1. Implement current recommendations for evaluating febrile infants and children in different age groups.

2. Choose the appropriate diagnostic test and treatment of urinary tract infections in children.

3. Determine when a young athlete with a concussion can return to play.

4. Recognize and manage postconcussion syndrome.

5. Determine when to perform computed tomography of the head after a concussion.

Approach to Fever in the Era of Pneumococcal Vaccine
Betsy C. Herold, MD, Professor, Department of Pediatrics, Department of Microbiology and Immunology, and Department of Obstetrics & Gynecology and Women’s Health, Albert Einstein College of Medicine of Yeshiva University, New York, NY

Fever: among most common reasons parents seek medical attention; accounts for ≈25% of emergency department (ED) and office visits; majority of patients have self-limited illness

Common diagnoses (by age group) of children with fever: majority have self-limited viral illness not identified; infants <1 mo of age—occult bacteremia and meningitis; pathogen most often Escherichia coli, less often group B streptococci, Listeria, Streptococcus pneumoniae, other enteric bacteria, and Staphylococcus aureus; urinary tract infections (UTIs) common; viruses, ie, enterovirus and herpesvirus; infants 1 to 3 mo of age—occult bacteremia; if meningitis seen, most likely meningococcus; late-onset group B streptococcal disease (prophylaxis does not prevent late-onset disease, only early-onset disease); UTIs and bone disease; children between 3 mo and 3 yr of age—occult bacteremia and UTIs

Occult bacteremia: in all studies, S pneumoniae main pathogen, followed by Haemophilus influenzae type b (Hib); remainder primarily Neisseria meningitidis, Salmonella, and others; development of meningitis depends on pathogen (most common with N meningitidis, least common with S pneumoniae)

Era of oral antibiotics: study—looked at febrile children (3-36 mo of age) presenting to ED and clinics who looked well; patients randomized to oral amoxicillin or placebo; no difference in major morbidities, with trend toward earlier resolution of fever in those who received amoxicillin; decision-analysis approach—most studies concluded that obtaining complete blood cell count (CBC), targeting children with high or low white blood cell (WBC) counts, and treating them best option

Era of ceftriaxone (1993): first major study—519 febrile high-risk children randomized to oral amoxicillin or intramuscular ceftriaxone; more patients receiving oral treatment had persistent fever, but otherwise, no difference in outcome; second study—≈6000 febrile high-risk children; randomized to oral amoxicillin or ceftriaxone; most of children with bacteremia had S pneumoniae; no difference in major morbidities, but fewer children in ceftriaxone group had persistent fever; ceftriaxone became standard of care for occult bacteremia

Hib vaccine and prevalence of occult bacteremia: 2 post-Hib vaccine studies on incidence of bacteremia (incidences of 1.6% and 1.9% found); S pneumoniae most common pathogen isolated (92% and 83%); 96% of children recovered without antibiotics (most S pneumoniae infections transient bacteremia and self-limited); rate of developing sepsis or meningitis, 1 in 3000; peak incidence of invasive pneumococcal disease seen in children 1 to 2 yr of age

High-risk populations: HIV-infected children; immunocompromised hosts; those with asplenia; children with cochlear implants; certain ethnic groups; elderly

Conjugate pneumococcal vaccine (March 2000): recommended for children 6 wk to 5 yr of age (allowed for children ≤9 yr of age); contains 7 capsular serotypes conjugated to diphtheria toxin; serotypes accounted for almost 90% of invasive disease and 75% of noninvasive disease; conjugation means vaccine T-cell-dependent, leading to good T-cell response, memory response, and strong booster response upon reexposure; leads to large decline in overall invasive disease and noninvasive disease (including otitis media) in all age groups; herd immunity effect strong; however, replacement disease (2 types) increased, including expansion in isolation of serotypes not present in vaccine; mechanisms include capsular switching

Laboratory testing in postvaccine era: postpneumococcal vaccine study looked at whether WBC count necessary; found sensitivity good but specificity poor; no studies document value of WBC count in predicting meningococcal bacteremia; C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) not documented as helpful in meningococcal, Salmonella, or group A streptococcal disease; sensitivity of single blood culture ≈80%, and specificity 95% to 99%

Infants <3 mo of age: serious bacterial infections seen in greater proportion of infants <3 mo than in older children; low-risk infants include those with no clinical findings on examination, WBC counts of 5000 to 15,000/µL, <1500 bands/mm3 , and normal urinalysis (UA); study found that only 1 in 144 infants who met criteria for low risk had serious bacterial illness (none bacteremic); those who did not meet criteria (22 of 89) considered high risk and had serious illness (prevaccine era); low-risk infants—full term; no perinatal antibiotics; no previous hospitalizations or chronic illnesses; WBC count of 5000 to 15,000/µL, without shift to left; normal UA (<10 WBC/hpf); negative predictive value almost 100%; meta-analysis of studies of febrile infants <3 mo of age found that in high-risk group, risk for serious bacterial illness (24%), bacteremia (13%), and meninigitis (4%) present; in low-risk group, 2.6%, 1.3%, and 0.6%, respectively

Current recommendations (based on literature and speaker’s opinion): infant <1 mo of age—obtain work-up that includes CBC with differential and platelet count, UA, blood and urine cultures, and lumbar puncture; chest x-ray only if clinically warranted; most experts (including speaker) would admit infant to hospital (but not necessarily give antibiotics); empiric treatment with ampicillin and gentamicin or ampicillin and cefotaxime; if high rate of methicillin-resistant S aureus (MRSA) present in institution, vancomycin and cefotaxime given (note, referring to low- risk infant); ampicillin not recommended for Listeria (vancomycin better option); consider herpes simplex virus (HSV) in diagnosis and treat if suggestion of HSV present; infant 1 to 3 mo of age—same work-up (CBC with differential and platelet count and UA); lumbar puncture not routine; if family reliable, with access to medical care, and infant low-risk (per Rochester criteria), may discharge patient home; if medical access is concern, admit and observe; if infant high- risk, admit and treat empirically; infant 3 to 36 mo of age—in immunized children, occult bacteremia rare; UA still necessary (UTI most common infection in this age group); need for CBC unknown; use clinical judgment to select those at risk for N meningitidis; unvaccinated children more concerning; infants who have not received conjugate vaccine managed according to existing practice guidelines

Urinary tract infection: most common cause of fever in infants; prevalence 3% to 7%; overall, more common in girls, but more common in boys in first few months after birth; increased likelihood of UTI in febrile children—history of UTI; temperature >40°C; suprapubic tenderness; for boys, lack of circumcision; circumcision only protective finding; diagnostic tests—positive predictive value (PPV) of pyuria (hemocytometric count on unspun urine) with bacteriuria, 85%; empiric treatment recommended before culture results available; lower PPV if only pyuria or only bacteriuria present and likelihood of UTI only 40% (delaying antibiotics recommended); management of asymptomatic bacteriuria controversial; routine ultrasonography (US) not recommended; voiding cystourethrography (VCUG) likely still indicated at 1 mo and dimercaptosuccinic acid (DMSA) scintigraphy 6 mo later to identify scarring; incidence of scarring after pyelonephritis ≈40%; dipstick not helpful in pediatrics; treatment—traditional therapy antibiotics; ampicillin and gentamicin number one recommendation; all studies looking at oral therapy conducted with cefixime (Suprax); not known whether oral nitrofurantoin, oral trimethoprim-sulfamethoxazole, and oral ampicillin as effective as intravenous therapy; prophylactic use of antibiotics (pending imaging studies) still recommended but somewhat controversial

Sports-Related Concussion
Christine A. Odell, MD, Assistant Professor of Pediatrics, Boston University School of Medicine, Boston, MA

Pathophysiology: head injury triggers release of excitatory neurotransmitters, followed by massive ion influx and brief period of hyperglycolysis; followed by persistent metabolic instability, mitochondrial dysfunction, decreased cerebral blood flow, and glucose metabolism; may result in axonal injury and neuronal dysfunction, with neurologic deficits, cognitive impairment, and somatic symptoms (postconcussion syndrome)

Present definition: involves alteration in consciousness (ie, patient confused, dazed, and disoriented, with or without loss of consciousness [LOC]); patient may have anterograde and retrograde amnesia; may be associated with lethargy, delirium, brief seizure, blurred vision, dizziness, headache, nausea, and vomiting; blow to head may result in confusional state (commonly referred to as “ding” [actually concussion]); definition of concussion does not require LOC— >90% of athletic concussions do not involve LOC; when sports injury occurs with LOC, LOC usually brief (seconds) and does not correlate with severity of concussion as defined by number, duration, and intensity of symptoms

Evaluation of athlete: baseline cognitive and postural stability testing recommended; on-the-field evaluation for signs and symptoms of concussion, neck injury, or other associated injuries; child with neck injury needs immediate immobilization and transport to trauma center or ED; grading systems—less important than clinical symptoms exhibited at time of evaluation and over time; in athlete with head injury, evaluate for altered mental status; determine whether child appears dazed, has confusion, forgetfulness, slowed response to questions, personality change, LOC, and/or retrograde amnesia; symptoms include headache, dizziness or balance problems, sensitivity to light or noise, feeling foggy or groggy, feeling slowed down, difficulty concentrating, and perceived memory loss; severity of concussion—determined by severity and persistence of signs and symptoms; eg, mild concussion may present as “ding,” very short period of confusion, prompt return to normal, and no other signs and symptoms; more severe concussion may include prolonged anterograde and retrograde amnesia, persistent confusion, slow response to questions, and somnolence; include formal cognitive and postural stability testing if possible; check vital signs and perform neurologic examination every 5 min until patient normalizes or clinical improvement seen

Return to play: assess whether all signs and symptoms of concussion have resolved at rest and with mild exertion (mild exercises that simulate sport but do not put child at risk for head injury); controversial recommendation—athletes with mild symptoms of head injury that resolve in <20 min may return to play, but must be monitored closely during practice or game, on sideline, and again at 24 to 48 hr for recurrence of symptoms; speaker wary of this recommendation, citing data showing that 33% of athletes with concussion who returned to play on same day had delayed symptoms (3 hr after injury), compared to 12.6% who did not return to play; if LOC or amnesia have occurred, child should not return to play on day of injury; athletes with history of concussion at increased risk for repeat injury and slow recovery from postconcussion signs and symptoms, cognitive dysfunction, and postural instability with repeat concussion; assess each athlete individually

Second-impact syndrome (SIS): potentially lethal condition that occurs when young athlete still symptomatic from previous brain injury sustains concussion; likely caused by loss of autoregulation of cerebral blood flow with subsequent vascular engorgement; almost all reported cases in young athletes (<19 yr of age); younger athletes recover more slowly than older athletes; because damage to maturing brain of young athlete possibly severe, younger the athlete, the more conservatively he or she should be managed; 300% increase in risk for concussion after 3 concussions in 7-yr period; players with 2 concussions have longer time to symptom resolution after subsequent injuries; in 92% of cases, recurrent in-season injury occurs in ≤10 days of initial injury; do not allow athlete to play after third concussion of season

Postconcussion syndrome: symptoms in 3 of following categories, eg, headache, dizziness, fatigue, noise intolerance, irritability, depression, anxiety, emotional lability, subjective concentration problems, memory loss, intellectual difficulties, insomnia, reduced alcohol tolerance, preoccupation with symptoms, fear of brain damage; study—college football players with concussions vs controls; 91% of players with concussions returned to personal baseline in 7 days (100% in 90 days); cognitive impairment most severe at time of injury and usually persisted until postinjury day 2, then steadily improved; only 77.8% of athletes with concussion had LOC or amnesia; study—athletes, 13 to 24 yr of age; considered use of functional magnetic resonance imaging (MRI) and clinical and neuropsychologic tests 1 wk after injury and at time of clinical recovery of standardized tests; initial changes in brain physiology linked to self-reported symptoms, neuropsychologic test results, and clinical recovery; confirmed that neurophysiologic abnormalities occur after even mild sports-related concussion

Current recommendations: most high school and college athletes return to play 3 to 5 days after concussion; data suggest 7 days better; however, 9% of athletes still not at baseline by 7 days and should not return to play until all signs and symptoms of concussion and cognitive and postural stability testing have returned to normal, or to athlete’s baseline

Glasgow Coma Scale (GCS): used to assess changes in mental status; lowest score 3; highest score 15; GCS score of 13 to 15 considered mild head injury (concussion usually in this category)

Computed tomography (CT) of head: <10% of children with concussion have intracranial injuries identified by head CT; <2% with abnormalities require neurosurgery; normal neurologic examination does not predict normal head CT; New Orleans decision rule for head CT after concussion— applicable only if patient’s GCS score 15; abnormal CT more likely if patient has headache, vomiting, age >60 yr, drug or alcohol intoxication, persistent anterograde amnesia, evidence of soft tissue or bone injury above clavicles, or seizure; Canadian head CT rule—applies to patients with GCS scores of 13 to 15 and age 16 yr; found high risk for neurosurgical intervention with GCS score <15 ≤2 hr after injury, suspected open or depressed skull fracture, any sign of basilar skull fracture, >2 episodes of vomiting, and advanced age; moderate risk for brain injury detected by CT if retrograde amnesia persists ≥30 min and if dangerous mechanism present (eg, pedestrian struck by car, ejection from motor vehicle injury, fall from 3 ft or 5 stairs [eg, gymnastics, diving]); University of California, Davis, predictors—scalp hematoma; signs of skull fracture; abnormal mental status (GCS score <15 or if patient confused, somnolent, repetitive, or slow to respond to verbal communication); vomiting; headache; take-home points—no criteria 100% sensitive and 100% specific; speaker combines criteria from all studies, and utilizes head CT if any of criteria observed; radiation exposure for CT highest for children <5 yr of age, especially if dose not adjusted for child’s size

Observation after concussion: CT showing small brain contusions or subarachnoid hemorrhage indicates severe impact and warrants further evaluation by neurologic or trauma surgeon and observation; skull fracture in middle meningeal artery distribution presents risk for epidural hematoma (also warrants neurosurgical consultation); persistence of altered mental status or decrease in mental status warrants hospital observation; if mental status and neurologic examination remain normal after observation period (4 hr from time of injury), patient discharged to care of responsible person; deterioration in mental status warrants CT; role of wake-up calls controversial; probably indicated (but no good data) if patient has experienced LOC, prolonged amnesia, and persistence of symptoms