p.14
Clinical Guidelines for Febrile Infants
When should antibiotic therapy not be given according to moderate recommendations?
If CSF (if collected) is normal.
p.5
Initial Management of Pediatric Emergencies
What past medical history details are important in a secondary assessment?
Health history (e.g., premature birth, previous illnesses, hospitalizations), significant underlying medical problems, past surgeries, immunization status.
p.7
Pediatric Assessment Triangle (PAT)
What was the patient's last meal in Case #1?
Formula several hours ago.
p.3
Pediatric Assessment Triangle (PAT)
How is 'look/gaze' assessed in the Pediatric Assessment Triangle (PAT)?
Gaze tracking vs. unfocused stare (does not fix or follow).
p.16
Fluid Resuscitation in Pediatric Septic Shock
What intervention was commenced for the patient?
Fluid resuscitation with LR bolus fluid (10 mL/kg) over 5 min with immediate reassessment of perfusion
p.17
Signs and Symptoms of Neonatal Sepsis
What general symptoms might indicate neonatal sepsis?
Fever, temperature instability, poor feeding.
p.17
Signs and Symptoms of Neonatal Sepsis
What respiratory symptoms might indicate neonatal sepsis?
Apnea, dyspnea, tachypnea, retractions, flaring, grunting, cyanosis.
p.3
Pediatric Assessment Triangle (PAT)
What does the use of accessory muscles indicate in the context of work of breathing?
Increase in tidal volume to improve minute ventilation via supraclavicular, intercostal, and/or substernal groups.
p.8
Clinical Guidelines for Febrile Infants
What are the four key components of evaluation for well-appearing febrile infants in the emergency department?
Urine, blood culture, inflammatory markers (procalcitonin, ANC, CRP), and cerebrospinal fluid.
p.2
Pediatric Assessment Triangle (PAT)
What factors should a clinician consider when assessing a child's appearance using the Pediatric Assessment Triangle (PAT)?
The clinician should consider the child's age, developmental stage, and ability to interact with the environment.
p.6
Differential Diagnosis for Ill-Appearing Neonates
What are some signs of inborn errors of metabolism in neonates?
Coma or seizures developing shortly after transition from breast to formula feeding, unusual urine odor, and hepatomegaly.
p.4
Pediatric Assessment Triangle (PAT)
How does heart rate change with age?
Heart rate is highest in neonates and declines with age to values seen in adults.
p.2
Pediatric Assessment Triangle (PAT)
What are some symptoms that can be induced by hypoxia, hypercarbia, or shock in a pediatric patient?
Agitation and inconsolability can be symptoms induced by hypoxia, hypercarbia, or shock.
p.4
Pediatric Assessment Triangle (PAT)
What does the AVPU scale stand for in the Disability assessment?
Alert, Voice, Pain, Unresponsive.
p.5
Initial Management of Pediatric Emergencies
What is the normal awake heart rate range for a neonate?
100–205 beats per minute.
p.7
Differential Diagnosis for Ill-Appearing Neonates
What is a characteristic symptom of pyloric stenosis?
Projectile nonbilious vomiting.
p.3
Pediatric Assessment Triangle (PAT)
What is a late finding of respiratory failure in the Pediatric Assessment Triangle (PAT)?
Decreased work of breathing due to loss of compensatory mechanisms.
p.3
Pediatric Assessment Triangle (PAT)
Why is it important to assess the environment when evaluating skin appearance?
Cool temperature can elicit peripheral vasoconstriction, leading to an ill appearance in an otherwise healthy infant without circulatory compromise.
p.12
Clinical Guidelines for Febrile Infants
Why should a single inflammatory marker not be used in isolation for decision making in febrile infants?
Because the reliability of a single marker to detect or risk stratify serious bacterial infection is lacking.
p.9
Clinical Guidelines for Febrile Infants
According to Powell et al., what was the incidence of bacteremia in febrile infants younger than 60 days?
84 out of 4778 febrile infants had bacteremia.
p.13
Clinical Guidelines for Febrile Infants
What is the recommendation for outpatient management of febrile infants?
Management as an outpatient is recommended if CSF/UA is normal, inflammatory markers are normal, and verbal teaching and written instructions are provided to the caregiver.
p.14
Clinical Guidelines for Febrile Infants
What is the strong recommendation for treatment if CSF suggests bacterial meningitis?
Should give parenteral antibiotic therapy in hospital.
p.6
Differential Diagnosis for Ill-Appearing Neonates
What are some signs of congenital heart disease in neonates?
Cyanosis, tachypnea, diaphoresis with feeding, rales, blood pressure gradient, pathologic heart murmur, and hepatomegaly (right-sided heart failure).
p.4
Pediatric Assessment Triangle (PAT)
What are the three components of the Pediatric Assessment Triangle?
Appearance, Work of Breathing, Circulation to Skin.
p.7
Pediatric Assessment Triangle (PAT)
What were the vital signs of the patient in Case #1 during the initial assessment?
Heart rate: 160 beats/min, Blood pressure: 80/54 mm Hg, Respiratory rate: 46 breaths/min, SpO2: 97% on room air, Temperature: 39.2°C.
p.10
Clinical Guidelines for Febrile Infants
What are the criteria for considering a urine sample positive in febrile, well-appearing infants aged 8-21 days?
1) Any presence of leukocyte esterase, 2) Greater than 5 WBCs/high-powered field (hpf) in centrifuged urine, or 3) Greater than 10 WBCs/mm³ in uncentrifuged urine.
p.11
Clinical Guidelines for Febrile Infants
What viral testing can be performed on CSF and what should be considered if CSF pleocytosis is present with a negative Gram stain?
Viral testing can be performed via multiplex PCR testing; consider HSV if CSF pleocytosis with a negative Gram stain.
p.12
Clinical Guidelines for Febrile Infants
What ANC level is recognized by the AAP as a threshold for considering sepsis?
Greater than 4000/mm³ and greater than 5000/mm³, but sepsis should be considered if ANC is less than 1000/mm³.
p.9
Clinical Guidelines for Febrile Infants
What are the most common pathogens in febrile infants according to the data?
E. coli (39.3%) and GBS (23.8%).
p.15
Pediatric Assessment Triangle (PAT)
What are the initial assessment signs of the patient in the case study?
Appearance: lethargic, does not react to voices in room; Breathing: increased rate and effort; Circulation: pale, with mottling of extremities.
p.13
Clinical Guidelines for Febrile Infants
What should be done if CSF is not obtained in a febrile infant?
The infant should be hospitalized.
p.14
Clinical Guidelines for Febrile Infants
Under what conditions should oral antibiotic therapy be given according to strong recommendations?
If CSF (if collected) is normal, UA is positive, and no inflammatory marker is abnormal.
p.2
Initial Management of Pediatric Emergencies
What is the chief complaint and history of present illness for the neonate HL?
HL is brought to the emergency department for vomiting, decreased appetite, decreased urine output, increased fussiness, and subjective fever.
p.7
Differential Diagnosis for Ill-Appearing Neonates
What symptom might indicate methemoglobinemia in a neonate?
Cyanosis despite 100% oxygen and normal cardiac exam.
p.3
Pediatric Assessment Triangle (PAT)
What are additional indicators of respiratory distress in the Pediatric Assessment Triangle (PAT)?
'Head bobbing' and 'nasal flaring'.
p.8
Empiric Antibiotic Therapy for Neonatal Sepsis
Which empiric antibiotic therapy is recommended for a febrile 16-day-old neonate suspected of late-onset neonatal sepsis?
Empiric antibiotic therapy should contain ampicillin 75 mg/kg PLUS gentamicin 5 mg/kg.
p.11
Clinical Guidelines for Febrile Infants
When should enterovirus be considered in CSF analysis?
During the season, irrespective of pleocytosis, as a positive result indicates a low probability of bacterial meningitis.
p.12
Clinical Guidelines for Febrile Infants
What did Kuppermann et al. find in their 2019 report regarding ANC and invasive bacterial infection?
Detection of invasive bacterial infection occurred in 29 of the 30 cases with ANC greater than 4090/mm³, abnormal UA, and procalcitonin greater than 1.7 ng/mL.
p.9
Clinical Guidelines for Febrile Infants
What is the incidence of bacterial meningitis in infants ≤ 28 days old compared to those 29-60 days old?
1.3% in infants ≤ 28 days old vs. 0.2% in infants 29-60 days old.
p.15
Pediatric Assessment Triangle (PAT)
What are the vital signs revealed by the cardiac monitor and pulse oximeter in the patient case?
The specific vital signs are not provided in the text.
p.14
Clinical Guidelines for Febrile Infants
What should be obtained as part of a moderate recommendation for febrile infants?
Blood culture and inflammatory markers.
p.17
Signs and Symptoms of Neonatal Sepsis
What findings are concerning for septic shock in neonates?
1. Hypothermia or hyperthermia, 2. Hypotension, 3. Inadequate tissue perfusion (e.g., decreased/altered mental status, delayed capillary refill time, diminished pulses, mottled cool extremities, flash capillary refill time, bounding peripheral pulses, wide pulse pressure, decreased urine output).
p.2
Pediatric Assessment Triangle (PAT)
What is the primary role of the Pediatric Assessment Triangle (PAT) in evaluating a pediatric patient?
The PAT is an evaluation tool that uses visual and auditory clues to rapidly identify a child's clinical assessment, consistently identifying high-acuity pediatric patients and underlying pathophysiology, and determining the category and urgency of intervention.
p.2
Initial Management of Pediatric Emergencies
What is the importance of determining whether a pediatric patient is 'ill-appearing' vs. 'well-appearing'?
Determining whether a pediatric patient is 'ill-appearing' vs. 'well-appearing' is crucial for guiding the initial approach and urgency of intervention.
p.4
Pediatric Assessment Triangle (PAT)
What are the key aspects to assess in the Airway during the primary assessment?
Patent, patent but requires airway maneuvers, partial/complete obstruction.
p.5
Initial Management of Pediatric Emergencies
What are some signs and symptoms to look for in a secondary assessment?
Breathing difficulty, tachypnea, tachycardia, decreased level of consciousness, fatigue, fever, headache, agitation, decreased oral intake, diarrhea, vomiting, abdominal pain, duration of symptoms.
p.7
Pediatric Assessment Triangle (PAT)
What were the findings in the primary assessment of the patient in Case #1?
Airway: Clear, Breathing: Respiratory rate around 46 breaths/min, no retractions or nasal flaring, SpO2 97% on room air, lungs clear to auscultation, Circulation: Adequate pulses, heart rate 160 beats/min, blood pressure 80/54 mm Hg, capillary refill time 2 seconds, warm and well-perfused extremities, Disability: Interactive, Exposure: Rectal temperature 39.2°C, no rash.
p.10
Clinical Guidelines for Febrile Infants
When is a urine culture considered diagnostic in febrile, well-appearing infants aged 8-21 days?
When there are greater than 10,000 colony-forming units/mL from a catheterized specimen.
p.11
Clinical Guidelines for Febrile Infants
What is the recommendation regarding obtaining inflammatory markers in febrile infants?
May obtain inflammatory markers (weak recommendation) to guide later management.
p.9
Clinical Guidelines for Febrile Infants
What did the AAP publish in 2021 to aid in the management of well-appearing febrile infants?
A Clinical Practice Guideline for the diagnostic workup and management of well-appearing febrile infants.
p.13
Clinical Guidelines for Febrile Infants
When should blood and urine cultures be collected in the management of febrile infants?
Blood and urine cultures should be collected as part of the diagnostic workup.
p.13
Clinical Guidelines for Febrile Infants
How should a positive urine, blood, or CSF culture be treated?
Treat the organism with targeted therapy for a duration determined by the specific pathogen.
p.14
Clinical Guidelines for Febrile Infants
When may parenteral antibiotic therapy be given according to moderate recommendations?
If CSF (if collected) is normal and any inflammatory marker obtained is abnormal.
p.6
Differential Diagnosis for Ill-Appearing Neonates
What are some important history findings for infant botulism?
Afebrile breastfed baby with decreased feeding, constipation, floppiness, and progressive weakness.
p.4
Pediatric Assessment Triangle (PAT)
What are the components of the Glasgow Coma Scale?
Eye Opening, Verbal Response, Motor Response.
p.5
Initial Management of Pediatric Emergencies
Why is it important to know the time and nature of the last meal in a secondary assessment?
Elapsed time between the last meal and presentation of current illness can affect treatment and management of the condition (e.g., anesthesia, intubation).
p.3
Pediatric Assessment Triangle (PAT)
What does 'speech/cry' evaluate in the Pediatric Assessment Triangle (PAT)?
Loud/strong cry vs. weak, clear speech vs. muffled voice.
p.3
Pediatric Assessment Triangle (PAT)
Why is skin appearance a dependable marker for systemic perfusion?
Because hypoperfusion will shunt blood away from the skin to vital organs.
p.8
Clinical Guidelines for Febrile Infants
What is the significance of C-Reactive Protein (CRP) in detecting bacterial infections in infants?
CRP rises 6–8 hours post-infection, peaks at 24 hours, and has low sensitivity as an early indicator of bacterial infection.
p.11
Clinical Guidelines for Febrile Infants
What is the alternative method for obtaining urine for analysis and what should be done if UA is positive?
Alternative: should obtain UA via bag, spontaneous void, or stimulated void (high false positive via this method); if UA positive, obtain urine via catheterization or SPA to culture.
p.9
Advanced Pathogen Identification
What do meningoencephalitis panels identify and how quickly?
They identify CSF pathogens in 1 hour.
p.13
Clinical Guidelines for Febrile Infants
When may parenteral antibiotic therapy be given in the hospital despite normal CSF/UA?
If any inflammatory marker obtained is abnormal.
p.14
Clinical Guidelines for Febrile Infants
When should a febrile infant be admitted to the hospital according to strong recommendations?
If CSF (if collected) is abnormal.
p.19
Neonatal Sepsis: Epidemiology and Risk Factors
When do symptoms of late-onset neonatal sepsis (LOS) typically appear?
Between 72 hours and 28 days of life.
p.6
Differential Diagnosis for Ill-Appearing Neonates
What are some exam findings that may indicate meningitis in an 'ill-appearing' neonate?
Hypothermia, bulging fontanelle, increased head circumference, and seizures.
p.4
Pediatric Assessment Triangle (PAT)
What should be assessed under Exposure in the primary assessment?
Fever or hypothermia, skin findings, evidence of trauma.
p.5
Initial Management of Pediatric Emergencies
What is the normal respiratory rate range for a toddler (1–2 years)?
22–37 breaths per minute.
p.7
Differential Diagnosis for Ill-Appearing Neonates
What are some toxic exposures that can affect neonates?
Carbon monoxide poisoning, methemoglobinemia, breast milk cross contaminants (heroin, cocaine, marijuana), intentional exposure to ethanol, drugs of abuse, or other medications, inadvertent medication dosing errors, neonatal abstinence syndrome.
p.10
Clinical Guidelines for Febrile Infants
What is the recommended method for obtaining a urine sample in febrile, well-appearing infants aged 8-21 days?
Urine should be obtained via catheterization or suprapubic aspiration (SPA) of the bladder.
p.11
Clinical Guidelines for Febrile Infants
What should be obtained for analysis in febrile infants and what is the percentage of meningitis cases?
CSF for analysis (WBC, protein, glucose, Gram stain, and culture for bacteria); 0.5–1.3% will have meningitis.
p.12
Clinical Guidelines for Febrile Infants
Why should abnormal WBC counts not be used for risk stratification in febrile infants?
Because literature has revealed that infants with invasive bacterial infection (IBI) can have a 'normal' WBC count.
p.9
Clinical Guidelines for Febrile Infants
Which age group of infants had the highest incidence of bacteremia according to Powell et al.?
Infants with a postnatal age of 8–14 days had the highest incidence at 5.3%.
p.15
Clinical Guidelines for Febrile Infants
What should be done if a CSF analysis indicates CSF pleocytosis?
Initiate treatment for bacterial meningitis.
p.14
Clinical Guidelines for Febrile Infants
When may a febrile infant be managed out of the hospital without CSF according to moderate recommendations?
If UA is negative, inflammatory markers are negative, and the caregiver can commit to rapid return and follow-up at 24 hours.
p.20
Diagnostic Tests for Early-Onset Sepsis (EOS) and Late-Onset Sepsis (LOS)
What are the recommended diagnostic tests for late-onset sepsis (LOS)?
CBC with differential, blood culture from 2 different sites, lumbar puncture, inflammatory markers, and UA/urine culture (suprapubic bladder aspiration or catheterization preferred).
p.19
Neonatal Sepsis: Epidemiology and Risk Factors
What are the most common pathogens in early-onset neonatal sepsis?
43% Group B Streptococcus and 29% Escherichia coli.
p.6
Differential Diagnosis for Ill-Appearing Neonates
What is the most common etiology for an 'ill-appearing' neonate?
Infection, including bacterial sepsis, infant botulism, and viral illnesses such as HSV, enterovirus, and bronchiolitis.
p.4
Pediatric Assessment Triangle (PAT)
How does blood pressure change with age?
Blood pressure values are lower in neonates and increase with age to values seen in adults.
p.7
Differential Diagnosis for Ill-Appearing Neonates
What are common symptoms of GI obstruction in neonates?
Fever, bilious vomiting, abdominal distension with infrequent or no stooling.
p.3
Pediatric Assessment Triangle (PAT)
What does 'work of breathing' describe in the Pediatric Assessment Triangle (PAT)?
Respiratory status and effort to maintain adequate oxygenation and ventilation.
p.3
Pediatric Assessment Triangle (PAT)
What are signs of hypoxemia and insufficient perfusion to the skin?
Pallor, cyanosis, poor capillary refill time, or cool skin.
p.11
Clinical Guidelines for Febrile Infants
What percentage of infants will have a UTI and how should urine be obtained for analysis?
7.5–10% will have UTI; should obtain UA via catheterization or SPA of bladder.
p.12
Clinical Guidelines for Febrile Infants
Under what conditions may the collection of CSF occur despite otherwise reassuring criteria?
Collection of CSF may occur despite negative or positive UA and normal inflammatory markers.
p.9
Advanced Pathogen Identification
What is the advantage of PCR testing of positive blood cultures?
It can detect bacterial pathogens and antimicrobial resistance genes in 1 hour.
p.15
Empiric Antibiotic Therapy for Neonatal Sepsis
What is the recommended antibiotic therapy for suspected bacterial meningitis in infants aged 29-60 days?
IV Ceftriaxone 50 mg/kg every 12 hours + Vancomycin 15 mg/kg every 6 hours.
p.16
Neonatal Sepsis: Epidemiology and Risk Factors
How has the epidemiology of neonatal sepsis changed?
With the advent of prenatal Group B Streptococcus screening, vaccination against Streptococcus pneumoniae, and food safety enhancements, reducing the frequency of infections induced by Listeria monocytogenes
p.2
Pediatric Assessment Triangle (PAT)
What symptoms might indicate that a child is not severely ill according to the Pediatric Assessment Triangle (PAT)?
A child is not likely to be severely ill if they are alert, consolable, demonstrating adequate muscle tone, and responsive.
p.6
Differential Diagnosis for Ill-Appearing Neonates
What are some potential causes of seizures in neonates related to glucose and electrolyte abnormalities?
Hypoglycemia, hyponatremia, hypernatremia, and hypocalcemia.
p.4
Pediatric Assessment Triangle (PAT)
What are the key indicators to assess in Circulation?
Skin color, skin temperature, heart rate/rhythm, blood pressure, peripheral/central pulses, capillary refill time.
p.7
Differential Diagnosis for Ill-Appearing Neonates
What are some surgical conditions that can cause GI obstruction in neonates?
Intussusception, malrotation with volvulus, necrotizing enterocolitis, pyloric stenosis.
p.7
Pediatric Assessment Triangle (PAT)
What was the past medical history of the patient in Case #1?
Term newborn; healthy until recent illness.
p.3
Pediatric Assessment Triangle (PAT)
What does 'consolability' indicate in the Pediatric Assessment Triangle (PAT)?
Distractibility by a caregiver vs. nonstop crying.
p.3
Pediatric Assessment Triangle (PAT)
How might a child position themselves to maximize airway opening?
By adopting the 'sniffing position' or 'tripod position'.
p.11
Clinical Guidelines for Febrile Infants
What is the disposition recommendation for febrile infants while awaiting culture results?
Should admit to hospital (moderate recommendation).
p.12
Clinical Guidelines for Febrile Infants
What role do inflammatory markers play if UA is negative and blood culture is pending?
The absence of abnormal inflammatory markers may contribute to the decision whether to perform a lumbar puncture (LP).
p.9
Signs and Symptoms of Neonatal Sepsis
What is Procalcitonin (PCT) and why is it significant in bacterial infections?
Procalcitonin (PCT) rises within 2 hours post-infection, peaks at 12 hours, and is a highly sensitive and specific early indicator of bacterial infection.
p.15
Clinical Guidelines for Febrile Infants
How should a positive urine, blood, or CSF culture be treated?
With targeted therapy and for a duration as determined by the specific pathogen.
p.13
Clinical Guidelines for Febrile Infants
Under what conditions should parenteral antibiotic therapy be given in the hospital?
If CSF suggests bacterial meningitis or if there is a positive UA.
p.13
Clinical Guidelines for Febrile Infants
Why should urine obtained outside of catheterization or SPA not be cultured?
Due to the risk of false contaminants.
p.2
Pediatric Assessment Triangle (PAT)
What does the 'TICLS' mnemonic stand for in the context of the Pediatric Assessment Triangle (PAT)?
TICLS stands for Tone, Interactiveness, Consolability, Look/Gaze, and Speech/Cry.
p.6
Differential Diagnosis for Ill-Appearing Neonates
What are some history and exam findings for congenital adrenal hyperplasia?
Ambiguous genitalia or clitoromegaly.
p.4
Pediatric Assessment Triangle (PAT)
How does respiratory rate change with age?
Respiratory rate is highest in neonates and declines with age to values seen in adults.
p.5
Initial Management of Pediatric Emergencies
What information should be gathered about medications during a secondary assessment?
Patient medications, medications in the child's environment, last dose, and time of recent medications.
p.3
Pediatric Assessment Triangle (PAT)
How is 'interactiveness' evaluated in the Pediatric Assessment Triangle (PAT)?
Playful vs. unresponsive/lethargic to caregiver.
p.10
Clinical Guidelines for Febrile Infants
What is the general approach to managing febrile, well-appearing infants aged 8-21 days according to the AAP Clinical Practice Guidelines?
Conservative practice with not a lot of deviation from standard practice for this age group.
p.12
Clinical Guidelines for Febrile Infants
How can inflammatory markers influence the decision to initiate antibiotic therapy if UA and/or urine/blood/CSF results are negative or pending?
Inflammatory markers may influence the decision whether to initiate antibiotic therapy.
p.9
Clinical Guidelines for Febrile Infants
What are some exclusion criteria for the 2021 AAP Guideline on Evaluation and Management of Well-Appearing, Term Infants?
Preterm less than 37 weeks, postnatal age less than 2 weeks with perinatal complications, high suspicion of HSV, focal bacterial infection, clinical bronchiolitis, respiratory symptoms, diarrhea, otitis media, immunocompromised, neonatal course complicated by surgery/infection, medically fragile or technology dependent, immunization within 48 hours.
p.15
Clinical Guidelines for Febrile Infants
What are the criteria for discontinuing parenteral antibiotic therapy and transitioning to PO for those managed at home?
Positive UA, negative cultures at 24 to 36 hours, and the patient maintains a well appearance (i.e., adequate PO).
p.13
Clinical Guidelines for Febrile Infants
What should be done if more than one inflammatory marker is abnormal?
Collection of CSF should occur.
p.14
Clinical Guidelines for Febrile Infants
When is it not necessary to collect CSF according to moderate recommendations?
If all inflammatory markers are normal.
p.19
Neonatal Sepsis: Epidemiology and Risk Factors
What is the incidence of hospital-acquired late-onset sepsis?
0.86 per 1000 live births.
p.18
Neonatal Sepsis: Epidemiology and Risk Factors
What is considered a prematurity risk factor for neonatal sepsis?
Being born at less than 37 weeks gestation.
p.18
Signs and Symptoms of Neonatal Sepsis
How can exposure to pathogenic bacteria during birth lead to neonatal sepsis?
Through colonization of pathogenic organisms acquired perinatally, causing infection post-delivery via entry of nonintact skin/mucous membranes.
p.21
Empiric Antibiotic Therapy for Neonatal Sepsis
What is the preferred empiric antibiotic therapy for late-onset sepsis (LOS) in neonates admitted from the community?
Ampicillin 100 mg/kg every 8 hours (age ≤ 7 days); 75 mg/kg every 6 hours (age ≥ 8 days) + gentamicin 4 mg/kg every 24 hours (age ≤ 7 days); 5 mg/kg every 24 hours (age ≥ 8 days)
p.23
Pediatric Septic Shock Recognition and Treatment
What are the 2020 pediatric sepsis guidelines for defining hypotension based on age?
SBP less than 50 mm Hg (if less than 1 year), less than 60 mm Hg (1–5 years), less than 70 mm Hg (greater than 5 years).
p.24
Pediatric Septic Shock Recognition and Treatment
What is the benefit of a resuscitation bundle in treating pediatric septic shock?
Studies have demonstrated that if protocolized at your institution, in-hospital mortality is reduced.
p.2
Pediatric Assessment Triangle (PAT)
What are the three observations included in the Pediatric Assessment Triangle (PAT)?
The three observations are appearance, work of breathing, and circulation to the skin.
p.6
Differential Diagnosis for Ill-Appearing Neonates
What are some indicators of child abuse in an 'ill-appearing' neonate?
Head trauma, bone fracture, abdominal injury, bulging fontanelle, increased head circumference, immobile extremity with pain on passive motion, seizures, and bruising.
p.4
Pediatric Assessment Triangle (PAT)
What factors are evaluated in the Breathing assessment?
Respiratory rate and effort, tidal volume, lung sounds, pulse oximetry.
p.7
Pediatric Assessment Triangle (PAT)
What were the signs and symptoms noted in the secondary assessment of the patient in Case #1?
Lethargy and high fever for 24 hours, intermittent rapid breathing noted by mom this morning.
p.3
Pediatric Assessment Triangle (PAT)
What does 'tone' assess in the Pediatric Assessment Triangle (PAT)?
Forceful movement vs. limp/weak.
p.3
Pediatric Assessment Triangle (PAT)
What airway sounds are considered when assessing work of breathing?
Stridor, snoring, grunting, wheezing.
p.11
Clinical Guidelines for Febrile Infants
When should parenteral antibiotic therapy be initiated and for how long should it be continued?
Should initiate parenteral antibiotic therapy (strong recommendation); reasonable to continue until blood and CSF cultures are negative for 24–36 hours.
p.12
Clinical Guidelines for Febrile Infants
Which inflammatory marker is considered the earliest to increase and has the most favorable test characteristics for identifying children with invasive bacterial infection?
Procalcitonin (greater than 0.5 ng/mL).
p.9
Clinical Guidelines for Febrile Infants
What are the inclusion criteria for the 2021 AAP Guideline on Evaluation and Management of Well-Appearing, Term Infants?
Well-appearing, rectal temperature at least 38°C in prior 24 hours or in clinical setting, gestational age at least 37 weeks but less than 42 weeks, age 8 to 60 days.
p.15
Clinical Guidelines for Febrile Infants
When should antibiotics be discontinued in a patient not admitted to the hospital?
If there is a negative culture at 24–36 hours, the patient maintains a well appearance (i.e., adequate PO), and there is no other infection requiring treatment.
p.13
Clinical Guidelines for Febrile Infants
What is the recommendation for obtaining a urine sample in infants aged 29 to 60 days?
Urine should be obtained via bag, spontaneous void, or stimulated void, and if positive, via catheterization or SPA for culture.
p.14
Clinical Guidelines for Febrile Infants
When should antibiotic therapy not be given in a patient awaiting culture results according to moderate recommendations?
If CSF (if collected) is normal, UA is negative, and no inflammatory marker obtained is abnormal.
p.17
Signs and Symptoms of Neonatal Sepsis
What are the 'Red Flag' indicators for infection according to NICE?
1. Respiratory distress more than 4 hours post-birth, 2. Seizures, 3. Mechanical ventilation in term newborn, 4. Signs of shock.
p.20
Diagnostic Tests for Early-Onset Sepsis (EOS) and Late-Onset Sepsis (LOS)
Why is urine not recommended for early-onset sepsis (EOS) diagnosis?
Because a UTI is usually a result of seeding from bacteremia.
p.17
Signs and Symptoms of Neonatal Sepsis
What hematologic symptoms might indicate neonatal sepsis?
Jaundice, splenomegaly, pallor, petechiae, purpura, bleeding.
p.19
Neonatal Sepsis: Epidemiology and Risk Factors
What are some risk factors for late-onset neonatal sepsis?
Prematurity, low birth weight, prolonged indwelling central venous catheter use, invasive procedures, ventilator-associated pneumonia, and prolonged antibiotic usage.
p.18
Neonatal Sepsis: Epidemiology and Risk Factors
What maternal medical history factors can increase the risk of neonatal sepsis?
Diabetes, hypertension, thyroid disease, and maternal drug abuse.
p.18
Signs and Symptoms of Neonatal Sepsis
How can L. monocytogenes be transmitted to the neonate?
Transplacental acquisition.
p.12
Clinical Guidelines for Febrile Infants
How can normal inflammatory markers guide decisions if CSF analysis is negative or LP is bloody/failed?
Normal inflammatory markers may guide decisions regarding hospitalization, initiation of antibiotic therapy, and treatment duration.
p.15
Empiric Antibiotic Therapy for Neonatal Sepsis
What is the initial empirical antibacterial therapy for well-appearing febrile infants aged 8-21 days with no focus identified?
IV Ampicillin 75 mg/kg every 6 hours + IV Ceftazidime 50 mg/kg every 8 hours.
p.17
Signs and Symptoms of Neonatal Sepsis
What are considered abnormal vital signs for a term neonate?
1. Temperature at least 38°C or less than 36°C, 2. Heart rate less than 100 bpm or greater than 180 bpm, 3. Respiratory rate greater than 50 breaths per minute, 4. Systolic blood pressure less than 65 mm Hg.
p.22
Intraosseous vs. Peripheral IV Access in Emergencies
What should be done if relying on peripheral IV access would delay initiation of antibiotic therapy in a pediatric patient?
IO vascular access should be established.
p.18
Neonatal Sepsis: Epidemiology and Risk Factors
What does antibiotic treatment for confirmed or suspected IBI during labor or in the 24 hours before or after delivery (excluding prophylactic intrapartum antibiotics) indicate?
A maternal risk factor for neonatal sepsis.
p.21
Empiric Antibiotic Therapy for Neonatal Sepsis
What is the recommended empiric antibiotic therapy for early-onset sepsis (EOS) in neonates?
Ampicillin 100 mg/kg every 8 hours + gentamicin 4 mg/kg every 24 hours
p.21
Empiric Antibiotic Therapy for Neonatal Sepsis
What should ampicillin be substituted with if the focus of infection involves the skin in late-onset sepsis?
Vancomycin 15 mg/kg every 12 hours (age ≤ 7 days); 15 mg/kg every 8 hours (age ≥ 8 days)
p.24
Pediatric Septic Shock Recognition and Treatment
Why do the 2020 pediatric guidelines not recommend using bedside clinical signs in isolation to categorize septic shock in children?
Because they inaccurately identify children with cardiac dysfunction.
p.24
Intraosseous vs. Peripheral IV Access in Emergencies
What is the intended duration of use for IO access?
Short term use, less than 24 hours.
p.14
Clinical Guidelines for Febrile Infants
Under what conditions should a febrile infant be discharged according to moderate recommendations?
If CSF (if collected) is normal, UA is negative, inflammatory markers are negative, and education and follow-up are provided to the caregiver.
p.20
Diagnostic Tests for Early-Onset Sepsis (EOS) and Late-Onset Sepsis (LOS)
What are the recommended diagnostic tests for early-onset sepsis (EOS)?
CBC with differential, blood culture from 2 different sites, lumbar puncture, inflammatory markers, and chest X-ray if respiratory symptoms.
p.17
Signs and Symptoms of Neonatal Sepsis
What gastrointestinal symptoms might indicate neonatal sepsis?
Abdominal distention, vomiting, diarrhea, hepatomegaly.
p.19
Neonatal Sepsis: Epidemiology and Risk Factors
What are some less common pathogens causing neonatal sepsis?
L. monocytogenes, non-typeable Hemophilus influenzae, gram-negative enteric bacilli other than E. coli, and Candida species.
p.19
Signs and Symptoms of Neonatal Sepsis
Why is diagnosing neonatal sepsis challenging?
Because the signs are often nonspecific and can be observed in noninfectious conditions.
p.18
Neonatal Sepsis: Epidemiology and Risk Factors
What is a history of invasive GBS infection in a prior neonate considered?
A maternal risk factor for neonatal sepsis.
p.21
Empiric Antibiotic Therapy for Neonatal Sepsis
What are the concerns with the empiric use of 3rd-generation cephalosporins instead of gentamicin in neonates?
1) Emergence of cephalosporin-resistant gram-negative organisms
2) Increased risk for invasive candidiasis
3) Lack of greater efficacy
4) Lack of advantage in providing synergy with ampicillin for GBS or Listeria
p.23
Pediatric Septic Shock Recognition and Treatment
Why is hypotension in children a critical sign of decompensated shock?
Children can maintain blood pressure longer relative to adults; if a child is hypotensive on presentation, they are in decompensated shock and may be near cardiovascular collapse.
p.20
Empiric Antibiotic Therapy for Neonatal Sepsis
When should antibiotic therapy be initiated in suspected neonatal sepsis cases?
If possible, initiate antibiotic therapy only after obtaining blood and CSF cultures.
p.17
Signs and Symptoms of Neonatal Sepsis
What cardiovascular symptoms might indicate neonatal sepsis?
Pallor, mottling, cold, clammy skin, tachycardia, hypotension, or bradycardia.
p.19
Neonatal Sepsis: Epidemiology and Risk Factors
What are the common modes of transmission for late-onset neonatal sepsis?
Vertical transmission (initial colonization and subsequent infection) and horizontal transmission from environmental sources.
p.18
Neonatal Sepsis: Epidemiology and Risk Factors
What are some obstetric risk factors for neonatal sepsis?
Prolonged rupture of membranes (at least 18 hours), chorioamnionitis, and UTI.
p.18
Signs and Symptoms of Neonatal Sepsis
What are maternal signs of chorioamnionitis?
Fever, leukocytosis, cloudy/odorous discharge, and lower abdominal tenderness.
p.23
Pediatric Septic Shock Recognition and Treatment
How is sepsis defined in the 2005 International Pediatric Sepsis Consensus Conference?
Sepsis is defined as SIRS plus a source of infection.
p.24
Pediatric Septic Shock Recognition and Treatment
What are the clinical signs of peripheral vasoconstriction in cold shock or decompensated shock?
Delayed, thready pulse, cold extremities, long capillary refill time, mottled appearance.
p.17
Signs and Symptoms of Neonatal Sepsis
What maternal risk factors are important to ascertain the risk of neonatal sepsis?
1. Exposure to infectious diseases, 2. Intrapartum fever ≥ 38°C.
p.17
Signs and Symptoms of Neonatal Sepsis
What central nervous system (CNS) symptoms might indicate neonatal sepsis?
Irritability, lethargy, tremors, seizures, hyporeflexia, hypotonia, irregular respirations, full fontanel, high-pitched cry.
p.19
Neonatal Sepsis: Epidemiology and Risk Factors
What are the more common pathogens in late-onset neonatal sepsis?
Group B Streptococcus, Escherichia coli, coagulase-negative Staphylococci, and Staphylococcus aureus.
p.18
Neonatal Sepsis: Epidemiology and Risk Factors
How does lack of or delayed prenatal care affect neonatal sepsis risk?
It is a maternal risk factor for neonatal sepsis.
p.23
Pediatric Septic Shock Recognition and Treatment
What additional criteria define severe sepsis?
Severe sepsis is defined as sepsis plus at least 1 organ dysfunction, such as cardiovascular dysfunction, Acute Respiratory Distress Syndrome, or at least 2 other organ dysfunctions (neurologic, hematologic, renal, hepatic).
p.24
Pediatric Septic Shock Recognition and Treatment
What is the goal in managing decompensated shock?
To support the heart to pump blood to the periphery.
p.20
Diagnostic Tests for Early-Onset Sepsis (EOS) and Late-Onset Sepsis (LOS)
What diagnostic tests are used for definitive diagnosis of early-onset sepsis (EOS) and late-onset sepsis (LOS)?
Isolation of organism from blood or CSF for EOS, and from urine, blood, or CSF for LOS.
p.19
Neonatal Sepsis: Epidemiology and Risk Factors
What are the most common pathogens in hospital-acquired late-onset sepsis?
Coagulase-negative staphylococci (40%), Staphylococcus aureus (16%), and Escherichia coli (16%).
p.22
Pediatric Septic Shock Recognition and Treatment
What are some challenges in recognizing sepsis in children?
Age-related variation in vital signs, hypotension as a late manifestation, and several alternative explanations for abnormal vital signs (e.g., fever/crying equating to tachycardia/tachypnea).
p.18
Neonatal Sepsis: Epidemiology and Risk Factors
How does low birth weight affect neonatal sepsis risk?
It is an infant risk factor for neonatal sepsis.
p.24
Intraosseous vs. Peripheral IV Access in Emergencies
What are the contraindications for attempting IO access?
Fractures/crush injuries near the access site, previous attempts to establish IO access in the same bone, osteogenesis imperfecta.
p.20
Diagnostic Tests for Early-Onset Sepsis (EOS) and Late-Onset Sepsis (LOS)
What additional diagnostic tests should be considered for localized infections in neonates?
Purulent eye discharge (chlamydia, gonorrhea), periumbilical skin or purulent discharge (if omphalitis), and skin, conjunctiva, mouth, anus swab (HSV).
p.19
Neonatal Sepsis: Epidemiology and Risk Factors
How has the use of intrapartum antibiotics affected the common causes of neonatal sepsis?
It has transitioned the most common cause from Group B Streptococcus to Escherichia coli.
p.19
Neonatal Sepsis: Epidemiology and Risk Factors
What are the most common pathogens in community-acquired late-onset sepsis?
Escherichia coli (41%) and Group B Streptococcus (41%).
p.18
Signs and Symptoms of Neonatal Sepsis
What is the most common cause of neonatal morbidity and mortality?
Early-onset neonatal sepsis (EOS).
p.21
Empiric Antibiotic Therapy for Neonatal Sepsis
When are antibiotics warranted for late-onset sepsis (LOS) in neonates?
For suspected or proven late-onset sepsis
p.21
Empiric Antibiotic Therapy for Neonatal Sepsis
Why is ceftriaxone contraindicated in neonates with a postmenstrual age less than 41 weeks?
Due to high protein binding and risk of kernicterus due to bilirubin displacement
p.23
Pediatric Septic Shock Recognition and Treatment
What are early indicators of septic shock in children?
Temperature irregularities (hyperthermia or hypothermia) and altered mental status (confusion, drowsiness, irritability, inconsolability, unresponsive).
p.24
Intraosseous vs. Peripheral IV Access in Emergencies
Why is it preferred to have two vascular access points in pediatric septic shock?
To ensure the ability to administer fluids, vasopressors/inotropes, and antimicrobials in a timely manner.
p.19
Neonatal Sepsis: Epidemiology and Risk Factors
What are the most common pathogens causing neonatal sepsis?
Streptococcus agalactiae (Group B Streptococcus) and Escherichia coli.
p.22
Pediatric Septic Shock Recognition and Treatment
What is the importance of adopting screening tools for sepsis recognition in children?
Screening tools are paramount to recognition and should take into consideration objective measures and subjective assessment by a care team to determine if sepsis pathway management is appropriate.
p.18
Neonatal Sepsis: Epidemiology and Risk Factors
What post-neonatal course factors can increase the risk of neonatal sepsis?
Requirement for resuscitation at birth, detailed history of NICU stay, and sick contacts.
p.23
Pediatric Septic Shock Recognition and Treatment
How does the WHO define hypotension in pediatric patients?
Cold extremities with prolonged capillary refill time >3 seconds and weak, fast pulse.
p.24
Intraosseous vs. Peripheral IV Access in Emergencies
When might intraosseous (IO) access be more appropriate than peripheral IV access?
In emergent or urgent situations where peripheral IV access cannot be achieved rapidly, such as in a patient in shock.
p.22
Empiric Antibiotic Therapy for Neonatal Sepsis
What is the most appropriate strategy for prompt administration of ampicillin and gentamicin to a pediatric patient with only one peripheral vascular access site?
Administer ampicillin 75 mg/kg first as an IV infusion over 15 min, followed by gentamicin 5 mg/kg as an IV infusion over 30 min.
p.18
Neonatal Sepsis: Epidemiology and Risk Factors
How does immunosuppression in the mother affect neonatal sepsis risk?
It is a maternal risk factor for neonatal sepsis.
p.18
Signs and Symptoms of Neonatal Sepsis
How can rupture of the amniotic membrane lead to neonatal sepsis?
Entry of birth canal organisms via nonintact membrane can result in infection of amniotic fluid (chorioamnionitis).
p.23
Pediatric Septic Shock Recognition and Treatment
What are the criteria for Systemic Inflammatory Response Syndrome (SIRS) according to the 2005 International Pediatric Sepsis Consensus Conference?
At least 2 criteria, 1 of which must be temperature or leukocyte: 1) Temperature greater than 38.5°C or less than 36°C, 2) Tachycardia (or bradycardia if younger than 1 year), 3) Tachypnea or mechanical ventilation, 4) Abnormal leukocyte count of greater than 10% bands.
p.24
Pediatric Septic Shock Recognition and Treatment
What is the goal in managing compensated shock?
To 'clamp down' on the peripheral vasculature.
p.18
Neonatal Sepsis: Epidemiology and Risk Factors
What is bacterial colonization, specifically Group B Streptococcus, considered?
A maternal risk factor for neonatal sepsis.
p.21
Empiric Antibiotic Therapy for Neonatal Sepsis
What is the recommended empiric antibiotic therapy for late-onset sepsis (LOS) in neonates hospitalized since birth?
Gentamicin (dosing as above) + vancomycin (or penicillinase-resistant penicillin, such as oxacillin or nafcillin)
p.24
Pediatric Septic Shock Recognition and Treatment
What are the clinical signs of peripheral vasodilation in warm shock or compensated shock?
Rapid capillary refill time, bounding pulses, warm extremities.
p.21
Empiric Antibiotic Therapy for Neonatal Sepsis
When are antibiotics warranted for early-onset sepsis (EOS) in neonates?
a. Critically ill neonates
b. Neonates with clinical signs and risk factors for EOS and less than 3 days old
c. Neonates with more than mild symptoms despite having no risk factors
p.23
Pediatric Septic Shock Recognition and Treatment
What defines septic shock according to the 2005 International Pediatric Sepsis Consensus Conference?
Septic shock is defined as sepsis plus cardiovascular dysfunction despite adequate fluid resuscitation.
p.24
Pediatric Septic Shock Recognition and Treatment
Why is early recognition of sepsis important?
Because earlier recognition equates to more timely therapy, which is associated with improved morbidity and mortality.
