Israel Medical Association Journal

Background: Clinical dysentery causes hundreds of thousands of deaths annually worldwide. However, current recommendations reserve antibiotics for those either clinically sick or with highly suspected cases of shigellosis. This treatment stems from rising antibiotic resistance. Children diagnosed with clinical dysentery in the pediatric emergency department (PED) are regarded more cautiously.

Objectives: To explore the use of antibiotics in children diagnosed with clinical dysentery in the PED.

Methods: A retrospective case study of children with clinical dysentery at a single PED during the years 2015 and 2018. Demographics as well as clinical findings were compared to culture results and antibiotic treatment.

Results: The study included 281 children who were diagnosed with clinical dysentery during the study period; 234 (83%) were treated with antibiotics. However, cultures were positive in only 162 cases (58%). Only 32% were Shigella spp. Younger age, fever, and leukocytosis were related to antibiotic treatment.

Conclusions: The diagnosis of clinical dysentery is misgiven commonly in the PED leading to widespread use of antibiotics when not indicated. This treatment may impact antibiotic resistance patterns. Further studies and interventions are necessary to create clear guidelines in the PED setting.

Background: Hypernatremic dehydration is a common and potentially life-threatening condition in children. There is currently no consensus as to the optimal strategy for fluid management. Objectives: To describe the relationship between the type, route and rate of fluids administered and the rate of decline in serum sodium (Na+) concentration. 

Methods: We reviewed the medical records of all children under the age of 2 years who were hospitalized with hypernatremic dehydration (serum Na+ ≥ 155 mEq/L) in Shaare Zedek Medical Center during the period 2001–2010. Collected data of 62 subjects included initial and subsequent serum Na+ levels, and rate and Na+ concentration of all intravenous and oral fluids administered until the serum Na+ reached ≤ 150 mEq/L.

Results: Median initial serum Na+ was 159.5 mEq/L (IQR 157–163, maximal value 170). The median rate of decline in serum Na+ until serum Na+ reached 150 mEq/L was 0.65 mEq/L/hr (IQR 0.45–0.95). Forty-two children received hypotonic oral fluids which accounted for approximately one-quarter of all fluids they received. There was no significant difference in the rate of decline in serum Na+ between those who consumed oral fluids and those who did not. Neither was there a correlation between the rate of IV fluids, receipt of oral fluids or the degree of dehydration, with the rate of decline in serum Na+. No child experienced an apparent short-term adverse outcome. 

Conclusions: A cumulative rate of 5.9 ml/kg/hr of IV fluid administration may reduce the serum Na+ to an acceptable rate (0.65 mEq/L/hr). Fluid therapy comprising up to 25% hypotonic oral fluids and 75% IV fluids high in Na+ concentration was not associated with any short-term adverse outcome in our patient population. 

 

Background: Ritual circumcision in neonates may cause a urinary tract infection within 2 weeks of the procedure.

Objectives: To evaluate the prevalence of urinary tract infection among Jewish male circumcised neonates (¡Ü 28 days old) evaluated for fever in the emergency room.

Methods: All available medical records of neonates presenting to the pediatric emergency room for evaluation of fever over a 10 year period were reviewed. Data included gender, ethnic background, age in days on presentation to the emergency room, age in days when circumcision was performed (in males ¡Ý 8 days of age), and results of urine, blood and cerebrospinal fluid cultures. Families of males older than 8 days of age who had a UTI[1] were contacted by telephone to verify the circumcision status when the infant presented to the ER[2], to ascertain whether the circumcision was performed ritually by a mohel* or by a physician, and, when not recorded in the chart, to verify the day of life on which circumcision was performed.

Results: Among neonates older than 8 days of age, 60 (24.7%) of the 243 febrile Jewish males had a UTI, as compared to 12 (8.4%) of 143 females (P < 0.0001). In 39 of 54 male neonates (72%) for whom circumcision was performed ritually on the eighth day of life, UTI occurred within 9 days of the circumcision. For females, there was no such clustering of UTI cases in the second week of life, nor during any other time period.

Conclusions: Febrile male neonates who have undergone ritual circumcision have a high prevalence of UTI and must be evaluated and treated accordingly. 

[1] UTI = urinary tract infection

[2] ER = emergency room

* Mohel is a Jewish man trained in the practice of Brit milah (circumcision).

Objectives: To determine whether children with multiple siblings are at increased risk for accidents, to assess whether quality of child supervision varies with family size, and to evaluate the relationship of family size with the rapidity of seeking medical care after an accident.

Methods: We prospectively studied 333 childhood accidents treated at TEREM (emergency care station) or Shaare Zedek Medical Center. Details on family composition and the accident were obtained through parental interview. Family size of the study population was compared with that of the Jerusalem population. Families with one to three children (Group 1) and four or more children (Group 2) were compared with regard to type of supervision and different "Gap times" – the time interval from when the accident occurred until medical assistance was sought ("Gap 1"), the time from that medical contact until arrival at Shaare Zedek ("Gap 2"), and the time from the accident until arrival at Shaare Zedek for those children for whom interim medical assistance either was ("Gap 3A") or was not ("Gap 3B") sought.

Results: Children from families with 1, 2, 3, 4 and ≥5 children comprised 7.2%, 18.3%, 14.4%, 18.6% and 41.4% of our sample compared to 20.4%, 21.8%, 18.4%, 14.7% and 24.7% in the general population respectively. Children from Group 2 were less often attended to by an adult (44.5% vs. 62.0%) and more often were in the presence only of other children at the time of the accident (27.0% vs. 10.5%). Gaps 1, 2 and 3A in Group 2 (6.3 hours, 16.5 hours, 27.8 hours respectively) were longer than for Group 1 (2.7, 10.7, 13.3 hours respectively).

Conclusions: The risk for accidents is increased among children from families with four or more children. The adequacy of child supervision in large families is impaired. There is a relative delay from the time of the accident until these children are brought for treatment.