This study attempts to address the question we’ve been asking ourselves since the dawn of antibiotics – does this child with a fever have a viral infection, or a bacterial infection? Of course, in reality, we should be asking a more complicated question – does this child have a viral infection, or a bacterial infection for which the increased likelihood of positive outcome with antibiotics outweighs the harms of the antibiotics? But, I digress.
One hypothesis that is bandied about in literature and practice is, if rapid viral testing were available in the Emergency Department, perhaps a positive viral test result would reduce the likelihood of antibiotic usage. These folks from Washington University performed viral PCR for a host of common viruses on 75 children with fever without a source, 15 children with probable bacterial infections, and 115 afebrile children presenting for outpatient surgery. The authors note the patients with bacterial infections were less likely to test positive for a virus – and suggest prospective trials might describe a strategy in which viral testing decreased antibiotic use.
In their cohort, 55% of children aged 2 to 12 months and 39% of those aged 13 to 24 months with no obvious source for fever received antibiotics. This is irresponsible lunacy. However, a much faster, cheaper way to decrease antibiotic use is: to simply return from the abyss of antibiotic overuse to a land of rational practice.
After all, 40% of the bacterial infections and 35% of the outpatient surgical patients tested positive for a virus – clearly indicating the presence of a virus has limited association with acute viral illness or absence of an acute bacterial infection. More tests are not the answer – at least, certainly not this battery of PCR tests.
“Detection of Viruses in Young Children With Fever Without an Apparent Source”
http://www.ncbi.nlm.nih.gov/pubmed/23129086
Category: Pediatrics
ALTEs That Need Admission Need Admission
Coming from the west-coast PEM powerhouses of Harbor-UCLA, CHLA, and USC, this prospective observational study attempts to distill the clinical characteristics of “apparent life threatening events” requiring hospitalization. Traditional teaching has always errs on the side of admission for ALTEs, despite the typical low-yield nature of the admission.
They collected data on 832 ALTEs, 191 (23%) of which they felt truly necessitated admission for a set of predefined criteria. Based on this data, they came up with a simple decision rule to identify ALTEs for admission:
– They obviously need to be admitted.
– Concerning medical history/prematurity/congenital comorbidities.
– >1 ALTE in 24 hours.
This captured 89% of necessary hospitalizations with a specificity of 61%, with an AUC of 0.71.
It’s a bit of an odd rule that includes “obvious need for admission”, but, I suppose it’s rather pragmatic. However, the adoption of a rule such as this – after prospective validation – would depend on the “acceptable miss rate” in an infant with a possible life-threatening condition. A sensitivity of 89% probably isn’t going to cut it, so, in the end, what this study is only good for is perusing the interesting data they’ve collected along the way.
“Apparent Life-Threatening Event: Multicenter Prospective Cohort Study to Develop a Clinical Decision Rule for Admission to the Hospital”
Normal Procalcitonin Rules-Out Line Sepsis
The use of procalcitonin in sepsis has been evolving rapidly in the recent literature. The theory behind procalcitonin is that, typically, it is rapidly converted to calcitonin. However, in the presence of gram-positive and gram-negative sepsis, circulating endotoxin results in a rapid rise in procalcitonin levels not seen during viral infection. There’s a nice study showing use of procalcitonin levels allows for reductions in antibiotic use in the ICU, without a corresponding increase in mortality – which makes it a promising test to assist in antibiotic stewardship.
This is a little bit different spin on the question addressing the use of procalcitonin levels in a population that is febrile all the time – pediatrics. Most of the time, when children are febrile, the infectious etiology is either readily identifiable as bacterial or presumed to be viral. However, in the subset of children with indwelling central venous catheters – they’re treated presumptively as line sepsis until proven otherwise, despite the preponderance of viral etiologies.
This is a small case series of 62 children with indwelling lines, 14 of whom eventually grew positive blood cultures. Using procalcitonin levels drawn in the Emergency Department to rule out bacteremia gave an AUC of 0.82 (0.70 to 0.93) with the “optimal” cutoff at 0.3 ng/mL giving a sensitivity of 93% and specificity of 63%. I’m not sure I’d settle for anything less than 100% sensitivity for line sepsis, but there is a point at which the risks associated with healthcare delivery are equivalent to the risks of bloodstream infection. This is a nice idea I wasn’t previously familiar with that hopefully will be confirmed in subsequent evaluation.
“Procalcitonin as a Marker of Bacteremia in Children With Fever and a Central Venous Catheter Presenting to the Emergency Department”
www.ncbi.nlm.nih.gov/pubmed/23023470
Death By Horticulture
This case report, by the surgeons across the street at Baylor, describes a novel cause for bowel obstruction in children. Apparently, in the course of plant cultivation, it is useful to have water-retaining gel spheres. Advertised to retain water and grow to 400 times their original size, a child swallowed a “Water Balz” and developed a small bowel obstruction requiring laparoscopy and enterotomy.
More interestingly, the surgeons obtained five of these balls and evaluated their growth pattern. The balls began life at ~0.95cm in diameter and, after 96 hours, reached a diameter of ~5.5cm, most of the growth in the first 12 hours. Based on this, the surgeons estimate any swallowed balls would likely easily pass through the pylorus before resulting in complete bowel obstruction.
The claim of growth to 400 times size, however, is unfounded. The balls they studied only grew to 200 times original size.
“Water-Absorbing Balls: A “Growing” Problem”
www.ncbi.nlm.nih.gov/pubmed/22987870
Pediatric Intubation – Not Always Successful
This is an observational study of pediatric medical resuscitation, published in Annals of Emergency Medicine, using video to evaluate the frequency of various adverse events during pediatric intubation.
As expected in a teaching institution, there is a fair bit of variability in initial success rates – ranging from 35% first-pass success for pediatrics residents up to 89% for PEM or anesthesia attendings. Overall 52% had success on the first attempt. Unfortunately, 61% experienced at least one adverse event during intubation. These were typically not clinically important with regard to patient-oriented outcomes.
However, what is more entertainingly concerning is how few of the complications make it into the medical record. The written documentation overestimates first-attempt success, underestimates desaturation during the procedure, and even completely omits any mention of one of the two episodes of CPR required during resuscitation.
My guess is that Cincinnati Children’s may have had a documentation quality review after this data were collected.
“Rapid Sequence Intubation for Pediatric Emergency Patients: Higher Frequency of Failed Attempts and Adverse Effects Found by Video Review”
www.ncbi.nlm.nih.gov/pubmed/22424653
Acetaminophen and Asthma
If this article strikes your fancy – then you’ll never look at acetaminophen the same way again.
Published in Pediatrics, this is a bit of a commentary summarizing epidemiological data in both children and adults related to the association between acetaminophen (paracetamol) use and asthma. Specifically, that there is one, based on the studies he reviews, including:
• A prospective childhood asthma study of 520,000 subjects suggesting a dose-response effect between acetaminophen and asthma in children, up to an increased OR for wheezing of 3.25 for children taking acetaminophen at least once a month.
• A meta-analysis of six pediatric studies with a pooled increased OR for wheezing of 1.95 related to acetaminophen use.
• A meta-analysis of six adult studies with up to an increased OR for asthma of 2.87 for adults taking acetaminophen weekly.
…and several others. The author does not suggest any specific mechanism through which acetaminophen increases airway reactivity, but he has changed his practice to reduce acetaminophen usage to the minimum. I can’t say I disagree with his hypothesis, and there does appear to be a preponderance of mounting evidence, although I wouldn’t say this is an area where I am intimately familiar with the literature.
“The Association of Acetaminophen and Asthma Prevalence and Severity”
www.ncbi.nlm.nih.gov/pubmed/22065272
Honey For Pediatric Cough
Sponsored by the Honey Board of Israel, this small study supposes to demonstrate that honey is superior to control in the treatment of pediatric nighttime cough. Specifically, honey is superior to silan date extract, which apparently resembles and tastes like honey.
This is a prospective, double-blind study of three different honey arms and one control arm. Each group had approximately the same pre-intervention symptomatology severity – cough severity, bothersome nature of the cough, and sleeplessness for bother parent and child – and all interventions improved symptoms. The scores, supposing clinical relevance to a 0.75 difference in score on a 4-point scale, were significantly improved by all interventions. Then, the various types of honey all either strongly trended towards or reached statistical superiority over the silan date extract.
So, if your child has a cough – honey seems to be a reasonable intervention. If you don’t have honey, give them silan date extract! If you have neither – well, just don’t use dextromethorphan. And, 20% of infant botulism cases are traced to contaminated honey, so the current recommendation is not to give honey to patients aged less than 1 year.
Incidental note is also made by the authors that some children likely disliked the more aromatic eucalyptus and citrus honeys.
“Effect of Honey on Noctural Cough and Sleep Quality: A Double-blind, Randomized, Placebo-Controlled Study”
http://www.ncbi.nlm.nih.gov/pubmed/22869830
Mistakes Were Made
This is a fascinating series in Pediatric Emergency Care in which interesting cases from published medical malpractice verdicts are featured. Each case – typically ending poorly – is followed by a short editorial on the underlying disease processes, with pearls regarding treatment, diagnosis, and the case outcome. Reading these cases, hopefully, will not contribute to recency bias, and ideally serve simply as brief reminders of clinical features of the rare sick children lurking in the haystack of walking well.
Medicine – as much as or greater than any other profession – is a delicate mix of confidence, humility, and the recognition of the underlying biases in our cognition and practice. Most of this blog focuses on practicing based on evidence, applying the rules and probabilities of populations as guides towards the diagnosis and treatment of individual patients. Therefore, when reading these Legal Briefs, I simply want to reinforce the dangers of anecdote-based medicine.
“Pediatric Emergency Medicine: Legal Briefs”
Keeping Children Happy
When I started in medicine – hardly long ago – Child Life, if it existed at all in the Emergency Department, might have consisted of a few plastic toys and perhaps a Nintendo Entertainment System. Now, the staple of every department is an iPad, filled with apps and distractions for children.
This is a short article from the Pediatric literature reviewing a few cases in which tablet computers proved useful, along with a review of several apps worth loading on for distraction during potentially troubling procedures. Most of the apps reviewed are for iPad, but equivalent exist for Android devices and iPhone.
I’ve definitely gotten mileage out of the movie “Toy Story 3” on my iPhone – perfect for the 3 AM laceration repair when Child Life has gone home for the night.
“Using a Tablet Computer During Pediatric Procedures – A Case Series and Review of the ‘Apps'”
Massive Overtesting for Febrile Seizures
Frightening, yet benign, febrile seizures are seen frequently in the Emergency Department. The American Academy of Pediatrics recommends minimal evaluation for uncomplicated febrile seizures, and invasive testing only in complex cases or those with other indications for testing.
Despite this, the real-world experience documented by these authors at a community hospital in New York is slightly different. Rather than minimal testing, 100% of patients – mostly aged greater than 12 months – received a CBC and Chem7. 94% received a blood culture, 94% received a urine culture, and 85% had a chest x-ray. 24% had CSF cultures and 21% had CT scans – mostly the complex febrile seizures.
The yield of all this testing – they diagnosed a few UTIs, and one blood culture grew out salmonella. The authors appropriately feel this testing strategy is excessively wasteful – and confirms the AAP recommendations.
“Current Role of the Laboratory Investigation and Source of the Fever in the Diagnostic Approach”
http://www.ncbi.nlm.nih.gov/pubmed/22653461