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BACKGROUND Chest radiographs (CXRs) are frequently used in the diagnosis of community-acquired pneumonia (CAP). We sought to construct a predictive model for radiographic CAP based on clinical features to decrease CXR use. METHODS We performed a single-center prospective study of patients 3 months to 18 years of age with signs of lower respiratory infection who received a CXR for suspicion of CAP. We used penalized multivariable logistic regression to develop a full model and bootstrapped backward selection models to develop a parsimonious reduced model. We evaluated model performance at different thresholds of predicted risk. RESULTS Radiographic CAP was identified in 253 (22.2%) of 1142 patients. In multivariable analysis, increasing age, prolonged fever duration, tachypnea, and focal decreased breath sounds were positively associated with CAP. Rhinorrhea and wheezing were negatively associated with CAP. The bootstrapped reduced model retained 3 variables: age, fever duration, and decreased breath sounds. The area under the receiver operating characteristic for the reduced model was 0.80 (95% confidence interval: 0.77–0.84). Of 229 children with a predicted risk of 39%, 140 (61.1%) had CAP (specificity of 90% at a 39% risk threshold). CONCLUSIONS A predictive model including age, fever duration, and decreased breath sounds has excellent discrimination for radiographic CAP. After external validation, this model may facilitate decisions around CXR or antibiotic use in CAP.

A 16-year-old white boy with a history of chronic lung disease of prematurity, cough-variant asthma, and incidental lung nodules presented to the emergency center in spring 2020 with acute onset dry cough, shortness of breath, and fever. An initial history, gathered from his mother because of the patient’s respiratory distress, revealed no recent travel. However, his mother is a health care worker at a hospital, and sick contacts included ongoing contact with a friend with cold-like symptoms. He had a variety of animals at home, including a dog, cats, fish, rodents, and reptiles. He had a history of vaping tobacco products >6 months ago. Fever and respiratory symptoms were associated with fatigue, chest tightness, abdominal pain, and myalgias. On examination, he was ill appearing and had tachycardia, tachypnea, borderline hypoxia with an oxygen saturation of 91% on room air, diminished breath sounds at the lung bases, and unremarkable abdominal examination results. A chest radiograph was consistent with the lung examination, revealing bilateral lower lobe hazy infiltrates. He showed initial improvement for 48 hours with antibiotics, intravenous fluid resuscitation, oxygen via nasal cannula, albuterol, and prednisone. Subsequently, he worsened with persistent high fever, increasing respiratory distress with pulmonary findings, and severe persistent epigastric pain, which added a layer of diagnostic complexity. As this patient’s clinical course evolved and further history became available, pulmonary medicine and infectious diseases services were consulted to guide diagnostic evaluation and treatment of this patient early in the era of coronavirus disease 2019.

Kaposiform hemangioendothelioma (KHE) is a rare infiltrative vascular tumor that is potentially life-threatening when presenting with Kasabach-Merritt phenomenon (KMP). KMP is clinically characterized as severe thrombocytopenia and hypofibrinogenemia and therefore is associated with a high mortality rate. There is no standard of cure for KHE currently. Potential medications, including corticosteroids, propranolol, and chemotherapy drugs such as sirolimus, are often used for alleviating KHE symptoms. Although some case reports of sirolimus treatment have shown promising results with recovered coagulant parameters, the off-target effects may cause severe problems. Here we describe 2 cases of infant patients with KHE and KMP who were scheduled to receive sirolimus on a long-term basis. However, both patients developed paroxysmal cough and tachypnea shortly after the onset of sirolimus treatment and succumbed to infection thereafter. This report reveals a potential risk of infection in sirolimus-treated infant patients. The fatal complication highlights the importance of antibiotic prophylaxis and serum sirolimus level monitoring to ensure the safe use of sirolimus in the treatment of infant patients with KHE.

Introduction: Disseminated tuberculosis involving multiple organs is rare among patients in developed countries, particularly immunocompetent patients. However, pregnancy is a risk factor for reactivation of latent tuberculosis and/or asymptomatic dissemination of primary tuberculosis. Case Description: A 17-year-old Guatemalan immigrant female, with recent history of spontaneous abortion requiring dilation and curettage at 16 weeks gestation, presented two weeks post-procedure with three days of worsening abdominal pain, diarrhea, fever, and cough. Her physical exam revealed a thin appearance, hypoxia, tachypnea and suprapubic abdominal tenderness without rebound or guarding. Initial labs revealed leukocytosis with neutrophil predominance, acute kidney injury, and synthetic liver dysfunction. CT angiogram of the chest demonstrated an apical lung cavity with …

A 3-day-old term, male infant presented to the emergency department for evaluation of bloody stools. The infant was born after an uncomplicated pregnancy followed by a normal spontaneous vaginal delivery. The mother was group B Streptococcus colonized, and received antenatal penicillin prophylaxis. The infant received routine delivery room care, and was given ophthalmic erythromycin and intramuscular vitamin K. Circumcision was performed without bleeding and he was discharged from the newborn nursery and the hospital after 48 hours. On the day of presentation, he had streaky bright red blood in 4 consecutive stools. After discussion with the infant’s pediatrician, the parents took him to the emergency department. The infant was afebrile, nursing well without emesis, and had made ∼10 wet diapers that day. The physical examination revealed a fussy infant with mild tachycardia, tachypnea, and scleral icterus. The complete blood count was unremarkable. Serum total bilirubin was 11.9 mg/dL, sodium 156 mmol/L, chloride 120 mmol/L, potassium 4.7 mmol/L, and bicarbonate 16 mmol/L. International normalized ratio was prolonged at 2.7, prothrombin time 26.6 seconds, partial thromboplastin time 38.9 seconds. The stool was hemeoccult positive. An obstructive radiograph series of the abdomen showed a nonobstructed gas pattern. Official radiology interpretation the following day reported possible pneumatosis intestinalis in the left and right colon. Our multidisciplinary panel will discuss the assessment of bloody stools in the term newborn, evaluation of electrolyte abnormalities, the diagnosis, and patient management.

This report describes the first known case of Mucopolysaccharidosis type IIIA presenting with respiratory symptoms and characteristic lung pathology. This case highlights under-recognized areas of systemic involvement and earlier modes of presentation in lysosomal storage disorders as well as the importance of investigating infants who have persistent tachypnea.

Functional constipation is a common pediatric problem that is often treated through well-established algorithms. Fecal disimpaction is the initial therapeutic step, and severe cases require hospitalization for intensive therapies. We describe a significant unexpected complication of this common clinical situation. An 8-year-old boy with suspected chronic functional constipation was hospitalized for disimpaction by continuous nasogastric administration of polyethylene glycol electrolyte (PEG-E) solution. On the sixth day of disimpaction, the patient abruptly developed fever, tachycardia, and tachypnea. Evaluation included blood culture, which grew Escherichia coli, and treatment with a course of appropriate antibiotics was provided. The safety of PEG-E solutions has been shown in studies of children with constipation, which made this patient’s illness surprising. Several potential etiologies of his infection were considered, including bacterial translocation (BT). BT is defined as the passage of live microbes and microbial products from the gastrointestinal tract to extraintestinal sites, such as the bloodstream. It has been shown to occur in a variety of clinical conditions but is of unclear clinical significance. In this case, physical damage to the intestinal mucosa was thought to contribute to the potential occurrence of BT, and prolonged disimpaction was considered as a risk factor. E coli sepsis in a child undergoing inpatient nasogastric fecal disimpaction with PEG-E represents a clinical problem never before reported in the literature and should increase clinicians’ indices of suspicion for uncommon complications of common procedures.

OBJECTIVE. Chronic snoring that does not adhere to the criteria for a diagnosis of obstructive sleep apnea syndrome may be associated with learning and behavioral problems. We investigated the sleep structure of chronic snorers who had an apnea-hypopnea index of METHODS. Fifteen successively seen chronic snorers (9.8 ± 4 years) with an apnea-hypopnea index of RESULTS. Chronic snorers have evidence of flow limitations and tachypnea during sleep even if they do not present with apneas, hypopneas, and decrease in oxygen saturations. They also present with abnormal cyclic alternating pattern rates and changes in phase A of cyclic alternating pattern compared with control subjects. CONCLUSIONS. An apnea-hypopnea index value cannot be the sole determinant in evaluating sleep-disordered breathing in children. Children who have chronic snoring and do not respond to the criteria for obstructive sleep apnea syndrome can present with an abnormal sleep electroencephalogram as evidenced by a significant increase in cyclic alternating pattern rates, with a predominance of abnormalities in slow wave sleep.

Objective. Nonsteroidal antiinflamma- tory drugs (NSAIDs), mainly ibuprofen, are used exten- sively among children as analgesic and antipyretic agents. Our initial survey in the Kendang Kerbau Chil- dren's Hospital in Singapore showed NSAIDs to be the second most common adverse drug reaction-causing medications among children of Asian descent. We at- tempted to characterize the clinical and epidemiologic profile of NSAID reactions in this group of patients. Methods. A retrospective case series from a hospital- based pediatric drug allergy clinic was studied. A diag- nosis of NSAID hypersensitivity was made with a mod- ified oral provocation test. Atopy was evaluated clinically and tested with a standard panel of skin-prick tests. We excluded from analysis patients with any un- provoked episodes of urticaria and/or angioedema, pa- tients

Objective. To assess the therapeutic effects of breathing a low-density gas mixture (heliox: 70% helium and 30% oxygen) in infants with bronchiolitis. Design. Prospective, interventional, comparative study. Setting. A pediatric intensive care unit (PICU) in a tertiary care, teaching hospital. Patients. Thirty-eight infants, 1 month to 2 years old, consecutively admitted to the PICU for treatment of moderate-to-severe acute respiratory syncytial virus bronchiolitis. Interventions. The first 19 patients were enrolled as the control group and received supportive care and nebulized epinephrine. In the next 19 patients, heliox therapy was added through a nonrebreather reservoir face mask. Measurements and Outcomes. Respiratory distress score, respiratory rate, heart rate, end-tidal CO2 (etCO2), and pulse oximetry oxygen saturation (satO2) values were recorded at baseline and at regular intervals. Data obtained during the first 4 hours were analyzed for comparison purposes. Demographic data, age, time elapsed from the start of the symptoms to the admission to PICU, length of stay in PICU (PICU-LOS), and duration of heliox therapy were also collected for each patient. Reductions in clinical scores and PICU-LOS were considered primary outcomes. Main Results. At baseline, the heliox and control groups had similar age (5.5 ± 3.1 vs 5.9 ± 3 months), previous length of course (47.3 ± 19.3 vs 45.4 ± 18.6 hours), clinical score (6.7 ± 1.1 vs 6.6 ± 1), heart rate (160 ± 24 vs 165 ± 20 beats per minute), respiratory rate (64 ± 7 vs 61 ± 7 respirations per minute), satO2 (91 ± 2.3 vs 91 ± 2.5%), and etCO2 (34 ± 7 vs 33 ± 6 mm Hg). Clinical score, heart rate, respiratory rate, and satO2 improved during the study in both groups. After 1 hour, the improvement in clinical score was significantly higher in the heliox group than in the control group (3.6 ± 1.16 vs 5.5 ± 0.89), and these differences continued to be significant at the end of the observation period (2.39 ± 0.69 and 4.07 ± 0.96, respectively), with a total average decrease in the score of 4.2 points in the heliox group versus 2.5 points in the control group. Heart and respiratory rates were also significantly lower in the heliox group compared with the control group after 1 hour and stayed lower throughout the rest of the study period. No changes were noted either in satO2 between groups or in etCO2 within or between groups throughout the study. Mean duration of heliox administration was 53 ± 24 hours (range: 24–112 hours) and no adverse effects were detected. PICU-LOS was significantly shorter in the heliox group (3.5 ± 1.1 days) than in the control group (5.4 ± 1.6 days). Conclusions. In infants with moderate-to-severe respiratory syncytial virus bronchiolitis, heliox therapy enhanced their clinical respiratory status, according to the marked improvement in their clinical scores and the reduction of the accompanying tachycardia and tachypnea. This beneficial response occurred within the first hour of its administration and was maintained as long as heliox therapy continued. In addition, PICU-LOS was reduced in heliox-treated patients. Long-term prospective studies are required to corroborate these findings and to establish the proper place of heliox in the therapeutic schedule of bronchiolitis.

Objective.To estimate the incidence of clinical deterioration leading to intensive care unit transfer in previously healthy infants with respiratory syncytial virus (RSV) infection hospitalized on a general pediatric unit and, to assess the hypothesis that history, physical examination, oximetry, and chest radiographic findings at time of presentation can accurately identify these infants.Study Design.A virology database was used to identify and determine the disposition of all children ≤1 year of age admitted to the Children's Hospital at Strong (CHaS) with RSV infection during the 1985 to 1994 respiratory seasons. Index patients were all previously healthy, full-term infants admitted initially to the general inpatient services at CHaS or Rochester General Hospital, a second University of Rochester teaching hospital, whose clinical deterioration led to transfer to the pediatric intensive care unit (PICU). These infants were matched retrospectively (for year and date of infection, sex, chronologic age, and race) with two hospitalized controls who did not require PICU transfer. Chest radiographic findings, respiratory rate (RR), O2 saturation, and presence of wheezing at time of presentation to the emergency department (ED) were compared.Results.During the study years, 542 previously healthy, full-term infants were admitted to the general pediatric unit at CHaS with proven RSV infection. Ten (1.8%; 95% confidence interval, 0.9%, 3.4%) were transferred subsequently to the PICU, primarily for close monitoring of progressive respiratory distress. Data for these patients and 7 patients transferred from Rochester General Hospital to the PICU at the CHaS were compared with those for control patients. The mean RR in the ED (63 vs 50), and O2 saturation in the ED (88% vs 93%) were modestly abnormal in cases compared with controls. Wheezing on examination at time of presentation and chest radiographic findings did not differ between the two groups. A RR >80 and an O2saturation 97% for predicting subsequent deterioration. Each parameter, however, had a sensitivity ≤30%.Conclusion.Clinical deterioration requiring PICU admission is an uncommon occurrence in previously healthy infants admitted to a general pediatric inpatient unit with RSV infection. Extreme tachypnea and hypoxemia were both associated with subsequent deterioration; however, only a small proportion of patients who clinically deteriorated presented in this way. The clinical usefulness of these parameters, therefore, is limited. respiratory syncytial virus, deterioration, healthy infants, prediction.

Objective. To examine the relationship between transient tachypnea of the newborn and asthma complicating pregnancy. Design. Historical cohort analysis. Setting. Singleton live deliveries in New Jersey hospitals during 1989 to 1992 (n = 447 963). Patients. Mother-infant dyads were identified from linked birth certificate and maternal and infant hospital claims data. Women with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code (493) for asthma (n = 2289) were compared with a four-fold larger randomly selected control sample (n = 9156) from the remaining pool of women. Main Outcome Measure. Transient tachypnea of the newborn. Results. In the overall sample, after controlling for the confounding effects of important variables, infants of asthmatic mothers were more likely [odds ratio (OR), 1.79; 95% confidence interval (CI), 1.35–2.37] than infants of control mothers to exhibit transient tachypnea of the newborn. A stratified analysis by gestational age and sex revealed larger and statistically significant associations in term infants (OR, 2.02; 95% CI, 1.42–2.87) as opposed to preterm infants (OR, 1.51; 95% CI, 0.94–2.43) and in male infants (OR, 1.91; 95% CI, 1.35–2.71) as opposed to female infants (OR, 1.51; 95% CI, 0.92–2.47). On the other hand, after adjusting for important confounding variables, respiratory distress syndrome and maternal asthma were not found to be associated (OR, 1.14; 95% CI, 0.79–1.64). Conclusion. The results of this study provide evidence that maternal asthma is a risk factor for transient tachypnea of the newborn and differences in gestational age and sex were apparent in this association. The mechanism for this association remains to be determined.

* Abbreviations: CHF = : congestive heart failure • ILS = : intralobar sequestration • ELS = : extralobar sequestration • RR = : respiratory rate • HR = : heart rate • MRI = : magnetic resonance imaging • AVM = : arteriovenous malformation • BPFM = : bronchopulmonary foregut malformation • MRA = : magnetic resonance angiography Signs and symptoms of congestive heart failure (CHF) in a newborn include tachycardia, respiratory distress, feeding intolerance, irritability, and a weak cry. The neonate with CHF will usually have hepatosplenomegaly. Wheezing or crackles may be heard. Edema may be generalized, and a chest radiograph will usually reveal cardiomegaly. Differential diagnosis of CHF in a full-term newborn includes congenital heart disease, asphyxial cardiomyopathy, viral myocarditis, supraventricular tachycardia, diabetic cardiomyopathy, and arteriovenous malformations. In this report we describe the first documented newborn with CHF due to a coexisting bilateral intralobar sequestration (ILS) and extralobar sequestration (ELS), and summarize the cases of bilateral sequestrations previously reported in the English literature. A 4117-g full-term boy was born via a spontaneous vaginal delivery to a group B streptococcus-negative 24-year-old woman. Apgar scores were 8/9 at 1 and 5 minutes. After the first 4 hours of life the patient remained tachypneic with a respiratory rate (RR) of 60 to 100 and tachycardic with a heart rate (HR) of 160 to 200. In room air the oxygen percent saturation was 100%. There were no maternal infectious risk factors, and the child was feeding well and otherwise asymptomatic. After 48 hours of observation, his RR remained at 70 to 80 and his HR remained at 170 to 190. He had a normal complete blood count and chest radiograph. The patient was discharged and was seen daily without resolution of the tachypnea or tachycardia and without developing any signs of sepsis. On the eighth day of life, in addition to his tachypnea and tachycardia, his liver was noted to be palpable 4 cm below the right costal margin. He was then admitted for observation and an evaluation by pediatric cardiology for suspected CHF. On admission the patient was afebrile. His weight was 4553 g; RR 68; HR 164; blood …

Because at some point during the first week after birth almost every newborn has a total serum bilirubin (TSB) level that exceeds 1 mg/dL (17 μmol/L), the upper limit of normal for an adult, and ∼2 of every 3 newborns are jaundiced to the clinician's eye, this type of transient bilirubinemia has been called “physiologic jaundice.” When TSB levels exceed a certain value, the infant is often described as having “pathologic jaundice.” I would like to argue that these terms have limited utility and are often used incorrectly, with potentially damaging consequences. They should be abandoned. The physiology of the newborn differs from that of older children and adults in many ways. Newborns breathe 40 to 60 times per minute, and their hearts beat 120 to 160 times per minute. Their hematocrit levels are frequently >60%. In time, all of these values return to normal levels, as does their bilirubin level. However, we don't talk about physiologic tachypnea, tachycardia, or polycythemia, so why pick on jaundice? Some like the term “physiologic jaundice” because it has a reassuring sound for parents and physicians. Presumably, physiologic jaundice should apply to newborns whose TSB levels fall within a certain range, but what is that range? Because very few (if any) newborns have peak TSB levels

There have been many reports of different heart rate–variability metrics and their association with sepsis in neonates, children, and adults.1–8 Common to all has been a lack of specificity between subjects, although sensitivity to dynamic changes within subjects has been very high. In this issue of Pediatrics , Griffin et al9 report on a specific group of measures (or metrics) of heart rate variability, termed the heart rate characteristics (HRC) index, and its association with blood-culture–proven sepsis in neonates. The basis for their research is the poor diagnostic sensitivity and specificity of the current clinical and laboratory evaluation of an infant for suspected sepsis. Current neonatal practice includes careful examination for sepsis-associated physical findings including temperature instability, tachycardia, tachypnea, apnea, prolonged capillary refill time, hypotension, and/or decreased urine output. Corroborative laboratory tests include significant elevation or depression of the white blood cell (WBC) count, the presence of immature neutrophils, metabolic acidosis (lowered pH and/or bicarbonate or elevated lactate), thrombocytopenia, coagulopathy, or evidence of renal or hepatic dysfunction. Of course, the “gold standard” is a positive culture of blood, cerebrospinal fluid, or urine, but there is an unacceptably long turn-around time for results (often ≥24–48 hours) and … Address correspondence to Brahm Goldstein, MD, FCCM, Department of Pediatrics, Pediatric Clinical Research Office, Doernbecher Children’s Hospital, 707 SW Gaines St, Mail Code: CDRCP, Portland, OR 97239. E-mail: goldsteb{at}ohsu.edu

Humidifiers are commonly used in the community to relieve symptoms associated with acute respiratory infections in young children; however, clear benefits of these devices have not been documented. The Environmental Protection Agency has not found any adverse health effects related to humidifier use. We report here the case of a young infant with significant accidental inhalational lung injury related to dispersal of mineral dust from an ultrasonic home-use humidifier. The clinical consequences included prolonged hypoxemia, tachypnea, and failure to thrive. Radiography revealed pneumonitis, and pulmonary-function testing showed a nonreversible mild obstructive ventilatory defect. Because of persistent symptoms, evolution of failure to thrive, and nonresponse to inhaled and short courses of systemic glucocorticoids, an aggressive management approach was successfully pursued with high-dose pulse steroid therapy, which could be a potential therapeutic approach for similar patients. In addition, this case raises important questions about the safety of exposing infants and young children to humidifiers and emphasizes the need for further study.

This study was designed to examine the relationship between respiratory signs and the likelihood of having an abnormal chest radiograph in a sample of febrile infants less than 8 weeks of age. The sample consisted of 242 infants who were admitted during a 3-year period with temperatures ≥38°C (100.4°F) and had a chest radiograph. The house officer recorded the presence of respiratory signs and symptoms including rhinorrhea, tachypnea, cough, rales, wheezes, retractions, and rhonchi. Each chest radiograph was reviewed independently according to predetermined criteria by a senior radiology resident and an attending pediatric radiologist. Interobserver agreement was 91%. Both observers were blind to the infants' respiratory signs. The chest radiograph interpretations were compared with the presence of respiratory signs. Of the 242 cases, 228 had chest radiographs available for interpretation. Of these, 27 chest radiographs (12%) were identified as abnormal, including 6 where there was initial disagreement as to the presence of an abnormality. Twenty-five (31%) of 80 infants with any respiratory signs had an abnormal chest radiograph, whereas only 2 (1%) of 148 asymptomatic infants did. The sensitivity of respiratory signs was 93% (confidence interval = 76% to 99%). These findings suggest that in the absence of respiratory signs, febrile infants are Unlikely to have an abnormal chest radiograph.

Bronchiolitis is the leading cause of hospitalization for infants younger than 1 year,1 and the associated hospitalization costs are more than $500 million per year in the United States.2 In this issue of Pediatrics , Carroll et al3 describe the increasing disease burden of bronchiolitis from 1996 to 2003 in healthy, term infants enrolled in the Tennessee Medicaid program. Over these 7 years, children with the International Classification of Diseases, Ninth Revision (ICD-9) codes 466.1 (bronchiolitis and bronchitis) or 480.1 (pneumonia caused by respiratory syncytial virus [RSV]) had an increasing number of visits at all levels of care: outpatient office visits, emergency department visits, and hospitalizations, including 23-hour observations. These data raise important questions not only about the definition of bronchiolitis but also about the reason for the increasing number of medical visits for bronchiolitis. The clinical picture of bronchiolitis was provided by the American Academy of Pediatrics in its 2006 position statement, which states that children with bronchiolitis typically have “rhinitis, tachypnea, wheezing, cough, crackles, use of accessory muscles, and/or nasal flaring.”4 This recognizable constellation of signs and symptoms makes bronchiolitis seem like a straightforward clinical diagnosis that then leads to assignment of the International Classification of Diseases, Ninth Revision codes used by Carroll et al.3 However, astute clinicians continue to debate when young children with an acute lower respiratory tract infection and wheezing should be diagnosed as having bronchiolitis, reactive airways disease, or even asthma. In addition to this basic diagnostic challenge, there is a microbiologic issue. Bronchiolitis is caused by many infectious pathogens, most notably … Address correspondence to Jonathan M. Mansbach, MD, Children's Hospital Boston, Main Clinical Building 9 South, 9157, Boston, MA 02115. E-mail: jonathan.mansbach{at}childrens.harvard.edu

A 3.5-year-old healthy boy with 4 days of fever was referred to the emergency department for respiratory distress. The physical examination was remarkable for stupor, tachycardia, tachypnea, and dyspnea. Initial blood tests showed pancytopenia. He rapidly developed torticollis. Computerized tomography of the neck revealed a thrombus in the internal jugular vein. A presumptive diagnosis of Lemierre's syndrome was made and he was started on antibiotics and anticoagulation. He subsequently developed adult respiratory distress syndrome and required high frequency oscillatory ventilation for 9 days. Blood cultures were positive for Fusobacterium necrophorum. Screening for hypercoagulability revealed 2 known risk factors: a mutation in the prothrombin gene and elevated lipoprotein a.

Objective. To determine predictive factors for the presence of focal infiltrates in children with clinically suspected pneumonia in a pediatric emergency department.Methods. Children (1–16 years) with clinically suspected pneumonia were studied prospectively. The presenting features were compared between the children with and without focal infiltrates using χ2 analysis, t test, and odds ratio with 95% confidence intervals. A multivariate prediction rule was developed using logistic regression.Results. A total of 570 were studied. Risk factors (odds ratio; 95% confidence interval) for the presence of focal infiltrates included history of fever (3.1; 1.7–5.3), decreased breath sounds (1.4; 1.0–2.0), crackles (2.0; 1.4–2.9), retractions (2.8; 1.0–7.6), grunting (7.3; 1.1–48.1), fever (1.5; 1.2–1.9), tachypnea (1.8; 1.3–2.5), and tachycardia (1.3; 1.0–1.6). We then used logistic regression to develop a candidate prediction rule for the variables of fever, decreased breath sounds, crackles, and tachypnea, which had an area under the receiver operating curve of 0.668. This rule had excellent sensitivity (93.1%–98%) yet poor specificity (5.7%–19.4%).Conclusions. Multiple predictive factors for children with suspected pneumonia have been identified. Patients with focal infiltrates were more likely in our study to have a history of fever, tachypnea, increased heart rate, retractions, grunting, crackles, or decreased breath sounds. A multivariate prediction rule shows promise for the accurate prediction of pneumonia in children. However, the prospective evaluation of this multivariate prediction rule in a clinical setting is still required.

Objective. Sin Nombre hantavirus (SNV) is the leading causative agent of hantavirus cardiopulmonary syndrome (HCPS) in the United States and Canada. Relatively few cases of HCPS have involved children. This report describes the clinical characteristics of a series of pediatric cases of SNV infection in the United States and Canada from 1993 through March 2000. Methods. We analyzed clinical and laboratory data on 13 patients who were ≤16 years old with SNV infection from 1993 through March 2000 identified from a database at the University of New Mexico. Results. The patients ranged from 10 to 16 years of age, with a median of 14. Fifty-four percent were female. Fifty-four percent were Native American. The most common prodromal symptoms were fever, headache, and cough or dyspnea (100%); nausea or vomiting (90%); and myalgia (80%). The most common physical findings at admission were tachypnea (67%) and fever (56%); hypotension was seen in 33% of patients. On admission, all patients manifested thrombocytopenia (median platelet count: 67 000/mm3) and elevated lactate dehydrogenase (median level: 1243 IU/L), and >85% of patients had elevated levels of serum aspartate aminotransferase, alanine aminotransferase, and hypoalbuminemia. Leukocytosis and hemoconcentration were seen in less than one third of patients at admission. HCPS developed in 12 of the 13 patients (92%), and 4 of those 12 died (33% case-fatality ratio). The majority of HCPS patients (8 of 12 [67%]) were critically ill and required mechanical ventilation. Extracorporeal membrane oxygenation was used in 2 patients, 1 of whom survived. An elevated prothrombin time (≥14 seconds) at admission was predictive of mortality. Conclusions. Infection with SNV in children and adolescents causes HCPS with a clinical course and mortality rate similar to that described in adults. We believe that early recognition of HCPS in children and adolescents and appropriate referral to tertiary care centers that are experienced with HCPS are important in reducing mortality.

Flexible fiberoptic bronchoscopy with bronchoalveolar lavage was performed in 16 pediatric patients with the acquired immunodeficiency syndrome (AIDS) and deterioration in pulmonary function suggestive of opportunistic infection. In 62% of the patients Pneumocystis carinii was identified. Culture results showed a pure growth of Pseudomonas aeruginosa for one patient in addition to the Pneumocystis carinii. Bronchoscopy with lavage was well tolerated, with few complications even among patients with significant tachypnea and hypoxia. Because of its relative safety and effectiveness, this procedure should be considered the first invasive measurement used for evaluation of parenchymal lung disease in this population of patients.

In an attempt to avoid the substantial risks of pulmonary injury associated with the use of high ventilator pressures and high oxygen concentrations, physicians often ask such questions as "What is the optimal Pao2?" and "What treatment should be used to achieve an optimal Pao2?" Although the intent to minimize secondary, ventilator-induced lung injury is laudable, any attempt to provide a fixed numeric response to this query is misguided not only because the oxygen requirements and clinical circumstances of our patients vary, but because the Pao2 is a particularly poor indicator of these needs. An example is the large full-term neonate admitted to a newborn intensive care unit from the delivery room with obvious tachypnea and an arterial Po2 of 60 mm Hg in room air. Is this Pao2 acceptable? A more appropriate question may be whether the infant's "oxygenation" is adequate. But what is "oxygenation"? If by this vaguely applied term we mean the partial pressure of oxygen in the arterial blood, and if we define the acceptable limits for this parameter as being between 50 and 80 mm Hg, as is often done, then the answer must clearly be in the affirmative. If, on the other hand, we take oxygenation to mean the balance between the rate of oxygen delivery to the tissues and their rate of oxygen consumption, then we must admit that we cannot know on the basis of the information provided by the Pao2 alone. Oxygen delivery is determined by the concentration o hemoglobin in the blood, its oxygen saturation, the rate at which this blood is circulated to the tissues (generally, the cardiac output), and the efficiency with which the oxygen is "unloaded" from hemoglobin to the tissues.

Lymphomatoid granulomatosis, a rare condition in children, affects the lungs primarily but may have significant extrapulmonary manifestations, especially in the central nervous system. We report a case of lymphomatoid granulomatosis with onset after the completion of chemotherapy for childhood acute lymphoblastic leukemia. Two months after treatment ended, the 7-year-old girl developed splenomegaly, cervical adenopathy, and bilateral interstitial pulmonary infiltrates. She improved on cefotaxime but experienced a seizure 1 month later. A computed tomography scan of the head was normal, but her pulmonary infiltrates had become nodular. A computed tomography–guided biopsy of 1 of the nodules revealed cellular interstitial pneumonitis. One month later, she had persistent pulmonary infiltrates, marked splenomegaly, and new seizures. Magnetic resonance imaging of the head revealed cerebral nodules. Itraconazole was begun, and the pulmonary infiltrates resolved. Five months after her initial symptoms, she developed tonic pupil and a decreased level of consciousness. Dexamethasone was initiated. Needle biopsies of the brain were carried out, yielding the diagnosis of severe chronic inflammatory changes focally consistent with granuloma. The child redeveloped splenomegaly and fever, and then suffered an acute decompensation with hypoxemia, tachypnea, splenomegaly, and cardiac gallop. Open-lung biopsy revealed lymphomatoid granulomatosis. Lymphoma-directed therapy was initiated, and the patient had complete resolution of pulmonary and cerebral nodules 5 months later. No intrathecal chemotherapy was administered, and radiation therapy was not necessary. Neuropsychological testing obtained after completion of therapy revealed an improvement in attention, coordination, and fine motor speed over time. She is now in good health and attending school.

Hyperammonemia with coma, tachypnea, and respiratory alkalosis developed in a 3-year-old boy with prune-belly syndrome during a urinary tract infection with Proteus mirabilis. Hyperammonemia is thought to have resulted from the production within the massively dilated urinary tract of excessive amounts of ammonia due to bacterial urease, and its subsequent reabsorption into the systemic circulation. The patient rapidly improved following parenteral antibiotic therapy and continuous catheter drainage of the urinary tract.

Cases of otitis media in infants under 12 weeks of age were reviewed to delineate the frequency, clinical features, and etiologic agents involved. Tympanocentesis was performed in 42 infants, 0 to 5 weeks of age, and in 17, from 6 to 11 weeks of age. The most common symptoms were irritability/lethargy (69%), fever (52%), cough (36%), vomiting (21%), diarrhea (20%), tachypnea (20%), and anorexia (18%). Associated illnesses were present in 33 (54%) of the patients, the most common being pneumonia (9), bronchiolitis (7), meningitis (6), conjunctivitis (4), and omphalitis (4). No peripartum infections or severe perinatal problems were found. Common respiratory pathogens were the predominant etiologic organisms, but coliform organisms were identified in 18% of the infants under 6 weeks of age. Cultures were sterile or grew organisms of questionable pathogenicity ("nonpathogens") in 39% of specimens. Since the signs and symptoms of otitis media in children less than 12 weeks of age are nonspecific and frequently associated with other major illnesses, the physician caring for these infants needs to be more aware of this disease and the therapeutic problems it presents.

THE commonly recognized causes of respiratory distress during infancy are pulmonary or tracheobronchial pathology, cardiac failure, and cerebral disease. The various mechanisms by which cardiac disease may produce increased respiratory effort are not, however, generally appreciated, with resultant confusion in the management of the underlying problem. The major pathological physiologic disturbances producing respiratory distress (in association with heart disease) are pulmonary edema and severe metabolic acidosis. Pulmonary edema occurs either in left ventricular failure or in association with lesions resulting in an obstruction of the pulmonary venous return. Metabolic acidosis is related to severe hypoxia which is the major manifestation of several types of cardiac anomaly. The respiratory pattern associated with pulmonary edema is that of tachypnea to rates of 60-100/min, with initially only mild increased effort. Rales are not usually heard until a considerable amount of fluid has entered the alveoli; thus absence of this clinical sign does not exclude the diagnosis. In advanced pulmonary edema, marked air hunger appears and in young infants head retraction with gasping respiration may occur, presenting an appearance of an obstructed airway. Cyanosis is usually only of mild degree unless associated with cyanotic congenital heart disease. Left ventricular failure and pulmonary venous congestion are far more frequently observed in heart disease in infancy than right-sided failure. It is surprising that most descriptions of heart failure in infancy stress hepatomegaly as one of the earliest signs of failure. However, respiratory distress as manifested by tachypnea and dyspnea is usually the first evidence of cardiac failure in infancy, and hepatomegaly and other evidences of right-sided failure occur much later.

The liquid which occupies the potential air spaces of the fetal lung is, at birth, displaced by air and removed by the pulmonary blood and lymphatic circulations. Delayed resorption of this liquid from the interstitial spaces may be associated with decreased lung compliance and be the cause of the syndrome "transient tachypnea of the newborn." Chest roentgenograms of these infants have shown the presence of alveolar and interstitial edema and pleural effusions which cleared during the first few days of life. We chose to test the possibility that a delay in clearance of lung liquid might occur and be associated with tachypnea and radiologic evidence of pulmonary edema in newborn lambs. Serial chest radiographs were obtained in 18 newborn lambs delivered at term by Caesarean section. The radiographs demonstrated the presence of lung liquid which gradually cleared in an average time of 2 hours following onset of breathing. Lung weight—body weight ratios obtained following sacrifice at various stages of clearing—decreased as pulmonary aeration increased. Microscopic examination of the lungs showed no evidence of inflammatory exudate or squamous debris but distension of perivascular tissues with liquid was demonstrated. An association between increasing lung aeration and decreasing respiratory rates was found.

Forty-one experiments with positive and negative atmospheric ions were performed on 19 children, of whom 13 were suffering from asthmatic (spastic) bronchitis. The results of these experiments indicate that the atmospheric ions have the following effects. Negative ions 1. Shorter duration of the spastic attack as compared with duration of the attack in children receiving the conventional therapeutic treatment. 2. Reduction of tachypnea in cases of spastic bronchitis and bronchopneumonia. 3. Termination of spastic attacks induced by positive ionization. 4. The effect of negative ions on respiratory spasticity usually becomes obvious about 8 hours after the beginning of the ionization. 5. When the negative ionization is stopped, a moderate rebound of spasticity and tachypnea was noticed in several cases. Positive ions 1. Induce spastic attacks in normal infants. 2. Cancel the therapeutic effects of negative ions on patients with spastic bronchitis. 3. Cause tachypnea in infants. 4. On the average, the effects of these ions on respiratory spasticity becomes evident about 10 hours after the beginning of ionization.

An infant, 5½ months of age, died after a brief acute illness characterized by irritability and somnolence leading terminally to coma, and by excessive sweating, abdominal distension, tachypnea and tachycardia. Acidosis and azotemia were marked. He was found at necropsy examination to have pathologic findings compatible with both beriberi and Wernicke's encephalopathy. Investigation of the dietary history and analysis of the formula fed the patient confirmed the suspicion of deficient intake of thiamine. This is the first case report in which the coexistence of these two pathologic conditions in a child proven to have had an inadequate diet, has been documented. It lends further support to the thesis that Wernicke's encephalopathy is caused by nutritional deficiency. The importance of vitamin supplementation of restricted diets used in the therapy of infantile eczema is emphasized.

Several recent reports have emphasized the association between gastroesophageal reflux with tracheobronchial aspiration and recurrent episodes of bronchitis, asthma, pneumonitis, bronchiolitis, apnea, and even aborted sudden infant death syndrome.1-4 The majority of these papers have stressed the fact that infants and children with recurrent pulmonary symptoms, such as wheezing, tachypnea, fever, cough, and chest roentgenographic evidence of pneumonitis or pneumonia, may be aspirating gastric contents into the lungs during periods of recumbency or after feeding. There has been enthusiasm for an antireflux surgical procedure to stop these suspected repeated episodes of aspiration.5 Investigators have relied on an indirect diagnosis of aspiration by demonstrating abnormalities in esophageal function associated with recurrent respiratory disease.

We have recently noted that an increase in tension of the anterior fontanelle has preceded the usual signs and symptoms of cardiac failure in infancy. After reviewing the standard pediatric and cardiology textbooks and pertinent literature, we have found that this physical finding is not listed as a sign of heart failure in infancy. CASE 1: A newborn with dextrocardia (without situs inversus) had shown cyanosis, when oxygen was not administered, and tachypnea since birth.