Victoria Trenchs

Do retinal haemorrhages occur in infants with convulsions

Aim: To determine the prevalence of retinal haemorrhages in infants presenting with convulsions and admitted to hospital, and to consider whether this finding indicates shaken baby syndrome. Methods: Prospective study of children aged 15 days to 2 years admitted with a diagnosis of first convulsion over a 2-year period (May 2004–May 2006). All infants were examined by an experienced ophthalmologist using indirect ophthalmoscopy within 72 h of admission. Results: 182 of 389 children seen in the accident and emergency department were admitted and two were found to have retinal haemorrhages. Both children were eventually diagnosed as being abused. Conclusions: Convulsions alone are unlikely to cause retinal haemorrhages in children under 2 years of age.

Subdural Haematomas and Physical Abuse in the First Two Years of Life

Objective: To analyze our institution’s work-up for patients with a diagnosis of subdural haematoma (SDH) in order to determine how many of them are secondary to child abuse, as well as to examine their final functional outcome. Methods: Retrospective review of children under 2 years of age diagnosed as having SDH between 1995 and 2005. Results: A total of 35 cases were identified. Fifteen patients that had underlying conditions that predispose them to bleed were excluded. Among the remaining 20 patients, seizures and head trauma were the main causes for consultation. All patients had a coagulation study and a head computed tomography carried out, 11 of these had a magnetic resonance imaging and 1 had a post-mortem examination. Bilateral SDHs in different stages of evolution was the most common pattern of intracranial haemorrhage. Fourteen infants had a skeletal survey, 4 had a bone scintigraphy and 19 had an ophthalmoscopic examination. Fractures were diagnosed in 7 patients and retinal haemorrhages in 11. The final diagnoses were: 10 shaken baby syndromes, 4 idiopathic SDH, 3 strokes, 2 coagulopathies and 1 accidental head injury. Upon follow-up, 1 patient had died and 9 had sustained permanent disabilities. Conclusions: Cases of infantile SDH are usually thoroughly investigated. In spite of this, sometimes it is not possible to determine the SDH aetiology. Nonetheless, shaken baby syndrome remains the most frequent cause of SDH in infants, and it carries a poor prognosis.

Minor head trauma and linear skull fracture in infants: cranial ultrasound or computed tomography?

Objective To determine the clinical evolution of children with skull fractures as a result of a minor head trauma from a witnessed accidental fall that have been studied by transfontanellar ultrasound (TFUS). Methods Observational study for 2 years (2004–2006) of children up to 1 year of age who suffered a skull fracture after minor head trauma and for whom a TFUS was carried out as the first neuroimaging test to rule out intracranial injuries. Results One hundred and twenty-three children were evaluated. The mean age was 5.7 months (SD 2.9) and the most common mechanism of injury was rolling off the bed. In seven (5.7%) patients, a computed tomography (CT) was eventually performed after TFUS; in two of these patients, this was because of the detection of possible intracranial alterations and in the others, it was because of a small fontanelle. Both patients with abnormal TFUS had a small epidural haematoma on the CT scan that did not need surgery. The clinical course for all patients was uneventful. Conclusion TFUS is a valid and reliable alternative to CT for minor head trauma in infants with skull fractures. Its innocuousness and cost-effectiveness in comparison with CT makes it a good choice in this situation.

Parental presence during invasive procedures in a Spanish pediatric emergency department: incidence, perspectives, and related anxiety.

Background Family presence during invasive procedures (IPs) is infrequent in Spanish pediatric emergency departments (PEDs), despite the benefits of family presence. Objectives To investigate the proportion of relatives who wish to be present during IP, to determine the percentage of relatives who stayed during IP in our PED, and to evaluate parental anxiety. Methods A prospective observational study was carried out in a PED of an urban, tertiary-care university-affiliated hospital in Barcelona (Spain). A written survey was given to the relatives of children who were admitted to the PED during the month of November 2009. Results Of the 365 given questionnaires, 213 (58.4%) were completed. Ninety-nine percent of surveys were answered by the parents. Mean age of respondents was 37 years (74.6% were women). IPs were performed on 73.3% of patients, and 97.4% of IPs were performed in the presence of relatives. Parents were present during blood sampling (98%), urethral catheterizations (97%), lumbar punctures (LP; 72%), simple wound repair (62%), and fracture reductions (37%). Parents wanted to stay during blood sampling (98%), urethral catheterization (89.9%), LP (82.4%), simple wound repair (88.6%), and fracture reduction (86.5%). Respondents (51.6%) believed that parents should decide on their own whether their presence was desirable. Parents were least anxious during blood sampling and were most nervous during LP. Conclusion Most of the parents wish to stay beside their children during IPs. In our PED, parents were present for more than 95% of IPs. The more invasive the procedure is, the more anxious parents feel.

Retinal hemorrhages and apparent life-threatening events.

Objective: To determine the prevalence of retinal hemorrhages in apparent life-threatening events (ALTEs) with the purpose of facilitating the differential diagnosis of the cases of nonaccidental head trauma. Methods: Prospective study on children aged 15 days to 2 years admitted to our hospital with a diagnosis of an ALTE over a period of 2 years (May 2004-May 2006). All the children underwent detailed ophthalmologic examination within 72 hours of admission. If retinal hemorrhages were detected, further investigation was undertaken to rule out systemic disorder or maltreatment. Results: One hundred eight children with an ALTE were examined. No patient was found to have retinal hemorrhages nor was any found to have experienced child abuse. Therefore, using the Hanley rule of 3, we can be confident to an upper limit of 95% that the chance of retinal hemorrhages occurring as a result of an ALTE alone is at the most 0.028. Conclusions: Apparent life-threatening events alone are unlikely to cause retinal hemorrhages in children younger than 2 years. Therefore, if retinal hemorrhages are detected, investigation into the possibility of nonaccidental injury is essential.

Afebrile very young infants with urinary tract infection and the risk for bacteremia.

Background: Some authors have assessed the utility of considering various risk factors in predicting bacteremia in young infants with urinary tract infection (UTI) in studies that included only febrile patients. Our aims were to determine whether fever was a predictor for bacteremia and to identify other associated risk factors. Methods: A retrospective study was conducted that included infants 29 to 90 days of age with UTI attended in the Pediatric Emergency Department from September 2006 through May 2013. UTI was defined as growth of ≥50,000 colony forming units/mL of a single pathogen from a catheterized specimen in association with an abnormal urinalysis. Patients without a blood culture were excluded. Univariate testing was used to identify clinical and laboratory factors associated with bacteremia. Receiver operating characteristic curves were constructed for the laboratory markers associated with bacteremia. Results: We analyzed 350 patients; 77 (22%) were afebrile. Ten had bacteremia (2.9%, 95% confidence interval: 1.6%–5.2%). No other adverse events were identified. No differences were found in bacteremia rates between febrile and afebrile patients (2.9% vs. 2.6%; P = 1.0). Risk factors detected for bacteremia were classified as not well-appearing (25.0% vs. 2.1%; P = 0.003) and a procalcitonin value ≥0.7 ng/mL (6.4% vs. 0.5%; P = 0.001). These low-risk criteria yielded a sensitivity of 88.9% for detecting bacteremia with a negative predictive value of 99.5%. Conclusions: Afebrile young infants with UTI should not be classified a priori as low risk for bacteremia. Well-appearing young infants with UTI and procalcitonin value <0.7 ng/mL were at very low risk for bacteremia; outpatient management with an appropriate follow-up could be considered.

Is pertussis in infants a potential cause of retinal haemorrhages

Aim To determine the prevalence of retinal haemorrhages in infants with pertussis infection with the purpose of clarifying the differential diagnosis of the cases of abusive head trauma. Methods Prospective study of children aged 15 days to 2 years admitted to our hospital with a diagnosis of pertussis over a period of 4 years (May 2004–May 2008). All children underwent one detailed ophthalmological examination within 72 h of admission. If retinal haemorrhages were detected, further investigation was undertaken to rule out systemic disorder or maltreatment. Results 35 children with pertussis infection were examined. None was found to have retinal haemorrhages. Therefore, applying Wilsons method, the data suggest with 95% confidence that the true effect estimate for retinal haemorrhage occurring due to symptomatic pertussis infection requiring admission to hospital is no higher than 9.9%. Conclusions Pertussis infections are unlikely to cause retinal haemorrhages in children under 2 years of age.