Clinical Pediatrics

Approaches to the management of children with urinary tract infection (UTI), vesicoureteral reflux (VUR), and renal scars have been challenged and have become controversial over the past decade. It is difficult to determine when, how, and which patients will benefit from the diagnosis and management of this condition. Therefore, the issues of diagnostic imaging, observation, follow-up, and intervention tend to be decided more on a case-by-case basis, rather than by using an algorithm. Over the past few years, there have been advances in the identification of risk factors that predispose patients with UTI to present with VUR, to develop recurrent UTIs and renal scars, to have deteriorating renal function, to show VUR improvement and/or spontaneous resolution, and to be candidates for and benefit from early surgical intervention.

Background. This is a retrospective chart review of autistic patients presenting to the emergency department (ED) in a tertiary care pediatric center during the year 2011. Results. There were 160 ED visits by 130 patients, 25% of visits were repeated, and 20% were admitted to the hospital. There were 126 (79%) male and 34 (21%) female patients mean age of 12 years, 79% had comorbid health conditions. Forty percent were CTAS 2 (Canadian Triage Acuity Score) acuity, 42% of visits were CTAS 3 acuity, and 7% rated their pain as “severe.” Visits were for behavior (10%), neurological concern (13%), 3% dental related, and the remainder were for gastrointestinal infections and other complaints. Average length of stay was 6 hours 21 minutes, with 2-hour wait to start assessment with physician. Conclusions. Autism is a prevalent diagnosis and patients with autism are accessing the ED. We hope to use these demographic findings to better serve these patients and their families.

Background. The American Academy of Pediatrics (AAP) guidelines on the workup for urinary tract infections (UTIs) in infants discourages the use of bagged urine specimens for urine culture. We report the results of a survey to assess urine collection preferences and adherence to AAP guidelines in clinical practice. Methods. A 29-question survey was e-mailed to pediatrician AAP members to determine their preferred method of urine collection in hypothetical infant patients. Results. Data from 155 respondents were analyzed. In febrile, circumcised boys, up to 18% preferred bagged specimens for urine culture, against AAP recommendations. In febrile girls, 13% of respondents preferred bagged specimens. There was no significant relationship between adherence to AAP guidelines and respondent’s age, gender, years in practice, fellowship training, academic affiliation, or other demographic factors. Conclusions. Up to 18% of practitioners prefer bagged specimens over more sterile ones in the workup of febrile UTIs in infants, against AAP guidelines.

Introduction. This study investigates radiographically acquired normative ranges of anterior fontanelle closure (AFC) and surface area (SA) in healthy full-term infants. Methods. High-resolution head computed tomography (CT) scans were retrospectively reviewed for AFC and AF dimensions to allow approximation of AF SA. Results. Between 15 and 23 head CT scans per monthly age-group (0-24 months) were reviewed, totaling 464 scans. AFC frequency increased steadily from age 10 (16%) to 20 months (88%), reaching higher than 50% at age 16 months (53%). The AF was closed in 3% to 5% of infants at 5 to 6 months. AF median SA increased from 769.3 mm² (age 0 months) to 1022.2 mm² (2 months), then declined steadily. Conclusions. This study provides reference charts detailing AFC frequency and AF SA as a function of age. Wide variability of AFC timing and AF size among healthy infants suggest that early or delayed AFC may represent normal variants.

Background. Accurate determination of temperature is important, especially in the diagnosis and treatment of febrile illnesses in the pediatric population. False negative measurement can lead to miss febrile and false positive measurement can cause excessive medical care. Temperatures can be measured at various sites, but we have not found the ideal thermometer yet. As a relatively new and popular alternative over traditional methods, infrared ear thermometry has many advantages, but its accuracy remains a major concern. Design. Systematic review and meta-analysis. Data Sources. Medline, Ovid, Elsevier, Google Scholar, Cochrane Library. Study Selection. Cross-sectional, prospective design. Data Extraction. Two investigators independently assessed selected studies and extracted data. Disagreements were resolved by discussion with other reviewers. Results. Mean tympanic temperature was always lower than rectal temperature. The overall pooled (random effects) mean difference between tympanic and rectal temperature was 0.22°C (95% limits of agreement −0.44°C to 1.30°C), which is similar to the within rectal device groups (mercury, 0.21°C, −0.44°C to 1.27°C; electronic, 0.24°C, −0.46°C to 1.34°C). In febrile children group, the pooled mean temperature difference between tympanic and rectal temperature was 0.15°C (95% limits of agreement −0.32°C to 1.10°C). Conclusion. The mean difference was large and the 95% limits of agreement was wide. The accuracy of infrared ear thermometry in children is poor, and it cannot replace rectal thermometry in clinical practice of children.

Objective. American parents were surveyed to isolate demographic factors that predict reliance on a pediatrician, the American Academy of Pediatrics (AAP), or both for media guidance. We then investigated whether reliance on these resources resulted in different media practices with children. Methods. A nationally representative survey was conducted (n = 1454). Parents were asked what medical professionals they relied on for advice and reported relevant home media practices related to their child. Results. In all, 29% reported relying on their pediatrician, 24.9% said that they relied on the AAP, and 14.9% of all parents said they relied on both. Those following the AAP’s media guidelines were more likely to prohibit bedroom television and to follow all guidelines. Conclusions. The relatively low reliance on the AAP and pediatricians for media guidance suggest that more outreach is necessary. However, parents who report relying on the AAP for advice are more likely to enact these recommendations.

Background. Validated clinical scales, such as the Canadian Acute Respiratory Illness and Flu Scale (CARIFS), have not been used to differentiate influenza (FLU) from other respiratory viruses. Methods. Secondary analysis of a prospective cohort presenting to the emergency department (ED) with an influenza-like infection from 2008 to 2010. Subjects were children aged 0 to 19 years who had a venipuncture and respiratory virus polymerase chain reaction. Demographics and CARIFS items were assessed during the ED visit; comparisons were made between FLU and non-FLU subjects. Results. The 203 subjects had median age 30.5 months; 61.6% were male. Comorbid conditions (51.2%) were common. FLU was identified in 26.6%, and were older than non-FLU patients (69.7 vs 47.9 months, P = .02). Demographic, household factors, and mean CARIFS score did not differ between FLU (33.7), and non-FLU (32.0) (mean difference 1.6, 95% CI: −2.0 to 5.2) groups. Conclusions. CARIFS cannot discriminate between FLU and non-FLU infection in ED children with influenza-like infection.

Aim. To systematically update diagnostic accuracy of the Clinical Dehydration Scale (CDS) in clinical recognition of dehydration in children with acute gastroenteritis. Methods. Six databases were searched for diagnostic accuracy studies in which population were children aged 1 to 36 months with acute gastroenteritis; index test was the CDS; and reference test was post-illness weight gain. Results. Three studies involving 360 children were included. Limited evidence showed that in high-income countries the CDS provides strong diagnostic accuracy for ruling in moderate and severe (>6%) dehydration (positive likelihood ratio 5.2-6.6), but has limited value for ruling it out (negative likelihood ratio 0.4-0.55). In low-income countries, the CDS has limited value either for ruling moderate or severe dehydration in or out. In both settings, the CDS had limited value for ruling in or out dehydration <3% or dehydration 3% to 6%. Conclusion. The CDS can help assess moderate to severe dehydration in high-income settings. Given the limited data, the evidence should be viewed with caution.

Objective. To assess the impact of a locally applied vibrating device on outpatient venipuncture in children. Method. A retrospective review of survey data collected prospectively as part of a quality improvement project. Both patients and phlebotomists were surveyed. The sample consisted of 64 children aged 4 to 18 years (29 prior to the implementation of the vibrating device and 35 afterward) and 7 phlebotomists. Results. Prior to the use of the vibrating device, 17 children (59%) indicated that they wished something had been done to decrease venipuncture pain. Eighty percent of the cohort that used the vibrating device indicated that they would like it used for future procedures. Children with previous venipuncture experiences appeared to benefit most from use of the vibrating technique. The phlebotomists reported that vibration made the procedure easier in 81% of the cases; none reported that it complicated the procedure. Conclusions. Locally applied vibration appears to be a well-accepted technique to minimize pediatric venipuncture discomfort that may facilitate completion of the procedure.