Teasing out serious infection in children – while minimizing testing and unnecessary interventions – remains a challenge. To this end, the National Institute for Health and Clinical Excellence in the United Kingdom created a “Traffic Light” clinical assessment tool. This tool, which uses colour, activity, respiratory, hydration, and other features to give a low-, intermediate-, or high-risk assessment.
These authors attempted to validate the tool by retrospectively applying it to a prospective registry of over 15,000 febrile children aged less than 5 years. The primary outcome was correctly classifying a serious bacterial infection as intermediate- or high-risk. And the answer: 85.8% sensitivity and 28.5% specificity. Meh.
108 of the 157 missed cases of SBI were urinary tract infections – for which the authors suggest perhaps urinalysis could be added to the NICE traffic light. This would increase sensitivity to 92.1%, but drop specificity to 22.3% – if you agree with the blanket categorization of UTI as SBI.
Regardless, the AUC for SBI was 0.64 without the UA and 0.61 with the UA – not good at all.
“Accuracy of the “traffic light” clinical decision rule for serious bacterial infections in young children with fever: a retrospective cohort study”
www.ncbi.nlm.nih.gov/pubmed/23407730
Category: Pediatrics
The Grim World of ALTE
“The risk of subsequent mortality in infants admitted from our pediatric ED with an ALTE is substantial.”
Dire conclusions! Doom and gloom associated with apparent life-threatening events!
This is a little bit of an odd article. It’s a chart review of all infants aged 0 to 6 months presenting with an ALTE – including seizure, choking spell, and cyanosis. The authors reviewed 176 charts of admitted patients, follow-up studies, and eventual mortality.
- 111 received blood cultures – all negative.
- 65 received lumbar puncture – all negative.
- 113 received chest x-rays – 12 of which had infiltrates.
- 35 received non-contrast head CT – all negative.
- 62 were tested for RSV – 9 were positive.
So, how many infants died after their ALTE to spawn this conclusion of “substantial” mortality?
Two.
This leads to the authors to conclude this high-risk complaint requires admission. However, each death was a generally previously healthy patient was admitted with ALTE, evaluated extensively as an inpatient, discharged from the inpatient service – and died within two weeks, regardless. The only reasoning I can fathom for this recommendation is as a cover-your-ass strategy to prevent being the physician who “last touched” the patient when someone comes back with a lawyer.
“Mortality after discharge in clinically stable infants admitted with a first-time apparent life-threatening event”
Pediatric Blunt Trauma Remains Confounding
The latest output from the Pediatric Emergency Care Applied Research Network is a clinical decision instrument intended to assist clinicians in managing pediatric blunt abdominal trauma.
Like previous PECARN studies, this is a multi-center, prospective, observational study conducted in tertiary pediatric emergency departments. This study enrolled 12,044 children with blunt trauma and prospectively collected structured data regarding their mechanism, external injuries, and physiologic variables. Using the magic of statistical partitioning, the authors derived a decision instrument for use in risk-stratifying a patient as “very low risk for intra-abdominal injury requiring acute intervention.” If the patient meets all criteria, the prediction rule is 97.0% sensitive, missing 6 out of 203 abdominal injuries.
This is critically valuable data – but, as a decision-instrument in a zero-miss environment, I’m not sure if it helps. The authors note that use of their CT decision-instrument actually increased resource utilization if retrospectively applied to the derivation cohort, if the requirement is held that a patient be negative for every variable. If the threshold is raised to 1 or 2 variables present, then sensitivity drops to 82% and 77%, respectively. Only about half received a CT scan, and a small percentage were lost to follow-up – though, given the outcome of “injuries requiring intervention”, the methodology is reasonable. However, because intervention-requiring injuries only represented 26% of all radiographically-identified intra-abdominal injuries, this study is still going to be ignored out-of-hand by folks who want to identify all injuries, not just intervention-requiring injuries. After all, the grade 1 splenic laceration may be intervention-free, but remains important regarding activity restrictions to prevent future morbidity.
The authors also note these findings require external validation – wherever they’re going to find another pedatric emergency care network to enroll 12,000 patients!
“Identifying Children at Very Low Risk of Clinically Important Blunt Abdominal Injuries”
http://www.ncbi.nlm.nih.gov/pubmed/23375510
UTI: Yet Another Windmill?
Medicine is full of windmills re-imagined as dragons – and two of the most prominent voices of reason in Emergency Medicine are David Newman and Jerome Hoffman. This skeptical take on pediatric urinary tract infections is David Newman’s latest, which covers content reflective of his SMART EM podcast on the same topic.
The premise of his argument is rather straightforward:
- There’s substantial overlap between UTI and asymptomatic bacteruria, leading to overdiagnosis.
- Even when the diagnosis is correctly made, prompt treatment does not prevent complications.
The complications in question are urosepsis and renal scarring. Urosepsis, in David’s literature review only results from urinary tract infections from the otherwise immunosuppressed, or in infants with congenital anomalies. Renal scarring, purportedly from pyelonephritis, has little or controversial evidence in supporting antibiotic use from preventing it.
This will be published in an upcoming issue of Annals of Emergency Medicine.
“Pediatric Urinary Tract Infection: Does the Evidence Support Aggressively Pursuing the Diagnosis?”
www.ncbi.nlm.nih.gov/pubmed/23312370
Breast Cancer From Pediatric Trauma Imaging
Evaluations for significant pediatric blunt trauma tend to be rather rare. However, one flip side to improved vehicular safety is that previously fatal accidents turn into diagnostic dilemmas with otherwise well-appearing children after horrific potential injury mechanisms.
This specific article tries to address the risk/benefit ratio for imaging the pediatric thoracic spine after trauma, with a focus on the lifetime excess attributable risk for breast cancer. They used estimates of radiation to breast tissue from plain films and CT, and then applied the predictions from the BEIR VII report to determine EAR. From all these various calculations, their worst-case scenario derived an excess of 79.6 cases of breast cancer per 10,000 CT scans in females aged less than 12 years.
Unfortunately, the proponents of CT imaging cite these studies and say we’ve done nothing but document theoretical risk (based on atomic bomb exposure) – while ignoring that the risk of missed injury is equally theoretical. As usual, the prudent course of action is to perform additional testing only when explicitly indicated – the additional cases of breast cancer are not trivial, but neither are missed injuries. The rate of additional breast cancer cases is certainly not so high that CTs should be skipped when clinically indicated.
“Theoretical Breast Cancer Induction Risk From Thoracic Spine CT in Female Pediatric Trauma Patients”
www.ncbi.nlm.nih.gov/pubmed/23184109
The AAP Policy on Firearm Safety
Might not it be helpful if, coincidentally, the Council on Injury, Violence, and Poison Prevention for the American Academy of Pediatrics had just updated their policy statement regarding firearm-related injuries? Indeed, just two months ago, the AAP published an update, featuring a mere 66 citations worth of evidence, rather than politicized talking points.
A couple interesting statistics from their summary:
– The firearm-associated death rate among youth ages 15 to 19 has fallen from its peak of 27.8 deaths per 100 000 in 1994 to 11.4 per 100 000 in 2009.
– However, of all injury deaths of individuals younger than 20 years, still 1 in 5 were firearm related.
– For youth 15 to 24 years of age, firearm homicide rates were 35.7 times higher than in other high-income countries.
– For children 5 to 14 years of age, firearm suicide rates were 8 times higher, and death rates from unintentional firearm injuries were 10 times higher in the United States than other high-income countries.
– The difference in rates is postulated to the ease of availability of guns in the United States compared with other high-income countries.
Their recommendations section seems quite straightforward:
– The most effective measure to prevent suicide, homicide, and unintentional firearm-related injuries to children and adolescents is the absence of guns from homes and communities.
– Health care professionals should counsel the parents of all adolescents to remove guns from the home or restrict access to them.
– Trigger locks, lock boxes, gun safes, and safe storage legislation are encouraged by the AAP.
– Other measures aimed at regulating access of guns should include legislative actions, such as mandatory waiting periods, closure of the gun show loophole, mental health restrictions for gun purchases, and background checks.
– The AAP recommends restoration of the ban on the sale of assault weapons to the general public.
Any chance policymakers might listen to the society of physicians “Dedicated to the health and well-being of infants, children, adolescents and young adults”?
“Firearm-Related Injuries Affecting the Pediatric Population”
www.ncbi.nlm.nih.gov/pubmed/10742344
Pain Control on the Wrong Track
Codeine, the oral narcotic analgesia that is long past its prime. Approximately 8% of the caucasian population cannot metabolize codeine into morphine – and then a small handful are rapid metabolizers that will overdose on an otherwise therapeutic dose. But, this didn’t stop these folks in Montreal from evaluating its efficacy for pediatric musculoskeletal limb pain.
Pediatric pain is a little odd. Overall, the Emergency Department does a poor job of treating pain. Studies in pediatric EDs show significant percentages of injured patients don’t receive any pain control. But, then, we all have the anecdotal experience in which a child is sitting on a stretcher watching TV with a fractured arm denying he’s in any pain at all – why are you bothering me again? Spongebob is on.
Long story short, this study randomized children to receive either ibuprofen alone or ibuprofen plus codeine. At each time point, the difference in pain scales was no different between groups. Pain scores weren’t that high to begin with, and had moderate improvement after either treatment.
For minor pain, acetaminophen and ibuprofen are adequate options. For more severe pain, intravenous narcotics, intranasal narcotics, or even intramuscular ketamine are probably better options.
“Efficacy of an Ibuprofen/Codeine Combination for Pain Management in Children Presenting to the Emergency Department With a Limb Injury: A Pilot Study”
www.ncbi.nlm.nih.gov/pubmed/23232154
Viral Testing in Children With Fever
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
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