Prospective External Validation of the Esbenshade Vanderbilt Models Accurately Predicts Bloodstream Infection Risk in Febrile Non-Neutropenic Children With Cancer

PURPOSE

The optimal management of fever without severe neutropenia (absolute neutrophil count [ANC] ≥500/µL) in pediatric patients with cancer is undefined. The previously proposed Esbenshade Vanderbilt (EsVan) models accurately predict bacterial bloodstream infections (BSIs) in this population and provide risk stratification to aid management, but have lacked prospective external validation.

MATERIALS AND METHODS

Episodes of fever with a central venous catheter and ANC ≥500/µL occurring in pediatric patients with cancer were prospectively collected from 18 academic medical centers. Variables included in the EsVan models and 7-day clinical outcomes were collected. Five versions of the EsVan models were applied to the data with calculation of C-statistics for both overall BSI rate and high-risk organism BSI (gram-negative and Staphylococcus aureus BSI), as well as model calibration.

RESULTS

In 2,565 evaluable episodes, the BSI rate was 4.7% (N = 120). Complications for the whole cohort were rare, with 1.1% (N = 27) needing intensive care unit (ICU) care by 7 days, and the all-cause mortality rate was 0.2% (N = 5), with only one potential infection-related death. C-statistics ranged from 0.775 to 0.789 for predicting overall BSI, with improved accuracy in predicting high-risk organism BSI (C-statistic 0.800-0.819). Initial empiric antibiotics were withheld in 14.9% of episodes, with no deaths or ICU admissions attributable to not receiving empiric antibiotics.

CONCLUSION

The EsVan models, especially EsVan2b, perform very well prospectively across multiple academic medical centers and accurately stratify risk of BSI in episodes of non-neutropenic fever in pediatric patients with cancer. Implementation of routine screening with risk-stratified management for non-neutropenic fever in pediatric patients with cancer could safely reduce unnecessary antibiotic use.

Risk of bacterial bloodstream infection does not vary by central-line type during neutropenic periods in pediatric acute myeloid leukemia

BACKGROUND

Bloodstream infections (BSIs) are a frequent cause of morbidity in patients with acute myeloid leukemia (AML), due in part to the presence of central venous access devices (CVADs) required to deliver therapy.

OBJECTIVE

To determine the differential risk of bacterial BSI during neutropenia by CVAD type in pediatric patients with AML.

METHODS

We performed a secondary analysis in a cohort of 560 pediatric patients (1,828 chemotherapy courses) receiving frontline AML chemotherapy at 17 US centers. The exposure was CVAD type at course start: tunneled externalized catheter (TEC), peripherally inserted central catheter (PICC), or totally implanted catheter (TIC). The primary outcome was course-specific incident bacterial BSI; secondary outcomes included mucosal barrier injury (MBI)-BSI and non-MBI BSI. Poisson regression was used to compute adjusted rate ratios comparing BSI occurrence during neutropenia by line type, controlling for demographic, clinical, and hospital-level characteristics.

RESULTS

The rate of BSI did not differ by CVAD type: 11 BSIs per 1,000 neutropenic days for TECs, 13.7 for PICCs, and 10.7 for TICs. After adjustment, there was no statistically significant association between CVAD type and BSI: PICC incident rate ratio [IRR] = 1.00 (95% confidence interval [CI], 0.75-1.32) and TIC IRR = 0.83 (95% CI, 0.49-1.41) compared to TEC. When MBI and non-MBI were examined separately, results were similar.

CONCLUSIONS

In this large, multicenter cohort of pediatric AML patients, we found no difference in the rate of BSI during neutropenia by CVAD type. This may be due to a risk-profile for BSI that is unique to AML patients.

Attention-deficit/hyperactivity disorder: evidence-based diagnosis and management for primary care clinicians

Attention-deficit/hyperactivity disorder (ADHD) is a disorder characterized by persistent hyperactivity, impulsivity and inattention that impairs educational achievement and/or social development. Families seek an evaluation for children with these behaviors due to the high prevalence of ADHD and potential personal, social, and economic burdens. This review covers the current state of knowledge regarding the epidemiology, etiology, diagnosis, treatment, and prognosis for ADHD. It concludes with recommendations for future research.

The child with ADHD: using the AAP Clinical Practice Guideline. American Academy of Pediatrics

The American Academy of Pediatrics developed an evidence-based clinical practice guideline that provides recommendations for the assessment and diagnosis of school-aged children with attention-deficit/hyperactivity disorder (ADHD). This guideline, the first of two guidelines to provide recommendations on this condition, is intended for use by primary care clinicians. The second set of guidelines will address the treatment of children with ADHD. The guideline contains six recommendations for the diagnosis of ADHD: (1) in a child six to 12 years of age who presents with inattention, hyperactivity, impulsivity, academic underachievement or behavior problems, primary care clinicians should initiate an evaluation for ADHD; (2) the diagnosis of ADHD requires that a child meet the criteria for ADHD in the Diagnostic and Statistical Manual of Mental Disorders; (3) the assessment of ADHD requires evidence directly obtained from parents or caregivers regarding the core symptoms of ADHD in various settings, the age of onset, duration of symptoms and degree of functional impairment; (4) the assessment of ADHD also requires evidence directly obtained from a teacher (or other school professional) regarding the core symptoms of ADHD, duration of symptoms, degree of functional impairment and associated conditions; (5) evaluation of the child with ADHD should include assessment for coexisting conditions; and (6) other diagnostic tests are not routinely indicated to establish the diagnosis of ADHD but may be used for the assessment of coexisting conditions.

Beyond infant colic

Some of the most interesting cases in pediatric practice evolve through time. What may begin as a clear, well defined problem with a predictable natural history and an accepted intervention strategy may develop into a more complex, multi-faceted set of problems. It is these children who potentially provide clinicians with new insights into behaviors. This case of a colicky infant illustrates the wide spectrum of behavioral and physiological symptoms that emerge from a specific underlying behavioral phenomenon. It also emphasizes the significant benefit derived from a longitudinal perspective of developmental events.

Prevalence and assessment of attention-deficit/hyperactivity disorder in primary care settings

Research literature relating to the prevalence of attention-deficit/hyperactivity disorder (ADHD) and co-occurring conditions in children from primary care settings and the general population is reviewed as the basis of the American Academy of Pediatrics clinical practice guideline for the assessment and diagnosis of ADHD. Epidemiologic studies revealed prevalence rates generally ranging from 4% to 12% in the general population of 6 to 12 year olds. Similar or slightly lower rates of ADHD were revealed in pediatric primary care settings. Other behavioral, emotional, and learning problems significantly co-occurred with ADHD. Also reviewed were rating scales and medical tests that could be employed in evaluating ADHD. The utility of using both parent- and teacher-completed rating scales that specifically assess symptoms of ADHD in the diagnostic process was supported. Recommendations were made regarding the assessment of children with suspected ADHD in the pediatric primary care setting.

An opportunity for office-based research

Robert, a nearly 12-year-old boy, traveled an hour to see a new pediatrician. Robert's mom told the pediatrician that Robert had not been seen by a doctor for several years because "no one seems to be able to help him with his problem." Robert had been wetting the bed "ever since he was toilet-trained" at age 2 years. Robert wets the bed about 5 out of 7 nights. He never has daytime accidents. He did not have a history of urinary tract infection, dysuria, urgency, or increased frequency of urination. He has daily bowel movements and denied soiling or accidents. Robert's mom said he had "toilet-trained himself" at age 2 years. Both Robert's mom and maternal grandfather had nocturnal enuresis "into their teenage years." The pediatrician was surprised to learn that another physician had treated Robert with imipramine at age 5 years. The medication worked intermittently and Robert continued to take it for about a year. At age 6 years, Robert's parents saw an advertisement for a bed-wetting alarm. They purchased the alarm but found that Robert never woke up when the alarm sounded. At age 7 years, Robert saw a urologist who told him he would "outgrow the problem." A year later, the urologist prescribed desmopressin acetate (DDAVP) nasal spray, which Robert took on occasion during the next 2 years. Every time he stopped the DDAVP, he resumed wetting the bed. His parents never punished him for his accidents, but they did try restricting fluids after dinner and also woke Robert in the middle of the night and encouraged him to go to the bathroom. Neither of these strategies was successful. Robert said he was "frustrated" and wondered if "I would still be wetting the bed as a grown-up." The pediatrician explained the nature of enuresis to Robert and his mom, provided them with instructions and an order form for a bed-wetting alarm, and arranged a follow-up visit. The next day, during nursery rounds, he asked several of his colleagues about their approaches to the treatment of enuresis. A few used DDAVP, one found imipramine beneficial, and one preferred behavioral treatment with a bed-wetting alarm. The pediatrician became concerned that he had misread the literature on enuresis. He brought the question up at the next pediatric staff meeting at the local hospital. A lively discussion ensued as the physicians realized that they employed a variety of treatments for enuresis. Robert's pediatrician wondered why his colleagues were not using the alarm because the literature seemed to indicate it to be the preferred treatment for enuresis. He asked the group if they would be interested in talking about the issue further and perhaps trying to understand the reasons for their varied approaches to this problem.

Parental refusal to immunize a 2-month-old infant

At a 2-month health supervision visit, Monica's pediatrician was surprised by her mother's wish to withhold immunizations. At prior encounters with her parents, including a prenatal visit, the meeting after Monica's birth, and the 2-week health supervision visit, there was no indication that standard immunizations would be refused. Monica's parents informed her pediatrician that the potential side effects from the immunization led them to think that their healthy child should not be immunized. After talking with other parents in the neighborhood, watching a television program on "children who were brain damaged after getting their shots," and looking at several web sites for parents on the Internet, they concluded that it was safer to withhold the immunizations. "Monica is so healthy.....why give her shots that may make her very sick?" Monica was the first child born to these college-educated parents who had been married for 5 years. The pregnancy was full term and notable for two transient episodes of spotting in the first trimester. Both parents looked forward to Monica's birth. There were no perinatal problems, breast feeding was successful with an appropriate weight gain, and the physical examination was normal. The pediatrician explained to the parents that she understood their concerns. "Most of the things we give children for prevention or treatment of disease may be associated with possible side effects. In the case of immunizations, the chance of a serious side effect is much less than the risk that Monica might acquire one of the diseases we can prevent with an immunization. I have seen a few unimmunized infants who were hospitalized with a very serious case of whooping cough, one of the diseases we can prevent by immunizing Monica." The parents thanked the pediatrician for the information and agreed to read several pamphlets about immunizations. The pediatrician observed that her interchange with the parents was cordial but stressful, for both herself and Monica's parents. As the parents left the office, she wondered if there was a more effective way to talk about immunizations with parents who refuse to immunize their children.

Feeding problems, sleep disturbances, and negative behaviors in a toddler

Tiffany, a 3-year-old girl, was referred to the developmental and behavioral pediatrics service for evaluation of significant and persistent negative behaviors associated with refusal to eat at meal time and constant snacking during the past 3 months. She lost 2 pounds, but her weight for her height was at the 50th percentile. Her mother indicated that Tiffany had frequent night awakenings (>10) and late sleep onset (between 12:00 and 1:00 a.m.). Her mother described her as being "easily frustrated," getting upset and angry very quickly. Tiffany was identified at an early intervention program as having mild to moderate developmental delays in pragmatic speech, gross and fine motor skills, and social interaction skills. Tiffany was born at 33 weeks gestation and was hospitalized for 10 days without significant perinatal problems. She was readmitted at 2 months of age when she was diagnosed with gastroesophageal reflux, lactose intolerance, sleep apnea, and bradycardia. She was discharged with an apnea monitor. A seizure disorder was diagnosed at 1 year of age and reactive airway disease at 2 years of age. At the time of the referral to the developmental and behavioral pediatrics service, Tiffany was followed by multiple services, including cardiology, neurology, gastroenterology, psychology, and pulmonary. Pharmacologic therapies included albuterol and cromalyn inhalers, phenobarbital, valproic acid, levocarnitine, ranitidine, and an inhaled steroid. She continued to use the apnea monitor each night, although three sleep studies demonstrated a normal sleep pattern with no evidence of apnea or bradycardia. A recent electroencephalogram was normal. Tiffany lives with her mother and maternal grandparents. Her mother is morbidly obese with a history of asthma and depression. She was infertile for a 10-year period, which she attributed to the stress associated with living with an abusive man. Tiffany was the result of a subsequent, brief relationship with another man; she has not had contact with her father. Her mother is a licensed practical nurse who has not worked as a nurse since Tiffany's birth. An interdisciplinary treatment approach to Tiffany's multiple biological and behavioral problems was implemented by admitting her to a collaborative care unit at a children's hospital.

A two-year-old boy with language regression and unusual social interactions

Jimmy, a 2 1/2-year-old boy, was seen for the first time by a new pediatrician after a recent family move. His mother made the appointment for a health supervision visit although she had concerns about his language and social skills. She stated that he spoke primarily with unintelligible sounds and often communicated by pointing with his finger. He spoke only 10 words that were clear enough to be understood. Jimmy's mother said that he could hear, but she was not sure whether he understood everything she said. Although he played at home with his 4-year-old brother, he typically played by himself when he was in the presence of other children. Jimmy's mother was asked if he had had a 2-year-old visit to a pediatrician and what the assessment was at that time. She said that his delayed development was discussed with the pediatrician, but she was reassured that he would progress during the following year. An uncomplicated full-term gestation was followed by a vaginal delivery without perinatal problems. Jimmy was a "calm" baby who was breastfed for the first 6 months of life. He sat at 7 months, pulled himself up to stand with support at approximately 9 months, and walked at 13 months. Transitions were always difficult for Jimmy; he screamed and was difficult to settle whenever cared for by someone other than his parents. He typically resists physical contact when children or adults approach him. His mother recalled that language emerged early. He acquired a significant number of words between 12 and 15 months of age. Jimmy apparently recognized letters when his parents were teaching the older sibling. At 15 months, Jimmy's language output regressed dramatically, and by 18 months, he no longer used words to communicate. Since then, he has spoken fewer than 10 single words. He mostly babbles and uses repetitions of the same sounds. The pediatrician inquired into family structure and life events at the time Jimmy lost language milestones. He was told that, at this time, the father, an engineer, changed his position in the company and began to travel extensively. Jimmy's mother thought that the absence of his father might be related to the language regression. She also noted that Jimmy seemed to have a stronger attachment for his father: "Jimmy has always been attracted to his father, and his brother seems to prefer me." The parents' marriage was strong and free of any major disharmony. During the interview, the pediatrician noted that Jimmy played persistently with his set of small trains, repetitiously lining them up in order. He was not interested in other toys that were on the floor next to him. He ran around the trains, mostly on his toes, while making unintelligible sounds. He looked away when the pediatrician called his name and became agitated when his mother attempted to redirect his attention to the examination. The pediatrician, 4 years in practice after his residency, had never seen a child with Jimmy's pattern of development. That Jimmy's development was unusual in two domains was apparent to his pediatrician from the preceding information and brief observations. He asked himself what the next steps should be.