C-reactive protein in febrile children 1 to 36 months of age with clinically undetectable serious bacterial infection.

OBJECTIVE: To determine the diagnostic properties of quantitative C-reactive protein (CRP) associated with clinically undetectable serious bacterial infection (SBI) in febrile children 1 to 36 months of age. METHODS: Febrile children presenting to a pediatric emergency department (ED) with ages ranging from 1 to 36 months, temperatures > or =39 degrees C, and clinically undetectable source of fever were enrolled in this prospective cohort study. Demographic information, ED temperature, duration of fever, and clinical evaluation using the Yale observation scale were recorded at the time of the initial evaluation. The white blood cell count (WBC), band count, absolute neutrophil count (ANC), and CRP concentration were measured at the same time. All patients received blood cultures and either a screening urinalysis or urine culture. A chest radiograph was obtained at the discretion of the ED physician. Patients with history of using antibiotics within 1 week of their presentation to the ED were excluded. The main outcome result was the presence of laboratory or radiographically proven SBI (bacteremia, meningitis, urinary tract infection, pneumonia, septic arthritis, and osteomyelitis). RESULTS: Seventy-seven patients were enrolled in the study. Fourteen (18%) had a SBI (6 urinary tract infection; 4 pneumonia, including 1 patient with Streptococcus pneumoniae bacteremia; and 4 occult S pneumoniae bacteremia), and 63 had no SBI. The 2 groups were indistinguishable in age, sex, ED temperature, duration of fever, and Yale observation scale. CRP concentration, WBC, and ANC were significantly different between the 2 groups. In a multivariate logistic regression analysis, only CRP remained as a predictor of SBI (Beta = 0.76, 95% confidence interval [CI]: 0.64, 0.89). Receiver-operating characteristic analysis demonstrated CRP (area under curve [AUC] 0.905, standard error [SE] 0.05, 95% CI: 0.808, 1.002) to be superior to ANC (AUC 0.805, SE 0.051, 95% CI: 0.705, 0.905) and to WBC (AUC 0.761, SE 0.068, 95% CI: 0.628, 0.895). A CRP cutoff point of 7 was determined to maximize both sensitivity and specificity (sensitivity 79%, specificity 91%, likelihood ratio 8.3, 95% CI: 3.8, 27.3). Multilevel likelihood ratios and posttest probabilities were calculated for a variety of CRP levels. A CRP concentration of <5 mg/dL effectively ruled out SBI (likelihood ratio 0.087, 95% CI: 0.02, 0.38, posttest probability of SBI 1.9%). CONCLUSIONS: Quantitative CRP concentration is a valuable laboratory test in the evaluation of febrile young children who are at risk for occult bacteremia and SBI, with a better predictive value than the WBC or ANC.

Performance of a predictive model for streptococcal pharyngitis in children.

CONTEXT: Group A beta-hemolytic streptococcus (GABHS) pharyngitis is a common childhood illness. The clinical diagnosis is difficult to determine and laboratory tests have limitations; hence, the condition is generally overdiagnosed and overtreated. Several clinical pediatric-specific predictive models have been published but none have been prospectively studied. OBJECTIVE: To test the performance of a previously published predictive model for GABHS pharyngitis in children in different clinical settings and during different seasons. DESIGN: Prospective cohort study. SETTINGS: Pediatric emergency department and 2 pediatric outpatient clinics. PATIENTS: Children aged between 1 and 18 years with pharyngitis on initial examination at study sites between April 1, 1999, and March 31, 2000. INTERVENTIONS: Recording of clinical features during initial evaluation using a standardized form and recovery of GABHS from patients' throats using reference standard methods. MAIN OUTCOME MEASURES: Posttest probability for GABHS positive throat culture associated with the model's positive predictors (moderate to severe tonsillar swelling, cervical lymphadenopathy [moderate to severe tenderness and enlargement of cervical lymph nodes], scarletiniform rash, and the absence of coryza) and the models' negative predictors (absence of the above signs and the presence of coryza). RESULTS: Of 587 patients analyzed, 218 (37%) had a positive throat culture for GABHS. Forty-nine percent were boys. Mean +/- SD age was 6.7 +/- 3.9 years. There was no difference between the subsets within the sample. The posttest probability values for a positive throat culture associated with positive and negative predictors of the model were 79% and 12%, respectively. CONCLUSIONS: A pediatric predictive model for GABHS pharyngitis performed better than physicians' subjective estimates for a positive throat culture and was comparable with a rapid antigen detection test. The model performed consistently well in different populations and across seasons. It can be useful if reliable microbiological testing and/or follow-up are not attainable.

Sports-related injuries in children.

OBJECTIVE: To describe the demographics and types of sports-related injuries (SRIs) in children. METHODS: The authors performed a retrospective chart review of children 5-18 years of age diagnosed as having an SRI in a pediatric emergency department (ED) during a two-year period. Patients were identified by ICD-9 codes. Data collected were age, sex, sport, ED interventions, consultations, mechanism, location, and injury type. Pairwise comparisons were reported as odds ratios with 95% confidence intervals. RESULTS: Six hundred seventy-seven SRIs fit the inclusion criteria; 480 of the patients were male (71%). The mean ages of the males and females were 13.0 years (SD +/- 3.0 yr) and 12.4 years (SD +/- 2.9 yr), respectively. The six most common sports implicated were basketball (19.5%), football (17.1%), baseball/softball (14.9%), soccer (14.2%), in-line skating (Rollerblading)/skating (5.7%), and hockey (4.6%). Sprains/strains (32.0%), fractures (29.4%), contusions/abrasions (19. 3%), and lacerations (9.7%) accounted for 90% of injury types. Pairwise comparison of the four injury types in the six sports listed showed significant associations for contusions/abrasions in baseball, sprains/strains in basketball, fractures in Rollerblading/skating, and lacerations in hockey. Age variance, including all sports, of the younger group (5-11 yr) in fractures and the older group (12-18 yr) in sprains was significant. The most common injury location was wrist/hand (28%), followed by head/face (22%) and ankle/foot (18%). Each had significant sport-specific predilections. Contact with person or object was the mechanism for >50% of the SRIs. Sport-specific mechanisms followed lines drawn from the sport-specific injury types and locations. CONCLUSIONS: The pediatric age group incurs a variety of injuries in numerous sports with diverse sex, age, mechanism, location, injury type, and sport-specific differences.

The blizzard of 1996: a pediatric emergency department.

OBJECTIVE: To determine the effect of the blizzard of 1996 on the utilization of a pediatric emergency department (ED). METHODS: The study consisted of a retrospective analysis of ED visits prior to, during, and after the storm using a computerized ED log, ED medical records, and Surface Weather observations. The setting was a suburban academic pediatric center in the mid-Atlantic region. Participants included all patients who visited the ED during the 36-hour storm period, the 72 hours before the storm, and the 72 hours after the storm. Number of visits, age, mode of arrival, triage acuity level, admission rate, and the ten most common discharge diagnoses for each time period were gleaned from medical records. RESULTS: The ED census rose 35% above baseline during the 24 hours before the storm. During the 36-hour storm period, the census dropped to 15% of the census prior to the storm. Mode of arrival, age, triage acuity level, admission rate, and the ten most common discharge diagnoses for children seen in the ED during the storm period were not significantly different from those for children seen during the 36 hours before the storm. During the 72 hours after the storm (test period), the census was 40% less than that during the control period (72 hours before the storm). By the fourth day, the census had returned to normal. During the test period, there was a significant increase in the triage acuity level of patients. The percentage of children triaged as urgent, emergent, or critical was 29%, compared with 15% triaged in those categories during the control period (p < 0.05). Also, the overall admission rate increased from 8% during the control period to 22% during the test period (p < 0.01). CONCLUSIONS: Among other effects, a significant increase in severity of presentations to a pediatric ED following a severe storm can be observed.

Effect of weather on the number and the nature of visits to a pediatric ED.

To determine whether unfavorable weather conditions affect the number and acuity of visits to a pediatric emergency department (ED), a retrospective analysis was conducted of children's hospital ED visits and weather conditions utilizing an ED log book and local climatological data during the year 1993. Visits, intensive care unit (ICU) admissions, non-ICU admissions, time periods with favorable weather (TPF), and time periods with unfavorable weather (TPUF) were measured. Each day of the year was divided into two time periods. The time periods were labeled TPF or TPUF based on certain weather conditions. There were 632 (86%) TPF and 98 (14%) TPUF. The number of visits, non-ICU admissions, and ICU admissions during TPF were 13,008 (88%), 1,031 (87%) and 121 (86%), respectively. The number of visits, non-ICU admissions, and ICU admissions during TPUF were 1,720 (12%), 148 (13%), and 19 (14%), respectively. No significant differences in visits and admissions during TPF and TPUF were identified. Also, there was no difference identified when the distribution of visits and admissions was examined during TPUF due to different weather factors, eg, low temperature, precipitation, etc. The results show that unfavorable weather due to the types of weather factors discussed does not affect the number or the nature of visits to a pediatric ED.