News and insights for health care professionals                                                  April 2009...
NEWS NOTES                                                                                                                ...
Program spotlight: Concussion and Sports Clinic                                                                           ...
CME CORNER                                                                                                                ...
A S K T H E E X P E R T : T R E AT i N g u T i

   Urinary tract infection (UTI) is one of the most common               ...
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Pediatric Views

  1. 1. PediatricViews News and insights for health care professionals April 2009 | Antibiotic resistance: MetroWest changes transmission and control affiliation for its pediatric care MetroWest Medical Center recently decided to change its pediatric affiliation to Tufts Medical Center, effective in July. This decision follows months of discussion with Children’s Hospital Boston, in which MetroWest indicated it wanted to greatly expand its pediatric services from its current offerings. Children’s was unable to staff the services desired by MetroWest and still adequately staff its existing facilities. Children’s remains committed to providing a safety net for pediatric care throughout New England. Our specialists continue to staff the neonatal intensive care units, pediatric inpatient units and emergency departments at seven community hospitals, including Donald Goldmann, MD Thomas Sandora, MD, MPH Beverly Hospital, the Caritas system (St. Elizabeth’s, Norwood, Holy Family and Good Samaritan), South M Shore Hospital and Winchester Hospital. ethicillin-resistant Staphylococcus used antibiotics. MRSA is a major problem aureus (MRSA) is a bacterium in hospitals and in the community.” The hospital also owns and operates three ambulatory that’s resistant to the antibiotics Staphylococcal infections, including facilities, in Waltham, Lexington and Peabody, and a that are usually used for first-line MRSA, are a frequent cause of health community health center, Martha Eliot Health Center, in treatment. Like more antibiotic-sensitive care-related infection, and are associated Jamaica Plain. strains of staphylococci, MRSA generally with considerable morbidity, mortality colonizes the nose and certain areas of and excess cost. Patients with weakened skin. Recent data suggest that MRSA can immune systems may be especially Children’s network locations: also colonize the throat even if the nose susceptible. The Centers for Disease is not colonized. Colonization does not Control and Prevention (CDC) estimates always result in infection, but can cause that there are approximately 94,000 skin and soft tissue infection, as well cases of serious MRSA infections and as bloodstream infection, pneumonia, approximately 19,000 deaths per year. bone infection and other serious (and Statistics also show that the proportion of sometimes fatal) infections. staphylococcal infections due to MRSA “Staphylococcus aureus has always have risen in U.S. intensive care units, been one of the most common causes from 2 percent in 1974 to 64 percent in of bacterial infections,” says Donald 2004. Goldmann, MD, an infectious disease In addition, another strain of MRSA specialist at Children’s Hospital Boston. has begun to emerge in otherwise healthy “But we now have MRSA strains that are people who have not been recently resistant to some of the most commonly hospitalized or had any medical procedure. continuEd on PAGE 6 What’s inside • A Q&A about PANDAS PAGE 3 • Program spotlight: Concussion and Sports Clinic PAGE 4 • Can we detect autism in infants? PAGE 5
  2. 2. NEWS NOTES Q&A PANDAS New Fetal-Neonatal MIBG treatment for Attention Children’s alumni It’s estimated that 1 to 3 percent of children fit criteria for Neuroimaging Center neuroblastoma patients This May, Children’s will launch an online community for our faculty and alumni. Obsessive-Compulsive Disorder (OCD) and 10 to 25 percent of Children’s Hospital Dana-Farber/Children’s Hospital Cancer Members will be able to: school-age children will develop tics or related neuropsychiatric Boston’s new Care recently started its first treatment Fetal-Neonatal protocol that uses radioiodine labeled • search the directory to locate friends disorders. Pediatricians and researchers now question if the and colleagues Neuroimaging and metaiodobenzylguanidine (I-131 MIBG) for • communicate with other members via onset of these disorders could be related to routine childhood Developmental patients with relapsed neuroblastoma. It’s a secure system strep infections. Here, Robert Fuhlbrigge, MD, PhD, assistant in Science Center will the first therapy of its kind offered in New • create professional sub-groups with develop hardware England. Medicine and attending in Pediatric Rheumatology at Children’s members in and outside of this and software that With a response of almost 40 Children’s community Hospital Boston, explains the possible connection. will help clinicians percent, I-131 MIBG is one of the most • find out about the latest news at diagnose brain injury in fetuses and effective therapies for children with Children’s and CME events What are PANDAS? neonates earlier and more effectively, relapsed neuroblastoma. While it doesn’t Pediatric Autoimmune Neuropsychiatric Disorders Associated then develop and implement therapies cure, I-131 MIBG can allow patients To receive your invitation to this with Streptococcal Infections (PANDAS) are neurological disorders that will improve long-term health and to gain control of their disease and, in community, send your email address, associated with common Group A-Beta-hemolytic streptococcus outcomes. combination with other treatments, brings name and information about your (GABHS) infections. The theory is that the normal immune These technologies will also provide them closer to being cured. training at Children’s to response to strep bacteria becomes misdirected and attacks Robert Fuhlbrigge, MD, PhD clinical scientists with the ability to test Treatment is delivered by a team of the brain, specifically the basal ganglia. This hypothesis, termed hypotheses and hopefully accelerate the multidisciplinary experts from the hospital, molecular mimicry, is familiar to physicians as the etiology of antibiotic prophylaxis. However, as with acute rheumatic fever, if application of neuroimaging advances to including specialists from Pediatric cardiac valve damage and Sydenham’s chorea in acute rheumatic recurrent symptoms develop in association with strep infections routine clinical practice. Ellen Grant, MD, Oncology, Nursing, Nuclear Medicine, fever (ARF). The question is whether a similar process can cause prophylaxis should be considered. I find it takes approximately MSc, who has trained in both adult and Radiation Safety and Child Life. cases of acute onset OCD, tics or Tourette’s syndrome. one year of monitoring to confirm or refute the diagnosis in those pediatric neuroradiology, was recruited ON BOOKSHELVES The difficulty in diagnosing PANDAS lies in the frequency from Mass. General Hospital for Children patients who meet the initial screening requirements. More information and eligibility of the associated symptoms: Tics and obsessive or compulsive to head up the clinic. requirements: 888-733-4662 congenital Heart disease: the behaviors are common, and most children display repetitive catheterization Manual behaviors at certain stages of development. Similarly, GABHS What is the treatment? Collaboration with the New sports psychologist By Children’s infections are common. Some children displaying new tics or Therapy has to be separated into prophylaxis for strep and treatment of the associated neuropsychiatric symptoms. The OCD symptoms will have coincidental evidence of a current Immune Disease Institute helps injured athletes cope cardiologist Lisa Bergersen, Md, and or recent strep infection, regardless of any possible etiologic only role for antibiotics is to prevent recurrent strep infections Children’s and the association. Unfortunately, there isn’t a diagnostic test or and reduce the risk of future injury to the affected regions of Children’s Division Audrey Marshall, the brain. It’s important to recognize that antibiotics won’t treat Immune Disease validated criteria set for PANDAS yet. Similar to ARF, suspicion of Sports Medicine Md, chief of Invasive neuropsychiatric symptoms. Institute (formerly of PANDAS is elevated in patients with abrupt onset of has added a new Cardiology, with others the Center for neuropsychiatric symptoms in the context of a preceding strep sports psychologist Blood Research) infection (positive culture and/or rising anti-strep antibody titer). to its team, This manual provides When should a physician refer? have entered Sharon Chirban, a comprehensive Physicians should consider referral to Psychiatry to treat specific into an affiliation PhD. Symptoms overview of how the Is PANDAS acknowledged as a syndrome? symptoms and to Rheumatology if there are questions of test agreement. that warrant a cardiac catheterization laboratory in a pediatric It’s still a controversial diagnosis. The hypothesis is coherent, but interpretation or prophylaxis for strep. Once a monitoring plan This eighth referral are those cardiology division works. Cases are described supporting evidence is weak. Research shows that anti-neuronal is established, the physician can provide the needed care with multidisciplinary associated with in detail and hemodynamics is covered in antibodies are found more often in the blood of patients with intermittent assistance. Again, in the acute phase, management research program at Children’s will overtraining, burnout, performance- depth. neuropsychiatric symptoms than in patients who have had strep of the neuropsychiatric symptoms is paramount. At present, be called the Program in Cellular and driven weight loss, female athlete but don’t have neuropsychiatric symptoms, but it’s not a perfect there is no conclusive evidence that early treatment with Molecular Medicine, and the program’s triad symptoms, career transitions, Fasten Your Seatbelt association. Animal studies have been mixed and there aren’t immune suppressive medications, plasmapheresis or intravenous researchers will pursue four primary performance anxiety and parent/coach/ post-mortem studies of human brains from patients with PANDAS immunoglobulin will improve neuropsychiatric symptoms or alter areas of research: adhesion molecules By Brian Skotko, Md, MPP, Department of athlete issues, as well as personality Medicine, with Sue reported. the course of the disorder. and inflammation; autoimmunology and changes after an athletic injury, depression allergy; genetics of immunodeficiency and Levin, MA, CSW and/or anxiety. What is the diagnostic process? cancer; and immune defenses against Can PANDAS be prevented? Subtitled “A Crash The best we can do is to be aware of the possibility and look for the The only way to prevent it would be to prevent all strep infections. infectious disease, virus and tumors. More information: Course on Down association when appropriate. Patients with acute onset of tics or Given the very low incidence of the disorder, it isn’t reasonable Fred Alt, PhD, co-chief of the Division of Syndrome for Brothers OCD should be interviewed for a history of recent throat infection to place all school-age children on long-term antibiotics. We Molecular Medicine, will be the executive and Sisters,” this book and tested for strep by culture and the presence of anti-streptolysin recommend the same care provided for ARF prevention: School-age director. is written for teens O (ASLO) and anti-DNase B antibodies. If the history and laboratory children with unexplained fever or sore throats should be evaluated with a brother or sister studies are negative, then no association can be identified and the for strep and, if confirmed, treated with an appropriate course of Learn more about research at Children’s: with Down syndrome. patient does not have PANDAS. If they are positive, the patient antibiotics. There is no evidence for additional preventive measures. In Q&A format, it tackles a broad range of their should be followed over time. most common issues and concerns. If flares of symptoms occur without evidence of recurrent Make a referral to Rheumatology: 617-355-6117 strep, or if strep infections occur without changes in symptoms, the patient does not have PANDAS and should not be given Make a referral to Psychiatry: 617-355-6688 2 Pediatric Views | April 2009 | Pediatric Views | April 2009 | 3
  3. 3. Program spotlight: Concussion and Sports Clinic RESEARCH Children’s Hospital Boston’s Concussion and Sports Clinic opened last year to diagnose and treat children and young adults with concussions sustained primarily from sports-related injuries. It’s critical Can we detect autism in infants? that patients are evaluated after sustaining a concussion or head injury: If children are cleared to return to sports but have not recovered normal brain function, a second concussion is more likely, more Autism spectrum disorders (ASDs) are difficult to diagnose before 12 to 18 months of age because many early signs, such as not responding to one’s name, aren’t reliable in a child so young. Charles Nelson, PhD, serious and, in rare cases, fatal. research director of Children’s Hospital Boston’s Division of Developmental Medicine, aims to move the diagnostic window back into the first year of life, allowing interventions to begin as early as possible. Most children will fully recover from a sports-related concussion Dr. Nelson’s team in the Laboratories of Cognitive Neuroscience is using electrophysiologic studies of within days to weeks. However, some take months to recover Probe trials with higher degree on injury the brain to find predictive measure that are unencumbered by behavior. "Our goal is to detect reliable risk completely. Children who get a second concussion before markers for ASDs, and ultimately to develop new methods for early screening and diagnosis,” he says. being fully recovered are at risk for serious, long-term problems. The study, still enrolling, is comparing infants at high risk for ASDs (having at least one older sibling Children who have already sustained a concussion are at greater with an ASD or a language impairment) to infants with no family history of the disorders. In addition to risk for subsequent concussions; the highest risk is within behavioral testing, the infants are shown images of their mother and a stranger while electrodes record their 10 days of sustaining the first one. The effects are actually brain activity and eye movements are tracked; in another test, they listen to familiar and unfamiliar language Injured cumulative, so each concussion causes more severe symptoms sounds while brain activity is recorded. and requires longer recovery times. Preliminary findings suggest that at 6 months of age, high-risk infants are less able to differentiate Sham Charles Nelson, PhD Diagnostics between native and non-native speech sounds than control infants, and at 6 and 12 months, respond more slowly to their mothers’ faces. Overall, their brains generate less of the kind of brain activity that has been associated with integrating • Children’s Concussion and Sports Clinic treats primarily sport-related concussions and concussions with a similar information. The team will follow the infants to 36 months old and see how well their measures predict the diagnosis of ASDs. mechanism to that seen in sports. Probe trials • Our team tracks all stages of concussion and guides athletes More about enrolling in this study: back to their original function so that they may be cleared to According to a Children’s study, mice who have sustained a concussion (injured) are unable to Beware glass tables play sports again. remember the location of a hidden platform, while uninjured (i.e. sham) mice remember. • Doctors conduct a physical examination, balance assessment and neuropsychological testing to evaluate cognitive function Most babies with simple febrile and reaction time, which may include a computerized test and/or written evaluation. MEET THE TEAM seizures can avoid lumbar Many homes harbor a threat that safety regulations, surprisingly, have overlooked: • We offer baseline neuropsychological testing so we can have a record of a patient’s normal brain function so that, Pierre d’Hemecourt, Md, FAcSM puncture glass tables. When children jump on them, sit on them or knock them over, should he later sustain a concussion, we can test him after Director, Primary Care Sports Medicine they can shatter, causing severe and injury and monitor his recovery. The largest study conducted to date concludes that routine lumbar puncture is unnecessary for a first simple febrile seizure sometimes fatal lacerations. Treatment in well-appearing 6- to 18-month-old children, calling into question Glass bottles, doors and • Physical and cognitive rest is the main treatment. We remove current American Academy of Pediatrics recommendations, which windshields—but not the child from athletics and other activities that pose a risk of date from 1996. tables—are mandated to Bill Meehan, Md additional injury until he’s completely recovered, and monitor Simple febrile seizures are generalized seizures lasting contain tempered glass, Fellow, Primary Care Sports Medicine his progress. no more than 15 minutes and not recurring within 24 hours. which is much stronger • When appropriate, we treat symptoms medically. The AAP recommends considering lumbar puncture for 12- to than standard glass • Days, weeks or months after a mild or moderate head injury 18-month-olds with a first simple febrile seizure, and “strongly” and breaks into uniform, or concussion, a child may experience pain, headaches, considering it for 6- to 12-month-olds. But now that H. influenzae harmless fragments. After trouble sleeping or behavior problems. Some patients may and pneumococcal vaccines have made bacterial meningitis rare, hearing media reports about Michelle Parker, MS, cP, nP require further care in our Brain Injury Clinic. spinal taps have been on the decline. patients with glass-table Nurse Practitioner, Brain Injury Clinic Researchers in Children’s Division of Emergency Medicine, lacerations at Children’s, Research studies underway led by Amir Kimia, MD, staff physician in the ED, reviewed the researchers in the Division • In partnership with Massachusetts General Hospital, charts of 704 babies seen for a first simple febrile seizure from of Emergency Medicine began a systematic study in we’re developing a model of concussion in mice that 1995 to 2006. Thirty-eight percent underwent lumbar puncture collaboration with Consumers Union, using a computer simulates concussive brain injury and using it to test that revealed an elevated white-cell count in 10 patients (3.8 algorithm to search electronic records. Mark Proctor, Md therapeutic agents that alleviate its effects. percent). However, no pathogen was identified on cerebrospinal Between 1995 and 2007, 174 injuries were logged Neurosurgeon, Department of Neurosurgery • We have three ongoing clinical trials; one looks fluid cultures, and no patient was diagnosed with bacterial by the Emergency Department. Chart review indicated at the time it takes younger vs. older children to recover from meningitis. that half would have been preventable or less severe with concussions. Another examines the effects of cognitive Dr. Kimia cautions that the findings, published in the January safety glass. Almost two-thirds of patients were male, and rest on concussions. A third uses imaging of patients whose Pediatrics, don’t necessarily extend to patients with complex the median age was 3.4 years. Lacerations were most symptoms persist. febrile seizures, concerning symptoms or signs of an underlying often on the face, especially in young children, followed dave Mooney, Md, MPH illness. “If a child appears very ill, is lethargic, fussy, non- by feet, legs, hands and arms. Forty percent of patients Referrals Director, Trauma Program, Department of Surgery responsive, or has neurologic symptoms or clinical signs such needed imaging to locate all the glass, and 80 percent Within one week of calling our office, most patients will have as a bulging fontanelle, lumbar puncture should be considered, needed surgical repair. Findings appear in the March issue an appointment. It’s important that an athlete who has regardless of age,” he says. of Pediatric Emergency Care. sustained a concussion or head injury see a doctor. Contact us at 617-355-8597. Online: Listen to an interview with Dr. Kimia: Online: Print a concussions handout at: To read the paper: 4 Pediatric Views | April 2009 | Pediatric Views | April 2009 | 5
  4. 4. CME CORNER NAMES & FACES CLiNiCAL TRiALS Pediatric Health care Summit Antibiotic resistance continuEd FroM PAGE 1 at Beverly Hospital These infections are termed community-associated MRSA infections (CA-MRSA) and Mark Fleming, MD, DPhil, has been named neuromuscular disease April 29, 7:30 a.m. to 12:30 p.m. usually manifest as skin and soft tissue infections. Severe pneumonia, bloodstream pathologist-in-chief of Children’s Hospital Boston. This study aims to discover which 85 Herrick Street infection, bone and joint infection can also occur. He served in that role on an interim basis since genes are involved in specific Beverly, MA June of last year. Dr. Fleming plans to expand the muscle disorders. The study credits: 4 hours Category 1 credits Spread and prevention scope of anatomic pathology diagnostic services and translational investigation to meet increasingly includes a medical record review, topics: Advances in radiology imaging that questionnaires, a blood sample and According to the CDC, approximately 2.3 million people in the United States are complex and diverse molecular modalities to help in the treatment of your patients, infant a muscle tissue sample (if available colonized with MRSA. Most people are unaware they are colonized, so it’s important that diagnose and monitor childhood diseases. nutrition, autism: what have we learned and from a previous or pending biopsy). preventive measures be taken to minimize its spread, particularly in high-risk areas, such Louis Kunkel, PhD how to manage, screening for anemia Family members are asked to provide as hospitals. “It’s generally spread by direct contact between individuals or occasionally their medical records and a blood or saliva sample. by objects in the environment,” says Dr. Goldmann. “In the community, transmission Thomas Kulik, MD, has returned to Children’s Pediatric Health care Summit at South can occur in athletic facilities or schools due to contaminated equipment. In hospitals, it’s as the director of the Pulmonary Hypertension Eligibility: Children with a genetic neuromuscular condition Shore Hospital usually spread on the hands of primary health care providers.” Program. Dr. Kulik has unique experience as a may be eligible. May 14, 7:30 a.m. to 12:30 p.m. MRSA can survive in the environment for a long time—on surfaces and on hands. leader in pediatric cardiology, having been the South Shore Hospital Thomas Sandora, MD, MPH, medical director of Infection Control at Children’s, advises director of the Cardiac Intensive Care Unit at C.S. Elicia Estrella, MS, CGC at 617-919-4552 or 55 Fogg road (at route 18) clinicians to always “wash their hands frequently, and more often if they have an Mott Children’s Hospital in Michigan and, most South Weymouth, MA infection or if are in contact with anyone who has an infection. If they have a wound or a recently, at Cincinnati Children’s Hospital. credits: 4 hours Category 1 credits skin abscess make sure it’s covered, and if changing a dressing or having contact with a Brain fMri for children and adolescents topics: Pediatric allergic gastrointestinal wound, wash hands very carefully afterward.” disorders, contraception for teens, water This study looks at how the brain activity of healthy kids Dr. Sandora also notes that health care providers must wear gowns and gloves when related injuries in children, bipolar disorder differs from the brain activity of seeing patients with MRSA, and should clean and disinfect patient-care equipment Audrey Marshall, MD, has been named chief children and adolescents with and surfaces in order to prevent transfer of microorganisms to other patients and of Invasive Cardiology. Dr. Marshall received her 3rd Annual Shillito Fellowship day complex regional pain syndrome, environments. medical degree from the University of Pennsylvania specifically in their sensitivity to May 15, 8 a.m. to 3:30 p.m. at Philadelphia, and came to Children’s for her touch and temperature. There are children’s Hospital Boston, Enders Auditorium Antibiotic sensitivity and treatment residency and Cardiology fellowship. She has been three study visits that last about at Children’s ever since. one-and-a-half hours each, and 300 Longwood Avenue As with any bacteria, MRSA can cause serious infections that need prompt antibiotic Alyssa Lebel, MD treatment. “MRSA is treatable, but there’s a limited selection of antibiotics that will include eyes, ears and reflexes Boston, MA work,” says Dr. Goldmann. According to Dr. Sandora, hospital-acquired strains and testing, sensitivity testing and an MRI. Children receive a credits: pending community-acquired strains also have different susceptibilities. “The strain acquired in picture of their brain from the MRI, as well as $30 at each of topics: Presentation and management of hospitals is resistant to more classes of antibiotics, whereas the strain in the community the visits. Parking is free at Children’s at Waltham. tethered cord–fatty filum, a common pediatric Carlos Estrada, MD, assistant in Urology, is the neurosurgical condition, featuring talks by local is resistant only to the main class of antibiotics,” he says. However, it isn’t uncommon to Eligibility: Healthy kids between 9 and 20 may be eligible. Children’s recipient of the 2009–2010 Harvard and invited faculty and trainees find hospital strains that have spread to the community and community strains that have Location Children’s Hospital Boston at Waltham Catalyst Program for Faculty Development and been introduced to hospitals. Dr. Sandora advises that wherever possible, it’s best to get Diversity Faculty Fellowship. The fellowship, More information: a culture if there’s an infection, so the bacteria can be identified. sponsored by the Catalyst and the HMS Office for Athena Drosos at 781-216-1199 or 617-355-6446 or In general, the most common treatment for MRSA is an antibiotic called Diversity and Community Partnership, is a two- kristin.meyers@childrens. Vancomycin, but recent development of new antibiotics has provided other options. Most year program that provides $100,000 in funding for antibiotics can be safely used in newborns. Dr. Sandora says that patients with MRSA clinical or translational research for junior faculty. Autism Spectrum disorders (ASds) infections should be referred to Children’s Division of Infectious Diseases for evaluation. This study examines genetic and environmental causes of Pediatric Health care Summit at ASDs to provide earlier diagnosis and better treatment. Framingham union Hospital Controversy over outpatient testing Louis Kunkel, PhD, chief of the Division Study procedures include a medical June 12, 7:30 a.m. to 12:30 p.m. of Genetics and a Howard Hughes Medical record review, family medical Given the potential harm MRSA can cause, some in the medical community have Framingham union Hospital Auditorium Investigator, received the 2009 March of Dimes history, questionnaires, a cognitive suggested testing every patient for it who gets admitted to the hospital, but Dr. Sandora 115 Lincoln road Prize for his pioneering work in discovering genes test, height, weight and head size thinks that might be overkill. “Right now I wouldn’t say it’s cost effective—in terms of Framingham, MA involved in muscular dystrophy and explaining the measurements, 3D photographs controlling the spread of MRSA—to test every patient,” he says. “We do test patients credits: 4 hours Category 1 credits molecular and biochemical mechanisms of the of the child’s face, head, hands who are at high risk for MRSA infection. We screen all patients who are admitted to the topics: Congenital anomalies of the disease in order to help design new treatments for it. and feet, a blood draw and saliva intensive care unit because they are more likely to get an infection. But for people who reproductive tract, evaluation of sports Chris Walsh, MD, PhD are healthy and who have no symptoms, MRSA isn’t something to worry about.” samples. A parking voucher and a injuries in the office (live demonstration), 2009 $40 gift certificate are provided. vaccine update, pediatric ophthalmology: non- Consult with the Division of Infectious Diseases: 617-919-2900 Janice Ware, PhD, a specialist in developmental Eligibility: Children with an ASD may be eligible. accidental trauma psychopathology and pediatric psychology at Full agendas and registration Children’s, was appointed to Governor Deval Ellen Hanson, PhD at 617-355-3076 information: Patrick’s Commission on Mental Retardation or and will participate in the development of public policy related to people with disabilities. She has More trials: an expertise in autism and will play an important role in advising the Department of Developmental Sciences as it moves forward with its new Autism Division and the provision of services to children with autism spectrum disorders. 6 Pediatric Views | April 2009 | Pediatric Views | April 2009 | 7
  5. 5. A S K T H E E X P E R T : T R E AT i N g u T i Urinary tract infection (UTI) is one of the most common There is variation in bacterial infections in children, with an estimated incidence of practice with respect to follow- 3 to 7 percent in girls and 1 to 2 percent in up imaging, used to identify boys by age 6. anatomic abnormalities that Diagnosis should be based on the presence of both may predispose children to pyuria on urinalysis and a positive urine culture (>100,000 recurrent infection, renal injury colony forming units (CFU) of a single organism for clean or other genitourinary pathology. catch specimen, >50,000 CFU for a catheterized specimen). In general, a child whose initial Both tests are necessary for diagnosis, although the clinical UTI presents with fever (or other impression should guide initial therapy. Urine specimens signs of pyelonephritis) should collected using an adhesive bag should be avoided, given undergo imaging, including renal the high rate of false-positive results. When UTI with fever and bladder sonography and or other symptoms leads to suspicion of pyelonephritis, voiding cystogram. Among Caleb Nelson, MD, MPH dimercaptosuccinic acid (DMSA) renal scintigraphy can school-aged and younger boys help confirm the diagnosis in the acute setting. Although with UTI, we recommend similar imaging. Among toilet- diagnosis in an infant may require a high index of suspicion, trained girls, initial non-febrile UTI generally doesn’t warrant the presence of high fever in a child under 2 should prompt imaging, unless the child develops recurrent infection. consideration of UTI. Among children for whom cystography is indicated, initiation Empiric therapy should be initiated if there is reasonable of antibiotic prophylaxis is appropriate. suspicion of UTI, particularly in the setting of fever. Animal Referrals should be based on the comfort level of the studies strongly suggest that timely initiation of effective primary clinician. Although some pediatricians manage low- parenteral antibiotics (within 24 to 48 hours) can prevent grade vesicoureteral reflux (VUR) themselves, patients with development of post-infectious renal scarring, so prompt higher-grade VUR, or persistent low-grade VUR, should intervention is essential. Persistent fevers should prompt be evaluated by a urologist, as should children with other further work-up or antibiotic change. Oral antibiotic therapy significant anatomic abnormalities. (usually 10 days) is appropriate if the child is non-toxic appearing and the family is reliable. —caleb nelson, Md, MPH, pediatric urologist PediatricViews April 2009 | Published by children’s Hospital Boston department of Public Affairs and Marketing © Children’s Hospital Boston, 2009. All rights reserved. Editors: Gina colavecchio, Alison dargie, Erin Graham | Contributors: Gina colavecchio, Matt cyr, chandra Edwards, Bryan Farrow, nancy Fliesler, Erin Graham, Yvonna reekie | Designer: Jeffrey Jalovec 300 Longwood Avenue, BK2, Boston, MA 02115 | 617-355-6000 | URL: | Email: NONPROFIT ORGANIZATION U.S. Postage 300 Longwood Avenue, BK-2, Boston, MA 02115 PAid Providence, RI Permit No. 1367