JAMA Pediatrics 2015

Treatment


1. JAMA Pediatr. 2015 Oct 19:1-7. doi: 10.1001/jamapediatrics.2015.2743. [Epub ahead
of print]

Association of a Guardian's Report of a Child Acting Abnormally With Traumatic
Brain Injury After Minor Blunt Head Trauma.

Nishijima DK(1), Holmes JF(1), Dayan PS(2), Kuppermann N(1).

Author information: 
(1)Department of Emergency Medicine, School of Medicine, University of
California-Davis, Sacramento. (2)Division of Pediatric Emergency Medicine,
College of Physicians and Surgeons, Columbia University, New York, New York.

Importance: Increased use of computed tomography (CT) in children is concerning
owing to the cancer risk from ionizing radiation, particularly in children
younger than 2 years. A guardian report that a child is acting abnormally is a
risk factor for clinically important traumatic brain injury (ciTBI) and may be a
driving factor for CT use in the emergency department.
Objective: To determine the prevalence of ciTBIs and TBIs in children younger
than 2 years with minor blunt head trauma and a guardian report of acting
abnormally with (1) no other findings or (2) other concerning findings for TBI.
Design, Setting, and Participants: Secondary analysis of a large, prospective,
multicenter cohort study that included 43 399 children younger than 18 years with
minor blunt head trauma evaluated in 25 emergency departments. The study was
conducted on data obtained between June 2004 and September 2006. Data analysis
was performed between August 21, 2014, and March 9, 2015.
Exposures: A guardian report that the child was acting abnormally after minor
blunt head trauma.
Main Outcomes and Measures: The prevalence of ciTBI (defined as death,
neurosurgery, intubation for >24 hours, or hospitalization for ≥2 nights in
association with TBI on CT imaging) and TBI on CT imaging in children with a
guardian report of acting abnormally with (1) no other findings and (2) other
concerning findings for TBI.
Results: Of 43 399 children in the cohort study, a total of 1297 children had
reports of acting abnormally, of whom 411 (31.7%) had this report as their only
finding. Reported as percentage (95% CI), 1 of 411 (0.2% [0-1.3%]) had a ciTBI,
and 4 TBIs were noted on the CT scans in 185 children who underwent imaging (2.2%
[0.6%-5.4%]). In children with reports of acting abnormally and other concerning
findings for TBI, 29 of 886 (3.3% [2.2%-4.7%]) had ciTBIs and 66 of 674 (9.8%
[7.7%-12.3%]) had TBIs on CT.
Conclusions and Relevance: Clinically important TBIs are very uncommon, and TBIs
noted on CT are uncommon in children younger than 2 years with minor blunt head
trauma and guardian reports of the child acting abnormally with no other clinical
findings suspicious for TBI. Computed tomographic scans are generally not
indicated in these children although observation in the emergency department may
be warranted.

PMID: 26502172  [PubMed - as supplied by publisher]


2. JAMA Pediatr. 2015 Nov 23:1-8. doi: 10.1001/jamapediatrics.2015.3210. [Epub ahead
of print]

Use of Procalcitonin Assays to Predict Serious Bacterial Infection in Young
Febrile Infants.

Milcent K(1), Faesch S(2), Gras-Le Guen C(3), Dubos F(4), Poulalhon C(5), Badier
I(6), Marc E(7), Laguille C(8), de Pontual L(9), Mosca A(10), Nissack G(11),
Biscardi S(12), Le Hors H(13), Louillet F(14), Dumitrescu AM(15), Babe P(16),
Vauloup-Fellous C(17), Bouyer J(5), Gajdos V(1).

Author information: 
(1)Department of Pediatrics, Antoine Béclère University Hospital, Assistance
Publique-Hôpitaux de Paris, Clamart, France2INSERM, CESP Centre for Research in
Epidemiology and Population Health, Paris-Sud, Paris-Saclay University,
Villejuif, France. (2)Pediatric Emergency Department, Paris Descartes University,
Necker Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris,
France. (3)Department of Pediatrics, Hôpital Mère Enfant, Nantes University
Hospital, Nantes, France. (4)Pediatric Emergency Unit and Infectious Diseases,
Lille University, Lille, France. (5)INSERM, CESP Centre for Research in
Epidemiology and Population Health, Paris-Sud, Paris-Saclay University,
Villejuif, France. (6)Department of Pediatrics, Poissy Hospital, Poissy, France. 
(7)Department of Pediatrics, Kremlin Bicêtre University Hospital, Assistance
Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France. (8)Department of
Pediatrics, Dupuytren University Hospital, Limoges, France. (9)Department of
Pediatrics, Jean Verdier Hospital, Assistance Publique-Hôpitaux de Paris, Paris
13 University, Bondy, France. (10)Department of Pediatrics, Sud Francilien
Hospital, Corbeil-Essonnes, France. (11)Department of Pediatrics, Centre
Hospitalier de Marne La Vallée, Jossigny, France. (12)Department of Pediatrics,
Créteil Hospital, Créteil, France. (13)Department of Paediatric Surgery, Hôpital
d'Enfants de La Timone, Marseille, France. (14)Department of Pediatrics, Rouen
University Hospital, Rouen, France. (15)Department of Pediatrics, Louis Mourier
University Hospital, Assistance Publique-Hôpitaux de Paris, Colombes, France.
(16)Pediatric Emergency Unit, Hôpitaux Pédiatriques de Nice, CHU Lenval, Nice,
France. (17)Assistance Publique-Hôpitaux de Paris, Hôpital Paul Brousse,
Virologie, National Reference Laboratory for Maternofetal Rubella Infections,
Villejuif, France.

Importance: The procalcitonin (PCT) assay is an accurate screening test for
identifying invasive bacterial infection (IBI); however, data on the PCT assay in
very young infants are insufficient.
Objective: To assess the diagnostic characteristics of the PCT assay for
detecting serious bacterial infection (SBI) and IBI in febrile infants aged 7 to
91 days.
Design, Setting, and Participants: A prospective cohort study that included
infants aged 7 to 91 days admitted for fever to 15 French pediatric emergency
departments was conducted for a period of 30 months (October 1, 2008, through
March 31, 2011). The data management and analysis were performed from October 1, 
2011, through October 31, 2014.
Main Outcomes and Measures: The diagnostic characteristics of the PCT assay,
C-reactive protein (CRP) concentration, white blood cell (WBC) count, and
absolute neutrophil cell (ANC) count for detecting SBI and IBI were described and
compared for the overall population and subgroups of infants according to the age
and the duration of fever. Laboratory test cutoff values were calculated based on
receiver operating characteristic (ROC) curve analysis. The SBIs were defined as
a pathogenic bacteria in positive culture of blood, cerebrospinal fluid, urine,
or stool samples, including bacteremia and bacterial meningitis classified as
IBIs.
Results: Among the 2047 infants included, 139 (6.8%) were diagnosed as having an
SBI and 21 (1.0%) as having an IBI (11.0% and 1.7% of those with blood culture (n
= 1258), respectively). The PCT assay offered an area under the curve (AUC) of
ROC curve similar to that for CRP concentration for the detection of SBI (AUC,
0.81; 95% CI, 0.75-0.86; vs AUC, 0.80; 95% CI, 0.75-0.85; P = .70). The AUC ROC
curve for the detection of IBI for the PCT assay was significantly higher than
that for the CRP concentration (AUC, 0.91; 95% CI, 0.83-0.99; vs AUC, 0.77; 95%
CI, 0.65-0.89; P = .002). Using a cutoff value of 0.3 ng/mL for PCT and 20 mg/L
for CRP, negative likelihood ratios were 0.3 (95% CI, 0.2-0.5) for identifying
SBI and 0.1 (95% CI, 0.03-0.4) and 0.3 (95% CI, 0.2-0.7) for identifying IBI,
respectively. Similar results were obtained for the subgroup of infants younger
than 1 month and for those with fever lasting less than 6 hours.
Conclusions and Relevance: The PCT assay has better diagnostic accuracy than CRP
measurement for detecting IBI; the 2 tests perform similarly for identifying SBI
in febrile infants aged 7 to 91 days.

PMID: 26595253  [PubMed - as supplied by publisher]


3. JAMA Pediatr. 2015 May;169(5):445-51. doi: 10.1001/jamapediatrics.2014.3809.

Comparison of isotonic and hypotonic intravenous maintenance fluids: a randomized
clinical trial.

Friedman JN(1), Beck CE(1), DeGroot J(1), Geary DF(2), Sklansky DJ(3), Freedman
SB(4).

Author information: 
(1)Division of Paediatric Medicine, Paediatric Outcomes Research Team, The
Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
(2)Division of Nephrology, The Hospital for Sick Children, University of Toronto,
Toronto, Ontario, Canada. (3)Division of Pediatrics, University of Wisconsin
School of Medicine and Public Health, Madison. (4)Sections of Pediatric Emergency
Medicine and Gastroenterology, Department of Paediatrics, Alberta Children's
Hospital, Alberta Children's Hospital Research Institute, University of Calgary, 
Calgary, Alberta, Canada.

IMPORTANCE: Use of hypotonic intravenous fluids for maintenance requirements is
associated with increased risk of hyponatremia that results in morbidity and
mortality in children. Clinical trial data comparing isotonic and hypotonic
maintenance fluids in nonsurgical hospitalized pediatric patients outside
intensive care units are lacking.
OBJECTIVE: To compare isotonic (sodium chloride, 0.9%, and dextrose, 5%) with
hypotonic (sodium chloride, 0.45%, and dextrose, 5%) intravenous maintenance
fluids in a hospitalized general pediatric population.
DESIGN, SETTING, AND PARTICIPANTS: In this double-blind randomized clinical
trial,we recruited 110 children admitted to a general pediatric unit of a
tertiary care children's hospital from March 1, 2008, through August 31, 2012
(age range, 1 month to 18 years), with normal baseline serum sodium levels who
were anticipated to require intravenous maintenance fluids for 48 hours or longer
(intent-to-treat analyses). Children with diagnoses that required specific fluid
tonicity and volumes were excluded.
INTERVENTIONS: Patients were randomized to receive isotonic or hypotonic
intravenous fluid at maintenance rates for 48 hours.
MAIN OUTCOMES AND MEASURES: The primary outcome was mean serum sodium level at 48
hours. The secondary outcomes were mean sodium level at 24 hours, hyponatremia
and hypernatremia, weight gain, hypertension, and edema. Confounding variables
were included in multiple regression models. Post hoc analyses included change
from baseline sodium level at 24 and 48 hours and subgroup analysis of children
with primary respiratory diagnosis.
RESULTS: Of 110 enrolled patients, 54 received isotonic fluids and 56 received
hypotonic fluids. The mean (SD) sodium level at 48 hours was 139.9 (2.7) mEq/L in
the isotonic group and 139.6 (2.6) mEq/L in the hypotonic group (95% CI of the
difference, -0.94 to 1.74 mEq/L; P = .60). Two patients in the hypotonic group
developed hyponatremia, 1 in each group developed hypernatremia, 2 in each group
developed hypertension, and 2 in the isotonic group developed edema. Mean (SD)
change from baseline to 48-hour sodium level was +1.3 (2.9) vs -0.12 (2.8) mEq/L,
respectively (absolute difference, 1.4 mEq/L; 95% CI of the difference, -0.01 to
2.8 mEq/L; P = .05).
CONCLUSIONS AND RELEVANCE: Our study results support the notion that isotonic
maintenance fluid administration is safe in general pediatric patients and may
result in fewer cases of hyponatremia.
TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00632775.

PMID: 25751673  [PubMed - indexed for MEDLINE]


4. JAMA Pediatr. 2015 Jul;169(7):631-8. doi: 10.1001/jamapediatrics.2015.0358.

Effect of Delayed Cord Clamping on Neurodevelopment at 4 Years of Age: A
Randomized Clinical Trial.

Andersson O(1), Lindquist B(2), Lindgren M(3), Stjernqvist K(3), Domellöf M(4),
Hellström-Westas L(1).

Author information: 
(1)Department of Women's and Children's Health, Uppsala University, Uppsala,
Sweden. (2)The Habilitation Center, Hospital of Halland, Halmstad, Sweden.
(3)Department of Psychology, Lund University, Lund, Sweden. (4)Department of
Clinical Sciences, Unit for Pediatrics, Umeå University, Umeå, Sweden.

Comment in
    JAMA Pediatr. 2015 Jul;169(7):623-4.
    BMJ. 2015;350:h2828.

IMPORTANCE: Prevention of iron deficiency in infancy may promote
neurodevelopment. Delayed umbilical cord clamping (CC) prevents iron deficiency
at 4 to 6 months of age, but long-term effects after 12 months of age have not
been reported.
OBJECTIVE: To investigate the effects of delayed CC compared with early CC on
neurodevelopment at 4 years of age.
DESIGN, SETTING, AND PARTICIPANTS: Follow-up of a randomized clinical trial
conducted from April 16, 2008, through May 21, 2010, at a Swedish county
hospital. Children who were included in the original study (n = 382) as full-term
infants born after a low-risk pregnancy were invited to return for follow-up at 4
years of age. Wechsler Preschool and Primary Scale of Intelligence (WPPSI-III)
and Movement Assessment Battery for Children (Movement ABC) scores (collected
between April 18, 2012, and July 5, 2013) were assessed by a blinded
psychologist. Between April 11, 2012, and August 13, 2013, parents recorded their
child's development using the Ages and Stages Questionnaire, Third Edition (ASQ) 
and behavior using the Strengths and Difficulties Questionnaire. All data were
analyzed by intention to treat.
INTERVENTIONS: Randomization to delayed CC (≥180 seconds after delivery) or early
CC (≤10 seconds after delivery).
MAIN OUTCOMES AND MEASURES: The main outcome was full-scale IQ as assessed by the
WPPSI-III. Secondary objectives were development as assessed by the scales from
the WPPSI-III and Movement ABC, development as recorded using the ASQ, and
behavior using the Strengths and Difficulties Questionnaire.
RESULTS: We assessed 263 children (68.8%). No differences were found in WPPSI-III
scores between groups. Delayed CC improved the adjusted mean differences (AMDs)
in the ASQ personal-social (AMD, 2.8; 95% CI, 0.8-4.7) and fine-motor (AMD, 2.1; 
95% CI, 0.2-4.0) domains and the Strengths and Difficulties Questionnaire
prosocial subscale (AMD, 0.5; 95% CI, >0.0-0.9). Fewer children in the delayed-CC
group had results below the cutoff in the ASQ fine-motor domain (11.0% vs 3.7%;
P = .02) and the Movement ABC bicycle-trail task (12.9% vs 3.8%; P = .02). Boys
who received delayed CC had significantly higher AMDs in the WPPSI-III
processing-speed quotient (AMD, 4.2; 95% CI, 0.8-7.6; P = .02), Movement ABC
bicycle-trail task (AMD, 0.8; 95% CI, 0.1-1.5; P = .03), and fine-motor (AMD,
4.7; 95% CI, 1.0-8.4; P = .01) and personal-social (AMD, 4.9; 95% CI, 1.6-8.3;
P = .004) domains of the ASQ.
CONCLUSIONS AND RELEVANCE: Delayed CC compared with early CC improved scores in
the fine-motor and social domains at 4 years of age, especially in boys,
indicating that optimizing the time to CC may affect neurodevelopment in a
low-risk population of children born in a high-income country.
TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01581489.

PMID: 26010418  [PubMed - indexed for MEDLINE]


5. JAMA Pediatr. 2015 Aug;169(8):755-60. doi: 10.1001/jamapediatrics.2015.0479.

Effect of Reduction in the Use of Computed Tomography on Clinical Outcomes of
Appendicitis.

Bachur RG(1), Levy JA(1), Callahan MJ(2), Rangel SJ(3), Monuteaux MC(1).

Author information: 
(1)Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical
School, Boston, Massachusetts. (2)Department of Radiology, Boston Children's
Hospital, Harvard Medical School, Boston, Massachusetts. (3)Department of
Surgery, Boston Children's Hospital, Harvard Medical School, Boston,
Massachusetts.

Comment in
    JAMA Pediatr. 2015 Aug;169(8):720-1.

IMPORTANCE: Advanced diagnostic imaging is commonly used in the evaluation of
suspected appendicitis in children. Despite its inferior diagnostic performance, 
ultrasonography (US) is now preferred to computed tomography (CT) owing to
concerns about ionizing radiation exposure. With changes in imaging modalities,
the influence on outcomes should be assessed.
OBJECTIVES: To review trends in the use of US and CT for children with
appendicitis and to investigate simultaneous changes in the proportions of
negative appendectomy, appendiceal perforation, and emergency department (ED)
revisits.
DESIGN, SETTING, AND PARTICIPANTS: We reviewed the Pediatric Health Information
System administrative database for children who presented to the ED with the
diagnosis of appendicitis or who underwent an appendectomy in 35 US pediatric
institutions from January 1, 2010, through December 31, 2013.
MAIN OUTCOMES AND MEASURES: We studied the use of US and CT for trends and their
association with negative appendectomy, appendiceal perforation, and 3-day ED
revisits.
RESULTS: Our investigation included 52,153 children with appendicitis. Use of US
increased 46% (from 24.0% in 2010 to 35.3% in 2013; absolute difference, 11.3%;
adjusted test for linear trend, P = .02), whereas use of CT decreased 48% (from
21.4% in 2010 to 11.6% in 2013; absolute difference, -9.8%; adjusted test for
linear trend, P < .001). The proportion of negative appendectomy declined during
the 4-year study period from 4.7% in 2010 to 3.6% in 2013 (test for linear trend,
P = .002), whereas the proportion of perforations (32.3% in 2010 to 31.9% in
2013) and ED revisits (5.6% in 2010 and 2013) did not change (adjusted tests for
linear trend, P = .64 and P = .84, respectively).
CONCLUSIONS AND RELEVANCE: Among children with suspected appendicitis, the use of
US imaging has increased substantially as the use of CT has declined. Despite the
increased reliance on the diagnostically inferior US, important
condition-specific quality measures, including the frequency of appendiceal
perforation and ED revisits, remained stable, and the proportion of negative
appendectomy declined slightly.

PMID: 26098076  [PubMed - indexed for MEDLINE]


6. JAMA Pediatr. 2014 Dec;168(12):1107-13. doi: 10.1001/jamapediatrics.2014.1609.

Placebo effect in the treatment of acute cough in infants and toddlers: a
randomized clinical trial.

Paul IM(1), Beiler JS(2), Vallati JR(2), Duda LM(2), King TS(3).

Author information: 
(1)Department of Pediatrics, Penn State College of Medicine, Hershey,
Pennsylvania2Department of Public Health Sciences, Penn State College of
Medicine, Hershey, Pennsylvania. (2)Department of Pediatrics, Penn State College
of Medicine, Hershey, Pennsylvania. (3)Department of Public Health Sciences, Penn
State College of Medicine, Hershey, Pennsylvania.

Comment in
    JAMA Pediatr. 2014 Dec;168(12):1091-2.
    JAMA Pediatr. 2015 May;169(5):505-6.
    JAMA Pediatr. 2015 May;169(5):504-5.
    J Pediatr. 2015 May;166(5):1321.
    JAMA Pediatr. 2015 May;169(5):505.

IMPORTANCE: Cough is one of the most common reasons why children visit a health
care professional.
OBJECTIVES: To compare the effect of a novel formulation of pasteurized agave
nectar vs placebo and no treatment on nocturnal cough and the sleep difficulty
associated with nonspecific acute cough in infants and toddlers.
DESIGN, SETTING, AND PARTICIPANTS: In this randomized clinical trial performed in
2 university-affiliated outpatient, general pediatric practices from January 28, 
2013, through February 28, 2014, children 2 to 47 months old with nonspecific
acute cough duration of 7 days or less were studied. Surveys were administered to
parents on 2 consecutive days, the day of presentation (when no medication had
been given the prior evening) and the next day (when agave nectar, placebo, or no
treatment had been administered to their child before bedtime) according to a
partially double-blind randomization scheme.
INTERVENTIONS: A single dose of agave nectar, placebo, or no treatment
administered 30 minutes before bedtime.
MAIN OUTCOMES AND MEASURES: Cough frequency, cough severity, cough
bothersomeness, congestion severity, rhinorrhea severity, and cough effect on
child and parent sleep.
RESULTS: Significant differences in symptom improvement were detected between the
study groups (P < .05 for all, except P = .06 for cough bothersomeness), with
agave nectar and placebo proving to be superior to no treatment, but no
significant differences for any outcome were found when comparing agave nectar
against placebo.
CONCLUSIONS AND RELEVANCE: In a comparison of agave nectar, placebo, and no
treatment, a placebo effect was demonstrated, with no additional benefit offered
by agave nectar. Health care professionals should consider the potential benefits
and costs when recommending a treatment with only a placebo effect for infants
and toddlers with nonspecific acute cough.
TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01721395.

PMID: 25347696  [PubMed - indexed for MEDLINE]

Diagnostic

None

Review

None

Clinical Prediction Rules

None