[Show abstract][Hide abstract] ABSTRACT: Acute respiratory conditions are a leading cause of childhood morbidity and mortality. Corticosteroids are effective and established treatments in some acute respiratory infections (e.g. croup) and asthma exacerbations; however, their role is controversial in other conditions owing to inconsistent effectiveness or safety concerns (e.g. bronchiolitis, acute wheeze).
Evidence-Based Child Health A Cochrane Review Journal 09/2014; 9(3):733-47.
[Show abstract][Hide abstract] ABSTRACT: To better understand factors that may impact infant mortality rates (IMR), we evaluated the consistency across birth hospitals in the classification of a birth event as either a fetal death or an early neonatal (infant) death using natality data from North Carolina for the years 1995-2000.
A database consisting of fetal deaths and infant deaths occurring within the first 24 hours after birth was constructed. Bivariate, followed by multivariable regression, analyses were used to control for relevant maternal and infant factors. Based upon hospital variances, adjustments were made to evaluate the impact of the classification on statewide infant mortality rate.
After controlling for multiple maternal and infant factors, birth hospital remained a factor related to the classification of early neonatal versus fetal death. Reporting of early neonatal deaths versus fetal deaths consistent with the lowest or highest hospital strata would have resulted in an adjusted IMR varying from 7.5 to 10.64 compared with the actual rate of 8.95.
Valid comparisons of IMR among geographic regions within and between countries require consistent classification of perinatal deaths. This study demonstrates that local variation in categorization of death events as fetal death versus neonatal death within the first 24 hours after delivery may impact a state-level IMR in a meaningful magnitude. The potential impact of this issue on IMRs should be examined in other state and national populations.
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES: The perineal and gluteal regions are the most frequent areas of skin and soft tissue infection (SSTI) in diapered children. No studies have investigated the relationship between perineal and general hygiene practices and SSTIs in this population. This study was conducted to evaluate this relationship. METHODS: A cross-sectional observational study was conducted in an urban pediatric emergency department. Subjects were recruited into 3 study groups as follows: gluteal/perineal SSTIs (SSTI), diaper dermatitis (DD), or healthy normal skin (NS). Survey responses were analyzed for significance followed by a clinically oriented staged regression to model predictors of SSTI compared with the NS and DD groups. RESULTS: There were 100 subjects in the SSTI, 206 in the NS, and 151 in the DD groups. Race was the only demographic characteristic that differed between the groups. After adjustment for race, no day care attendance, history of SSTI, household contact with SSTI history, and higher propensity for diaper rash were associated with SSTI compared with NS. Regression results comparing SSTI to DD revealed no day care attendance, history of SSTI, household contact with SSTI history, less sensitive skin, and less diaper cream use to be predictors of SSTI. CONCLUSIONS: Perineal and general hygiene practices were not significantly different between children with SSTI compared with children with NS or DD. Based on the results of this study, further prospective studies should evaluate diaper hygiene practices that prevent DD and subsequent SSTIs, the preventative role of day care attendance, and effective interventions that minimize the risk of recurrent SSTIs.
Pediatric emergency care 04/2013; · 0.92 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Rocky Mountain spotted fever is typically undifferentiated from many other infections in the first few days of illness. Treatment should not be delayed pending confirmation of infection when Rocky Mountain spotted fever is suspected. Doxycycline is the drug of choice even for infants and children less than 8 years old.
Pediatric Clinics of North America 04/2013; 60(2):455-470. · 1.78 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Viral pathogens are commonly isolated from children with community-acquired pneumonia (CAP). Viruses like respiratory syncytial virus, human rhinovirus, human metapneumovirus, parainfluenza viruses, and influenza may act as sole pathogens or may predispose to bacterial pneumonia by a variety of mechanisms. New, emerging, or reemerging viral pathogens occasionally cause outbreaks of severe respiratory tract infection in children. The 2009-2010 H1N1 influenza virus pandemic resulted in increased rates of influenza-related hospitalizations and deaths in children. Rapid viral diagnostic tests based on antigen detection or nucleic acid amplification are increasingly available for clinical use and confirm the importance of viral infection in children hospitalized with CAP. Recently published guidelines for the management of CAP in children note that positive viral test results can modify clinical decision making in children with suspected pneumonia by allowing antibacterial therapy to be withheld in the absence of clinical, laboratory, or radiographic findings that suggest bacterial coinfection.
[Show abstract][Hide abstract] ABSTRACT: To assess the effectiveness of guidelines and education on empirical therapy for community-acquired pneumonia.
Administrative records for children with a primary diagnosis of pneumonia from January 2007 to September 2009 were reviewed. Antimicrobial use was measured monthly over 3 periods: (1) before creation of an antimicrobial stewardship task force (ASTF), (2) after ASTF formation but before release of guidelines for antimicrobial use, and (3) after guideline release. Antimicrobial use over time was assessed by using quasi-binomial logistic regression models that incorporated interrupted events, seasonality, and autocorrelation. Allowing calculation of immediate changes due to specific interventions and trends in use over each time period. The primary outcome was use of ampicillin as recommended in the guidelines versus ceftriaxone, the historical standard. Secondary outcomes included other antimicrobial use, length of stay, mortality, and readmission.
One thousand two hundred forty-six children met study criteria. Ampicillin use increased from 2% at baseline to 6% after ASTF formation and 44% after guideline release. Ceftriaxone use increased slightly (from 56% to 59%) after ASTF formation but decreased to 28% after guideline release. An immediate change in prescription occurred in the month after guideline publication and remained stable over the following year.
Guidelines and education can have an impact on antimicrobial use in the pediatric setting. Although the optimal strategies for pediatric antimicrobial stewardship programs still are being determined, we believe that our approach offers an inexpensive and low-risk step in the right direction.
[Show abstract][Hide abstract] ABSTRACT: This study reviewed Kentucky Medicaid claims data for children with autism spectrum disorders to determine psychotropic drug (PTD) use in this population. Children with autism spectrum disorders (ICD-9 code 299.XX) in 3 different age-groups from 2005 to 2008 were identified; PTD use was defined as at least 1 prescription per year. PTD use in all age ranges was higher than in previously reported studies. High PTD use in children between 1 and 5 years is particularly of concern and may reflect perceived inadequacies of comprehensive educational/behavioral services for these children.
[Show abstract][Hide abstract] ABSTRACT: Studies of pediatric intensive care unit (PICU) patients have shown a significant association of morbidity and mortality with hyperglycemia. We retrospectively evaluated the degree of hyperglycemia as well as its correlation with glucocorticoid and insulin use and assessed its association with hospital length of stay (LOS) and mortality. This study preceded the initiation of a standard glycemic control protocol.
We examined medical records at Kosair Children's Hospital for all PICU admissions from 2008 of patients without diabetes mellitus. Critical illness hyperglycemia (CIH) was defined by having three or more peak glucose values greater than thresholds of 110, 140, 180, and 200 mg/dl. These patients were evaluated for glucocorticoid, insulin use, and outcome measures.
We evaluated the eligible 1173 admissions, where 10.5% of these patients reached the highest threshold (200 mg/dl) of CIH. Glucocorticoids were used in 43% of these patients, with dexamethasone being the most common (58%). There was a significant correlation between glucocorticoids and higher peak glucose values, where 81% of the patients who were above the 200 mg/dl cutoff level were treated with glucocorticoids. Only 36.8% in that group were also treated with insulin. Patients at the 200 mg/dl cutoff had the highest median PICU and total hospital length of stays (4 and 10 days, respectfully). Mortality was associated with increasing glucose levels, reaching 18.7% among patients above the 200 mg/dl cutoff.
Hyperglycemia was prevalent in the PICU and was associated with increased morbidity, as characterized by increased LOS and increased mortality. Glucocorticoid use was prevalent among patients exhibiting hyperglycemia. Insulin use was uncommon.
Journal of diabetes science and technology 01/2012; 6(1):5-14.
[Show abstract][Hide abstract] ABSTRACT: Purpose: Community acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is the most frequent cause of skin and soft tissue infections (SSTI). The perineal and gluteal (diaper) regions are a common site of CA-MRSA SSTI in young children, but no studies have investigated the relationship between hygiene practices and SSTI. This study was conducted to evaluate the relationship of perineal and general hygiene practices with SSTI.
Methods: A cross-sectional, age-matched observational study was conducted in an urban pediatric emergency department. Children were eligible when <36 months of age, diapered for >90% of the day, and with an adult who provided care >50% of the time. Children with immunosuppression, chronic antibiotic use, or group home residence were ineligible. Parents/guardians of eligible children completed a survey regarding the child’s perineal hygiene, a validated measure of general hygiene, other potential risk factors for SSTI, and demographic characteristics. Subjects were recruited into three study groups: gluteal or perineal skin and soft tissue infection (SSTI), diaper dermatitis (DD), or healthy normal perineal skin (NS). Survey responses were analyzed for significance between groups using chi-square or Mann-Whitney U as appropriate. Binary logistic regression was used to model predictors of the presence of SSTI in comparison to NS and DD when univariate analysis revealed a p value <0.1.
Results: 100 subjects were recruited into the SSTI group, with 201 and 82 children in the NS and DD groups, respectively. Race was the only demographic characteristic that differed between SSTI and NS groups (% white: 56%, 46%, respectively, P =0.015). In univariate analysis, the propensity for diaper rash, diaper rash frequency, barrier cream use, daycare attendance, prior history of SSTI, household contact with abscess or boil, and recent antibiotic use differed between SSTI and NS groups (all P<0.05). After adjustment for race, daycare attendance (adjusted odds ratio (aOR) 0.43 [95% confidence interval (CI): 0.22, 0.82]), prior history of SSTI (aOR 6.46, [95% CI: 2.87, 14.5]), household contact with an SSTI (aOR 3.5, [95% CI; 1.75, 7.01]), and increasing frequency of diaper rash (P =0.004) were associated with SSTI when compared to NS. Regression results comparing SSTI with DD revealed prior history of SSTI and household contact with SSTI to be the best predictors of SSTI. Neither number of diapers used per day nor degree of general hygiene was significantly associated with SSTI.
Conclusions: Perineal and general hygiene practices were not significantly different between children with SSTI compared to children with NS or DD. Parents of children with SSTI reported more frequent episodes of diaper rash than those of children with healthy perineal skin. The role of diaper dermatitis as a risk factor for SSTI warrants further investigation in order to develop preventative interventions.
2011 American Academy of Pediatrics National Conference and Exhibition; 10/2011
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to characterize the practice of routinely obtaining tracheal aspirate cultures in children with tracheostomy tubes and to analyze the appropriateness of using this information to guide antibiotic selection for treatment of subsequent lower respiratory infections.
Pediatric otolaryngologists and pulmonologists were surveyed regarding surveillance culture practices. Records of children with tracheostomy tubes from January 1, 2003, through December 31, 2007, were reviewed. Consecutive cultures were compared for similarity of bacteria and antibiotic sensitivity when a clinic culture preceded a culture from when the child was ill and received antibiotics and when a hospital culture preceded a hospital culture from a separate hospitalization.
Seventy-nine of 146 pulmonologists and five of 33 otolaryngologists obtained routine surveillance tracheal aspirate cultures (P < .001); 97% of pulmonologists used these cultures to guide subsequent empiric therapy. There were 36 of 170 children with one or more eligible pairs of cultures. Nearly all children had a change in flora in their tracheal cultures. Limiting empiric antibiotic choices to those that would cover microbes isolated in the previous culture likely would not have been effective in covering one or more microbes isolated in the second culture in 56% of pairs with the first culture from hospitalization vs 30% with the first culture from an outpatient setting (P = .15).
This study demonstrated that there are significant changes in bacteria or antibiotic sensitivity between consecutive tracheal cultures in children with tracheostomy tubes. Use of prior tracheal cultures from these children was of limited value for choosing empiric antibiotic therapy in treating acute lower respiratory exacerbations. Surveillance cultures, thus, are an unnecessary burden and expense of care.
[Show abstract][Hide abstract] ABSTRACT: Approximately 2% to 5% of children presenting to pediatric emergency departments (PEDs) leave prior to a complete evaluation. This study assessed risk factors for premature departure (PD) from a PED to identify key metrics and cutoffs for reducing the PD rate.
A 3-year cohort (June 2004-May 2007) of children presenting to a PED was evaluated. Children were excluded if they presented for psychiatric issues, were held awaiting hospital admission in the PED due to a lack of inpatient beds, were more than 21 years old, or died before disposition. Univariate analyses, multivariable logistic regression, and recursive partitioning were used to identify factors associated with PD. A fourth year of data (June 2007-May 2008) was used for validation and sensitivity analysis.
There were 132,324 patient visits in the 3-year derivation data set with a 3.8% PD rate, and 45,001 visits in the fourth-year validation data set with a 4.3% PD rate. PDs were minimized when average wait time was below 110 minutes, concurrent PDs were fewer than two, and average length of stay (LOS) was less than 224 minutes in the derivation set, with similar results in the validation set. When these metrics were exceeded, PD rates were over 10% among low-acuity patients. These findings were robust across a broad range of assumptions during sensitivity analysis.
The authors identified five key metrics associated with PD in the PED: average wait time, average LOS, acuity, concurrent PDs, and arrival rate. Operational cutoffs for these metrics, determined by recursive partitioning, may be useful to physicians and administrators when selecting specific interventions to address PDs from the PED.
Academic Emergency Medicine 11/2010; 17(11):1197-206. · 2.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine whether children who received recommended vaccines on time during the first year of life had different neuropsychological outcomes at 7 to 10 years of age as compared with children with delayed receipt or nonreceipt of these vaccines.
Publicly available data, including age at vaccination, from a previous VaccineSafety Datalink study of thimerosal exposure and 42 neuropsychological outcomes were analyzed. Vaccine receipt was defined as timely when each vaccine was received within 30 days of the recommended age. Associations between timeliness and each outcome were tested in univariate analyses. Multivariable regression models were constructed for further assessment of the impact of timeliness on neuropsychological outcomes after adjustment for potential confounders. Secondary analyses were performed on a subset of children with the highest and lowest vaccine exposures during the first 7 months of life.
Timely vaccination was associated with better performance on 12 outcomes in univariate testing and remained associated with better performance for 2 outcomes in multivariable analyses. No statistically significant differences favored delayed receipt. In secondary analyses, children with the greatest vaccine exposure during the first 7 months of life performed better than children with the least vaccine exposure on 15 outcomes in univariate testing; these differences did not persist in multivariable analyses. No statistically significant differences favored the less vaccinated children.
Timely vaccination during infancy has no adverse effect on neuropsychological outcomes 7 to 10 years later. These data may reassure parents who are concerned that children receive too many vaccines too soon.
[Show abstract][Hide abstract] ABSTRACT: Previous literature suggests that process-related factors (eg, time of day, patient volume) and patient-related factors (eg, acuity, socioeconomic status) are associated with premature departure from emergency departments. We sought to evaluate the relationship of these and other factors with premature departure in a large, unselected cohort of pediatric emergency department patients.
This study was a retrospective cohort analysis of visits to a single tertiary site during a 1-year period. Patients' zip codes determined assignment of census-based socioeconomic metrics. Multivariate regression identified factors associated with premature departure. Sensitivity and subset analyses were performed. Return visits within 48 hours after premature departure were also reviewed.
There were 46,417 visits, of which 2164 were premature departures. In multivariate analysis, independent predictors of premature departures were arrival time, arrival month, arrival day of week, patient acuity, concurrent premature departures, arrival rate, arrival period average length of stay, and poverty rate. Aside from patient acuity and poverty rate, no patient-related factors were significant in multivariate analysis. These results were robust in sensitivity analysis across different multivariate models. Among premature departures, there were 120 return visits (5.5%), of which 15 were admitted (0.7%). There were no deaths. Acuity was similar between initial and subsequent visits.
Process-related factors and individual patient acuity have the strongest influence on premature departure from the pediatric emergency department. Health care organizations concerned with premature departure should focus efforts on improving pediatric emergency process flow.
Pediatric emergency care 05/2010; 26(5):349-56. · 0.92 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A 9-year-old white male with congenital aortic and subaortic stenosis palliated by the Ross-Konno procedure presented with culture-negative endocarditis. Serologic studies and polymerase chain reaction testing of resected homograft valvular tissue provided evidence of Bartonella henselae as the etiology. B. henselae can cause endocarditis in children, particularly those with underlying valvular disease. Serologic testing for B. henselae should be considered in children with culture-negative endocarditis.