Serious Bacterial Infections in Young Febrile Infants With Positive Urinalysis Results.

It is unknown whether febrile infants 29 to 60 days old with positive urinalysis results require routine lumbar punctures for evaluation of bacterial meningitis. OBJECTIVE: To determine the prevalence of bacteremia and/or bacterial meningitis in febrile infants ≤60 days of age with positive urinalysis (UA) results. METHODS: Secondary analysis of a prospective observational study of noncritical febrile infants ≤60 days between 2011 and 2019 conducted in the Pediatric Emergency Care Applied Research Network emergency departments. Participants had temperatures ≥38°C and were evaluated with blood cultures and had UAs available for analysis. We report the prevalence of bacteremia and bacterial meningitis in those with and without positive UA results. RESULTS: Among 7180 infants, 1090 (15.2%) had positive UA results. The risk of bacteremia was higher in those with positive versus negative UA results (63/1090 [5.8%] vs 69/6090 [1.1%], difference 4.7% [3.3% to 6.1%]). There was no difference in the prevalence of bacterial meningitis in infants ≤28 days of age with positive versus negative UA results (∼1% in both groups). However, among 697 infants aged 29 to 60 days with positive UA results, there were no cases of bacterial meningitis in comparison to 9 of 4153 with negative UA results (0.2%, difference -0.2% [-0.4% to -0.1%]). In addition, there were no cases of bacteremia and/or bacterial meningitis in the 148 infants ≤60 days of age with positive UA results who had the Pediatric Emergency Care Applied Research Network low-risk blood thresholds of absolute neutrophil count <4 × 103 cells/mm3 and procalcitonin <0.5 ng/mL. CONCLUSIONS: Among noncritical febrile infants ≤60 days of age with positive UA results, there were no cases of bacterial meningitis in those aged 29 to 60 days and no cases of bacteremia and/or bacterial meningitis in any low-risk infants based on low-risk blood thresholds in both months of life. These findings can guide lumbar puncture use and other clinical decision making.

A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections.

Importance: In young febrile infants, serious bacterial infections (SBIs), including urinary tract infections, bacteremia, and meningitis, may lead to dangerous complications. However, lumbar punctures and hospitalizations involve risks and costs. Clinical prediction rules using biomarkers beyond the white blood cell count (WBC) may accurately identify febrile infants at low risk for SBIs. Objective: To derive and validate a prediction rule to identify febrile infants 60 days and younger at low risk for SBIs. Design, Setting, and Participants: Prospective, observational study between March 2011 and May 2013 at 26 emergency departments. Convenience sample of previously healthy febrile infants 60 days and younger who were evaluated for SBIs. Data were analyzed between April 2014 and April 2018. Exposures: Clinical and laboratory data (blood and urine) including patient demographics, fever height and duration, clinical appearance, WBC, absolute neutrophil count (ANC), serum procalcitonin, and urinalysis. We derived and validated a prediction rule based on these variables using binary recursive partitioning analysis. Main Outcomes and Measures: Serious bacterial infection, defined as urinary tract infection, bacteremia, or bacterial meningitis. Results: We derived the prediction rule on a random sample of 908 infants and validated it on 913 infants (mean age was 36 days, 765 were girls [42%], 781 were white and non-Hispanic [43%], 366 were black [20%], and 535 were Hispanic [29%]). Serious bacterial infections were present in 170 of 1821 infants (9.3%), including 26 (1.4%) with bacteremia, 151 (8.3%) with urinary tract infections, and 10 (0.5%) with bacterial meningitis; 16 (0.9%) had concurrent SBIs. The prediction rule identified infants at low risk of SBI using a negative urinalysis result, an ANC of 4090/µL or less (to convert to ×109 per liter, multiply by 0.001), and serum procalcitonin of 1.71 ng/mL or less. In the validation cohort, the rule sensitivity was 97.7% (95% CI, 91.3-99.6), specificity was 60.0% (95% CI, 56.6-63.3), negative predictive value was 99.6% (95% CI, 98.4-99.9), and negative likelihood ratio was 0.04 (95% CI, 0.01-0.15). One infant with bacteremia and 2 infants with urinary tract infections were misclassified. No patients with bacterial meningitis were missed by the rule. The rule performance was nearly identical when the outcome was restricted to bacteremia and/or bacterial meningitis, missing the same infant with bacteremia. Conclusions and Relevance: We derived and validated an accurate prediction rule to identify febrile infants 60 days and younger at low risk for SBIs using the urinalysis, ANC, and procalcitonin levels. Once further validated on an independent cohort, clinical application of the rule has the potential to decrease unnecessary lumbar punctures, antibiotic administration, and hospitalizations.

Building Capacity in Pediatric Environmental Health: The Academic Pediatric Association's Professional Development Program.

BACKGROUND: Environmental exposures contribute to multiple diseases in children; yet, few pediatricians have training in pediatric environmental health (PEH), and few academic health centers have PEH expertise. To build national capacity in PEH, the Academic Pediatric Association (APA) launched a professional development program that since 2002 has encouraged the establishment of post-residency/post-doctoral training programs, supported a special interest group, and convened an annual mentored retreat for PEH trainees. OBJECTIVE: Describe the APA's professional development program in PEH and assess its impact by tracking careers of former trainees. METHODS: Careers were tracked through interviews with trainees and program directors supplemented by searches of institutional websites. Publication listings were obtained through PubMed. Publication impact was assessed using bibliometric and altmetric measures. Grant histories were accessed through the National Institutes of Health RePORTER project. Information on advocacy work was obtained through interviews with program directors. RESULTS: Fifty-five trainees (36 physicians and 19 health scientists) completed PEH training and attended the APA retreat between 2002 and 2017. Forty-one (75%) are pursuing academic careers, 11 are associate or full professors, 11 are practicing general pediatrics or a pediatric subspecialty, 2 are Centers for Disease Control and Prevention epidemiologists, and 1 is a data scientist. Forty-two former trainees (76%) listed "environment" or "environmental" in their job titles or on their websites. Former trainees have published 632 scientific papers. These papers have been cited 3094times, have a relative citation ratio of 2.97, and have been read or viewed 1,274,388times. Twenty-one former trainees have been awarded 43 National Institutes of Health grants. Trainees have developed education and advocacy skills by teaching medical students and residents, presenting grand rounds, preparing policy papers, presenting legislative testimony, and making presentations to public audiences. CONCLUSIONS: The APA's professional development program has contributed to the expansion of national capacity in PEH. Former trainees are populating the field, generating new knowledge, and moving into leadership positions.

Association of Delay in Appendectomy With Perforation in Children With Appendicitis.

OBJECTIVE: The aim of this study was to assess whether increased time from emergency department (ED) triage to appendectomy is associated with a greater risk of children developing appendiceal perforation. METHODS: We performed a multicenter retrospective cohort study of children younger than 18 years hospitalized with appendicitis. To avoid enrolling patients who had perforated prior to ED arrival, we included only children who had a computed tomography (CT) scan demonstrating nonperforated appendicitis. Time to appendectomy was measured as time from ED triage to incision. The main outcome was appendiceal perforation as documented in the surgical report. Variables associated with perforation in bivariate analysis (P < 0.05) were adjusted for using logistic regression. RESULTS: Overall, 857 patients had a CT scan that demonstrated nonperforated appendicitis. The median age was 12 years (interquartile range, 9-15 years), and 500 (58%) were male. The median time to appendectomy was 11 hours (interquartile range, 8-15 hours). In total, 111 patients (13%) had perforated appendicitis at operation. Children who developed perforation were more likely to require additional CT scans and return to the ED and had a significantly longer length of stay. After adjusting for potential confounders, every hour increase in the time from ED triage to incision was independently associated with a 2% increase in the odds of perforation (P = 0.03; adjusted odds ratio, 1.02; 95% confidence interval, 1.00-1.04). CONCLUSIONS: Delays in appendectomy were associated with an increase in the odds of perforation. These results suggest that prolonged delays to appendectomy might be harmful for children with appendicitis and should be minimized to prevent associated morbidity.

Prospective Investigation of a Novel Ultrasound-assisted Lumbar Puncture Technique on Infants in the Pediatric Emergency Department.

OBJECTIVE: The objective was to describe a novel ultrasound-assisted lumbar puncture (UALP) technique and to compare it to standard lumbar puncture (SLP) technique in infants. METHODS: A prospective, randomized, controlled study in infants 60 days old and younger undergoing a lumbar puncture (LP) in a pediatric emergency department. Patients with a spinal anomaly or ventriculoperitoneal shunt were excluded. Eligible infants were randomized to UALP or SLP. A spinal sonogram was performed on all patients by an investigator not involved in performing the LP. Spinal landmarks and maximum safe depth were identified for the UALP providers. Providers in the SLP group were blinded to sonographic measurements. A successful LP was defined as the collection of cerebrospinal fluid (CSF) with a red blood cell count of less than 10,000 cells/mm3 . Statistical analysis included chi-square, Mann-Whitney U-test, and number needed to treat (NNT). RESULTS: Forty-three patients were enrolled, 21 in the UALP group and 22 in the SLP group. Prematurity, weight, length, provider experience, anesthesia use, stylet technique, and number of attempts were similar between groups. The median age in the UALP group was 38 days (interquartile range [IQR] = 33 days) versus 45 days (IQR = 19 days) in the SLP group (p = 0.02). CSF was obtained in all UALP subjects (100%) versus in 18 of 22 (82%) in the SLP group (p = 0.04); 20 (95%) UALP subjects versus 15 (68%) SLP subjects met our definition of success (p = 0.023). The odds ratio of successful LP using UALP technique was 9.33 (95% confidence interval [CI] = 1.034 to 84.026) and the NNT was 3.7 (95% CI = 2.02 to 24.18). CONCLUSION: The UALP technique increases the rate of a successful LP in infants compared to standard technique.

Association of RNA Biosignatures With Bacterial Infections in Febrile Infants Aged 60 Days or Younger.

IMPORTANCE: Young febrile infants are at substantial risk of serious bacterial infections; however, the current culture-based diagnosis has limitations. Analysis of host expression patterns ("RNA biosignatures") in response to infections may provide an alternative diagnostic approach. OBJECTIVE: To assess whether RNA biosignatures can distinguish febrile infants aged 60 days or younger with and without serious bacterial infections. DESIGN, SETTING, AND PARTICIPANTS: Prospective observational study involving a convenience sample of febrile infants 60 days or younger evaluated for fever (temperature >38° C) in 22 emergency departments from December 2008 to December 2010 who underwent laboratory evaluations including blood cultures. A random sample of infants with and without bacterial infections was selected for RNA biosignature analysis. Afebrile healthy infants served as controls. Blood samples were collected for cultures and RNA biosignatures. Bioinformatics tools were applied to define RNA biosignatures to classify febrile infants by infection type. EXPOSURE: RNA biosignatures compared with cultures for discriminating febrile infants with and without bacterial infections and infants with bacteremia from those without bacterial infections. MAIN OUTCOMES AND MEASURES: Bacterial infection confirmed by culture. Performance of RNA biosignatures was compared with routine laboratory screening tests and Yale Observation Scale (YOS) scores. RESULTS: Of 1883 febrile infants (median age, 37 days; 55.7% boys), RNA biosignatures were measured in 279 randomly selected infants (89 with bacterial infections-including 32 with bacteremia and 15 with urinary tract infections-and 190 without bacterial infections), and 19 afebrile healthy infants. Sixty-six classifier genes were identified that distinguished infants with and without bacterial infections in the test set with 87% (95% CI, 73%-95%) sensitivity and 89% (95% CI, 81%-93%) specificity. Ten classifier genes distinguished infants with bacteremia from those without bacterial infections in the test set with 94% (95% CI, 70%-100%) sensitivity and 95% (95% CI, 88%-98%) specificity. The incremental C statistic for the RNA biosignatures over the YOS score was 0.37 (95% CI, 0.30-0.43). CONCLUSIONS AND RELEVANCE: In this preliminary study, RNA biosignatures were defined to distinguish febrile infants aged 60 days or younger with vs without bacterial infections. Further research with larger populations is needed to refine and validate the estimates of test accuracy and to assess the clinical utility of RNA biosignatures in practice.

Calling 911! What role does the pediatrician play?

OBJECTIVE: The objective of this study was to compare admission rates and medical interventions among children whose caregivers called their child's primary care provider (PCP) before taking an ambulance to the pediatric emergency department (PED) versus those who did not. METHODS: This was a prospective cohort study of patients brought to an urban, public hospital PED via emergency medical system (EMS). Children were included if the caregiver called 911 to have them transported via EMS and was present in the PED. The main variable was whether the child's PCP was called before EMS utilization. Study outcomes were medical interventions, such as intravenous line insertion or laboratory tests, and hospital admission. χ Test and logistic regression were used to evaluate the relationship of the main variable to the study outcomes. RESULTS: Six hundred fourteen patients met inclusion criteria and were enrolled. Five hundred eighty-five patients (95.3%) were reported to have a PCP. Seventy-four caregivers (12.1%) called their child's PCP before calling EMS. Two hundred seventy-seven patients (45.1%) had medical interventions performed; of these, 42 (15.2%) called their PCP (P = 0.03). Forty-two patients (6.8%) were admitted; among these, 14 (33.3%) called their PCP (P < 0.01). Adjusting for triage level, patients whose caregiver called the PCP before calling EMS were 3.2 times (95% confidence interval, 1.9-5.2 times) more likely to be admitted and 1.7 times (95% confidence interval, 1.1-2.9 times) more likely to have a medical intervention compared with patients whose caregivers did not call their child's PCP. CONCLUSIONS: Children were more likely to be admitted or require a medical intervention if their caregiver called their PCP before calling EMS. The availability of a PCP for telephone triage may help to optimize EMS utilization.

A survey of the management of febrile infants in pediatric emergency departments.

OBJECTIVE: To determine whether emergency departments (EDs) at pediatric emergency medicine (PEM) fellowship training institutions have a departmental policy regarding the evaluation and management of febrile infants and if reported policies are based on published guidelines (PGs). METHODS: A 32-item telephone survey was administered to PEM fellowship directors (FDs). Departmental demographics and criteria used to evaluate febrile infants were collected. Scenarios were presented regarding the evaluation and management of low-risk febrile infants. Reported consistency among ED attending physicians at the same institution was also assessed. RESULTS: The response rate was 83% (53 of 64). Fifty-one percent (26 of 53) of FDs reported the existence of a departmental policy regarding the evaluation of febrile infants. Of those who have a departmental policy, 19% (5 of 26) stated that it was one of the PGs. The FDs who reported the existence of a departmental policy were significantly more likely to report consistent management by all ED attending physicians in their department compared with those without a departmental policy (81% vs 19%, P < 0.05). The most frequent age and temperature cutoff for a mandatory sepsis evaluation were 28 days (45%, 28 of 53) and 100.4°F (66%, 35 of 53). The FDs reported a lack of consistency among ED attending physicians at the same institution regarding age and temperature (66% and 17% of the time, respectively). Eighty-five percent (45 of 53) of FDs reported that a new guideline is needed. CONCLUSIONS: Nearly one half of EDs at PEM fellowship training institutions are reported not to have a departmental policy regarding the management of febrile infants, and departmental policies rarely conform to any of the PGs. There is substantial interdepartmental and intradepartmental practice variability regarding the management of febrile infants and a strong consensus regarding the need for a new guideline.

The effect of Lactobacillus GG on acute diarrheal illness in the pediatric emergency department.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of the probiotic Lactobacillus GG (LGG) in reducing the duration of acute infectious diarrhea in the pediatric emergency department. METHODS: We conducted a double-blind, randomized controlled trial of children 6 months to 6 years presenting to the pediatric emergency department with a complaint of diarrhea. Patients were randomized to receive either placebo or LGG powder twice daily for 5 days. With each dose, parents recorded the stool history in a home diary and were followed up daily by a blinded researcher. Groups were compared in terms of time to normal stool and number of diarrheal stools. RESULTS: Of 155 patients enrolled, 129 completed the study: 63 in the LGG group and 66 in the placebo group. There was no significant difference in the median (interquartile range) time to normal stool (LGG: 60 hours [37-111] vs placebo: 74 hours [43-120]; P = 0.37) or the number of diarrheal stools (LGG: 5.0 [1-10] vs placebo: 6.5 [2-14]; P = 0.19). Among children who presented with more than 2 days of diarrhea, the LGG group returned to normal stool earlier (LGG: 51 hours [32-78] vs placebo: 74 hours [45-120]; P = 0.02), had fewer episodes of diarrheal stools (LGG: 3.5 [1.0-7.5] vs placebo: 7 [3.0-16.3]; P = 0.02), and were 2.2 times more likely to return to normal stool (95% confidence interval, 1.3-3.9; P = 0.01) compared with children in the placebo group. CONCLUSIONS: Lactobacillus GG may reduce the duration of acute diarrheal illness among children presenting with more than 2 days of symptoms.

Is nonperforated pediatric appendicitis still considered a surgical emergency? A survey of pediatric surgeons.

OBJECTIVE: To describe the beliefs and preferences of pediatric surgeons regarding the emergent nature of nonperforated appendicitis. METHODS: An electronic mailing was sent to all 1052 members of the American Pediatric Surgical Association (APSA) inviting participation in a 26-item survey, which was administered by Survey Monkey (www.surveymonkey.com). Chi-square and Mann-Whitney tests were used for bivariate analysis. Spearman's rho was used for nonparametric correlation. RESULTS: Four hundred eighty-four pediatric surgeons (46%) responded to the survey. Few respondents (4%) considered nonperforated appendicitis to be a surgical emergency. A minority (14%) would come in from home to perform an overnight appendectomy. Most (92%) believe that postponing overnight appendectomy until daytime does not result in a clinically significant increase in perforation. Respondents endorsed surgeon fatigue (56%) and limited operating room availability (56%) most often among factors that would make them more likely to postpone surgery. Sixty-eight percent reported no departmental guideline regarding delay of overnight appendectomy. CONCLUSIONS: Most pediatric surgeons in our study believe nonperforated appendicitis is not a surgical emergency and prefer to postpone overnight appendectomy.

Screening for postpartum depression in a pediatric emergency department.

OBJECTIVE: The objective was to determine whether a 3-question version of the Edinburgh Postpartum Depression Scale (EPDS) performs as well as the full EPDS in screening for postpartum depression in a pediatric emergency department (PED). METHODS: Mothers of infants younger than 6 months presenting to an urban PED were enrolled. After the PED encounter, mothers were asked about demographics, health problems, insurance status, social support, food and housing security, and 3 questions from the EPDS. Mothers then completed the full EPDS. The primary outcome was the score on the full EPDS. Agreement between the 3 questions and the full EPDS for screening positive was measured. Test performance characteristics for screening positive with the 3 questions were calculated. Logistic regression determined the association between sociodemographic characteristics and screening positive. Provider impression of maternal depressive symptoms was recorded. RESULTS: Of 195 mothers enrolled, 23% screened positive using the EPDS; 34% screened positive using the 3 questions (κ = 0.74). Compared with the EPDS, sensitivity of the 3 questions was 100%. Number of children younger than 5 years at home and having food and housing concerns were associated with screening positive. Of 44 mothers who screened positive on the full EPDS, providers identified 14 (32%) as having depressive symptoms or possibly being depressed. CONCLUSIONS: Three questions from the EPDS performed similarly to the full EPDS in screening for postpartum depressive symptoms in a PED. Future studies are needed to confirm these findings and examine whether screening improves maternal and child health outcomes and quality-of-life concerns.

The predictive value of a normal radiographic anterior fat pad sign following elbow trauma in children.

OBJECTIVE: The purposes of this study were to describe the characteristics of a normal anterior fat pad (AFP) and to determine the association between a normal AFP and the absence of fracture. METHODS: A prospective cohort of children aged 1 to 18 years with elbow trauma underwent radiographic examination. All patients received standard orthopedic management and follow-up 7 to 14 days after injury. A pediatric radiologist evaluated all radiographs for the presence or absence of fracture and documented whether the AFP was normal or abnormal on the lateral view. The radiologist also recorded specific measurements of the AFP including the apical angle, which is formed by the intersection of the humerus and the superior aspect of the AFP. The interpretation of the AFP on the initial lateral radiograph was compared with the final patient outcome (fracture/no fracture). RESULTS: Two hundred thirty-one patients had elbow radiographs; 34 patients (15%) were lost to follow-up. A total of 56 fractures were identified: 49 (87%) on the initial radiograph and an additional 7 (13%) on follow-up radiographs. This latter group was defined as occult fractures. Among the 197 patients available for analysis, 113 (57%) had a normal AFP on the initial radiograph. Of these, 2 children had a final diagnosis of fracture. The sensitivity of a normal AFP was 96.4% (95% confidence interval, 86.6%-99.4%), and the negative predictive value was 98.2% (95% confidence interval, 93.1%-99.7%). There was a significant difference in mean AFP angle when the AFP was read as normal (14.7 [SD, 3.3] degrees) compared with when it was read as abnormal (27.0 [SD, 6.8] degrees) (P < 0.01). CONCLUSIONS: Our data suggest that a normal AFP is highly associated with absence of elbow fracture and that the determination of a normal AFP can be aided by measuring the apical angle of the AFP.

Adherence and morbidity following emergency department care among inner-city children with asthma.

OBJECTIVES: To explore the utility of two measures, Risk for Nonadherence (RN) and Admitted Nonadherence (AN), developed in a national sample of children with chronic asthma, for predicting short-term morbidity among children following a pediatric emergency department (PED) visit for acute asthma and to compare verbal and self-completion of these measures. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of children 3 to 11 years of age presenting to a PED with an acute asthma exacerbation. Caretakers were randomized to self-completion of a questionnaire assessing RN and AN or to verbally respond to the same questionnaire administered by a research assistant. Five asthma morbidity indicators were collected at 2, 4, and 8 weeks following discharge from the PED. RESULTS: One hundred fifty-four patients were enrolled. There were no significant differences in asthma severity, RN, or AN, or the number of items missing on questionnaires between the self-completion and verbal administration groups. Patients with a RN score >4 had an adjusted odds of 3.67 (95% confidence interval [CI] 1.57-8.58) for waking >2 nights due to asthma symptoms. The adjusted odds of patients with any AN to report needing >4 days of rescue asthma medication was 3.16 (95% CI 1.37-7.26). CONCLUSION: RN and AN were both associated with morbidity indices following an acute asthma exacerbation and can identify children at risk for increased short-term morbidity regardless of the method of questionnaire administration. Assessment of RN and AN by self-administered questionnaire during an ED visit for asthma maybe feasible.

Identifying children at low risk for bacterial conjunctivitis.

OBJECTIVE: To identify a population of children at low risk for bacterial conjunctivitis on the basis of history and physical examination findings. DESIGN: Prospective observational cohort study. SETTING: Urban pediatric emergency department. PARTICIPANTS: Children aged 6 months to 17 years with conjunctival erythema, eye discharge, or both. The exclusion criteria were eye trauma, exposure to a noxious chemical, contact lens use, and antibiotic drug use in the past 5 days. INTERVENTIONS: Clinicians completed a checklist of signs and symptoms and collected a conjunctival swab for bacterial culture. MAIN OUTCOME MEASURES: The chi(2) test, the Mann-Whitney test, and logistic regression were used to create a prediction model for a negative bacterial culture. RESULTS: Of 368 patients enrolled, 194 (52.7%) were males. The median patient age was 3 years (interquartile range, 1-5 years). Conjunctival cultures were negative in 130 patients (35.3%). Age 6 years or older, presentation in April through November, no or watery discharge, and no glued eye in the morning were the clinical factors found to be independently associated with a negative conjunctival culture. If 3 factors were present, 76.4% (95% confidence interval, 63.6%-85.6%) of patients had a negative culture. If all 4 factors were present, 92.3% (95% confidence interval, 66.1%-98.2%) of patients had a negative culture. CONCLUSION: The combination of 4 clinical factors may enable clinicians to identify children at low risk for bacterial conjunctivitis and may reduce routine antibiotic drug administration.

Does parental involvement in pediatric emergency department asthma treatment affect home management?

To determine whether parents who deliver albuterol treatments in a pediatric emergency department with a metered dose inhaler with a spacer device (MDIS) report better adherence to MDIS use at home compared to parents whose children undergo standard nebulizer therapy. Children aged 1-5 years were randomized by day to usual treatment with nebulized albuterol (40 children) or to treatment by the parent with albuterol with an MDIS (46 children). All caregivers received standard discharge instructions, a spacer and an MDI. Two weeks following the visit, a trained research assistant blinded to the child's group status, administered a brief telephone questionnaire to each caretaker. At follow-up, children in the MDIS group were 7.5 times more likely to be using the MDIS for their albuterol treatments (95%CI 1.6-35.6). Involving parents in treatment of asthma exacerbations in the emergency department using an MDIS may improve adherence to MDIS use at home.

The cranial rhythmic impulse and excessive crying of infancy.

BACKGROUND: Osteopathic physicians believe that the birthing process causes cranial dysfunction that may be manifested in somatic symptoms, one of which is excessive crying of infancy. Cranial dysfunction can be determined by assessing the cranial rhythmic impulse (CRI). OBJECTIVE: The objective of this study is to examine whether an abnormal CRI is associated with excessive crying of infancy. DESIGN: Full-term infants in the well-baby nursery of an urban public hospital in the Bronx, New York were enrolled. Two (2) osteopathic physicians independently measured the CRI in infants before discharge. One (1) osteopath repeated the CRI measurement at 2 weeks. At 6 weeks, an investigator blinded to the CRI and birth data assessed infant crying using the modified Ames Cry Score via telephone interview with the primary caretaker. The caretaker was also asked about maternal stress, use of home or cultural remedies, and the infant's diet. The main outcome measure was the presence of excessive crying. RESULTS: One hundred and thirty-nine (139) patients were included in the final sample. The overall incidence of excessive crying was 41.7%. Excessive crying was associated with an abnormal CRI at 2 weeks (p < 0.001) but not with the CRI at birth (p = 0.23). Infants with an abnormal CRI at 2 weeks were 6.8 times (95% confidence intervals 2.2, 20.6) more likely to develop excessive crying than infants with a normal CRI. Infant diet was independently associated with excessive crying. Inter-rater agreement for CRI measurement was 0.70 using the kappa statistic. CONCLUSIONS: These data suggest that an abnormal CRI at 2 weeks of age may be associated with excessive crying.

The utility of bedside ultrasonography in identifying fractures and guiding fracture reduction in children.

OBJECTIVE: To compare bedside ultrasonography (BUS) to radiography for identifying long bone fractures, the need for reduction, and the adequacy of reduction. METHODS: Children aged 2 to 17 years presenting to a pediatric emergency department with long bone injuries were prospectively enrolled. Bedside ultrasonography was performed before ordering initial radiographs. If a fracture was identified, measurements of angulation and displacement were made based on BUS images. Radiographs were used to guide management. Patients who had a fracture identified on radiograph underwent standard care. Later, agreement between BUS and radiography for fracture identification, the need for reduction, and the adequacy of reduction were determined. RESULTS: Thirty-three patients were enrolled, the mean age was 9.1 years (+/-3.1 years). Sixty six bones were studied; 56 (84.8%) involved the upper extremity. Fractures were identified in 59.1% of all bones; 13 (33.3%) required reduction.The agreement between BUS and radiography for fracture identification was 95.5%, for the need for reduction 92.3%, and for the adequacy of reduction 92.3%. The sensitivity and specificity of BUS for fracture identification, need for reduction and reduction adequacy was 0.97 (95% confidence interval [CI], 0.85-1.00), 0.93 (95% CI, 0.74-0.99), and 1.00 (95% CI 0.79-1.00), and 0.85 (95% CI, 0.61-0.96), 1.00 (95% CI, 0.59-1.00) and 0.80 (95% CI, 0.30-0.99), respectively. CONCLUSIONS: These data suggest that BUS evaluation of upper extremity injuries not involving joints maybe comparable to radiography for identifying fractures, the need for reduction, and the adequacy of reduction in children. If further investigations which include a larger number of lower extremity, growth plate, and joint injuries support our findings, BUS may gain a more prominent role in managing children with all long bone injuries.

Association between skin testing in the pediatric emergency department and adherence to follow-up in children with asthma.

BACKGROUND: Efforts to enroll inner-city asthmatic children into continuity care after a pediatric emergency department (PED) visit are frequently unsuccessful. Providing parents with documentation of their child's allergic status and how this can be used to tailor an asthma management plan may improve adherence to scheduled continuity appointments. OBJECTIVE: To determine whether skin testing children during PED visits for wheezing and providing parents with skin test results improves adherence to follow-up visits. METHODS: A convenience sample of children aged 2 to 12 years with asthma who presented to the PED with wheezing were eligible. Enrolled children were randomized to group 1 (no skin test) or group 2 (skin test). At discharge, both groups scheduled asthma clinic appointments for within 1 week. Children in group 2 underwent skin testing with standard allergens, and parents were given documentation of skin test results. Adherence was assessed by computer confirmation of the patient's asthma clinic visit. RESULTS: Seventy-seven children were enrolled: 39 in group 1 and 38 in group 2. The mean age was 7 years; 69% had mild intermittent asthma. Twenty-four percent of children (9 of 38) in group 1 vs 46% (17 of 37) in group 2 were followed up in the asthma clinic (P < .05). Children in group 2 were 2.6 (95% confidence interval, 1.02-6.65) times more likely to keep appointments compared with children in group 1. CONCLUSIONS: Parents who receive evidence in the PED of their child's allergic status and probable relationship to the child's asthma are more likely to adhere to scheduled continuity visits.

Comparison of two approaches to observation therapy for acute otitis media in the emergency department.

OBJECTIVE: This study compared parental adherence to delayed antibiotic therapy for acute otitis media with and without a written prescription in a pediatric emergency department. PATIENTS AND METHODS: Children aged 2 to 12 years who met criteria for delayed antibiotic treatment were randomly assigned to observation therapy with or without a prescription. Patients randomly assigned to observation therapy without prescription were instructed to seek follow-up care if symptoms persisted for 2 to 3 days. Patients assigned to observation therapy with a prescription were discharged with an antibiotic prescription, and instructed to fill it if their child's symptoms persisted 2 to 3 days. A research assistant who was blinded to group assignment called parents 7 to 10 days after the visit to assess adherence to observation therapy. RESULTS: Of 117 children assigned to the observation therapy group, 100 completed follow-up; of 115 assigned to the observation therapy with a prescription group, 106 completed follow-up. In the observation therapy group, 87 parents reported no antibiotic use within the 3-day observation period compared with 66 parents in the prescription group. During the entire study period, 81% of the observation therapy group reported no use of antibiotics compared with 53% in the prescription group. These groups did not differ in satisfaction with the visit; 91% and 95% were very or extremely satisfied, respectively. No complications were reported. CONCLUSIONS: Observation therapy with and without a prescription were both well accepted by parents of children diagnosed with acute otitis media in an urban pediatric emergency department. Adherence to delayed antibiotic therapy was better for those not offered a prescription. These data suggest that, in the pediatric emergency department setting, observation therapy reduces antibiotic use without compromising satisfaction with the visit.