for the Febrile Infant Working Group of the Pediatric Emergency Care Applied Research Network (PECARN) IMPORTANCE In young febrile infants, serious bacterial infections (SBIs), including urinary tract infections, bacteremia, and meningitis, may lead to dangerous complications. However, lumbar punctures and hospitalizations involve risks and costs. Clinical prediction rules using biomarkers beyond the white blood cell count (WBC) may accurately identify febrile infants at low risk for SBIs.OBJECTIVE To derive and validate a prediction rule to identify febrile infants 60 days and younger at low risk for SBIs. DESIGN, SETTING, AND PARTICIPANTS Prospective, observational study between March 2011 and May 2013 at 26 emergency departments. Convenience sample of previously healthy febrile infants 60 days and younger who were evaluated for SBIs. Data were analyzed between April 2014 and April 2018.EXPOSURES Clinical and laboratory data (blood and urine) including patient demographics, fever height and duration, clinical appearance, WBC, absolute neutrophil count (ANC), serum procalcitonin, and urinalysis. We derived and validated a prediction rule based on these variables using binary recursive partitioning analysis. MAIN OUTCOMES AND MEASURESSerious bacterial infection, defined as urinary tract infection, bacteremia, or bacterial meningitis. RESULTSWe derived the prediction rule on a random sample of 908 infants and validated it on 913 infants (mean age was 36 days, 765 were girls [42%], 781 were white and non-Hispanic [43%], 366 were black [20%], and 535 were Hispanic [29%]). Serious bacterial infections were present in 170 of 1821 infants (9.3%), including 26 (1.4%) with bacteremia, 151 (8.3%) with urinary tract infections, and 10 (0.5%) with bacterial meningitis; 16 (0.9%) had concurrent SBIs. The prediction rule identified infants at low risk of SBI using a negative urinalysis result, an ANC of 4090/μL or less (to convert to ×10 9 per liter, multiply by 0.001), and serum procalcitonin of 1.71 ng/mL or less. In the validation cohort, the rule sensitivity was 97.7% (95% CI, 91.3-99.6), specificity was 60.0% (95% CI, 56.6-63.3), negative predictive value was 99.6% (95% CI, 98.4-99.9), and negative likelihood ratio was 0.04 (95% CI, 0.01-0.15). One infant with bacteremia and 2 infants with urinary tract infections were misclassified. No patients with bacterial meningitis were missed by the rule. The rule performance was nearly identical when the outcome was restricted to bacteremia and/or bacterial meningitis, missing the same infant with bacteremia. CONCLUSIONS AND RELEVANCEWe derived and validated an accurate prediction rule to identify febrile infants 60 days and younger at low risk for SBIs using the urinalysis, ANC, and procalcitonin levels. Once further validated on an independent cohort, clinical application of the rule has the potential to decrease unnecessary lumbar punctures, antibiotic administration, and hospitalizations.

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Initial research supports the use of propranolol to prevent posttraumatic stress disorder (PTSD); research has not examined pharmacological prevention for children. Twenty-nine injury patients (ages 10-18 years old) at risk for PTSD were randomized to a double-blind 10-day trial of propranolol or placebo initiated within 12 hours post admission. Six-week PTSD symptoms and heart rate were assessed. Although intent-to-treat analyses revealed no group differences, findings supported a significant interaction between gender and treatment in medication-adherent participants, ΔR 2 = .21. Whereas girls receiving propranolol reported more PTSD symptoms relative to girls receiving placebo, ΔR 2 = .44, boys receiving propranolol showed a nonsignificant trend toward fewer PTSD symptoms than boys receiving placebo, ΔR 2 = .32. Findings inform gender differences regarding pharmacological PTSD prevention in youth. Keywords PTSD; pediatric trauma; propranololThe Efficacy of Early Propranolol Administration at Reducing PTSD Symptoms in Pediatric Injury Patients: A Pilot Study To date, no randomized controlled trials have examined the efficacy of pharmacologic agents administered shortly posttrauma in the prevention of posttraumatic stress disorder (PTSD) in youth. One promising candidate, propranolol, is a centrally-acting beta-blocker that has been found to block the memory-enhancing effects of emotional arousal (Cahill et al. 1994). Pitman and colleagues (2002) tested propranolol as a secondary intervention for the prevention of PTSD in adults. Following a 10-day medication regimen, 30% (6 out of 20) of placebo recipients as compared with 10% (1 out of 10) of propranolol recipients met PTSD criteria one month post-trauma. Three months post-trauma, Method ParticipantsParticipants included 29 pediatric trauma emergency department patients (see Table 1). Eligibility criteria included a Glasgow Coma Scale score of 14 or greater and an "at-risk" child score on a screen for risk of PTSD. Medication-specific exclusion criteria included hypersensitivity to beta-blockers, bradycardia; cardiogenic or hypovolemic shock, diabetes, preexisting heart condition, or treatment for asthma (Lacy et al., 2002). Children were also excluded if their injuries or medical treatment procedures contraindicated propranolol. Figure 1 summarizes recruitment and retention. MeasuresHeart rate and blood pressure were recorded with an automated blood pressure cuff ( Parents completed a medication log. Six participants were judged to show poor adherence (> 1 missed dose or > 4 incidents of poor time adherence). Adequate adherence was equally prevalent in propranolol (n = 9) and placebo (n = 11) groups.Posttraumatic stress disorder symptom severity and diagnosis were determined via the Clinician Administered PTSD Scale for Children and Adolescents (Nader et al., 1996). The CAPS-CA has demonstrated adequate psychometric properties (Nader et al., 1996; Carrion et al., 2002;Newman & Ribbe, 1996). Each symptom is scored for frequency and intensity. Sympto...

Children made up a small part of EMS providers' clinical practice; those encountered most frequently had respiratory distress, seizures, trauma, or an undefined assessment (i.e., "other"). EMS providers frequently encounter children with physiologic evidence of acute illness, although vital sign documentation was incomplete. Prehospital providers infrequently perform pediatric interventions. Describing EMS providers' interaction with children provides the opportunity to target improvements in pediatric prehospital treatment, training, and research.

Febrile infants ≤60 days of age with viral infections are at significantly lower, but non-negligible risk for SBIs, including bacteremia and bacterial meningitis.