Anne F. Brayer

Duration of hospitalization in previously well infants with respiratory syncytial virus infection

To describe the typical hospital course of infection in previously well infants hospitalized with respiratory syncytial virus (RSV) infection, we reviewed the charts of 196 patients with laboratory-proved respiratory syncytial virus infection in the 1987–1988 respiratory disease season. Eighty-seven of the children had been previously well. Their mean duration of hospitalization was 3.4 days. Previously well infants younger than 6 weeks of age experienced significantly longer hospitalizations and more days of supplemental oxygen and were more likely to require intensive care than were older children. Children older than 12 weeks of age were hospitalized for a mean of 2.5 days and did not require intensive care. Oxygen saturation was measured in the emergency room for 67 of the previously well infants; in 42 oxygen saturation was at least 90% whereas in 25 saturation was less than 90% or infants were receiving supplemental oxygen at the time of measurement. Decreased initial oxygen saturation was associated with a prolonged hospitalization (5.3 vs. 3.2 days, P < 0.01) and with more days of supplemental oxygen (4.4 vs. 1.5 days, P < 0.01). We conclude that among previously well infants admitted to the hospital with respiratory syncytial virus infection, infants younger than 6 weeks of age are at in±

RNA transcriptional biosignature analysis for identifying febrile infants with serious bacterial infections in the emergency department: a feasibility study.

Objectives To develop the infrastructure and demonstrate the feasibility of conducting microarray-based RNA transcriptional profile analyses for the diagnosis of serious bacterial infections in febrile infants 60 days and younger in a multicenter pediatric emergency research network. Methods We designed a prospective multicenter cohort study with the aim of enrolling more than 4000 febrile infants 60 days and younger. To ensure success of conducting complex genomic studies in emergency department (ED) settings, we established an infrastructure within the Pediatric Emergency Care Applied Research Network, including 21 sites, to evaluate RNA transcriptional profiles in young febrile infants. We developed a comprehensive manual of operations and trained site investigators to obtain and process blood samples for RNA extraction and genomic analyses. We created standard operating procedures for blood sample collection, processing, storage, shipping, and analyses. We planned to prospectively identify, enroll, and collect 1 mL blood samples for genomic analyses from eligible patients to identify logistical issues with study procedures. Finally, we planned to batch blood samples and determined RNA quantity and quality at the central microarray laboratory and organized data analysis with the Pediatric Emergency Care Applied Research Network data coordinating center. Below we report on establishment of the infrastructure and the feasibility success in the first year based on the enrollment of a limited number of patients. Results We successfully established the infrastructure at 21 EDs. Over the first 5 months we enrolled 79% (74 of 94) of eligible febrile infants. We were able to obtain and ship 1 mL of blood from 74% (55 of 74) of enrolled participants, with at least 1 sample per participating ED. The 55 samples were shipped and evaluated at the microarray laboratory, and 95% (52 of 55) of blood samples were of adequate quality and contained sufficient RNA for expression analysis. Conclusions It is possible to create a robust infrastructure to conduct genomic studies in young febrile infants in the context of a multicenter pediatric ED research setting. The sufficient quantity and high quality of RNA obtained suggests that whole blood transcriptional profile analysis for the diagnostic evaluation of young febrile infants can be successfully performed in this setting.

Spontaneous passage of coins lodged in the upper esophagus.

Coin ingestion with subsequent esophageal coin impaction is common in children. Although spontaneous passage to the stomach of coins at the gastroesophageal sphincter is fairly common, spontaneous passage of coins from the upper or mid-esophagus has only rarely been reported. Thus, in an effort at cost savings, an endoscopist might forego obtaining a second set of radiographs prior to removal of an esophageal coin. We present two cases of spontaneous passage of coins from the upper esophagus, both of which occurred hours after coin ingestion. These cases suggest that spontaneous passage of proximal esophageal coins does, in fact, occur in some children. A second set of radiographs, therefore, may identify these children, and prevent unnecessary invasive removal procedures.

Invasive Meningococcal Disease in Childhood

1. Anne F. Brayer, MD* 2. Sharon G. Humiston, MD, MPH* 1. *Associate Professor of Pediatrics and Emergency Medicine, Department of Emergency Medicine and Pediatrics, University of Rochester, Rochester, NY. After completing this article, readers should be able to: 1. Describe the epidemiology of meningococcal disease, including predisposing host and environmental factors. 2. Recognize early and key clinical features of meningococcal meningitis and severe meningococcal sepsis. 3. Know current treatment guidelines for invasive meningococcal disease. 4. Identify the most common complications and prognosis for meningococcal disease. 5. Be familiar with current vaccination recommendations in the United States. Neisseria meningitidis remains a serious bacterial threat to the well-being of children. Since the introduction of immunization against Haemophilus influenzae and Streptococcus pneumoniae, the risk of serious illness from these organisms has decreased sharply among immunized children, and it is hoped that widespread use of meningococcal conjugate vaccine will lead to the same outcome. The meningococcus causes a variety of disease entities, but this review focuses primarily on its two major manifestations: severe meningococcal septicemia (SMS), sometimes confusingly called “meningococcemia,” and meningococcal meningitis (MM). ### Prevalence Annually, meningococcal disease has affected as many as 3,000 people in the United States. Although outbreaks of illness tend to receive major media attention, fewer than 5% of cases occur during outbreaks. The prevalence of the asymptomatic carrier state varies from less than 2% in children younger than 2 years of age to as high as 10% to 40% among adolescents and young adults. The highest carrier prevalence is among those living in close quarters, such as college students and military recruits. Based on data from the United States Active Bacterial Core Surveillance sites, the estimated average annual incidence of meningococcal disease is 0.53 cases per 100,000 population, with the annual incidence decreasing from 0.92 per 100,000 population in 1998 to 0.33 cases …

Pediatric coin ingestion: an unusual presentation

A 35-month-old child presented to the Emergency Department with a suspected coin ingestion. A physical examination and radiographic examination revealed no evidence of the coin, and the child was prepared for discharge. When the child continued to refuse to drink, digital examination of the hard palate revealed the coin lodged behind the upper incisors. It was only possible to visualize when the patients neck was fully extended. This case represents an unusual presentation of coin ingestion. It points out the importance of a meticulous physical examination and the need for reevaluation when findings are contradictory.

Is Care in Alternative Settings Safe for Infants with Possible Serious Bacterial Infection

Febrile infants are frequently hospitalized for possible serious bacterial illness (SBI). Potential to replace hospitalization of selected febrile infants with care in alternative settings was assessed by estimating risk for deterioration and by determining resource use. Lower and upper bound estimates for the number of infants admitted to a tertiary care hospital from 1994 to 1998 for possible SBI were 537 and 836, respectively. Detailed record reviews were conducted for febrile infants among this group, who, on the basis of positive blood or cerebrospinal cultures, were considered most likely to have SBI. No infant with a positive blood culture who was eligible for alternative setting care (ASC) deteriorated. Ninety-five percent confidence interval for the worst-case (assuming denominator of 537) estimate of risk for deterioration was 0% to 0.56%. Most resource use was compatible with ASC. Alternative setting care for selected febrile infants is both safe and feasible.

Risk of Bacterial Coinfections in Febrile Infants 60 Days Old and Younger with Documented Viral Infections

Objective To determine the risk of serious bacterial infections (SBIs) in young febrile infants with and without viral infections. Study design Planned secondary analyses of a prospective observational study of febrile infants 60 days of age or younger evaluated at 1 of 26 emergency departments who did not have clinical sepsis or an identifiable site of bacterial infection. We compared patient demographics, clinical, and laboratory findings, and prevalence of SBIs between virus‐positive and virus‐negative infants. Results Of the 4778 enrolled infants, 2945 (61.6%) had viral testing performed, of whom 1200 (48.1%) were virus positive; 44 of the 1200 had SBIs (3.7%; 95% CI, 2.7%‐4.9%). Of the 1745 virus‐negative infants, 222 had SBIs (12.7%; 95% CI, 11.2%‐14.4%). Rates of specific SBIs in the virus‐positive group vs the virus‐negative group were: UTIs (33 of 1200 [2.8%; 95% CI, 1.9%‐3.8%] vs 186 of 1745 [10.7%; 95% CI, 9.2%‐12.2%]) and bacteremia (9 of 1199 [0.8%; 95% CI, 0.3%‐1.4%] vs 50 of 1743 [2.9%; 95% CI, 2.1%‐3.8%]). The rate of bacterial meningitis tended to be lower in the virus‐positive group (0.4%) than in the viral‐negative group (0.8%); the difference was not statistically significant. Negative viral status (aOR, 3.2; 95% CI, 2.3‐4.6), was significantly associated with SBI in multivariable analysis. Conclusions Febrile infants ≤60 days of age with viral infections are at significantly lower, but non‐negligible risk for SBIs, including bacteremia and bacterial meningitis.