or their families frequently misrepresented their compliance when interviewed. These data suggest that efforts are necessary to improve overall compliance, and they identify groups at greatest risk for noncompliance.

Bacterial infections in infants 60 days and younger: epidemiology, resistance, and implications for treatment.

OBJECTIVE: To establish what might be more optimal initial antibiotic therapy for suspected invasive bacterial infections in infants 60 days or younger who are evaluated in the emergency department (ED). SETTING: Urban university-affiliated pediatric referral center with an average yearly ED census of 52000 visits during the study period. DESIGN AND METHODS: We assembled a retrospective case series of all positive blood, urine, and cerebrospinal fluid cultures in children 60 days or younger from January 1, 1994, through December 31, 1997, obtained from both inpatients and patients initially evaluated in the ED. From this case series we determined the frequency of bacterial pathogens responsible for such infections in this age group. Pathogens were defined as group B streptococcus, various enteric gram-negative rods (GNRs), Listeria monocytogenes, enterococcus, Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type B, and Staphylococcus aureus. A subgroup analysis was performed to determine resistance patterns among the GNRs isolated from patients evaluated in the ED. RESULTS: A total of 367 pathogens were isolated: 187 (51.0%) in the neonatal intensive care unit, 153 (41.7%) in the ED, 20 (5.4%) in the inpatient wards, and 7 (1.9%) in the pediatric intensive care unit. Of the 121 pathogens isolated from 120 ED patients that were eligible for review, 94 (77.7%) were in the urine only, 16 (13.2%) in blood only, 4 (3.3%) in cerebrospinal fluid only, 3 (2.5%) in blood and cerebrospinal fluid, and 4 (3.3%) in blood and urine. Organisms isolated included GNRs (n = 96, 79.3%), group B streptococcus (n = 14, 11.6%), enterococcus (n = 7, 5.8%), S. pneumoniae (n = 3, 2.5%), and N. meningitidis (n = 1, 0.8%). No Listeria were isolated. Of the 96 GNRs isolated, 60 (62.5%; 95% confidence interval, 52.8%-72.1%) were ampicillin resistant. All were sensitive to gentamicin sulfate and cefotaxime sodium. CONCLUSIONS: Our results reveal 2 important facts: (1) during a 4-year period, no isolates of Listeria were identified from any patients 60 days or younger; and (2) of the 96 GNRs isolated from patients in the ED, more than 60% were ampicillin resistant. These data suggest that in similar centers with a low incidence of infection with Listeria and high levels of ampicillin resistance among GNRs, empiric use of ampicillin as part of a combination for presumed bacterial infections in patients 60 days or younger initially evaluated in the ED may be neither necessary nor beneficial. Consideration should be given to empiric initial antibiotic therapy using a third-generation cephalosporin with or without gentamicin.

Human herpesviruses types 6 and 7 and febrile seizures.

The frequency was studied with which human herpesviruses types 6 and 7 (HHV-6 and HHV-7) occur in the cerebrospinal fluid (CSF) of patients with febrile seizures and matched control patients. CSF samples were prospectively collected from a case series of patients with febrile seizures and from age-, sex-, and race-matched control patients without febrile seizures, all of whom were evaluated in the emergency department of an urban, tertiary care, pediatric medical center. Using polymerase chain reaction, the samples were examined for the presence of viral DNA from HHV-6, HHV-7, herpes simplex viruses types 1 and 2 (HSV-1 and HSV-2), and cytomegalovirus (CMV). CSF from a subset of both groups was also examined for RNA from enteroviruses. During the 7-month, 2-week collection period, a total of 174 patients were evaluated for fever and seizures. Of these, 23 (13.2%) met the study criteria. Their mean age was 1.4 +/- 0.7 years. Sixteen (70%) of the 23 were male. The 23 patients were matched to 21 control subjects. None of the samples from the patients or control subjects had polymerase chain reaction evidence of HHV-6, HHV-7, HSV-1, or HSV-2. All samples from the patients were negative for CMV. One control subject was positive for CMV. The 10 patients and seven control subjects tested for enteroviral RNA were negative. Neither HHV-6 nor HHV-7 appears to be present in the CSF of patients with febrile seizures. What role, if any, they have in the pathogenesis of febrile seizures merits further study.

Pneumococcal bacteremia and focal infection in young children.

We reviewed a consecutive case series of 178 immunocompetent children aged 3-36 months without central venous lines who had blood cultures positive for Streptococcus pneumoniae by either of paired broth and quantitative culture methods. The incidence of accompanying focal infection was significantly greater in patients with > 10 colony-forming units (cfu)/mL than in patients with < or = 10 cfu/mL (30.4% vs 12.9% respectively, p = 0.04). No significant relationships existed between the magnitude of bacteremia and the age, gender, presenting temperature, interval until the blood culture turned positive, total peripheral blood white cell count, absolute neutrophil count, or absolute band count. Overall, the quantitative method detected 59/178 (33.1%) of the isolates, including five isolates (2.8%) that the broth method failed to detect.

Laboratory predictors of fluid deficit in acutely dehydrated children.

To determine which laboratory studies are most predictive of the fluid deficit in acutely dehydrated children, we studied a convenience sample of 40 children requiring intravenous fluid resuscitation. Nine laboratory studies (serum BUN/cr, total serum CO2, serum uric acid, serum anion gap, urine anion gap, venous pH, venous base deficit, urine specific gravity, and fractional excretion of sodium) were individually assessed in simple linear regression models with fluid deficit as the dependent variable. Only the serum BUN/cr and serum uric acid were significantly associated with increasing fluid deficit (r = 0.52, P = 0.0005 and r = 0.35, P = 0.03, respectively). The sensitivities and specificities of these two laboratory studies for the detection of > 5% fluid deficit were poor. Conventional laboratory studies used to assess dehydration in children are poorly predictive of fluid deficits.

Rectal bleeding in the pediatric emergency department.

STUDY OBJECTIVES: To describe the presumptive diagnoses in an unselected, ambulatory, pediatric population complaining of rectal bleeding; to determine how often those diagnoses changed with follow-up; and to determine how often the bleeding represented an acutely life-threatening condition. DESIGN: Retrospective case series. SETTING: Urban, tertiary care pediatric emergency department. PARTICIPANTS: One hundred four patients with 109 visits with a chief complaint of blood in the stool. INTERVENTIONS: None. MAIN RESULTS: Follow-up was available on 95 of 109 visits (87.1%), with a mean duration of 7.5 months. A specific presumptive etiology was established for 73 of 109 patients (67%) at the initial ED visit and for 74 of 95 patients (77%) at follow-up. The etiologies varied markedly by age. Four patients (4.2%; 95% confidence interval, 0.2% to 8.2%) presented with a life-threatening condition (requiring an RBC transfusion or operative intervention): intussusception (three patients) and Meckel's diverticulum (one patient). Concordance between the ED diagnosis and the follow-up diagnosis was 81%. CONCLUSION: A complaint of rectal bleeding is typically not life threatening in children. Emergency physicians normally are able to establish a presumptive diagnosis, which usually remains the same with follow-up.

Duration of fever and its relationship to bacteremia in febrile outpatients three to 36 months old. The Occult Bacteremia Study Group.

OBJECTIVE: To determine the relationship between the duration of fever as reported by caregivers and the likelihood of occult bacteremia in highly febrile young children. METHODS: This is a prospective cohort study performed as part of a prior, multicenter, randomized, interventional trial of oral versus intramuscular antibiotics in the prevention of complications of occult bacteremia in febrile children presenting to nine urban pediatric emergency departments at eight medical centers. Participants included children three to 36 months of age with a temperature of > or = 39.0 degrees C and a nonfocal illness (or uncomplicated otitis media) managed as outpatients. The outcome measure was the presence of bacteremia. RESULTS: Of the 6680 randomized patients, 6619 (99.1%) had a culture of their blood and a valid reported duration of fever. The median duration of fever in patients with bacteremia (n = 192) and without bacteremia (n = 6427) was the same, one to two days, but the mean rank of patients with bacteremia was significantly lower than that of patients without bacteremia (P + 0.0009). A significantly greater proportion of patients with fever < 1 day had bacteremia than patients with fever > or = 1 day (P = 0.004), and a significantly greater proportion of patients with fever < 2 days had bacteremia than patients with fever > or = 2 days (P = 0.009). The sensitivity, specificity, positive predictive value, and negative predictive value of fever < 1 day in detecting occult bacteremia were 40.1, 69.8, 3.8, and 97.5%, respectively.

Efficacy of an observation scale in detecting bacteremia in febrile children three to thirty-six months of age, treated as outpatients. Occult Bacteremia Study Group.

OBJECTIVE: To assess the efficacy of the Yale Observation Scale (YOS) in detecting occult bacteremia in febrile, ambulatory pediatric patients with no apparent signs or symptoms of severe infection and with no focal infection. DESIGN: YOS scores were assigned as part of a prospective, multicenter, randomized, interventional trial of oral and intramuscular antibiotics in preventing the complications of occult bacteremia in febrile children. SETTING: Pediatric emergency departments at eight urban medical centers. PARTICIPANTS: Children, 3 to 36 months of age with a temperature at least 39.0 degrees C, a nonfocal, non-toxic-appearing illness (or uncomplicated otitis media), treated as outpatients. INTERVENTIONS: None. RESULTS: There were 6611 assessable patients, who had both a blood culture result and a YOS score assigned. The median YOS score for both patients with bacteremia (n = 192) and patients without bacteremia (n = 6419) was 6, but the mean rank among patients with bacteremia was significantly higher (p < 0.0001). The sensitivity, specificity, and positive and negative predictive values for a YOS score greater than 10 were 5.2%, 96.7%, 4.5%, and 97.1%, respectively. CONCLUSIONS: The YOS scores are higher among patients with bacteremia than among patients without bacteremia, but the difference is not clinically useful in detecting occult bacteremia in febrile children, with nonfocal, apparently nontoxic infection, treated as outpatients in this age group.

Incidence of bacteremia, urinary tract infections, and unsuspected bacterial meningitis in children with febrile seizures.

PURPOSE: To determine the incidence of bacteremia, urinary tract infections, and unsuspected bacterial meningitis in a cohort of children diagnosed with febrile seizures. METHODS: We assembled a retrospective, consecutive case series of patients who presented to an urban tertiary care pediatric emergency department for evaluation of febrile seizures during a consecutive 12- month period. A febrile seizure was defined as a convulsion associated with a temperature > or = 38.0 degrees C occurring in a child < or = 6 years. Children with initial laboratory evidence of meningoencephalitis in the emergency department (>8 white blood cells per milliliter of cerebrospinal fluid), known seizure disorders, chronic neurologic disease, or documented immunodeficiencies were excluded. RESULTS: There were 243 eligible patient encounters among 218 patients during the study period. The mean age was 1.9+/-0.96 years (range 0.3-5.9, median 1.7), and 156 (64.2%) were male. Of the 243 encounters, 214 (88.1%) were for simple febrile seizures and 29 (11.9%) were for complex febrile seizures. Blood cultures were performed during 206/243 encounters (84.8%), and 6/206 (2.9%, 95%CI 0.6-5.2%) were positive, all for Streptococcus pneumoniae. All six positive cultures occurred among the 154 encounters in children 3 to 36 months with a temperature > or = 39.0 degrees C and no pretreatment with antibiotics (incidence 6/154 or 3.9%, 95% CI 0.9-6.9%). Urine cultures were performed during 130/243 encounters (53.5%), and 1/130 (0.7%, 95% CI 0.0-2.2%) yielded a bacterial pathogen. Cerebrospinal fluid analysis was performed during 66/243 encounters (27.2%), and 0/66 (0.0%, 95% CI 0.0-4.5%) yielded bacterial pathogens. CONCLUSIONS: Patients presenting for evaluation of febrile seizures are not at increased risk for bacteremia or urinary tract infections. Bacterial meningitis in the absence of initial laboratory evidence of meningoencephalitis is very uncommon in children diagnosed with febrile seizures.

Death and resuscitation in the pediatric emergency department.

STUDY OBJECTIVE: To describe a population of patients who arrived in a pediatric emergency department with pulse and respirations but then sustained cardiopulmonary or respiratory arrest while in the ED. DESIGN: Retrospective case series of patients from July 1987 to June 1993. SETTING: Urban, tertiary care pediatric ED. PARTICIPANTS: All patients who sustained cardiopulmonary or respiratory arrest while in the ED. RESULTS: Thirty-two cases of cardiopulmonary (n = 18) or respiratory arrest (n = 14) were identified, for an incidence of 1.2 arrests per 10,000 patient visits. Causes of arrest varied widely. Excluding those patients with do-not-resuscitate orders (n = 2), an initial response to resuscitative efforts was obtained in 22 of 30 (73%) patients. Overall rates of survival to discharge from the ED and from the hospital were 21 of 30 (70%) and 15 of 30 (50%), respectively. Of those patients who survived to hospital discharge, 12 of 15 (80%) were discharged at a baseline level of overall function. CONCLUSION: Cardiopulmonary or respiratory arrest in the pediatric emergency department is rare. The rate of survival of such an arrest is superior to that in outpatient arrests but inferior to that in inpatient arrests.

Prehospital fluid therapy in pediatric trauma patients.

In order to evaluate the impact of prehospital intravenous fluid therapy on the outcome of pediatric trauma patients and to evaluate the effect of such therapy on the on-scene interval, we performed a retrospective chart review of 50 pediatric trauma patients less than 18 years old transported directly from the field by Emergency Medical Services personnel with an intravenous catheter in place and admitted to the Trauma Service of a level I urban pediatric trauma center. As judged by an expert panel using a new grading system, prehospital intravenous fluid therapy was inconsequential to outcome in 47 of 50 patients, possibly beneficial in two of 50 patients, and possibly detrimental in one of 50 patients. Patients who received their catheters at the scene had significantly longer on-scene intervals than those who received them in the ambulance (15.4 vs 11.4 minutes, P < 0.05). The mean volume of fluid administered was 4.4 ml/kg body weight. Placement of the catheter (at the scene vs in the ambulance) and prehospital fluid volume administered were independent of the Injury Severity Score. The role of prehospital fluid therapy in pediatric trauma patients in an urban setting requires reevaluation.