Category Archives: Pediatrics

Association Between Uropathogen and Pyuria. (Emrath)

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Shaikh N, Shope TR, Hoberman A, Vigliotti A, Kurs-Lasky M, Martin JM. Association Between Uropathogen and Pyuria. Pediatrics. 2016 Jul;138(1). pii: e20160087.

OBJECTIVE: We sought to determine factors associated with the absence of pyuria in symptomatic children whose urine culture was positive for a known uropathogen.

METHODS: We obtained data on children evaluated at the Children’s Hospital of Pittsburgh emergency department between 2007 and 2013 with symptoms of urinary tract infection (UTI) who had paired urinalysis and urine cultures. We excluded children with an unknown or bag urine collection method, major genitourinary anomalies, immunocompromising conditions, or with multiple organisms on culture. We chose a single, randomly-selected urine specimen per child and limited the analysis to those with positive cultures.

RESULTS: There were 46 158 visits during the study period; 1181 children diagnosed with UTI met all inclusion criteria and had a microscopic urinalysis for pyuria. Pyuria (≥5 white blood cells per high-powered field or ≥10 white blood cells per cubic millimeter) was present in 1031 (87%) children and absent in 150 (13%). Children with Enterococcus species, Klebsiella species, and Pseudomonas aeruginosa were significantly less likely to exhibit pyuria than children with Escherichia coli (odds ratio of 0.14, 0.34, and 0.19, respectively). Children with these organisms were also less likely to have a positive leukocyte esterase on dipstick urinalysis. Results were similar when we restricted the analysis to children whose urine samples were collected by bladder catheterization.

CONCLUSIONS: We found that certain uropathogens are less likely to be associated with pyuria in symptomatic children. Identification of biomarkers more accurate than pyuria or leukocyte esterase may help reduce over- and undertreatment of UTIs.

The Fecal Microbiota Profile and Bronchiolitis in Infants. (Emrath)

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Hasegawa K, Linnemann RW, Mansbach JM, Ajami NJ, Espinola JA, Petrosino JF,
Piedra PA, Stevenson MD, Sullivan AF, Thompson AD, Camargo CA Jr. The Fecal Microbiota Profile and Bronchiolitis in Infants. Pediatrics. 2016 Jul;138(1). pii: e20160218.

BACKGROUND: Little is known about the association of gut microbiota, a potentially modifiable factor, with bronchiolitis in infants. We aimed to determine the association of fecal microbiota with bronchiolitis in infants.

METHODS: We conducted a case-control study. As a part of multicenter prospective study, we collected stool samples from 40 infants hospitalized with bronchiolitis. We concurrently enrolled 115 age-matched healthy controls. By applying 16S rRNA gene sequencing and an unbiased clustering approach to these 155 fecal samples, we identified microbiota profiles and determined the association of microbiota profiles with likelihood of bronchiolitis.

RESULTS: Overall, the median age was 3 months, 55% were male, and 54% were non-Hispanic white. Unbiased clustering of fecal microbiota identified 4 distinct profiles: Escherichia-dominant profile (30%), Bifidobacterium-dominant profile (21%), Enterobacter/Veillonella-dominant profile (22%), and Bacteroides-dominant profile (28%). The proportion of bronchiolitis was lowest in infants with the Enterobacter/Veillonella-dominant profile (15%) and highest in the Bacteroides-dominant profile (44%), corresponding to an odds ratio of 4.59 (95% confidence interval, 1.58-15.5; P = .008). In the multivariable model, the significant association between the Bacteroides-dominant profile and a greater likelihood of bronchiolitis persisted (odds ratio for comparison with the Enterobacter/Veillonella-dominant profile, 4.24; 95% confidence interval, 1.56-12.0; P = .005). In contrast, the likelihood of bronchiolitis in infants with the Escherichia-dominant or Bifidobacterium-dominant profile was not significantly different compared with those with the Enterobacter/Veillonella-dominant profile.

CONCLUSIONS: In this case-control study, we identified 4 distinct fecal microbiota profiles in infants. The Bacteroides-dominant profile was associated with a higher likelihood of bronchiolitis.

Obesity and Mortality Risk in Critically Ill Children.

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Ross PA, et al. Obesity and Mortality Risk in Critically Ill Children. Pediatrics. 2016 Mar; 137(3):1-8.

BACKGROUND AND OBJECTIVES: Childhood obesity is epidemic and may be associated with PICU mortality. Using a large multicenter PICU database, we investigated the association between obesity and PICU mortality, adjusting for initial severity of illness. We further investigated whether height- and weight-based classifications of obesity compared with a weight-based classification alone alter the mortality distribution.

METHODS: This retrospective analysis used prospectively collected data from the Virtual PICU Systems database. Height, weight, age, and gender were used to calculate z score groups based on Centers for Disease Control and Prevention and World Health Organization growth curves. A random effects mixed logistic regression model was used to evaluate the association between obesity and PICU mortality, controlling for hospital, initial severity of illness, and comorbidities.

RESULTS: A total of 127 607 patients were included; the mortality rate was 2.48%. Being overweight was independently associated with increased PICU mortality after controlling for severity of illness with the Pediatric Index of Mortality 2 score and preexisting comorbidities. Mortality had a U-shaped distribution when classified according to weight-for-age or weight-for-height/BMI. When classifying patients using weight-for-age without respect to height, the nadir of the mortality curve was shifted, potentially falsely implying a benefit to mild obesity.

CONCLUSIONS: Risk-adjusted PICU mortality significantly increases as weight-for-height/BMI increases into the overweight and obese ranges. We believe that height data are necessary to correctly classify body habitus; without such information, a protective benefit from mild obesity may be incorrectly concluded.

3% Hypertonic Saline Versus Normal Saline in Inpatient Bronchiolitis: A Randomized Controlled Trial. (Betters)

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Silver AH, et al. 3% Hypertonic Saline Versus Normal Saline in Inpatient Bronchiolitis: A Randomized Controlled Trial. Pediatrics. 2015 Dec;136(6): 1036-43.

BACKGROUND AND OBJECTIVES: Bronchiolitis, the most common reason for hospitalization in children younger than 1 year in the United States, has no proven therapies effective beyond supportive care. We aimed to investigate the effect of nebulized 3% hypertonic saline (HS) compared with nebulized normal saline (NS) on length of stay (LOS) in infants hospitalized with bronchiolitis.

METHODS: We conducted a prospective, randomized, double-blind, controlled trial in an urban tertiary care children’s hospital in 227 infants younger than 12 months old admitted with a diagnosis of bronchiolitis (190 completed the study); 113 infants were randomized to HS (93 completed the study), and 114 to NS (97 completed the study). Subjects received 4 mL nebulized 3% HS or 4 mL 0.9% NS every 4 hours from enrollment until hospital discharge. The primary outcome was median LOS. Secondary outcomes were total adverse events, subdivided as clinical worsening and readmissions.

RESULTS: Patient characteristics were similar in groups. In intention-to-treat analysis, median LOS (interquartile range) of HS and NS groups was 2.1 (1.2-4.6) vs 2.1 days (1.2-3.8), respectively, P = .73. We confirmed findings with per-protocol analysis, HS and NS groups with 2.0 (1.3-3.3) and 2.0 days (1.2-3.0), respectively, P = .96. Seven-day readmission rate for HS and NS groups were 4.3% and 3.1%, respectively, P = .77. Clinical worsening events were similar between groups (9% vs 8%, P = .97).

CONCLUSIONS: Among infants admitted to the hospital with bronchiolitis, treatment with nebulized 3% HS compared with NS had no difference in LOS or 7-day readmission rates.