Outpatient Children Research Articles

Causes of fever in outpatient Tanzanian children.

Causes of fever in outpatient Tanzanian children.

Causes of fever in outpatient Tanzanian children.

To the Editor: As physicians working in the only public emergency department in Tanzania, we are acutely aware of the need for better data to guide management of febrile illness in children, as described by D’Acremont et al. (Feb. 27 issue).1 However, we question the suggestion that it is safe to send febrile children home without antimicrobial treatment. In this study, 22% of febrile children had bacterial infections, and 10.5% had malaria. Since Tanzania has limited pediatric health care capabilities, follow-up cannot be ensured, and delayed treatment can lead to severe morbidity and mortality. In addition, in the studies that the authors cite to support the withholding of antimalarial drugs, investigators used rapid diagnostic testing,2-4 which is often unavailable. In the studies that they cite to support the withholding of antibiotics, the children had respiratory symptoms,4,5 not nonspecific febrile illness. Furthermore, since most medications are available without prescription, children often receive antimicrobial drugs before they arrive at a health center; the exclusion of children with previous treatment further limits generalizability. At this time, we would hesitate to support changing clinical practice. Hendry R. Sawe, M.D.

Surveillance of norovirus-associated diarrhea in children in Shanghai, 2009-2011

To monitor the epidemiology of norovirus infection in diarrheal children in Shanghai between 2009 and 2011 and characterize the genotypes of norovirus strains. The stool samples were collected from children visiting outpatient clinic for acute non-dysenteric diarrhea between 2009 and 2011.One step real-time RT-PCR was used for screening norovirus genogroups GI and GII. The genotypes of norovirus genogroup GII were classified based on the nucleotide sequences of both partial capsid and polymerase fragments. A total of 2 288 outpatient children with acute diarrhea were included in this study, out of whom, 531 (23.1%) were positive for norovirus in the fecal specimens based on real-time RT-PCR test.Norovirus was prevalent throughout the year and an increased activity of norovirus infection was usually observed between July and October. Children <4 years of age accounted for 95.2% of norovirus-infected cases, and the detection rate of norovirus was significantly higher in diarrheal children <4 years than in those ≥ 4 years (24.4% vs. 10.7%,χ(2) = 10.66, P < 0.05).Of 531 norovirus-positive specimens, 4 (1.7%) were positive for genogroup GI and 527 (98.3%) positive for genogroup GII. Seven distinct capsid genotypes were identified in 234 norovirus strains, including 153 (64.4%) GII.4 (9 belonging to 2010 variants and 145 belonging to 2006b variants), 66 (27.6%) GII.3, 7 (2.9%) GII.2, 6 (2.5%) GII.6, 4 (1.7%) GII.12, 1 (0.4%) GII.7 and GII.14 in each. Seven polymerase genotypes were identified in 244 norovirus strains, including 189 (77.5%) GII.4 (14 belonging to 2010 variants and 175 belonging to 2006b variants), 47 (19.3%) GII.12, 2 (0.8%) GII.16, GII.b and GII.g in each, 1 (0.4%) GII.2 and GII.6 in each. A new GII.4-2010 (New Orleans) variant was first detected in June 2010 and sporadically circulated afterwards.Of 198 norovirus strains in which both polymerase and capsid genotypes were determined, 56 showed discordant results, indicating potential norovirus recombinants. The common discordant combinations of the polymerase and capsid genotypes were GII.12/GII.3 (69.6%) and GII.4/GII.3 (8.9%). Norovirus is a common causative agent responsible for diarrhea in Shanghai children over the three years and norovirus-associated diarrhea was epidemic year round with high activity in late summer and autumn in Shanghai.Infants and young children are susceptible to norovirus infection. The circulating norovirus showed genetic diversity. The GII.4-2006b variant continued to predominate in Shanghai during the period of 2009-2011 despite the emergence of the novel GII.4-2010 (New Orleans) variant.

A Comparison Between Comprehensive System and an Early Version of the Rorschach Performance Assessment System Administration With Outpatient Children and Adolescents

For many years, the effects of variability in the length of Rorschach records has been debated, and a new administration procedure aimed at reducing the proportion of short and long records has recently been introduced. Using an outpatient sample of children and adolescents, this study explored the impact of an early version of the Rorschach Performance Assessment System (R–PAS) administration, on the central tendencies of Rorschach variables. Specifically, the mean values of 51 variables in 142 Comprehensive System versus 99 R–PAS collected records were compared with each other. Results found comparable mean values across CS and R–PAS administration methods for the variables that guide interpretation with children and adolescents. Both methods produced a comparable number of long (> 27 responses) records. The only relevant difference that emerged is that the early R–PAS administration version yielded significantly fewer short (14–16 responses) records and lower variability in the number of responses.

Urinary tract infection in small outpatient children: the influence of age and gender on resistance to oral antimicrobials

Urinary tract infection (UTI) is a common bacterial disease in small children in which treatment with antimicrobials is used. The worldwide increase of bacterial resistance to these drugs is threatening the efficacy of such treatment and may increase the risk for long-term damage. The aim of this retrospective study was to analyse the development of resistance to oral antimicrobials over a 10-year period in an unselected outpatient population of small children with first-time UTI. The patient material included 494 boys and 512 girls below 2years of age with community acquired symptomatic UTI. Escherichia coli bacteria were isolated in 96% of girls and 89% of boys (p < 0.0001). The overall resistance of E. coli was 14% to trimethoprim and below 1% to cefadroxil and nitrofurantoin. Over the 10-year period, the trimethoprim resistance of E. coli increased from 5 to 17% but remained unchanged to cefadroxil and nitrofurantoin. E. coli resistance to trimethoprim was related to age: 11% below and 19% above 9months (p < 0.01). The increase in resistance over time and with age was found only in girls. The increasing resistance of E. coli to trimethoprim makes this drug less suitable for empiric treatment of UTI. Young children with UTI seem predisposed to early development of resistance. Therefore, surveillance of resistance to antimicrobials with special regard to age and gender is recommended.

Leukocyte populations and C-reactive protein as predictors of bacterial infections in febrile outpatient children.

Objective: Infections remain the major cause of unnecessary antibiotic use in pediatric outpatient settings. Complete blood count (CBC) is the essential test in the diagnosis of infections. C-reactive protein (CRP) is also useful for assessment of young children with serious bacterial infections. The purpose of the study was to evaluate leukocyte populations and CRP level to predict bacterial infections in febrile outpatient children.Materials and Methods: The values of CBC by Cell-DYN 4000 autoanalyzer and serum CRP levels were evaluated in 120 febrile patients with documented infections (n:74 bacterial, n:46 viral) and 22 healthy controls. Results: The mean CRP, neutrophil and immature granulocyte (IG) values were significantly higher in bacterial infections than in viral infections and controls (p<0.05). C-reactive protein was significantly correlated with neutrophil level in bacterial infections (r: 0.76, p<0.05). Specificity of IG was greatest at 93%, only a modest 56% for neutrophil and mild 18% for CRP, whereas 100% for combination of IG, neutrophil and CRP. Conclusion: Acute bacterial infection seems to be very unlikely in children with normal leukocyte populations and CRP values, even if clinically signs and symptoms indicate acute bacterial infections.

Effectiveness of Nebulized Beclomethasone in Preventing Viral Wheezing: An RCT

The goal of this study was to evaluate the effectiveness of nebulized beclomethasone in preventing the recurrence of viral wheezing. The study was designed as a randomized, double-blind, placebo-controlled trial. Outpatient children aged 1 to 5 years with at least 1 episode of viral wheezing in the last 12 months, presenting to any of 40 Italian pediatricians for an upper respiratory tract infection, were randomly allocated to receive beclomethasone 400 μg or placebo twice daily for 10 days. Medications were administered through a nebulizer. A clinical evaluation was performed by the pediatrician at the start and end of the treatment period. A subjective evaluation of symptoms and efficacy of treatment was performed by the parents. The primary endpoint was the incidence of viral wheezing diagnosed by the pediatricians during the 10-day treatment period. A total of 525 children were enrolled in the study, 521 of whom were visited at the end of the treatment period. Wheezing was diagnosed by the pediatricians in 47 children (9.0% [95% confidence interval: 6.7 to 11.3]), with no statistically significant differences between treatment groups (beclomethasone versus placebo relative risk: 0.61 [95% confidence interval: 0.35 to 1.08]).The treatment was considered helpful by 63% of parents (64% in the beclomethasone group vs 61% in the placebo group). In all, 46% of children still had infection symptoms at the end of the treatment period, with no differences between groups. The findings from this study confirm that inhaled steroids are not effective in preventing recurrence of viral wheezing. Moreover, no benefits were found in reducing symptoms of respiratory tract infections.

PD48 ‐ Relationship between Second Hand Smoke (SHS) exposure and atopy in social disadvantaged asthmatic children

The evidence of a relationship between second hand smoke (SHS) exposure and atopy is inadequate. Smoke habit prevalence is higher in lower parental educational levels. The aim of this study was to investigate the relationship between SHS and atopy in asthmatic children focusing on socioeconomic status (SES). We studied 170 outpatient asthmatic children with different levels of asthma (GINA guidelines). Medical history was taken in standardized way to determine prevalence of SHS exposure and maternal smoking during pregnancy. Information about the highest level of parental education was collected as a proxy of SES level. All patients underwent skin prick test (SPT) and spirometry according to international guidelines. Statistical analyses were performed using SPSS 19. 78 (45,9%) SHS exposed (SHSe) and 92 (54,1%) SHS non exposed (SHSne) asthmatic children were analyzed, aged 8.71±2.58 and 8.75±2.95, respectively. Exposure to maternal smoke in pregnancy was found only in SHSe (p <0.0001). With regard to SHSne, SHSe showed higher Body Mass Index (BMI) (19.50±4.17 vs 18.14±4.41, p <0.0044), higher percentage of the lower level of parental education (26.9% vs 13%, p <0.025). Moreover, SHSe showed a higher percentage of current exposure to pet (29.5% vs 16.3%, p <0.044) and at least one positive SPT, mainly indoor allergens (1.89 ±1.50 vs 1.45±1.39, p <0.062). No differences were found in pulmonary function tests (PFTs) and level of asthma even if SHSe showed more exacerbations than SHSne (3.19 ±4.23 vs 1.73±2.33, p <0.067). Exposure to SHS in children is associated with disadvantaged SES level and atopy.

Nasal Carriage of Multi-Drug Resistant Panton-Valentine Leucocidin-Positive Methicillin-Resistant Staphylococcus aureus in Children in Tripoli-Libya

Methicillin-resistant Staphylococcus aureus (MRSA) colonized children are at an increased risk of developing infections than methicillin-sensitive S. aureus colonized children. Nasal specimens from inpatient children, mothers of inpatient children, healthcare workers, and outpatient children at Tripoli Children Hospital (TCH) were examined for MRSA by chromogenic MRSA ID medium. Susceptibility of MRSA isolates to antibiotics was determined by the disc diffusion method. The nasal carriage rate of MRSA among inpatient children (8.3%, 24 of 289), their mothers (11%, 22 of 200), and healthcare workers (12.4%, 22 of 178) was significantly higher than among outpatient children (2.2%, 2 of 91) (P < 0.05, P < 0.02, and P < 0.006, respectively). Of the examined MRSA isolates (N = 35) 10 (28.6%) were positive for Panton-Valentine leucocidin genes by polymerase chain reaction. Multidrug resistance was found in 24.3% (17 of 70) of MRSA isolates. Nasal carriage of multidrug-resistant Panton-Valentine leucocidin-positive MRSA is not uncommon among inpatient children and their mothers in Tripoli.

Relationship between Serum C-reactive Protein Levels and Severity of Plasmodium falciparum Malaria in Children Seen in South-South Nigeria

Aim: To determine the relationship between serum C-reactive protein levels and severity of malaria infection in children aged six months to five years in a malaria endemic setting. Study Design: A prospective cross-sectional study. Place and Duration of Study: This study was carried out in the Children Out-patient (CHOP) Clinic, Children Emergency Unit (CHEU), Child Welfare/Growth Monitoring Clinic, Immunization Centre and main Paediatric Ward of the University of Uyo Teaching Hospital (UUTH), Uyo in Akwa-Ibom State. It was conducted over a six month period. Methodology: We studied three hundred and sixty (360) children with microscopically confirmed Plasmodium falciparum malaria and three hundred and sixty (360) healthy controls matched for age and gender. Their serum C-reactive protein levels were measured using the highly sensitive Enzyme Linked Immunosorbent assay (ELISA). Data analysis was done using the Statistical Package for Social Sciences (SPSS) version 17.0. Original Research Article International Journal of TROPICAL DISEASE & Health, 4(10): 1078-1087, 2014 1079 Results: The serum C-reactive protein levels showed a positive correlation with the malaria parasite count (r = 0.55; p < 0.001). Children presenting with severe manifestations of malaria had significantly higher mean serum C-reactive protein levels (33.3± 6.88mg/l) than the 8.12±9.09mg/l obtained in those with uncomplicated malaria (t = -15.57; p = 0.001. Conclusion: This study shows that C-reactive protein levels are increased in children with malaria, especially in severe malaria. Its estimation therefore holds potential usefulness as an adjunct for assessment of malarial severity.

Antibiotic Susceptibility of Group A Β-Hemolytic Streptococci Isolated From Tonsillar Swab Samples in 5-15 Years Old Children

Tonsillopharyngitis is a common infectious disease in the pediatric age group. Group A Beta Hemolytic Streptococcus (GAS) is a main infectious agent of pharyngitis. Optimal therapeutic approach in these patients has been a matter of debate to avoid the complications of infection. The aim of this study was to investigate of antibiotic susceptibility for group A b-hemolytic Streptococci which isolated from tonsillar swab samples of 5-15 years old children. 2599 outpatient children who are 5-15 years old and have general infection symptoms like high fever, weakness, chills-shivering and observed hyperemia at tonsils and pharynx were included in the study. Tonsillopharyngeal culture and antimicrobial susceptibility tests were performed. 319 (12,3%) GAS isolates was obtained from tonsillopharyngeal cultures of the 2599 patients. Susceptibility to penicillin, vancomycin, linezolid, cefotaxime, erythromycin, chloramphenicol, and clindamycin were 100%, 100%, 100%, 100%, 97,2%, 98,3%, and 94,7% respectively.Resistance to penicillin was not yet observed, penicillin may safely be chosen to treatment of these infections for non-allergic patients to penicillin. It is considered that culture and antibiotic susceptibility testing may be more useful to for the diagnosis and treatment of these patients.

Evaluating Educational Intervention to Improve Drug Administration Practice in Out-Patient Children in Northwestern Nigeria

Drug administration practice of mothers from 20 facilities (12 primary and 8 secondary) in northwestern Nigeria were assessed prospectively with the aim of identifying the type, frequency and potential clinical significance of drug administration errors in paediatric outpatients. The data was analyzed and errors classified according to National Coordinating Council for Medication Error Reporting and Prevention taxonomy. Educational interventions were designed and administered to mothers of 10 (6 primary and 4 secondary) least performing facilities, while the remaining 10 facilities acted as control. The percentage of the parents that claimed to knew the correct dosage were relatively high (78% to 93%) and differ significantly between the secondary and primary facilities. Further assessment shows that the dose of the drugs dispensed, the time/frequency of administration, and the duration of use were not known by 68.2% (330/484), 63.0% (305/484), and 12.0% (58/484) of the mothers respectively. The overall total possibility of the drug administration errors significantly reduced in the right direction (p<0.0005; d=4.27) after the intervention.

PREDICTORS OF C-REACTIVE PROTEIN RESPONSE IN CHILDREN INFECTED WITH PLASMODIUM FALCIPARUM MALARIA.

To assess the predictors of C-reactive protein response in plasmodium falciparum malaria as seen in children in a malaria endemic region of Nigeria. A prospective cross-sectional study. The Children Out-patient (CHOP) Clinic, Children Emergency Unit (CHEU), Child Welfare/Growth Monitoring Clinic, Immunisation Centre and Paediatric Ward of the University of Uyo Teaching Hospital (UUTH), Uyo in Akwa-Ibom State. Three hundred and sixty children aged six to sixty months with microscopically confirmed P. falciparum malaria compared with 360 healthy children without malaria parasitaemia matched for age and gender. The predictors of the C-reactive protein response in malaria (CRP ≥ 10mg/l) were fever (t = 6.867; p = 0.001), malaria parasite count (t = 5.387; p = 0.001), severe anaemia (t = -11.23; p = 0.001) and age. Younger children had a greater CRP response. The logistic regression curve showed a 66.9% sensitivity, 92.1% specificity, positive predictive value, 83.2% and negative predictive value of 82.2% of predicting C-reactive protein response in malaria. P. falciparum malaria induces significant CRP responses. Younger children who present with fever, hyperparasitaemia and severe anaemia are more likely to have C-reactive protein response with malaria.

A Pediatric Infection Screening System with a Radar Respiration Monitor for Rapid Detection of Seasonal Influenza among Outpatient Children

Background: Seasonal influenza virus outbreaks cause annual epidemics, mostly during winter in temperate zone countries, especially resulting in increased morbidity and higher mortality in children. In order to conduct rapid screening for influenza in pediatric outpatient units, we developed a pediatric infection screening system with a radar respiration monitor. Methods: The system conducts influenza screening within 10 seconds based on vital signs (i.e., respiration rate monitored using a 24 GHz microwave radar; facial temperature, using a thermopile array; and heart rate, using a pulse photosensor). A support vector machine (SVM) classification method was used to discriminate influenza children from healthy children based on vital signs. To assess the classification performance of the screening system that uses the SVM, we conducted influenza screening for 70 children (i.e., 27 seasonal influenza patients (11 ± 2 years) at a pediatric clinic and 43 healthy control subjects (9 ± 4 years) at a pediatric dental clinic) in the winter of 2013-2014. Results: The screening system using the SVM identified 26 subjects with influenza (22 of the 27 influenza patients and 4 of the 43 healthy subjects). The system discriminated 44 subjects as healthy (5 of the 27 influenza patients and 39 of the 43 healthy subjects), with sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 81.5%, 90.7%, 84.6%, and 88.6%, respectively. Conclusion: The SVM-based screening system achieved classification results for the outpatient children based on vital signs with comparatively high NPV within 10 seconds. At pediatric clinics and hospitals, our system seems potentially useful in the first screening step for infections in the future.

Physician Use of White Coats in Pediatric Ophthalmology

PURPOSE Recent literature reports that patients and parents of pediatric patients prefer their physician to wear a white coat and to address them informally. This study aims to characterize current practice patterns of pediatric ophthalmologists regarding their use of white coats and salutations during outpatient pediatric encounters. METHODS An eight-question survey was e-mailed to members of the American Academy of Pediatric Ophthalmology and Strabismus in 2012. The questions focused on clinical setting, use of white coats in out-patient encounters, and preferred language used to address the patient's parents. Surveys not completed in full were excluded from data analysis. RESULTS Of approximately 1,266 members who received the survey, 606 completed the survey. Five hundred ninety-nine surveys were included in the data analysis. Sixty-three percent of attending physicians and 80% of fellows reported they did not routinely wear white coats while examining outpatient children. Forty-six percent of attending physicians and 48% of fellows addressed the patient's parents as mom or dad. There was no significant association between wearing a white coat and type of practice setting, practice characteristics, or location in a children's hospital for attending physicians or fellows. CONCLUSIONS Contrary to preferences expressed by patients and their parents, a majority of pediatric ophthalmologists do not routinely wear white coats during pediatric outpatient examinations. Practice patterns appear to be in line with previously reported parental greeting preferences.

Physician Use of White Coats in Pediatric Ophthalmology

Recent literature reports that patients and parents of pediatric patients prefer their physician to wear a white coat and to address them informally. This study aims to characterize current practice patterns of pediatric ophthalmologists regarding their use of white coats and salutations during outpatient pediatric encounters. An eight-question survey was e-mailed to members of the American Academy of Pediatric Ophthalmology and Strabismus in 2012. The questions focused on clinical setting, use of white coats in out-patient encounters, and preferred language used to address the patient's parents. Surveys not completed in full were excluded from data analysis. Of approximately 1,266 members who received the survey, 606 completed the survey. Five hundred ninety-nine surveys were included in the data analysis. Sixty-three percent of attending physicians and 80% of fellows reported they did not routinely wear white coats while examining outpatient children. Forty-six percent of attending physicians and 48% of fellows addressed the patient's parents as "mom" or "dad". There was no significant association between wearing a white coat and type of practice setting, practice characteristics, or location in a children's hospital for attending physicians or fellows. Contrary to preferences expressed by patients and their parents, a majority of pediatric ophthalmologists do not routinely wear white coats during pediatric outpatient examinations. Practice patterns appear to be in line with previously reported parental greeting preferences.

Care-seeking and quality of care for outpatient sick children in rural Hebei, China: a cross-sectional study

AimTo assess the quality of outpatient pediatric care provided by township and village doctors, prevalence of common childhood diseases, care-seeking behavior, and coverage of key interventions in Zhao County in China.MethodsWe conducted two cross-sectional surveys: 1) maternal, newborn, and child health household survey including1601 caregivers of children younger than two years; 2) health facility survey on case management of 348 sick children younger than five years by local health workers and assessment of the availability of drugs and supplies in health facility.ResultsOur household survey showed that the prevalence of fever, cough, and diarrhea was 16.8%, 9.2%, and 15.6% respectively. Caregivers of children with fever, cough, and diarrhea sought care primarily in village clinics and township hospitals. Only 41.2% of children with suspected pneumonia received antibiotics, and very few children with diarrhea received oral rehydration solutions (1.2%) and zinc (4.4%). Our facility survey indicated that very few sick children were fully assessed, and only 43.8% were correctly classified by health workers when compared with the gold standard. Use of antibiotics for sick children was high and not according to guidelines.ConclusionWe showed poor quality of services for outpatient sick children in Zhao County. Since Integrated Management of Childhood Illness strategy has shown positive effects on child health in some areas of China, it is advisable to implement it in other areas as well.

Levels of moderate–vigorous physical activity are low in Spanish children with cystic fibrosis: A comparison with healthy controls

Physical activity (PA) is recommended as part of the treatment regimen for cystic fibrosis (CF) although objective methods have been scarcely used to monitor achievement of PA guidelines. PA was measured by accelerometer in outpatient CF children (n=47) and results were compared with those obtained in age- and gender-matched healthy controls (n=39). 2.1% of the outpatients fulfilled PA guidelines (i.e. ≥60min·day(-1) of moderate-to-vigorous PA (MVPA)) vs. 34.2% of controls. Overall, lower MVPA levels were observed in CF patients than controls despite the former undergoing more light or total PA. Peak oxygen uptake was also lower in the CF group than in controls (37.5±7.8 vs. 43.5±7.6ml·kg(-1)·min(-1), p=0.002) and was correlated with MVPA and vigorous PA in the former. These findings support a need to promote PA interventions (including MVPA) targeted at improving cardiorespiratory fitness in CF children.

Glomerular filtration rate and cardiometabolic risk in an outpatient pediatric population with high prevalence of obesity

To evaluate the relationship between estimated glomerular filtration rate (eGFR) and cardiometabolic risk factors (CMRF) in an outpatient pediatric population with high prevalence of obesity. eGFR was evaluated in 901 children unselected for chronic kidney disease of whom 694 were overweight/obese (6-16 years) and 207 were age- and sex-matched normal weight (NW). We generated three categories of eGFR: mild-low eGFR (< 20th percentile), high eGFR (>80th percentile) and intermediate eGFR (20-80th percentile), considered as the reference category Children with either mild-low or high eGFR category showed a 2-4 fold higher Odds ratio of high blood pressure, left ventricular hypertrophy, and microalbuminuria compared with children of the intermediate eGFR category. In addition, children with mild-low eGFR levels showed a 1.5-2 fold higher Odds ratio of impaired fasting glucose and high white blood cell count compared with children with intermediate eGFR levels. In outpatient children with high prevalence of obesity, children with either mildly reduced or high eGFR have an increased burden of CMRF. Children with eGFR < 97 mL/min/1.73 m² show a worse CMR profile. This finding supports the usefulness to assess eGFR to identify children with unfavorable CMR profile.

Is pro-adrenomedullin a more useful marker in hospitalized infants with sepsis?

Dear Editor, We read with great interest the recent article by Benito et al. [1] whose objective was to assess the usefulness of two biomarkers, midregional pro-adrenomedullin (pro-ADM) and C-proendothelin-1 (CT-pro-ET-1), in predicting bacterial infection and, especially, invasive bacterial infection (IBI) in wellappearing infants with fever without source. They found that plasma levels of both endothelium-derived precursor peptides were higher in well-appearing febrile infants with focal and IBI than in patients with viral or self-limited infection. CT-pro-ET-1 showed a significant difference between patients with no bacterial infection and those with focal bacterial infection (p<0.05), but not between patients with focal bacterial infection and IBI. Levels of midregional pro-ADM showed no statistically significant differences among the three groups. These markers had a lower diagnostic accuracy for assessing the severity of bacterial infection than other biomarkers such as C-reactive protein (CRP) and procalcitonin (PCT). In the initial univariate analysis, they found that PCT of ≥0.5 ng/mL, midregional pro-ADM of ≥0.7 nmol/L, andCRPof≥40mg/Lwere significantly associated with IBI. The only independent risk factor identified in the final multivariate model was a higher PCT level (≥0.5 ng/mL). In a recent similar study, we sought to compare sequential measurements of white blood cell count, CRP, interleukin-6 (IL-6), and pro-ADM in proven sepsis and clinical sepsis and the control group in newborns. A total of 76 patients with neonatal sepsis (31 with proven sepsis and 45 with clinical sepsis) and 52 healthy controls were enrolled. Mean baseline serum levels of CRP, IL-6, and pro-ADM were significantly higher in both proven and clinical sepsis groups compared to those in healthy controls (p <0.001 for both). Although mean baseline CRP and IL-6 levels were similar between groups, mean baseline pro-ADM level was higher in the proven sepsis group than that in clinical sepsis group (p <0.001). The calculated cutoff values for CRP, IL-6, and pro-ADM in distinguishing patients with sepsis group were 4.87 mg/L, 26 pg/mL, and 3.9 nmol/L, respectively. Area under the curve analysis for comparing patients with proven sepsis and healthy controls once again revealed the set cutoff values for CRP, IL-6, and pro-ADM to have specificities and positive predictive values of 100 %, with respective sensitivities of 96.7, 93.5, and 93.5 %. Negative predictive values for the three markers were 98.1, 96.2, and 96.2 %, respectively. Our study demonstrated that pro-ADM is a novel marker that may be used especially for the early diagnosis of neonatal sepsis. The fact that pro-ADM levels showed more rapid decreases compared to CRP in our study, we suggested that rather than being used alone, the use of pro-ADM in combination with conventional acute phase reactants may be more useful in the diagnosis and follow-up of patients with neonatal sepsis [2]. In conclusion, in relation to our study, we think that the result by Benito et al. [1] which showed pro-ADM as a weak marker in diagnosis of IBI might be both due to short half-life of the marker and the time of the obtaining the blood (whether early or late in emergency room). In contrast, we found proADM to be useful in the early detection of neonatal sepsis. Results of both studies suggest that pro-ADMmay be a useful marker in closely followed up hospitalized patients rather than outpatient infants and children. M. Y. Oncel (*) :N. Uras :U. Dilmen Division of Neonatology, Zekai Tahir Burak Maternity Teaching Hospital, Ankara 06230, Turkey e-mail: dryekta@gmail.com