Amanda Rogers, MD

Introduction

Lumbar puncture (also called “spinal tap”) is a common procedure that involves obtaining cerebral spinal fluid via needle from the spinal canal. It is generally performed for diagnostic purposes, most often to assess for central nervous system infections, including meningitis. Other indications include the evaluation of idiopathic intracranial hypertension (IIH), altered mental status or neurologic deterioration, subarachnoid hemorrhage, and demyelinating diseases such as Guillain Barré. Lumbar puncture may also be performed for therapeutic purposes, including management of IIH or administration of intrathecal medications. A lumbar puncture often elicits great concern from both patients and the family/caregivers due to concerns of pain and a misunderstanding of risk to the spinal cord. Adequate discussion with patients and the family/caregivers and appropriate use of topical anesthesia, anxiolysis, or sedation can create the environment needed for a successful procedure. Pediatric hospitalists frequently encounter patients requiring lumbar puncture and should be adept at performing lumbar puncture in all appropriately selected pediatric patients.

Pediatric hospitalists should be able to:

• List the indications for lumbar puncture, such as confirmation of pleocytosis or pathogen, therapeutic removal of fluid, assessment of response to treatment, performance of neurometabolic studies, and others.
• Review the basic anatomy of the spine and spinal column.
• List the indications for obtaining an imaging study of the brain or spinal cord prior to performing a lumbar puncture.
• Describe the relative contraindications to lumbar puncture, such as pre-existing ventriculoperitoneal shunt, previous spinal surgeries, and others, and discuss the options for safely obtaining cerebrospinal fluid in these patients.
• List the absolute contraindications to lumbar puncture, such as increased intracranial pressure, unstable cardiorespiratory status, unstable coagulopathies, and others.
• Describe the risks and complications of lumbar puncture attending to infection, bleeding, nerve injury, pain, post-procedure headache, and others.
• Summarize factors that may increase risk for complications, including age, disease process, and anatomy.
• Review the steps in performing a lumbar puncture, attending to aspects such as infection control, patient identification, positioning options, monitoring, presence of the family/caregivers, and others.
• Discuss the roles of each member of the healthcare team during lumbar puncture, attending to responsibility for performing proper level of monitoring to maximize safety, timeout, documentation, specimen labeling and transport to the laboratory, and communication with patients and the family/caregivers.

Pediatric hospitalists should be able to:

• Perform a pre-procedural evaluation to determine risks and benefits of lumbar puncture.
• Obtain informed consent from the family/caregivers.
• Order and ensure proper performance of procedural sedation if indicated, including assurance of adequate staff presence for both the lumbar puncture and the sedation.
• Demonstrate proficiency in performance of lumbar puncture on infants, children, and adolescents.
• Identify the need for and efficiently offer education to healthcare providers on proper techniques for holding and calming patients before, during, and after lumbar puncture attempts.
• Adhere to infection control practices.
• Order appropriate monitoring and correctly interpret monitor data.
• Identify complications and respond with appropriate actions.
• Use the pressure manometer as appropriate.
• Identify the need for and efficiently access appropriate consultants and support services for assistance with pain management, sedation, and performance of a lumbar puncture, as indicated.

Pediatric hospitalists should be able to:

• Appreciate the importance of working collaboratively with hospital staff and subspecialists to ensure coordinated planning and performance of lumbar punctures.
• Realize the importance of effective communication with patients and the family/caregivers regarding the indications for, risks, benefits, and steps of the procedure.
• Role model and advocate for strict adherence to infection control practices.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based procedures and policies for performance of lumbar punctures for children.
• Work with hospital administration, hospital staff, and others to develop and implement standardized documentation tools for the procedure.
• Lead, coordinate, or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction into procedural strategies.
• Lead, coordinate, or participate in the development and implementation of educational initiatives designed to teach the proper technique for lumbar puncture to trainees and other healthcare providers.

Introduction

Lumbar puncture (also called “spinal tap”) is a common procedure that involves obtaining cerebral spinal fluid via needle from the spinal canal. It is generally performed for diagnostic purposes, most often to assess for central nervous system infections, including meningitis. Other indications include the evaluation of idiopathic intracranial hypertension (IIH), altered mental status or neurologic deterioration, subarachnoid hemorrhage, and demyelinating diseases such as Guillain Barré. Lumbar puncture may also be performed for therapeutic purposes, including management of IIH or administration of intrathecal medications. A lumbar puncture often elicits great concern from both patients and the family/caregivers due to concerns of pain and a misunderstanding of risk to the spinal cord. Adequate discussion with patients and the family/caregivers and appropriate use of topical anesthesia, anxiolysis, or sedation can create the environment needed for a successful procedure. Pediatric hospitalists frequently encounter patients requiring lumbar puncture and should be adept at performing lumbar puncture in all appropriately selected pediatric patients.

Pediatric hospitalists should be able to:

• List the indications for lumbar puncture, such as confirmation of pleocytosis or pathogen, therapeutic removal of fluid, assessment of response to treatment, performance of neurometabolic studies, and others.
• Review the basic anatomy of the spine and spinal column.
• List the indications for obtaining an imaging study of the brain or spinal cord prior to performing a lumbar puncture.
• Describe the relative contraindications to lumbar puncture, such as pre-existing ventriculoperitoneal shunt, previous spinal surgeries, and others, and discuss the options for safely obtaining cerebrospinal fluid in these patients.
• List the absolute contraindications to lumbar puncture, such as increased intracranial pressure, unstable cardiorespiratory status, unstable coagulopathies, and others.
• Describe the risks and complications of lumbar puncture attending to infection, bleeding, nerve injury, pain, post-procedure headache, and others.
• Summarize factors that may increase risk for complications, including age, disease process, and anatomy.
• Review the steps in performing a lumbar puncture, attending to aspects such as infection control, patient identification, positioning options, monitoring, presence of the family/caregivers, and others.
• Discuss the roles of each member of the healthcare team during lumbar puncture, attending to responsibility for performing proper level of monitoring to maximize safety, timeout, documentation, specimen labeling and transport to the laboratory, and communication with patients and the family/caregivers.

Pediatric hospitalists should be able to:

• Perform a pre-procedural evaluation to determine risks and benefits of lumbar puncture.
• Obtain informed consent from the family/caregivers.
• Order and ensure proper performance of procedural sedation if indicated, including assurance of adequate staff presence for both the lumbar puncture and the sedation.
• Demonstrate proficiency in performance of lumbar puncture on infants, children, and adolescents.
• Identify the need for and efficiently offer education to healthcare providers on proper techniques for holding and calming patients before, during, and after lumbar puncture attempts.
• Adhere to infection control practices.
• Order appropriate monitoring and correctly interpret monitor data.
• Identify complications and respond with appropriate actions.
• Use the pressure manometer as appropriate.
• Identify the need for and efficiently access appropriate consultants and support services for assistance with pain management, sedation, and performance of a lumbar puncture, as indicated.

Pediatric hospitalists should be able to:

• Appreciate the importance of working collaboratively with hospital staff and subspecialists to ensure coordinated planning and performance of lumbar punctures.
• Realize the importance of effective communication with patients and the family/caregivers regarding the indications for, risks, benefits, and steps of the procedure.
• Role model and advocate for strict adherence to infection control practices.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based procedures and policies for performance of lumbar punctures for children.
• Work with hospital administration, hospital staff, and others to develop and implement standardized documentation tools for the procedure.
• Lead, coordinate, or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction into procedural strategies.
• Lead, coordinate, or participate in the development and implementation of educational initiatives designed to teach the proper technique for lumbar puncture to trainees and other healthcare providers.

Introduction

Lumbar puncture (also called “spinal tap”) is a common procedure that involves obtaining cerebral spinal fluid via needle from the spinal canal. It is generally performed for diagnostic purposes, most often to assess for central nervous system infections, including meningitis. Other indications include the evaluation of idiopathic intracranial hypertension (IIH), altered mental status or neurologic deterioration, subarachnoid hemorrhage, and demyelinating diseases such as Guillain Barré. Lumbar puncture may also be performed for therapeutic purposes, including management of IIH or administration of intrathecal medications. A lumbar puncture often elicits great concern from both patients and the family/caregivers due to concerns of pain and a misunderstanding of risk to the spinal cord. Adequate discussion with patients and the family/caregivers and appropriate use of topical anesthesia, anxiolysis, or sedation can create the environment needed for a successful procedure. Pediatric hospitalists frequently encounter patients requiring lumbar puncture and should be adept at performing lumbar puncture in all appropriately selected pediatric patients.

Pediatric hospitalists should be able to:

• List the indications for lumbar puncture, such as confirmation of pleocytosis or pathogen, therapeutic removal of fluid, assessment of response to treatment, performance of neurometabolic studies, and others.
• Review the basic anatomy of the spine and spinal column.
• List the indications for obtaining an imaging study of the brain or spinal cord prior to performing a lumbar puncture.
• Describe the relative contraindications to lumbar puncture, such as pre-existing ventriculoperitoneal shunt, previous spinal surgeries, and others, and discuss the options for safely obtaining cerebrospinal fluid in these patients.
• List the absolute contraindications to lumbar puncture, such as increased intracranial pressure, unstable cardiorespiratory status, unstable coagulopathies, and others.
• Describe the risks and complications of lumbar puncture attending to infection, bleeding, nerve injury, pain, post-procedure headache, and others.
• Summarize factors that may increase risk for complications, including age, disease process, and anatomy.
• Review the steps in performing a lumbar puncture, attending to aspects such as infection control, patient identification, positioning options, monitoring, presence of the family/caregivers, and others.
• Discuss the roles of each member of the healthcare team during lumbar puncture, attending to responsibility for performing proper level of monitoring to maximize safety, timeout, documentation, specimen labeling and transport to the laboratory, and communication with patients and the family/caregivers.

Pediatric hospitalists should be able to:

• Perform a pre-procedural evaluation to determine risks and benefits of lumbar puncture.
• Obtain informed consent from the family/caregivers.
• Order and ensure proper performance of procedural sedation if indicated, including assurance of adequate staff presence for both the lumbar puncture and the sedation.
• Demonstrate proficiency in performance of lumbar puncture on infants, children, and adolescents.
• Identify the need for and efficiently offer education to healthcare providers on proper techniques for holding and calming patients before, during, and after lumbar puncture attempts.
• Adhere to infection control practices.
• Order appropriate monitoring and correctly interpret monitor data.
• Identify complications and respond with appropriate actions.
• Use the pressure manometer as appropriate.
• Identify the need for and efficiently access appropriate consultants and support services for assistance with pain management, sedation, and performance of a lumbar puncture, as indicated.

Pediatric hospitalists should be able to:

• Appreciate the importance of working collaboratively with hospital staff and subspecialists to ensure coordinated planning and performance of lumbar punctures.
• Realize the importance of effective communication with patients and the family/caregivers regarding the indications for, risks, benefits, and steps of the procedure.
• Role model and advocate for strict adherence to infection control practices.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based procedures and policies for performance of lumbar punctures for children.
• Work with hospital administration, hospital staff, and others to develop and implement standardized documentation tools for the procedure.
• Lead, coordinate, or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction into procedural strategies.
• Lead, coordinate, or participate in the development and implementation of educational initiatives designed to teach the proper technique for lumbar puncture to trainees and other healthcare providers.

Clostridium difficile (name changed to Clostridioides difficile [CDI]) are a major public health problem, with 500,000 infections annually in the United States, 15,000-30,000 associated deaths, and acute care costs exceeding $4.8 billion. The recent clinical practice guideline for CDI provides recommendations about the epidemiology, diagnosis, treatment, prevention, and environmental management. A total of 52 recommendations are included, and we will review 11 with pertinence to pediatrics in this highlight.

Recommendation 1. In infants ≤12 months of age, testing for CDI should never be routinely recommended because of the high prevalence of asymptomatic carriage of toxigenic C. difficile in infants (strong recommendation, moderate quality of evidence).

Recommendation 2. In children 1-2 years of age, testing should not be routinely performed unless other causes have been excluded (weak recommendation, low quality of evidence).Recommendation 3. In children ≥2 years of age, testing is recommended for patients with prolonged or worsening diarrhea and risk factors (eg, underlying inflammatory bowel disease) or immunocompromising conditions) or relevant exposures (eg, contact with the healthcare system or recent antibiotics) (weak recommendation, moderate quality of evidence).

The rate of C. difficile colonization among asymptomatic infants can exceed 40%. This rate declines over the first year but remains 15% at 12 months of age.¹ Therefore, the guideline recommends against routinely testing infants ≤12 months of age as a positive test probably reflects colonization rather than disease. Testing in infants is recommended only when other causes have been excluded and a concern for pseudomembranous colitis, toxic megacolon, or clinically significant diarrhea exists.

The rate of asymptomatic colonization remains elevated in the second year of life. By 2-3 years, the rate is 1%-3% which is similar to that in healthy adults. However, the role of C. difficile in community-onset diarrhea in otherwise healthy children is controversial. In a study of 100 hospitalized children aged <2 years with CDI and diarrhea, all had resolution of diarrhea regardless of whether therapy was administered.² Another study found an alternative pathogen in >50% of hospitalized children with CDI.³ Therefore, the guideline recommends against testing in children aged 1-2 years unless other causes have been excluded and in children aged >2 years only when they have prolonged or worsening diarrhea along with risk factors or exposures.

Recommendation 4. In institutions without specific required criteria for stool submissions, use a stool toxin test as part of a multistep algorithm (ie, glutamate dehydrogenase [GDH] plus toxin, GDH plus toxin arbitrated by nucleic-acid amplification tests [NAAT], or NAAT plus toxin) rather than a NAAT alone (weak recommendation, low quality of evidence).

Recommendation 5. In institutions with specific required criteria for stool submissions, use a NAAT alone or a multistep algorithm for testing (ie, GDH plus toxin, GDH plus toxin arbitrated by NAAT, or NAAT plus toxin) rather than a toxin test alone (weak recommendation, low quality of evidence).

There are a variety of testing approaches for CDI and recommendations vary based on local practice. If laboratories accept all stools, a more specific approach is recommended, including a toxin test as part of a multistep algorithm to limit false positives. If laboratories first screen for symptoms and antibiotic exposure before accepting stool samples, a more sensitive approach is recommended including NAAT alone or a multistep algorithm rather than toxin alone.

Infection Prevention and Control

Recommendation 6. There is insufficient evidence for discontinuation of PPIs (proton pump inhibitors) as a measure for preventing CDI (no recommendation).

The guideline acknowledges data suggesting an association between PPI use and CDI, but not a causal relationship. Due to the lack of high-quality evidence, it does not recommend stopping PPIs to prevent CDI.

Recommendation 7. There are insufficient data to recommend probiotics for primary prevention of CDI outside of clinical trials (no recommendation).

The guideline notes that although several meta-analyses indicate that probiotics may prevent CDI; however there were limitations, including a high incidence of CDI in placebo arms and differences in probiotic formulations and duration of use, leading to insufficient data to recommend probiotic use to prevent CDI.

Treatment

Recommendation 8. Either per os (PO) metronidazole or PO vancomycin is recommended for an initial episode or first recurrence of nonsevere pediatric CDI (weak recommendation, low quality of evidence).

Data assessing the optimal treatment for nonsevere pediatric CDI are limited. Emerging data support the use of vancomycin,⁴ which is now recommended for initial episodes of CDI in adults. However, there are insufficient data to recommend vancomycin over metronidazole for nonsevere pediatric CDI; therefore, either option is recommended.

Recommendation 9. For children with an initial episode of severe CDI, oral vancomycin with or without IV metronidazole is recommended over metronidazole alone (strong recommendation, moderate quality of evidence).

Recommendation 10. For children with a second or greater episode of recurrent CDI, oral vancomycin is recommended over metronidazole (weak recommendation, low quality of evidence).

There is no well-designed trial comparing metronidazole and vancomycin for severe or recurrent pediatric CDI. For children previously treated with metronidazole, vancomycin is recommended based on adult literature.⁴ For children previously treated with metronidazole and vancomycin, an extended course of tapered or pulse regimen vancomycin or vancomycin followed by rifaximin is recommended.

Recommendations must weigh potential harms. Metronidazole has been associated with neuropathies,⁵ cramping, and nausea. PO vancomycin has poor enteral absorption, minimizing systemic effects. Both vancomycin and metronidazole may promote carriage of resistant enterococci.

Recommendation 11. Fecal microbiota transplantation (FMT) should be considered for pediatric patients with multiple recurrences of CDI following standard treatments (weak recommendation, very low quality of evidence).

There are no robust data examining the effectiveness of pediatric FMT. Recommendations are guided by adult studies. Limited evidence suggests that FMT can be effective in children with multiple recurrent CDI.⁶ Concerns include procedure-related risks, transmission of resistant organisms and blood-borne pathogens, and induced metabolic or immunologic disorders.

Methods in Preparing a Guideline

The strength of a guideline includes representation from a diverse panel, including the Infectious Diseases Society of America (IDSA), the Society for Healthcare Epidemiology of America, the American Society of Health-Systems Pharmacists, the Society of Infectious Diseases Pharmacists, and the Pediatric Infectious Diseases Society.

The panel utilized the Grading of Recommendations Assessment, Development, and Evaluation system to weigh the strength and quality of evidence.

From a pediatric perspective, the current guideline added pediatric-specific recommendations based on a comprehensive review of the literature from 1977 to 2016. The strength of these recommendations is somewhat limited by the lack of well-designed pediatric studies. An additional limitation is that treatment recommendations are based on illness severity, although the definitions used to classify severity are not pediatric-specific and are based on unvalidated expert opinion.

Sources of Potential Conflicts or Interest or Bias

The panel complied with the IDSA policy on conflicts of interest and disclosed any interest that might be construed as a conflict, regardless of relevancy. These were evaluated by the IDSA Standards and Practice Guidelines Committee.

Generalizability

Guideline generalizability may be impacted by testing availabilities within a particular setting. Cost factors and local formularies may also limit treatment options within a given setting.

Areas in Need of Future Study

Research gaps exist regarding at what age C. difficile is pathogenic given the prevalence of asymptomatic carriage. Future studies can also focus on a newly available molecular polymerase chain reaction test platform that detects C. difficile.⁷

There is limited pediatric evidence to recommend metronidazole versus vancomycin in children, particularly in nonsevere cases. There is also an opportunity to further explore alternative therapies, including fidaxomicin (not currently approved for children) and bezlotoxumab, a new agent approved as adult adjunctive therapy.⁸

Clostridium difficile (name changed to Clostridioides difficile [CDI]) are a major public health problem, with 500,000 infections annually in the United States, 15,000-30,000 associated deaths, and acute care costs exceeding $4.8 billion. The recent clinical practice guideline for CDI provides recommendations about the epidemiology, diagnosis, treatment, prevention, and environmental management. A total of 52 recommendations are included, and we will review 11 with pertinence to pediatrics in this highlight.

Recommendation 1. In infants ≤12 months of age, testing for CDI should never be routinely recommended because of the high prevalence of asymptomatic carriage of toxigenic C. difficile in infants (strong recommendation, moderate quality of evidence).

Recommendation 2. In children 1-2 years of age, testing should not be routinely performed unless other causes have been excluded (weak recommendation, low quality of evidence).Recommendation 3. In children ≥2 years of age, testing is recommended for patients with prolonged or worsening diarrhea and risk factors (eg, underlying inflammatory bowel disease) or immunocompromising conditions) or relevant exposures (eg, contact with the healthcare system or recent antibiotics) (weak recommendation, moderate quality of evidence).

The rate of C. difficile colonization among asymptomatic infants can exceed 40%. This rate declines over the first year but remains 15% at 12 months of age.¹ Therefore, the guideline recommends against routinely testing infants ≤12 months of age as a positive test probably reflects colonization rather than disease. Testing in infants is recommended only when other causes have been excluded and a concern for pseudomembranous colitis, toxic megacolon, or clinically significant diarrhea exists.

The rate of asymptomatic colonization remains elevated in the second year of life. By 2-3 years, the rate is 1%-3% which is similar to that in healthy adults. However, the role of C. difficile in community-onset diarrhea in otherwise healthy children is controversial. In a study of 100 hospitalized children aged <2 years with CDI and diarrhea, all had resolution of diarrhea regardless of whether therapy was administered.² Another study found an alternative pathogen in >50% of hospitalized children with CDI.³ Therefore, the guideline recommends against testing in children aged 1-2 years unless other causes have been excluded and in children aged >2 years only when they have prolonged or worsening diarrhea along with risk factors or exposures.

Recommendation 4. In institutions without specific required criteria for stool submissions, use a stool toxin test as part of a multistep algorithm (ie, glutamate dehydrogenase [GDH] plus toxin, GDH plus toxin arbitrated by nucleic-acid amplification tests [NAAT], or NAAT plus toxin) rather than a NAAT alone (weak recommendation, low quality of evidence).

Recommendation 5. In institutions with specific required criteria for stool submissions, use a NAAT alone or a multistep algorithm for testing (ie, GDH plus toxin, GDH plus toxin arbitrated by NAAT, or NAAT plus toxin) rather than a toxin test alone (weak recommendation, low quality of evidence).

There are a variety of testing approaches for CDI and recommendations vary based on local practice. If laboratories accept all stools, a more specific approach is recommended, including a toxin test as part of a multistep algorithm to limit false positives. If laboratories first screen for symptoms and antibiotic exposure before accepting stool samples, a more sensitive approach is recommended including NAAT alone or a multistep algorithm rather than toxin alone.

Infection Prevention and Control

Recommendation 6. There is insufficient evidence for discontinuation of PPIs (proton pump inhibitors) as a measure for preventing CDI (no recommendation).

The guideline acknowledges data suggesting an association between PPI use and CDI, but not a causal relationship. Due to the lack of high-quality evidence, it does not recommend stopping PPIs to prevent CDI.

Recommendation 7. There are insufficient data to recommend probiotics for primary prevention of CDI outside of clinical trials (no recommendation).

The guideline notes that although several meta-analyses indicate that probiotics may prevent CDI; however there were limitations, including a high incidence of CDI in placebo arms and differences in probiotic formulations and duration of use, leading to insufficient data to recommend probiotic use to prevent CDI.

Treatment

Recommendation 8. Either per os (PO) metronidazole or PO vancomycin is recommended for an initial episode or first recurrence of nonsevere pediatric CDI (weak recommendation, low quality of evidence).

Data assessing the optimal treatment for nonsevere pediatric CDI are limited. Emerging data support the use of vancomycin,⁴ which is now recommended for initial episodes of CDI in adults. However, there are insufficient data to recommend vancomycin over metronidazole for nonsevere pediatric CDI; therefore, either option is recommended.

Recommendation 9. For children with an initial episode of severe CDI, oral vancomycin with or without IV metronidazole is recommended over metronidazole alone (strong recommendation, moderate quality of evidence).

Recommendation 10. For children with a second or greater episode of recurrent CDI, oral vancomycin is recommended over metronidazole (weak recommendation, low quality of evidence).

There is no well-designed trial comparing metronidazole and vancomycin for severe or recurrent pediatric CDI. For children previously treated with metronidazole, vancomycin is recommended based on adult literature.⁴ For children previously treated with metronidazole and vancomycin, an extended course of tapered or pulse regimen vancomycin or vancomycin followed by rifaximin is recommended.

Recommendations must weigh potential harms. Metronidazole has been associated with neuropathies,⁵ cramping, and nausea. PO vancomycin has poor enteral absorption, minimizing systemic effects. Both vancomycin and metronidazole may promote carriage of resistant enterococci.

Recommendation 11. Fecal microbiota transplantation (FMT) should be considered for pediatric patients with multiple recurrences of CDI following standard treatments (weak recommendation, very low quality of evidence).

There are no robust data examining the effectiveness of pediatric FMT. Recommendations are guided by adult studies. Limited evidence suggests that FMT can be effective in children with multiple recurrent CDI.⁶ Concerns include procedure-related risks, transmission of resistant organisms and blood-borne pathogens, and induced metabolic or immunologic disorders.

Methods in Preparing a Guideline

The strength of a guideline includes representation from a diverse panel, including the Infectious Diseases Society of America (IDSA), the Society for Healthcare Epidemiology of America, the American Society of Health-Systems Pharmacists, the Society of Infectious Diseases Pharmacists, and the Pediatric Infectious Diseases Society.

The panel utilized the Grading of Recommendations Assessment, Development, and Evaluation system to weigh the strength and quality of evidence.

From a pediatric perspective, the current guideline added pediatric-specific recommendations based on a comprehensive review of the literature from 1977 to 2016. The strength of these recommendations is somewhat limited by the lack of well-designed pediatric studies. An additional limitation is that treatment recommendations are based on illness severity, although the definitions used to classify severity are not pediatric-specific and are based on unvalidated expert opinion.

Sources of Potential Conflicts or Interest or Bias

The panel complied with the IDSA policy on conflicts of interest and disclosed any interest that might be construed as a conflict, regardless of relevancy. These were evaluated by the IDSA Standards and Practice Guidelines Committee.

Generalizability

Guideline generalizability may be impacted by testing availabilities within a particular setting. Cost factors and local formularies may also limit treatment options within a given setting.

Areas in Need of Future Study

Research gaps exist regarding at what age C. difficile is pathogenic given the prevalence of asymptomatic carriage. Future studies can also focus on a newly available molecular polymerase chain reaction test platform that detects C. difficile.⁷

There is limited pediatric evidence to recommend metronidazole versus vancomycin in children, particularly in nonsevere cases. There is also an opportunity to further explore alternative therapies, including fidaxomicin (not currently approved for children) and bezlotoxumab, a new agent approved as adult adjunctive therapy.⁸

Clostridium difficile (name changed to Clostridioides difficile [CDI]) are a major public health problem, with 500,000 infections annually in the United States, 15,000-30,000 associated deaths, and acute care costs exceeding $4.8 billion. The recent clinical practice guideline for CDI provides recommendations about the epidemiology, diagnosis, treatment, prevention, and environmental management. A total of 52 recommendations are included, and we will review 11 with pertinence to pediatrics in this highlight.

Recommendation 1. In infants ≤12 months of age, testing for CDI should never be routinely recommended because of the high prevalence of asymptomatic carriage of toxigenic C. difficile in infants (strong recommendation, moderate quality of evidence).

Recommendation 2. In children 1-2 years of age, testing should not be routinely performed unless other causes have been excluded (weak recommendation, low quality of evidence).Recommendation 3. In children ≥2 years of age, testing is recommended for patients with prolonged or worsening diarrhea and risk factors (eg, underlying inflammatory bowel disease) or immunocompromising conditions) or relevant exposures (eg, contact with the healthcare system or recent antibiotics) (weak recommendation, moderate quality of evidence).

The rate of C. difficile colonization among asymptomatic infants can exceed 40%. This rate declines over the first year but remains 15% at 12 months of age.¹ Therefore, the guideline recommends against routinely testing infants ≤12 months of age as a positive test probably reflects colonization rather than disease. Testing in infants is recommended only when other causes have been excluded and a concern for pseudomembranous colitis, toxic megacolon, or clinically significant diarrhea exists.

The rate of asymptomatic colonization remains elevated in the second year of life. By 2-3 years, the rate is 1%-3% which is similar to that in healthy adults. However, the role of C. difficile in community-onset diarrhea in otherwise healthy children is controversial. In a study of 100 hospitalized children aged <2 years with CDI and diarrhea, all had resolution of diarrhea regardless of whether therapy was administered.² Another study found an alternative pathogen in >50% of hospitalized children with CDI.³ Therefore, the guideline recommends against testing in children aged 1-2 years unless other causes have been excluded and in children aged >2 years only when they have prolonged or worsening diarrhea along with risk factors or exposures.

Recommendation 4. In institutions without specific required criteria for stool submissions, use a stool toxin test as part of a multistep algorithm (ie, glutamate dehydrogenase [GDH] plus toxin, GDH plus toxin arbitrated by nucleic-acid amplification tests [NAAT], or NAAT plus toxin) rather than a NAAT alone (weak recommendation, low quality of evidence).

Recommendation 5. In institutions with specific required criteria for stool submissions, use a NAAT alone or a multistep algorithm for testing (ie, GDH plus toxin, GDH plus toxin arbitrated by NAAT, or NAAT plus toxin) rather than a toxin test alone (weak recommendation, low quality of evidence).

There are a variety of testing approaches for CDI and recommendations vary based on local practice. If laboratories accept all stools, a more specific approach is recommended, including a toxin test as part of a multistep algorithm to limit false positives. If laboratories first screen for symptoms and antibiotic exposure before accepting stool samples, a more sensitive approach is recommended including NAAT alone or a multistep algorithm rather than toxin alone.

Infection Prevention and Control

Recommendation 6. There is insufficient evidence for discontinuation of PPIs (proton pump inhibitors) as a measure for preventing CDI (no recommendation).

The guideline acknowledges data suggesting an association between PPI use and CDI, but not a causal relationship. Due to the lack of high-quality evidence, it does not recommend stopping PPIs to prevent CDI.

Recommendation 7. There are insufficient data to recommend probiotics for primary prevention of CDI outside of clinical trials (no recommendation).

The guideline notes that although several meta-analyses indicate that probiotics may prevent CDI; however there were limitations, including a high incidence of CDI in placebo arms and differences in probiotic formulations and duration of use, leading to insufficient data to recommend probiotic use to prevent CDI.

Treatment

Recommendation 8. Either per os (PO) metronidazole or PO vancomycin is recommended for an initial episode or first recurrence of nonsevere pediatric CDI (weak recommendation, low quality of evidence).

Data assessing the optimal treatment for nonsevere pediatric CDI are limited. Emerging data support the use of vancomycin,⁴ which is now recommended for initial episodes of CDI in adults. However, there are insufficient data to recommend vancomycin over metronidazole for nonsevere pediatric CDI; therefore, either option is recommended.

Recommendation 9. For children with an initial episode of severe CDI, oral vancomycin with or without IV metronidazole is recommended over metronidazole alone (strong recommendation, moderate quality of evidence).

Recommendation 10. For children with a second or greater episode of recurrent CDI, oral vancomycin is recommended over metronidazole (weak recommendation, low quality of evidence).

There is no well-designed trial comparing metronidazole and vancomycin for severe or recurrent pediatric CDI. For children previously treated with metronidazole, vancomycin is recommended based on adult literature.⁴ For children previously treated with metronidazole and vancomycin, an extended course of tapered or pulse regimen vancomycin or vancomycin followed by rifaximin is recommended.

Recommendations must weigh potential harms. Metronidazole has been associated with neuropathies,⁵ cramping, and nausea. PO vancomycin has poor enteral absorption, minimizing systemic effects. Both vancomycin and metronidazole may promote carriage of resistant enterococci.

Recommendation 11. Fecal microbiota transplantation (FMT) should be considered for pediatric patients with multiple recurrences of CDI following standard treatments (weak recommendation, very low quality of evidence).

There are no robust data examining the effectiveness of pediatric FMT. Recommendations are guided by adult studies. Limited evidence suggests that FMT can be effective in children with multiple recurrent CDI.⁶ Concerns include procedure-related risks, transmission of resistant organisms and blood-borne pathogens, and induced metabolic or immunologic disorders.

Methods in Preparing a Guideline

The strength of a guideline includes representation from a diverse panel, including the Infectious Diseases Society of America (IDSA), the Society for Healthcare Epidemiology of America, the American Society of Health-Systems Pharmacists, the Society of Infectious Diseases Pharmacists, and the Pediatric Infectious Diseases Society.

The panel utilized the Grading of Recommendations Assessment, Development, and Evaluation system to weigh the strength and quality of evidence.

From a pediatric perspective, the current guideline added pediatric-specific recommendations based on a comprehensive review of the literature from 1977 to 2016. The strength of these recommendations is somewhat limited by the lack of well-designed pediatric studies. An additional limitation is that treatment recommendations are based on illness severity, although the definitions used to classify severity are not pediatric-specific and are based on unvalidated expert opinion.

Sources of Potential Conflicts or Interest or Bias

The panel complied with the IDSA policy on conflicts of interest and disclosed any interest that might be construed as a conflict, regardless of relevancy. These were evaluated by the IDSA Standards and Practice Guidelines Committee.

Generalizability

Guideline generalizability may be impacted by testing availabilities within a particular setting. Cost factors and local formularies may also limit treatment options within a given setting.

Areas in Need of Future Study

Research gaps exist regarding at what age C. difficile is pathogenic given the prevalence of asymptomatic carriage. Future studies can also focus on a newly available molecular polymerase chain reaction test platform that detects C. difficile.⁷

There is limited pediatric evidence to recommend metronidazole versus vancomycin in children, particularly in nonsevere cases. There is also an opportunity to further explore alternative therapies, including fidaxomicin (not currently approved for children) and bezlotoxumab, a new agent approved as adult adjunctive therapy.⁸

NASHVILLE, TENN. – Various instructional tools and techniques can help hospitalists teach medical learners at a variety of levels, according to experts who spoke at Pediatric Hospital Medicine 2017, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Session

Tools for Engaging Learners of All Levels: Multilevel Teaching Techniques & Cognitive Apprenticeship

Presenters

Session summary

Hospitalists are commonly charged with teaching learners at a variety of levels. There are various tools that can be used to accomplish this including multilevel teaching and cognitive apprenticeship.

Multilevel teaching is defined as teaching multiple levels of learners simultaneously. The goal is to maintain engagement without being boring or teaching over any learner’s head. Examples include:

1. Broadening: Change the case to make it more challenging or interesting such as asking what to do if the patient was a different age or had a comorbid condition.

2. Targeting: Target questions at specific team members depending on difficulty such as asking students common causes of bacterial meningitis and asking residents about admission criteria.

3. Novelty: Provide new data such as a recent journal article.

4. Up the Ladder: Ask the same question to all team members, starting with the most junior.

5. Student as Teacher: Ask a senior learner to teach a junior learner.

6. Multi-Answer: Seek multiple answers to one question such as asking each learner to contribute an item to a differential diagnosis.

7. No Right Answer: Ask questions that do not have a single correct answer such as how to approach a difficult conversation.

8. Teaching to the Top: Teach to the level of the most senior learner.

9. Extreme Challenge: Teach at a level above all learners on the team.

Laura Certain, MD, PhD, et al¹ found that most trainees feel Targeting, Up the Ladder, Student as Teacher, and Multi-Answer are most effective. No Right Answer, Teaching to the Top, and Extreme Challenge were felt to be least effective.

Another concept for engaging learners at all levels is cognitive apprenticeship, which is an instructional model whereby teachers make explicit their generally tacit cognitive processes. Examples include:

1. Modeling: Actively demonstrate skills such as performing a procedure while verbalizing the steps and thought processes.

2. Couching: Observe learners and provide feedback on their performance.

3. Scaffolding: Inquire about past experiences and provide opportunity for independent activities, while also providing help for activities that are difficult for learners.

4. Articulation: Ask learners to explain their thought processes.

5. Reflection: Prompt students to deliberately consider their strengths and weaknesses.

6. Exploration: Encourage students to set personal learning goals.

Coaching and articulation have been found to be more useful for novice learners. Reflection and exploration are more useful for advanced learners.

Key takeaways for Pediatric HM

• Multilevel teaching can be used to engage a variety of learners simultaneously. Targeting, Up the Ladder, Student as Teacher, and Multi-Answer are effective methods to achieve this goal.

• Cognitive apprenticeship can be used in clinical teaching to make a tacit cognitive process explicit. Methods such as coaching and articulation have been found to be more useful for novice learners. Reflection and exploration are more useful for advanced learners.

• Regardless of the method used, teachers should demonstrate interest in the learners’ education and treat them with respect.

Dr. Rogers is assistant professor of pediatrics and Section of Hospital Medicine associate program director, Pediatric Residency Program, at the Medical College of Wisconsin, Milwaukee.

References

1. Certain LK, Guarino AJ, Greenwald JL. Effective multilevel teaching techniques on attending rounds: a pilot survey and systematic review of the literature. Med Teach. 2011;33(12),e644-650. doi: 10.3109/0142159X.2011.610844.


 

NASHVILLE, TENN. – Various instructional tools and techniques can help hospitalists teach medical learners at a variety of levels, according to experts who spoke at Pediatric Hospital Medicine 2017, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Session

Tools for Engaging Learners of All Levels: Multilevel Teaching Techniques & Cognitive Apprenticeship

Presenters

Session summary

Hospitalists are commonly charged with teaching learners at a variety of levels. There are various tools that can be used to accomplish this including multilevel teaching and cognitive apprenticeship.

Multilevel teaching is defined as teaching multiple levels of learners simultaneously. The goal is to maintain engagement without being boring or teaching over any learner’s head. Examples include:

1. Broadening: Change the case to make it more challenging or interesting such as asking what to do if the patient was a different age or had a comorbid condition.

2. Targeting: Target questions at specific team members depending on difficulty such as asking students common causes of bacterial meningitis and asking residents about admission criteria.

3. Novelty: Provide new data such as a recent journal article.

4. Up the Ladder: Ask the same question to all team members, starting with the most junior.

5. Student as Teacher: Ask a senior learner to teach a junior learner.

6. Multi-Answer: Seek multiple answers to one question such as asking each learner to contribute an item to a differential diagnosis.

7. No Right Answer: Ask questions that do not have a single correct answer such as how to approach a difficult conversation.

8. Teaching to the Top: Teach to the level of the most senior learner.

9. Extreme Challenge: Teach at a level above all learners on the team.

Laura Certain, MD, PhD, et al¹ found that most trainees feel Targeting, Up the Ladder, Student as Teacher, and Multi-Answer are most effective. No Right Answer, Teaching to the Top, and Extreme Challenge were felt to be least effective.

Another concept for engaging learners at all levels is cognitive apprenticeship, which is an instructional model whereby teachers make explicit their generally tacit cognitive processes. Examples include:

1. Modeling: Actively demonstrate skills such as performing a procedure while verbalizing the steps and thought processes.

2. Couching: Observe learners and provide feedback on their performance.

3. Scaffolding: Inquire about past experiences and provide opportunity for independent activities, while also providing help for activities that are difficult for learners.

4. Articulation: Ask learners to explain their thought processes.

5. Reflection: Prompt students to deliberately consider their strengths and weaknesses.

6. Exploration: Encourage students to set personal learning goals.

Coaching and articulation have been found to be more useful for novice learners. Reflection and exploration are more useful for advanced learners.

Key takeaways for Pediatric HM

• Multilevel teaching can be used to engage a variety of learners simultaneously. Targeting, Up the Ladder, Student as Teacher, and Multi-Answer are effective methods to achieve this goal.

• Cognitive apprenticeship can be used in clinical teaching to make a tacit cognitive process explicit. Methods such as coaching and articulation have been found to be more useful for novice learners. Reflection and exploration are more useful for advanced learners.

• Regardless of the method used, teachers should demonstrate interest in the learners’ education and treat them with respect.

Dr. Rogers is assistant professor of pediatrics and Section of Hospital Medicine associate program director, Pediatric Residency Program, at the Medical College of Wisconsin, Milwaukee.

References

1. Certain LK, Guarino AJ, Greenwald JL. Effective multilevel teaching techniques on attending rounds: a pilot survey and systematic review of the literature. Med Teach. 2011;33(12),e644-650. doi: 10.3109/0142159X.2011.610844.


 

NASHVILLE, TENN. – Various instructional tools and techniques can help hospitalists teach medical learners at a variety of levels, according to experts who spoke at Pediatric Hospital Medicine 2017, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Session

Tools for Engaging Learners of All Levels: Multilevel Teaching Techniques & Cognitive Apprenticeship

Presenters

Session summary

Hospitalists are commonly charged with teaching learners at a variety of levels. There are various tools that can be used to accomplish this including multilevel teaching and cognitive apprenticeship.

Multilevel teaching is defined as teaching multiple levels of learners simultaneously. The goal is to maintain engagement without being boring or teaching over any learner’s head. Examples include:

1. Broadening: Change the case to make it more challenging or interesting such as asking what to do if the patient was a different age or had a comorbid condition.

2. Targeting: Target questions at specific team members depending on difficulty such as asking students common causes of bacterial meningitis and asking residents about admission criteria.

3. Novelty: Provide new data such as a recent journal article.

4. Up the Ladder: Ask the same question to all team members, starting with the most junior.

5. Student as Teacher: Ask a senior learner to teach a junior learner.

6. Multi-Answer: Seek multiple answers to one question such as asking each learner to contribute an item to a differential diagnosis.

7. No Right Answer: Ask questions that do not have a single correct answer such as how to approach a difficult conversation.

8. Teaching to the Top: Teach to the level of the most senior learner.

9. Extreme Challenge: Teach at a level above all learners on the team.

Laura Certain, MD, PhD, et al¹ found that most trainees feel Targeting, Up the Ladder, Student as Teacher, and Multi-Answer are most effective. No Right Answer, Teaching to the Top, and Extreme Challenge were felt to be least effective.

Another concept for engaging learners at all levels is cognitive apprenticeship, which is an instructional model whereby teachers make explicit their generally tacit cognitive processes. Examples include:

1. Modeling: Actively demonstrate skills such as performing a procedure while verbalizing the steps and thought processes.

2. Couching: Observe learners and provide feedback on their performance.

3. Scaffolding: Inquire about past experiences and provide opportunity for independent activities, while also providing help for activities that are difficult for learners.

4. Articulation: Ask learners to explain their thought processes.

5. Reflection: Prompt students to deliberately consider their strengths and weaknesses.

6. Exploration: Encourage students to set personal learning goals.

Coaching and articulation have been found to be more useful for novice learners. Reflection and exploration are more useful for advanced learners.

Key takeaways for Pediatric HM

• Multilevel teaching can be used to engage a variety of learners simultaneously. Targeting, Up the Ladder, Student as Teacher, and Multi-Answer are effective methods to achieve this goal.

• Cognitive apprenticeship can be used in clinical teaching to make a tacit cognitive process explicit. Methods such as coaching and articulation have been found to be more useful for novice learners. Reflection and exploration are more useful for advanced learners.

• Regardless of the method used, teachers should demonstrate interest in the learners’ education and treat them with respect.

Dr. Rogers is assistant professor of pediatrics and Section of Hospital Medicine associate program director, Pediatric Residency Program, at the Medical College of Wisconsin, Milwaukee.

References

1. Certain LK, Guarino AJ, Greenwald JL. Effective multilevel teaching techniques on attending rounds: a pilot survey and systematic review of the literature. Med Teach. 2011;33(12),e644-650. doi: 10.3109/0142159X.2011.610844.


 

Summary:

Presenters of the PHM15 session "Evidence Based Diagnostic Evaluation of Infants Presenting with an Apparent Life Threatening Event" discussed four main diagnostic categories for ALTEs: cardiac, infectious, non-accidental trauma/neurologic, and gastrointestinal. They reviewed the incidence of each of these diagnoses in infants presenting with ALTE, discussed the utility of various diagnostic modalities, and suggested elements of the history and physical that might make those etiologies higher on the differential.

The evidence shows a 0%-2% rate of cardiac disease in infants presenting with ALTE. Given low sensitivity and low specificity for echocardiograms in these patients, the presenters did not recommend routine echocardiograms in all patients. Given high sensitivity and low specificity for EKGs, they suggested EKGs could be considered to help exclude cardiac etiologies, but cautioned that the high false positive rate could lead to additional unnecessary testing. They did not find a high association between most historical facts and an increased likelihood of cardiac etiologies in patients presenting with an ALTE.

Infectious etiologies discussed included bacteremia (0%-2.5%), UTI (0%-7.7%), meningitis (0%-1.2%) and pertussis (0.6%-9.2%), with rates in ALTE as noted.

Again, the literature does not support the use of routine testing for these diagnoses unless there are suggestive clinical findings. Findings that might warrant further infectious investigations:

• Multiple events,
• Prematurity,
• Fever/hypothermia,
• Toxic appearance,
• Altered mental status, or
• Clinical signs of pertussis.

From their literature review, the speakers found a 1.4%-3.7% rate of non-accidental trauma in infants presenting with an ALTE. They did not feel there was sufficient evidence to support skeletal surveys or dilated ophthalmologic exams as part of a standard ALTE workup. Historical clues that might lead the provider to consider NAT include recurrent events, a history of SIDS or ALTE in siblings, delay in seeking care or a confusing history. Suggestive physical exam findings included blood in the nose/mouth, abnormal neurological exam, ear bruising, oral injuries, or bruising in a non-mobile child.

Regarding GE reflux, the presenters discussed the difficulty in identifying the incidence since temporal association does not necessarily equate with causation. They did not recommend routine testing for GER or acid suppression in low risk patients, but said patients could be counseled on various behavioral interventions such as avoiding tobacco and overfeeding, providing frequent burping and upright positioning and exclusive breastfeeding.

Finally, the speakers discussed the upcoming practice guideline for the management of patients with ALTE. They reviewed the proposed change in nomenclature, with the transition to "BRUE" (brief resolved unexplained event), as well as a new algorithm for the evaluation of low-risk patients. The new guidelines currently are being reviewed, with plans to be published and available for general dissemination within the next 12 months. TH

Amanda Rogers, MD, is a hospitalist and assistant professor in the Department of Pediatrics, Section of Hospital Medicine, at the Medical College of Wisconsin in Milwaukee.

Summary:

Presenters of the PHM15 session "Evidence Based Diagnostic Evaluation of Infants Presenting with an Apparent Life Threatening Event" discussed four main diagnostic categories for ALTEs: cardiac, infectious, non-accidental trauma/neurologic, and gastrointestinal. They reviewed the incidence of each of these diagnoses in infants presenting with ALTE, discussed the utility of various diagnostic modalities, and suggested elements of the history and physical that might make those etiologies higher on the differential.

The evidence shows a 0%-2% rate of cardiac disease in infants presenting with ALTE. Given low sensitivity and low specificity for echocardiograms in these patients, the presenters did not recommend routine echocardiograms in all patients. Given high sensitivity and low specificity for EKGs, they suggested EKGs could be considered to help exclude cardiac etiologies, but cautioned that the high false positive rate could lead to additional unnecessary testing. They did not find a high association between most historical facts and an increased likelihood of cardiac etiologies in patients presenting with an ALTE.

Infectious etiologies discussed included bacteremia (0%-2.5%), UTI (0%-7.7%), meningitis (0%-1.2%) and pertussis (0.6%-9.2%), with rates in ALTE as noted.

Again, the literature does not support the use of routine testing for these diagnoses unless there are suggestive clinical findings. Findings that might warrant further infectious investigations:

• Multiple events,
• Prematurity,
• Fever/hypothermia,
• Toxic appearance,
• Altered mental status, or
• Clinical signs of pertussis.

From their literature review, the speakers found a 1.4%-3.7% rate of non-accidental trauma in infants presenting with an ALTE. They did not feel there was sufficient evidence to support skeletal surveys or dilated ophthalmologic exams as part of a standard ALTE workup. Historical clues that might lead the provider to consider NAT include recurrent events, a history of SIDS or ALTE in siblings, delay in seeking care or a confusing history. Suggestive physical exam findings included blood in the nose/mouth, abnormal neurological exam, ear bruising, oral injuries, or bruising in a non-mobile child.

Regarding GE reflux, the presenters discussed the difficulty in identifying the incidence since temporal association does not necessarily equate with causation. They did not recommend routine testing for GER or acid suppression in low risk patients, but said patients could be counseled on various behavioral interventions such as avoiding tobacco and overfeeding, providing frequent burping and upright positioning and exclusive breastfeeding.

Finally, the speakers discussed the upcoming practice guideline for the management of patients with ALTE. They reviewed the proposed change in nomenclature, with the transition to "BRUE" (brief resolved unexplained event), as well as a new algorithm for the evaluation of low-risk patients. The new guidelines currently are being reviewed, with plans to be published and available for general dissemination within the next 12 months. TH

Amanda Rogers, MD, is a hospitalist and assistant professor in the Department of Pediatrics, Section of Hospital Medicine, at the Medical College of Wisconsin in Milwaukee.

Summary:

Presenters of the PHM15 session "Evidence Based Diagnostic Evaluation of Infants Presenting with an Apparent Life Threatening Event" discussed four main diagnostic categories for ALTEs: cardiac, infectious, non-accidental trauma/neurologic, and gastrointestinal. They reviewed the incidence of each of these diagnoses in infants presenting with ALTE, discussed the utility of various diagnostic modalities, and suggested elements of the history and physical that might make those etiologies higher on the differential.

The evidence shows a 0%-2% rate of cardiac disease in infants presenting with ALTE. Given low sensitivity and low specificity for echocardiograms in these patients, the presenters did not recommend routine echocardiograms in all patients. Given high sensitivity and low specificity for EKGs, they suggested EKGs could be considered to help exclude cardiac etiologies, but cautioned that the high false positive rate could lead to additional unnecessary testing. They did not find a high association between most historical facts and an increased likelihood of cardiac etiologies in patients presenting with an ALTE.

Infectious etiologies discussed included bacteremia (0%-2.5%), UTI (0%-7.7%), meningitis (0%-1.2%) and pertussis (0.6%-9.2%), with rates in ALTE as noted.

Again, the literature does not support the use of routine testing for these diagnoses unless there are suggestive clinical findings. Findings that might warrant further infectious investigations:

• Multiple events,
• Prematurity,
• Fever/hypothermia,
• Toxic appearance,
• Altered mental status, or
• Clinical signs of pertussis.

From their literature review, the speakers found a 1.4%-3.7% rate of non-accidental trauma in infants presenting with an ALTE. They did not feel there was sufficient evidence to support skeletal surveys or dilated ophthalmologic exams as part of a standard ALTE workup. Historical clues that might lead the provider to consider NAT include recurrent events, a history of SIDS or ALTE in siblings, delay in seeking care or a confusing history. Suggestive physical exam findings included blood in the nose/mouth, abnormal neurological exam, ear bruising, oral injuries, or bruising in a non-mobile child.

Regarding GE reflux, the presenters discussed the difficulty in identifying the incidence since temporal association does not necessarily equate with causation. They did not recommend routine testing for GER or acid suppression in low risk patients, but said patients could be counseled on various behavioral interventions such as avoiding tobacco and overfeeding, providing frequent burping and upright positioning and exclusive breastfeeding.

Finally, the speakers discussed the upcoming practice guideline for the management of patients with ALTE. They reviewed the proposed change in nomenclature, with the transition to "BRUE" (brief resolved unexplained event), as well as a new algorithm for the evaluation of low-risk patients. The new guidelines currently are being reviewed, with plans to be published and available for general dissemination within the next 12 months. TH

Amanda Rogers, MD, is a hospitalist and assistant professor in the Department of Pediatrics, Section of Hospital Medicine, at the Medical College of Wisconsin in Milwaukee.