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ABSTRACT. Objective. To determine the validity and reliability of various clinical findings in the diagnosis of dehydration in children.Design. Prospective cohort study.Setting. An urban pediatric hospital emergency department.Participants. One hundred eighty-six children ranging in age from 1 month to 5 years old with diarrhea, vomiting, or poor oral fluid intake, either admitted or followed as outpatients. Exclusion criteria included malnutrition, recent prior therapy at another facility, symptoms for longer than 5 days' duration, and hyponatremia or hypernatremia.Methods. All children were evaluated for 10 clinical signs before treatment. The diagnostic standard for dehydration was fluid deficit as determined from serial weight gain after treatment.Main Results. Sixty-three children (34%) had dehydration, defined as a deficit of 5% or more of body weight. At this deficit, clinical signs were already apparent (median ‫؍‬ 5). Individual findings had generally low sensitivity and high specificity, although parent report of decreased urine output was sensitive but not specific. The presence of any three or more signs had a sensitivity of 87% and specificity of 82% for detecting a deficit of 5% or more. A subset of four factors-capillary refill >2 seconds, absent tears, dry mucous membranes, and ill general appearance-predicted dehydration as well as the entire set, with the presence of any two or more of these signs indicating a deficit of at least 5%. Interobserver reliability was good to excellent for all but one of the findings studied (quality of respirations).Conclusions. Conventionally used clinical signs of dehydration are valid and reliable; however, individual findings lack sensitivity. Diagnosis of clinically important dehydration should be based on the presence of at least three clinical findings. Pediatrics 1997;99(5). URL: http://www. pediatrics.org/cgi/content/full/99/5/e6; dehydration, capillary refill, clinical assessment, interobserver agreement.

ABSTRACT.Objective. Establish prevalence rates of urinary tract infection (UTI) in febrile infants and young girls in an emergency department (ED) by demographics and clinical parameters.Methods. Cross-sectional prevalence survey of 2411 (83%) of all infants younger than 12 months and girls younger than 2 years of age presenting to the ED with a fever (>38.5°C) who did not have a definite source for their fever and who were not on antibiotics or immunosuppressed. Otitis media, gastroenteritis, and upper respiratory infection were considered potential but not definite sources of fever.Results. Conclusions. UTI is prevalent in young children, particularly white girls, without a definite source of fever. Specific clinical signs and symptoms of UTI are uncommon, and the presence of another potential source of fever such as upper respiratory infection or otitis media is not reliable in excluding UTI. Pediatrics 1998;102(2). URL: http://www.pediatrics.org/cgi/content/full/102/2/ e16; UTI, evaluation of febrile infants, prevalence.ABBREVIATIONS. UTI, urinary tract infection; ED, emergency department; URI, upper respiratory infection; CI, confidence interval; WBC, white blood cell; GI, gastrointestinal. N uclear renal scans suggest that the vast majority of febrile young children with urinary tract infection (UTI) have pyelonephritis, putting them at risk for renal scarring and the longterm sequelae of hypertension and renal failure. [1][2][3][4] It is imperative that physicians identify these children to institute early treatment, evaluate the urinary tract, and monitor for recurrent UTI. 4 Unfortunately, the classic signs of UTI and pyelonephritis in older children and adults are not present or easily discerned in the toddler or young child. Fever is the most common symptom of UTI in the infant. 5,6 Also, the presence of another source of fever on examination, such as otitis media or other viral symptoms, does not exclude a UTI.7-9 Screening for UTI is uncomfortable for patients, time-consuming for staff, and expensive in the aggregate. Physicians throughout the United States vary in their clinical practice of when to obtain a urine culture in a febrile infant. 10,11Community studies suggest that boys younger than 1 year of age and girls younger than 5 years of age are most at risk for UTI. 5 The literature estimates that the prevalence of UTI in febrile children presenting for outpatient evaluation ranges from 1% to 20%. [7][8][9]12 The studies vary in their definition of UTI, method of urine collection, and eligibility criteria. Most have small sample sizes, and none have been true prevalence studies in which data are collected on all children.The aims of this study were 1) to establish prevalence rates of UTI among young febrile children seen in an urban emergency department (ED), and (2) to evaluate the effect of age, sex, race, and clinical symptoms and signs on the prevalence rates of UTI. METHODS Study Design and SubjectsThis was a cross-sectional study of the current clinical practice over a 1-year period...

Objectives: The authors sought to describe the epidemiology of and risk factors for recurrent and highfrequency use of the emergency department (ED) by children.Methods: This was a retrospective cohort study using a database of children aged 0 to 17 years, inclusive, presenting to 22 EDs of the Pediatric Emergency Care Applied Research Network (PECARN) during 2007, with 12-month follow-up after each index visit. ED diagnoses for each visit were categorized as trauma, acute medical, or chronic medical conditions. Recurrent visits were defined as any repeat visit; high-frequency use was defined as four or more recurrent visits. Generalized estimating equations (GEEs) were used to measure the strength of associations between patient and visit characteristics and recurrent ED use.Results: A total of 695,188 unique children had at least one ED visit each in 2007, with 455,588 recurrent ED visits in the 12 months following the index visits. Sixty-four percent of patients had no recurrent visits, 20% had one, 8% had two, 4% had three, and 4% had four or more recurrent visits. Acute medical diagnoses accounted for most visits regardless of the number of recurrent visits. As the number of recurrent visits per patient rose, chronic diseases were increasingly represented, with asthma being the most common ED diagnosis. Trauma-related diagnoses were more common among patients without recurrent visits than among those with high-frequency recurrent visits (28% vs. 9%; p < 0.001). Highfrequency recurrent visits were more often within the highest severity score classifications. In multivariable analysis, recurrent visits were associated with younger age, black or Hispanic race or ethnicity, and public health insurance. Conclusions:Risk factors for recurrent ED use by children include age, race and ethnicity, and insurance status. Although asthma plays an important role in recurrent ED use, acute illnesses account for the majority of recurrent ED visits.ACADEMIC EMERGENCY MEDICINE 2014;21:365-373

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ABSTRACT. Objective. Comparison of rapid tests and screening strategies for detecting urinary tract infection (UTI) in infants.Methods. Cross-sectional study conducted in an urban tertiary care children's hospital emergency department and clinical laboratories of 3873 infants <2 years of age who had a urine culture obtained in the emergency department by urethral catheterization; results of urine dipstick tests for leukocyte esterase or nitrites, enhanced urinalysis (UA) (urine white blood cell count/mm 3 plus Gram stain), Gram stain alone, and dipstick plus microscopic UA (white blood cells and bacteria per high-powered field) compared with urine culture results (positive urine results defined as >10 4 colony-forming units per milliliter of urinary tract pathogen) for each sample. Cost comparison of 1) dipstick plus culture of all urine specimens versus 2) cell count ؎ Gram stain of urine, culture only those with positive results.Results. The enhanced UA was most sensitive at detecting UTI (94%; 95% confidence interval: 83,99), but had more false-positive results (16%) than the urine dipstick or Gram stain (3%). The most cost-effective strategy was to perform cultures on all infants and begin presumptive treatment on those whose dipstick had at least moderate (؉2) leukocyte esterase or positive nitrite at a cost of $3.70 per child. With this strategy, all infants with UTI were detected. If the enhanced UA was used to screen for when to send the urine for culture, 82% of cultures would be eliminated, but 4% to 6% of infants with UTI would be missed and the cost would be higher ($6.66 per child).Conclusion. No rapid test can detect all infants with UTI. Physicians should send urine for culture from all infants and begin presumptive treatment only on those with a significantly positive dipstick result. The enhanced UA is most sensitive for detecting UTI, but is less specific and more costly, and should be reserved for the neonate for whom a UTI should not be missed at first visit. Pediatrics 1998;101(6). URL: http://www.pediatrics. org/cgi/content/full/101/6/e1; urinalysis, Gram stain, dipstick, UTI, rapid screening, febrile infants.ABBREVIATIONS. UTI, urinary tract infection; ED, emergency department; WBC, white blood cells; UA, urinalysis; LE, leukocyte esterase; CFU/mL, colony forming units per milliliter; CI, confidence interval. R ecent research has indicated that the prevalence of urinary tract infection (UTI) in febrile young children in the emergency department (ED) is ϳ3% to 5%, and in some groups, as high as 30%.1,2 Additionally, recent use of nuclear renal scans has indicated that the majority of febrile young children with UTI have pyelonephritis, putting them at risk for renal scarring and the possible long-term sequelae of hypertension and chronic renal failure. [3][4][5] It is imperative that physicians identify these children to institute early treatment, work-up of their urinary tracts, and provide follow-up.Although there are several screening tests for UTI, there has been no prospective clinical...

BACKGROUND Acute gastroenteritis develops in millions of children in the United States every year, and treatment with probiotics is common. However, data to support the use of probiotics in this population are limited. METHODS We conducted a prospective, randomized, double-blind trial involving children 3 months to 4 years of age with acute gastroenteritis who presented to one of 10 U.S. pediatric emergency departments. Participants received a 5-day course of Lactobacillus rhamnosus GG at a dose of 1×1010 colony-forming units twice daily or matching placebo. Follow-up surveys were conducted daily for 5 days and again 14 days after enrollment and 1 month after enrollment. The primary outcome was moderate-to-severe gastroenteritis, which was defined as an illness episode with a total score on the modified Vesikari scale of 9 or higher (scores range from 0 to 20, with higher scores indicating more severe disease), within 14 days after enrollment. Secondary outcomes included the duration and frequency of diarrhea and vomiting, the duration of day-care absenteeism, and the rate of household transmission (defined as the development of symptoms of gastroenteritis in previously asymptomatic household contacts). RESULTS Among the 971 participants, 943 (97.1%) completed the trial. The median age was 1.4 years (interquartile range, 0.9 to 2.3), and 513 participants (52.9%) were male. The modified Vesikari scale score for the 14-day period after enrollment was 9 or higher in 55 of 468 participants (11.8%) in the L. rhamnosus GG group and in 60 of 475 participants (12.6%) in the placebo group (relative risk, 0.96; 95% confidence interval, 0.68 to 1.35; P = 0.83). There were no significant differences between the L. rhamnosus GG group and the placebo group in the duration of diarrhea (median, 49.7 hours in the L. rhamnosus GG group and 50.9 hours in the placebo group; P = 0.26), duration of vomiting (median, 0 hours in both groups; P = 0.17), or day-care absenteeism (median, 2 days in both groups; P = 0.67) or in the rate of household transmission (10.6% and 14.1% in the two groups, respectively; P = 0.16). CONCLUSIONS Among preschool children with acute gastroenteritis, those who received a 5-day course of L. rhamnosus GG did not have better outcomes than those who received placebo. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and others; ClinicalTrials.gov number, NCT01773967.)