Approach to: Pediatric urinary tract infection (UTI)

Urinary tract infections (UTIs) are prevalent in the children. Presentation of UTI vary in children of different ages. In infants, who cannot localize symptoms, UTI can present with a fever whereas in older children a UTI can present with urinary symptoms (dysuria, urinary frequency, incontinence). It is important to establish a clear diagnosis in order to treat and resolve the infection with antibiotics therapy to prevent bacteremia, pyelonephritis, and long-tern renal disease. Urine is collected through a mid-stream urine sample, in toilet trained children, via urethral catheterization, suprapubic aspiration and pediatric urine collection bags. Urine analysis and culture are the first-line investigations in children with suspected UTI. Goals of treatment include elimination of infection, relief of acute symptoms, and prevention of recurrent and long-term complications. The Canadian Pediatric Society recommends initial treatment with oral antibiotics for nontoxic children with febrile UTIs. Imaging, such as a renal/bladder ultrasound, may be used.

20 Evaluation of Compliance with the 2017 Canadian Pediatric Society (CPS) Position Statement for the Management of Newborns at Risk for Early-Onset Sepsis (EOS): A Retrospective Cohort Study

Background Due to the high mortality and non-specific clinical presentation, clinicians often empirically treat newborns at risk of early-onset sepsis (EOS). Recently, the Canadian Pediatric Society (CPS) published updated recommendations that promote a more judicious approach to EOS management. Objectives To examine the compliance with the CPS position statement at a tertiary perinatal site. Design/Methods A retrospective chart review was conducted between Jan 1 – Jun 30, 2018. Newborns were categorized into 5 groups, depending on the number of EOS risk factors. Management strategies were assessed against the CPS recommendations to establish the rate of non-compliance. The reason for non-compliance, readmission rate and rate of culture-positive EOS were also examined. Results were expressed using descriptive statistics. A Chi-squared test was conducted to assess the association between the readmission rate and initial management. Results The total non-compliance rate was 47%. This was mostly due to inappropriate investigations in lower EOS risk groups [3 (71%) and 4 (94%)] and withholding antibiotics in groups with more risk factors [1 (43%) and 2 (67%)]. The rate of readmission for a septic work-up was low (<2%), and no newborns had culture-positive EOS. There was no significant association between the readmission rate and initial management (p=0.13). Conclusion Although the rate of non-compliance to the 2017 CPS recommendations was high, no neonates had culture-positive EOS, suggesting that our management strategies may be too aggressive. An initial observational period for newborns at lower EOS risk (groups 3 and 4) may warrant consideration for future quality improvement initiatives.

A Simulation Study to Assess the Effect of Analytic Error on Neonatal Glucose Measurements Using the Canadian Pediatric Society Position Statement Action Thresholds

Background: The Canadian Pediatric Society (CPS) has endorsed an algorithm for the screening and immediate management of babies at risk of neonatal hypoglycemia that provides time-dependent glucose concentration action thresholds. The objective of this study was to evaluate the impact of glucose analytic error (bias and imprecision) on the misclassification of glucose meter results from a neonatal intensive care unit (NICU) using the CPS guidelines. Methods: A simulation dataset of true glucose values ( N = 100 000) was derived by finite mixture model analysis of NICU glucose data ( N = 23 749). Bias and imprecision were added to create measured glucose values. The percentages of measured glucose values that were misclassified at CPS action thresholds were determined by Monte Carlo simulation. Results: Measurement biases ranging from −20 to +20 mg/dL combined with coefficients of variation 0% to 20% were evaluated to predict misclassification rates at 32, 36, and 47 mg/dL. The models demonstrated low risk of false normoglycemia—at 5% CV and +10 mg/dL bias: 0.8% to 5% misclassification at the 32 and 47 mg/dL thresholds due to bias. The models demonstrated risk of false hypoglycemia—at 5% CV and −10 mg/dL bias: 3% to 12.5% misclassification at 32 and 47 mg/dL thresholds due to both bias and imprecision. Conclusion: Using CPS action thresholds, the simulation model predicted the proportion of neonates at risk of inappropriate clinical action—both of omission or “failure to treat” and commission or “overtreatment” in response to NICU glucose meter results at specific bias and imprecision values.

It is time for an ethical, evidence-based approach to youth presenting to the ED with an opioid overdose

Currently, there is a dangerous inconsistency between our current understanding of adolescent development and the effects of drugs on cognition when compared to our collective approach to youth who present in the emergency department with an opioid overdose. We call upon practitioners to embrace a new paradigm and we ask the Canadian Pediatric Society (CPS) to spearhead the development of guidelines to advise on best practices to manage youth who present to the emergency department with an illicit drug overdose.

MP29: Did the Canadian Pediatric Society policy statement in 2007 impact trampoline-related injuries in Halifax, Nova Scotia?

Introduction: The Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) found a significant rise in trampoline-related injuries from 1999-2005, many of which required hospitalization. In 2007 and again in 2013, the Canadian Pediatric Society (CPS) recommended against the recreational use of trampolines at home. The purpose of this study was to evaluate the impact of this policy statement on trampoline-related injuries in Halifax, Nova Scotia. Methods: Trampoline injury data was obtained from the CHIRPP database at the IWK Health Centre, the paediatric referral hospital for the Maritimes. The data was stratified according to the timing of the CPS policy statement (before: 2001-2006, after: 2008-2013 and after reaffirmation 2013-2015). Data variables included mechanism, site, nature and context of injury. The data were evaluated using SPSS and chi-squared tests. Results: Since the 2007 CPS policy statement, an average of 162 per 10,000 ED visits at the IWK Health Centre were the result of trampoline-related injuries compared to 95 per 10,000 pre-policy. The majority of injuries (76-80%) occurred in children 5-14 years of age. Recreational use at home in the yard was the most common location of the accident (78-88%), with most injuries occurring on the trampoline mat itself (83-85%) due to incorrect landing (32-35%), falls (21-27%), or being struck by a person or object (24-25%). Soft tissue injuries (15-17%), sprains (19-22%) or fractures (40-46%) to the elbow (11-12%), forearm (5-9%) or ankle (19-21%) continued to be the most common nature and sites of injuries. The injury data before compared to after the CPS policy statement did not differ significantly in gender, the mechanism of injury, the type of injury, or body part involved (p-value >0.05). There was a significant difference in the number of injuries between age groups post-policy, with more occurring in children less than 4 and between the age of 10-14 (p<0.009). Moreover, where the trampoline injury was located was also significantly different post-policy with more injuries occurring in sports/recreational facilities (p<0.001). Conclusion: Trampolining is a high-risk activity with injuries occurring predominantly in children and youth. Despite the recommendations brought forth by the CPS, trampoline-related injuries remain an important source of pediatric injuries at the IWK Health Centre in Halifax, Nova Scotia.

INFANTILE SCURVY AND NUTRITIONAL RICKETS IN THE UNITED STATES

During the summer of 1960, the Committee on Nutrition of the Canadian Pediatric Society requested co-operation of the Committee on Nutrition of the American Academy of Pediatrics in evaluation of the problem of scurvy in Canada. Reports in the Canadian literature in 1958 and 19591-6 recorded occurrence of 180 cases of scurvy during the 15 years from 1945 through 1959, and personal communications accounted for 142 cases not recorded in the literature. It was somewhat difficult to derive a satisfactory estimate of the true incidence of scurvy from these figures. However, an unpublished report by Dr. J. W. Davies, Chief Medical Officer of Health, Newfoundland, indicated that 77 cases of scurvy had been diagnosed in 1959 for an estimated 30,000 children less than 2 years of age, an incidence of 2.5 cases per 1,000 children. As an aid in evaluation of the problem of scurvy in Canada and to obtain information concerning the magnitude of the problem in the United States, a survey was carried out concerning incidence of scurvy in the United States during the years 1956 through 1960, inclusive. Questionnaires concerning the incidence of scurvy and rickets among children admitted to the hospital were mailed to 294 hospitals that maintain approved7 residency programs in pediatrics. Replies were received from 176 of the 294 hospitals (60%). Preliminary tabulation and analysis of results were then carried out, and a brief summary was mailed to each hospital. At the time of this mailing a second questionnaire was sent to those hospitals that had not responded to the initial questionnaire.