Intravenous Fluid Bolus Prior to Neonatal and Infant Lumbar Puncture: A Sonographic Assessment of the Subarachnoid Space After Intravenous Fluid Administration.

Rankin J, Wang VJ, Goodarzian F, Lai HA. Intravenous Fluid Bolus Prior to Neonatal and Infant Lumbar Puncture: A Sonographic Assessment of the Subarachnoid Space After Intravenous Fluid Administration. JAMA Pediatr. 2016 Mar 7;170(3):e154636.

IMPORTANCE: Neonatal and infant lumbar puncture is a commonly performed procedure in emergency departments, yet traumatic and unsuccessful lumbar punctures occur 30% to 50% of the time. Dehydration may be a risk factor for unsuccessful lumbar punctures, but to our knowledge, no studies have investigated the use of intravenous (IV) fluid bolus prior to lumbar puncture.

OBJECTIVE: To investigate the association of IV fluid bolus administration with the sonographic measure of the neonatal and infant lumbar subarachnoid space. We hypothesized that IV fluids would increase subarachnoid space size.

DESIGN, SETTING, AND PARTICIPANTS: Prospective observational study conducted from August 2012 to April 2015.The study took place at the emegency department of the Children’s Hospital Los Angeles, an urban pediatric emergency department with an annual census of 76 000 visits.A convenience sample of patients aged 0 to 3 months were enrolled if they had a clinical presentation consistent with pyloric stenosis. This population was used as a proxy because they are similar in age to patients undergoing lumbar puncture for evaluation of neonatal fever and are routinely given IV fluids for dehydration.

EXPOSURES: Patients with a sonographic diagnosis of pyloric stenosis underwent additional ultrasonography evaluation to determine the size of the subarachnoid space before and after IV fluids.

MAIN OUTCOMES AND MEASURES: Primary outcomes included the difference in the size of the subarachnoid space in millimeters squared before and 1 hour after administration of an IV fluid bolus in the emergency department. Interobserver consistency for the subarachnoid space measurement between attending radiologists was measured using intraclass correlation coefficient. The Wilcoxon signed-rank test was used to examine changes in subarachnoid space measurements (millimeters squared).

RESULTS: The study sample consisted of 40 patients with a mean (SD) age of 37 (11.3) days (range, 15-71 days). The mean (SD) size of the subarachnoid space before and 1 hour after IV fluid bolus was 37.8 (11.1) mm2 and 36.9 (11.2) mm2 respectively (P = .42). The intraclass correlation coefficient ranged from 0.96 to 0.99 (95% CI, 0.90-0.99).

CONCLUSIONS AND RELEVANCE: Intravenous fluid boluses were not associated with a significant increase in the sonographic measure of the neonatal and infant subarachnoid space.

Less is more: combination antibiotic therapy for the treatment of gram-negative bacteremia in pediatric patients. (Hebbar)

Tamma PD, Turnbull AE, Harris AD, Milstone AM, Hsu AJ, Cosgrove SE. Less is more: combination antibiotic therapy for the treatment of gram-negative bacteremia in pediatric patients. JAMA Pediatr. 2013 Oct 1;167(10):903-910.

IMPORTANCE Definitive combination antibiotic therapy with a β-lactam and an aminoglycoside for the treatment of gram-negative bacteremia is commonly prescribed in pediatric patients; however, its efficacy and toxicity relative to β-lactam monotherapy are unknown.

OBJECTIVE To determine whether definitive combination antibiotic therapy affects mortality and nephrotoxicity in pediatric patients with gram-negative bacteremia.

DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study including pediatric patients (aged ≤18 years) with gram-negative bacteremia hospitalized at the Johns Hopkins Children’s Center between 2002 and 2011.

MAIN OUTCOMES AND MEASURES Outcomes included 30-day mortality and nephrotoxicity classified according to the pediatric RIFLE (risk for renal dysfunction, injury to the kidney, failure of kidney function, loss of kidney function, and end-stage renal disease) criteria. To account for nonrandom assignment of combination therapy, propensity score weighting was combined with multivariable logistic regression to estimate the effect of combination therapy on mortality and nephrotoxicity.

RESULTS Of the 879 eligible pediatric patients with bacteremia, 537 (61.1%) received combination therapy. After propensity score adjustment, baseline demographic and clinical characteristics between the groups were well balanced. There was no association between combination therapy and 30-day mortality (odds ratio, 0.98; 95% CI, 0.93-1.02; P = .27). There were 170 patients (19.3%) with evidence of acute kidney injury, including 135 (25.1%) and 35 (10.2%) in the combination therapy and monotherapy arms, respectively. Patients receiving combination therapy had approximately twice the odds of nephrotoxicity compared with those receiving monotherapy (odds ratio, 2.15; 95% CI, 2.09-2.21).

CONCLUSIONS AND RELEVANCE The use of β-lactam monotherapy for gram-negative bacteremia in pediatric patients reduces subsequent nephrotoxicity without compromising survival.

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The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. (Hebbar)

JAMA Pediatr. 2013 Aug 1;167(8):700-7. PMID: 23754213

IMPORTANCE: Increased use of computed tomography (CT) in pediatrics raises concerns about cancer risk from exposure to ionizing radiation.

OBJECTIVES: To quantify trends in the use of CT in pediatrics and the associated radiation exposure and cancer risk. DESIGN Retrospective observational study.

SETTING: Seven US health care systems. PARTICIPANTS The use of CT was evaluated for children younger than 15 years of age from 1996 to 2010, including 4 857 736 child-years of observation. Radiation doses were calculated for 744 CT scans performed between 2001 and 2011.

MAIN OUTCOMES AND MEASURES: Rates of CT use, organ and effective doses, and projected lifetime attributable risks of cancer.

RESULTS: The use of CT doubled for children younger than 5 years of age and tripled for children 5 to 14 years of age between 1996 and 2005, remained stable between 2006 and 2007, and then began to decline. Effective doses varied from 0.03 to 69.2 mSv per scan. An effective dose of 20 mSv or higher was delivered by 14% to 25% of abdomen/pelvis scans, 6% to 14% of spine scans, and 3% to 8% of chest scans. Projected lifetime attributable risks of solid cancer were higher for younger patients and girls than for older patients and boys, and they were also higher for patients who underwent CT scans of the abdomen/pelvis or spine than for patients who underwent other types of CT scans. For girls, a radiation-induced solid cancer is projected to result from every 300 to 390 abdomen/pelvis scans, 330 to 480 chest scans, and 270 to 800 spine scans, depending on age. The risk of leukemia was highest from head scans for children younger than 5 years of age at a rate of 1.9 cases per 10 000 CT scans. Nationally, 4 million pediatric CT scans of the head, abdomen/pelvis, chest, or spine performed each year are projected to cause 4870 future cancers. Reducing the highest 25% of doses to the median might prevent 43% of these cancers.

CONCLUSIONS AND RELEVANCE: The increased use of CT in pediatrics, combined with the wide variability in radiation doses, has resulted in many children receiving a high-dose examination. Dose-reduction strategies targeted to the highest quartile of doses could dramatically reduce the number of radiation-induced cancers.

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Factors that influence parental decisions to participate in clinical research: consenters vs nonconsenters. (Hebbar)

JAMA Pediatr. 2013 Jun 1;167(6):561-6. PMID: 23546617

IMPORTANCE: A child’s health, positive perceptions of the research team and consent process, and altruistic motives play significant roles in the decision-making process for parents who consent for their child to enroll in clinical research. This study identified that nonconsenting parents were better educated, had private insurance, showed lower levels of altruism, and less understanding of study design.

OBJECTIVE: To determine the factors associated with parental consent for their child’s participation in a randomized, placebo-controlled trial.

DESIGN: Cross-sectional survey conducted from July 2008 to May 2011. The survey was an ancillary study to the Randomized Intervention for Children with VesicoUreteral Reflux Study.

SETTING: Seven children’s hospitals participating in a randomized trial evaluating management of children with vesicoureteral reflux.

PARTICIPANTS: Parents asked to provide consent for their child’s participation in the randomized trial were invited to complete an anonymous online survey about factors influencing their decision. A total of 120 of the 271 (44%) invited completed the survey; 58 of 125 (46%) who had provided consent and 62 of 144 (43%) who had declined consent completed the survey.

MAIN OUTCOMES AND MEASURES: A 60-question survey examining child, parent, and study characteristics; parental perception of the study; understanding of the design; external influences; and decision-making process.

RESULTS: Having graduated from college and private health insurance were associated with a lower likelihood of providing consent. Parents who perceived the trial as having a low degree of risk, resulting in greater benefit to their child and other children, causing little interference with standard care, or exhibiting potential for enhanced care, or who perceived the researcher as professional were significantly more likely to consent to participate. Higher levels of understanding of the randomization process, blinding, and right to withdraw were significantly positively associated with consent to participate.

CONCLUSIONS AND RELEVANCE: Parents who declined consent had a relatively higher socioeconomic status, had more anxiety about their decision, and found it harder to make their decision compared with consenting parents, who had higher levels of trust and altruism, perceived the potential for enhanced care, reflected better understanding of randomization, and exhibited low decisional uncertainty. Consideration of the factors included in the conceptual model should enhance the quality of the informed consent process and improve participation in pediatric clinical trials.

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Risk factors for peripherally inserted central venous catheter complications in children. (Kiran)

JAMA Pediatr. 2013 May 1;167(5):429-35. PMID: 23549677

IMPORTANCE: Peripherally inserted central venous catheters (PICCs) are prone to infectious, thrombotic, and mechanical complications. These complications are associated with morbidity, so data are needed to inform quality improvement efforts.

OBJECTIVES: To characterize the epidemiology of and to identify risk factors for complications necessitating removal of PICCs in children. DESIGN Cohort study.

SETTING: Johns Hopkins Children’s Center, Baltimore, Maryland.

PARTICIPANTS: Hospitalized children who had a PICC inserted outside of the neonatal intensive care unit (ICU) from January 1, 2003, through December 31, 2009.

MAIN OUTCOME MEASURES: Complications necessitating PICC removal as recorded by the PICC Team.

RESULTS: During the study period, 2574 PICCs were placed in 1807 children. Complications necessitating catheter removal occurred in 534 PICCs (20.8%) during 46 021 catheter-days (11.6 complications per 1000 catheter-days). These included accidental dislodgement (4.6%), infection (4.3%), occlusion (3.7%), local infiltration (3.0%), leakage (1.5%), breakage (1.4%), phlebitis (1.2%), and thrombosis (0.5%). From 2003 to 2009, complications decreased by 15% per year (incidence rate ratio [IRR], 0.85; 95% CI, 0.81-0.89). In adjusted analysis, all noncentral PICC tip locations-midline (IRR 4.59, 95% CI, 3.69-5.69), midclavicular (2.15; 1.54-2.98), and other (3.26; 1.72-6.15)-compared with central tip location were associated with an increased risk of complications. Pediatric ICU exposure and age younger than 1 year were independently associated with complications necessitating PICC removal.

CONCLUSIONS AND RELEVANCE: Noncentral PICC tip locations, younger age, and pediatric ICU exposure were independent risk factors for complications necessitating PICC removal. Despite reductions in PICC complications, further efforts are needed to prevent PICC-associated complications in children.

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