Reviews of pediatric research

October 1, 2007

Pediatric hypertension * Procalcitonin and C-reactive protein * Newborn hearing tests * Total parenteral nutrition

Procalcitonin and C-reactive protein are markers of severe bacterial infection in febrile children

A prospective observational study conducted in 408 children admitted to a tertiary care emergency department of a children's hospital in Italy showed that levels of both procalcitonin (PCT) and C-reactive protein (CRP) are valuable markers in predicting severe bacterial infections (SBIs) in children with fever without a source. Further, PCT and CRP performed better than traditional markers: total white-blood cell count (WBC) and absolute neutrophil count (ANC).

The children were almost equally divided by gender, and half were hospitalized. Median age was 10 months and ranged from 7 days to 36 months. Following extensive clinical and diagnostic evaluations, SBI (bacteremia, acute pyelonephritis, lobar pneumonia, bacterial meningitis, bone or joint infections, or sepsis) was diagnosed in 94 (23.1%) of the children; 314 children were judged non-SBI. The SBI and non-SBI groups were similar in sex, median age, and duration of fever before admission. But body temperature and Yale Observation Score were significantly higher in the SBI group than in the non-SBI group, as were levels of PCT, CRP, WBC, and ANC.

Commentary:

Add this article to a growing list that suggest screening with procalcitonin and/or C-reactive protein to identify children with bacterial infection. I am looking forward to wider availability of procalcitonin testing. It seems as if this is overdue.

Clinicians frequently miss hypertension

A review of the electronic health records of more than 14,000 children from 3 to 18 years of age shows that clinicians frequently failed to diagnose hypertension and prehypertension. Children in the study group had at least three well-child visits in the outpatient clinics of a large academic urban medical system. They were seen by a variety of pediatric clinicians, including family practitioners, pediatricians (general pediatricians and combined internists and pediatricians) and a few nurse practitioners.

Although 507 children (3.6%) met criteria for hypertension, the electronic medical record of only 131 (26%) of those 507 showed a diagnosis of hypertension or of elevated blood pressure. Hence, the rest of the 507 hypertensive children-376 or 74%-had undiagnosed hypertension. In 51 of the 131 medical records where the diagnosis was documented, the problem was recorded as elevated blood pressure without hypertension rather than the correct diagnosis, hypertension. Therefore, only the other 80 of the 131 children, or 15.8% of the 507 children who met criteria for hypertension, had a true hypertension diagnosis in the electronic medical record. In addition, 17 of the 507 children (3%) with hypertension had stage 2 hypertension, yet the electronic health record of only 10 of these 17 (59%) showed elevated blood pressure or a hypertension-related diagnosis. Seven of these 17 hypertensive children therefore had undiagnosed stage 2 hypertension.

Several patient factors were associated with increased likelihood that clinicians would recognize hypertension or prehypertension. Specifically, abnormal blood pressure was more likely to be identified in older and taller children. Presence of an obesity-related diagnosis also increased the odds of diagnosis. Finally, magnitude and frequency of abnormal blood pressure readings raised the odds of diagnosis. A positive family history of hypertension did not augment the likelihood that abnormal blood pressure would be recognized, however (Hansen ML et al: JAMA 2007;298:874).

Commentary:

Definitions used here were based on a consensus statement published in Pediatrics in 2004 (114:555). Hypertension is blood pressure at or above the 95th percentile for age, sex, and height, on three different visits. Prehypertension requires three measurements at greater than the 90th but lower than the 95th percentile. And stage 2 hypertension requires measurements that are greater than the 99th percentile, plus 5 mm Hg.