Keri Losavio

A65-lb., 25-year-old, male cerebral palsy (CP) patient with pneumonia arrives at your Children’s Hospital via ambulance. Although chronologically this patient is an adult, in many ways he’s still a child, and the parents told the paramedics that they’ve always taken their son to Children’s. You’ve been the treating physician during the patient’s frequent hospital stays. Is Children’s Hospital still the best destination for this patient? Will the family’s insurance still cover an admission at Children’s?

During the hospital stay, the patient has complications. He has to be intubated. IV antibiotics need to be continued for a course after hospital discharge. A long recovery is expected. Is it time for the family to consider discharge to a long-term care facility rather than home? Are there any long-term care facilities in the area that accept young adult CP patients?

As the treating pediatric hospitalist, what is your role in helping this patient and his family transition from pediatric care to an adult-care medical home?

Introduction

Approximately 8.6 million children in the United States age 10–17 have a disability, according to the Adolescent Health Transition Project, which is housed at the Center on Human Development and Disability (CHDD) at the University of Washington, Seattle. Of these, 16% (or 1.4 million) experience limitations in their activities and will likely have difficulty making the transition to adult healthcare.1

Given enough time in the profession, every pediatric hospitalist will face the challenge of transitioning patients from child-centered to adult-oriented healthcare systems. The good news: Medical advances have made it increasingly possible for children who once would have died in childhood to survive into adulthood.

Example: One in 2,500 children is born with cystic fibrosis (CF); however, with the recent, unprecedented increase in the success of diagnosis and treatment modalities for the pulmonary component of CF, the estimated median survival age for those born in the 1990s is now 40.2 As of the year 2004, 41.8% of the 22,301 patients with CF were 18 or older.3 In fact, each year nearly 500,000 children with special healthcare needs reach adulthood, and 90% of children with a chronic illness and/or disability now survive to adulthood.4,5

The bad news: Many physicians whose practices focus on adults aren’t familiar with disease processes, such as CF, that have historically been considered pediatric illnesses.

For patients with chronic physical and medical conditions—particularly for those who are medically fragile and/or technology-dependent—the transition can prove especially difficult. And pediatric hospitalists in children’s hospitals face different challenges than those in facilities that admit patients of all ages. One thing remains the same, though, the goal: to provide uninterrupted, coordinated, developmentally appropriate healthcare.

Why Transition?

There are several good reasons for patients to be transitioned from pediatric care to adult care. First, as patients age medical issues develop that are beyond the sphere of pediatricians. In CF, for example, diabetes and biliary tract problems occur with greater frequency in adults. However, because so few CF patients historically survived to adulthood, few physicians who care for adults learned about the disease. Thus, the pediatricians who cared for CF patients continued to do so, leading to situations in which 30- and 40-year-olds have been hospitalized with children. But is that truly appropriate?

Adult patients may have high blood pressure, gynecologic issues, osteoporosis, or other problems the pediatrician may not be prepared to deal with. Example: A primary care pediatrician has been the “medical home” for a small, cerebral palsy patient since she was 10. She’s now 25. If she presents with a breast mass, will the pediatrician pick up on the condition adequately? Will they know where to send the patient?

“Adult providers know those systems better,” says Brett Pickering, MD, director of the Special Needs Clinic at San Diego’s UCSD Medical Center, Department of Pediatrics.

The adult patient has different emotional needs than the pediatric patient, and the pediatric hospitalist may not be in tune with adult needs. “Pediatricians do a lot of handholding,” says Dr. Pickering. “Adult providers are more matter of fact.”

Age restrictions on admissions, insurance, and funding issues also affect transition. For example, funding under the Social Security Act’s Title V Children with Special Health Care Needs typically ends at 21 despite a patient’s education or employment status.

Given these factors, what is the appropriate age to transition care from a pediatric floor or facility to an adult-oriented unit? According to the American Academy of Pediatrics, the responsibility of pediatrics continues through age 21, but there’s no hard-and-fast rule.

Challenges

The transition to adult-care facilities is typically a lengthy process involving multiple specialties and possibly joint care during a transition period—and a process that should ideally be coordinated by the patient’s primary care pediatrician. But hospitalists know that circumstances are typically far from ideal.

First, during a transition, the patient may feel abandoned by the medical team they’ve known for most of their lives. It takes time to develop trust and confidence in a new doctor. In this respect, pediatric hospitalists in facilities that care for patients of all ages have an advantage over hospitalists in children’s hospitals. They can call on their adult-care colleagues in other areas of the hospital for consultations and transfer care over time.

“The pediatric hospitalist must make bridges with their adult colleagues who are comfortable [with the issues] and willing to take on this patient population,” says Dr. Pickering.

Second, parents may feel an emotional dependency on the pediatric team and can feel threatened by the adult environment as they lose some control. To the parents, the patient will always be their child, Dr. Pickering notes.

Third, pediatric hospitalists may be reluctant to let go, particularly if they feel adult services are inferior to those they have provided, which brings us to the fourth major challenge: To whom do you transition care?

Many adult healthcare providers receive only limited training in disorders associated with pediatrics (e.g., CF, spina bifida). The Cystic Fibrosis Foundation is leading the way in educating physicians in what have historically been considered pediatric problems. In the 1980s, the foundation launched an educational program to train physicians already involved in adult pulmonary care in CF. Unfortunately, education in other areas has lagged. And finding a physician with both an interest in and knowledge of such disorders can prove challenging.

“It’s incumbent on our adult colleagues to take these patients on, but they need training,” says Dr. Pickering. “Long-term issues require long-term solutions.

How do you jazz people up to take care of this population?” she asks. Physicians must have at least a little bit of desire to learn about these special patient populations, but academic institutions also need to identify core knowledge and skills and make them part of training and certification requirements for primary care residents and physicians in practice. Continuing medical education for physicians, nurses, and allied healthcare professionals should include drug dosing, medical complications seen in transition populations, and related developmental, psychosocial, and behavioral issues.

Steps to a Successful Transition

So what should hospitalists do? In an April 2005 presentation at the SHM Annual Meeting, Joseph M. Geskey, DO, assistant professor of pediatrics and medicine, and director of inpatient pediatrics at Penn State College of Medicine, Hershey, Penn., recommended that pediatric hospitalists take the following steps:

1. Identify the key aspects of transition;
2. Bring stakeholders together;
3. Identify transitional needs;
4. Identify and provide resources;
5. Create an audit and evaluation process;
6. Decide who will hand off care of these patients when they are admitted to the hospital (the hospitalist or the disease-specific specialist);
7. Create an up-to-date medical summary that is portable and accessible. It should include important historic information, such as diagnostic data, procedures, operations, and medications;
8. Upon patient discharge, include specific instructions on who to call if the patient develops a problem after leaving the hospital;
9. Create a working group in your area that represents pediatric and adult hospitalists to examine transition issues in the hospitalized patient; and
10. Facilitate effective communication between patients and their families, primary care physicians and specialists; and
11. Know when to transfer care to a center with more expertise in caring for specific conditions.

Conclusion

Just as every patient is different and every patient’s circumstances are unique, every transition needs to be individualized. “It’s hard to set policy,” says Dr. Pickering. Open, direct communication, specific discharge instructions, an up-to-date medical summary and knowledge of the adult resources in your area can make any transition a success. TH

Keri Losavio regularly writes for “Pediatric Special Section.”

References

1. Adolescent Health Transition Project, Center on Human Development and Disability (CHDD) at the University of Washington, Seattle. Available at http://depts.washington.edu/healthtr/Providers/intro.htm. Last accessed January 16, 2006.
2. Bufi PL. Cystic fibrosis: therapeutic options for co-management. Available at www.thorne.com/altmedrev/fulltext/cystic.html. Last accessed January 16, 2006.
3. Cystic Fibrosis Foundation: 2004 Patient Registry Report. Available at www.cff.org/living_with_cf/. Last accessed Jan. 26, 2006
4. Newacheck PW, Taylor WR. Childhood chronic illness: prevalence, severity, and impact. Am J Pub Health. 1992;82(3):364-371.
5. Committee on Children with Disabilities and Committee on Adolescence, American Academy of Pediatrics. Transition of care provided for adolescents with special health care needs. Pediatrics. 1996;98(6):1203–1206.

Pediatric Special Section

In the Literature

By Mary Ann Queen, MD, and Amita Amonker, MD

Utilization of a Clinical Pathway Improves Care for Bronchiolitis

Cheney J, Barber S, Altamirano L, et al. A Clinical Pathway for Bronchiolitis is Effective in Reducing Readmission Rates. J Pediatr. 2005;147(5):622-626.

Bronchiolitis is the most common respiratory illness in infants that results in hospitalization. Many hospitals have developed clinical pathways to assist clinicians in managing this common infection; however, the effectiveness of such pathways has not been fully studied. Of those clinical practice guidelines analyzed, varying results have been identified.

To determine the effectiveness of a bronchiolitis pathway, this study compared infants managed prospectively using a pathway protocol with a retrospective analysis of infants managed without a pathway. Infants from a tertiary care children’s hospital and three regional hospitals were enrolled prospectively from May 2000 to August 2001. (One must note this study was completed in Australia, hence the difference from the typical Northern Hemisphere winter months.) The historical control group was admitted between May 1998 and August 1999 at the same four institutions. Two-hundred-twenty-nine patients admitted with bronchiolitis were treated using the pathway protocol. These patients were compared with 207 randomly selected control patients who were admitted prior to the institution of the bronchiolitis pathway. All patients were less than 12 months of age with their first episode of wheezing necessitating hospitalization.

These particular guidelines were developed and used to promote consistency of nursing management during a separate study on bronchiolitis. The pathway included an initial admission assessment. It also stated parameters for initiating and stopping both oxygen therapy and intravenous fluid therapy along with discharge guidelines.

The authors found no significant difference in length of stay or time in oxygen. Fifteen infants (7.2%) in the control group required readmission within two weeks of discharge compared with two infants (0.9%) in the pathway group (p=.001). Of the control group 33.8% received intravenous fluids (IVFs) compared with 19.2% of the pathway infants (p=.001). There was also greater steroid use in the control group but no difference in antibiotic usage. Specific data regarding steroids and antibiotics is not included.

The clinical pathway appears a useful tool for discharge planning with a decreased incidence of hospital readmission when specific discharge goals are utilized. The authors also reported a decreased use of IVFs in the pathway group. This was attributed to having specific parameters (O2 required, RR>60/min or inadequate oral feeding) for when to initiate them. It is unclear from the article whether meeting a single parameter or all three parameters triggered the initiation of IVFs.

The authors also point out the limitation of using a historical control given annual variations in severity sometimes seen with bronchiolitis. They attempted to minimize this by collecting data for each group over two consecutive winters.

Preprinted Paper Orders Reduce Medication Errors

Kozer E, Scolnik D, MacPherson A, et al. Using a preprinted order sheet to reduce prescription errors in a pediatric emergency department: A randomized, controlled trial. Pediatrics. 2005(116):1299-1302.

Medical errors, including medication errors, are common and are written about with increasing frequency in the lay press. Accreditation bodies and individual hospitals are striving for ways to decrease these errors. In some instances potential solutions include purchasing new computer systems for electronic physician order entry. This study looks at whether implementing a preprinted paper order sheet can decrease the incidence of medication errors in a pediatric ED.

This randomized, prospective study occurred during 18 days in July 2001 with nine days randomly assigned into each arm. The first arm used the hospital’s regular blank order sheets for all medication orders. The second arm used the experimental preprinted order sheet. This sheet required the staff to specify the dose, weight-adjusted dose, total daily dose, route of administration, and frequency for each medication ordered. Two medical students entered the data into a database that included information about patients’ demographics, diagnosis, acuity, details on the prescribing physician, the form used, and all medications prescribed and given to the patient. This information was subsequently reviewed by two blinded pediatric emergency physicians who determined if an error occurred and, if so, the degree of the error.

During the study period there were 2,157 visits to the ED with 95.4% charts available for review. Seven-hundred-ninety-five medications were prescribed with 376 ordered on the new form. Drug errors were identified in 68 (16.6%) orders when the regular form was used and in 37 (9.8%) orders on the new form. There was one severe error and 13 significant errors using the new form and 36 significant errors on the regular form. The new form was associated with a twofold decrease in the risk for a medication error even after accounting for the level of training of the ordering practitioner. There was an even greater reduction in the risk for a severe or significant error.

The literature has shown that computerized physician order entry can reduce the number of medication errors in the inpatient setting; however, it is not available in many hospitals and its effectiveness has not been shown in EDs. The authors point out that most medications ordered in the ED are prepared and given by nurses. The benefits of a computerized system in this setting is unclear.

This study occurred over an 18-day period with the new form only used for nine days outside of an earlier pilot period. One could speculate that the novelty of the form encouraged the physicians to examine orders more carefully, leading to decreased errors. It is unknown if the decrease in errors would be sustained over time.

Also important to note is that the definition of an error was limited to a mistake in dose, interval between doses, dose unit, and/or route. Errors such as legibility, medication allergy, or drug interactions are not discussed. However, as hospitals strive to implement technologies aimed at reducing errors this simple, economical solution may be of benefit.

No Association between Kawasaki Disease and Adenovirus

Shike H, Shimizu C, Kanegaye J, et al. Adenovirus, adeno-associated virus and Kawasaki disease. Pediatr Infect Dis J. 2005;24:1011-1014.

Kawasaki disease is a self-limited acute vasculitis of children with a suspected infectious etiology and defined seasonality. In an attempt to find a clue for a possible infectious cause of Kawasaki disease this study examined the seasonality of different viruses. The study recognized a similar bimodal seasonality for some serotypes of adenovirus. Adenovirus accounts for 5%-10% of respiratory tract infections in children and can mimic the clinical manifestations and laboratory abnormalities seen in Kawasaki disease.

This study postulated that infection with a non-cultivatable adenovirus or antecedent adenovirus infection might be a trigger for Kawasaki disease. The study analyzed patient samples using polymerase chain reaction primers for all 51 adenovirus serotypes, viral culture, and neutralization assay for the most common adenovirus serotypes. This study also investigated possible involvement of adeno-associated viruses (AAVs), because AAVs depend on helper viruses, such as adenovirus.

Kawasaki disease patients were enrolled during a 25-month period from February 2002 to February 2004 at Children’s Hospital and Health Center in San Diego. Illness day one was defined as the first day of fever. Clinical samples used in this study were collected within the first 14 days of fever onset and before intravenous immunoglobulin (IVIG) therapy.

Nasopharyngeal swabs were cultured for adenovirus. Standard adenoviral neutralization assays for the five most common serotypes were performed with the use of patient sera. Sera with a titer of 1/10 or greater were scored as positive. At least two clinical samples from each patient, including throat swabs, sera or urine, were tested by quantitative polymerase chain reaction (PCR) for adenovirus and AAV.

Nasopharyngeal viral cultures were collected before IVIG administration on illness day three—14 from 70 Kawasaki disease patients. Of the 70 patients, 52 patients fulfilled four of the five classic criteria or three of the five criteria with abnormal coronary arteries by echocardiogram. Of the remaining 18 patients with atypical Kawasaki disease, six had coronary artery abnormalities. Overall, seven patients had coronary artery aneurysms and 22 patients had coronary artery dilatation. Viral cultures were negative in 66 of the 70 Kawasaki disease patients. The viral isolates in four patients were respiratory syncytial (one), parainfluenza virus 3 (one) and adenovirus (two). Therefore adenovirus culture was negative in 97% of patients.

Fifteen Kawasaki disease patients with negative adenovirus cultures were evaluated by PCR assay on at least two clinical samples. Fourteen patients had a negative PCR result. The throat swab from one patient collected on illness day seven contained 800 adenovirus genome copies.

Results of the adenovirus neutralization assays from 26 Kawasaki disease patients revealed that neutralization titers against any of the five most common adenovirus serotypes were undetectable in four of 26 patients.

None of the 36 samples from the same 15 acute Kawasaki disease patients described for the PCR assay was positive for AAV.

This study concluded that despite the striking similarities between Kawasaki disease and adenovirus infection there is no evidence to suggest a link between the two.

Epidemiology and Clinical Description of Severe, Multifocal Staphylococcus aureus Infection

Miles F, Voss L, Segedin E, et al. Review of Staphylococcus aureus infections requiring admission to a paediatric intensive care unit. Arch Dis Child. 2005;90(12):1274-1278.

Staphylococcus aureus is a recognized cause of multifocal infection with a high mortality rate. Children with community acquired S. aureus bacteremia (SAB) have higher frequencies of unknown foci compared with hospital-acquired SAB. Those children with S. aureus sepsis (SAS) presenting to the pediatric intensive care unit tend to have multisystemic disease—either by direct invasion or toxin production—before the diagnosis is made and treatment is initiated.

This study evaluates the clinical features and mortality from SAS in those children who required intensive care management. A retrospective review of clinical notes from all children with SAS admitted from October 1993 to April 2004 to the PICU in Auckland Children’s Hospital in New Zealand was undertaken. Children coded for SAS were identified from the PICU database.

All clinical notes were reviewed by one investigator using a standardized questionnaire that sought information on patient demographics, clinical findings, investigations, microbiology, and management in the PICU. Cases were included if blood or an isolate from a site that is normally sterile was positive for S. aureus. Hospital-acquired infection was defined by an isolate obtained at least 48 hours after hospital admission; community acquired infection was defined by an isolate obtained within 48 hours of admission.

Fifty-eight patients were identified with SAS over the 10-year study period; 55 were community acquired. Children with staphylococcal illness comprised 1% of all admission to the PICU. Musculoskeletal symptoms (79%) dominated presentation rather than isolated pneumonia (10%). An aggressive search for foci and surgical drainage of infective foci was required in 50% of children.

Most children (67%) either presented with multiple site involvement or secondary sites developed during their hospital stay. These pathologies included pneumonia, septic arthritis, osteomyelitis, and soft tissue involvement (cellulitis, fasciitis, abscess). A transthoracic echocardiogram detected valve abnormalities in only 5% of children, and these children were known to have pre-existing cardiac lesions. Few children (12%) presenting with methicillin-resistant S. aureus (MRSA) had community-acquired infection. The median length of stay in the PICU was three (mean 5.8, range one-44) days. Mortality due to SAS was 8.6%. Ten children had significant morbidity after discharge; these morbidities included renal failure requiring dialysis (three), an ongoing oxygen requirement at three months follow-up (two), and problems relating to limb movement and function (eight). Two children with epidural abscesses were paraplegic.

Community-acquired SAS affects healthy children, is multifocal, and has a high morbidity and mortality. It is imperative to look for sites of dissemination and to drain and debride foci. Routine echocardiography had a low yield in the absence of pre-existing cardiac lesions, persisting fever, or persisting bacteremia.

Long-Term Outcomes for Childhood Headache

Brna P, Dooley J, Gordon K Dewan T. The prognosis of childhood headache. Arch Pediatr Adolesc Med. 2005;159(12):1157-1160.

Headaches affect most children and rank third among illness-related causes of school absenteeism. Although the short-term outcome for most children appears favorable, few studies have reported long-term outcome. The objective of this study was to evaluate the long-term prognosis of childhood headaches 20 years after initial diagnosis in a cohort of Atlantic Canadian children who had headaches diagnosed in 1983.

Ninety-five patients with headaches who consulted one of the authors in 1983 were subsequently studied in 1993. The 77 patients contacted in 1993 were followed up in 2003. A standard telephone interview was used. Data were collected regarding headache symptoms, severity, frequency, treatment, and precipitants. Headache severity was simply classified as mild, moderate, or severe.

Sixty (78%) of 77 patients responded (60 of the 95 in the original cohort). At 20 years 16 (27%) were headache free, 20 (33%) had tension-type headaches, 10 (17%) had migraine, 14 (23%) had migraine and tension-type headaches. Having more than one headache type was more than at diagnosis or initial follow-up, and headache type varied across time. Of those who had headaches at follow-up, 80% (35/44) described their headaches as moderate or severe, although improvement in headaches was reported by 29 (66%). Tension-type headaches were more likely than migraine to resolve. During the month before follow-up, non-prescription medications were used by six (14%). However, 20 (45%) felt that non-pharmacological methods were most effective. Medication use increased during the 10 years since the last follow-up. No patient used selective serotonin receptor agonists.

This study concluded that 20 years after the diagnosis of pediatric headache, most patients continue to have headache, although the headache classification often changed across time. Most patients report moderate or severe headache and increasingly choose to care for their headaches pharmacologically. TH

A65-lb., 25-year-old, male cerebral palsy (CP) patient with pneumonia arrives at your Children’s Hospital via ambulance. Although chronologically this patient is an adult, in many ways he’s still a child, and the parents told the paramedics that they’ve always taken their son to Children’s. You’ve been the treating physician during the patient’s frequent hospital stays. Is Children’s Hospital still the best destination for this patient? Will the family’s insurance still cover an admission at Children’s?

During the hospital stay, the patient has complications. He has to be intubated. IV antibiotics need to be continued for a course after hospital discharge. A long recovery is expected. Is it time for the family to consider discharge to a long-term care facility rather than home? Are there any long-term care facilities in the area that accept young adult CP patients?

As the treating pediatric hospitalist, what is your role in helping this patient and his family transition from pediatric care to an adult-care medical home?

Introduction

Approximately 8.6 million children in the United States age 10–17 have a disability, according to the Adolescent Health Transition Project, which is housed at the Center on Human Development and Disability (CHDD) at the University of Washington, Seattle. Of these, 16% (or 1.4 million) experience limitations in their activities and will likely have difficulty making the transition to adult healthcare.1

Given enough time in the profession, every pediatric hospitalist will face the challenge of transitioning patients from child-centered to adult-oriented healthcare systems. The good news: Medical advances have made it increasingly possible for children who once would have died in childhood to survive into adulthood.

Example: One in 2,500 children is born with cystic fibrosis (CF); however, with the recent, unprecedented increase in the success of diagnosis and treatment modalities for the pulmonary component of CF, the estimated median survival age for those born in the 1990s is now 40.2 As of the year 2004, 41.8% of the 22,301 patients with CF were 18 or older.3 In fact, each year nearly 500,000 children with special healthcare needs reach adulthood, and 90% of children with a chronic illness and/or disability now survive to adulthood.4,5

The bad news: Many physicians whose practices focus on adults aren’t familiar with disease processes, such as CF, that have historically been considered pediatric illnesses.

For patients with chronic physical and medical conditions—particularly for those who are medically fragile and/or technology-dependent—the transition can prove especially difficult. And pediatric hospitalists in children’s hospitals face different challenges than those in facilities that admit patients of all ages. One thing remains the same, though, the goal: to provide uninterrupted, coordinated, developmentally appropriate healthcare.

Why Transition?

There are several good reasons for patients to be transitioned from pediatric care to adult care. First, as patients age medical issues develop that are beyond the sphere of pediatricians. In CF, for example, diabetes and biliary tract problems occur with greater frequency in adults. However, because so few CF patients historically survived to adulthood, few physicians who care for adults learned about the disease. Thus, the pediatricians who cared for CF patients continued to do so, leading to situations in which 30- and 40-year-olds have been hospitalized with children. But is that truly appropriate?

Adult patients may have high blood pressure, gynecologic issues, osteoporosis, or other problems the pediatrician may not be prepared to deal with. Example: A primary care pediatrician has been the “medical home” for a small, cerebral palsy patient since she was 10. She’s now 25. If she presents with a breast mass, will the pediatrician pick up on the condition adequately? Will they know where to send the patient?

“Adult providers know those systems better,” says Brett Pickering, MD, director of the Special Needs Clinic at San Diego’s UCSD Medical Center, Department of Pediatrics.

The adult patient has different emotional needs than the pediatric patient, and the pediatric hospitalist may not be in tune with adult needs. “Pediatricians do a lot of handholding,” says Dr. Pickering. “Adult providers are more matter of fact.”

Age restrictions on admissions, insurance, and funding issues also affect transition. For example, funding under the Social Security Act’s Title V Children with Special Health Care Needs typically ends at 21 despite a patient’s education or employment status.

Given these factors, what is the appropriate age to transition care from a pediatric floor or facility to an adult-oriented unit? According to the American Academy of Pediatrics, the responsibility of pediatrics continues through age 21, but there’s no hard-and-fast rule.

Challenges

The transition to adult-care facilities is typically a lengthy process involving multiple specialties and possibly joint care during a transition period—and a process that should ideally be coordinated by the patient’s primary care pediatrician. But hospitalists know that circumstances are typically far from ideal.

First, during a transition, the patient may feel abandoned by the medical team they’ve known for most of their lives. It takes time to develop trust and confidence in a new doctor. In this respect, pediatric hospitalists in facilities that care for patients of all ages have an advantage over hospitalists in children’s hospitals. They can call on their adult-care colleagues in other areas of the hospital for consultations and transfer care over time.

“The pediatric hospitalist must make bridges with their adult colleagues who are comfortable [with the issues] and willing to take on this patient population,” says Dr. Pickering.

Second, parents may feel an emotional dependency on the pediatric team and can feel threatened by the adult environment as they lose some control. To the parents, the patient will always be their child, Dr. Pickering notes.

Third, pediatric hospitalists may be reluctant to let go, particularly if they feel adult services are inferior to those they have provided, which brings us to the fourth major challenge: To whom do you transition care?

Many adult healthcare providers receive only limited training in disorders associated with pediatrics (e.g., CF, spina bifida). The Cystic Fibrosis Foundation is leading the way in educating physicians in what have historically been considered pediatric problems. In the 1980s, the foundation launched an educational program to train physicians already involved in adult pulmonary care in CF. Unfortunately, education in other areas has lagged. And finding a physician with both an interest in and knowledge of such disorders can prove challenging.

“It’s incumbent on our adult colleagues to take these patients on, but they need training,” says Dr. Pickering. “Long-term issues require long-term solutions.

How do you jazz people up to take care of this population?” she asks. Physicians must have at least a little bit of desire to learn about these special patient populations, but academic institutions also need to identify core knowledge and skills and make them part of training and certification requirements for primary care residents and physicians in practice. Continuing medical education for physicians, nurses, and allied healthcare professionals should include drug dosing, medical complications seen in transition populations, and related developmental, psychosocial, and behavioral issues.

Steps to a Successful Transition

So what should hospitalists do? In an April 2005 presentation at the SHM Annual Meeting, Joseph M. Geskey, DO, assistant professor of pediatrics and medicine, and director of inpatient pediatrics at Penn State College of Medicine, Hershey, Penn., recommended that pediatric hospitalists take the following steps:

1. Identify the key aspects of transition;
2. Bring stakeholders together;
3. Identify transitional needs;
4. Identify and provide resources;
5. Create an audit and evaluation process;
6. Decide who will hand off care of these patients when they are admitted to the hospital (the hospitalist or the disease-specific specialist);
7. Create an up-to-date medical summary that is portable and accessible. It should include important historic information, such as diagnostic data, procedures, operations, and medications;
8. Upon patient discharge, include specific instructions on who to call if the patient develops a problem after leaving the hospital;
9. Create a working group in your area that represents pediatric and adult hospitalists to examine transition issues in the hospitalized patient; and
10. Facilitate effective communication between patients and their families, primary care physicians and specialists; and
11. Know when to transfer care to a center with more expertise in caring for specific conditions.

Conclusion

Just as every patient is different and every patient’s circumstances are unique, every transition needs to be individualized. “It’s hard to set policy,” says Dr. Pickering. Open, direct communication, specific discharge instructions, an up-to-date medical summary and knowledge of the adult resources in your area can make any transition a success. TH

Keri Losavio regularly writes for “Pediatric Special Section.”

References

1. Adolescent Health Transition Project, Center on Human Development and Disability (CHDD) at the University of Washington, Seattle. Available at http://depts.washington.edu/healthtr/Providers/intro.htm. Last accessed January 16, 2006.
2. Bufi PL. Cystic fibrosis: therapeutic options for co-management. Available at www.thorne.com/altmedrev/fulltext/cystic.html. Last accessed January 16, 2006.
3. Cystic Fibrosis Foundation: 2004 Patient Registry Report. Available at www.cff.org/living_with_cf/. Last accessed Jan. 26, 2006
4. Newacheck PW, Taylor WR. Childhood chronic illness: prevalence, severity, and impact. Am J Pub Health. 1992;82(3):364-371.
5. Committee on Children with Disabilities and Committee on Adolescence, American Academy of Pediatrics. Transition of care provided for adolescents with special health care needs. Pediatrics. 1996;98(6):1203–1206.

Pediatric Special Section

In the Literature

By Mary Ann Queen, MD, and Amita Amonker, MD

Utilization of a Clinical Pathway Improves Care for Bronchiolitis

Cheney J, Barber S, Altamirano L, et al. A Clinical Pathway for Bronchiolitis is Effective in Reducing Readmission Rates. J Pediatr. 2005;147(5):622-626.

Bronchiolitis is the most common respiratory illness in infants that results in hospitalization. Many hospitals have developed clinical pathways to assist clinicians in managing this common infection; however, the effectiveness of such pathways has not been fully studied. Of those clinical practice guidelines analyzed, varying results have been identified.

To determine the effectiveness of a bronchiolitis pathway, this study compared infants managed prospectively using a pathway protocol with a retrospective analysis of infants managed without a pathway. Infants from a tertiary care children’s hospital and three regional hospitals were enrolled prospectively from May 2000 to August 2001. (One must note this study was completed in Australia, hence the difference from the typical Northern Hemisphere winter months.) The historical control group was admitted between May 1998 and August 1999 at the same four institutions. Two-hundred-twenty-nine patients admitted with bronchiolitis were treated using the pathway protocol. These patients were compared with 207 randomly selected control patients who were admitted prior to the institution of the bronchiolitis pathway. All patients were less than 12 months of age with their first episode of wheezing necessitating hospitalization.

These particular guidelines were developed and used to promote consistency of nursing management during a separate study on bronchiolitis. The pathway included an initial admission assessment. It also stated parameters for initiating and stopping both oxygen therapy and intravenous fluid therapy along with discharge guidelines.

The authors found no significant difference in length of stay or time in oxygen. Fifteen infants (7.2%) in the control group required readmission within two weeks of discharge compared with two infants (0.9%) in the pathway group (p=.001). Of the control group 33.8% received intravenous fluids (IVFs) compared with 19.2% of the pathway infants (p=.001). There was also greater steroid use in the control group but no difference in antibiotic usage. Specific data regarding steroids and antibiotics is not included.

The clinical pathway appears a useful tool for discharge planning with a decreased incidence of hospital readmission when specific discharge goals are utilized. The authors also reported a decreased use of IVFs in the pathway group. This was attributed to having specific parameters (O2 required, RR>60/min or inadequate oral feeding) for when to initiate them. It is unclear from the article whether meeting a single parameter or all three parameters triggered the initiation of IVFs.

The authors also point out the limitation of using a historical control given annual variations in severity sometimes seen with bronchiolitis. They attempted to minimize this by collecting data for each group over two consecutive winters.

Preprinted Paper Orders Reduce Medication Errors

Kozer E, Scolnik D, MacPherson A, et al. Using a preprinted order sheet to reduce prescription errors in a pediatric emergency department: A randomized, controlled trial. Pediatrics. 2005(116):1299-1302.

Medical errors, including medication errors, are common and are written about with increasing frequency in the lay press. Accreditation bodies and individual hospitals are striving for ways to decrease these errors. In some instances potential solutions include purchasing new computer systems for electronic physician order entry. This study looks at whether implementing a preprinted paper order sheet can decrease the incidence of medication errors in a pediatric ED.

This randomized, prospective study occurred during 18 days in July 2001 with nine days randomly assigned into each arm. The first arm used the hospital’s regular blank order sheets for all medication orders. The second arm used the experimental preprinted order sheet. This sheet required the staff to specify the dose, weight-adjusted dose, total daily dose, route of administration, and frequency for each medication ordered. Two medical students entered the data into a database that included information about patients’ demographics, diagnosis, acuity, details on the prescribing physician, the form used, and all medications prescribed and given to the patient. This information was subsequently reviewed by two blinded pediatric emergency physicians who determined if an error occurred and, if so, the degree of the error.

During the study period there were 2,157 visits to the ED with 95.4% charts available for review. Seven-hundred-ninety-five medications were prescribed with 376 ordered on the new form. Drug errors were identified in 68 (16.6%) orders when the regular form was used and in 37 (9.8%) orders on the new form. There was one severe error and 13 significant errors using the new form and 36 significant errors on the regular form. The new form was associated with a twofold decrease in the risk for a medication error even after accounting for the level of training of the ordering practitioner. There was an even greater reduction in the risk for a severe or significant error.

The literature has shown that computerized physician order entry can reduce the number of medication errors in the inpatient setting; however, it is not available in many hospitals and its effectiveness has not been shown in EDs. The authors point out that most medications ordered in the ED are prepared and given by nurses. The benefits of a computerized system in this setting is unclear.

This study occurred over an 18-day period with the new form only used for nine days outside of an earlier pilot period. One could speculate that the novelty of the form encouraged the physicians to examine orders more carefully, leading to decreased errors. It is unknown if the decrease in errors would be sustained over time.

Also important to note is that the definition of an error was limited to a mistake in dose, interval between doses, dose unit, and/or route. Errors such as legibility, medication allergy, or drug interactions are not discussed. However, as hospitals strive to implement technologies aimed at reducing errors this simple, economical solution may be of benefit.

No Association between Kawasaki Disease and Adenovirus

Shike H, Shimizu C, Kanegaye J, et al. Adenovirus, adeno-associated virus and Kawasaki disease. Pediatr Infect Dis J. 2005;24:1011-1014.

Kawasaki disease is a self-limited acute vasculitis of children with a suspected infectious etiology and defined seasonality. In an attempt to find a clue for a possible infectious cause of Kawasaki disease this study examined the seasonality of different viruses. The study recognized a similar bimodal seasonality for some serotypes of adenovirus. Adenovirus accounts for 5%-10% of respiratory tract infections in children and can mimic the clinical manifestations and laboratory abnormalities seen in Kawasaki disease.

This study postulated that infection with a non-cultivatable adenovirus or antecedent adenovirus infection might be a trigger for Kawasaki disease. The study analyzed patient samples using polymerase chain reaction primers for all 51 adenovirus serotypes, viral culture, and neutralization assay for the most common adenovirus serotypes. This study also investigated possible involvement of adeno-associated viruses (AAVs), because AAVs depend on helper viruses, such as adenovirus.

Kawasaki disease patients were enrolled during a 25-month period from February 2002 to February 2004 at Children’s Hospital and Health Center in San Diego. Illness day one was defined as the first day of fever. Clinical samples used in this study were collected within the first 14 days of fever onset and before intravenous immunoglobulin (IVIG) therapy.

Nasopharyngeal swabs were cultured for adenovirus. Standard adenoviral neutralization assays for the five most common serotypes were performed with the use of patient sera. Sera with a titer of 1/10 or greater were scored as positive. At least two clinical samples from each patient, including throat swabs, sera or urine, were tested by quantitative polymerase chain reaction (PCR) for adenovirus and AAV.

Nasopharyngeal viral cultures were collected before IVIG administration on illness day three—14 from 70 Kawasaki disease patients. Of the 70 patients, 52 patients fulfilled four of the five classic criteria or three of the five criteria with abnormal coronary arteries by echocardiogram. Of the remaining 18 patients with atypical Kawasaki disease, six had coronary artery abnormalities. Overall, seven patients had coronary artery aneurysms and 22 patients had coronary artery dilatation. Viral cultures were negative in 66 of the 70 Kawasaki disease patients. The viral isolates in four patients were respiratory syncytial (one), parainfluenza virus 3 (one) and adenovirus (two). Therefore adenovirus culture was negative in 97% of patients.

Fifteen Kawasaki disease patients with negative adenovirus cultures were evaluated by PCR assay on at least two clinical samples. Fourteen patients had a negative PCR result. The throat swab from one patient collected on illness day seven contained 800 adenovirus genome copies.

Results of the adenovirus neutralization assays from 26 Kawasaki disease patients revealed that neutralization titers against any of the five most common adenovirus serotypes were undetectable in four of 26 patients.

None of the 36 samples from the same 15 acute Kawasaki disease patients described for the PCR assay was positive for AAV.

This study concluded that despite the striking similarities between Kawasaki disease and adenovirus infection there is no evidence to suggest a link between the two.

Epidemiology and Clinical Description of Severe, Multifocal Staphylococcus aureus Infection

Miles F, Voss L, Segedin E, et al. Review of Staphylococcus aureus infections requiring admission to a paediatric intensive care unit. Arch Dis Child. 2005;90(12):1274-1278.

Staphylococcus aureus is a recognized cause of multifocal infection with a high mortality rate. Children with community acquired S. aureus bacteremia (SAB) have higher frequencies of unknown foci compared with hospital-acquired SAB. Those children with S. aureus sepsis (SAS) presenting to the pediatric intensive care unit tend to have multisystemic disease—either by direct invasion or toxin production—before the diagnosis is made and treatment is initiated.

This study evaluates the clinical features and mortality from SAS in those children who required intensive care management. A retrospective review of clinical notes from all children with SAS admitted from October 1993 to April 2004 to the PICU in Auckland Children’s Hospital in New Zealand was undertaken. Children coded for SAS were identified from the PICU database.

All clinical notes were reviewed by one investigator using a standardized questionnaire that sought information on patient demographics, clinical findings, investigations, microbiology, and management in the PICU. Cases were included if blood or an isolate from a site that is normally sterile was positive for S. aureus. Hospital-acquired infection was defined by an isolate obtained at least 48 hours after hospital admission; community acquired infection was defined by an isolate obtained within 48 hours of admission.

Fifty-eight patients were identified with SAS over the 10-year study period; 55 were community acquired. Children with staphylococcal illness comprised 1% of all admission to the PICU. Musculoskeletal symptoms (79%) dominated presentation rather than isolated pneumonia (10%). An aggressive search for foci and surgical drainage of infective foci was required in 50% of children.

Most children (67%) either presented with multiple site involvement or secondary sites developed during their hospital stay. These pathologies included pneumonia, septic arthritis, osteomyelitis, and soft tissue involvement (cellulitis, fasciitis, abscess). A transthoracic echocardiogram detected valve abnormalities in only 5% of children, and these children were known to have pre-existing cardiac lesions. Few children (12%) presenting with methicillin-resistant S. aureus (MRSA) had community-acquired infection. The median length of stay in the PICU was three (mean 5.8, range one-44) days. Mortality due to SAS was 8.6%. Ten children had significant morbidity after discharge; these morbidities included renal failure requiring dialysis (three), an ongoing oxygen requirement at three months follow-up (two), and problems relating to limb movement and function (eight). Two children with epidural abscesses were paraplegic.

Community-acquired SAS affects healthy children, is multifocal, and has a high morbidity and mortality. It is imperative to look for sites of dissemination and to drain and debride foci. Routine echocardiography had a low yield in the absence of pre-existing cardiac lesions, persisting fever, or persisting bacteremia.

Long-Term Outcomes for Childhood Headache

Brna P, Dooley J, Gordon K Dewan T. The prognosis of childhood headache. Arch Pediatr Adolesc Med. 2005;159(12):1157-1160.

Headaches affect most children and rank third among illness-related causes of school absenteeism. Although the short-term outcome for most children appears favorable, few studies have reported long-term outcome. The objective of this study was to evaluate the long-term prognosis of childhood headaches 20 years after initial diagnosis in a cohort of Atlantic Canadian children who had headaches diagnosed in 1983.

Ninety-five patients with headaches who consulted one of the authors in 1983 were subsequently studied in 1993. The 77 patients contacted in 1993 were followed up in 2003. A standard telephone interview was used. Data were collected regarding headache symptoms, severity, frequency, treatment, and precipitants. Headache severity was simply classified as mild, moderate, or severe.

Sixty (78%) of 77 patients responded (60 of the 95 in the original cohort). At 20 years 16 (27%) were headache free, 20 (33%) had tension-type headaches, 10 (17%) had migraine, 14 (23%) had migraine and tension-type headaches. Having more than one headache type was more than at diagnosis or initial follow-up, and headache type varied across time. Of those who had headaches at follow-up, 80% (35/44) described their headaches as moderate or severe, although improvement in headaches was reported by 29 (66%). Tension-type headaches were more likely than migraine to resolve. During the month before follow-up, non-prescription medications were used by six (14%). However, 20 (45%) felt that non-pharmacological methods were most effective. Medication use increased during the 10 years since the last follow-up. No patient used selective serotonin receptor agonists.

This study concluded that 20 years after the diagnosis of pediatric headache, most patients continue to have headache, although the headache classification often changed across time. Most patients report moderate or severe headache and increasingly choose to care for their headaches pharmacologically. TH

A65-lb., 25-year-old, male cerebral palsy (CP) patient with pneumonia arrives at your Children’s Hospital via ambulance. Although chronologically this patient is an adult, in many ways he’s still a child, and the parents told the paramedics that they’ve always taken their son to Children’s. You’ve been the treating physician during the patient’s frequent hospital stays. Is Children’s Hospital still the best destination for this patient? Will the family’s insurance still cover an admission at Children’s?

During the hospital stay, the patient has complications. He has to be intubated. IV antibiotics need to be continued for a course after hospital discharge. A long recovery is expected. Is it time for the family to consider discharge to a long-term care facility rather than home? Are there any long-term care facilities in the area that accept young adult CP patients?

As the treating pediatric hospitalist, what is your role in helping this patient and his family transition from pediatric care to an adult-care medical home?

Introduction

Approximately 8.6 million children in the United States age 10–17 have a disability, according to the Adolescent Health Transition Project, which is housed at the Center on Human Development and Disability (CHDD) at the University of Washington, Seattle. Of these, 16% (or 1.4 million) experience limitations in their activities and will likely have difficulty making the transition to adult healthcare.1

Given enough time in the profession, every pediatric hospitalist will face the challenge of transitioning patients from child-centered to adult-oriented healthcare systems. The good news: Medical advances have made it increasingly possible for children who once would have died in childhood to survive into adulthood.

Example: One in 2,500 children is born with cystic fibrosis (CF); however, with the recent, unprecedented increase in the success of diagnosis and treatment modalities for the pulmonary component of CF, the estimated median survival age for those born in the 1990s is now 40.2 As of the year 2004, 41.8% of the 22,301 patients with CF were 18 or older.3 In fact, each year nearly 500,000 children with special healthcare needs reach adulthood, and 90% of children with a chronic illness and/or disability now survive to adulthood.4,5

The bad news: Many physicians whose practices focus on adults aren’t familiar with disease processes, such as CF, that have historically been considered pediatric illnesses.

For patients with chronic physical and medical conditions—particularly for those who are medically fragile and/or technology-dependent—the transition can prove especially difficult. And pediatric hospitalists in children’s hospitals face different challenges than those in facilities that admit patients of all ages. One thing remains the same, though, the goal: to provide uninterrupted, coordinated, developmentally appropriate healthcare.

Why Transition?

There are several good reasons for patients to be transitioned from pediatric care to adult care. First, as patients age medical issues develop that are beyond the sphere of pediatricians. In CF, for example, diabetes and biliary tract problems occur with greater frequency in adults. However, because so few CF patients historically survived to adulthood, few physicians who care for adults learned about the disease. Thus, the pediatricians who cared for CF patients continued to do so, leading to situations in which 30- and 40-year-olds have been hospitalized with children. But is that truly appropriate?

Adult patients may have high blood pressure, gynecologic issues, osteoporosis, or other problems the pediatrician may not be prepared to deal with. Example: A primary care pediatrician has been the “medical home” for a small, cerebral palsy patient since she was 10. She’s now 25. If she presents with a breast mass, will the pediatrician pick up on the condition adequately? Will they know where to send the patient?

“Adult providers know those systems better,” says Brett Pickering, MD, director of the Special Needs Clinic at San Diego’s UCSD Medical Center, Department of Pediatrics.

The adult patient has different emotional needs than the pediatric patient, and the pediatric hospitalist may not be in tune with adult needs. “Pediatricians do a lot of handholding,” says Dr. Pickering. “Adult providers are more matter of fact.”

Age restrictions on admissions, insurance, and funding issues also affect transition. For example, funding under the Social Security Act’s Title V Children with Special Health Care Needs typically ends at 21 despite a patient’s education or employment status.

Given these factors, what is the appropriate age to transition care from a pediatric floor or facility to an adult-oriented unit? According to the American Academy of Pediatrics, the responsibility of pediatrics continues through age 21, but there’s no hard-and-fast rule.

Challenges

The transition to adult-care facilities is typically a lengthy process involving multiple specialties and possibly joint care during a transition period—and a process that should ideally be coordinated by the patient’s primary care pediatrician. But hospitalists know that circumstances are typically far from ideal.

First, during a transition, the patient may feel abandoned by the medical team they’ve known for most of their lives. It takes time to develop trust and confidence in a new doctor. In this respect, pediatric hospitalists in facilities that care for patients of all ages have an advantage over hospitalists in children’s hospitals. They can call on their adult-care colleagues in other areas of the hospital for consultations and transfer care over time.

“The pediatric hospitalist must make bridges with their adult colleagues who are comfortable [with the issues] and willing to take on this patient population,” says Dr. Pickering.

Second, parents may feel an emotional dependency on the pediatric team and can feel threatened by the adult environment as they lose some control. To the parents, the patient will always be their child, Dr. Pickering notes.

Third, pediatric hospitalists may be reluctant to let go, particularly if they feel adult services are inferior to those they have provided, which brings us to the fourth major challenge: To whom do you transition care?

Many adult healthcare providers receive only limited training in disorders associated with pediatrics (e.g., CF, spina bifida). The Cystic Fibrosis Foundation is leading the way in educating physicians in what have historically been considered pediatric problems. In the 1980s, the foundation launched an educational program to train physicians already involved in adult pulmonary care in CF. Unfortunately, education in other areas has lagged. And finding a physician with both an interest in and knowledge of such disorders can prove challenging.

“It’s incumbent on our adult colleagues to take these patients on, but they need training,” says Dr. Pickering. “Long-term issues require long-term solutions.

How do you jazz people up to take care of this population?” she asks. Physicians must have at least a little bit of desire to learn about these special patient populations, but academic institutions also need to identify core knowledge and skills and make them part of training and certification requirements for primary care residents and physicians in practice. Continuing medical education for physicians, nurses, and allied healthcare professionals should include drug dosing, medical complications seen in transition populations, and related developmental, psychosocial, and behavioral issues.

Steps to a Successful Transition

So what should hospitalists do? In an April 2005 presentation at the SHM Annual Meeting, Joseph M. Geskey, DO, assistant professor of pediatrics and medicine, and director of inpatient pediatrics at Penn State College of Medicine, Hershey, Penn., recommended that pediatric hospitalists take the following steps:

1. Identify the key aspects of transition;
2. Bring stakeholders together;
3. Identify transitional needs;
4. Identify and provide resources;
5. Create an audit and evaluation process;
6. Decide who will hand off care of these patients when they are admitted to the hospital (the hospitalist or the disease-specific specialist);
7. Create an up-to-date medical summary that is portable and accessible. It should include important historic information, such as diagnostic data, procedures, operations, and medications;
8. Upon patient discharge, include specific instructions on who to call if the patient develops a problem after leaving the hospital;
9. Create a working group in your area that represents pediatric and adult hospitalists to examine transition issues in the hospitalized patient; and
10. Facilitate effective communication between patients and their families, primary care physicians and specialists; and
11. Know when to transfer care to a center with more expertise in caring for specific conditions.

Conclusion

Just as every patient is different and every patient’s circumstances are unique, every transition needs to be individualized. “It’s hard to set policy,” says Dr. Pickering. Open, direct communication, specific discharge instructions, an up-to-date medical summary and knowledge of the adult resources in your area can make any transition a success. TH

Keri Losavio regularly writes for “Pediatric Special Section.”

References

1. Adolescent Health Transition Project, Center on Human Development and Disability (CHDD) at the University of Washington, Seattle. Available at http://depts.washington.edu/healthtr/Providers/intro.htm. Last accessed January 16, 2006.
2. Bufi PL. Cystic fibrosis: therapeutic options for co-management. Available at www.thorne.com/altmedrev/fulltext/cystic.html. Last accessed January 16, 2006.
3. Cystic Fibrosis Foundation: 2004 Patient Registry Report. Available at www.cff.org/living_with_cf/. Last accessed Jan. 26, 2006
4. Newacheck PW, Taylor WR. Childhood chronic illness: prevalence, severity, and impact. Am J Pub Health. 1992;82(3):364-371.
5. Committee on Children with Disabilities and Committee on Adolescence, American Academy of Pediatrics. Transition of care provided for adolescents with special health care needs. Pediatrics. 1996;98(6):1203–1206.

Pediatric Special Section

In the Literature

By Mary Ann Queen, MD, and Amita Amonker, MD

Utilization of a Clinical Pathway Improves Care for Bronchiolitis

Cheney J, Barber S, Altamirano L, et al. A Clinical Pathway for Bronchiolitis is Effective in Reducing Readmission Rates. J Pediatr. 2005;147(5):622-626.

Bronchiolitis is the most common respiratory illness in infants that results in hospitalization. Many hospitals have developed clinical pathways to assist clinicians in managing this common infection; however, the effectiveness of such pathways has not been fully studied. Of those clinical practice guidelines analyzed, varying results have been identified.

To determine the effectiveness of a bronchiolitis pathway, this study compared infants managed prospectively using a pathway protocol with a retrospective analysis of infants managed without a pathway. Infants from a tertiary care children’s hospital and three regional hospitals were enrolled prospectively from May 2000 to August 2001. (One must note this study was completed in Australia, hence the difference from the typical Northern Hemisphere winter months.) The historical control group was admitted between May 1998 and August 1999 at the same four institutions. Two-hundred-twenty-nine patients admitted with bronchiolitis were treated using the pathway protocol. These patients were compared with 207 randomly selected control patients who were admitted prior to the institution of the bronchiolitis pathway. All patients were less than 12 months of age with their first episode of wheezing necessitating hospitalization.

These particular guidelines were developed and used to promote consistency of nursing management during a separate study on bronchiolitis. The pathway included an initial admission assessment. It also stated parameters for initiating and stopping both oxygen therapy and intravenous fluid therapy along with discharge guidelines.

The authors found no significant difference in length of stay or time in oxygen. Fifteen infants (7.2%) in the control group required readmission within two weeks of discharge compared with two infants (0.9%) in the pathway group (p=.001). Of the control group 33.8% received intravenous fluids (IVFs) compared with 19.2% of the pathway infants (p=.001). There was also greater steroid use in the control group but no difference in antibiotic usage. Specific data regarding steroids and antibiotics is not included.

The clinical pathway appears a useful tool for discharge planning with a decreased incidence of hospital readmission when specific discharge goals are utilized. The authors also reported a decreased use of IVFs in the pathway group. This was attributed to having specific parameters (O2 required, RR>60/min or inadequate oral feeding) for when to initiate them. It is unclear from the article whether meeting a single parameter or all three parameters triggered the initiation of IVFs.

The authors also point out the limitation of using a historical control given annual variations in severity sometimes seen with bronchiolitis. They attempted to minimize this by collecting data for each group over two consecutive winters.

Preprinted Paper Orders Reduce Medication Errors

Kozer E, Scolnik D, MacPherson A, et al. Using a preprinted order sheet to reduce prescription errors in a pediatric emergency department: A randomized, controlled trial. Pediatrics. 2005(116):1299-1302.

Medical errors, including medication errors, are common and are written about with increasing frequency in the lay press. Accreditation bodies and individual hospitals are striving for ways to decrease these errors. In some instances potential solutions include purchasing new computer systems for electronic physician order entry. This study looks at whether implementing a preprinted paper order sheet can decrease the incidence of medication errors in a pediatric ED.

This randomized, prospective study occurred during 18 days in July 2001 with nine days randomly assigned into each arm. The first arm used the hospital’s regular blank order sheets for all medication orders. The second arm used the experimental preprinted order sheet. This sheet required the staff to specify the dose, weight-adjusted dose, total daily dose, route of administration, and frequency for each medication ordered. Two medical students entered the data into a database that included information about patients’ demographics, diagnosis, acuity, details on the prescribing physician, the form used, and all medications prescribed and given to the patient. This information was subsequently reviewed by two blinded pediatric emergency physicians who determined if an error occurred and, if so, the degree of the error.

During the study period there were 2,157 visits to the ED with 95.4% charts available for review. Seven-hundred-ninety-five medications were prescribed with 376 ordered on the new form. Drug errors were identified in 68 (16.6%) orders when the regular form was used and in 37 (9.8%) orders on the new form. There was one severe error and 13 significant errors using the new form and 36 significant errors on the regular form. The new form was associated with a twofold decrease in the risk for a medication error even after accounting for the level of training of the ordering practitioner. There was an even greater reduction in the risk for a severe or significant error.

The literature has shown that computerized physician order entry can reduce the number of medication errors in the inpatient setting; however, it is not available in many hospitals and its effectiveness has not been shown in EDs. The authors point out that most medications ordered in the ED are prepared and given by nurses. The benefits of a computerized system in this setting is unclear.

This study occurred over an 18-day period with the new form only used for nine days outside of an earlier pilot period. One could speculate that the novelty of the form encouraged the physicians to examine orders more carefully, leading to decreased errors. It is unknown if the decrease in errors would be sustained over time.

Also important to note is that the definition of an error was limited to a mistake in dose, interval between doses, dose unit, and/or route. Errors such as legibility, medication allergy, or drug interactions are not discussed. However, as hospitals strive to implement technologies aimed at reducing errors this simple, economical solution may be of benefit.

No Association between Kawasaki Disease and Adenovirus

Shike H, Shimizu C, Kanegaye J, et al. Adenovirus, adeno-associated virus and Kawasaki disease. Pediatr Infect Dis J. 2005;24:1011-1014.

Kawasaki disease is a self-limited acute vasculitis of children with a suspected infectious etiology and defined seasonality. In an attempt to find a clue for a possible infectious cause of Kawasaki disease this study examined the seasonality of different viruses. The study recognized a similar bimodal seasonality for some serotypes of adenovirus. Adenovirus accounts for 5%-10% of respiratory tract infections in children and can mimic the clinical manifestations and laboratory abnormalities seen in Kawasaki disease.

This study postulated that infection with a non-cultivatable adenovirus or antecedent adenovirus infection might be a trigger for Kawasaki disease. The study analyzed patient samples using polymerase chain reaction primers for all 51 adenovirus serotypes, viral culture, and neutralization assay for the most common adenovirus serotypes. This study also investigated possible involvement of adeno-associated viruses (AAVs), because AAVs depend on helper viruses, such as adenovirus.

Kawasaki disease patients were enrolled during a 25-month period from February 2002 to February 2004 at Children’s Hospital and Health Center in San Diego. Illness day one was defined as the first day of fever. Clinical samples used in this study were collected within the first 14 days of fever onset and before intravenous immunoglobulin (IVIG) therapy.

Nasopharyngeal swabs were cultured for adenovirus. Standard adenoviral neutralization assays for the five most common serotypes were performed with the use of patient sera. Sera with a titer of 1/10 or greater were scored as positive. At least two clinical samples from each patient, including throat swabs, sera or urine, were tested by quantitative polymerase chain reaction (PCR) for adenovirus and AAV.

Nasopharyngeal viral cultures were collected before IVIG administration on illness day three—14 from 70 Kawasaki disease patients. Of the 70 patients, 52 patients fulfilled four of the five classic criteria or three of the five criteria with abnormal coronary arteries by echocardiogram. Of the remaining 18 patients with atypical Kawasaki disease, six had coronary artery abnormalities. Overall, seven patients had coronary artery aneurysms and 22 patients had coronary artery dilatation. Viral cultures were negative in 66 of the 70 Kawasaki disease patients. The viral isolates in four patients were respiratory syncytial (one), parainfluenza virus 3 (one) and adenovirus (two). Therefore adenovirus culture was negative in 97% of patients.

Fifteen Kawasaki disease patients with negative adenovirus cultures were evaluated by PCR assay on at least two clinical samples. Fourteen patients had a negative PCR result. The throat swab from one patient collected on illness day seven contained 800 adenovirus genome copies.

Results of the adenovirus neutralization assays from 26 Kawasaki disease patients revealed that neutralization titers against any of the five most common adenovirus serotypes were undetectable in four of 26 patients.

None of the 36 samples from the same 15 acute Kawasaki disease patients described for the PCR assay was positive for AAV.

This study concluded that despite the striking similarities between Kawasaki disease and adenovirus infection there is no evidence to suggest a link between the two.

Epidemiology and Clinical Description of Severe, Multifocal Staphylococcus aureus Infection

Miles F, Voss L, Segedin E, et al. Review of Staphylococcus aureus infections requiring admission to a paediatric intensive care unit. Arch Dis Child. 2005;90(12):1274-1278.

Staphylococcus aureus is a recognized cause of multifocal infection with a high mortality rate. Children with community acquired S. aureus bacteremia (SAB) have higher frequencies of unknown foci compared with hospital-acquired SAB. Those children with S. aureus sepsis (SAS) presenting to the pediatric intensive care unit tend to have multisystemic disease—either by direct invasion or toxin production—before the diagnosis is made and treatment is initiated.

This study evaluates the clinical features and mortality from SAS in those children who required intensive care management. A retrospective review of clinical notes from all children with SAS admitted from October 1993 to April 2004 to the PICU in Auckland Children’s Hospital in New Zealand was undertaken. Children coded for SAS were identified from the PICU database.

All clinical notes were reviewed by one investigator using a standardized questionnaire that sought information on patient demographics, clinical findings, investigations, microbiology, and management in the PICU. Cases were included if blood or an isolate from a site that is normally sterile was positive for S. aureus. Hospital-acquired infection was defined by an isolate obtained at least 48 hours after hospital admission; community acquired infection was defined by an isolate obtained within 48 hours of admission.

Fifty-eight patients were identified with SAS over the 10-year study period; 55 were community acquired. Children with staphylococcal illness comprised 1% of all admission to the PICU. Musculoskeletal symptoms (79%) dominated presentation rather than isolated pneumonia (10%). An aggressive search for foci and surgical drainage of infective foci was required in 50% of children.

Most children (67%) either presented with multiple site involvement or secondary sites developed during their hospital stay. These pathologies included pneumonia, septic arthritis, osteomyelitis, and soft tissue involvement (cellulitis, fasciitis, abscess). A transthoracic echocardiogram detected valve abnormalities in only 5% of children, and these children were known to have pre-existing cardiac lesions. Few children (12%) presenting with methicillin-resistant S. aureus (MRSA) had community-acquired infection. The median length of stay in the PICU was three (mean 5.8, range one-44) days. Mortality due to SAS was 8.6%. Ten children had significant morbidity after discharge; these morbidities included renal failure requiring dialysis (three), an ongoing oxygen requirement at three months follow-up (two), and problems relating to limb movement and function (eight). Two children with epidural abscesses were paraplegic.

Community-acquired SAS affects healthy children, is multifocal, and has a high morbidity and mortality. It is imperative to look for sites of dissemination and to drain and debride foci. Routine echocardiography had a low yield in the absence of pre-existing cardiac lesions, persisting fever, or persisting bacteremia.

Long-Term Outcomes for Childhood Headache

Brna P, Dooley J, Gordon K Dewan T. The prognosis of childhood headache. Arch Pediatr Adolesc Med. 2005;159(12):1157-1160.

Headaches affect most children and rank third among illness-related causes of school absenteeism. Although the short-term outcome for most children appears favorable, few studies have reported long-term outcome. The objective of this study was to evaluate the long-term prognosis of childhood headaches 20 years after initial diagnosis in a cohort of Atlantic Canadian children who had headaches diagnosed in 1983.

Ninety-five patients with headaches who consulted one of the authors in 1983 were subsequently studied in 1993. The 77 patients contacted in 1993 were followed up in 2003. A standard telephone interview was used. Data were collected regarding headache symptoms, severity, frequency, treatment, and precipitants. Headache severity was simply classified as mild, moderate, or severe.

Sixty (78%) of 77 patients responded (60 of the 95 in the original cohort). At 20 years 16 (27%) were headache free, 20 (33%) had tension-type headaches, 10 (17%) had migraine, 14 (23%) had migraine and tension-type headaches. Having more than one headache type was more than at diagnosis or initial follow-up, and headache type varied across time. Of those who had headaches at follow-up, 80% (35/44) described their headaches as moderate or severe, although improvement in headaches was reported by 29 (66%). Tension-type headaches were more likely than migraine to resolve. During the month before follow-up, non-prescription medications were used by six (14%). However, 20 (45%) felt that non-pharmacological methods were most effective. Medication use increased during the 10 years since the last follow-up. No patient used selective serotonin receptor agonists.

This study concluded that 20 years after the diagnosis of pediatric headache, most patients continue to have headache, although the headache classification often changed across time. Most patients report moderate or severe headache and increasingly choose to care for their headaches pharmacologically. TH

Each week in the United States, child protective services and agencies receive reports of more than 50,000 suspected child abuse incidents. In 2002, 2.6 million incidents involving 4.5 million children were reported. Approximately four children die every day as a result of abuse or neglect.1 But numbers don’t tell the whole story. Behind every number is a child at risk.

“I can picture right now in my mind a young baby who was about six months of age with a belly that was protruded and distended,” says Erin R. Stucky, MD, a pediatric hospitalist at Children’s Hospital and Health Center San Diego, and an associate professor of pediatrics at the University of California San Diego. “[She had] no bowel sounds, and the arms and legs were so thin, had no fat whatsoever. The skin was rolling. The face looked dysmorphic, but it was simply because the eyes were so white, and there was no fat on the face at all. The baby had an irritated cry. The hair was thin. [She] had a look of anxiety, true anxiety [in her] eyes. It was impressive, as though this infant was saying, ‘Help me. I can’t speak.’ [She] was very socially engaged, but tired. If you had to qualify the look further, it would be something like, ‘I’m in pain. Protect me. Please don’t walk out the door.’

“The child had been admitted from the emergency department at an outside facility. They had been focused, appropriately to some extent, on the fact that the belly was distended and that the baby had no bowel sounds. They were focused on the fact that the parent’s history [of the child] was of vomiting during the day, but it clearly did not equate whatsoever with the way the child looked. It was immediately clear, simply looking at the baby while walking in the room, that something very bad was wrong and that the parents’ answers and explanations did not fit.”

What It Is

Child abuse manifests in many forms, including physical abuse, sexual abuse, emotional abuse, and neglect, with a “child” typically defined as a person under 18. Legal definitions of the forms of child abuse vary, but, in general, they reflect societal views of actions deemed improper and unacceptable because they place a child at risk of physical or emotional harm.2 The federal Child Abuse Prevention and Treatment Act (CAPTA) defines child abuse and neglect as:

• Any recent act or failure to act on the part of a parent or caretaker that results in death, serious physical or emotional harm, sexual abuse, or exploitation; or
• An act or failure to act that presents an imminent risk of serious harm.3

States must include these minimum standards in their statutes in order to receive federal funds.

Neglect is the most common form of child abuse.2 Although definitions of neglect vary by state, they share characteristics. Minnesota defines neglect as inadequate food, shelter, clothing, or medical care. California includes both overt acts and omissions in the definition of neglect, defining general neglect as a lack of food, clothing, or medical care and severe neglect as malnutrition, failure to thrive, or willfully putting a child in danger. And Rhode Island’s neglect definition goes even further, including the above acts and omissions as well as the failure to provide a minimum degree of care or proper supervision or guardianship due to unwillingness, social problems, mental incompetency, or the use of a drug, drugs or alcohol, desertion, or abandonment. Rhode Island also includes the failure to take financial responsibility for a child.4

According to Georgia Berrenberg, esq., deputy district attorney, Second Judicial District of New Mexico, sexual abuse is the most common type that goes to trial. Berrenberg, who has been a prosecutor since 1984 and was in the child abuse division from 1996–2005, estimates that approximately 70% of cases involve sexual abuse compared with 30% that involve physical abuse.

However, pediatric hospitalists will most commonly see neglect, presenting as malnutrition or failure to thrive, in a child admitted to the hospital.4

Recognize Abuse and Neglect

Pediatric hospitalists are in a unique position to recognize child abuse and neglect, intervene appropriately, and help families avoid ultimate tragedy. They are trained to consider the entire child—no matter the presenting condition—to look at general issues and to think about development and nutrition every time they examine a child.

“When someone says, ‘This child has pneumonia,’ my job is to not think pneumonia; my job is to think, ‘What’s causing this child to breathe fast?’ to make sure I don’t miss anything,” says Dr. Stucky. “If the history doesn’t fit the examination and my first, second, [and] third thoughts are child abuse/neglect. It’s my job to work on that, but it’s also my job to push my own buttons to make sure that it’s not anything else medically going on. The child that never has a bruise or fracture is the odd one out. The key [to recognizing abuse] is history.”

Don’t jump to conclusions. Hospitalists need to consider the history reported by the parent in light of the physical exam of the child. For example, if the parent tells you that the child fell headfirst off a tricycle and landed on his face, note the pattern of the bruising. If the child has bruising around the eye then that could be consistent with the history, but if the child’s eyelid is cut or bruised and there’s no bruising around the eye, that’s another matter. The eyebrow and cheekbone will protect the eye when you fall and land on your face.

“Pay attention to what you hear and see in those first few minutes and hours with that family because stories are going to change,” says Berrenberg. “Be very, very clear about the initial things that are said.”

Dealing with the medical issues that led to the admission is paramount, and it’s important for the hospitalist to communicate effectively with the parent to ensure that the child receives the most appropriate treatment. Asking open-ended questions while you take the history can be revealing:

• Can you tell me how long this has been happening?
• What do you think might be contributing to this?
• Can you tell me how you’ve been dealing with these issues at home?
• Run me through a typical day at home with your baby.

In addition to the history, consider the parent/child interaction. “Most kids, even when they’re stressed and in pain are very attentive to where their parents are,” says Dr. Stucky. “They want to be with them no matter what. They may be angry and battling. They may respond to pain differently, but that relationship is very important. As you watch it you can really get a good sense [of whether] this child’s anger outburst is because they’re in pain, they’re confused, they have autism, or they are really angry with their parent and this is the way they’re protecting themselves.”

The hospitalist has to be up front with the parent about what the next step in their child’s treatment is going to be. “It’s a delicate discussion, but an honest one,” says Dr. Stucky. “It’s important to say to the parent, overtly, ‘I’m very concerned about your baby’s weight loss. I’m very concerned that this has happened over the past several months and that it has taken this long for your baby to be seen by a doctor. I’m very concerned, and I want you to understand that your baby has a critical condition right now. It’s so malnourished that the body’s organs aren’t working properly. ... Because of this concern, I’m going to call social workers. Because of this concern I’ll use [work with] a team of people to help me to take care of your baby. They’ll ask a lot of questions, and it’s very important that you answer honestly so we can do the best for your baby and make sure that the whole family can get whatever help is needed to take care of the problem.’ ”

Reporting Requirements

In most states healthcare workers not only have a moral responsibility to report suspected abuse, they are required by law to do so. In fact, New Mexico’s statute requires anyone who suspects child abuse to report it and makes failure to do so a misdemeanor. Hospitalists should know in advance to whom to report the suspected abuse.

Consider making a call to a social worker your first step. “Social workers are invaluable,” says Dr. Stucky. “They’re there for the families. They ask the harder questions that allow us to have that medical relationship and continue to care for the child’s needs. They can look up information that we can’t. They can look up child protection history, whether the parent has been incarcerated, things that support the possibility of abuse. They can file the CPS report, allowing the hospitalist to continue caring medically for the child.”

According to Berrenberg, the police should be your second call.

Dealing with child abuse and neglect is a team effort. In addition to the police and a social worker, you need to involve the nutritionist and the primary care pediatrician (if they have one). If you’re lucky, your hospital may have a child abuse specialist on staff. “Be ready to deal with a whole variety of people who may or may not know what else has already happened,” says Berrenberg.

After the Hospital Stay

Although child abuse is all too common, most pediatric hospitalists won’t often see the inside of a courtroom. Dr. Stucky says that cases with which she’s been involved have gone to trial twice during her 10 years as a pediatric hospitalist. And Berrenberg says, “Failure to thrive is not something we charge very often. That’s a difficult thing to prove.”

That said, prepare for the possibility of being called as a fact witness. According to Berrenberg, physicians may be asked to report on not just their observations of the child, but also on statements made in their presence.

“Statements made to physicians and to healthcare personnel are critical—be it by parents, caretakers, or the child themselves in the case of sexual abuse,” she says. “If statements are made in the course of diagnosis and treatment, then those statements can come in under hearsay exceptions. ... The doctor can testify about those statements.”

Remember it’s the doctor/patient relationship that’s important. Your patient’s parents have no doctor/patient relationship.

Berrenberg offers the following advice for physicians preparing to testify: “Be patient. Read everything you have on your case. Expect everything to change. When you’re told that you’re going to trial on Monday, expect that to change. If you’ve testified before and there are transcripts available, expect the defense to know about that previous testimony. If you’re basing your opinion on literature, expect the defense attorney to have found that literature and be familiar with it.

“Work with your prosecutor. Know what they want you for. They might only want you for a limited piece; they might want you for the whole gamut. They will tell you what they’re going to expect of you. Spend as much time as you can with them, with the photos, with the file. It’s always what you don’t expect to come up that comes up.”

Pediatric hospitalists should also be prepared for old cases to come back. “We’ll bring you from wherever you are—even if you’re out of the country,” says Berrenberg. “We’ll bring you back if we need you to testify. We’ll find you. If you’re the one who saw the child and were the initial responder, so to speak, no one else can say what you saw.”

Conclusion

What happened to the six-month-old baby Dr. Stucky remembers so clearly?

“I only know what happened during the hospital stay,” she says. “This family clearly needed help and guidance. There was an overwhelming, clear [indication] that the mother had significant, major depression. She wasn’t feeding the baby. She was completely ignoring the child, and she acknowledged that. ... The father was at work and thought that perhaps this baby was just ill or sickly. He was told that the baby was being taken to the doctor, and that wasn’t happening. He was naive and innocent in thinking that things were being dealt with and thinking that their baby was simply a baby who cried a lot and wasn’t gaining weight well.

“Once this was all [addressed], he jumped at the opportunity to have the mother in therapy and on medications. The mother herself was completely willing to give up the care. ... In this case, the paternal grandmother took over the care of this child. The father would drop off the baby at her house during the day and pick up the baby at night. On weekends they would share the duties. That was the plan at discharge. ... I can’t guarantee it, but it’s my sense that this worked very well.”

Keri Losavio is a medical journalist with more than 10 years’ experience.

References

1. National Clearinghouse on Child Abuse and Neglect Information: http://nccanch.acf.hhs.gov/topics/prevention/index.cfm.
2. “What Is Child Maltreatment?” From A Coordinated Response to Child Abuse and Neglect: The Foundation for Practice. National Clearinghouse on Child Abuse and Neglect Information: http://nccanch.acf.hhs.gov.
3. Child Abuse Prevention and Treatment Act. Download the complete text from the Cornell University Legal Information Institute: www4.law.cornell.edu/uscode/42/ch67.html.
4. “Monitoring Child Neglect.” Summary of discussions at a meeting co-sponsored by the Centers for Disease Control and Prevention (CDC) and Prevent Child Abuse America (PCA America), March 29, 2002.

PEDIATRIC SPECIAL SECTION

In the Literature

Optimizing Management of GERD: Medical therapy or surgical intervention?

Hassall E. Outcomes of fundoplication: causes for concern, newer options. Arch Dis Child. 2005;90:1047-1052.

Review by Ray Chan, MD

This narrative review provides a concise overview of gastroesophageal reflux disease (GERD) while specifically addressing surgical treatment. The author focuses on the potential complications of surgical treatment and cites several studies demonstrating a high rate of complications and patient dissatisfaction with their outcomes. In contrast, the review does cite several sources that concluded good outcomes; however, the article questions the conclusions of these studies due to study designs with poorly defined and subjective outcome measures.

In contrast to the discussion on fundoplication, the review offers a more favorable description of proton pump inhibitor therapy. In the concluding remarks Hassall argues that medical therapy options should be exhausted prior to surgical therapy. The author states that the risk of mortality and morbidity combined with less than desirable efficacy of fundoplication should caution clinicians from being too eager in recommending fundoplication.

Clinically significant GERD is a common inpatient problem. This article provides a good review of the pathophysiology of this disease and available treatment options. Unfortunately, this narrative review does not utilize a systematic method of identifying relevant studies nor does it include a systematic approach for critical appraisal of these studies. Nevertheless the caution it raises about fundoplication is a worthy one that should be explored further. It is interesting to note that prior to this review the author has received grant support and was a paid consultant for AstraZeneca and TAP Pharmaceutical Products Inc.

Support for Bag UA Screening During Evaluation for UTI

McGillivray D, Mok E, Mulrooney E, et al. A head-to-head comparison: “clean-void” bag versus catheter urinalysis in the diagnosis of urinary tract infection in young children. J Pediatr. 2005;147(4):451-456.

Review by Jenny Geheb, RN, CPNP

Early detection of urinary tract infection (UTI) can be especially important in children. This study uses a cross-sectional design to compare the validity of the urinalysis on clean-voided bag versus catheter urine specimens using the catheter culture as the “gold” standard. This study looked at 303 non-toilet-trained children under age three at risk for UTI who presented to a children’s hospital emergency department. Paired bag and catheter specimens were obtained from each child and sent for dipstick and microscopic urinalysis. Sensitivity and specificity were compared using McNemar’s [chi]2 test for paired specimens and the ordinary [chi]2 test for unpaired comparisons.

The study, which was conducted at the Montreal Children’s Hospital, found that the bag dipstick was more sensitive than the catheter dipstick for the entire study sample: 0.85 (95% confidence interval [CI] = 0.78 to 0.93) versus 0.71 (95% CI= 0.95 to 0.99), respectively. Both bag and catheter dipstick sensitivities were lower in infants <90 days old. Specificity was consistently lower for the bag specimens than for the catheter specimens.

A child at high risk for UTI (previous history of UTI, anatomic abnormalities, immunosuppressed, or presence of urinary symptoms) should be catheterized to obtain both a UA and culture; however, in children older than 90 days with fever without source and at low risk for UTI, a “selective catheterization” approach, as outlined in the American Academy of Pediatrics practice parameter, appears to be reasonable.

In low-risk children, serious consequences of infection are less likely, and the authors propose that the risks of missing a UTI are likely to be outweighed by the risks of catheterization, including pain, false-positive result, trauma, introduction of infection, test resistance by staff, and parental concern.

In summary, the provider may choose to use a bag urine screening strategy to reduce the number of unnecessary catheterizations in children who are considered low risk and over 90 days old. Further studies are needed to analyze the cost-benefit ratio of this approach as well as to confirm these findings with larger populations.

Short-Course Antibiotic Treatment for Streptococcal Pharyngitis

Casey JR, Pichichero ME. Meta-analysis of short course antibiotic treatment for group A streptococcal tonsillopharyngitis. Ped Infect Dis J. 2005;24(10):909-917.

Review by Jenny Geheb, RN, CPNP

Group A streptococcal (GAS) tonsillopharyngitis is a common cause for antibiotic treatment in children. Researchers at the University of Rochester Medical Center (N.Y.) performed a meta-analysis of current data to compare bacterial and clinical cure rates in patients with GAS tonsillopharyngitis treated with short course antibiotic treatment with oral [beta]-lactam or macrolide antibiotics for four to five days with standard 10-day treatment courses. Medline, Embase, reference lists, and abstract searches were all used to identify applicable publications. Trials were included if there was bacteriologic confirmation of GAS tonsillopharyngitis, random assignment to antibiotic therapy for a [beta]-lactam or macrolide antibiotic of shortened course versus a 10-day course, and assessment of bacteriologic outcome using a throat culture.

Twenty-two trials involving 7,470 patients were included in four separate analyses. Trials were grouped by a short course of cephalosporins (n=14), macrolides (other than azithromycin) (n=6), penicillin (n=2), and amoxicillin (n=2). Cephalosporin trials were further grouped by penicillin (n=12) or the same cephalosporin (n=3). Five trials were conducted in the United States with the remainder conducted in Europe.

Meta-analysis showed that short course cephalosporin treatment was superior for bacterial cure rate compared with 10 days of penicillin (OR 1.47; 95% CI, 1.06-2.03). Short-course penicillin therapy was inferior in achieving bacterial cure versus 10 days of penicillin. Clinical cure rate mirrored the bacterial cure rate results. Small sample size limited the statistical power and conclusions of the short course macrolide trials as well as trials of four or five days of cephalosporin therapy compared with 10 days of the same.

This meta-analysis shows that short-course treatment of GAS tonsillopharyngitis can be more effective when prescribing four or five days of cefdinir, cefpodoxime, or cefuroxime treatment than standard 10-day treatment of penicillin. In the United States cefdinir, cefpodoxime, and azithromycin are indicated for short-course treatment. As prescribing practitioners, it is important for us to consider the advantages of shortened antibiotic courses, including improved patient compliance, fewer adverse effects, and reduced impact on development of antibiotic resistance and nasopharyngeal colonization with resistant bacteria. However, the authors emphasize that caution must be used in interpretation of the results of this meta-analysis.

For example, the trials were grouped according to class of antibiotics so that the cephalosporin group included seven different cephalosporins (one first generation, two second generation, and four third generation). In addition, there was much variability in the quality and design of compared studies, which makes it difficult to make strong conclusions. Repeat studies are needed, especially in regard to short-course macrolide or amoxicillin treatment.

Each week in the United States, child protective services and agencies receive reports of more than 50,000 suspected child abuse incidents. In 2002, 2.6 million incidents involving 4.5 million children were reported. Approximately four children die every day as a result of abuse or neglect.1 But numbers don’t tell the whole story. Behind every number is a child at risk.

“I can picture right now in my mind a young baby who was about six months of age with a belly that was protruded and distended,” says Erin R. Stucky, MD, a pediatric hospitalist at Children’s Hospital and Health Center San Diego, and an associate professor of pediatrics at the University of California San Diego. “[She had] no bowel sounds, and the arms and legs were so thin, had no fat whatsoever. The skin was rolling. The face looked dysmorphic, but it was simply because the eyes were so white, and there was no fat on the face at all. The baby had an irritated cry. The hair was thin. [She] had a look of anxiety, true anxiety [in her] eyes. It was impressive, as though this infant was saying, ‘Help me. I can’t speak.’ [She] was very socially engaged, but tired. If you had to qualify the look further, it would be something like, ‘I’m in pain. Protect me. Please don’t walk out the door.’

“The child had been admitted from the emergency department at an outside facility. They had been focused, appropriately to some extent, on the fact that the belly was distended and that the baby had no bowel sounds. They were focused on the fact that the parent’s history [of the child] was of vomiting during the day, but it clearly did not equate whatsoever with the way the child looked. It was immediately clear, simply looking at the baby while walking in the room, that something very bad was wrong and that the parents’ answers and explanations did not fit.”

What It Is

Child abuse manifests in many forms, including physical abuse, sexual abuse, emotional abuse, and neglect, with a “child” typically defined as a person under 18. Legal definitions of the forms of child abuse vary, but, in general, they reflect societal views of actions deemed improper and unacceptable because they place a child at risk of physical or emotional harm.2 The federal Child Abuse Prevention and Treatment Act (CAPTA) defines child abuse and neglect as:

• Any recent act or failure to act on the part of a parent or caretaker that results in death, serious physical or emotional harm, sexual abuse, or exploitation; or
• An act or failure to act that presents an imminent risk of serious harm.3

States must include these minimum standards in their statutes in order to receive federal funds.

Neglect is the most common form of child abuse.2 Although definitions of neglect vary by state, they share characteristics. Minnesota defines neglect as inadequate food, shelter, clothing, or medical care. California includes both overt acts and omissions in the definition of neglect, defining general neglect as a lack of food, clothing, or medical care and severe neglect as malnutrition, failure to thrive, or willfully putting a child in danger. And Rhode Island’s neglect definition goes even further, including the above acts and omissions as well as the failure to provide a minimum degree of care or proper supervision or guardianship due to unwillingness, social problems, mental incompetency, or the use of a drug, drugs or alcohol, desertion, or abandonment. Rhode Island also includes the failure to take financial responsibility for a child.4

According to Georgia Berrenberg, esq., deputy district attorney, Second Judicial District of New Mexico, sexual abuse is the most common type that goes to trial. Berrenberg, who has been a prosecutor since 1984 and was in the child abuse division from 1996–2005, estimates that approximately 70% of cases involve sexual abuse compared with 30% that involve physical abuse.

However, pediatric hospitalists will most commonly see neglect, presenting as malnutrition or failure to thrive, in a child admitted to the hospital.4

Recognize Abuse and Neglect

Pediatric hospitalists are in a unique position to recognize child abuse and neglect, intervene appropriately, and help families avoid ultimate tragedy. They are trained to consider the entire child—no matter the presenting condition—to look at general issues and to think about development and nutrition every time they examine a child.

“When someone says, ‘This child has pneumonia,’ my job is to not think pneumonia; my job is to think, ‘What’s causing this child to breathe fast?’ to make sure I don’t miss anything,” says Dr. Stucky. “If the history doesn’t fit the examination and my first, second, [and] third thoughts are child abuse/neglect. It’s my job to work on that, but it’s also my job to push my own buttons to make sure that it’s not anything else medically going on. The child that never has a bruise or fracture is the odd one out. The key [to recognizing abuse] is history.”

Don’t jump to conclusions. Hospitalists need to consider the history reported by the parent in light of the physical exam of the child. For example, if the parent tells you that the child fell headfirst off a tricycle and landed on his face, note the pattern of the bruising. If the child has bruising around the eye then that could be consistent with the history, but if the child’s eyelid is cut or bruised and there’s no bruising around the eye, that’s another matter. The eyebrow and cheekbone will protect the eye when you fall and land on your face.

“Pay attention to what you hear and see in those first few minutes and hours with that family because stories are going to change,” says Berrenberg. “Be very, very clear about the initial things that are said.”

Dealing with the medical issues that led to the admission is paramount, and it’s important for the hospitalist to communicate effectively with the parent to ensure that the child receives the most appropriate treatment. Asking open-ended questions while you take the history can be revealing:

• Can you tell me how long this has been happening?
• What do you think might be contributing to this?
• Can you tell me how you’ve been dealing with these issues at home?
• Run me through a typical day at home with your baby.

In addition to the history, consider the parent/child interaction. “Most kids, even when they’re stressed and in pain are very attentive to where their parents are,” says Dr. Stucky. “They want to be with them no matter what. They may be angry and battling. They may respond to pain differently, but that relationship is very important. As you watch it you can really get a good sense [of whether] this child’s anger outburst is because they’re in pain, they’re confused, they have autism, or they are really angry with their parent and this is the way they’re protecting themselves.”

The hospitalist has to be up front with the parent about what the next step in their child’s treatment is going to be. “It’s a delicate discussion, but an honest one,” says Dr. Stucky. “It’s important to say to the parent, overtly, ‘I’m very concerned about your baby’s weight loss. I’m very concerned that this has happened over the past several months and that it has taken this long for your baby to be seen by a doctor. I’m very concerned, and I want you to understand that your baby has a critical condition right now. It’s so malnourished that the body’s organs aren’t working properly. ... Because of this concern, I’m going to call social workers. Because of this concern I’ll use [work with] a team of people to help me to take care of your baby. They’ll ask a lot of questions, and it’s very important that you answer honestly so we can do the best for your baby and make sure that the whole family can get whatever help is needed to take care of the problem.’ ”

Reporting Requirements

In most states healthcare workers not only have a moral responsibility to report suspected abuse, they are required by law to do so. In fact, New Mexico’s statute requires anyone who suspects child abuse to report it and makes failure to do so a misdemeanor. Hospitalists should know in advance to whom to report the suspected abuse.

Consider making a call to a social worker your first step. “Social workers are invaluable,” says Dr. Stucky. “They’re there for the families. They ask the harder questions that allow us to have that medical relationship and continue to care for the child’s needs. They can look up information that we can’t. They can look up child protection history, whether the parent has been incarcerated, things that support the possibility of abuse. They can file the CPS report, allowing the hospitalist to continue caring medically for the child.”

According to Berrenberg, the police should be your second call.

Dealing with child abuse and neglect is a team effort. In addition to the police and a social worker, you need to involve the nutritionist and the primary care pediatrician (if they have one). If you’re lucky, your hospital may have a child abuse specialist on staff. “Be ready to deal with a whole variety of people who may or may not know what else has already happened,” says Berrenberg.

After the Hospital Stay

Although child abuse is all too common, most pediatric hospitalists won’t often see the inside of a courtroom. Dr. Stucky says that cases with which she’s been involved have gone to trial twice during her 10 years as a pediatric hospitalist. And Berrenberg says, “Failure to thrive is not something we charge very often. That’s a difficult thing to prove.”

That said, prepare for the possibility of being called as a fact witness. According to Berrenberg, physicians may be asked to report on not just their observations of the child, but also on statements made in their presence.

“Statements made to physicians and to healthcare personnel are critical—be it by parents, caretakers, or the child themselves in the case of sexual abuse,” she says. “If statements are made in the course of diagnosis and treatment, then those statements can come in under hearsay exceptions. ... The doctor can testify about those statements.”

Remember it’s the doctor/patient relationship that’s important. Your patient’s parents have no doctor/patient relationship.

Berrenberg offers the following advice for physicians preparing to testify: “Be patient. Read everything you have on your case. Expect everything to change. When you’re told that you’re going to trial on Monday, expect that to change. If you’ve testified before and there are transcripts available, expect the defense to know about that previous testimony. If you’re basing your opinion on literature, expect the defense attorney to have found that literature and be familiar with it.

“Work with your prosecutor. Know what they want you for. They might only want you for a limited piece; they might want you for the whole gamut. They will tell you what they’re going to expect of you. Spend as much time as you can with them, with the photos, with the file. It’s always what you don’t expect to come up that comes up.”

Pediatric hospitalists should also be prepared for old cases to come back. “We’ll bring you from wherever you are—even if you’re out of the country,” says Berrenberg. “We’ll bring you back if we need you to testify. We’ll find you. If you’re the one who saw the child and were the initial responder, so to speak, no one else can say what you saw.”

Conclusion

What happened to the six-month-old baby Dr. Stucky remembers so clearly?

“I only know what happened during the hospital stay,” she says. “This family clearly needed help and guidance. There was an overwhelming, clear [indication] that the mother had significant, major depression. She wasn’t feeding the baby. She was completely ignoring the child, and she acknowledged that. ... The father was at work and thought that perhaps this baby was just ill or sickly. He was told that the baby was being taken to the doctor, and that wasn’t happening. He was naive and innocent in thinking that things were being dealt with and thinking that their baby was simply a baby who cried a lot and wasn’t gaining weight well.

“Once this was all [addressed], he jumped at the opportunity to have the mother in therapy and on medications. The mother herself was completely willing to give up the care. ... In this case, the paternal grandmother took over the care of this child. The father would drop off the baby at her house during the day and pick up the baby at night. On weekends they would share the duties. That was the plan at discharge. ... I can’t guarantee it, but it’s my sense that this worked very well.”

Keri Losavio is a medical journalist with more than 10 years’ experience.

References

1. National Clearinghouse on Child Abuse and Neglect Information: http://nccanch.acf.hhs.gov/topics/prevention/index.cfm.
2. “What Is Child Maltreatment?” From A Coordinated Response to Child Abuse and Neglect: The Foundation for Practice. National Clearinghouse on Child Abuse and Neglect Information: http://nccanch.acf.hhs.gov.
3. Child Abuse Prevention and Treatment Act. Download the complete text from the Cornell University Legal Information Institute: www4.law.cornell.edu/uscode/42/ch67.html.
4. “Monitoring Child Neglect.” Summary of discussions at a meeting co-sponsored by the Centers for Disease Control and Prevention (CDC) and Prevent Child Abuse America (PCA America), March 29, 2002.

PEDIATRIC SPECIAL SECTION

In the Literature

Optimizing Management of GERD: Medical therapy or surgical intervention?

Hassall E. Outcomes of fundoplication: causes for concern, newer options. Arch Dis Child. 2005;90:1047-1052.

Review by Ray Chan, MD

This narrative review provides a concise overview of gastroesophageal reflux disease (GERD) while specifically addressing surgical treatment. The author focuses on the potential complications of surgical treatment and cites several studies demonstrating a high rate of complications and patient dissatisfaction with their outcomes. In contrast, the review does cite several sources that concluded good outcomes; however, the article questions the conclusions of these studies due to study designs with poorly defined and subjective outcome measures.

In contrast to the discussion on fundoplication, the review offers a more favorable description of proton pump inhibitor therapy. In the concluding remarks Hassall argues that medical therapy options should be exhausted prior to surgical therapy. The author states that the risk of mortality and morbidity combined with less than desirable efficacy of fundoplication should caution clinicians from being too eager in recommending fundoplication.

Clinically significant GERD is a common inpatient problem. This article provides a good review of the pathophysiology of this disease and available treatment options. Unfortunately, this narrative review does not utilize a systematic method of identifying relevant studies nor does it include a systematic approach for critical appraisal of these studies. Nevertheless the caution it raises about fundoplication is a worthy one that should be explored further. It is interesting to note that prior to this review the author has received grant support and was a paid consultant for AstraZeneca and TAP Pharmaceutical Products Inc.

Support for Bag UA Screening During Evaluation for UTI

McGillivray D, Mok E, Mulrooney E, et al. A head-to-head comparison: “clean-void” bag versus catheter urinalysis in the diagnosis of urinary tract infection in young children. J Pediatr. 2005;147(4):451-456.

Review by Jenny Geheb, RN, CPNP

Early detection of urinary tract infection (UTI) can be especially important in children. This study uses a cross-sectional design to compare the validity of the urinalysis on clean-voided bag versus catheter urine specimens using the catheter culture as the “gold” standard. This study looked at 303 non-toilet-trained children under age three at risk for UTI who presented to a children’s hospital emergency department. Paired bag and catheter specimens were obtained from each child and sent for dipstick and microscopic urinalysis. Sensitivity and specificity were compared using McNemar’s [chi]2 test for paired specimens and the ordinary [chi]2 test for unpaired comparisons.

The study, which was conducted at the Montreal Children’s Hospital, found that the bag dipstick was more sensitive than the catheter dipstick for the entire study sample: 0.85 (95% confidence interval [CI] = 0.78 to 0.93) versus 0.71 (95% CI= 0.95 to 0.99), respectively. Both bag and catheter dipstick sensitivities were lower in infants <90 days old. Specificity was consistently lower for the bag specimens than for the catheter specimens.

A child at high risk for UTI (previous history of UTI, anatomic abnormalities, immunosuppressed, or presence of urinary symptoms) should be catheterized to obtain both a UA and culture; however, in children older than 90 days with fever without source and at low risk for UTI, a “selective catheterization” approach, as outlined in the American Academy of Pediatrics practice parameter, appears to be reasonable.

In low-risk children, serious consequences of infection are less likely, and the authors propose that the risks of missing a UTI are likely to be outweighed by the risks of catheterization, including pain, false-positive result, trauma, introduction of infection, test resistance by staff, and parental concern.

In summary, the provider may choose to use a bag urine screening strategy to reduce the number of unnecessary catheterizations in children who are considered low risk and over 90 days old. Further studies are needed to analyze the cost-benefit ratio of this approach as well as to confirm these findings with larger populations.

Short-Course Antibiotic Treatment for Streptococcal Pharyngitis

Casey JR, Pichichero ME. Meta-analysis of short course antibiotic treatment for group A streptococcal tonsillopharyngitis. Ped Infect Dis J. 2005;24(10):909-917.

Review by Jenny Geheb, RN, CPNP

Group A streptococcal (GAS) tonsillopharyngitis is a common cause for antibiotic treatment in children. Researchers at the University of Rochester Medical Center (N.Y.) performed a meta-analysis of current data to compare bacterial and clinical cure rates in patients with GAS tonsillopharyngitis treated with short course antibiotic treatment with oral [beta]-lactam or macrolide antibiotics for four to five days with standard 10-day treatment courses. Medline, Embase, reference lists, and abstract searches were all used to identify applicable publications. Trials were included if there was bacteriologic confirmation of GAS tonsillopharyngitis, random assignment to antibiotic therapy for a [beta]-lactam or macrolide antibiotic of shortened course versus a 10-day course, and assessment of bacteriologic outcome using a throat culture.

Twenty-two trials involving 7,470 patients were included in four separate analyses. Trials were grouped by a short course of cephalosporins (n=14), macrolides (other than azithromycin) (n=6), penicillin (n=2), and amoxicillin (n=2). Cephalosporin trials were further grouped by penicillin (n=12) or the same cephalosporin (n=3). Five trials were conducted in the United States with the remainder conducted in Europe.

Meta-analysis showed that short course cephalosporin treatment was superior for bacterial cure rate compared with 10 days of penicillin (OR 1.47; 95% CI, 1.06-2.03). Short-course penicillin therapy was inferior in achieving bacterial cure versus 10 days of penicillin. Clinical cure rate mirrored the bacterial cure rate results. Small sample size limited the statistical power and conclusions of the short course macrolide trials as well as trials of four or five days of cephalosporin therapy compared with 10 days of the same.

This meta-analysis shows that short-course treatment of GAS tonsillopharyngitis can be more effective when prescribing four or five days of cefdinir, cefpodoxime, or cefuroxime treatment than standard 10-day treatment of penicillin. In the United States cefdinir, cefpodoxime, and azithromycin are indicated for short-course treatment. As prescribing practitioners, it is important for us to consider the advantages of shortened antibiotic courses, including improved patient compliance, fewer adverse effects, and reduced impact on development of antibiotic resistance and nasopharyngeal colonization with resistant bacteria. However, the authors emphasize that caution must be used in interpretation of the results of this meta-analysis.

For example, the trials were grouped according to class of antibiotics so that the cephalosporin group included seven different cephalosporins (one first generation, two second generation, and four third generation). In addition, there was much variability in the quality and design of compared studies, which makes it difficult to make strong conclusions. Repeat studies are needed, especially in regard to short-course macrolide or amoxicillin treatment.

Each week in the United States, child protective services and agencies receive reports of more than 50,000 suspected child abuse incidents. In 2002, 2.6 million incidents involving 4.5 million children were reported. Approximately four children die every day as a result of abuse or neglect.1 But numbers don’t tell the whole story. Behind every number is a child at risk.

“I can picture right now in my mind a young baby who was about six months of age with a belly that was protruded and distended,” says Erin R. Stucky, MD, a pediatric hospitalist at Children’s Hospital and Health Center San Diego, and an associate professor of pediatrics at the University of California San Diego. “[She had] no bowel sounds, and the arms and legs were so thin, had no fat whatsoever. The skin was rolling. The face looked dysmorphic, but it was simply because the eyes were so white, and there was no fat on the face at all. The baby had an irritated cry. The hair was thin. [She] had a look of anxiety, true anxiety [in her] eyes. It was impressive, as though this infant was saying, ‘Help me. I can’t speak.’ [She] was very socially engaged, but tired. If you had to qualify the look further, it would be something like, ‘I’m in pain. Protect me. Please don’t walk out the door.’

“The child had been admitted from the emergency department at an outside facility. They had been focused, appropriately to some extent, on the fact that the belly was distended and that the baby had no bowel sounds. They were focused on the fact that the parent’s history [of the child] was of vomiting during the day, but it clearly did not equate whatsoever with the way the child looked. It was immediately clear, simply looking at the baby while walking in the room, that something very bad was wrong and that the parents’ answers and explanations did not fit.”

What It Is

Child abuse manifests in many forms, including physical abuse, sexual abuse, emotional abuse, and neglect, with a “child” typically defined as a person under 18. Legal definitions of the forms of child abuse vary, but, in general, they reflect societal views of actions deemed improper and unacceptable because they place a child at risk of physical or emotional harm.2 The federal Child Abuse Prevention and Treatment Act (CAPTA) defines child abuse and neglect as:

• Any recent act or failure to act on the part of a parent or caretaker that results in death, serious physical or emotional harm, sexual abuse, or exploitation; or
• An act or failure to act that presents an imminent risk of serious harm.3

States must include these minimum standards in their statutes in order to receive federal funds.

Neglect is the most common form of child abuse.2 Although definitions of neglect vary by state, they share characteristics. Minnesota defines neglect as inadequate food, shelter, clothing, or medical care. California includes both overt acts and omissions in the definition of neglect, defining general neglect as a lack of food, clothing, or medical care and severe neglect as malnutrition, failure to thrive, or willfully putting a child in danger. And Rhode Island’s neglect definition goes even further, including the above acts and omissions as well as the failure to provide a minimum degree of care or proper supervision or guardianship due to unwillingness, social problems, mental incompetency, or the use of a drug, drugs or alcohol, desertion, or abandonment. Rhode Island also includes the failure to take financial responsibility for a child.4

According to Georgia Berrenberg, esq., deputy district attorney, Second Judicial District of New Mexico, sexual abuse is the most common type that goes to trial. Berrenberg, who has been a prosecutor since 1984 and was in the child abuse division from 1996–2005, estimates that approximately 70% of cases involve sexual abuse compared with 30% that involve physical abuse.

However, pediatric hospitalists will most commonly see neglect, presenting as malnutrition or failure to thrive, in a child admitted to the hospital.4

Recognize Abuse and Neglect

Pediatric hospitalists are in a unique position to recognize child abuse and neglect, intervene appropriately, and help families avoid ultimate tragedy. They are trained to consider the entire child—no matter the presenting condition—to look at general issues and to think about development and nutrition every time they examine a child.

“When someone says, ‘This child has pneumonia,’ my job is to not think pneumonia; my job is to think, ‘What’s causing this child to breathe fast?’ to make sure I don’t miss anything,” says Dr. Stucky. “If the history doesn’t fit the examination and my first, second, [and] third thoughts are child abuse/neglect. It’s my job to work on that, but it’s also my job to push my own buttons to make sure that it’s not anything else medically going on. The child that never has a bruise or fracture is the odd one out. The key [to recognizing abuse] is history.”

Don’t jump to conclusions. Hospitalists need to consider the history reported by the parent in light of the physical exam of the child. For example, if the parent tells you that the child fell headfirst off a tricycle and landed on his face, note the pattern of the bruising. If the child has bruising around the eye then that could be consistent with the history, but if the child’s eyelid is cut or bruised and there’s no bruising around the eye, that’s another matter. The eyebrow and cheekbone will protect the eye when you fall and land on your face.

“Pay attention to what you hear and see in those first few minutes and hours with that family because stories are going to change,” says Berrenberg. “Be very, very clear about the initial things that are said.”

Dealing with the medical issues that led to the admission is paramount, and it’s important for the hospitalist to communicate effectively with the parent to ensure that the child receives the most appropriate treatment. Asking open-ended questions while you take the history can be revealing:

• Can you tell me how long this has been happening?
• What do you think might be contributing to this?
• Can you tell me how you’ve been dealing with these issues at home?
• Run me through a typical day at home with your baby.

In addition to the history, consider the parent/child interaction. “Most kids, even when they’re stressed and in pain are very attentive to where their parents are,” says Dr. Stucky. “They want to be with them no matter what. They may be angry and battling. They may respond to pain differently, but that relationship is very important. As you watch it you can really get a good sense [of whether] this child’s anger outburst is because they’re in pain, they’re confused, they have autism, or they are really angry with their parent and this is the way they’re protecting themselves.”

The hospitalist has to be up front with the parent about what the next step in their child’s treatment is going to be. “It’s a delicate discussion, but an honest one,” says Dr. Stucky. “It’s important to say to the parent, overtly, ‘I’m very concerned about your baby’s weight loss. I’m very concerned that this has happened over the past several months and that it has taken this long for your baby to be seen by a doctor. I’m very concerned, and I want you to understand that your baby has a critical condition right now. It’s so malnourished that the body’s organs aren’t working properly. ... Because of this concern, I’m going to call social workers. Because of this concern I’ll use [work with] a team of people to help me to take care of your baby. They’ll ask a lot of questions, and it’s very important that you answer honestly so we can do the best for your baby and make sure that the whole family can get whatever help is needed to take care of the problem.’ ”

Reporting Requirements

In most states healthcare workers not only have a moral responsibility to report suspected abuse, they are required by law to do so. In fact, New Mexico’s statute requires anyone who suspects child abuse to report it and makes failure to do so a misdemeanor. Hospitalists should know in advance to whom to report the suspected abuse.

Consider making a call to a social worker your first step. “Social workers are invaluable,” says Dr. Stucky. “They’re there for the families. They ask the harder questions that allow us to have that medical relationship and continue to care for the child’s needs. They can look up information that we can’t. They can look up child protection history, whether the parent has been incarcerated, things that support the possibility of abuse. They can file the CPS report, allowing the hospitalist to continue caring medically for the child.”

According to Berrenberg, the police should be your second call.

Dealing with child abuse and neglect is a team effort. In addition to the police and a social worker, you need to involve the nutritionist and the primary care pediatrician (if they have one). If you’re lucky, your hospital may have a child abuse specialist on staff. “Be ready to deal with a whole variety of people who may or may not know what else has already happened,” says Berrenberg.

After the Hospital Stay

Although child abuse is all too common, most pediatric hospitalists won’t often see the inside of a courtroom. Dr. Stucky says that cases with which she’s been involved have gone to trial twice during her 10 years as a pediatric hospitalist. And Berrenberg says, “Failure to thrive is not something we charge very often. That’s a difficult thing to prove.”

That said, prepare for the possibility of being called as a fact witness. According to Berrenberg, physicians may be asked to report on not just their observations of the child, but also on statements made in their presence.

“Statements made to physicians and to healthcare personnel are critical—be it by parents, caretakers, or the child themselves in the case of sexual abuse,” she says. “If statements are made in the course of diagnosis and treatment, then those statements can come in under hearsay exceptions. ... The doctor can testify about those statements.”

Remember it’s the doctor/patient relationship that’s important. Your patient’s parents have no doctor/patient relationship.

Berrenberg offers the following advice for physicians preparing to testify: “Be patient. Read everything you have on your case. Expect everything to change. When you’re told that you’re going to trial on Monday, expect that to change. If you’ve testified before and there are transcripts available, expect the defense to know about that previous testimony. If you’re basing your opinion on literature, expect the defense attorney to have found that literature and be familiar with it.

“Work with your prosecutor. Know what they want you for. They might only want you for a limited piece; they might want you for the whole gamut. They will tell you what they’re going to expect of you. Spend as much time as you can with them, with the photos, with the file. It’s always what you don’t expect to come up that comes up.”

Pediatric hospitalists should also be prepared for old cases to come back. “We’ll bring you from wherever you are—even if you’re out of the country,” says Berrenberg. “We’ll bring you back if we need you to testify. We’ll find you. If you’re the one who saw the child and were the initial responder, so to speak, no one else can say what you saw.”

Conclusion

What happened to the six-month-old baby Dr. Stucky remembers so clearly?

“I only know what happened during the hospital stay,” she says. “This family clearly needed help and guidance. There was an overwhelming, clear [indication] that the mother had significant, major depression. She wasn’t feeding the baby. She was completely ignoring the child, and she acknowledged that. ... The father was at work and thought that perhaps this baby was just ill or sickly. He was told that the baby was being taken to the doctor, and that wasn’t happening. He was naive and innocent in thinking that things were being dealt with and thinking that their baby was simply a baby who cried a lot and wasn’t gaining weight well.

“Once this was all [addressed], he jumped at the opportunity to have the mother in therapy and on medications. The mother herself was completely willing to give up the care. ... In this case, the paternal grandmother took over the care of this child. The father would drop off the baby at her house during the day and pick up the baby at night. On weekends they would share the duties. That was the plan at discharge. ... I can’t guarantee it, but it’s my sense that this worked very well.”

Keri Losavio is a medical journalist with more than 10 years’ experience.

References

1. National Clearinghouse on Child Abuse and Neglect Information: http://nccanch.acf.hhs.gov/topics/prevention/index.cfm.
2. “What Is Child Maltreatment?” From A Coordinated Response to Child Abuse and Neglect: The Foundation for Practice. National Clearinghouse on Child Abuse and Neglect Information: http://nccanch.acf.hhs.gov.
3. Child Abuse Prevention and Treatment Act. Download the complete text from the Cornell University Legal Information Institute: www4.law.cornell.edu/uscode/42/ch67.html.
4. “Monitoring Child Neglect.” Summary of discussions at a meeting co-sponsored by the Centers for Disease Control and Prevention (CDC) and Prevent Child Abuse America (PCA America), March 29, 2002.

PEDIATRIC SPECIAL SECTION

In the Literature

Optimizing Management of GERD: Medical therapy or surgical intervention?

Hassall E. Outcomes of fundoplication: causes for concern, newer options. Arch Dis Child. 2005;90:1047-1052.

Review by Ray Chan, MD

This narrative review provides a concise overview of gastroesophageal reflux disease (GERD) while specifically addressing surgical treatment. The author focuses on the potential complications of surgical treatment and cites several studies demonstrating a high rate of complications and patient dissatisfaction with their outcomes. In contrast, the review does cite several sources that concluded good outcomes; however, the article questions the conclusions of these studies due to study designs with poorly defined and subjective outcome measures.

In contrast to the discussion on fundoplication, the review offers a more favorable description of proton pump inhibitor therapy. In the concluding remarks Hassall argues that medical therapy options should be exhausted prior to surgical therapy. The author states that the risk of mortality and morbidity combined with less than desirable efficacy of fundoplication should caution clinicians from being too eager in recommending fundoplication.

Clinically significant GERD is a common inpatient problem. This article provides a good review of the pathophysiology of this disease and available treatment options. Unfortunately, this narrative review does not utilize a systematic method of identifying relevant studies nor does it include a systematic approach for critical appraisal of these studies. Nevertheless the caution it raises about fundoplication is a worthy one that should be explored further. It is interesting to note that prior to this review the author has received grant support and was a paid consultant for AstraZeneca and TAP Pharmaceutical Products Inc.

Support for Bag UA Screening During Evaluation for UTI

McGillivray D, Mok E, Mulrooney E, et al. A head-to-head comparison: “clean-void” bag versus catheter urinalysis in the diagnosis of urinary tract infection in young children. J Pediatr. 2005;147(4):451-456.

Review by Jenny Geheb, RN, CPNP

Early detection of urinary tract infection (UTI) can be especially important in children. This study uses a cross-sectional design to compare the validity of the urinalysis on clean-voided bag versus catheter urine specimens using the catheter culture as the “gold” standard. This study looked at 303 non-toilet-trained children under age three at risk for UTI who presented to a children’s hospital emergency department. Paired bag and catheter specimens were obtained from each child and sent for dipstick and microscopic urinalysis. Sensitivity and specificity were compared using McNemar’s [chi]2 test for paired specimens and the ordinary [chi]2 test for unpaired comparisons.

The study, which was conducted at the Montreal Children’s Hospital, found that the bag dipstick was more sensitive than the catheter dipstick for the entire study sample: 0.85 (95% confidence interval [CI] = 0.78 to 0.93) versus 0.71 (95% CI= 0.95 to 0.99), respectively. Both bag and catheter dipstick sensitivities were lower in infants <90 days old. Specificity was consistently lower for the bag specimens than for the catheter specimens.

A child at high risk for UTI (previous history of UTI, anatomic abnormalities, immunosuppressed, or presence of urinary symptoms) should be catheterized to obtain both a UA and culture; however, in children older than 90 days with fever without source and at low risk for UTI, a “selective catheterization” approach, as outlined in the American Academy of Pediatrics practice parameter, appears to be reasonable.

In low-risk children, serious consequences of infection are less likely, and the authors propose that the risks of missing a UTI are likely to be outweighed by the risks of catheterization, including pain, false-positive result, trauma, introduction of infection, test resistance by staff, and parental concern.

In summary, the provider may choose to use a bag urine screening strategy to reduce the number of unnecessary catheterizations in children who are considered low risk and over 90 days old. Further studies are needed to analyze the cost-benefit ratio of this approach as well as to confirm these findings with larger populations.

Short-Course Antibiotic Treatment for Streptococcal Pharyngitis

Casey JR, Pichichero ME. Meta-analysis of short course antibiotic treatment for group A streptococcal tonsillopharyngitis. Ped Infect Dis J. 2005;24(10):909-917.

Review by Jenny Geheb, RN, CPNP

Group A streptococcal (GAS) tonsillopharyngitis is a common cause for antibiotic treatment in children. Researchers at the University of Rochester Medical Center (N.Y.) performed a meta-analysis of current data to compare bacterial and clinical cure rates in patients with GAS tonsillopharyngitis treated with short course antibiotic treatment with oral [beta]-lactam or macrolide antibiotics for four to five days with standard 10-day treatment courses. Medline, Embase, reference lists, and abstract searches were all used to identify applicable publications. Trials were included if there was bacteriologic confirmation of GAS tonsillopharyngitis, random assignment to antibiotic therapy for a [beta]-lactam or macrolide antibiotic of shortened course versus a 10-day course, and assessment of bacteriologic outcome using a throat culture.

Twenty-two trials involving 7,470 patients were included in four separate analyses. Trials were grouped by a short course of cephalosporins (n=14), macrolides (other than azithromycin) (n=6), penicillin (n=2), and amoxicillin (n=2). Cephalosporin trials were further grouped by penicillin (n=12) or the same cephalosporin (n=3). Five trials were conducted in the United States with the remainder conducted in Europe.

Meta-analysis showed that short course cephalosporin treatment was superior for bacterial cure rate compared with 10 days of penicillin (OR 1.47; 95% CI, 1.06-2.03). Short-course penicillin therapy was inferior in achieving bacterial cure versus 10 days of penicillin. Clinical cure rate mirrored the bacterial cure rate results. Small sample size limited the statistical power and conclusions of the short course macrolide trials as well as trials of four or five days of cephalosporin therapy compared with 10 days of the same.

This meta-analysis shows that short-course treatment of GAS tonsillopharyngitis can be more effective when prescribing four or five days of cefdinir, cefpodoxime, or cefuroxime treatment than standard 10-day treatment of penicillin. In the United States cefdinir, cefpodoxime, and azithromycin are indicated for short-course treatment. As prescribing practitioners, it is important for us to consider the advantages of shortened antibiotic courses, including improved patient compliance, fewer adverse effects, and reduced impact on development of antibiotic resistance and nasopharyngeal colonization with resistant bacteria. However, the authors emphasize that caution must be used in interpretation of the results of this meta-analysis.

For example, the trials were grouped according to class of antibiotics so that the cephalosporin group included seven different cephalosporins (one first generation, two second generation, and four third generation). In addition, there was much variability in the quality and design of compared studies, which makes it difficult to make strong conclusions. Repeat studies are needed, especially in regard to short-course macrolide or amoxicillin treatment.

Scenario: A 32-day-old female presents with vomiting and jaundice, and the mother reports that the child is irritable and not eating as well as usual. The pediatric hospitalist suspects a UTI and orders a dipstick/urinalysis and urine culture. The dipstick/urinalysis results are positive for nitrite and leukocyte esterase, indicating antibiotic therapy for presumed UTI.

Introduction

UTI is one of the most common bacterial infections in infants and young children. To prevent progression to pyelonephritis and avoid potential renal scarring or failure, early recognition and prompt treatment are critical.

Clinical signs and symptoms of UTI in newborns include jaundice, sepsis, failure to thrive, poor feeding, vomiting, and fever. In infants and preschoolers, hospitalists should also suspect UTI in the presence of diarrhea, strong-smelling urine, abdominal or flank pain, and new onset urinary incontinence.1

Treatment recommendations, which are age-dependent, include antibiotic therapy initiated upon an abnormal dipstick/urinalysis. If a urine culture is positive, a seven- to 14-day course of antibiotic therapy is recommended, followed by prophylactic antibiotics until results of imaging studies are available.1 According to a study by Hoberman and Wald, treatment of UTI with oral antibiotics alone is generally effective, even for young children with pyelonephritis.2

Imaging recommendations for a first UTI include ultrasound, cystogram, and renal cortical scan.

Up to this point, there’s been very little disagreement about the management of UTI. However, the question of whether the one-month-old patient in our scenario should be admitted or sent home with strict instructions on the administration of antibiotics remains controversial. The pediatric UTI guideline from Cincinnati Children’s Hospital Medical Center recommends routine hospital admission if the infant is under 30 days old.1 On the other hand, Santen and Altieri, among others, recommend, “Sick children and infants less than three months should be treated as inpatients, and healthy children and older infants may be treated as outpatients.”3,4

The Set-Up

We asked several pediatric hospitalists across the country—including an instructor of pediatrics at Cincinnati Children’s Hospital Medical Center—to respond to this simple scenario, posing the following questions: “What recommendation would you follow? Would you admit the one-month-old infant in our scenario or send her home? Why?”

Predictably, admission criteria varied, but most agreed that this infant should be admitted. No one based their response on age.

Automatic Admission Cut-off Not Well Supported

Jeffrey M. Simmons, MD, instructor of pediatrics, Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center, responds: “My perspective on the UTI scenario is that the only dogma that applies is that the infant needs antibiotics. Because [the scenario] mentions vomiting, I would, therefore, most likely give parenteral antibiotics and admit.

“An issue within this scenario that I don’t believe the literature answers clearly is once a UTI is identified by the U/A, what risk remains of bacteremia or meningitis in the over 30-day-old infant? We are taught that infants don’t ‘localize’ infections well (i.e., a serious bacterial infection in one place can rapidly lead to disseminated infection). I sense a growing consensus that after 30 days or so this concern is less at issue. However, for clarity, I would prefer to obtain blood and CSF cultures on this infant prior to initiating antibiotic therapy. Without those cultures, and the screening tests that go with them (i.e., serum WBC count, CSF cell count, and glucose), I would be uncomfortable sending the infant home.

“However, if the WBC count was between 5 and 15, the CSF reassuring, the parents in agreement and reliable with good primary care follow-up the next morning, I think such an infant could be managed with one dose of IV/IM antibiotics after cultures are obtained and sent home. The following day, depending on culture results and the clinical situation, this infant might either be admitted, given another dose of parenteral antibiotics pending final blood culture, or switched to oral antibiotics.

“Such a plan is complex, so if the primary care physician or family was at all uncomfortable, admission to accomplish that plan would clearly be appropriate.

“A final issue not adequately addressed within the scenario is an assessment of the infant’s hydration—potentially an issue due to the vomiting. If the infant was mildly to moderately dehydrated with persistent vomiting, I would also then admit until this improved.

“In regard to the cited evidence, I would say that clearly an arbitrary cut-off of automatic admission under three months is not well supported by current literature, but is certainly many practitioners’ ‘style.’ Oral antibiotics are clearly efficacious for pyelonephritis, but the clinician needs to be confident the family can give them and the infant will keep them down. I believe most practitioners would agree with admission for an infant under 30 days, but where to precisely draw that line needs to be better established through investigation. Potential concomitant bacteremia and meningitis lead me to support obtaining blood and CSF cultures on any infant under 60 days for which I plan to initiate antibiotics for UTI.”

Possibility of Dehydration Indicates Admission

Michael P. Fullmer, DO, Central Iowa Pediatric Hospitalists, Mercy Medical Center, Des Moines, Iowa, responds: “This patient is not febrile, but does have other systemic symptoms, including poor feeding, irritability, jaundice, and vomiting. These systemic symptoms could be indicative of a serious bacterial infection like UTI, bacteremia, or meningitis. This patient most likely has a UTI. These symptoms may suggest pyelonephritis rather than lower UTI, but the distinction is not necessary for our decision here.

“Bacteremia is present in up to 22.7% of infants less than two months old with a UTI. This adds to the complexity of the issue, and a blood culture is probably indicated. Meningitis should be considered, but a lumbar puncture is probably not indicated in this scenario.

“A one-month-old with a UTI should be admitted to the hospital and started on parenteral antibiotics. There are several reasons for admission. First, the presence of vomiting makes oral antibiotic administration impractical (if not impossible). Intramuscular antibiotic injection may be an option, but the IV route gives the provider more options and is usually better accepted by parents. Next, if the patient is not already dehydrated, the poor feeding and vomiting could lead to dehydration. This alone would be an indication for admission. Finally, admission would give the physician time to observe the infant for clinical improvement. This may be subtle in the absence of fever.

“Another consideration is the recommended imaging for all children less than two years old. The AAP has recommended a renal ultrasound and VCUG for all infants and young children with their first UTI. This is important for discovery of urinary tract anomalies that predispose the patient to recurrent UTIs and eventual renal scarring and dysfunction. The imaging should be performed at the earliest convenient time if the patient is responding to therapy. In our practice, we generally have the renal ultrasound performed while the patient is in the hospital and arrange the VCUG as an outpatient [exam] prior to completion of the course of antibiotics.

“Patients are discharged when they are afebrile for 24 hours, have adequate oral intake and are able to take oral antibiotics. Please refer to the AAP Clinical Practice Guideline for more detail.5,6

Admission Criteria Must Take Fever Into Account

John W. Graef, MD, chief, Services Office at Children’s Hospital, Harvard Vanguard Services Office, Boston, responds: “The presence or absence of fever is an important variable. Dipstick urines are shortcuts and don’t provide such information as the presence or absence of casts, although the fact that the child is vomiting and irritable is suggestive of pyelonephritis as opposed to a simple UTI/cystitis. [The scenario doesn’t] mention how the urine is obtained. Presumably it is a cath specimen, but that needs to be specified.

“Jaundice can occur with a UTI, but usually in the first week or so of life. A 32-day-old infant with pyelo is unlikely to be jaundiced unless for some other reason.

“I certainly agree with routine admission of a febrile infant up to one month, but not necessarily an otherwise well female infant. The presence of vomiting and irritability with or without fever might prompt a full septic work-up, in which case the decision to admit an afebrile infant would depend on the results of the CBC/UA and probably an LP. A blood culture and CBC should be drawn in the ED.

“In other words, one can’t have it both ways. If the irritability and vomiting are due to pyelo, a septic work-up is warranted. If all parameters are normal, the only reason for admission is hydration of a vomiting infant. If the infant was afebrile and had an uncomplicated UTI, I would not automatically admit an otherwise well 32-day-old.

“Poor PO (per OS, i.e., oral, by mouth) intake in an infant with a UTI warrants IV fluid regardless of age.”

True Emesis With Decreased Oral Intake Indicates Admission

Erin R. Stucky, MD, pediatric hospitalist, Children’s Hospital and Health Center San Diego, associate professor, UCSD Pediatrics, responds: “The decision to admit or discharge this one-month-old with vomiting, jaundice, poor eating, and irritability should include consideration of hydration status, toxicity, sepsis potential, and ability to secure close follow-up. We will make the assumption that the infant is term, with no past medical history, family history, or prenatal evaluation that would put the infant at greater risk for sepsis or likelihood of underlying anatomic genitourinary abnormality. In addition we will assume that the urinalysis was performed by catheterization in a non-pretreated infant.

“A careful history should elicit the change in urine output, frequency, and volume of emesis to contrast with small ‘spit-ups,’ and change in feeding duration or volume. Observation of a feeding in the office or emergency department can be of great value in determining likelihood of ability to maintain hydration at home. Feeding type should be confirmed [because] parents may dilute or alternately concentrate formula in response to vomiting. In this scenario, true emesis in an infant with decreased oral intake would be grounds for admission, intravenous hydration, and evaluation of electrolytes.

“A newly irritable infant evokes a visceral sensation for all pediatric hospitalists. An irritable one-month-old may be suffering from a single system infection, electrolyte imbalance, or other insult, but unfortunately may just as easily have multisystem involvement. Vital signs and physical exam findings of toxicity, such as tachycardia and delayed capillary refill, are not known to us. The presence of jaundice raises concern for cholestasis induced by E. coli or possibly rarer metabolic disease, such as galactosemia. Admission would allow for evaluation and monitoring of the more likely causes of irritability in our index patient, which include sepsis, meningitis, and electrolyte and acid-base imbalances.

“The urinalysis in this infant is suggestive of a urinary tract infection, although infants may have no abnormalities noted on initial urinalysis.7,8 The risk of bacteremia in infants under 60 days with documented urinary tract infection is significant. A number of studies support the need to treat infants less than 30 days with parenteral antibiotics.9-14 Addition of C-reactive protein testing at this time does not aid in distinguishing those who are bacteremic in this age group.15 The often quoted study by Hoberman of 306 children included only 13 under the age of two months.16 Of the 13 reported positive blood cultures, 10 were in children under age six months. Daily intramuscular ceftriaxone treatment would cover a majority of the typical neonatal UTI organisms, can be administered in the outpatient setting, and is proven to be as effective as intravenous delivery. The clinical response to bacteremia is, however, unpredictable in young infants. The sepsis potential in this infant requires admission for physiologic monitoring and support as needed.

“Final, but not inconsequential, concerns are barriers to follow-up. These include parental experience and coping skills with feeding and monitoring an ill infant, ability to educate on the illness and reasons for follow-up, transportation, and operational issues, such as weekend clinic hours or holiday office closures. For the index patient these issues are overshadowed by the clinical criteria for admission but would be of great importance for discharge.”

Conclusion

Based on these responses, admitting a suspected UTI patient on the basis of age alone, as suggested by Santen and Altieri, is likely inappropriate. Many other factors must be weighed and would likely indicate admission for the patient in the scenario, regardless of the infant’s age. In short, until there’s better evidence for age-based admission criteria, clinical judgment based on the individual patient presentation must continue to drive care and treatment decisions.

Keri Losavio is a medical journalist with more than 10 years’ experience.

References

1. UTI Guideline Team, Cincinnati Children’s Hospital Medical Center. “Evidence based clinical practice guideline for children 12 years of age or less with acute first time urinary tract infection.” www.cincinnatichildrens.org/svc/dept-div/health-policy/ev-based/uti.htm. Guideline 7, pages 1–20, April 2005.
2. Hoberman A, Wald ER. Treatment of urinary tract infections. Pediatr Infect Dis J. 1999;18(11):1020–1021.
3. Santen SA, Altieri MF. Pediatric urinary tract infection. Emerg Med Clin North Am. 200119(3):675–690.
4. Egland AG, Egland TK. Pyelonephritis. eMedicine. www.emedicine.com/emerg/topic769.htm. Accessed Oct. 16, 2005.
5. No authors listed. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. American Academy of Pediatrics. Committee on Quality Improvement. Subcommittee on Urinary Tract Infection. Pediatrics. 1999;103(4):843–852.
6. Pitetti RD, Choi S. Utility of blood cultures in febrile children with UTI. Am J Emerg Med. 2002;20:271–274.
7. Dayan PS, Bennett J, Best R, et al. Test characteristics of the urine Gram stain in infants 60 days of age with fever. Pediatr Emerg Care. 2002;18(1):12–14.
8. Huicho L, Campos-Sanchez M, Alamo C. Meta-analysis of urine screening tests for determining the risk of urinary tract infection in children. Pediatr Infect Dis J. 2002;21 (1):1-11.
9. Byington C L, Enriquez F, Hoff C, et al. Serious bacterial infections in febrile infants 1 to 90 days old with and without viral infections. Pediatrics. 2004; 113(6):1662–1666.
10. Baraff L. Management of fever without source in infants and children. Ann Emerg Med. 2000;36(6):602–614.
11. Baraff LJ, Oslund SA, Schriger DL, Stephen ML. Probability of bacterial infections in febrile infants less than three months of age: A meta-analysis. Pediatr Infect Dis J. 1992;11(4):257–264.
12. Klein JO. Management of the febrile child without a focus of infection in the era of universal pneumococcal immunization. Pediatr Infect Dis J. 2002;21(6):584–588.
13. Syrogiannopoulos G, Grieva I, Anastassiou E, et al. Sterile cerebrospinal fluid pleocytosis in young infants with urinary tract infections. Pediatr Infect Dis J. 2001;20(10):927–930.
14. Jaskiewicz JA, McCarthy CA, Richardson AC, et al. Febrile infants at low risk for serious bacterial infection—an appraisal of the Rochester criteria and implications for management. Febrile Collaborative Study Group. Pediatrics. 1994;94(3):390–396.
15. Malik A, Hui C, Pennie RA, Kirpalani H. Beyond the complete blood cell count and C-reactive protein: A systematic review of modern diagnostic tests for neonatal sepsis. Arch Pediatr Adolesc Med. 2003;157(6):511–516.
16. Hoberman A, Wald ER, Hickey RW, et al. Oral versus intravenous therapy for urinary tract Infections in young children. Pediatrics.1999;104:79–86

PEDIATRIC SPECIAL SECTION

IN THE LITERATURE

Utilize Clinical and Demographic Factors to Diagnose UTIs in Young Febrile Infants

Review by Sara E. Gardner, MD

Zorc JJ, Levine DA, Platt SL, et al. Clinical and demographic factors associated with urinary tract infections in young febrile infants. Pediatrics. 2000;116(3):644-648.

UTI is a common cause of serious bacterial infection in the febrile infant <60 days of age. Standard urinalysis and urine dipstick techniques, commonly used to diagnose UTI, have relatively low sensitivity increasing the possibility of a missed diagnosis. An accurate initial diagnosis is critical in this age group for whom complications from UTI include bacteremia and renal scarring.

To describe the demographic and clinical factors associated with UTI in infants ≤60 days of age with fever, these authors conducted a prospective cross sectional study from October 1999 to March 2001. Patients were enrolled at eight different institutions after presentation to an emergency department. One-thousand-twenty-five patients age 60 days or younger (mean age 35.5 days, 60.5% male) were enrolled with either reported or documented fever >38. Routine testing for all children included respiratory syncytial virus (RSV) sampling and bladder catheterization or suprapubic aspiration for urinalysis and culture.

A positive urinalysis was defined as a trace or greater result for leukocyte esterase and/or nitrite on dipstick or greater than or equal to five WBCs per high power field (hpf) on urine microscopy. UTI was defined as growth of a single pathogen of ≥1,000 colony forming units (cfu)/mL for urine cultures obtained by suprapubic catheterization, ≥50,000 cfu/mL from a catheterized specimen, or ≥10,000 cfu/ml from a catheterized specimen with a positive urinalysis.

Of the patients enrolled in the study, 92 were found to have UTI by these diagnostic criteria. Using the chi-squared test and calculated odds ratios with 95% confidence intervals, uncircumcised male (OR: 10.4; 95% CI: 4.7-31.4) and maximum temperature of ≥39º C (OR: 2.4 per degree C; 95% CI: 1.5-3.6) were found to be statistically significant variables for predicting UTI. These risk factors remained statistically significant after multivariable analysis controlling for other factors.

Interestingly of the above 92 patients diagnosed with UTI, 85 grew ≥50,000 cfu of a single pathogen, but six (8%) grew 10,000-49,000 cfu with a positive UA based on the study criteria. Zorc, et al. included these patients with >10,000 cfu and >5 WBC/hpf in this study despite previous studies that have established a definition of positive urinalysis to be ≥10 WBC/hpf. Zorc, et al. acknowledge the conservative definition applied in their current study, but assert that the overall results of the study would have been similar had 10,000 or 50,000 cfu/mL thresholds been chosen. To support this assertion, Zorc, et al. retrospectively applied enhanced urinalysis, a sensitive form of urinalysis including hemocytometric cell count and gram stain described by Hoberman, et al. to study patients with low bacteria counts. Based on Hoberman’s study, enhanced urinalysis can differentiate acute infection from asymptomatic bacteriuria in patients with bacterial growth between 10,000 to 50,000 cfu/mL.

Another significant limitation of this study was failure to enroll one-third of eligible patients to the study. In addition, the authors note that missed patients had a lower rate of UTI compared with enrolled patients.

Although this study design prohibits generalization to patient care areas outside the emergency department, the findings can assist the hospitalist in the evaluation of the febrile infant during RSV season and potentially guide decisions regarding empiric antibiotic therapy as part of evaluations to diagnose or exclude serious bacterial infection. Additionally, this study raises the question of need for better methods of urinalysis for febrile, uncircumcised male infants.

Back to the Basics: A Clinical Approach to Excluding Acute Appendicitis

Review by Jane G. Buss, MD

Kharbanda AB, Taylor GA, Fishman SJ, et al. A clinical decision rule to identify children at low risk for appendicitis. Pediatrics. 2005;116(3):709-16.

Appendicitis is the most common condition requiring emergency abdominal surgery in the pediatric population. To diagnosis appendicitis, clinicians typically utilize clinical findings, imaging studies, and laboratory testing. The use of clinical scoring systems to improve the diagnosis of appendicitis in children has been limited, mostly resulting from unacceptably low sensitivities/specificities, or the lack of validation. The use of CT scan to aid in the evaluation of children with appendicitis has become widespread. Concerns remain, however, regarding long-term radiation effects and increased healthcare costs associated with this approach.

The authors of this study sought to develop clinical scores for children to predict which of those with acute abdominal pain do not have appendicitis. Additionally, they hoped to lessen the use of CT scanning. Their goal was to identify those groups of children who have significant abdominal pain without appendicitis who could be safely observed without CT scan or possible surgery.

This prospective cohort study enrolled 601 eligible children ages three to 18 with suspected appendicitis who presented to the emergency department over a 15-month period. Two low-risk clinical decision rules were developed using logistic regression and recursive partitioning. Using logistic regression, six factors were identified from analysis of 425 patients in the derivation set significantly associated with an increased likelihood of appendicitis. The score components include:

1. Nausea (2 points);
2. History of focal right lower quadrant pain (RLQ) (2 points);
3. Migration of pain (1 point);
4. Difficulty walking (1 point);
5. Rebound tenderness (2 points); and
6. Absolute neutrophil count (ANC) >6.75 x 103/uL (6 points).

When tested with data from the 176 patients in the validation set, a score of less than or equal to five had a sensitivity of 96.3%, and a negative predictive value of 95.6% for excluding appendicitis.

The authors then derived a second clinical low-risk decision rule by recursive partitioning. They determined that a combination of ANC <6.75 X 10 to the third/microliter, absence of nausea (or emesis or anorexia), and absence of maximal tenderness in the RLQ essentially excluded appendicitis in the derivation and validation groups. This rule had a sensitivity of 98.1%, and a negative predictive value of 97.5%.

In summary, these authors derived two clinical decision rules giving the clinician the option of a clinical score (logistic regression) or a decision tree (recursive partitioning) to identify children at low risk for appendicitis. Their findings suggest application of either low-risk rule would lead to decreased reliance on CT scan. Applying these clinical rules to their patients could have reduced the rate of CT scan by 20%. They conclude that pediatric patients who have suspected appendicitis and are at low risk by either model should be considered for observation rather than undergo CT scan or operative care.

Epidemiology of Fungal Infection in the Tertiary Care Inpatient Setting

Review by Brandan P. Kennedy, MD

Abelson, JA, Moore T, Bruckner D, et al. Frequency of fungemia in hospitalized pediatric inpatients over 11 years at a tertiary care institution. Pediatrics. 2005;116(1):611-617.

Fungal organisms are relatively uncommon causes of blood infections in the pediatric population. When they do occur, they cause significant morbidity and mortality. The incidence of fungal blood infections appears to be rising at a faster rate than that of other pathogens. Authors from the University of California performed this study to describe those rate changes, and to evaluate whether treatment has improved in the past 11 years.

This retrospective cohort study involved children admitted to Mattel Children’s Hospital in Los Angeles, California, during an 11-year period from January 1991 to December 2001. Information obtained on all positive fungal cultures from all body sites included date and site of culture, demographics, and fungal etiology. Additionally, data regarding underlying illness, hospital course, outcome, and antimicrobial treatment were considered.

Study results demonstrated a significant increase in diagnosed fungemia in children. There was a 15% increase in overall pediatric admissions in the study period, and a 23% increase in positive fungal cultures in the same period. Of 272 blood cultures, 97 were positive for fungus. Although this is a relatively small number of total infections, data demonstrated a 91% increase in fungemia during the study period. Candida species were the organisms most frequently isolated from any body site with 85% of the total isolates. Of the total positive isolates, it appeared that approximately 78% reflected colonization as opposed to infection.

Outcomes for fungal infections improved only marginally in the study period. Fifty percent of patients with fungemia died between 1991 and 1996, and 45% died between 1997 and 2001. The mortality rate for immunocompromised conditions was 57%. The cost effectiveness of fungal screening cultures was also evaluated, which demonstrated that fungal cultures identified 14 patients independent of bacterial blood cultures at a cost of $560,000, which resulted in a cost of $40,000 per identified patient.

The study reaches several significant conclusions. First there has been a significant increase in fungal infections that exceeds the increase in overall pediatric hospital admissions. However, it is important to recognize the increase in immunocompromised conditions during the study period, which may account for the higher incidence of fungemia.

Second the addition of fungal blood cultures to bacterial blood cultures as part of a routine workup for febrile patients appeared to yield limited clinical information at a very high cost. Third this study highlights the serious threat fungal infections pose to immunocompromised hosts who have a significantly higher incidence of infection, as well as higher morbidity and mortality. Fourth the use of broad spectrum antibiotics may be increasing fungal colonization in patients and consequently increasing the risk for pathologic fungal infection. Finally morbidity and mortality rates for fungal infections did not greatly improve, despite significant improvements in supportive care made during the study period

This study demonstrates a need for better diagnostic markers for fungal infections, especially those that might provide earlier detection and diagnosis at less cost. The importance of judicious use of antibiotics is underscored while the need for a broader base of therapeutic agents is highlighted. These issues may be key ingredients needed to reduce adverse outcomes from fungal infections, especially in the immunocompromised host.

Rotavirus Vaccine Revisited

Salinas B, Perez Schael I, Linhares AC, et al. Evaluation of safety, immunogenicity and efficacy of an attenuated rotavirus vaccine, RIX4414. Ped Infect Dis J. 2005;24(9):807-816.

Rotavirus is the leading cause of severe gastroenteritis among children worldwide. In the United States, rotavirus is responsible for approximately 5%-10% of all diarrhea among children older than five and accounts for approximately 50,000 hospitalizations each year. An estimated one in 200,000 children with rotavirus diarrhea dies from complications of infection. The immunizing effect of rotavirus infection stimulated the development of live attenuated vaccines. In 1998, a three-dose regimen of a tetravalent rhesus-human reassortant vaccine (RotaShield: Wyeth Laboratories,) was licensed for infant immunization in the United States. Within the first year of use, it was withdrawn due to an observed risk of intussusception. The current study was designed to evaluate immunogenicity and efficacy of a live attenuated monovalent human rotavirus vaccine, RIX4414.

A double-blind, randomized, placebo-controlled design was utilized with the RIX4414 rotavirus vaccine administered at three different virus concentrations. Infants were randomly assigned to one of the three study groups or the placebo group. Infants in the vaccine groups received two oral doses of the vaccine at the age of two and four months. An identical placebo containing the same constituents as the vaccine except for the vaccine virus was used as the control. The vaccine was given concomitantly with other routine vaccinations. To determine immunogenicity, blood samples were obtained from all infants immediately before the first vaccination to exclude previous rotavirus infection. Blood samples were obtained two months after the first second vaccine doses and again at one year to measure anti-rotavirus IgA antibodies. Additionally, stool was obtained from 25% of the study sample and tested for rotavirus viral shedding, with differentiation between wild type and vaccine also being performed.

There were 2,155 infants enrolled in this study from three countries in South America, allowing for slightly more than 500 infants in each group. The study began in May 2001, and the final one-year follow-up was completed in April 2003. The anti-rotavirus IgA seroconversion rates two months after first and second doses were 38%-43% and 61%-65%, respectively. This compared with a 5.3% seroconversion rate in the control group, which was determined to be a wild type virus. Vaccine take after two doses was shown in all three vaccine study groups, ranging from 65% to 75% for the lowest to highest vaccine concentration groups. Reactogenicity and safety was evaluated by monitoring incidences of fever, diarrhea, vomiting, irritability, and loss of appetite during the 15 days after vaccine administration. The results were similar for the four study groups suggesting no significant reactogenicity. There were 220 serious adverse events reported including one intussusception. However, none of these events was determined to be related to the vaccine. The RIX4414 vaccine was demonstrated to effectively protect against severe gastroenteritis caused by G1 type rotavirus and also was shown to provide some cross protection to other serotypes.

This well-designed study demonstrated a statistically significant reduction in gastroenteritis due to rotavirus infection, especially of the predominant G1 serotype, after two doses of the RIX4414 human rotavirus vaccine. Objective measures of viral shedding and IgA seroconversion support the efficacy of the vaccine. This study provided a large sample population with good controls.

An important and possibly confounding variable not addressed by the study was breastfeeding status of the infants. There is clinical evidence demonstrating the protective properties of secretory IgA in human milk against rotavirus infection, and this could have influenced the observed severity of disease in the sample population. It would have been interesting to isolate breastfeeding status as a study variable and note any effect on the results of the study.

Aside from this observation, this study appears to show a promising new oral rotavirus vaccine. As further research on the RIX4414 vaccine continues, there is hope that this vaccine could make a significant positive impact on morbidity and hospitalization rates for rotavirus infections worldwide. TH

Scenario: A 32-day-old female presents with vomiting and jaundice, and the mother reports that the child is irritable and not eating as well as usual. The pediatric hospitalist suspects a UTI and orders a dipstick/urinalysis and urine culture. The dipstick/urinalysis results are positive for nitrite and leukocyte esterase, indicating antibiotic therapy for presumed UTI.

Introduction

UTI is one of the most common bacterial infections in infants and young children. To prevent progression to pyelonephritis and avoid potential renal scarring or failure, early recognition and prompt treatment are critical.

Clinical signs and symptoms of UTI in newborns include jaundice, sepsis, failure to thrive, poor feeding, vomiting, and fever. In infants and preschoolers, hospitalists should also suspect UTI in the presence of diarrhea, strong-smelling urine, abdominal or flank pain, and new onset urinary incontinence.1

Treatment recommendations, which are age-dependent, include antibiotic therapy initiated upon an abnormal dipstick/urinalysis. If a urine culture is positive, a seven- to 14-day course of antibiotic therapy is recommended, followed by prophylactic antibiotics until results of imaging studies are available.1 According to a study by Hoberman and Wald, treatment of UTI with oral antibiotics alone is generally effective, even for young children with pyelonephritis.2

Imaging recommendations for a first UTI include ultrasound, cystogram, and renal cortical scan.

Up to this point, there’s been very little disagreement about the management of UTI. However, the question of whether the one-month-old patient in our scenario should be admitted or sent home with strict instructions on the administration of antibiotics remains controversial. The pediatric UTI guideline from Cincinnati Children’s Hospital Medical Center recommends routine hospital admission if the infant is under 30 days old.1 On the other hand, Santen and Altieri, among others, recommend, “Sick children and infants less than three months should be treated as inpatients, and healthy children and older infants may be treated as outpatients.”3,4

The Set-Up

We asked several pediatric hospitalists across the country—including an instructor of pediatrics at Cincinnati Children’s Hospital Medical Center—to respond to this simple scenario, posing the following questions: “What recommendation would you follow? Would you admit the one-month-old infant in our scenario or send her home? Why?”

Predictably, admission criteria varied, but most agreed that this infant should be admitted. No one based their response on age.

Automatic Admission Cut-off Not Well Supported

Jeffrey M. Simmons, MD, instructor of pediatrics, Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center, responds: “My perspective on the UTI scenario is that the only dogma that applies is that the infant needs antibiotics. Because [the scenario] mentions vomiting, I would, therefore, most likely give parenteral antibiotics and admit.

“An issue within this scenario that I don’t believe the literature answers clearly is once a UTI is identified by the U/A, what risk remains of bacteremia or meningitis in the over 30-day-old infant? We are taught that infants don’t ‘localize’ infections well (i.e., a serious bacterial infection in one place can rapidly lead to disseminated infection). I sense a growing consensus that after 30 days or so this concern is less at issue. However, for clarity, I would prefer to obtain blood and CSF cultures on this infant prior to initiating antibiotic therapy. Without those cultures, and the screening tests that go with them (i.e., serum WBC count, CSF cell count, and glucose), I would be uncomfortable sending the infant home.

“However, if the WBC count was between 5 and 15, the CSF reassuring, the parents in agreement and reliable with good primary care follow-up the next morning, I think such an infant could be managed with one dose of IV/IM antibiotics after cultures are obtained and sent home. The following day, depending on culture results and the clinical situation, this infant might either be admitted, given another dose of parenteral antibiotics pending final blood culture, or switched to oral antibiotics.

“Such a plan is complex, so if the primary care physician or family was at all uncomfortable, admission to accomplish that plan would clearly be appropriate.

“A final issue not adequately addressed within the scenario is an assessment of the infant’s hydration—potentially an issue due to the vomiting. If the infant was mildly to moderately dehydrated with persistent vomiting, I would also then admit until this improved.

“In regard to the cited evidence, I would say that clearly an arbitrary cut-off of automatic admission under three months is not well supported by current literature, but is certainly many practitioners’ ‘style.’ Oral antibiotics are clearly efficacious for pyelonephritis, but the clinician needs to be confident the family can give them and the infant will keep them down. I believe most practitioners would agree with admission for an infant under 30 days, but where to precisely draw that line needs to be better established through investigation. Potential concomitant bacteremia and meningitis lead me to support obtaining blood and CSF cultures on any infant under 60 days for which I plan to initiate antibiotics for UTI.”

Possibility of Dehydration Indicates Admission

Michael P. Fullmer, DO, Central Iowa Pediatric Hospitalists, Mercy Medical Center, Des Moines, Iowa, responds: “This patient is not febrile, but does have other systemic symptoms, including poor feeding, irritability, jaundice, and vomiting. These systemic symptoms could be indicative of a serious bacterial infection like UTI, bacteremia, or meningitis. This patient most likely has a UTI. These symptoms may suggest pyelonephritis rather than lower UTI, but the distinction is not necessary for our decision here.

“Bacteremia is present in up to 22.7% of infants less than two months old with a UTI. This adds to the complexity of the issue, and a blood culture is probably indicated. Meningitis should be considered, but a lumbar puncture is probably not indicated in this scenario.

“A one-month-old with a UTI should be admitted to the hospital and started on parenteral antibiotics. There are several reasons for admission. First, the presence of vomiting makes oral antibiotic administration impractical (if not impossible). Intramuscular antibiotic injection may be an option, but the IV route gives the provider more options and is usually better accepted by parents. Next, if the patient is not already dehydrated, the poor feeding and vomiting could lead to dehydration. This alone would be an indication for admission. Finally, admission would give the physician time to observe the infant for clinical improvement. This may be subtle in the absence of fever.

“Another consideration is the recommended imaging for all children less than two years old. The AAP has recommended a renal ultrasound and VCUG for all infants and young children with their first UTI. This is important for discovery of urinary tract anomalies that predispose the patient to recurrent UTIs and eventual renal scarring and dysfunction. The imaging should be performed at the earliest convenient time if the patient is responding to therapy. In our practice, we generally have the renal ultrasound performed while the patient is in the hospital and arrange the VCUG as an outpatient [exam] prior to completion of the course of antibiotics.

“Patients are discharged when they are afebrile for 24 hours, have adequate oral intake and are able to take oral antibiotics. Please refer to the AAP Clinical Practice Guideline for more detail.5,6

Admission Criteria Must Take Fever Into Account

John W. Graef, MD, chief, Services Office at Children’s Hospital, Harvard Vanguard Services Office, Boston, responds: “The presence or absence of fever is an important variable. Dipstick urines are shortcuts and don’t provide such information as the presence or absence of casts, although the fact that the child is vomiting and irritable is suggestive of pyelonephritis as opposed to a simple UTI/cystitis. [The scenario doesn’t] mention how the urine is obtained. Presumably it is a cath specimen, but that needs to be specified.

“Jaundice can occur with a UTI, but usually in the first week or so of life. A 32-day-old infant with pyelo is unlikely to be jaundiced unless for some other reason.

“I certainly agree with routine admission of a febrile infant up to one month, but not necessarily an otherwise well female infant. The presence of vomiting and irritability with or without fever might prompt a full septic work-up, in which case the decision to admit an afebrile infant would depend on the results of the CBC/UA and probably an LP. A blood culture and CBC should be drawn in the ED.

“In other words, one can’t have it both ways. If the irritability and vomiting are due to pyelo, a septic work-up is warranted. If all parameters are normal, the only reason for admission is hydration of a vomiting infant. If the infant was afebrile and had an uncomplicated UTI, I would not automatically admit an otherwise well 32-day-old.

“Poor PO (per OS, i.e., oral, by mouth) intake in an infant with a UTI warrants IV fluid regardless of age.”

True Emesis With Decreased Oral Intake Indicates Admission

Erin R. Stucky, MD, pediatric hospitalist, Children’s Hospital and Health Center San Diego, associate professor, UCSD Pediatrics, responds: “The decision to admit or discharge this one-month-old with vomiting, jaundice, poor eating, and irritability should include consideration of hydration status, toxicity, sepsis potential, and ability to secure close follow-up. We will make the assumption that the infant is term, with no past medical history, family history, or prenatal evaluation that would put the infant at greater risk for sepsis or likelihood of underlying anatomic genitourinary abnormality. In addition we will assume that the urinalysis was performed by catheterization in a non-pretreated infant.

“A careful history should elicit the change in urine output, frequency, and volume of emesis to contrast with small ‘spit-ups,’ and change in feeding duration or volume. Observation of a feeding in the office or emergency department can be of great value in determining likelihood of ability to maintain hydration at home. Feeding type should be confirmed [because] parents may dilute or alternately concentrate formula in response to vomiting. In this scenario, true emesis in an infant with decreased oral intake would be grounds for admission, intravenous hydration, and evaluation of electrolytes.

“A newly irritable infant evokes a visceral sensation for all pediatric hospitalists. An irritable one-month-old may be suffering from a single system infection, electrolyte imbalance, or other insult, but unfortunately may just as easily have multisystem involvement. Vital signs and physical exam findings of toxicity, such as tachycardia and delayed capillary refill, are not known to us. The presence of jaundice raises concern for cholestasis induced by E. coli or possibly rarer metabolic disease, such as galactosemia. Admission would allow for evaluation and monitoring of the more likely causes of irritability in our index patient, which include sepsis, meningitis, and electrolyte and acid-base imbalances.

“The urinalysis in this infant is suggestive of a urinary tract infection, although infants may have no abnormalities noted on initial urinalysis.7,8 The risk of bacteremia in infants under 60 days with documented urinary tract infection is significant. A number of studies support the need to treat infants less than 30 days with parenteral antibiotics.9-14 Addition of C-reactive protein testing at this time does not aid in distinguishing those who are bacteremic in this age group.15 The often quoted study by Hoberman of 306 children included only 13 under the age of two months.16 Of the 13 reported positive blood cultures, 10 were in children under age six months. Daily intramuscular ceftriaxone treatment would cover a majority of the typical neonatal UTI organisms, can be administered in the outpatient setting, and is proven to be as effective as intravenous delivery. The clinical response to bacteremia is, however, unpredictable in young infants. The sepsis potential in this infant requires admission for physiologic monitoring and support as needed.

“Final, but not inconsequential, concerns are barriers to follow-up. These include parental experience and coping skills with feeding and monitoring an ill infant, ability to educate on the illness and reasons for follow-up, transportation, and operational issues, such as weekend clinic hours or holiday office closures. For the index patient these issues are overshadowed by the clinical criteria for admission but would be of great importance for discharge.”

Conclusion

Based on these responses, admitting a suspected UTI patient on the basis of age alone, as suggested by Santen and Altieri, is likely inappropriate. Many other factors must be weighed and would likely indicate admission for the patient in the scenario, regardless of the infant’s age. In short, until there’s better evidence for age-based admission criteria, clinical judgment based on the individual patient presentation must continue to drive care and treatment decisions.

Keri Losavio is a medical journalist with more than 10 years’ experience.

References

1. UTI Guideline Team, Cincinnati Children’s Hospital Medical Center. “Evidence based clinical practice guideline for children 12 years of age or less with acute first time urinary tract infection.” www.cincinnatichildrens.org/svc/dept-div/health-policy/ev-based/uti.htm. Guideline 7, pages 1–20, April 2005.
2. Hoberman A, Wald ER. Treatment of urinary tract infections. Pediatr Infect Dis J. 1999;18(11):1020–1021.
3. Santen SA, Altieri MF. Pediatric urinary tract infection. Emerg Med Clin North Am. 200119(3):675–690.
4. Egland AG, Egland TK. Pyelonephritis. eMedicine. www.emedicine.com/emerg/topic769.htm. Accessed Oct. 16, 2005.
5. No authors listed. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. American Academy of Pediatrics. Committee on Quality Improvement. Subcommittee on Urinary Tract Infection. Pediatrics. 1999;103(4):843–852.
6. Pitetti RD, Choi S. Utility of blood cultures in febrile children with UTI. Am J Emerg Med. 2002;20:271–274.
7. Dayan PS, Bennett J, Best R, et al. Test characteristics of the urine Gram stain in infants 60 days of age with fever. Pediatr Emerg Care. 2002;18(1):12–14.
8. Huicho L, Campos-Sanchez M, Alamo C. Meta-analysis of urine screening tests for determining the risk of urinary tract infection in children. Pediatr Infect Dis J. 2002;21 (1):1-11.
9. Byington C L, Enriquez F, Hoff C, et al. Serious bacterial infections in febrile infants 1 to 90 days old with and without viral infections. Pediatrics. 2004; 113(6):1662–1666.
10. Baraff L. Management of fever without source in infants and children. Ann Emerg Med. 2000;36(6):602–614.
11. Baraff LJ, Oslund SA, Schriger DL, Stephen ML. Probability of bacterial infections in febrile infants less than three months of age: A meta-analysis. Pediatr Infect Dis J. 1992;11(4):257–264.
12. Klein JO. Management of the febrile child without a focus of infection in the era of universal pneumococcal immunization. Pediatr Infect Dis J. 2002;21(6):584–588.
13. Syrogiannopoulos G, Grieva I, Anastassiou E, et al. Sterile cerebrospinal fluid pleocytosis in young infants with urinary tract infections. Pediatr Infect Dis J. 2001;20(10):927–930.
14. Jaskiewicz JA, McCarthy CA, Richardson AC, et al. Febrile infants at low risk for serious bacterial infection—an appraisal of the Rochester criteria and implications for management. Febrile Collaborative Study Group. Pediatrics. 1994;94(3):390–396.
15. Malik A, Hui C, Pennie RA, Kirpalani H. Beyond the complete blood cell count and C-reactive protein: A systematic review of modern diagnostic tests for neonatal sepsis. Arch Pediatr Adolesc Med. 2003;157(6):511–516.
16. Hoberman A, Wald ER, Hickey RW, et al. Oral versus intravenous therapy for urinary tract Infections in young children. Pediatrics.1999;104:79–86

PEDIATRIC SPECIAL SECTION

IN THE LITERATURE

Utilize Clinical and Demographic Factors to Diagnose UTIs in Young Febrile Infants

Review by Sara E. Gardner, MD

Zorc JJ, Levine DA, Platt SL, et al. Clinical and demographic factors associated with urinary tract infections in young febrile infants. Pediatrics. 2000;116(3):644-648.

UTI is a common cause of serious bacterial infection in the febrile infant <60 days of age. Standard urinalysis and urine dipstick techniques, commonly used to diagnose UTI, have relatively low sensitivity increasing the possibility of a missed diagnosis. An accurate initial diagnosis is critical in this age group for whom complications from UTI include bacteremia and renal scarring.

To describe the demographic and clinical factors associated with UTI in infants ≤60 days of age with fever, these authors conducted a prospective cross sectional study from October 1999 to March 2001. Patients were enrolled at eight different institutions after presentation to an emergency department. One-thousand-twenty-five patients age 60 days or younger (mean age 35.5 days, 60.5% male) were enrolled with either reported or documented fever >38. Routine testing for all children included respiratory syncytial virus (RSV) sampling and bladder catheterization or suprapubic aspiration for urinalysis and culture.

A positive urinalysis was defined as a trace or greater result for leukocyte esterase and/or nitrite on dipstick or greater than or equal to five WBCs per high power field (hpf) on urine microscopy. UTI was defined as growth of a single pathogen of ≥1,000 colony forming units (cfu)/mL for urine cultures obtained by suprapubic catheterization, ≥50,000 cfu/mL from a catheterized specimen, or ≥10,000 cfu/ml from a catheterized specimen with a positive urinalysis.

Of the patients enrolled in the study, 92 were found to have UTI by these diagnostic criteria. Using the chi-squared test and calculated odds ratios with 95% confidence intervals, uncircumcised male (OR: 10.4; 95% CI: 4.7-31.4) and maximum temperature of ≥39º C (OR: 2.4 per degree C; 95% CI: 1.5-3.6) were found to be statistically significant variables for predicting UTI. These risk factors remained statistically significant after multivariable analysis controlling for other factors.

Interestingly of the above 92 patients diagnosed with UTI, 85 grew ≥50,000 cfu of a single pathogen, but six (8%) grew 10,000-49,000 cfu with a positive UA based on the study criteria. Zorc, et al. included these patients with >10,000 cfu and >5 WBC/hpf in this study despite previous studies that have established a definition of positive urinalysis to be ≥10 WBC/hpf. Zorc, et al. acknowledge the conservative definition applied in their current study, but assert that the overall results of the study would have been similar had 10,000 or 50,000 cfu/mL thresholds been chosen. To support this assertion, Zorc, et al. retrospectively applied enhanced urinalysis, a sensitive form of urinalysis including hemocytometric cell count and gram stain described by Hoberman, et al. to study patients with low bacteria counts. Based on Hoberman’s study, enhanced urinalysis can differentiate acute infection from asymptomatic bacteriuria in patients with bacterial growth between 10,000 to 50,000 cfu/mL.

Another significant limitation of this study was failure to enroll one-third of eligible patients to the study. In addition, the authors note that missed patients had a lower rate of UTI compared with enrolled patients.

Although this study design prohibits generalization to patient care areas outside the emergency department, the findings can assist the hospitalist in the evaluation of the febrile infant during RSV season and potentially guide decisions regarding empiric antibiotic therapy as part of evaluations to diagnose or exclude serious bacterial infection. Additionally, this study raises the question of need for better methods of urinalysis for febrile, uncircumcised male infants.

Back to the Basics: A Clinical Approach to Excluding Acute Appendicitis

Review by Jane G. Buss, MD

Kharbanda AB, Taylor GA, Fishman SJ, et al. A clinical decision rule to identify children at low risk for appendicitis. Pediatrics. 2005;116(3):709-16.

Appendicitis is the most common condition requiring emergency abdominal surgery in the pediatric population. To diagnosis appendicitis, clinicians typically utilize clinical findings, imaging studies, and laboratory testing. The use of clinical scoring systems to improve the diagnosis of appendicitis in children has been limited, mostly resulting from unacceptably low sensitivities/specificities, or the lack of validation. The use of CT scan to aid in the evaluation of children with appendicitis has become widespread. Concerns remain, however, regarding long-term radiation effects and increased healthcare costs associated with this approach.

The authors of this study sought to develop clinical scores for children to predict which of those with acute abdominal pain do not have appendicitis. Additionally, they hoped to lessen the use of CT scanning. Their goal was to identify those groups of children who have significant abdominal pain without appendicitis who could be safely observed without CT scan or possible surgery.

This prospective cohort study enrolled 601 eligible children ages three to 18 with suspected appendicitis who presented to the emergency department over a 15-month period. Two low-risk clinical decision rules were developed using logistic regression and recursive partitioning. Using logistic regression, six factors were identified from analysis of 425 patients in the derivation set significantly associated with an increased likelihood of appendicitis. The score components include:

1. Nausea (2 points);
2. History of focal right lower quadrant pain (RLQ) (2 points);
3. Migration of pain (1 point);
4. Difficulty walking (1 point);
5. Rebound tenderness (2 points); and
6. Absolute neutrophil count (ANC) >6.75 x 103/uL (6 points).

When tested with data from the 176 patients in the validation set, a score of less than or equal to five had a sensitivity of 96.3%, and a negative predictive value of 95.6% for excluding appendicitis.

The authors then derived a second clinical low-risk decision rule by recursive partitioning. They determined that a combination of ANC <6.75 X 10 to the third/microliter, absence of nausea (or emesis or anorexia), and absence of maximal tenderness in the RLQ essentially excluded appendicitis in the derivation and validation groups. This rule had a sensitivity of 98.1%, and a negative predictive value of 97.5%.

In summary, these authors derived two clinical decision rules giving the clinician the option of a clinical score (logistic regression) or a decision tree (recursive partitioning) to identify children at low risk for appendicitis. Their findings suggest application of either low-risk rule would lead to decreased reliance on CT scan. Applying these clinical rules to their patients could have reduced the rate of CT scan by 20%. They conclude that pediatric patients who have suspected appendicitis and are at low risk by either model should be considered for observation rather than undergo CT scan or operative care.

Epidemiology of Fungal Infection in the Tertiary Care Inpatient Setting

Review by Brandan P. Kennedy, MD

Abelson, JA, Moore T, Bruckner D, et al. Frequency of fungemia in hospitalized pediatric inpatients over 11 years at a tertiary care institution. Pediatrics. 2005;116(1):611-617.

Fungal organisms are relatively uncommon causes of blood infections in the pediatric population. When they do occur, they cause significant morbidity and mortality. The incidence of fungal blood infections appears to be rising at a faster rate than that of other pathogens. Authors from the University of California performed this study to describe those rate changes, and to evaluate whether treatment has improved in the past 11 years.

This retrospective cohort study involved children admitted to Mattel Children’s Hospital in Los Angeles, California, during an 11-year period from January 1991 to December 2001. Information obtained on all positive fungal cultures from all body sites included date and site of culture, demographics, and fungal etiology. Additionally, data regarding underlying illness, hospital course, outcome, and antimicrobial treatment were considered.

Study results demonstrated a significant increase in diagnosed fungemia in children. There was a 15% increase in overall pediatric admissions in the study period, and a 23% increase in positive fungal cultures in the same period. Of 272 blood cultures, 97 were positive for fungus. Although this is a relatively small number of total infections, data demonstrated a 91% increase in fungemia during the study period. Candida species were the organisms most frequently isolated from any body site with 85% of the total isolates. Of the total positive isolates, it appeared that approximately 78% reflected colonization as opposed to infection.

Outcomes for fungal infections improved only marginally in the study period. Fifty percent of patients with fungemia died between 1991 and 1996, and 45% died between 1997 and 2001. The mortality rate for immunocompromised conditions was 57%. The cost effectiveness of fungal screening cultures was also evaluated, which demonstrated that fungal cultures identified 14 patients independent of bacterial blood cultures at a cost of $560,000, which resulted in a cost of $40,000 per identified patient.

The study reaches several significant conclusions. First there has been a significant increase in fungal infections that exceeds the increase in overall pediatric hospital admissions. However, it is important to recognize the increase in immunocompromised conditions during the study period, which may account for the higher incidence of fungemia.

Second the addition of fungal blood cultures to bacterial blood cultures as part of a routine workup for febrile patients appeared to yield limited clinical information at a very high cost. Third this study highlights the serious threat fungal infections pose to immunocompromised hosts who have a significantly higher incidence of infection, as well as higher morbidity and mortality. Fourth the use of broad spectrum antibiotics may be increasing fungal colonization in patients and consequently increasing the risk for pathologic fungal infection. Finally morbidity and mortality rates for fungal infections did not greatly improve, despite significant improvements in supportive care made during the study period

This study demonstrates a need for better diagnostic markers for fungal infections, especially those that might provide earlier detection and diagnosis at less cost. The importance of judicious use of antibiotics is underscored while the need for a broader base of therapeutic agents is highlighted. These issues may be key ingredients needed to reduce adverse outcomes from fungal infections, especially in the immunocompromised host.

Rotavirus Vaccine Revisited

Salinas B, Perez Schael I, Linhares AC, et al. Evaluation of safety, immunogenicity and efficacy of an attenuated rotavirus vaccine, RIX4414. Ped Infect Dis J. 2005;24(9):807-816.

Rotavirus is the leading cause of severe gastroenteritis among children worldwide. In the United States, rotavirus is responsible for approximately 5%-10% of all diarrhea among children older than five and accounts for approximately 50,000 hospitalizations each year. An estimated one in 200,000 children with rotavirus diarrhea dies from complications of infection. The immunizing effect of rotavirus infection stimulated the development of live attenuated vaccines. In 1998, a three-dose regimen of a tetravalent rhesus-human reassortant vaccine (RotaShield: Wyeth Laboratories,) was licensed for infant immunization in the United States. Within the first year of use, it was withdrawn due to an observed risk of intussusception. The current study was designed to evaluate immunogenicity and efficacy of a live attenuated monovalent human rotavirus vaccine, RIX4414.

A double-blind, randomized, placebo-controlled design was utilized with the RIX4414 rotavirus vaccine administered at three different virus concentrations. Infants were randomly assigned to one of the three study groups or the placebo group. Infants in the vaccine groups received two oral doses of the vaccine at the age of two and four months. An identical placebo containing the same constituents as the vaccine except for the vaccine virus was used as the control. The vaccine was given concomitantly with other routine vaccinations. To determine immunogenicity, blood samples were obtained from all infants immediately before the first vaccination to exclude previous rotavirus infection. Blood samples were obtained two months after the first second vaccine doses and again at one year to measure anti-rotavirus IgA antibodies. Additionally, stool was obtained from 25% of the study sample and tested for rotavirus viral shedding, with differentiation between wild type and vaccine also being performed.

There were 2,155 infants enrolled in this study from three countries in South America, allowing for slightly more than 500 infants in each group. The study began in May 2001, and the final one-year follow-up was completed in April 2003. The anti-rotavirus IgA seroconversion rates two months after first and second doses were 38%-43% and 61%-65%, respectively. This compared with a 5.3% seroconversion rate in the control group, which was determined to be a wild type virus. Vaccine take after two doses was shown in all three vaccine study groups, ranging from 65% to 75% for the lowest to highest vaccine concentration groups. Reactogenicity and safety was evaluated by monitoring incidences of fever, diarrhea, vomiting, irritability, and loss of appetite during the 15 days after vaccine administration. The results were similar for the four study groups suggesting no significant reactogenicity. There were 220 serious adverse events reported including one intussusception. However, none of these events was determined to be related to the vaccine. The RIX4414 vaccine was demonstrated to effectively protect against severe gastroenteritis caused by G1 type rotavirus and also was shown to provide some cross protection to other serotypes.

This well-designed study demonstrated a statistically significant reduction in gastroenteritis due to rotavirus infection, especially of the predominant G1 serotype, after two doses of the RIX4414 human rotavirus vaccine. Objective measures of viral shedding and IgA seroconversion support the efficacy of the vaccine. This study provided a large sample population with good controls.

An important and possibly confounding variable not addressed by the study was breastfeeding status of the infants. There is clinical evidence demonstrating the protective properties of secretory IgA in human milk against rotavirus infection, and this could have influenced the observed severity of disease in the sample population. It would have been interesting to isolate breastfeeding status as a study variable and note any effect on the results of the study.

Aside from this observation, this study appears to show a promising new oral rotavirus vaccine. As further research on the RIX4414 vaccine continues, there is hope that this vaccine could make a significant positive impact on morbidity and hospitalization rates for rotavirus infections worldwide. TH

Scenario: A 32-day-old female presents with vomiting and jaundice, and the mother reports that the child is irritable and not eating as well as usual. The pediatric hospitalist suspects a UTI and orders a dipstick/urinalysis and urine culture. The dipstick/urinalysis results are positive for nitrite and leukocyte esterase, indicating antibiotic therapy for presumed UTI.

Introduction

UTI is one of the most common bacterial infections in infants and young children. To prevent progression to pyelonephritis and avoid potential renal scarring or failure, early recognition and prompt treatment are critical.

Clinical signs and symptoms of UTI in newborns include jaundice, sepsis, failure to thrive, poor feeding, vomiting, and fever. In infants and preschoolers, hospitalists should also suspect UTI in the presence of diarrhea, strong-smelling urine, abdominal or flank pain, and new onset urinary incontinence.1

Treatment recommendations, which are age-dependent, include antibiotic therapy initiated upon an abnormal dipstick/urinalysis. If a urine culture is positive, a seven- to 14-day course of antibiotic therapy is recommended, followed by prophylactic antibiotics until results of imaging studies are available.1 According to a study by Hoberman and Wald, treatment of UTI with oral antibiotics alone is generally effective, even for young children with pyelonephritis.2

Imaging recommendations for a first UTI include ultrasound, cystogram, and renal cortical scan.

Up to this point, there’s been very little disagreement about the management of UTI. However, the question of whether the one-month-old patient in our scenario should be admitted or sent home with strict instructions on the administration of antibiotics remains controversial. The pediatric UTI guideline from Cincinnati Children’s Hospital Medical Center recommends routine hospital admission if the infant is under 30 days old.1 On the other hand, Santen and Altieri, among others, recommend, “Sick children and infants less than three months should be treated as inpatients, and healthy children and older infants may be treated as outpatients.”3,4

The Set-Up

We asked several pediatric hospitalists across the country—including an instructor of pediatrics at Cincinnati Children’s Hospital Medical Center—to respond to this simple scenario, posing the following questions: “What recommendation would you follow? Would you admit the one-month-old infant in our scenario or send her home? Why?”

Predictably, admission criteria varied, but most agreed that this infant should be admitted. No one based their response on age.

Automatic Admission Cut-off Not Well Supported

Jeffrey M. Simmons, MD, instructor of pediatrics, Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center, responds: “My perspective on the UTI scenario is that the only dogma that applies is that the infant needs antibiotics. Because [the scenario] mentions vomiting, I would, therefore, most likely give parenteral antibiotics and admit.

“An issue within this scenario that I don’t believe the literature answers clearly is once a UTI is identified by the U/A, what risk remains of bacteremia or meningitis in the over 30-day-old infant? We are taught that infants don’t ‘localize’ infections well (i.e., a serious bacterial infection in one place can rapidly lead to disseminated infection). I sense a growing consensus that after 30 days or so this concern is less at issue. However, for clarity, I would prefer to obtain blood and CSF cultures on this infant prior to initiating antibiotic therapy. Without those cultures, and the screening tests that go with them (i.e., serum WBC count, CSF cell count, and glucose), I would be uncomfortable sending the infant home.

“However, if the WBC count was between 5 and 15, the CSF reassuring, the parents in agreement and reliable with good primary care follow-up the next morning, I think such an infant could be managed with one dose of IV/IM antibiotics after cultures are obtained and sent home. The following day, depending on culture results and the clinical situation, this infant might either be admitted, given another dose of parenteral antibiotics pending final blood culture, or switched to oral antibiotics.

“Such a plan is complex, so if the primary care physician or family was at all uncomfortable, admission to accomplish that plan would clearly be appropriate.

“A final issue not adequately addressed within the scenario is an assessment of the infant’s hydration—potentially an issue due to the vomiting. If the infant was mildly to moderately dehydrated with persistent vomiting, I would also then admit until this improved.

“In regard to the cited evidence, I would say that clearly an arbitrary cut-off of automatic admission under three months is not well supported by current literature, but is certainly many practitioners’ ‘style.’ Oral antibiotics are clearly efficacious for pyelonephritis, but the clinician needs to be confident the family can give them and the infant will keep them down. I believe most practitioners would agree with admission for an infant under 30 days, but where to precisely draw that line needs to be better established through investigation. Potential concomitant bacteremia and meningitis lead me to support obtaining blood and CSF cultures on any infant under 60 days for which I plan to initiate antibiotics for UTI.”

Possibility of Dehydration Indicates Admission

Michael P. Fullmer, DO, Central Iowa Pediatric Hospitalists, Mercy Medical Center, Des Moines, Iowa, responds: “This patient is not febrile, but does have other systemic symptoms, including poor feeding, irritability, jaundice, and vomiting. These systemic symptoms could be indicative of a serious bacterial infection like UTI, bacteremia, or meningitis. This patient most likely has a UTI. These symptoms may suggest pyelonephritis rather than lower UTI, but the distinction is not necessary for our decision here.

“Bacteremia is present in up to 22.7% of infants less than two months old with a UTI. This adds to the complexity of the issue, and a blood culture is probably indicated. Meningitis should be considered, but a lumbar puncture is probably not indicated in this scenario.

“A one-month-old with a UTI should be admitted to the hospital and started on parenteral antibiotics. There are several reasons for admission. First, the presence of vomiting makes oral antibiotic administration impractical (if not impossible). Intramuscular antibiotic injection may be an option, but the IV route gives the provider more options and is usually better accepted by parents. Next, if the patient is not already dehydrated, the poor feeding and vomiting could lead to dehydration. This alone would be an indication for admission. Finally, admission would give the physician time to observe the infant for clinical improvement. This may be subtle in the absence of fever.

“Another consideration is the recommended imaging for all children less than two years old. The AAP has recommended a renal ultrasound and VCUG for all infants and young children with their first UTI. This is important for discovery of urinary tract anomalies that predispose the patient to recurrent UTIs and eventual renal scarring and dysfunction. The imaging should be performed at the earliest convenient time if the patient is responding to therapy. In our practice, we generally have the renal ultrasound performed while the patient is in the hospital and arrange the VCUG as an outpatient [exam] prior to completion of the course of antibiotics.

“Patients are discharged when they are afebrile for 24 hours, have adequate oral intake and are able to take oral antibiotics. Please refer to the AAP Clinical Practice Guideline for more detail.5,6

Admission Criteria Must Take Fever Into Account

John W. Graef, MD, chief, Services Office at Children’s Hospital, Harvard Vanguard Services Office, Boston, responds: “The presence or absence of fever is an important variable. Dipstick urines are shortcuts and don’t provide such information as the presence or absence of casts, although the fact that the child is vomiting and irritable is suggestive of pyelonephritis as opposed to a simple UTI/cystitis. [The scenario doesn’t] mention how the urine is obtained. Presumably it is a cath specimen, but that needs to be specified.

“Jaundice can occur with a UTI, but usually in the first week or so of life. A 32-day-old infant with pyelo is unlikely to be jaundiced unless for some other reason.

“I certainly agree with routine admission of a febrile infant up to one month, but not necessarily an otherwise well female infant. The presence of vomiting and irritability with or without fever might prompt a full septic work-up, in which case the decision to admit an afebrile infant would depend on the results of the CBC/UA and probably an LP. A blood culture and CBC should be drawn in the ED.

“In other words, one can’t have it both ways. If the irritability and vomiting are due to pyelo, a septic work-up is warranted. If all parameters are normal, the only reason for admission is hydration of a vomiting infant. If the infant was afebrile and had an uncomplicated UTI, I would not automatically admit an otherwise well 32-day-old.

“Poor PO (per OS, i.e., oral, by mouth) intake in an infant with a UTI warrants IV fluid regardless of age.”

True Emesis With Decreased Oral Intake Indicates Admission

Erin R. Stucky, MD, pediatric hospitalist, Children’s Hospital and Health Center San Diego, associate professor, UCSD Pediatrics, responds: “The decision to admit or discharge this one-month-old with vomiting, jaundice, poor eating, and irritability should include consideration of hydration status, toxicity, sepsis potential, and ability to secure close follow-up. We will make the assumption that the infant is term, with no past medical history, family history, or prenatal evaluation that would put the infant at greater risk for sepsis or likelihood of underlying anatomic genitourinary abnormality. In addition we will assume that the urinalysis was performed by catheterization in a non-pretreated infant.

“A careful history should elicit the change in urine output, frequency, and volume of emesis to contrast with small ‘spit-ups,’ and change in feeding duration or volume. Observation of a feeding in the office or emergency department can be of great value in determining likelihood of ability to maintain hydration at home. Feeding type should be confirmed [because] parents may dilute or alternately concentrate formula in response to vomiting. In this scenario, true emesis in an infant with decreased oral intake would be grounds for admission, intravenous hydration, and evaluation of electrolytes.

“A newly irritable infant evokes a visceral sensation for all pediatric hospitalists. An irritable one-month-old may be suffering from a single system infection, electrolyte imbalance, or other insult, but unfortunately may just as easily have multisystem involvement. Vital signs and physical exam findings of toxicity, such as tachycardia and delayed capillary refill, are not known to us. The presence of jaundice raises concern for cholestasis induced by E. coli or possibly rarer metabolic disease, such as galactosemia. Admission would allow for evaluation and monitoring of the more likely causes of irritability in our index patient, which include sepsis, meningitis, and electrolyte and acid-base imbalances.

“The urinalysis in this infant is suggestive of a urinary tract infection, although infants may have no abnormalities noted on initial urinalysis.7,8 The risk of bacteremia in infants under 60 days with documented urinary tract infection is significant. A number of studies support the need to treat infants less than 30 days with parenteral antibiotics.9-14 Addition of C-reactive protein testing at this time does not aid in distinguishing those who are bacteremic in this age group.15 The often quoted study by Hoberman of 306 children included only 13 under the age of two months.16 Of the 13 reported positive blood cultures, 10 were in children under age six months. Daily intramuscular ceftriaxone treatment would cover a majority of the typical neonatal UTI organisms, can be administered in the outpatient setting, and is proven to be as effective as intravenous delivery. The clinical response to bacteremia is, however, unpredictable in young infants. The sepsis potential in this infant requires admission for physiologic monitoring and support as needed.

“Final, but not inconsequential, concerns are barriers to follow-up. These include parental experience and coping skills with feeding and monitoring an ill infant, ability to educate on the illness and reasons for follow-up, transportation, and operational issues, such as weekend clinic hours or holiday office closures. For the index patient these issues are overshadowed by the clinical criteria for admission but would be of great importance for discharge.”

Conclusion

Based on these responses, admitting a suspected UTI patient on the basis of age alone, as suggested by Santen and Altieri, is likely inappropriate. Many other factors must be weighed and would likely indicate admission for the patient in the scenario, regardless of the infant’s age. In short, until there’s better evidence for age-based admission criteria, clinical judgment based on the individual patient presentation must continue to drive care and treatment decisions.

Keri Losavio is a medical journalist with more than 10 years’ experience.

References

1. UTI Guideline Team, Cincinnati Children’s Hospital Medical Center. “Evidence based clinical practice guideline for children 12 years of age or less with acute first time urinary tract infection.” www.cincinnatichildrens.org/svc/dept-div/health-policy/ev-based/uti.htm. Guideline 7, pages 1–20, April 2005.
2. Hoberman A, Wald ER. Treatment of urinary tract infections. Pediatr Infect Dis J. 1999;18(11):1020–1021.
3. Santen SA, Altieri MF. Pediatric urinary tract infection. Emerg Med Clin North Am. 200119(3):675–690.
4. Egland AG, Egland TK. Pyelonephritis. eMedicine. www.emedicine.com/emerg/topic769.htm. Accessed Oct. 16, 2005.
5. No authors listed. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. American Academy of Pediatrics. Committee on Quality Improvement. Subcommittee on Urinary Tract Infection. Pediatrics. 1999;103(4):843–852.
6. Pitetti RD, Choi S. Utility of blood cultures in febrile children with UTI. Am J Emerg Med. 2002;20:271–274.
7. Dayan PS, Bennett J, Best R, et al. Test characteristics of the urine Gram stain in infants 60 days of age with fever. Pediatr Emerg Care. 2002;18(1):12–14.
8. Huicho L, Campos-Sanchez M, Alamo C. Meta-analysis of urine screening tests for determining the risk of urinary tract infection in children. Pediatr Infect Dis J. 2002;21 (1):1-11.
9. Byington C L, Enriquez F, Hoff C, et al. Serious bacterial infections in febrile infants 1 to 90 days old with and without viral infections. Pediatrics. 2004; 113(6):1662–1666.
10. Baraff L. Management of fever without source in infants and children. Ann Emerg Med. 2000;36(6):602–614.
11. Baraff LJ, Oslund SA, Schriger DL, Stephen ML. Probability of bacterial infections in febrile infants less than three months of age: A meta-analysis. Pediatr Infect Dis J. 1992;11(4):257–264.
12. Klein JO. Management of the febrile child without a focus of infection in the era of universal pneumococcal immunization. Pediatr Infect Dis J. 2002;21(6):584–588.
13. Syrogiannopoulos G, Grieva I, Anastassiou E, et al. Sterile cerebrospinal fluid pleocytosis in young infants with urinary tract infections. Pediatr Infect Dis J. 2001;20(10):927–930.
14. Jaskiewicz JA, McCarthy CA, Richardson AC, et al. Febrile infants at low risk for serious bacterial infection—an appraisal of the Rochester criteria and implications for management. Febrile Collaborative Study Group. Pediatrics. 1994;94(3):390–396.
15. Malik A, Hui C, Pennie RA, Kirpalani H. Beyond the complete blood cell count and C-reactive protein: A systematic review of modern diagnostic tests for neonatal sepsis. Arch Pediatr Adolesc Med. 2003;157(6):511–516.
16. Hoberman A, Wald ER, Hickey RW, et al. Oral versus intravenous therapy for urinary tract Infections in young children. Pediatrics.1999;104:79–86

PEDIATRIC SPECIAL SECTION

IN THE LITERATURE

Utilize Clinical and Demographic Factors to Diagnose UTIs in Young Febrile Infants

Review by Sara E. Gardner, MD

Zorc JJ, Levine DA, Platt SL, et al. Clinical and demographic factors associated with urinary tract infections in young febrile infants. Pediatrics. 2000;116(3):644-648.

UTI is a common cause of serious bacterial infection in the febrile infant <60 days of age. Standard urinalysis and urine dipstick techniques, commonly used to diagnose UTI, have relatively low sensitivity increasing the possibility of a missed diagnosis. An accurate initial diagnosis is critical in this age group for whom complications from UTI include bacteremia and renal scarring.

To describe the demographic and clinical factors associated with UTI in infants ≤60 days of age with fever, these authors conducted a prospective cross sectional study from October 1999 to March 2001. Patients were enrolled at eight different institutions after presentation to an emergency department. One-thousand-twenty-five patients age 60 days or younger (mean age 35.5 days, 60.5% male) were enrolled with either reported or documented fever >38. Routine testing for all children included respiratory syncytial virus (RSV) sampling and bladder catheterization or suprapubic aspiration for urinalysis and culture.

A positive urinalysis was defined as a trace or greater result for leukocyte esterase and/or nitrite on dipstick or greater than or equal to five WBCs per high power field (hpf) on urine microscopy. UTI was defined as growth of a single pathogen of ≥1,000 colony forming units (cfu)/mL for urine cultures obtained by suprapubic catheterization, ≥50,000 cfu/mL from a catheterized specimen, or ≥10,000 cfu/ml from a catheterized specimen with a positive urinalysis.

Of the patients enrolled in the study, 92 were found to have UTI by these diagnostic criteria. Using the chi-squared test and calculated odds ratios with 95% confidence intervals, uncircumcised male (OR: 10.4; 95% CI: 4.7-31.4) and maximum temperature of ≥39º C (OR: 2.4 per degree C; 95% CI: 1.5-3.6) were found to be statistically significant variables for predicting UTI. These risk factors remained statistically significant after multivariable analysis controlling for other factors.

Interestingly of the above 92 patients diagnosed with UTI, 85 grew ≥50,000 cfu of a single pathogen, but six (8%) grew 10,000-49,000 cfu with a positive UA based on the study criteria. Zorc, et al. included these patients with >10,000 cfu and >5 WBC/hpf in this study despite previous studies that have established a definition of positive urinalysis to be ≥10 WBC/hpf. Zorc, et al. acknowledge the conservative definition applied in their current study, but assert that the overall results of the study would have been similar had 10,000 or 50,000 cfu/mL thresholds been chosen. To support this assertion, Zorc, et al. retrospectively applied enhanced urinalysis, a sensitive form of urinalysis including hemocytometric cell count and gram stain described by Hoberman, et al. to study patients with low bacteria counts. Based on Hoberman’s study, enhanced urinalysis can differentiate acute infection from asymptomatic bacteriuria in patients with bacterial growth between 10,000 to 50,000 cfu/mL.

Another significant limitation of this study was failure to enroll one-third of eligible patients to the study. In addition, the authors note that missed patients had a lower rate of UTI compared with enrolled patients.

Although this study design prohibits generalization to patient care areas outside the emergency department, the findings can assist the hospitalist in the evaluation of the febrile infant during RSV season and potentially guide decisions regarding empiric antibiotic therapy as part of evaluations to diagnose or exclude serious bacterial infection. Additionally, this study raises the question of need for better methods of urinalysis for febrile, uncircumcised male infants.

Back to the Basics: A Clinical Approach to Excluding Acute Appendicitis

Review by Jane G. Buss, MD

Kharbanda AB, Taylor GA, Fishman SJ, et al. A clinical decision rule to identify children at low risk for appendicitis. Pediatrics. 2005;116(3):709-16.

Appendicitis is the most common condition requiring emergency abdominal surgery in the pediatric population. To diagnosis appendicitis, clinicians typically utilize clinical findings, imaging studies, and laboratory testing. The use of clinical scoring systems to improve the diagnosis of appendicitis in children has been limited, mostly resulting from unacceptably low sensitivities/specificities, or the lack of validation. The use of CT scan to aid in the evaluation of children with appendicitis has become widespread. Concerns remain, however, regarding long-term radiation effects and increased healthcare costs associated with this approach.

The authors of this study sought to develop clinical scores for children to predict which of those with acute abdominal pain do not have appendicitis. Additionally, they hoped to lessen the use of CT scanning. Their goal was to identify those groups of children who have significant abdominal pain without appendicitis who could be safely observed without CT scan or possible surgery.

This prospective cohort study enrolled 601 eligible children ages three to 18 with suspected appendicitis who presented to the emergency department over a 15-month period. Two low-risk clinical decision rules were developed using logistic regression and recursive partitioning. Using logistic regression, six factors were identified from analysis of 425 patients in the derivation set significantly associated with an increased likelihood of appendicitis. The score components include:

1. Nausea (2 points);
2. History of focal right lower quadrant pain (RLQ) (2 points);
3. Migration of pain (1 point);
4. Difficulty walking (1 point);
5. Rebound tenderness (2 points); and
6. Absolute neutrophil count (ANC) >6.75 x 103/uL (6 points).

When tested with data from the 176 patients in the validation set, a score of less than or equal to five had a sensitivity of 96.3%, and a negative predictive value of 95.6% for excluding appendicitis.

The authors then derived a second clinical low-risk decision rule by recursive partitioning. They determined that a combination of ANC <6.75 X 10 to the third/microliter, absence of nausea (or emesis or anorexia), and absence of maximal tenderness in the RLQ essentially excluded appendicitis in the derivation and validation groups. This rule had a sensitivity of 98.1%, and a negative predictive value of 97.5%.

In summary, these authors derived two clinical decision rules giving the clinician the option of a clinical score (logistic regression) or a decision tree (recursive partitioning) to identify children at low risk for appendicitis. Their findings suggest application of either low-risk rule would lead to decreased reliance on CT scan. Applying these clinical rules to their patients could have reduced the rate of CT scan by 20%. They conclude that pediatric patients who have suspected appendicitis and are at low risk by either model should be considered for observation rather than undergo CT scan or operative care.

Epidemiology of Fungal Infection in the Tertiary Care Inpatient Setting

Review by Brandan P. Kennedy, MD

Abelson, JA, Moore T, Bruckner D, et al. Frequency of fungemia in hospitalized pediatric inpatients over 11 years at a tertiary care institution. Pediatrics. 2005;116(1):611-617.

Fungal organisms are relatively uncommon causes of blood infections in the pediatric population. When they do occur, they cause significant morbidity and mortality. The incidence of fungal blood infections appears to be rising at a faster rate than that of other pathogens. Authors from the University of California performed this study to describe those rate changes, and to evaluate whether treatment has improved in the past 11 years.

This retrospective cohort study involved children admitted to Mattel Children’s Hospital in Los Angeles, California, during an 11-year period from January 1991 to December 2001. Information obtained on all positive fungal cultures from all body sites included date and site of culture, demographics, and fungal etiology. Additionally, data regarding underlying illness, hospital course, outcome, and antimicrobial treatment were considered.

Study results demonstrated a significant increase in diagnosed fungemia in children. There was a 15% increase in overall pediatric admissions in the study period, and a 23% increase in positive fungal cultures in the same period. Of 272 blood cultures, 97 were positive for fungus. Although this is a relatively small number of total infections, data demonstrated a 91% increase in fungemia during the study period. Candida species were the organisms most frequently isolated from any body site with 85% of the total isolates. Of the total positive isolates, it appeared that approximately 78% reflected colonization as opposed to infection.

Outcomes for fungal infections improved only marginally in the study period. Fifty percent of patients with fungemia died between 1991 and 1996, and 45% died between 1997 and 2001. The mortality rate for immunocompromised conditions was 57%. The cost effectiveness of fungal screening cultures was also evaluated, which demonstrated that fungal cultures identified 14 patients independent of bacterial blood cultures at a cost of $560,000, which resulted in a cost of $40,000 per identified patient.

The study reaches several significant conclusions. First there has been a significant increase in fungal infections that exceeds the increase in overall pediatric hospital admissions. However, it is important to recognize the increase in immunocompromised conditions during the study period, which may account for the higher incidence of fungemia.

Second the addition of fungal blood cultures to bacterial blood cultures as part of a routine workup for febrile patients appeared to yield limited clinical information at a very high cost. Third this study highlights the serious threat fungal infections pose to immunocompromised hosts who have a significantly higher incidence of infection, as well as higher morbidity and mortality. Fourth the use of broad spectrum antibiotics may be increasing fungal colonization in patients and consequently increasing the risk for pathologic fungal infection. Finally morbidity and mortality rates for fungal infections did not greatly improve, despite significant improvements in supportive care made during the study period

This study demonstrates a need for better diagnostic markers for fungal infections, especially those that might provide earlier detection and diagnosis at less cost. The importance of judicious use of antibiotics is underscored while the need for a broader base of therapeutic agents is highlighted. These issues may be key ingredients needed to reduce adverse outcomes from fungal infections, especially in the immunocompromised host.

Rotavirus Vaccine Revisited

Salinas B, Perez Schael I, Linhares AC, et al. Evaluation of safety, immunogenicity and efficacy of an attenuated rotavirus vaccine, RIX4414. Ped Infect Dis J. 2005;24(9):807-816.

Rotavirus is the leading cause of severe gastroenteritis among children worldwide. In the United States, rotavirus is responsible for approximately 5%-10% of all diarrhea among children older than five and accounts for approximately 50,000 hospitalizations each year. An estimated one in 200,000 children with rotavirus diarrhea dies from complications of infection. The immunizing effect of rotavirus infection stimulated the development of live attenuated vaccines. In 1998, a three-dose regimen of a tetravalent rhesus-human reassortant vaccine (RotaShield: Wyeth Laboratories,) was licensed for infant immunization in the United States. Within the first year of use, it was withdrawn due to an observed risk of intussusception. The current study was designed to evaluate immunogenicity and efficacy of a live attenuated monovalent human rotavirus vaccine, RIX4414.

A double-blind, randomized, placebo-controlled design was utilized with the RIX4414 rotavirus vaccine administered at three different virus concentrations. Infants were randomly assigned to one of the three study groups or the placebo group. Infants in the vaccine groups received two oral doses of the vaccine at the age of two and four months. An identical placebo containing the same constituents as the vaccine except for the vaccine virus was used as the control. The vaccine was given concomitantly with other routine vaccinations. To determine immunogenicity, blood samples were obtained from all infants immediately before the first vaccination to exclude previous rotavirus infection. Blood samples were obtained two months after the first second vaccine doses and again at one year to measure anti-rotavirus IgA antibodies. Additionally, stool was obtained from 25% of the study sample and tested for rotavirus viral shedding, with differentiation between wild type and vaccine also being performed.

There were 2,155 infants enrolled in this study from three countries in South America, allowing for slightly more than 500 infants in each group. The study began in May 2001, and the final one-year follow-up was completed in April 2003. The anti-rotavirus IgA seroconversion rates two months after first and second doses were 38%-43% and 61%-65%, respectively. This compared with a 5.3% seroconversion rate in the control group, which was determined to be a wild type virus. Vaccine take after two doses was shown in all three vaccine study groups, ranging from 65% to 75% for the lowest to highest vaccine concentration groups. Reactogenicity and safety was evaluated by monitoring incidences of fever, diarrhea, vomiting, irritability, and loss of appetite during the 15 days after vaccine administration. The results were similar for the four study groups suggesting no significant reactogenicity. There were 220 serious adverse events reported including one intussusception. However, none of these events was determined to be related to the vaccine. The RIX4414 vaccine was demonstrated to effectively protect against severe gastroenteritis caused by G1 type rotavirus and also was shown to provide some cross protection to other serotypes.

This well-designed study demonstrated a statistically significant reduction in gastroenteritis due to rotavirus infection, especially of the predominant G1 serotype, after two doses of the RIX4414 human rotavirus vaccine. Objective measures of viral shedding and IgA seroconversion support the efficacy of the vaccine. This study provided a large sample population with good controls.

An important and possibly confounding variable not addressed by the study was breastfeeding status of the infants. There is clinical evidence demonstrating the protective properties of secretory IgA in human milk against rotavirus infection, and this could have influenced the observed severity of disease in the sample population. It would have been interesting to isolate breastfeeding status as a study variable and note any effect on the results of the study.

Aside from this observation, this study appears to show a promising new oral rotavirus vaccine. As further research on the RIX4414 vaccine continues, there is hope that this vaccine could make a significant positive impact on morbidity and hospitalization rates for rotavirus infections worldwide. TH

Denver—The Pediatric Hospital Medicine 2005 conference, held July 28–31, got off to a rousing start with a networking reception that preceded the keynote lecture on Thursday evening, July 28. Dan Rauch, MD, cochair of the Ambulatory Pediatric Association (APA) Special Interest Group in Hospital Medicine, welcomed the 200+ attendees. He described the meeting as the result of tremendous cooperation among the APA, the American Academy of Pediatrics (AAP), and the SHM.

“It’s been a tremendous pleasure to work with all three organizations,” said Dr. Rauch. “We have been truly blessed with leaders who think that growth of the field is more important than individual turf battles. I highly recommend that everybody in the room become members of all three organizations.”

Dr. Rauch later told The Hospitalist that he was surprised by how many attendees actually weren’t members of any of the three organizations.

The mostly young pediatric hospitalists in attendance came from all over the United States and Canada. According to keynote speaker Larry Wellikson, MD, CEO of SHM, the median age of the typical hospitalist is 37, and fewer than 10% are 50 or older. Dr. Rauch said the typical pediatric hospitalist is even younger.

In fact, the pediatric hospitalist profession is still in its infancy, a point underscored by the panel discussion during Friday’s plenary session, “Future Directions.” The conversation centered on whether pediatric hospitalist medicine is truly a new subspecialty or simply a job type within general pediatrics. Most attendees seemed to agree that in practice it is a new subspecialty, but gaining acknowledgement of that fact from the professional organizations, academics, hospital administrators, insurers, general practice pediatricians, and even from some pediatric hospitalists themselves is the continuing challenge.

Professional advancement was a theme every speaker emphasized, beginning with Dr. Wellikson.

You are building and defining the hospital of the future.

—Larry Wellikson, MD, CEO of SHM, explaining that the legacy of this generation of hospitalists will be to define hospital medicine.

CREATING THE HOSPITAL OF THE FUTURE

“My life’s goals were to be dean of a med school when I was 40 and a United States senator at 50,” said Dr. Wellikson during his keynote address. He may not have achieved those particular goals, but, he revealed, “believe it or not, my life has been even better than that.”

Dr. Wellikson, who discussed the current status of hospital medicine, is a sought-after speaker and consultant who helps hospitals and physicians understand the current medical environment and create strategies to succeed in it.

“You are building and defining the hospital of the future,” Dr. Wellikson told participants, explaining that the legacy of this generation of hospitalists will be to define hospital medicine. “[Hospitalists] are going to be the most important part of the hospital of the future.

“Hospitals are changing,” he said, describing the hospital of the future as patient-centered with medical care driven by measurable data and practiced in teams. With emergency departments overcrowded and hospitals and ICUs running at capacity, he predicts that $20 billion per year will be spent on hospital construction over the next 10 years. He foresees primary care pediatricians giving up inpatient care.

“Hospitalist medicine is by far the fastest growing medical specialty in the country,” said Dr. Wellikson. Currently, there are approximately 11,295 hospitalists, and he predicts that there will be 30,000 by the end of the decade. Approximately 9% of hospitalists are pediatricians.

According to Dr. Wellikson, 30% of 4,895 community hospitals today have hospitalists on staff, with about eight hospitalists per hospital. The larger the hospital, the more likely it is to have hospitalists:

• 71% of hospitals with more than 500 beds have hospitalists on staff; and
• 50% of hospitals with more than 100 beds have hospitalists.

“We believe at SHM that in 15 years 25% of the CEOs will be hospitalists and 15% of CMOs will be hospitalists,” said Dr. Wellikson, “ ... and you’re not all going to be able to take time off to go get an MBA. We’re going to be in the business of educating you to be a leader, how to be a manager. ... If you will commit to creating the hospital of the future, [SHM] will commit to giving you the tools to do it.”

VALUE VERSUS COMPENSATION

During the keynote, Dr. Wellikson set the stage for a compensation discussion that continued throughout the conference, both during sessions and in networking conversations.

“One of the things that makes the compensation model so unfair for hospital medicine,” said Dr. Wellikson, “is that the way we pay for medical care in this country is so screwed up. We pay by the unit of the visit and by the unit of the procedure. And so it is much better to do something wrong and do it a lot than it is to sit down and spend an hour talking with a family. And God forbid that you’re asked to sit on a QI committee; that’s really down time. ... And God forbid that instead of earning a living and seeing patients for three days you’re wasting your time here in Denver trying to be a better doctor. Our system doesn’t reward that.”

Several attendees mentioned that their hospitals consider them loss leaders. “Don’t allow yourself to be called a loss leader,” said Linda Snelling, MD, in her Friday session on contract negotiation. “You’re a system sustainer. If you want this profession to be respected, you’ve got to be paid for it.” Dr. Snelling is chief of pediatric critical care and associate professor of pediatrics and surgery (anesthesiology) at Brown University, Providence, R.I.

“Hospitalists need to convince ourselves of the value we bring to our institutions and to our patients,” said Mark Joffe, MD, director of community pediatric medicine for the Children’s Hospital of Philadelphia.

Dr. Wellikson emphasized that hospitalists do add value to hospitals—whether it’s educating, whether it’s throughput, whether it’s 24/7, whether it’s improving the quality. He said that hospital administrators—the CMOs at your hospital—understand that. “The reason that leadership and that hospitalists are important is that hospitals see you as the solution to many hospital issues,” he said. “When anthrax was thought to be a public health problem, every hospital started a bioterrorism committee and put the hospitalist on it.

“Almost every place I go, they want more of you. You’re better for their bottom line,” he continued. “If they’re ever going to be a better hospital, they need more of you, and they need you motivated, and they need you seeing the right number of patients so that you have the time to do a better job.”

According to Dr. Wellikson, the expectations of hospitalists is that they will improve efficiency, save the hospital money, provide measurable quality improvement (creating standards and measuring compliance), collect data, do things no one else will (e.g., provide uncompensated care, serve on committees).

Dr. Snelling agreed. “The benefit of hospitalists is not in what you bill,” she said, “but in systems improvements, patient satisfaction, QI, initiatives to start or change a program, teaching, cost-savings, and value-added services you provide to the hospital. ... Start with value. Figure out what you want. Identify common ground. Bargaining is the last thing you do.”

Hospitalists create a seamless continuity from inpatient to outpatient, from the emergency department to the floor, from the ICU to the floor. They improve efficiency via throughput and early discharge. They help uncrowd the emergency department and open ICU beds. “We make other physicians’ lives better,” said Dr. Wellikson. “We do a lot of things for the generalists so that they can go and have a better life.”

There is a definite bright side to being a hospitalist right now. According to Dr. Wellikson there are many more jobs than hospitalists—a trend that he predicts will continue for at least for the next five years.

“Don’t let the fact that we have a totally screwed up healthcare system get you down,” he said. “You’re not replaceable. The service you provide, someone must provide. Your hospital has more wastage in durable goods than it spends on pediatric hospitalists. They will pay for expertise.”

Dr. Snelling advised, “Be direct and shameless about compensation. No surgeon works for free unless they want to; no hospitalist should work for free unless that’s your selected charity, and my favorite charity is not the hospital I work for.

“Continually self-promote,” she continued. “Make sure [the person determining your compensation] knows what your successes are. If you’re doing something that’s successful—you get praise, you get a grant, you get a nice letter from a parent—pass that on. Document your value. If you save your hospital a million bucks, why shouldn’t you get a hunk of that? The CEO’s job is to pay you as little as possible.”

One attendee interjected, “I feel uncomfortable with the idea that what I’m doing as a hospitalist is worth more than what my private-practice colleagues are doing. I don’t want to be offensive.”

To which Dr. Snelling replied, “We’re not talking about being elitist. ‘Mine’s bigger than yours.’ What you’re talking about is the differences between C care—the minimum standard—and A care—the hospitalist. ... Who in this room wants to go to an average doctor?”

Dr. Snelling’s bottom line: “My message is not to gouge the system; it’s about respect. In an ideal situation, everybody gains.”

SHOULD PEDIATRIC HOSPITAL MEDICINE BE A BOARD-CERTIFIED SPECIALTY?

“This is a specialty,” emphasized Dr. Snelling during the contract negotiation session.

On the other hand, during the “Future Directions” plenary panel Dr. Wellikson said, “It is almost not relevant whether there is board certification or no board certification.” He described board certification as a way to measure quality.

“Clearly we need to find a way to validate what we’re doing for our good as well as for the good of our patients,” said Doug Carlson, MD, director of the Pediatric Hospital Medicine Program at St. Louis Children’s Hospital and associate professor of pediatrics at Washington University, St. Louis.

Stephen Ludwig, MD, associate chair for medical education at the Children’s Hospital of Philadelphia presented the case for becoming a board-certified specialty. Some benefits: recognition, prestige, job security, and professional advancement.

“Is this just a job, or do you want to fit into—become a thread in—the fabric of organized medicine?” asked Dr. Ludwig. Most important, though, would be the impact on child health. “Is [board certification] good for children and their parents? Unless you can demonstrate that, it won’t happen.”

According to Dr. Ludwig, becoming a board-certified specialty requires a defined body of knowledge, scientific basis, a sufficient number of practitioners, viable academic training programs, sufficient number of trainees willing to go into those fellowship programs, a board exam, geographic diversity, creation of new knowledge (or at least the application of existing knowledge in new ways), the support of national societies and organizations, and the consent of other specialties, such as internal medicine and family practice. It also takes time—likely years.

Some questions pediatric hospitalists still need to consider: Can you fill a void? Is there sufficient novel material for creating a certifying exam? Are there enough people who would take this exam? How will physicians view maintenance of certification? Where will the naysayers come from? What will be the response from primary care general pediatricians? What will be the response from academic generalists/pediatricians? What will be the subspecialist response?

Dr. Ludwig expressed one concern succinctly: “You might ultimately decrease the number of practitioners willing to make the commitment.”

Dr. Wellikson concurred. “Those of you who are group leaders are constantly in a recruiting mode,” he said. “You need something to help you determine who is good and who is not, but adding three years may drive those who would have been great pediatric hospitalists to become great pediatric anesthesiologists.”

In the end, the group could not agree on an answer. “You have an amazing amount of excitement,” said Dr. Ludwig. “Temper your excitement with focus. You need to decide whether becoming another subspecialty is what you want.”

SOMETHING FOR EVERYONE

The conference offered a broad range of learning opportunities.

Those interested in research heard about opportunities to collaborate and learned how to share resources and develop research projects.

Educators—and aren’t all hospitalists involved in education at some level?—learned “Seven Simple Secrets to Successful Supervision” from Vinny Chiang, MD, chief of inpatient services at Children’s Hospital, Boston. He says the single most powerful question you can ask as an educator is, “What do you think?”

“The med student may say, ‘I think the kid is sick.’ The intern may say, ‘I think it’s rejection.’ The resident may say, ‘We need to distinguish between infection and rejection,’” said Dr. Chiang. By asking this question, he said, “You make that trainee an active participant.”

Evidence-based medicine and the use of pathways were also on the agenda. The discussions started with the basics, defining terms. According to Dr. Chiang, evidence-based medicine is, “the conscientious, explicit, and judicious use of current best evidence in making a clinical decision.” (See also “Evidence-Based Medicine for the Hospitalist,” p. 22.)

Pathways, developed from that best evidence, are tools that guide clinical care. “It’s the same as with calculators and PDAs,” said Stephen E. Muething, MD, associate director of clinical services at Cincinnati Children’s Hospital. “A pathway is a tool that allows a resident to spend their time identifying the 20% who shouldn’t be on the pathway and figuring out what to do for them.”

“Medicine can be systematized,” said Dr. Wellikson. “You can have best practices.”

Attendees expressed concerns that pathways may not leave room for a hospitalist’s judgment.

“There is no pathway that addresses 100% of patients,” said Dr. Muething. “A pathway should be defined as a guideline not a standard of care. From a medicallegal standpoint, you need to document why you deviated from a pathway. You still need to use clinical judgment. Don’t forget to think.”

One reason to use pathways, according to Dr. Muething, is that you can more rapidly identify what works and what doesn’t. “If everyone is doing it the same way,” he said, “then even if everyone is doing it wrong, you’ll be able to identify the problem and resolve it more quickly, improving outcome.”

Zoster can occur in immunized kids. Immunization does not preclude disease. We all know that breakthrough can happen.” The question is, “If a kid’s not immunized but exposed to a milder case, will he/she get the milder case? Case studies indicate that’s a possibility. Vaccine may not prevent but mute disease.

—Erin Stiucky, MD

HOT TOPICS

Clinical topics were also on the agenda. On the final day of the conference, Erin R. Stucky, MD, director of graduate medical education, an associate clinical professor in the University of California at San Diego Department of Pediatrics, and a pediatric hospitalist at the Children’s

Hospital and Health Center San Diego, tackled “The Top Five in ’05,” discussing:

1. Bronchiolitis;
2. Emerging pathogens;
3. Venous thrombosis;
4. Fungal infections; and
5. Kawasaki disease (KD).

In a whirlwind review, she presented the latest research on each of these topics.

Bronchiolitis: Surveys reveal that there’s a lot of variability in how hospitalists currently manage bronchiolitis, beginning with whether or not viral testing is helpful. “Testing, do we care? Does more than RSV matter?” asked Dr. Stucky. Her literature review of studies on bronchiolitis reveals, “Actually knowing the viral type is probably not helpful. Think before you test. Prevention is key.”

She also mentioned the need for additional studies on the use of heliox and CPAP in treating the condition.

Emerging pathogens: Dr. Stucky rapidly reviewed West Nile virus, coronavirus, varicella, influenza, MRSA, and pneumococcus. Discussing West Nile, Dr. Stucky said that diagnosing children with the condition can be tricky, particularly because the “predictive value [of diagnostic tests] isn’t 100%,” making the history and exam crucial. Of particular note for pediatric hospitalists, she said, is that the virus can be transmitted in blood, in utero, and via breast milk.

When speaking about coronavirus, Dr. Stucky said, “Transspecies jump (from civets, raccoons, ferrets, mice) is a great concern.” For diagnostic purposes, “Consider travel and exposure to animals.”

On varicella, Dr. Stucky said, “Zoster can occur in immunized kids. Immunization does not preclude disease. We all know that breakthrough can happen.” The question is, “If a kid’s not immunized but exposed to a milder case, will he/she get the milder case? Case studies indicate that’s a possibility. Vaccine may not prevent but mute disease.”

On influenza, the discussion focused upon the reality of the avian strain causing human disease and increasing resistance as farmers use prophylactic doses of antibiotics for their poultry. There is worldwide effect of both human and avian strains. “The hospitalist as leader: public speaking in anxious times and real crises” is critical, said Dr Stucky.

Venous thrombosis: Kids with venous thrombosis typically have at least one known risk factor, with diabetics at increased risk. Thrombolytics can help save a limb or an organ, but “long-term prophylaxis is controversial,” said Dr. Stucky.

Fungal infections: Truly eradicating a fungal infection is difficult, said Dr. Stucky, with recurrence common. There’s currently no empirical evidence to support combination therapy. More research is needed.

KD: “Treat early and often,” said Dr. Stucky. Treatment goals are to stop inflammation, inhibit thrombosis, and avoid stenosis. Because stenotic lesions progress, “long-term therapy and follow-up are needed.” Children with KD should avoid ibuprofen. They should receive the influenza vaccine, but defer measles and varicella vaccines for 11 months after intravenous immunoglobulin.

COMING SOON

The pediatric hospitalists who met in Denver left the conference energized, armed with new leadership skills and clinical knowledge, and asking for more. Organizers are now starting to plan for Pediatric Hospital Medicine 2007. The Hospitalist will keep you posted with information on the next conference as soon as it’s available, and we’ll publish half a dozen additional articles related to pediatric hospital medicine in the coming months.

Keri Losavio is a medical journalist with more than 10 years’ experience writing about healthcare issues.

PEDIATRIC SPECIAL SECTION

In The Literature

Systemic Steroid Use in Pediatric Sepsis Patients

Review by Julia Simmons, MD

Markovitz BP, Goodman DM, Watson RS, et al. A retrospective cohort study of prognostic factors associated with outcome in pediatric severe sepsis: what is the role of steroids? Pediatr Crit Care Med. 2005:6:270-274.

The use of systemic steroids in septic adults with relative adrenal insufficiency has recently been shown to decrease mortality. The use of systemic steroids in the septic pediatric population remains a topic of debate and research focus. The goal of this retrospective cohort study was to determine factors associated with mortality in pediatric patients with severe sepsis treated with systemic steroids.

The authors searched the Pediatric Health Information System for their data. This system is a database for 35 pediatric hospitals within the Child Heath Corporation of America, a children’s hospital consortium. The International Classification Disease Codes for infection were used to search the database for patients from birth through 17 with sepsis during a one-year period.

Severe sepsis was defined as one or more organ dysfunction secondary to an infectious etiology during which the patient required mechanical ventilation and vasoactive medications. The primary outcome variable was mortality. Other variables analyzed included duration of hospitalization, duration of mechanical ventilatory support and vasoactive medications. Predictor variable was the use of parenteral systemic steroids given at least one day during which the patient required artificial ventilation and vasoactive medications.

There were 6,693 participants in the study. Mean days of ventilation was 24.4 +/- 37.3, median 13. Mean number of days hospitalized was 46.8 +/- 51.3 with a median of 30. The mean number of days requiring cardiac supportive medications was 7.8 +/- 9.9 with a median of five. The use of systemic steroids (hydrocortisone, dexamethasone, or methylprednisolone) with increased age, decreased hospital volume, and a history of a hematological/oncological disease were associated with an increased mortality. Even after controlling for the variables, steroids were a strong predictor of mortality. The overall mortality rate in the study was 24%.

In summary, there was an increase in mortality associated with systemic steroid use in the severely septic pediatric patient. As noted by the authors, the study was limited because there was no stratification for disease severity. Further, the rationale for giving the steroids was not known. Overall, larger prospective studies with controlled protocols are necessary in order to make recommendations regarding the use of systemic steroids in septic pediatric patients. TH

Denver—The Pediatric Hospital Medicine 2005 conference, held July 28–31, got off to a rousing start with a networking reception that preceded the keynote lecture on Thursday evening, July 28. Dan Rauch, MD, cochair of the Ambulatory Pediatric Association (APA) Special Interest Group in Hospital Medicine, welcomed the 200+ attendees. He described the meeting as the result of tremendous cooperation among the APA, the American Academy of Pediatrics (AAP), and the SHM.

“It’s been a tremendous pleasure to work with all three organizations,” said Dr. Rauch. “We have been truly blessed with leaders who think that growth of the field is more important than individual turf battles. I highly recommend that everybody in the room become members of all three organizations.”

Dr. Rauch later told The Hospitalist that he was surprised by how many attendees actually weren’t members of any of the three organizations.

The mostly young pediatric hospitalists in attendance came from all over the United States and Canada. According to keynote speaker Larry Wellikson, MD, CEO of SHM, the median age of the typical hospitalist is 37, and fewer than 10% are 50 or older. Dr. Rauch said the typical pediatric hospitalist is even younger.

In fact, the pediatric hospitalist profession is still in its infancy, a point underscored by the panel discussion during Friday’s plenary session, “Future Directions.” The conversation centered on whether pediatric hospitalist medicine is truly a new subspecialty or simply a job type within general pediatrics. Most attendees seemed to agree that in practice it is a new subspecialty, but gaining acknowledgement of that fact from the professional organizations, academics, hospital administrators, insurers, general practice pediatricians, and even from some pediatric hospitalists themselves is the continuing challenge.

Professional advancement was a theme every speaker emphasized, beginning with Dr. Wellikson.

You are building and defining the hospital of the future.

—Larry Wellikson, MD, CEO of SHM, explaining that the legacy of this generation of hospitalists will be to define hospital medicine.

CREATING THE HOSPITAL OF THE FUTURE

“My life’s goals were to be dean of a med school when I was 40 and a United States senator at 50,” said Dr. Wellikson during his keynote address. He may not have achieved those particular goals, but, he revealed, “believe it or not, my life has been even better than that.”

Dr. Wellikson, who discussed the current status of hospital medicine, is a sought-after speaker and consultant who helps hospitals and physicians understand the current medical environment and create strategies to succeed in it.

“You are building and defining the hospital of the future,” Dr. Wellikson told participants, explaining that the legacy of this generation of hospitalists will be to define hospital medicine. “[Hospitalists] are going to be the most important part of the hospital of the future.

“Hospitals are changing,” he said, describing the hospital of the future as patient-centered with medical care driven by measurable data and practiced in teams. With emergency departments overcrowded and hospitals and ICUs running at capacity, he predicts that $20 billion per year will be spent on hospital construction over the next 10 years. He foresees primary care pediatricians giving up inpatient care.

“Hospitalist medicine is by far the fastest growing medical specialty in the country,” said Dr. Wellikson. Currently, there are approximately 11,295 hospitalists, and he predicts that there will be 30,000 by the end of the decade. Approximately 9% of hospitalists are pediatricians.

According to Dr. Wellikson, 30% of 4,895 community hospitals today have hospitalists on staff, with about eight hospitalists per hospital. The larger the hospital, the more likely it is to have hospitalists:

• 71% of hospitals with more than 500 beds have hospitalists on staff; and
• 50% of hospitals with more than 100 beds have hospitalists.

“We believe at SHM that in 15 years 25% of the CEOs will be hospitalists and 15% of CMOs will be hospitalists,” said Dr. Wellikson, “ ... and you’re not all going to be able to take time off to go get an MBA. We’re going to be in the business of educating you to be a leader, how to be a manager. ... If you will commit to creating the hospital of the future, [SHM] will commit to giving you the tools to do it.”

VALUE VERSUS COMPENSATION

During the keynote, Dr. Wellikson set the stage for a compensation discussion that continued throughout the conference, both during sessions and in networking conversations.

“One of the things that makes the compensation model so unfair for hospital medicine,” said Dr. Wellikson, “is that the way we pay for medical care in this country is so screwed up. We pay by the unit of the visit and by the unit of the procedure. And so it is much better to do something wrong and do it a lot than it is to sit down and spend an hour talking with a family. And God forbid that you’re asked to sit on a QI committee; that’s really down time. ... And God forbid that instead of earning a living and seeing patients for three days you’re wasting your time here in Denver trying to be a better doctor. Our system doesn’t reward that.”

Several attendees mentioned that their hospitals consider them loss leaders. “Don’t allow yourself to be called a loss leader,” said Linda Snelling, MD, in her Friday session on contract negotiation. “You’re a system sustainer. If you want this profession to be respected, you’ve got to be paid for it.” Dr. Snelling is chief of pediatric critical care and associate professor of pediatrics and surgery (anesthesiology) at Brown University, Providence, R.I.

“Hospitalists need to convince ourselves of the value we bring to our institutions and to our patients,” said Mark Joffe, MD, director of community pediatric medicine for the Children’s Hospital of Philadelphia.

Dr. Wellikson emphasized that hospitalists do add value to hospitals—whether it’s educating, whether it’s throughput, whether it’s 24/7, whether it’s improving the quality. He said that hospital administrators—the CMOs at your hospital—understand that. “The reason that leadership and that hospitalists are important is that hospitals see you as the solution to many hospital issues,” he said. “When anthrax was thought to be a public health problem, every hospital started a bioterrorism committee and put the hospitalist on it.

“Almost every place I go, they want more of you. You’re better for their bottom line,” he continued. “If they’re ever going to be a better hospital, they need more of you, and they need you motivated, and they need you seeing the right number of patients so that you have the time to do a better job.”

According to Dr. Wellikson, the expectations of hospitalists is that they will improve efficiency, save the hospital money, provide measurable quality improvement (creating standards and measuring compliance), collect data, do things no one else will (e.g., provide uncompensated care, serve on committees).

Dr. Snelling agreed. “The benefit of hospitalists is not in what you bill,” she said, “but in systems improvements, patient satisfaction, QI, initiatives to start or change a program, teaching, cost-savings, and value-added services you provide to the hospital. ... Start with value. Figure out what you want. Identify common ground. Bargaining is the last thing you do.”

Hospitalists create a seamless continuity from inpatient to outpatient, from the emergency department to the floor, from the ICU to the floor. They improve efficiency via throughput and early discharge. They help uncrowd the emergency department and open ICU beds. “We make other physicians’ lives better,” said Dr. Wellikson. “We do a lot of things for the generalists so that they can go and have a better life.”

There is a definite bright side to being a hospitalist right now. According to Dr. Wellikson there are many more jobs than hospitalists—a trend that he predicts will continue for at least for the next five years.

“Don’t let the fact that we have a totally screwed up healthcare system get you down,” he said. “You’re not replaceable. The service you provide, someone must provide. Your hospital has more wastage in durable goods than it spends on pediatric hospitalists. They will pay for expertise.”

Dr. Snelling advised, “Be direct and shameless about compensation. No surgeon works for free unless they want to; no hospitalist should work for free unless that’s your selected charity, and my favorite charity is not the hospital I work for.

“Continually self-promote,” she continued. “Make sure [the person determining your compensation] knows what your successes are. If you’re doing something that’s successful—you get praise, you get a grant, you get a nice letter from a parent—pass that on. Document your value. If you save your hospital a million bucks, why shouldn’t you get a hunk of that? The CEO’s job is to pay you as little as possible.”

One attendee interjected, “I feel uncomfortable with the idea that what I’m doing as a hospitalist is worth more than what my private-practice colleagues are doing. I don’t want to be offensive.”

To which Dr. Snelling replied, “We’re not talking about being elitist. ‘Mine’s bigger than yours.’ What you’re talking about is the differences between C care—the minimum standard—and A care—the hospitalist. ... Who in this room wants to go to an average doctor?”

Dr. Snelling’s bottom line: “My message is not to gouge the system; it’s about respect. In an ideal situation, everybody gains.”

SHOULD PEDIATRIC HOSPITAL MEDICINE BE A BOARD-CERTIFIED SPECIALTY?

“This is a specialty,” emphasized Dr. Snelling during the contract negotiation session.

On the other hand, during the “Future Directions” plenary panel Dr. Wellikson said, “It is almost not relevant whether there is board certification or no board certification.” He described board certification as a way to measure quality.

“Clearly we need to find a way to validate what we’re doing for our good as well as for the good of our patients,” said Doug Carlson, MD, director of the Pediatric Hospital Medicine Program at St. Louis Children’s Hospital and associate professor of pediatrics at Washington University, St. Louis.

Stephen Ludwig, MD, associate chair for medical education at the Children’s Hospital of Philadelphia presented the case for becoming a board-certified specialty. Some benefits: recognition, prestige, job security, and professional advancement.

“Is this just a job, or do you want to fit into—become a thread in—the fabric of organized medicine?” asked Dr. Ludwig. Most important, though, would be the impact on child health. “Is [board certification] good for children and their parents? Unless you can demonstrate that, it won’t happen.”

According to Dr. Ludwig, becoming a board-certified specialty requires a defined body of knowledge, scientific basis, a sufficient number of practitioners, viable academic training programs, sufficient number of trainees willing to go into those fellowship programs, a board exam, geographic diversity, creation of new knowledge (or at least the application of existing knowledge in new ways), the support of national societies and organizations, and the consent of other specialties, such as internal medicine and family practice. It also takes time—likely years.

Some questions pediatric hospitalists still need to consider: Can you fill a void? Is there sufficient novel material for creating a certifying exam? Are there enough people who would take this exam? How will physicians view maintenance of certification? Where will the naysayers come from? What will be the response from primary care general pediatricians? What will be the response from academic generalists/pediatricians? What will be the subspecialist response?

Dr. Ludwig expressed one concern succinctly: “You might ultimately decrease the number of practitioners willing to make the commitment.”

Dr. Wellikson concurred. “Those of you who are group leaders are constantly in a recruiting mode,” he said. “You need something to help you determine who is good and who is not, but adding three years may drive those who would have been great pediatric hospitalists to become great pediatric anesthesiologists.”

In the end, the group could not agree on an answer. “You have an amazing amount of excitement,” said Dr. Ludwig. “Temper your excitement with focus. You need to decide whether becoming another subspecialty is what you want.”

SOMETHING FOR EVERYONE

The conference offered a broad range of learning opportunities.

Those interested in research heard about opportunities to collaborate and learned how to share resources and develop research projects.

Educators—and aren’t all hospitalists involved in education at some level?—learned “Seven Simple Secrets to Successful Supervision” from Vinny Chiang, MD, chief of inpatient services at Children’s Hospital, Boston. He says the single most powerful question you can ask as an educator is, “What do you think?”

“The med student may say, ‘I think the kid is sick.’ The intern may say, ‘I think it’s rejection.’ The resident may say, ‘We need to distinguish between infection and rejection,’” said Dr. Chiang. By asking this question, he said, “You make that trainee an active participant.”

Evidence-based medicine and the use of pathways were also on the agenda. The discussions started with the basics, defining terms. According to Dr. Chiang, evidence-based medicine is, “the conscientious, explicit, and judicious use of current best evidence in making a clinical decision.” (See also “Evidence-Based Medicine for the Hospitalist,” p. 22.)

Pathways, developed from that best evidence, are tools that guide clinical care. “It’s the same as with calculators and PDAs,” said Stephen E. Muething, MD, associate director of clinical services at Cincinnati Children’s Hospital. “A pathway is a tool that allows a resident to spend their time identifying the 20% who shouldn’t be on the pathway and figuring out what to do for them.”

“Medicine can be systematized,” said Dr. Wellikson. “You can have best practices.”

Attendees expressed concerns that pathways may not leave room for a hospitalist’s judgment.

“There is no pathway that addresses 100% of patients,” said Dr. Muething. “A pathway should be defined as a guideline not a standard of care. From a medicallegal standpoint, you need to document why you deviated from a pathway. You still need to use clinical judgment. Don’t forget to think.”

One reason to use pathways, according to Dr. Muething, is that you can more rapidly identify what works and what doesn’t. “If everyone is doing it the same way,” he said, “then even if everyone is doing it wrong, you’ll be able to identify the problem and resolve it more quickly, improving outcome.”

Zoster can occur in immunized kids. Immunization does not preclude disease. We all know that breakthrough can happen.” The question is, “If a kid’s not immunized but exposed to a milder case, will he/she get the milder case? Case studies indicate that’s a possibility. Vaccine may not prevent but mute disease.

—Erin Stiucky, MD

HOT TOPICS

Clinical topics were also on the agenda. On the final day of the conference, Erin R. Stucky, MD, director of graduate medical education, an associate clinical professor in the University of California at San Diego Department of Pediatrics, and a pediatric hospitalist at the Children’s

Hospital and Health Center San Diego, tackled “The Top Five in ’05,” discussing:

1. Bronchiolitis;
2. Emerging pathogens;
3. Venous thrombosis;
4. Fungal infections; and
5. Kawasaki disease (KD).

In a whirlwind review, she presented the latest research on each of these topics.

Bronchiolitis: Surveys reveal that there’s a lot of variability in how hospitalists currently manage bronchiolitis, beginning with whether or not viral testing is helpful. “Testing, do we care? Does more than RSV matter?” asked Dr. Stucky. Her literature review of studies on bronchiolitis reveals, “Actually knowing the viral type is probably not helpful. Think before you test. Prevention is key.”

She also mentioned the need for additional studies on the use of heliox and CPAP in treating the condition.

Emerging pathogens: Dr. Stucky rapidly reviewed West Nile virus, coronavirus, varicella, influenza, MRSA, and pneumococcus. Discussing West Nile, Dr. Stucky said that diagnosing children with the condition can be tricky, particularly because the “predictive value [of diagnostic tests] isn’t 100%,” making the history and exam crucial. Of particular note for pediatric hospitalists, she said, is that the virus can be transmitted in blood, in utero, and via breast milk.

When speaking about coronavirus, Dr. Stucky said, “Transspecies jump (from civets, raccoons, ferrets, mice) is a great concern.” For diagnostic purposes, “Consider travel and exposure to animals.”

On varicella, Dr. Stucky said, “Zoster can occur in immunized kids. Immunization does not preclude disease. We all know that breakthrough can happen.” The question is, “If a kid’s not immunized but exposed to a milder case, will he/she get the milder case? Case studies indicate that’s a possibility. Vaccine may not prevent but mute disease.”

On influenza, the discussion focused upon the reality of the avian strain causing human disease and increasing resistance as farmers use prophylactic doses of antibiotics for their poultry. There is worldwide effect of both human and avian strains. “The hospitalist as leader: public speaking in anxious times and real crises” is critical, said Dr Stucky.

Venous thrombosis: Kids with venous thrombosis typically have at least one known risk factor, with diabetics at increased risk. Thrombolytics can help save a limb or an organ, but “long-term prophylaxis is controversial,” said Dr. Stucky.

Fungal infections: Truly eradicating a fungal infection is difficult, said Dr. Stucky, with recurrence common. There’s currently no empirical evidence to support combination therapy. More research is needed.

KD: “Treat early and often,” said Dr. Stucky. Treatment goals are to stop inflammation, inhibit thrombosis, and avoid stenosis. Because stenotic lesions progress, “long-term therapy and follow-up are needed.” Children with KD should avoid ibuprofen. They should receive the influenza vaccine, but defer measles and varicella vaccines for 11 months after intravenous immunoglobulin.

COMING SOON

The pediatric hospitalists who met in Denver left the conference energized, armed with new leadership skills and clinical knowledge, and asking for more. Organizers are now starting to plan for Pediatric Hospital Medicine 2007. The Hospitalist will keep you posted with information on the next conference as soon as it’s available, and we’ll publish half a dozen additional articles related to pediatric hospital medicine in the coming months.

Keri Losavio is a medical journalist with more than 10 years’ experience writing about healthcare issues.

PEDIATRIC SPECIAL SECTION

In The Literature

Systemic Steroid Use in Pediatric Sepsis Patients

Review by Julia Simmons, MD

Markovitz BP, Goodman DM, Watson RS, et al. A retrospective cohort study of prognostic factors associated with outcome in pediatric severe sepsis: what is the role of steroids? Pediatr Crit Care Med. 2005:6:270-274.

The use of systemic steroids in septic adults with relative adrenal insufficiency has recently been shown to decrease mortality. The use of systemic steroids in the septic pediatric population remains a topic of debate and research focus. The goal of this retrospective cohort study was to determine factors associated with mortality in pediatric patients with severe sepsis treated with systemic steroids.

The authors searched the Pediatric Health Information System for their data. This system is a database for 35 pediatric hospitals within the Child Heath Corporation of America, a children’s hospital consortium. The International Classification Disease Codes for infection were used to search the database for patients from birth through 17 with sepsis during a one-year period.

Severe sepsis was defined as one or more organ dysfunction secondary to an infectious etiology during which the patient required mechanical ventilation and vasoactive medications. The primary outcome variable was mortality. Other variables analyzed included duration of hospitalization, duration of mechanical ventilatory support and vasoactive medications. Predictor variable was the use of parenteral systemic steroids given at least one day during which the patient required artificial ventilation and vasoactive medications.

There were 6,693 participants in the study. Mean days of ventilation was 24.4 +/- 37.3, median 13. Mean number of days hospitalized was 46.8 +/- 51.3 with a median of 30. The mean number of days requiring cardiac supportive medications was 7.8 +/- 9.9 with a median of five. The use of systemic steroids (hydrocortisone, dexamethasone, or methylprednisolone) with increased age, decreased hospital volume, and a history of a hematological/oncological disease were associated with an increased mortality. Even after controlling for the variables, steroids were a strong predictor of mortality. The overall mortality rate in the study was 24%.

In summary, there was an increase in mortality associated with systemic steroid use in the severely septic pediatric patient. As noted by the authors, the study was limited because there was no stratification for disease severity. Further, the rationale for giving the steroids was not known. Overall, larger prospective studies with controlled protocols are necessary in order to make recommendations regarding the use of systemic steroids in septic pediatric patients. TH

Denver—The Pediatric Hospital Medicine 2005 conference, held July 28–31, got off to a rousing start with a networking reception that preceded the keynote lecture on Thursday evening, July 28. Dan Rauch, MD, cochair of the Ambulatory Pediatric Association (APA) Special Interest Group in Hospital Medicine, welcomed the 200+ attendees. He described the meeting as the result of tremendous cooperation among the APA, the American Academy of Pediatrics (AAP), and the SHM.

“It’s been a tremendous pleasure to work with all three organizations,” said Dr. Rauch. “We have been truly blessed with leaders who think that growth of the field is more important than individual turf battles. I highly recommend that everybody in the room become members of all three organizations.”

Dr. Rauch later told The Hospitalist that he was surprised by how many attendees actually weren’t members of any of the three organizations.

The mostly young pediatric hospitalists in attendance came from all over the United States and Canada. According to keynote speaker Larry Wellikson, MD, CEO of SHM, the median age of the typical hospitalist is 37, and fewer than 10% are 50 or older. Dr. Rauch said the typical pediatric hospitalist is even younger.

In fact, the pediatric hospitalist profession is still in its infancy, a point underscored by the panel discussion during Friday’s plenary session, “Future Directions.” The conversation centered on whether pediatric hospitalist medicine is truly a new subspecialty or simply a job type within general pediatrics. Most attendees seemed to agree that in practice it is a new subspecialty, but gaining acknowledgement of that fact from the professional organizations, academics, hospital administrators, insurers, general practice pediatricians, and even from some pediatric hospitalists themselves is the continuing challenge.

Professional advancement was a theme every speaker emphasized, beginning with Dr. Wellikson.

You are building and defining the hospital of the future.

—Larry Wellikson, MD, CEO of SHM, explaining that the legacy of this generation of hospitalists will be to define hospital medicine.

CREATING THE HOSPITAL OF THE FUTURE

“My life’s goals were to be dean of a med school when I was 40 and a United States senator at 50,” said Dr. Wellikson during his keynote address. He may not have achieved those particular goals, but, he revealed, “believe it or not, my life has been even better than that.”

Dr. Wellikson, who discussed the current status of hospital medicine, is a sought-after speaker and consultant who helps hospitals and physicians understand the current medical environment and create strategies to succeed in it.

“You are building and defining the hospital of the future,” Dr. Wellikson told participants, explaining that the legacy of this generation of hospitalists will be to define hospital medicine. “[Hospitalists] are going to be the most important part of the hospital of the future.

“Hospitals are changing,” he said, describing the hospital of the future as patient-centered with medical care driven by measurable data and practiced in teams. With emergency departments overcrowded and hospitals and ICUs running at capacity, he predicts that $20 billion per year will be spent on hospital construction over the next 10 years. He foresees primary care pediatricians giving up inpatient care.

“Hospitalist medicine is by far the fastest growing medical specialty in the country,” said Dr. Wellikson. Currently, there are approximately 11,295 hospitalists, and he predicts that there will be 30,000 by the end of the decade. Approximately 9% of hospitalists are pediatricians.

According to Dr. Wellikson, 30% of 4,895 community hospitals today have hospitalists on staff, with about eight hospitalists per hospital. The larger the hospital, the more likely it is to have hospitalists:

• 71% of hospitals with more than 500 beds have hospitalists on staff; and
• 50% of hospitals with more than 100 beds have hospitalists.

“We believe at SHM that in 15 years 25% of the CEOs will be hospitalists and 15% of CMOs will be hospitalists,” said Dr. Wellikson, “ ... and you’re not all going to be able to take time off to go get an MBA. We’re going to be in the business of educating you to be a leader, how to be a manager. ... If you will commit to creating the hospital of the future, [SHM] will commit to giving you the tools to do it.”

VALUE VERSUS COMPENSATION

During the keynote, Dr. Wellikson set the stage for a compensation discussion that continued throughout the conference, both during sessions and in networking conversations.

“One of the things that makes the compensation model so unfair for hospital medicine,” said Dr. Wellikson, “is that the way we pay for medical care in this country is so screwed up. We pay by the unit of the visit and by the unit of the procedure. And so it is much better to do something wrong and do it a lot than it is to sit down and spend an hour talking with a family. And God forbid that you’re asked to sit on a QI committee; that’s really down time. ... And God forbid that instead of earning a living and seeing patients for three days you’re wasting your time here in Denver trying to be a better doctor. Our system doesn’t reward that.”

Several attendees mentioned that their hospitals consider them loss leaders. “Don’t allow yourself to be called a loss leader,” said Linda Snelling, MD, in her Friday session on contract negotiation. “You’re a system sustainer. If you want this profession to be respected, you’ve got to be paid for it.” Dr. Snelling is chief of pediatric critical care and associate professor of pediatrics and surgery (anesthesiology) at Brown University, Providence, R.I.

“Hospitalists need to convince ourselves of the value we bring to our institutions and to our patients,” said Mark Joffe, MD, director of community pediatric medicine for the Children’s Hospital of Philadelphia.

Dr. Wellikson emphasized that hospitalists do add value to hospitals—whether it’s educating, whether it’s throughput, whether it’s 24/7, whether it’s improving the quality. He said that hospital administrators—the CMOs at your hospital—understand that. “The reason that leadership and that hospitalists are important is that hospitals see you as the solution to many hospital issues,” he said. “When anthrax was thought to be a public health problem, every hospital started a bioterrorism committee and put the hospitalist on it.

“Almost every place I go, they want more of you. You’re better for their bottom line,” he continued. “If they’re ever going to be a better hospital, they need more of you, and they need you motivated, and they need you seeing the right number of patients so that you have the time to do a better job.”

According to Dr. Wellikson, the expectations of hospitalists is that they will improve efficiency, save the hospital money, provide measurable quality improvement (creating standards and measuring compliance), collect data, do things no one else will (e.g., provide uncompensated care, serve on committees).

Dr. Snelling agreed. “The benefit of hospitalists is not in what you bill,” she said, “but in systems improvements, patient satisfaction, QI, initiatives to start or change a program, teaching, cost-savings, and value-added services you provide to the hospital. ... Start with value. Figure out what you want. Identify common ground. Bargaining is the last thing you do.”

Hospitalists create a seamless continuity from inpatient to outpatient, from the emergency department to the floor, from the ICU to the floor. They improve efficiency via throughput and early discharge. They help uncrowd the emergency department and open ICU beds. “We make other physicians’ lives better,” said Dr. Wellikson. “We do a lot of things for the generalists so that they can go and have a better life.”

There is a definite bright side to being a hospitalist right now. According to Dr. Wellikson there are many more jobs than hospitalists—a trend that he predicts will continue for at least for the next five years.

“Don’t let the fact that we have a totally screwed up healthcare system get you down,” he said. “You’re not replaceable. The service you provide, someone must provide. Your hospital has more wastage in durable goods than it spends on pediatric hospitalists. They will pay for expertise.”

Dr. Snelling advised, “Be direct and shameless about compensation. No surgeon works for free unless they want to; no hospitalist should work for free unless that’s your selected charity, and my favorite charity is not the hospital I work for.

“Continually self-promote,” she continued. “Make sure [the person determining your compensation] knows what your successes are. If you’re doing something that’s successful—you get praise, you get a grant, you get a nice letter from a parent—pass that on. Document your value. If you save your hospital a million bucks, why shouldn’t you get a hunk of that? The CEO’s job is to pay you as little as possible.”

One attendee interjected, “I feel uncomfortable with the idea that what I’m doing as a hospitalist is worth more than what my private-practice colleagues are doing. I don’t want to be offensive.”

To which Dr. Snelling replied, “We’re not talking about being elitist. ‘Mine’s bigger than yours.’ What you’re talking about is the differences between C care—the minimum standard—and A care—the hospitalist. ... Who in this room wants to go to an average doctor?”

Dr. Snelling’s bottom line: “My message is not to gouge the system; it’s about respect. In an ideal situation, everybody gains.”

SHOULD PEDIATRIC HOSPITAL MEDICINE BE A BOARD-CERTIFIED SPECIALTY?

“This is a specialty,” emphasized Dr. Snelling during the contract negotiation session.

On the other hand, during the “Future Directions” plenary panel Dr. Wellikson said, “It is almost not relevant whether there is board certification or no board certification.” He described board certification as a way to measure quality.

“Clearly we need to find a way to validate what we’re doing for our good as well as for the good of our patients,” said Doug Carlson, MD, director of the Pediatric Hospital Medicine Program at St. Louis Children’s Hospital and associate professor of pediatrics at Washington University, St. Louis.

Stephen Ludwig, MD, associate chair for medical education at the Children’s Hospital of Philadelphia presented the case for becoming a board-certified specialty. Some benefits: recognition, prestige, job security, and professional advancement.

“Is this just a job, or do you want to fit into—become a thread in—the fabric of organized medicine?” asked Dr. Ludwig. Most important, though, would be the impact on child health. “Is [board certification] good for children and their parents? Unless you can demonstrate that, it won’t happen.”

According to Dr. Ludwig, becoming a board-certified specialty requires a defined body of knowledge, scientific basis, a sufficient number of practitioners, viable academic training programs, sufficient number of trainees willing to go into those fellowship programs, a board exam, geographic diversity, creation of new knowledge (or at least the application of existing knowledge in new ways), the support of national societies and organizations, and the consent of other specialties, such as internal medicine and family practice. It also takes time—likely years.

Some questions pediatric hospitalists still need to consider: Can you fill a void? Is there sufficient novel material for creating a certifying exam? Are there enough people who would take this exam? How will physicians view maintenance of certification? Where will the naysayers come from? What will be the response from primary care general pediatricians? What will be the response from academic generalists/pediatricians? What will be the subspecialist response?

Dr. Ludwig expressed one concern succinctly: “You might ultimately decrease the number of practitioners willing to make the commitment.”

Dr. Wellikson concurred. “Those of you who are group leaders are constantly in a recruiting mode,” he said. “You need something to help you determine who is good and who is not, but adding three years may drive those who would have been great pediatric hospitalists to become great pediatric anesthesiologists.”

In the end, the group could not agree on an answer. “You have an amazing amount of excitement,” said Dr. Ludwig. “Temper your excitement with focus. You need to decide whether becoming another subspecialty is what you want.”

SOMETHING FOR EVERYONE

The conference offered a broad range of learning opportunities.

Those interested in research heard about opportunities to collaborate and learned how to share resources and develop research projects.

Educators—and aren’t all hospitalists involved in education at some level?—learned “Seven Simple Secrets to Successful Supervision” from Vinny Chiang, MD, chief of inpatient services at Children’s Hospital, Boston. He says the single most powerful question you can ask as an educator is, “What do you think?”

“The med student may say, ‘I think the kid is sick.’ The intern may say, ‘I think it’s rejection.’ The resident may say, ‘We need to distinguish between infection and rejection,’” said Dr. Chiang. By asking this question, he said, “You make that trainee an active participant.”

Evidence-based medicine and the use of pathways were also on the agenda. The discussions started with the basics, defining terms. According to Dr. Chiang, evidence-based medicine is, “the conscientious, explicit, and judicious use of current best evidence in making a clinical decision.” (See also “Evidence-Based Medicine for the Hospitalist,” p. 22.)

Pathways, developed from that best evidence, are tools that guide clinical care. “It’s the same as with calculators and PDAs,” said Stephen E. Muething, MD, associate director of clinical services at Cincinnati Children’s Hospital. “A pathway is a tool that allows a resident to spend their time identifying the 20% who shouldn’t be on the pathway and figuring out what to do for them.”

“Medicine can be systematized,” said Dr. Wellikson. “You can have best practices.”

Attendees expressed concerns that pathways may not leave room for a hospitalist’s judgment.

“There is no pathway that addresses 100% of patients,” said Dr. Muething. “A pathway should be defined as a guideline not a standard of care. From a medicallegal standpoint, you need to document why you deviated from a pathway. You still need to use clinical judgment. Don’t forget to think.”

One reason to use pathways, according to Dr. Muething, is that you can more rapidly identify what works and what doesn’t. “If everyone is doing it the same way,” he said, “then even if everyone is doing it wrong, you’ll be able to identify the problem and resolve it more quickly, improving outcome.”

Zoster can occur in immunized kids. Immunization does not preclude disease. We all know that breakthrough can happen.” The question is, “If a kid’s not immunized but exposed to a milder case, will he/she get the milder case? Case studies indicate that’s a possibility. Vaccine may not prevent but mute disease.

—Erin Stiucky, MD

HOT TOPICS

Clinical topics were also on the agenda. On the final day of the conference, Erin R. Stucky, MD, director of graduate medical education, an associate clinical professor in the University of California at San Diego Department of Pediatrics, and a pediatric hospitalist at the Children’s

Hospital and Health Center San Diego, tackled “The Top Five in ’05,” discussing:

1. Bronchiolitis;
2. Emerging pathogens;
3. Venous thrombosis;
4. Fungal infections; and
5. Kawasaki disease (KD).

In a whirlwind review, she presented the latest research on each of these topics.

Bronchiolitis: Surveys reveal that there’s a lot of variability in how hospitalists currently manage bronchiolitis, beginning with whether or not viral testing is helpful. “Testing, do we care? Does more than RSV matter?” asked Dr. Stucky. Her literature review of studies on bronchiolitis reveals, “Actually knowing the viral type is probably not helpful. Think before you test. Prevention is key.”

She also mentioned the need for additional studies on the use of heliox and CPAP in treating the condition.

Emerging pathogens: Dr. Stucky rapidly reviewed West Nile virus, coronavirus, varicella, influenza, MRSA, and pneumococcus. Discussing West Nile, Dr. Stucky said that diagnosing children with the condition can be tricky, particularly because the “predictive value [of diagnostic tests] isn’t 100%,” making the history and exam crucial. Of particular note for pediatric hospitalists, she said, is that the virus can be transmitted in blood, in utero, and via breast milk.

When speaking about coronavirus, Dr. Stucky said, “Transspecies jump (from civets, raccoons, ferrets, mice) is a great concern.” For diagnostic purposes, “Consider travel and exposure to animals.”

On varicella, Dr. Stucky said, “Zoster can occur in immunized kids. Immunization does not preclude disease. We all know that breakthrough can happen.” The question is, “If a kid’s not immunized but exposed to a milder case, will he/she get the milder case? Case studies indicate that’s a possibility. Vaccine may not prevent but mute disease.”

On influenza, the discussion focused upon the reality of the avian strain causing human disease and increasing resistance as farmers use prophylactic doses of antibiotics for their poultry. There is worldwide effect of both human and avian strains. “The hospitalist as leader: public speaking in anxious times and real crises” is critical, said Dr Stucky.

Venous thrombosis: Kids with venous thrombosis typically have at least one known risk factor, with diabetics at increased risk. Thrombolytics can help save a limb or an organ, but “long-term prophylaxis is controversial,” said Dr. Stucky.

Fungal infections: Truly eradicating a fungal infection is difficult, said Dr. Stucky, with recurrence common. There’s currently no empirical evidence to support combination therapy. More research is needed.

KD: “Treat early and often,” said Dr. Stucky. Treatment goals are to stop inflammation, inhibit thrombosis, and avoid stenosis. Because stenotic lesions progress, “long-term therapy and follow-up are needed.” Children with KD should avoid ibuprofen. They should receive the influenza vaccine, but defer measles and varicella vaccines for 11 months after intravenous immunoglobulin.

COMING SOON

The pediatric hospitalists who met in Denver left the conference energized, armed with new leadership skills and clinical knowledge, and asking for more. Organizers are now starting to plan for Pediatric Hospital Medicine 2007. The Hospitalist will keep you posted with information on the next conference as soon as it’s available, and we’ll publish half a dozen additional articles related to pediatric hospital medicine in the coming months.

Keri Losavio is a medical journalist with more than 10 years’ experience writing about healthcare issues.

PEDIATRIC SPECIAL SECTION

In The Literature

Systemic Steroid Use in Pediatric Sepsis Patients

Review by Julia Simmons, MD

Markovitz BP, Goodman DM, Watson RS, et al. A retrospective cohort study of prognostic factors associated with outcome in pediatric severe sepsis: what is the role of steroids? Pediatr Crit Care Med. 2005:6:270-274.

The use of systemic steroids in septic adults with relative adrenal insufficiency has recently been shown to decrease mortality. The use of systemic steroids in the septic pediatric population remains a topic of debate and research focus. The goal of this retrospective cohort study was to determine factors associated with mortality in pediatric patients with severe sepsis treated with systemic steroids.

The authors searched the Pediatric Health Information System for their data. This system is a database for 35 pediatric hospitals within the Child Heath Corporation of America, a children’s hospital consortium. The International Classification Disease Codes for infection were used to search the database for patients from birth through 17 with sepsis during a one-year period.

Severe sepsis was defined as one or more organ dysfunction secondary to an infectious etiology during which the patient required mechanical ventilation and vasoactive medications. The primary outcome variable was mortality. Other variables analyzed included duration of hospitalization, duration of mechanical ventilatory support and vasoactive medications. Predictor variable was the use of parenteral systemic steroids given at least one day during which the patient required artificial ventilation and vasoactive medications.

There were 6,693 participants in the study. Mean days of ventilation was 24.4 +/- 37.3, median 13. Mean number of days hospitalized was 46.8 +/- 51.3 with a median of 30. The mean number of days requiring cardiac supportive medications was 7.8 +/- 9.9 with a median of five. The use of systemic steroids (hydrocortisone, dexamethasone, or methylprednisolone) with increased age, decreased hospital volume, and a history of a hematological/oncological disease were associated with an increased mortality. Even after controlling for the variables, steroids were a strong predictor of mortality. The overall mortality rate in the study was 24%.

In summary, there was an increase in mortality associated with systemic steroid use in the severely septic pediatric patient. As noted by the authors, the study was limited because there was no stratification for disease severity. Further, the rationale for giving the steroids was not known. Overall, larger prospective studies with controlled protocols are necessary in order to make recommendations regarding the use of systemic steroids in septic pediatric patients. TH