Association of Radiology Findings with Etiology of Community Acquired Pneumonia among Children.

OBJECTIVE: To evaluate the association between consolidation on chest radiograph and typical bacterial etiology of childhood community acquired pneumonia (CAP) in the Etiology of Pneumonia in the Community study. STUDY DESIGN: Hospitalized children <18 years of age with CAP enrolled in the Etiology of Pneumonia in the Community study at 3 children's hospitals between January 2010 and June 2012 were included. Testing of blood and respiratory specimens used multiple modalities to identify typical and atypical bacterial, or viral infection. Study radiologists classified chest radiographs (consolidation, other infiltrates [interstitial and/or alveolar], pleural effusion) using modified World Health Organization pneumonia criteria. Infiltrate patterns were compared according to etiology of CAP. RESULTS: Among 2212 children, there were 1302 (59%) with consolidation with or without other infiltrates, 910 (41%) with other infiltrates, and 296 (13%) with pleural effusion. In 1795 children, at least 1 pathogen was detected. Among these patients, consolidation (74%) was the most frequently observed pattern (74% in typical bacterial CAP, 58% in atypical bacterial CAP, and 54% in viral CAP). Positive and negative predictive values of consolidation for typical bacterial CAP were 12% (95% CI 10%-15%) and 96% (95% CI 95%-97%) respectively. In a multivariable model, typical bacterial CAP was associated with pleural effusion (OR 7.3, 95% CI 4.7-11.2) and white blood cell ≥15 000/mL (OR 3.2, 95% CI 2.2-4.9), and absence of wheeze (OR 0.5, 95% CI 0.3-0.8) or viral detection (OR 0.2, 95% CI 0.1-0.4). CONCLUSIONS: Consolidation predicted typical bacterial CAP poorly, but its absence made typical bacterial CAP unlikely. Pleural effusion was the best predictor of typical bacterial infection, but too uncommon to aid etiology prediction.

Low Retinol-Binding Protein and Vitamin D Levels Are Associated with Severe Outcomes in Children Hospitalized with Lower Respiratory Tract Infection and Respiratory Syncytial Virus or Human Metapneumovirus Detection.

Retinol binding protein and vitamin D were measured in children aged <5 years hospitalized with lower respiratory tract infection and respiratory syncytial virus and/or human metapneumovirus detections. Low vitamin levels were observed in 50% of the children and were associated with significantly elevated risk of the need for intensive care unit admission and invasive mechanical ventilation.

Community-Acquired Pneumonia Hospitalization among Children with Neurologic Disorders.

OBJECTIVE: To describe and compare the clinical characteristics, outcomes, and etiology of pneumonia among children hospitalized with community-acquired pneumonia (CAP) with neurologic disorders, non-neurologic underlying conditions, and no underlying conditions. STUDY DESIGN: Children <18 years old hospitalized with clinical and radiographic CAP were enrolled at 3 US children's hospitals. Neurologic disorders included cerebral palsy, developmental delay, Down syndrome, epilepsy, non-Down syndrome chromosomal abnormalities, and spinal cord abnormalities. We compared the epidemiology, etiology, and clinical outcomes of CAP in children with neurologic disorders with those with non-neurologic underlying conditions, and those with no underlying conditions using bivariate, age-stratified, and multivariate logistic regression analyses. RESULTS: From January 2010-June 2012, 2358 children with radiographically confirmed CAP were enrolled; 280 (11.9%) had a neurologic disorder (52.1% of these individuals also had non-neurologic underlying conditions), 934 (39.6%) had non-neurologic underlying conditions only, and 1144 (48.5%) had no underlying conditions. Children with neurologic disorders were older and more likely to require intensive care unit (ICU) admission than children with non-neurologic underlying conditions and children with no underlying conditions; similar proportions were mechanically ventilated. In age-stratified analysis, children with neurologic disorders were less likely to have a pathogen detected than children with non-neurologic underlying conditions. In multivariate analysis, having a neurologic disorder was associated with ICU admission for children ≥2 years of age. CONCLUSIONS: Children with neurologic disorders hospitalized with CAP were less likely to have a pathogen detected and more likely to be admitted to the ICU than children without neurologic disorders.

Secondhand Smoke Exposure and Illness Severity among Children Hospitalized with Pneumonia.

OBJECTIVE: To assess the relationship between secondhand smoke (SHS) exposure and disease severity among children hospitalized with community-acquired pneumonia (CAP). STUDY DESIGN: Children hospitalized with clinical and radiographic CAP were enrolled between January 1, 2010, and June 30, 2012 at 3 hospitals in Tennessee and Utah as part of the Centers for Disease Control and Prevention's Etiology of Pneumonia in the Community study. Household SHS exposure was defined based on the number of smokers in the child's home. Outcomes included hospital length of stay, intensive care unit admission, and mechanical ventilation. Proportional hazards and logistic regression models were used to assess associations between SHS exposure and outcomes. All models were adjusted for age, sex, race/ethnicity, household education level, government insurance, comorbidities, enrollment site, year, and season. RESULTS: Of the 2219 children included in the study, SHS exposure was reported in 785 (35.4%), including 325 (14.8%) with ≥2 smokers in the home. Compared with nonexposed children, the children exposed to ≥2 smokers had longer length of stay (median, 70.4 hours vs 64.4 hours; adjusted hazard ratio, 0.85; 95% CI, 0.75-0.97) and were more likely to receive intensive care (25.2% vs 20.9%; aOR, 1.44; 95% CI, 1.05-1.96), but not mechanical ventilation. Outcomes in children exposed to only 1 household smoker were similar to those in nonexposed children. CONCLUSION: Children hospitalized with CAP from households with ≥2 smokers had a longer length of stay and were more likely to require intensive care compared with children from households with no smokers, suggesting that they experienced greater pneumonia severity.

Distinguishing Benign Mediastinal Masses from Malignancy in a Histoplasmosis-Endemic Region.

OBJECTIVE: To describe the characteristics of benign and malignant mediastinal masses, which may predict their etiology and facilitate the safe and timely management of patients, especially those residing in histoplasmosis-endemic regions. STUDY DESIGN: We conducted a retrospective review of the health records of 131 patients aged <19 years who were referred to 2 tertiary care children's hospitals between 2005 and 2010 for evaluation of mediastinal masses. RESULTS: Most patients (79%) had benign masses, including 98 with confirmed or suspected histoplasmosis. Overall, compared with patients with malignant masses, patients with benign masses were younger and more likely to be African American, to complain of cough, and to have pulmonary nodules by chest computed tomography. In addition, patients with malignant disease were more likely to complain of malaise and to have neck swelling, abnormal extrathoracic lymphadenopathy, lymphopenia, anterior mediastinal involvement, and/or pleural effusion. Positive histoplasmosis serologic tests were specific but insensitive for a benign etiology. No single clinical, laboratory, or radiologic feature was sufficiently sensitive and specific for distinguishing between benign and malignant masses; however, the presence of lymphopenia, anterior mediastinal involvement, or enlarged cervical lymph nodes on computed tomography had a sensitivity of 93%, specificity of 95%, positive predictive value of 86%, and negative predictive value of 97% for cancer. Sixty-four patients (49%) underwent invasive testing, including 37 (36%) of those with benign masses. CONCLUSION: Patients in this series who had involvement of the anterior mediastinum, lymphopenia, or enlarged cervical lymph nodes had a high likelihood of cancer. Expectant management of patients lacking these characteristics may be safe and reduce unnecessary invasive testing.

Early childrearing practices and their relationship to academic performance in Mexican American children.

PURPOSE: To examine whether parenting behaviors and childrearing practices in the first 3 years of life among Mexican American (MA) families predict children's academic performance at school age. METHODS: Thirty-six children were assessed using the Parent Behavior Checklist, Nursing Child Assessment Teaching Scale, Home Observation for Measurement of the Environment Inventory, and Bayley Scales of Infant Development II. Academic performance was measured with the Illinois Standards Achievement Test during third grade. RESULTS: Correlation between parents' developmental expectations, nurturing behaviors, discipline, and academic performance were statistically significant (P < .05). Developmental expectations and discipline strategies predicted 30% of the variance in the Illinois Standards Achievement Test of reading. CONCLUSIONS: The results of this study suggest that early developmental expectations that MA parents have for their children, and the nurturing and discipline behaviors they engage in, are related to how well the children perform on academic tests at school age.

Planning and implementation of an infection control training program for healthcare providers in Latin America.

OBJECTIVE: The lack of well-trained, dedicated infection control personnel prevents optimal control of nosocomial infections in Latin American pediatric oncology centers. We collaboratively planned and implemented a multinational training course in San Salvador, El Salvador, to address this need. METHODS: The course relied on its organizers' experience in training international healthcare providers, the availability of the International Training Center for Nurses, previous infection control collaboration with the Hospital Nacional de Ninos Benjamin Bloom, and resources available at the University of El Salvador. The 4-week course consisted of lecture sessions combined with practical laboratory and hospital experience. RESULTS: Two courses, one conducted in 2005 and one in 2006, trained 44 professionals from 15 Latin American countries. Evaluations showed that course content and teacher performance met the trainees' needs and that all trainees acquired the necessary knowledge and skills. CONCLUSIONS: The course met the need for the training of Latin American infection control practitioners. Our experience can serve as a model for other organizations interested in strengthening infection control and prevention at international sites.

Antibiotic prescribing for upper respiratory tract infection: the importance of diagnostic uncertainty.

OBJECTIVES: Antibiotic misuse for viral upper respiratory tract infections (URI) in children is a significant problem. We determined the influence on antibiotic prescribing of clinical features that may increase concern about possible bacterial infection (age, appearance, fever) in children with URI. STUDY DESIGN: We created 16 scenarios of children with URI and distributed them by mail survey to 540 pediatricians and family practitioners in Ontario, Canada. The association of patient clinical features, parental pressure, and physician characteristics with antibiotic prescribing was determined through the use of logistic regression analysis. RESULTS: A total of 257 physicians responded (48%). Poor appearance (OR, 6.50; 95% CI, 5.06 to 3.84), fever above 38.5 degrees C (OR, 1.48; 95% CI, 1.21 to 1.82), and age older than 2 years (OR, 2.27; 95% CI, 1.85 to 2.78) were associated with prescribing, whereas parental pressure was not. Physician characteristics associated with antibiotic use were family practitioner (OR, 1.54; 95% CI, 1.22 to 1.96), increasing number of patients seen per week (OR, 1.05; 95% CI, 1.01 to 1.08 for every 20-patient increase), and increasing physician age (OR, 1.17; 95% CI, 1.11 to 1.24, 5-year increments). CONCLUSIONS: Clinical factors, which may lead physicians to be concerned about possible bacterial infection in children, are associated with antibiotic use for pediatric URI.