Journal of Pediatrics 2015

Treatment


1. J Pediatr. 2015 Sep;167(3):593-8.e1. doi: 10.1016/j.jpeds.2015.05.041. Epub 2015
Jun 26.

The BIG Score and Prediction of Mortality in Pediatric Blunt Trauma.

Davis AL(1), Wales PW(2), Malik T(1), Stephens D(3), Razik F(4), Schuh S(5).

Author information: 
(1)Division of Pediatric Emergency Medicine, Hospital for Sick Children, Toronto,
Ontario, Canada. (2)Division of General and Thoracic Surgery, Hospital for Sick
Children, Toronto, Ontario, Canada; Research Institute, Hospital for Sick
Children, Toronto, Ontario, Canada. (3)Research Institute, Hospital for Sick
Children, Toronto, Ontario, Canada. (4)Division of General Pediatrics, Hospital
for Sick Children, Toronto, Ontario, Canada. (5)Division of Pediatric Emergency
Medicine, Hospital for Sick Children, Toronto, Ontario, Canada; Research
Institute, Hospital for Sick Children, Toronto, Ontario, Canada. Electronic
address: Suzanne.schuh@sickkids.ca.

Comment in
    J Pediatr. 2015 Sep;167(3):513-4.

OBJECTIVES: To examine the association between in-hospital mortality and the BIG
(composed of the base deficit [B], International normalized ratio [I], Glasgow
Coma Scale [G]) score measured on arrival to the emergency department in
pediatric blunt trauma patients, adjusted for pre-hospital intubation, volume
administration, and presence of hypotension and head injury. We also examined the
association between the BIG score and mortality in patients requiring admission
to the intensive care unit (ICU).
STUDY DESIGN: A retrospective 2001-2012 trauma database review of patients with
blunt trauma ≤ 17 years old with an Injury Severity score ≥ 12. Charts were
reviewed for in-hospital mortality, components of the BIG score upon arrival to
the emergency department, prehospital intubation, crystalloids ≥ 20 mL/kg,
presence of hypotension, head injury, and disposition.
RESULTS: 50/621 (8%) of the study patients died. Independent mortality predictors
were the BIG score (OR 11, 95% CI 6-25), prior fluid bolus (OR 3, 95% CI 1.3-9), 
and prior intubation (OR 8, 95% CI 2-40). The area under the receiver operating
characteristic curve was 0.95 (CI 0.93-0.98), with the optimal BIG cutoff of 16. 
With BIG <16, death rate was 3/496 (0.006, 95% CI 0.001-0.007) vs 47/125 (0.38,
95% CI 0.15-0.7) with BIG ≥ 16, (P < .0001). In patients requiring admission to
the ICU, the BIG score remained predictive of mortality (OR 14.3, 95% CI 7.3-32, 
P < .0001).
CONCLUSIONS: The BIG score accurately predicts mortality in a population of North
American pediatric patients with blunt trauma independent of pre-hospital
interventions, presence of head injury, and hypotension, and identifies children
with a high probability of survival (BIG <16). The BIG score is also associated
with mortality in pediatric patients with trauma requiring admission to the ICU.

Copyright © 2015 Elsevier Inc. All rights reserved.

PMID: 26118931  [PubMed - in process]


2. J Pediatr. 2015 Nov 9. pii: S0022-3476(15)01198-1. doi:
10.1016/j.jpeds.2015.10.026. [Epub ahead of print]

Point-of-Care Ultrasonography for the Diagnosis of Pediatric Soft
Tissue Infection.

Adams CM(1), Neuman MI(2), Levy JA(2).

Author information: 
(1)Division of Emergency Medicine, Boston Children's Hospital, Boston, MA;
Department of Pediatrics, Harvard Medical School, Boston, MA. Electronic address:
Cynthia.Adams@childrens.harvard.edu. (2)Division of Emergency Medicine, Boston
Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical
School, Boston, MA.

OBJECTIVES: To determine the test characteristics of point-of-care
ultrasonography for the identification of a drainable abscess and to compare the
test characteristics of ultrasonography with physical examination. In addition,
we sought to measure the extent to which ultrasonography impacts clinical
management of children with skin and soft tissue infections (SSTIs).
STUDY DESIGN: We performed a prospective study of children with SSTIs evaluated
in a pediatric emergency department. Treating physicians recorded their initial
impression of whether a drainable abscess was present based on physical
examination. Another physician, blinded to the treating physician's assessment,
performed an ultrasound study and conveyed their interpretation and
recommendations to the treating physician. Any management change was recorded. An
abscess was defined as a lesion from which purulent fluid was expressed during a
drainage procedure in the emergency department or during the 2- to 5-day
follow-up period. We defined a change in management as correct when the
ultrasound diagnosis was discordant from physical examination and matched the
ultimate lesion classification.
RESULTS: Of 151 SSTIs evaluated among 148 patients, the sensitivity and
specificity of point-of-care ultrasonography for the presence of abscess were 96%
(95% CI 90%-99%) and 87% (74%-95%), respectively. The sensitivity and specificity
of physical examination for the presence of abscess were 84% (75%-90%) and 60%
(44%-73%), respectively. For every 4 ultrasound examinations performed, there was
1 correct change in management.
CONCLUSIONS: Point-of-care ultrasonography demonstrates excellent test
characteristics for the identification of skin abscess and has superior test
characteristics compared with physical examination alone.

Copyright © 2015 Elsevier Inc. All rights reserved.

PMID: 26563535  [PubMed - as supplied by publisher]


3. J Pediatr. 2015 Nov 11. pii: S0022-3476(15)01216-0. doi:
10.1016/j.jpeds.2015.10.044. [Epub ahead of print]

Trimethoprim-Sulfamethoxazole Therapy Reduces Failure and Recurrence in
Methicillin-Resistant Staphylococcus aureus Skin Abscesses after Surgical
Drainage.

Holmes L(1), Ma C(2), Qiao H(3), Drabik C(3), Hurley C(3), Jones D(3), Judkiewicz
S(3), Faden H(4).

Author information: 
(1)University at Buffalo, Buffalo, NY; Women & Children's Hospital of Buffalo,
Buffalo, NY. Electronic address: LHolmes@upa.chob.edu. (2)University at Buffalo, 
Buffalo, NY. (3)Women & Children's Hospital of Buffalo, Buffalo, NY.
(4)University at Buffalo, Buffalo, NY; Women & Children's Hospital of Buffalo,
Buffalo, NY.

OBJECTIVE: To determine whether a 3-day vs 10-day course of antibiotics after
surgical drainage of skin abscesses is associated with different failure and
recurrence rates.
STUDY DESIGN: Patients age 3 months to 17 years seeking care at a pediatric
emergency department with an uncomplicated skin abscess that required surgical
drainage were randomized to receive 3 or 10 days of oral
trimethoprim-sulfamethoxazole therapy. Patients were evaluated 10-14 days later
to assess clinical outcome. Patients were followed for 6 months to determine the
cumulative rate of recurrent skin infections.
RESULTS: Among the 249 patients who were enrolled, 87% of wound cultures grew
Staphylococcus aureus (S aureus) (55% methicillin-resistant S aureus [MRSA], 32% 
methicillin-sensitive S aureus), 11% other organisms, and 2% no growth. Thirteen
patients experienced treatment failure. Among all patients, no significant
difference in failure rates between the 3- and 10-day treatment groups was found.
After we stratified patients by the infecting organism, only patients with MRSA
infection were more likely to experience treatment failure in the 3-day group
than the 10-day group (P = .03, rate difference 10.1%, 95% CI 2.1%-18.2%)
Recurrent infection within 1 month of surgical drainage was more likely in
patients infected with MRSA who received 3 days of antibiotics. (P = .046, rate
difference 10.3%, 95% CI 0.8%-19.9%).
CONCLUSION: Patients with MRSA skin abscesses are more likely to experience
treatment failure and recurrent skin infection if given 3 rather than 10 days of
trimethoprim-sulfamethoxazole after surgical drainage.
TRIAL REGISTRATION: ClinicalTrials.gov: NCT02024867.

Copyright © 2015 Elsevier Inc. All rights reserved.

PMID: 26578074  [PubMed - as supplied by publisher]


4. J Pediatr. 2015 Mar;166(3):703-9.e2. doi: 10.1016/j.jpeds.2014.11.058. Epub 2015
Jan 13.

Children with Down syndrome are high-risk for severe respiratory syncytial virus
disease.

Stagliano DR(1), Nylund CM(2), Eide MB(2), Eberly MD(2).

Author information: 
(1)Department of Pediatrics, Walter Reed National Military Medical Center,
Bethesda, MD; Department of Pediatrics, Uniformed Services University of the
Health Sciences, Bethesda, MD. Electronic address:
david.r.stagliano.mil@health.mil. (2)Department of Pediatrics, Uniformed Services
University of the Health Sciences, Bethesda, MD.

OBJECTIVE: To assess Down syndrome as an independent risk factor for respiratory
syncytial virus (RSV) hospitalization in children younger than 3 years of age and
to evaluate illness severity.
STUDY DESIGN: A retrospective cohort study of children enrolled in the military
health system database was conducted. The effect of Down syndrome on RSV
hospitalization was assessed by Cox proportional hazards model, while we
controlled for risk factors. Disease severity was assessed by length of hospital
stay, need for respiratory support, and age at hospitalization.
RESULTS: The study included 633 200 children and 3 209 378 person-years. Children
with Down syndrome had a hospitalization rate of 9.6% vs 2.8% in children without
Down syndrome. Down syndrome had a greater adjusted hazard ratio (HR) for RSV
hospitalization than most risk factors, 3.46 (95% CI 2.75-4.37). A sensitivity
analysis demonstrated HR 3.21 (95% CI 2.51-4.10) for patients with Down syndrome
ages 0-23 months and HR 5.07 (95% CI 2.21-11.59) ages 24-36 months. The median
(IQR) length of stay of children with and without Down syndrome was 4 days (2-7) 
and 2 days (1-4) (P < .001). Patients with Down syndrome had a greater risk of
requiring respiratory support (relative risk 5.5; 95% CI, 2.5-12.3). The median
(IQR) ages at admission for children with and without Down syndrome were 9.8
months (5.5-17.7) and 3.5 months (1.7-8.7) (P < .001).
CONCLUSIONS: Down syndrome is independently associated with an increased risk for
RSV hospitalization. Children with Down syndrome are older at time of RSV
hospitalization and have more severe RSV illness than children without Down
syndrome. This increased risk for hospitalization continues beyond 24 months.

Published by Elsevier Inc.

PMID: 25596098  [PubMed - indexed for MEDLINE]


5. J Pediatr. 2015 Mar;166(3):767-70.e3. doi: 10.1016/j.jpeds.2014.11.030. Epub 2014
Dec 30.

No effect of proton pump inhibitors on crying and irritability in infants:
systematic review of randomized controlled trials.

Gieruszczak-Białek D(1), Konarska Z(1), Skórka A(1), Vandenplas Y(2), Szajewska
H(3).

Author information: 
(1)Department of Pediatrics, The Medical University of Warsaw, Warsaw, Poland.
(2)Department of Pediatrics, UZ Brussel, Vrije Universiteit Brussel, Brussels,
Belgium. (3)Department of Pediatrics, The Medical University of Warsaw, Warsaw,
Poland. Electronic address: hania@ipgate.pl.

Proton pump inhibitors are increasingly being used to treat infants with crying
and/or irritability based on the assumption that these symptoms are attributable
to gastroesophageal reflux. However, the data from a systematic review of
randomized controlled trials do not support the use of proton pump inhibitors to
decrease infant crying and irritability.

Copyright © 2015 Elsevier Inc. All rights reserved.

PMID: 25556017  [PubMed - indexed for MEDLINE]


6. J Pediatr. 2015 Jan;166(1):74-8. doi: 10.1016/j.jpeds.2014.09.020. Epub 2014 Oct
23.

Probiotics for infantile colic: a randomized, double-blind, placebo-controlled
trial investigating Lactobacillus reuteri DSM 17938.

Chau K(1), Lau E(2), Greenberg S(3), Jacobson S(4), Yazdani-Brojeni P(5), Verma
N(5), Koren G(6).

Author information: 
(1)Department of Pharmacology and Toxicology, University of Toronto, Ontario,
Canada; Division of Clinical Pharmacology and Toxicology, The Hospital for Sick
Children, Ontario, Canada. (2)Department of Pediatrics, University of Toronto,
Ontario, Canada; Department of Emergency Medicine, The Hospital for Sick
Children, Ontario, Canada; Department of Pediatrics, St Joseph's Health Care,
Ontario, Canada. (3)Department of Pediatric Medicine, The Hospital for Sick
Children, Ontario, Canada. (4)Division of Clinical Pharmacology and Toxicology,
The Hospital for Sick Children, Ontario, Canada; Department of Pediatric
Medicine, The Hospital for Sick Children, Ontario, Canada. (5)Division of
Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Ontario,
Canada. (6)Department of Pharmacology and Toxicology, University of Toronto,
Ontario, Canada; Division of Clinical Pharmacology and Toxicology, The Hospital
for Sick Children, Ontario, Canada; Department of Pediatrics, University of
Toronto, Ontario, Canada; Department of Pediatric Medicine, The Hospital for Sick
Children, Ontario, Canada; Department of Physiology and Pharmacology, Schulich
School of Medicine and Dentistry, University of Western Ontario, London, Ontario,
Canada. Electronic address: gkoren@sickkids.ca.

OBJECTIVE: To investigate the effectiveness of Lactobacillus reuteri DSM 17938
for the treatment of infantile colic in breastfed Canadian infants, compared with
placebo.
STUDY DESIGN: A randomized, double-blind, placebo-controlled trial was conducted
involving 52 infants with colic, according to modified Wessel criteria, who were
assigned at random to receive L reuteri DSM 17938 (10(8) colony-forming units) (n
= 24) or placebo (n = 28) for 21 days. Daily crying and fussing times were
recorded in a structured diary, and maternal questionnaires were completed to
monitor changes in infant colic symptoms and adverse events.
RESULTS: Total average crying and fussing times throughout the study (from
baseline to day 21) were significantly shorter among infants with colic in the
probiotic group compared with infants in the placebo group (1719 ± 750 minutes
[29 ± 13 hours] vs 2195 ± 764 minutes [37 ± 13 hours]; P = .028) (relative risk, 
0.78; 95% CI, 0.58-0.98). Infants given L reuteri DSM 17938 showed a significant
reduction in daily crying and fussing times at the end of treatment period
compared with those receiving placebo (median, 60 minutes/day [IQR, 64
minutes/day] vs 102 minutes/day [IQR, 87 minutes/day]; P = .045). On day 21, a
significantly higher proportion of infants in the L reuteri DSM 17938 group
responded to treatment with a ≥50% crying time reduction compared with infants
given placebo (17 vs 6, P = .035; relative risk, 3.3; 95% CI, 1.55-7.03).
CONCLUSION: Administration of L reuteri DSM 17938 significantly improved colic
symptoms by reducing crying and fussing times in breastfed Canadian infants with
colic.

Copyright © 2015 Elsevier Inc. All rights reserved.

PMID: 25444531  [PubMed - indexed for MEDLINE]


7. J Pediatr. 2015 Dec;167(6):1375-1381.e1. doi: 10.1016/j.jpeds.2015.09.018. Epub
2015 Oct 23.

Potential Impact of a Validated Screening Tool for Pediatric Abusive Head Trauma.

Hymel KP(1), Herman BE(2), Narang SK(3), Graf JM(4), Frazier TN(5), Stoiko M(6), 
Christie LM(7), Harper NS(8), Carroll CL(9), Boos SC(10), Dias M(11), Pullin
DA(12), Wang M(13); Pediatric Brain Injury Research Network (PediBIRN)
Investigators; Pediatric Brain Injury Research Network PediBIRN Investigators.

Collaborators: Willson DF, Homa K, Lorenz D, Isaac R, Armijo-Garcia V, Foster R, 
Weeks K, Hyden P, Sirotnak A, Truemper E, Ornstein AE.

Author information: 
(1)Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
Electronic address: kphymel@gmail.com. (2)Department of Pediatrics, University of
Utah School of Medicine, Primary Children's Medical Center, Salt Lake City, UT.
(3)Department of Pediatrics, University of Texas Health Science Center, Houston, 
TX. (4)Department of Pediatrics, Baylor College of Medicine, Texas Children's
Hospital, Houston, TX. (5)Department of Pediatrics, Children's Mercy Hospital,
Kansas City, MO. (6)Department of Pediatrics, DeVos Children's Hospital, Grand
Rapids, MI. (7)Department of Critical Care, Dell Children's Medical Center of
Central Texas, Austin, TX. (8)Children's Physician Services of South Texas,
Driscoll Children's Hospital, Corpus Christi, TX. (9)Department of Pediatrics,
Connecticut Children's Medical Center, Hartford, CT. (10)Department of
Pediatrics, Baystate Children's Hospital, Springfield, MA. (11)Departments of
Neurosurgery and Pediatrics, Penn State College of Medicine, Hershey, PA.
(12)Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
(13)Department of Public Health Sciences, Penn State College of Medicine,
Hershey, PA.

OBJECTIVE: To conduct a retrospective, theoretical comparison of actual pediatric
intensive care unit (PICU) screening for abusive head trauma (AHT) vs AHT
screening guided by a previously validated 4-variable clinical prediction rule
(CPR) in datasets used by the Pediatric Brain Injury Research Network to derive
and validate the CPR.
STUDY DESIGN: We calculated CPR-based estimates of abuse probability for all 500
patients in the datasets. Next, we demonstrated a positive and very strong
correlation between these estimates of abuse probability and the overall
diagnostic yields of our patients' completed skeletal surveys and retinal
examinations. Having demonstrated this correlation, we applied mean estimates of
abuse probability to predict additional, positive abuse evaluations among
patients lacking skeletal survey and/or retinal examination. Finally, we used
these predictions of additional, positive abuse evaluations to extrapolate and
compare AHT detection (and 2 other measures of AHT screening accuracy) in actual
PICU screening for AHT vs AHT screening guided by the CPR.
RESULTS: Our results suggest that AHT screening guided by the CPR could
theoretically increase AHT detection in PICU settings from 87%-96% (P < .001),
and increase the overall diagnostic yield of completed abuse evaluations from
49%-56% (P = .058), while targeting slightly fewer, though not significantly
less, children for abuse evaluation.
CONCLUSIONS: Applied accurately and consistently, the recently validated,
4-variable CPR could theoretically improve the accuracy of AHT screening in PICU
settings.

Copyright © 2015 Elsevier Inc. All rights reserved.

PMID: 26477871  [PubMed - in process]


8. J Pediatr. 2014 Dec;165(6):1230-1235.e5. doi: 10.1016/j.jpeds.2014.08.014. Epub
2014 Sep 27.

Accuracy of the abdominal examination for identifying children with blunt
intra-abdominal injuries.

Adelgais KM(1), Kuppermann N(2), Kooistra J(3), Garcia M(4), Monroe DJ(5),
Mahajan P(6), Menaker J(7), Ehrlich P(8), Atabaki S(9), Page K(10), Kwok M(11),
Holmes JF(12); Intra-Abdominal Injury Study Group of the Pediatric Emergency Care
Applied Research Network (PECARN).

Collaborators: Tunik M, Lee L, Mahajan P, Kwok M, Ellison A, Atabaki S, Kerrey B,
Kooistra J, Monroe D, Borgialli D, Blumberg S, Yen K, Bonsu B, Kuppermann N,
Holmes JF, Menaker J, Rodgers A, Garcia M, Adelgais K, Quayle K, Lillis K,
Kuppermann N, Alpern E, Borgialli D, Callahan J, Chamberlain J, Dayan P, Dean JM,
Gerardi M, Gorelick M, Hoyle J, Jacobs E, Jaffe D, Lichenstein R, Lillis K,
Prashant M, Maio R, Moler F, Monroe D, Ruddy R, Stanley R, Tunik M, Walker A,
Kavanaugh D, Park H, Dean M, Holubkov R, Knight S, Donaldson A, Zuspan S, Miskin
M, Wade J, Jones A, Fjelstad M, Singh T, Drongowski A, Fukushima L, Kim E, Monroe
D, O'Gara G, Rincon H, Tunik M, Zuspan S, Gorelick M, Alpern E, Borgialli D,
Brown K, Cimpello L, Donaldson A, Foltin G, Moler F, Teach S, Jaffe D,
Chamberlain J, Cooper A, Dayan P, Dean JM, Holubkov R, Mahajan P, Maio R, Mann
NC, Shaw K, Walker A, Stanley R, Ehrlich P, Enriquez R, Gerardi M, Holubkov R,
Jacobs E, Lichenstein R, Lillis K, Millar B, Ruddy R, Shults M, Schalick W,
Callahan J, Atabaki S, Burr J, Call K, Hoyle J, Ruddy R, Suhajda J, Schamban N.

OBJECTIVE: To determine the accuracy of complaints of abdominal pain and findings
of abdominal tenderness for identifying children with intra-abdominal injury
(IAI) stratified by Glasgow Coma Scale (GCS) score.
STUDY DESIGN: This was a prospective, multicenter observational study of children
with blunt torso trauma and a GCS score ≥13. We calculated the sensitivity of
abdominal findings for IAI with 95% CI stratified by GCS score. We examined the
association of isolated abdominal pain or tenderness with IAI and that undergoing
acute intervention (therapeutic laparotomy, angiographic embolization, blood
transfusion, or ≥2 nights of intravenous fluid therapy).
RESULTS: Among the 12 044 patients evaluated, 11 277 (94%) had a GCS score of ≥13
and were included in this analysis. Sensitivity of abdominal pain for IAI was 79%
(95% CI, 76%-83%) for patients with a GCS score of 15, 51% (95% CI, 37%-65%) for
patients with a GCS score of 14, and 32% (95% CI, 14%-55%) for patients with a
GCS score of 13. Sensitivity of abdominal tenderness for IAI also decreased with
decreasing GCS score: 79% (95% CI, 75%-82%) for a GCS score of 15, 57% (95% CI,
42%-70%) for a GCS score of 14, and 37% (95% CI, 19%-58%) for a GCS score of 13. 
Among patients with isolated abdominal pain and/or tenderness, the rate of IAI
was 8% (95% CI, 6%-9%) and the rate of IAI undergoing acute intervention was 1%
(95% CI, 1%-2%).
CONCLUSION: The sensitivity of abdominal findings for IAI decreases as GCS score
decreases. Although abdominal computed tomography is not mandatory, the risk of
IAI is sufficiently high that diagnostic evaluation is warranted in children with
isolated abdominal pain or tenderness.

Copyright © 2014 Elsevier Inc. All rights reserved.

PMID: 25266346  [PubMed - indexed for MEDLINE]

Diagnostic

None

Review

None

Clinical Prediction Rules

None