UMEM Educational Pearls - By Rachel Wiltjer

Standard practice regarding various pediatric fractures has started to shift over the last several years, often to less restrictive means of treatment. Torus (buckle) fractures of the distal radius are one of the most common pediatric fractures and tend to heal very well with minimal intervention. 

The FORCE study (FOrearm fracture Recovery in Children Evaluation), a multicenter study out of the UK, was conducted to compare rigid immobilization (splinting) to a soft bandage used as needed per family discretion for treatment of these fractures. There was no different in outcomes of self-reported pain, function, quality of life, complications, or school absences. UK orthopedic guidelines have been updated to reflect a recommendation against rigid immobilization as well as against any need for specialist follow-up. American guidelines are slower to follow suit, but in recent years have transitioned to an approach of a removable brace. 

Take Home: Pediatric torus fractures of the distal radius likely do not require immobilization and can be managed with self-limited activity instead. Practice in the US is in flux, but it is reasonable to manage with a removable brace or soft dressing as well as pediatrician follow up.

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Kids eat everything (except perhaps carefully prepared and balanced meals). While button battery ingestions are feared, there is more to worry about. Magnet ingestions – especially rare earth metal magnet ingestions – can lead to high morbidity and mortality.

When more than one magnet (or a magnet and another metallic object) are ingested, they can become stuck together through walls in the GI tract, creating risk for obstruction, erosion, fistula formation, and perforation. Sharp metallic foreign objects can be particularly dangerous as they can do much damage while being moved around by the magnet.  

If there is concern for magnet ingestion, care should be taken to try to determine the number ingested (if parents have the magnets, you can compare the size of an object on xray to the size of the magnets as it can otherwise sometimes be difficult to differentiate if it is one magnet or more than one stuck together).  

Higher risk features of ingestion include: 

  • Ingestion of a magnet and a sharp metallic object
  • Higher number of magnets ingested
  • A longer interval over which the magnets were ingested
  • Multiple magnets in the esophagus (raises concern for concomitant aspiration)

 

Ingestions should prompt consultation with pediatric GI and surgery when isolated as many will require either endoscopic or surgical removal. This may include need for referral and transfer.  

 

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Some things are easy, even reflexive, and one of those things is putting oxygen on cyanotic patients. Usually, this is a great thing. Blue = bad. Occasionally, though, blue = baseline and even in those patients who are too blue, you want to keep them closer to purple than pink. 

This issue is commonly encountered in certain types of congenital heart disease and as well as through various phases of their repair. These include ductal dependent lesions, those with significant shunts, and single ventricle physiology. Oxygen functions as a pulmonary vasodilator and can increase or change the direction of shunting, directly impacting physiology by causing pulmonary overcirculation, increased strain on the right ventricle, and decreases in systemic circulation. 


Helpful Hints:

1) Find out and shoot for the patient’s goal oxygen saturation range (many lesions will be 75%-85%). This may be available from parents, in the EMR, or by calling the child’s cardiac center if they are an established patient.

2) In an undiagnosed neonate with hypoxia and signs of heart failure (crackles, enlarged liver, edema to the sacrum and/or occiput) or if unresponsive to initial trial of oxygen, decrease FiO2 and titrate support (nasal cannula with blender to set FiO2, HFNC, NIPPV, or intubation if necessary) to address respiratory distress as well as evaluation and treatment for ductal dependent lesions. 

3) You may still need to use additional FiO2 to obtain reasonable oxygen saturations, but titrate thoughtfully.

 

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Category: Pediatrics

Title: Putting the 'Omph' in Omphalitis

Keywords: Pediatrics, infections, neonatal (PubMed Search)

Posted: 5/5/2023 by Rachel Wiltjer, DO (Updated: 3/29/2024)
Click here to contact Rachel Wiltjer, DO

Neonatal rashes are common and, usually, benign. There are some skin findings, however, that require early recognition and treatment for best outcomes. One of these concerning etiologies is omphalitis, infection of the umbilical stump and surrounding tissues.

Features of omphalitis may include erythema and induration around the umbilicus, purulent drainage, and potentially systemic illness.

Risk factors include poor cord hygiene, premature or prolonged rupture of membranes, maternal infection, low birth weight, umbilical catheterization, and home birth.

Evaluation includes surface cultures from the site of infection as well as age-appropriate fever workup if patient is febrile. Consider ultrasound to evaluate for urachal anomalies as these can co-exist.

Management is IV antibiotics to cover S. aureus and gram negatives with surgical consultation if there are signs of necrotizing fasciitis or abscess. Some newer literature suggests that patients with omphalitis seen and treated in high-income countries may not be as sick as previously thought (as most data has been obtained in lower income countries where incidence is higher) and there has been a suggestion that there may be a role for oral antibiotics in well appearing, lower risk infants. This deserves further exploration but cannot yet be considered standard of care.

Other umbilical cord findings to consider (when it isn’t omphalitis): patent urachus, granuloma, local irritation, or partial cord separation

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Background: Intranasal dexmedetomidine has seen usage in the anesthesia and sedation realms over the past few years, with an increasing interest in usage in the ED setting given its generally favorable safety profile and ease of administration. There has been specific interest and consideration in children with autism and neurodevelopmental disorders.

Study: Single center prospective provider study (compared to a retrospective group of patients under 18 who received oral midazolam for indications of agitation or anxiety via chart review) looking at patients 6 months to 18 years of age with an order for intranasal dexmedetomidine. Following use, a provider survey was completed to evaluate indication/rationale for use, satisfaction, comfort with use, and perceived time to onset as well as duration of effect.   

Results: 29% of patients receiving IN dexmedetomidine experienced treatment failure compared with 20.7% of patients receiving oral midazolam (not statistically significant). In subgroup analysis, rates of treatment failure were lower for patients diagnosed with autism spectrum disorder receiving IN dexmedetomidine versus oral versed (21.2% versus 66.7%). Length of stay was longer in the IN dexmedetomidine group (6.0 hours versus 4.4 hours). Indication for use had variability between the two groups.  

 

Bottom Line: IN dexmedetomidine may be a reasonable agent to utilize for anxiolysis in pediatric patients, especially those who have previously had paradoxical reactions or poor efficacy of benzodiazepines. It may be specifically useful when effects are desired for a slightly longer time and for non-painful/minimally painful interventions 

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Otitis media is a common pediatric complaint seen in the primary care, urgent care, and ED settings. Recommendations for timing of treatment and deferral of treatment have emerged over the last several years, as have recommendations for regimens for recurrent infections in the age of resistant organisms.

When to consider observation over antibiotics:

  • If symptoms <48 hours, no severe pain, and fever < 39C and child is 2 years or older (either unilateral or bilateral AOM) OR unilateral AOM with symptoms <48 hours, no severe pain, and fever < 39C and child is 6 months to 2 years
  • If observing, consider either a prescription that parents can fill if symptoms persist or ensure prompt primary care follow up

Initial treatment

High dose amoxicillin (90 mg/kg/day divided BID)

  • If true penicillin allergy, can use cefdinir or cefpodoxime if tolerated or trimethoprim-sulfamethoxazole or a macrolide (e.g. azithromycin) but rates of resistance are higher
  • Cefdinir and azithromycin are the most commonly used  
  • Levofloxacin is also an option for age >8 years

Recurrent Otitis Media

If less than 30 days from initial treatment, presumed to be persistent

  • If previously on amoxicillin, start amoxicillin-clavulanate (extra strength suspension has highest amoxicillin to clavulanate ratio and should be used)
  • If previously on amoxicillin-clavulanate, ceftriaxone either for 3 days or 2 doses 36 hours apart

If greater than 30 days from initial treatment can treat as new episode (so amoxicillin unless previous documented resistant infections)

Duration of Antibiotics

  • Less than 2 years, 10 days
  • 2 years and up, 5-7 days

Other Considerations

  • Amoxicillin-clavulanate should be used as an initial agent if there is concurrent purulent conjunctivitis
  • Children with tympanostomy tubes and purulent otorrhea may be treated with otic fluoroquinolones (with or without dexamethasone), as long as debris does not obstruct entry of antibiotic drops
  • Remember that the otic canal and TM can become red with fever and non-purulent effusion is common with URI
  • Remember to treat pain and fever!

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Universal Human Rights

  • Human rights are rights inherent to all human beings, whether our nationality, place of residency, sex, national or ethnic origin, color, religion, language defines , or any other status 

  • The United Nations Human Rights Council (UNHRC) defines seven substantive rights: the right to life, freedom from torture, freedom from slavery, right to a fair trial, freedom of speech, freedom of thought, conscience and religion, and freedom of movement 

  • The right to life is the essential right that a human being has a right not to be killed by another human being. This has been central in debates on issues of abortion and euthanasia. 

  • Emergency care is an often overlooked, but essential component of the right to life in the highest attainable standard of health and universal health coverage (UHC - a WHO description used to describe access to care). Particularly for vulnerable and disadvantaged populations, emergency care is often the last chance for the health system to save a life.

  • The focus on vulnerable populations with little access to care and subsequent poor health outcomes has many similarities to the delivery of emergency care. Emergency conditions, such as traumatic injuries, disproportionately affect people in low- and middle-income countries. About 90% of the burden of death and disability from injuries occurs in low- and middle-income countries

  • COVID-19 emphatically highlighted how far countries (and differences in regulations between states in the US) are from meeting the supreme human rights command of non-discrimination, from achieving the highest attainable standard of health that is equally the right of all people everywhere, and from taking the human rights obligation of international assistance and cooperation seriously. 

  •  Implementation of a rights-based framework for emergency care requires countries to enact legislation that ensures access to non-discriminatory emergency care and establish a regulatory body with appropriate oversight and authority to enforce these laws.



 

Childhood vaccination has significantly decreased the incidence of bacterial meningitis and bacteremia in infants and young children, specifically vaccines against H. influenzae and S. pneumoniae, shifting broad workups for these disease and empiric antibiosis to younger age groups as rates declined. In recent years the percentage of unvaccinated and under-vaccinated children has been rising due to multiple factors; now over 1% of children in the US under 2 years of age are unvaccinated. The question becomes, should these children be treated more similarly to young infants as they lack to immunity to these organisms?

Literature on this topic is sparse, although, Finkel, Ospina-Jimenez, et al. reviewed the literature available and proposed an algorithm for well appearing children 3-24 months of age without a clear source and a temperature of >39C (102.2F). Recommendations included UA (to determine possible source) in the following patients: fever > 2 days, prior UTI, female or uncircumcised male <12 months, or male <6 months. They also recommended evaluation with viral panel. If no source was determined, they then recommended CBC and procalcitonin with a CXR for WBC > 20,000/mm3. For WBC >15,000/mm3, ANC >10,000/mm3, absolute band count >1,500/mm3, or procalcitonin >0.5ng/mL they recommended blood culture, ceftriaxone 50 mg/kg, and follow up within 24 hours.

Bottom line: Literature is scarce and practice patterns are likely to evolve as ramifications of decrease in vaccination rates become clearer. The above algorithm is proposed, however covers limited situations and may not be practical in all settings. Clinical judgement should be used in the evaluation and management of these patients. A more conservative approach compared to vaccinated infants is reasonable at this time.

 

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Approximately 1.4 million transgender and gender nonbinary patients live in the United States. Unfortunately, prior research has shown negative experiences with the health system are common after disclosing their trans/NB status. As a result, almost a ¼ report avoiding or delaying needed health care.

 

This qualitative study interviewed a subset of trans/NB individuals about their experiences visiting emergency departments. Several key themes emerged:

  • ED intake forms are commonly unequipped to reflect patients’ pronouns and chosen names. This leads to downstream misgendering and the use of deadnames.
  • Patients often fielded inappropriate questions and comments unrelated to their medical care
  • Many patients felt they had to educate clinicians regarding issues of trans health, rather than the other way around
  •  These negative experiences decreased the likelihood patients would return for needed medical care

 

Overall, the study found that clinicians have many opportunities to improve the care of transgender and nonbinary patients, including updating forms, using inclusive language, avoiding medically unnecessary questions, and providing training for staff on trans/NB health.

 

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IPV can occur once or over years by a current or former romantic partner.  Types of IPV include: Physical and/or Sexual violence, Stalking, and Psychological/Financial aggression (the use of verbal and non-verbal communication to harm mentally or emotionally and to exert control over another partner). 

IPV is more prevalent that Aortic Dissection and Pulmonary Embolism combined.   Think about how risky it is to NOT recognize IPV.

1:4 women and 1:10 men have been victims of IPV during their lifetime.

1:5 homicide victims are killed by an intimate partner.

Over 50% of female homicide victims are killed by a current or former intimate partner.  Patients who have been strangled are 4 times more likely to be killed within a year.

Your Spidey Sense should go off when:

  1. Stories Change
  2. History doesn’t match up with injuries
  3. Injuries in areas that are concealed, multiple injuries of varying ages, defensive wounds
  4. Major delays in seeking care
  5. Non-specific complaints - headache, gastric issues
  6. Multiple ED visits at odd hours
  7. Refusing the use of an interpreter by partner (why we always use an official interpreter)

 

Once patient is identified as a victim:

  1. Place victim in a safe, inaccessible by visitors, and hidden area
  2. Treat all medical issues
  3. Contact Social Work/SAFE/SANE examiner (some institutions will have IPV specific resources)
  4. Contact police if patient is willing to report
  5. Safe disposition
  6. If unable to ensure a safe disposition, be very careful about documentation provided in discharge paperwork and language used

 

 

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Subcutaneous Fluid Administration for Rehydration

  • An old school technique (described in the 1800’s) that fell out of favor but still has applicability - primarily in pediatrics although it has been explored for use in geriatrics and mass casualty events (due to ease and speed of use)
  • Most appropriate for stable but mildly to moderately dehydrated patients who need rehydration, are not tolerating PO, and in whom an PIV is difficult to establish (this should not replace an IO in a critically ill child)
  • Either a small gauge angiocath or butterfly can be used for access
  • Most common area to access in younger children is between the shoulder blades, although the lateral abdomen, thighs, or outer upper arms can be used as well; the site must have adequate subcutaneous tissue (can test by pinching between the fingers)
  • Subcutaneous catheter placement is generally quite easy, however care should be taken with securing the catheter as there will be expected swelling at the area which can cause dislodgement or discomfort
  • Mild erythema may also occur at the site of administration
  • Injection of hyaluronidase (150 U) at the site being used increases the volume that can be administered as well as speed of absorption (hospitals may carry this product for treatment of severe PIV infiltration events)
  • It is not necessary to have hyaluronidase to utilize subcutaneous fluid administration, but improves efficiency and efficacy
  • Fluids administered should be isotonic and can be administered at 20 mL/kg over an hour – this can be repeated as necessary

 

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Category: Pediatrics

Title: What Sound Does an ALCAPA Make?

Keywords: pediatric cardiology, ALCAPA (anomalous left coronary artery from the pulmonary artery) (PubMed Search)

Posted: 10/7/2022 by Rachel Wiltjer, DO
Click here to contact Rachel Wiltjer, DO

 

  • Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital defect in which there is an altered origin of the left coronary artery (also known as Bland-White-Garland syndrome)
  • Generally asymptomatic at birth, but can present in late infancy, toddlerhood, or later with signs of congestive heart failure, a myocarditis picture, or sudden cardiac death
  • Flow through the left coronary artery is normal at birth due to high pulmonary pressures, but as those pressures drop the blood flow drops as well and may become reversed due to the pressure gradient
  • This can cause chronic myocardial ischemia, the severity of which, is dependent on collateral flow
  • Most patients will also develop mitral regurgitation
  • Cardiomegaly may be seen on CXR (and some patients will present with respiratory symptoms/wheezing)
  • EKG findings include: findings consistent with ischemia (ST changes, q waves – specifically in the anterolateral leads), leftward axis (for age), abnormal R wave progression (loss of R wave amplitude in affected leads)
  • Diagnosis can generally be made with echocardiogram (although not 100% sensitive) and the disease is generally treated with surgical repair

 

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Approximately 284,000 immigrants reside in Baltimore (10% of the total population). In April 2022, Governor Abbott of Texas began sending migrants from the US southern border to Washington, DC, with Arizona joining soon after. It is important for emergency providers to be aware of these changes and how new disparities may arise.

1. Social Determinants of Health: A meta-analysis in 2018 suggests that Health literacy is a key determinant of health in refugee and migrant populations living in in high-income countries such as America. Using patient centered language and taking time to explain diagnoses are CRITICAL in caring for immigrant populations particularly in the ED. Use of appropriate language services are also important.
 

2. Assess acute vs non-acute needs: A study done in pediatric migrant populations suggests that the severity of the reasons for visiting the ED and the hospitalization rates were not higher in the pediatric migrant population than in the general pediatric population. Some common non-urgent diagnoses include scabies, anemia, oral and dental disorders.

 

3. Create a safe environment: In a study done in 2013, up to 12% of undocumented immigrants that presented to the ED expressed fear of discovery and consequent deportation. On further assessment there was the belief that medical staff are required to report these patients to immigration. It is important to proactively address inaccurate beliefs to promote a safe trusting environment.

 

Resources in Baltimore/Maryland:

-CASA

-Esperanza Center

-International Rescue Committee

- John's Hopkins Centro Sol

- National Immigration Law Center

 

National Resources (US):

-Rural Health Information Hub

-National Resource Center for Refugees, Immigrants, and Migrants

 

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  • TXA has been used for pediatric non-traumatic (surgical) bleeding with good evidence
  • Currently used in around 1/3 of pediatric trauma centers based on survey data
  • PED-TRAX (retrospective review of pediatric trauma admissions in a combat zone) showed an association between use of TXA and decreased mortality, with no increase in thromboembolic events
  • Dosing strategies in the literature and in practice have been variable (bolus at variable dosing versus bolus + infusion)
  • The TIC TOC trial was recently completed - a multicenter randomized pilot study looking at 2 dosing strategies of TXA versus placebo which demonstrated feasibility of a larger study and will hopefully serve as a model for further research to determine efficacy as well as ideal dosing

 

Bottom line: There is not clear evidence for efficacy, but trends are positive and the documented rates of adverse effects in this population are low. It is reasonable to give, especially in patients requiring massive transfusion or who are critically ill.

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  • Use of FAST is less common in pediatric trauma than in adult trauma
  • FAST in pediatric trauma has a lower negative predictive value than in adults
    • 1/3 of pediatric patients with hemoperitoneum on CT will have a negative FAST
    • Lowest sensitivity and specificity is in the under 2 years age group
  • A 2017 randomized clinical trial of ~900 patients showed no difference in clinical care, use of resources, or length of stay in hemodynamically stable children who received FAST + standard trauma evaluation versus standard trauma evaluation alone
  • There may be a role for FAST as a screening in patients with low suspicion for intraabdominal injury in conjunction with labs and physical exam, but this has not been fully explored

Bottom line: A positive FAST warrants further workup and may be helpful in the hemodynamically unstable pediatric trauma patient, but a negative FAST does not exclude intraabdominal injury and evidence for performing FAST in hemodynamically stable pediatric patients is limited.

 

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Category: Pediatrics

Title: Environment Modifications for Autism in the ED

Keywords: autism spectrum disorder, neurodevelopmental disorder (PubMed Search)

Posted: 5/6/2022 by Rachel Wiltjer, DO (Updated: 3/29/2024)
Click here to contact Rachel Wiltjer, DO

 

  • Autism spectrum disorder and other neurodevelopmental disorders can predispose to challenging ED encounters secondary to difficulties with sensory processing and communication
  • Small changes to the environment can help to reduce stress, generally by decreasing stimulation
  • Use quieter areas of the ED when possible, decrease volume of alarms, and consider noise cancelling headphones or white noise if available
  • Consider dimming the lights, turning the monitor/computer screen away from the patient
  • Allow the patient to remain in their own clothing and consider whether restrictive items such as the monitor, pulse oximeter, and blood pressure cuff are necessary (but continue to use them when they are medically appropriate)
  • Offering distraction via electronics, fidget toys, or weighted blanket (or lead apron) may help with managing stress
  • Ask the patient or family which modifications would be helpful for the patient and ask child life for assistance where available

 

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Category: Pediatrics

Title: Organic Acidemias - What you Need to Know in the ED

Keywords: inborn error of metabolism (IEM), organic acidemia (PubMed Search)

Posted: 4/1/2022 by Rachel Wiltjer, DO (Updated: 3/29/2024)
Click here to contact Rachel Wiltjer, DO

 

  • 2/3’s present in the neonatal period and can mimic conditions such as sepsis, gastroenteritis, and meningitis requiring careful consideration to prompt testing
  • Common symptoms are poor feeding, lethargy, irritability, vomiting, and encephalopathy
  • May be referred in if detected on newborn screen, but not all are tested on the newborn screen
  • Should look on labs for acidosis, elevated anion gap, hyperammonemia, lactic acidosis, ketosis/ketonuria, and hyper/hypoglycemia  
  • Emergent treatment includes: identification and treatment of any underlying triggers (such as infection), stopping any protein intake until situation can be clarified, providing fluids with glucose (requirements of 8-10 mg/kg/min of glucose in neonates), and genetics consultation

 

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Acute facial palsy is common in children and while bell’s palsy is significant proportion, there are other more concerning etiologies that make up a number of cases. A retrospective cohort study of pediatric patients with an ED diagnosis of Bell’s palsy was done using the Pediatric Health Information System and showed an incidence of 0.3% (0.03% in control) for new diagnosis of malignancy within the 60 days following the visit at which bell’s palsy was diagnosed. Younger age increased the risk. There was also a subset of patient’s excluded for diagnosis of bell’s palsy as well as malignancy at the index visit.

These numbers are small but may be clinically significant. They likely do not warrant laboratory or imaging workup as a rule but do make a case for detailed history taking and thorough exam. Consider avoiding steroids which are used commonly but lack high quality data and may undermine later efforts at tissue diagnosis of malignancy or even worsen prognosis.

 

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Category: Pediatrics

Title: Sever Disease - What a Heel

Keywords: peds ortho, calcaneus, stress injury (PubMed Search)

Posted: 12/3/2021 by Rachel Wiltjer, DO
Click here to contact Rachel Wiltjer, DO

Sever Disease

  • Calcaneal apophysitis – inflammation of the growth plate of the calcaneus
  • One of the most common causes of heel pain in adolescents, caused by repetitive stress (overuse injury)
  • Most common in those who are involved in sports, especially those with lots of running and jumping
  • Symptoms are heel pain and tenderness at/underneath the heel, with possible mild swelling
  • Pain is reproduced by squeezing the posterior calcaneus and standing on tip toes
  • Does not require imaging for typical presentation
  • Treat with reduction of activity (specifically avoid painful activities), NSAIDs, and stretching exercises

 

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Category: Pediatrics

Title: AAP Guidelines on the Febrile Infant 2021

Keywords: febrile infant, neonatal fever (PubMed Search)

Posted: 10/1/2021 by Rachel Wiltjer, DO
Click here to contact Rachel Wiltjer, DO

What they are: Clinical practice guidelines put together by an AAP subcommittee over a span of several years based on changing bacteriology and incidence of illness, advances in testing, and evidence that has accumulated

Includes: Healthy infants 8 to 60 days of life with an episode of temperature greater than or equal to 38.0 C who at now at home after being born at home or after discharge from the newborn nursery, born between 37 and 42 weeks, without focal infection on exam (cellulitis, vesicles, etc)

Recommendations:

For the well appearing 8-21 day old:

  • Obtain UA (and culture if + UA), blood culture, CSF (including enterovirus PCR if pleocytosis in CSF or seasonal periods), inflammatory markers are optional
  • Start empiric antimicrobials regardless of results of UA/CSF or any inflammatory markers
  • Infant should be admitted

For well appearing 22- 28 day olds:

  • Obtain UA (and culture if +UA), blood culture, and inflammatory markers
    • procalcitonin preferred over CRP if available, ANC is helpful but less so than others
    • several studies used in making these guidelines used more than 1 inflammatory marker
      • Temp >38.5 is considered an inflammatory marker
  • If any inflammatory marker is abnormal:
    • Obtain CSF and start empiric antibiotics
      • CSF is optional if no inflammatory markers are abnormal (provider judgment/risk assessment)
    • If CSF is not obtained, infant should be hospitalized for observation
  • Discharge home is acceptable if all of the following are true: UA is normal, CSF is normal or enterovirus +, no obtained inflammatory marker is abnormal (or if abnormal they have subsequently had normal CSF testing), return precautions are discussed and follow up is assured within 24 hours for clinical re-examination
    • Infants being discharged home should receive empiric parental antibiotics prior to discharge
  • If the infant is hospitalized antibiotics should be started if: CSF with pleocytosis or uninterpretable or if UA is +
    • If workup is normal, antibiotics optional
    • If CSF not obtained, may start antibiotics but not required
  • Shared decision making with parents is recommended for decisions regarding LP and disposition in this group

For well appearing 29-60 day olds:

  • Obtain UA ( and culture if +UA), blood culture, and inflammatory markers
  • If inflammatory markers are normal LP does not need to be performed, antibiotics do not need to be administered (unless UTI present), and patient can be monitored closely at home with follow up in 24-36 hours
  • If positive UA in this group with normal inflammatory markers, obtain cath urine culture and start oral antibiotics
  • Consider obtaining CSF if abnormal inflammatory markers
  • If CSF obtained and normal antibiotics are optional, may be observed in hospital or closely at home
  • If CSF is not obtained or is uninterpretable with abnormal inflammatory markers, administer parenteral antibiotics
    • May be observed in hospital or closely at home

Notable changes:

  • UTIs have been differentiated from bacteremia and bacterial meningitis, the guideline discourages the use of the historic “serious bacterial illness”
  • A 2 step process where decision for catheretized urine culture is based on UA is suggested, UA to be obtained by bag or stimulated void

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