Pediatric peanut aspirations before and after 2015 recommendation for early peanut exposure.

OBJECTIVES: To investigate if there has been an increase in peanut foreign body aspirations (FBA) in children since the publication of the Learning Early About Peanut Allergy (LEAP) trial, which revealed that early exposure to peanut-containing foods prevented peanut allergies in children at risk of atopic disease. METHODS: Retrospective chart reviews were conducted separately at two pediatric institutions. Institutions One and Two reviewed children less than 7 years old who underwent bronchoscopy for FBA over ten-year periods between January 2007 and September 2017 and November 2008 and May 2018, respectively. The proportion of FBAs attributed to peanuts was compared before and after the publication LEAP. RESULTS: Out of 515 reviewed cases, there was no change in pediatric peanut aspirations prior to and following the LEAP trial and AAP guideline change (33.5% vs 31.4%, p = 0.70). At Institution One, 317 patients met inclusion criteria. When comparing FBAs before and after LEAP, there were no significant changes in the rate of peanut aspiration (53.5% vs. 45.1%, p = 0.17). Institution Two also found no significant increase in the rate of peanut aspirations before and after the Addendum Guidelines (41.4% vs. 28.6%, p = 0.65) upon review of 198 cases. CONCLUSIONS: Multiple institutions demonstrated a non-significant change in the rate of peanut FBAs following the AAP recommendation. Given that peanuts comprise a large proportion of FBAs, it is important to continue to track peanut aspirations. Longer term data tracking is needed from more institutions to further understand how recommendations from other specialties and the media impacts pediatric aspiration outcomes.

Streptococcal Pharyngitis: Compliance With National Testing Guidelines in a Pediatric Emergency Department.

OBJECTIVES: The Infectious Diseases Society of America (IDSA) guidelines regarding group A streptococcal (GAS) pharyngitis advise against routine testing for patients younger than 3 years, patients without pharyngitis, and patients with symptoms suggesting a viral infection. Group A streptococcal testing may be overused in some clinical settings; thus, we conducted this study to evaluate compliance with the IDSA guidelines in a pediatric emergency department (ED) setting. METHODS: This retrospective cohort study describes patients younger than 18 years presenting to 2 urban pediatric EDs in 2016 who underwent rapid antigen detection testing for GAS pharyngitis. Testing was classified as noncompliant with the IDSA guidelines if the chief complaint was not indicative of GAS infection and/or the patient age was younger than 3 years. Appropriate nonparametric tests compared groups by IDSA testing compliance status. RESULTS: A total of 13,585 patient encounters met inclusion criteria; 5255 (39%) were noncompliant with the IDSA testing guidelines, the majority due to a chief complaint inconsistent with GAS pharyngitis (67%) and secondarily due to the age of younger than 3 years (48%). Among the patients with noncompliant testing, 51% were prescribed an antibiotic, and return encounters were more likely to occur (13% vs 10%, P < 0.001). Return encounters more commonly resulted in respiratory diagnoses in those with noncompliant GAS testing (60% vs 45%, P < 0.001). CONCLUSIONS: Nearly 40% of all pediatric ED encounters with GAS testing were noncompliant with the IDSA guidelines and were associated with greater return encounter rates. Potential negative outcomes from noncompliant GAS testing include misdiagnosis, inappropriate use of antibiotics, allergic reactions, and loss of school days. Informed interventions to reduce unnecessary GAS testing are warranted.

Predictors of Invasive Herpes Simplex Virus Infection in Young Infants.

OBJECTIVES: To identify independent predictors of and derive a risk score for invasive herpes simplex virus (HSV) infection. METHODS: In this 23-center nested case-control study, we matched 149 infants with HSV to 1340 controls; all were ≤60 days old and had cerebrospinal fluid obtained within 24 hours of presentation or had HSV detected. The primary and secondary outcomes were invasive (disseminated or central nervous system) or any HSV infection, respectively. RESULTS: Of all infants included, 90 (60.4%) had invasive and 59 (39.6%) had skin, eyes, and mouth disease. Predictors independently associated with invasive HSV included younger age (adjusted odds ratio [aOR]: 9.1 [95% confidence interval (CI): 3.4-24.5] <14 and 6.4 [95% CI: 2.3 to 17.8] 14-28 days, respectively, compared with >28 days), prematurity (aOR: 2.3, 95% CI: 1.1 to 5.1), seizure at home (aOR: 6.1, 95% CI: 2.3 to 16.4), ill appearance (aOR: 4.2, 95% CI: 2.0 to 8.4), abnormal triage temperature (aOR: 2.9, 95% CI: 1.6 to 5.3), vesicular rash (aOR: 54.8, (95% CI: 16.6 to 180.9), thrombocytopenia (aOR: 4.4, 95% CI: 1.6 to 12.4), and cerebrospinal fluid pleocytosis (aOR: 3.5, 95% CI: 1.2 to 10.0). These variables were transformed to derive the HSV risk score (point range 0-17). Infants with invasive HSV had a higher median score (6, interquartile range: 4-8) than those without invasive HSV (3, interquartile range: 1.5-4), with an area under the curve for invasive HSV disease of 0.85 (95% CI: 0.80-0.91). When using a cut-point of ≥3, the HSV risk score had a sensitivity of 95.6% (95% CI: 84.9% to 99.5%), specificity of 40.1% (95% CI: 36.8% to 43.6%), and positive likelihood ratio 1.60 (95% CI: 1.5 to 1.7) and negative likelihood ratio 0.11 (95% CI: 0.03 to 0.43). CONCLUSIONS: A novel HSV risk score identified infants at extremely low risk for invasive HSV who may not require routine testing or empirical treatment.

Utilization of the electrocardiogram in the pediatric emergency department.

OBJECTIVE: Review pediatric electrocardiogram (ECG) result severity classification and describe the utilization of ECG testing, and rate of clinically significant results, in the pediatric emergency department (PED). METHODS: This was a review of patients ≤18 years who had an ECG performed in a tertiary children's hospital PED 2005-2017. Using established guidelines and expert consultation, ECG results were categorized: Class 0 = normal, Class I = mild abnormality (no cardiology follow-up), Class II = moderate abnormality (cardiology follow-up), Class III = severe abnormality (immediate intervention). Chi-square tests were used to examine differences between patients with clinically insignificant (Class 0/I) and clinically significant (Class II/III) results. Multivariable regression was used to examine factors associated with clinically significant results. RESULTS: 16,147 unique PED encounters with ECG performed were included for analysis. The most common ECG indications were chest pain (32.5%), syncope (22.0%), arrhythmia (11.8%), toxicology/ingestion (9.4%), and seizure (5.7%). Overall, 12.7% (n = 2056) of ECGs had clinically significant (Class II/III) results, and only 2.0% (n = 325) had severe abnormality (Class III) that would require immediate intervention or cardiologist input. Factors associated with increased odds of clinically significant ECG were age ≤ 1 year (OR = 1.20, 95% CI: 1.02-1.41), male (OR = 1.33, 95% CI: 1.20-1.46), and indications of arrhythmia (OR = 1.84, 95% CI: 1.59-2.13), cardiac (OR = 2.57, 95% CI: 1.99-3.31), blank indication (OR = 1.52, 95% CI: 1.17-1.98), and electrolyte abnormality (OR = 1.42, 95% CI: 1.03-1.95). CONCLUSIONS: In this study, we provided a valuable review of ECG result severity classification in the pediatric population. We found that chest pain and syncope represented over half of all ECGs performed. We found that clinically significant results are rare in the pediatric population at 12.7% of all ECGs performed, and very few (2.0%) have severe abnormalities that would require immediate intervention. Those with increased odds of a clinically significant ECG include young patients ≤1 year of age, male patients, and certain ECG indications.

Socioeconomic Status and Analgesia Provision at Discharge Among Children With Long-Bone Fractures Requiring Emergency Care.

BACKGROUND: Inadequate treatment of painful conditions in children is a significant and complex problem. The objective of this study was to examine the effect of socioeconomic status on the provision of analgesic medicines at discharge in children treated emergently for a long-bone fracture. METHODS: A retrospective review of all patients during a 1-year period with a long-bone fracture treated in 2 urban pediatric emergency departments (EDs) was performed. RESULTS: Eight hundred seventy-three patients were identified who met our inclusion criteria. Sixty percent of patients received a prescription for an opioid-containing medicine, and 22% received a prescription for an over-the-counter analgesic medicine at ED discharge. Socioeconomic status had no effect on opioid analgesic prescriptions at discharge. Patients in the lowest-income group were younger, presented to the ED longer after an injury, were likely nonwhite, and had higher rates of over-the-counter analgesic medicine prescriptions provided at discharge. Higher-income patients were likely white and non-Hispanic, presented to the ED sooner, and were less likely to receive a prescription for a nonopioid analgesic medicine. CONCLUSIONS: Socioeconomic status is associated with different nonopioid analgesic prescription patterns in children treated in the ED for a long-bone fracture, but had no effect on opioid analgesic prescriptions.

Performance of the Modified Boston and Philadelphia Criteria for Invasive Bacterial Infections.

BACKGROUND: The ability of the decades-old Boston and Philadelphia criteria to accurately identify infants at low risk for serious bacterial infections has not been recently reevaluated. METHODS: We assembled a multicenter cohort of infants 29 to 60 days of age who had cerebrospinal fluid (CSF) and blood cultures obtained. We report the performance of the modified Boston criteria (peripheral white blood cell count [WBC] ≥20 000 cells per mm3, CSF WBC ≥10 cells per mm3, and urinalysis with >10 WBC per high-power field or positive urine dip result) and modified Philadelphia criteria (peripheral WBC ≥15 000 cells per mm3, CSF WBC ≥8 cells per mm3, positive CSF Gram-stain result, and urinalysis with >10 WBC per high-power field or positive urine dip result) for the identification of invasive bacterial infections (IBIs). We defined IBI as bacterial meningitis (growth of pathogenic bacteria from CSF culture) or bacteremia (growth from blood culture). RESULTS: We applied the modified Boston criteria to 8344 infants and the modified Philadelphia criteria to 8131 infants. The modified Boston criteria identified 133 of the 212 infants with IBI (sensitivity 62.7% [95% confidence interval (CI) 55.9% to 69.3%] and specificity 59.2% [95% CI 58.1% to 60.2%]), and the modified Philadelphia criteria identified 157 of the 219 infants with IBI (sensitivity 71.7% [95% CI 65.2% to 77.6%] and specificity 46.1% [95% CI 45.0% to 47.2%]). The modified Boston and Philadelphia criteria misclassified 17 of 53 (32.1%) and 13 of 56 (23.3%) infants with bacterial meningitis, respectively. CONCLUSIONS: The modified Boston and Philadelphia criteria misclassified a substantial number of infants 29 to 60 days old with IBI, including those with bacterial meningitis.

Hospital Course of Croup After Emergency Department Management.

OBJECTIVES: To describe inpatient management of patients with croup admitted from the emergency department (ED). METHODS: In a multicentered, cross-sectional observational study based on retrospective chart review, we identified children 6 months to 5 years of age with a discharge diagnosis of croup. All patients were evaluated in the ED and treated with at least 1 dose of racemic epinephrine (RE) before admission. Children with hypoxia or directly admitted to the PICU were excluded. RESULTS: We identified 628 admissions for croup. Significant interventions, defined as additional RE, helium-oxygen use, or PICU transfer, occurred in 142 patients (22.6%). A total of 137 children received additional RE on the inpatient ward, and 5 received RE and were transferred to the PICU. No patient was treated with helium-oxygen. A total 486 (77.4%) of patients did not receive significant interventions postadmission. Length of stay for children not requiring significant intervention was, on average, <24 hours (18.8 hours [SD 9.3]; range 1.2-111 hours). Children with tachypnea (odds ratio = 2.5; P = .002) on arrival to ED and patients who had ED radiographs (odds ratio = 1.7; P = .018) had increased odds of receiving a significant intervention after admission. CONCLUSIONS: Less than one-quarter of children admitted to the general wards for croup received significant interventions after admission. Tachypnea in the ED and use of radiograph were associated with an increased use of significant interventions.

Cerebrospinal Fluid Reference Values for Young Infants Undergoing Lumbar Puncture.

OBJECTIVES: To determine age-specific reference values and quantify age-related changes for cerebrospinal fluid (CSF) white blood cell (WBC) counts and protein and glucose concentrations in infants ≤60 days of age. METHODS: This multicenter, cross-sectional study included infants ≤60 days old with CSF cultures and complete CSF profiles obtained within 24 hours of presentation. Those with conditions suspected or known to cause abnormal CSF parameters (eg, meningitis) and those with a hospital length of stay of >72 hours were excluded. Reference standards were determined for infants ≤28 days of age and 29 to 60 days of age by using the third quartile +1.5 interquartile range for WBC and protein and the first quartile -1.5 interquartile range for glucose. CSF parameter centile curves based on age were calculated by using the LMST method. RESULTS: A total of 7766 patients were included. CSF WBC counts were higher in infants ≤28 days of age (upper bound: 15 cells/mm3) than in infants 29 to 60 days of age (upper bound: 9 cells/mm3; P < .001). CSF protein concentrations were higher in infants ≤28 days of age (upper bound: 127 mg/dL) than in infants 29 to 60 days of age (upper bound: 99 mg/dL; P < .001). CSF glucose concentrations were lower in infants ≤28 days of age (lower bound: 25 mg/dL) than in infants 29 to 60 days of age (lower bound: 27 mg/dL; P < .001). CONCLUSIONS: The age-specific CSF WBC count, protein concentration, and glucose concentration reference values identified in this large, multicenter cohort of infants can be used to interpret the results of lumbar puncture in infants ≤60 days of age.

Herpes Simplex Virus Infection in Infants Undergoing Meningitis Evaluation.

BACKGROUND: Although neonatal herpes simplex virus (HSV) is a potentially devastating infection requiring prompt evaluation and treatment, large-scale assessments of the frequency in potentially infected infants have not been performed. METHODS: We performed a retrospective cross-sectional study of infants ≤60 days old who had cerebrospinal fluid culture testing performed in 1 of 23 participating North American emergency departments. HSV infection was defined by a positive HSV polymerase chain reaction or viral culture. The primary outcome was the proportion of encounters in which HSV infection was identified. Secondary outcomes included frequency of central nervous system (CNS) and disseminated HSV, and HSV testing and treatment patterns. RESULTS: Of 26 533 eligible encounters, 112 infants had HSV identified (0.42%, 95% confidence interval [CI]: 0.35%-0.51%). Of these, 90 (80.4%) occurred in weeks 1 to 4, 10 (8.9%) in weeks 5 to 6, and 12 (10.7%) in weeks 7 to 9. The median age of HSV-infected infants was 14 days (interquartile range: 9-24 days). HSV infection was more common in 0 to 28-day-old infants compared with 29- to 60-day-old infants (odds ratio 3.9; 95% CI: 2.4-6.2). Sixty-eight (0.26%, 95% CI: 0.21%-0.33%) had CNS or disseminated HSV. The proportion of infants tested for HSV (35%; range 14%-72%) and to whom acyclovir was administered (23%; range 4%-53%) varied widely across sites. CONCLUSIONS: An HSV infection was uncommon in young infants evaluated for CNS infection, particularly in the second month of life. Evidence-based approaches to the evaluation for HSV in young infants are needed.

Impact of Enteroviral Polymerase Chain Reaction Testing on Length of Stay for Infants 60 Days Old or Younger.

OBJECTIVE: To determine the impact of a cerebrospinal fluid enterovirus polymerase chain reaction (PCR) test performance on hospital length of stay (LOS) in a large multicenter cohort of infants undergoing evaluation for central nervous system infection. STUDY DESIGN: We performed a planned secondary analysis of a retrospective cohort of hospitalized infants ≤60 days of age who had a cerebrospinal fluid culture obtained at 1 of 18 participating centers (2005-2013). After adjustment for patient age and study year as well as clustering by hospital center, we compared LOS for infants who had an enterovirus PCR test performed vs not performed and among those tested, for infants with a positive vs negative test result. RESULTS: Of 19 953 hospitalized infants, 4444 (22.3%) had an enterovirus PCR test performed and 945 (21.3% of tested infants) had positive test results. Hospital LOS was similar for infants who had an enterovirus PCR test performed compared with infants who did not (incident rate ratio 0.98 hours; 95% CI 0.89-1.06). However, infants PCR positive for enterovirus had a 38% shorter LOS than infants PCR negative for enterovirus (incident rate ratio 0.62 hours; 95% CI 0.57-0.68). No infant with a positive enterovirus PCR test had bacterial meningitis (0%; 95% CI 0-0.4). CONCLUSIONS: Although enterovirus PCR testing was not associated with a reduction in LOS, infants with a positive enterovirus PCR test had a one-third shorter LOS compared with infants with a negative enterovirus PCR test. Focused enterovirus PCR test use could increase the impact on LOS for infants undergoing cerebrospinal fluid evaluation.

Correction of Cerebrospinal Fluid Protein in Infants With Traumatic Lumbar Punctures.

In our multicenter cohort of infants ≤60 days of age, we identified 2646 infants with a traumatic lumbar puncture, of which 31 (1.2%) had bacterial meningitis. For every 1000 cerebrospinal fluid red blood cells/mm, cerebrospinal (cerebrospinal fluid) protein increased 1.1 mg/dL (95% confidence interval: 1.0-1.2 mg/dL).

Throw rug-related injuries treated in US EDs: are children the same as adults?

BACKGROUND: Various characteristics of floors and floor coverings are well established as injury hazards. Loose carpeting, such as rugs, is often cited as a hazard leading to injury. PURPOSE: To describe the epidemiology and patterns of rug, mat, and runner-related injuries in patients seeking emergency treatment. METHODS: Data from the National Electronic Injury Surveillance System from 1990 through 2009 were investigated. Sample weights were used to calculate national estimates. US Census Bureau data were used to calculate injury rates per 100 000 individuals. Linear regression and computation of relative risks (RRs) with 95% confidence intervals (CIs) were performed. RESULTS: An estimated 245 605 patients were treated in US emergency departments for rug-related injuries during the study period, with an average of 12 280 cases per year. Females (72.3%) and individuals older than 64 years (47.1%) sustained the largest number of injuries. Patients younger than 6 years were more likely to injure the head or neck region (RR, 3.52 [95% CI, 3.26-3.81]) compared with all other groups. Patients older than 18 years were more likely to experience a fracture or dislocation (RR, 2.52 [95% CI, 2.13-2.88]) and sustain an injury as a result of tripping or slipping on a rug (RR, 1.36 [95% CI, 1.26-1.41] compared with other age groups. Increasing age was associated with increased risk of hospitalization in this study. Patients who sustained an injury from a rubber or plastic mat/rug were significantly less likely to be admitted (RR, 0.67 [95% CI, 0.55-0.83]). Injuries occurring in kitchens or bathrooms resulted in significantly higher admission rates (RR, 1.45 [95% CI, 1.34-1.54]). CONCLUSIONS: Rug-related injuries are an important source of injury for individuals of all ages.

Chronological and clinical characteristics of apnea associated with respiratory syncytial virus infection: a retrospective case series.

OBJECTIVE: Infants with respiratory syncytial virus (RSV) infection are at risk for developing apnea. The authors compared patients with RSV infection who develop apnea with those who do not, to help ambulatory physicians risk stratify their patients with RSV infection. METHODS: Entry criteria were age less than 1 year, RSV infection, and presentation to the authors' pediatric emergency departments. Random and weighted sampling techniques were used to identify the study group and provide the control sample. Charts were abstracted for 34 clinical variables. RESULTS: The study group consisted of 42 patients with apnea, and the control group consisted of 198 patients without apnea. Logistic regression analysis identified 2 independent variables associated with apnea: young age and presentation with apnea. Most patients with apnea were less than 2 months of age and were ill for less than 5 days. CONCLUSIONS: Age and duration of illness may help clinicians determine which previously healthy infants are at risk for apnea.

Safety and efficacy of a protocol using bougienage or endoscopy for the management of coins acutely lodged in the esophagus: a large case series.

STUDY OBJECTIVE: We report our experience using the bougienage procedure in the management of esophageal coins. METHODS: Observational case series of all patients presenting to our emergency departments with coins acutely lodged in the esophagus between 1994 and 2006. All patients were treated according to our protocol with either endoscopy or bougienage. Patients are eligible for bougienage if they have had a witnessed coin ingestion less than 24 hours before presentation and if esophageal coin position is confirmed by chest radiograph and there is no history of esophageal disease, surgery, or foreign body. Primary outcomes measured were complications, efficacy of procedure, hospital charges, length of stay, and return to the hospital. Length of stay and hospital charges data were gathered for patients presenting in the final 24 months of the study. RESULTS: Six hundred twenty patients were identified as having esophageal coins. Three hundred fifty-five patients had a successful bougienage, and 17 patients had unsuccessful bougienage. By comparison, 248 patients underwent endoscopy, and the coin was successfully removed in all but 1 of these patients. Of patients undergoing endoscopy, 89 were eligible for bougienage, but patient, parent, or physician preference was for endoscopic management. Eleven patients required reevaluation or readmission for complaints related to esophageal coin. The only complication was subglottic edema, causing respiratory distress in a single patient who had undergone endoscopy. Patients undergoing endoscopy had an average length of stay of 6.1 hours and average hospital charges were $6,087. Patients undergoing bougienage had an average length of stay of 2.2 hours and average hospital charges of $1,884. CONCLUSION: In properly screened patients with coins acutely lodged in the esophagus, bougienage offers a safe and effective alternative to other methods of coin management.