Shaul Sofer

Ambulatory care of febrile infants younger than 2 months of age classified as being at low risk for having serious bacterial infections.

We prospectively examined whether febrile infants younger than 2 months of age who were defined as being at low risk for having bacterial infection could be observed as outpatients without the usual complete evaluation for sepsis and without antibiotic treatment. A total of 237 previously healthy febrile infants were seen at the Pediatric Emergency Room over 17 1/2 months. One hundred forty-eight infants (63%) fulfilled the criteria for being at low risk: no physical findings consisting of soft tissue or skeletal infections, no purulent otitis media, normal urinalysis, less than 25 white blood cells per high-power field on microsopic stool examination, peripheral leukocyte count 5000 to 15,000/mm3 with less than 1500 band cells/mm3. One infant appeared too ill to be included, and had sepsis and meningitis. None of the 148 infants at low risk had bacterial infections, versus 21 of 88 (24%) of those at high risk (P less than 0.0001); eight of 88 (9%) had bacteremia. Of the 148 infants classified as being at low risk for having bacterial infection, 62 (42%) were discharged to home, and 72 (49%) were initially observed for less than or equal to 24 hours and then discharged. Seventeen infants (11%) were hospitalized: in six, low risk became high risk; six had indications other than fever; and five because the study physicians could not be found. The 137 nontreated infants were closely observed as outpatients. The duration of fever was less than 48 hours in 42%, and less than 96 hours in 91%. All infants were observed for at least 10 days after the last examination. The fever resolved spontaneously in all infants but two, with otitis media, who were treated as outpatients. Our data suggest that management of fever in selected young infants as outpatients is feasible if meticulous follow-up is provided.

Interleukin-6 release following scorpion sting in children

Interleukin-6 levels were measured in the serum of ten children following severe scorpion envenomation. Measurements were taken on arrival, at the emergency room, and 12 and 24 hr after arrival. Interleukin-6 was markedly elevated in the serum of eight out of ten children on arrival. Interleukin-6 levels gradually decreased toward normal values on 12 and 24 hr measurements, but remained above control levels on all measurements. These results imply that signs and symptoms following scorpion envenomation may in part be explained by release of cytokines. Human and experimental animal studies are required in order to verify the assumption that interleukin-6 and other cytokines are involved in the pathogenesis of scorpion envenomation.

Carbamate and organophosphate poisoning in young children

OBJECTIVE Retrospective evaluation of the clinical course of carbamate and organophosphate poisoning in young children. DESIGN The records of 36 children intoxicated with carbamate and 16 children intoxicated with organophosphate (age range: 2 to 8 years, median: 2.8 years) were examined retrospectively. The carbamate agents were identified as methomyl or aldicarb, and the organophosphate as parathion, fenthion, malathion, and diazinon. The causes of poisoning were accidental ingestion in 46 children and inhalation in six children. CLINICAL SETTING Pediatric Intensive Care Unit of a teaching hospital. INTERVENTIONS Gastric lavage was performed, and activated charcoal was administered to all children who had ingested poisonous pesticides. Atropine sulphate was administered intravenously in repeated doses to all children with bradycardia, diarrhea, salivation, and miosis. Obidoxime chloride was administered to patients with organophosphate poisoning and to those in whom the ingested material was unidentified on admission. RESULTS Predominant symptoms were related to central nervous system depression and severe hypotonia. Other clinical signs such as miosis, diarrhea, salivation, bradycardia, and fasciculation were less frequent, while tearing and diaphoresis were not observed. Pulmonary edema developed in six patients with organophosphte poisoning. Three children required mechanical ventilation for several hours. One child (organophosphate poisoning) died shortly after arrival at the emergency department. All other children recovered completely. CONCLUSION Based on a relatively large group of young pediatric patients with carbamate and organophosphate poisoning, it is concluded that the clinical presentation differed from those described in adults. Absence of classic muscarinic effects does not exclude the possibility of cholinesterase inhibitor agents poisoning in young children with central nervous system depression.

Repeat computed tomographic scan within 24-48 hours of admission in children with moderate and severe head trauma.

Objective: To asses the yield and contribution of a routine predetermined repeat head computed tomographic (CT) scan within 24‐36 hrs in pediatric patients with moderate to severe head trauma. Design: Records review. Setting: Five pediatric intensive care units. Patients: We reviewed the charts of 173 consecutive pediatric patients with moderate to severe head trauma (Glasgow Coma Scale score of ≤ 11) that survived the first 24 hrs after being admitted to five Israeli trauma centers. Clinical data collected included status at admission, at the time between the first and second CT scans, and after the second scan. Head details of the first, second, and, if performed, third CT scan were collected. Treatment strategy during each period was recorded, including any change in treatment after each CT scan. Measurements and Main Results: A total of 47 (27%) of the second CT scans showed new lesions including six intracranial hemorrhages, 17 cases of worsening brain edema, and 18 newly diagnosed brain contusions. However, none of these findings necessitated surgical intervention or any change in therapy. Of the 67 patients who underwent a third CT scan, two cases required surgical intervention because of new findings in the third CT. Conclusions: A second routine prescheduled head CT scan within 24‐36 hrs after admission in pediatric patients with moderate to severe head trauma is unlikely to yield any change in therapy. Clinically and intracranial pressure‐oriented CT scan may better select and diagnose patients who require changes in therapy, including surgery. Studies aimed to determine the ideal timing for the second are warranted.

Carbamate and organophosphate poisoning in early childhood

Twenty-five infants and young children intoxicated by carbamate and organophosphorus compounds are described. Presenting signs and symptoms in children differed from those described in adults and were mainly related to severe CNS depression, coma and stupor, dyspnea, and flaccidity. Other clinical signs such as miosis, excessive salivation and tearing, sweaty, cold skin, and gastrointestinal symptoms were less frequent, while fasciculations and bradycardia were quite uncommon on arrival. Only two patients presented with all typical signs of organophosphate poisoning as described in adults. Signs of carbamate poisoning were indistinguishable from those of organophosphate poisoning and included signs of myoneural and CNS cholinergic receptor involvement, in addition to parasympathetic muscarinic dysfunction. Atropine sulfate was found to have a clear beneficial CNS effect in addition to its known peripheral antimuscarinic effect. Our data suggest that the clinical presentation of carbamate and organophosphate poisoning in early childhood and its response to therapy are quite different from those of adults and older children.

Acute pancreatitis in children following envenomation by the yellow scorpion Leiurus quinquestriatus

Plasma immunoreactive cationic trypsin (ICT), which is a specific and highly sensitive indicator of pancreatic injury, was measured in 14 children with signs of systemic envenomation following a sting by the scorpion Leiurus quinquestriatus. High ICT levels were found in 13 children (93%), indicating that acute pancreatitis is a common complication of envenomation by this scorpion. The pancreatitis may account for the abdominal pain and vomiting commonly seen in scorpion envenomation and may also contribute to the agitation and discomfort noted in young children.

Hydrocarbon Poisoning in Children: A 5-Year Retrospective Study

OBJECTIVE To investigate the demographics, incidence, and symptoms and signs of hydrocarbon poisoning in admitted children from the Negev Desert area of Israel. METHODS The medical records of all children admitted for hydrocarbon poisoning from 1995 to 1999 were reviewed retrospectively. RESULTS Of the 274 admitted children, 61% were boys and 39% were girls, with ages ranging from 6 months to 18 years (median, 1.58 years). Ninety-four percent of the patients were Moslem Arab Bedouins, and 6% were Jews. The largest group of patients (106) was admitted during the summer months (P < .003). Also, more patients were admitted in spring (63) and autumn (67) than in winter (38) (P < .013). Thirty-two percent of the cases were seen in the Pediatrics Ambulatory Unit and then discharged, while 68% were hospitalized. The most commonly observed symptoms were tachypnea (73.7%), fever (63.5%), vomiting (51.1%), and cough (38.0%). About one third of the patients showed signs of central nervous system (CNS) impairment, including drowsiness, restlessness, stupor, and convulsions. These symptoms were significantly correlated with pneumonia, hypoxemia, and fever (P < .001). Of 274 patients, 43% (118 children) had pneumonia--usually interstitial pneumonitis (90%). Vomiting was significantly correlated with pneumonia (P < .05). CONCLUSIONS 1) There is a higher risk of hydrocarbon poisoning during the hot months of the year; 2) the respiratory system is the main target organ affected; 3) pneumonia is in most cases interstitial and bilateral; 4) vomiting after hydrocarbon ingestion is related to the rate of development of pneumonia; 5) symptoms of CNS impairment were correlated with hypoxemia, pneumonia, and fever; and 6) CNS toxicity may occur without hypoxemia, concurrent pulmonary pathology, or other pathology.

Obstructive sleep apnea in young infants.

Obstructive sleep apnea (OSA) was diagnosed in 14 infants less than 18 months of age. Snoring, apnea, failure to thrive, developmental delay and recurrent respiratory infections were the main presenting symptoms. The diagnosis was made by polysomnographic studies or overnight monitoring. Adenotonsillectomy resulted in the relief of symptoms and signs in 13 children. In one infant prolonged nasopharyngeal intubation was needed. An increased awareness of OSA in young infants may prevent the delay in diagnosis, will allow early treatment and thus prevent the development of sequela or complications associated with this syndrome.

Hemodynamic effects following injection of venom from the scorpion Leiurus quinquestriatus

PURPOSE The present study tested the hypothesis that scorpion sting induces left ventricular (LV) hypokinesia and myocardial ischemia shortly after injection due to reduction of coronary blood flow (CBF) and increased oxygen demand. METHODS In 5 mechanically ventilated, open-chest dogs, we measured LV function following i.v. injection of venom (0.05 mg/kg) obtained from the scorpion Leiurus quinquestriatus. Hemodynamic responses to the venom were followed up for 90 minutes. RESULTS The venom induced significant combined respiratory and metabolic acidosis (arterial pH progressed from 7.35 +/- 0.03 at baseline to 7.10 +/- 0.06 at 90 minutes). There were large increases in blood pressure, LV end systolic pressure, stroke work, and velocity of contraction. Twenty minutes following venom injection, cardiac output (CO) increased by 37% but then declined to 36% below baseline by 90 minutes (P < .05). CBF increased significantly in proportion to increased perfusion pressure; hence, there was no change in coronary vascular resistance. There was no evidence of myocardial ischemia or LV dysfunction because there was no change in myocardial pH, percentage fiber shortening, or LV end-diastolic pressure. Despite the fact that some variables returned to baseline at 90 minutes, they did not reach steady state; thus, the preparation would have continued to deteriorate. CONCLUSIONS Myocardial ischemia does not occur in this dog model immediately following administration of scorpion venom. There are significant peripheral circulatory effects of the venom, which account for many of the hemodynamic changes.

Differences in the epidemiology of childhood community-acquired bacterial meningitis between two ethnic populations cohabiting in one geographic area

A comparison of the epidemiology of community-acquired bacterial meningitis between Jewish and Bedouin populations cohabiting one geographical area is reported here. During the years 1981 to 1985, 100 children younger than 13 years old with community-acquired bacterial meningitis were hospitalized. Seventy-one patients were younger than 12 months. The principal bacteria isolated were Haemophilus influenzae 42%; Streptococcus pneumoniae 29% and Neisseria meningitidis 20%. The case fatality rate was 12%. The chance of acquiring meningitis during the first 5 years of life was twice as common among Bedouins than among Jews (328/100,000 vs. 173/100,000, respectively; P less than 0.0001). The most common cause of meningitis during the first year of life was S. pneumoniae among Bedouins and H. influenzae among Jews. Meningitis caused by H. influenzae and S. pneumoniae was usually associated with respiratory morbidity during fall and winter among Jews, but with diarrheal morbidity during summer and fall among Bedouins. Since the most prevalent type of morbidity among Jews results from respiratory infections and among Bedouins from diarrhea, our findings suggest that community-acquired bacterial meningitis is associated with the type of morbidity most prevalent in the community at any given season rather than with a specific type of infection.