eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Urinary Tract Infections and Pyelonephritis

Stephen L Thornton, MD, Attending Physician, Department of Emergency Medicine, St John's Hospital

Updated: Dec 15, 2009

Introduction

Background

In the pediatric patient, urinary tract infections (UTIs) are among the most common serious bacterial infections (SBI) encountered.^{[1 ]}They are a frequent cause of fever and can cause significant morbidity if not properly identified and treated.

Presentation varies based on the age of the patient. Neonates and infants often present with vague, nonspecific symptoms, necessitating a high index of suspicion for UTIs in this age group. Older pediatric patients are more likely to present with more typical and localized complaints.

Treatment should be tailored to treat the most commonly encountered causative organisms, keeping in mind increasing antibiotic resistance among urinary pathogens. If not properly identified or treated, UTIs can progress to pyelonephritis or urosepsis. Long-term complications from UTIs may include renal scarring, hypertension, and even renal failure.

Pathophysiology

The urinary tract is normally a sterile environment and has several mechanisms that work to maintain urine sterility (urethral sphincter, length of urethra, constant anterograde flow). In most cases, failure of one of these mechanisms leads to or exacerbates infection.

The most common causative organisms are bowel flora, typically gram-negative rods. Escherichia coli is the most commonly isolated organism from pediatric patients with UTIs. However, any organism that gains access to the urinary tract system may cause infection, including fungi (Candida species) and viruses.

Pathogens can infect the urinary tract through direct spread via the fecal-perineal-urethral route or from hematogenous seeding. Hematogenous spread is much more likely in neonates than in older children. Most infections begin in the bladder, and, from there, pathogens can spread up the urinary tract to the kidneys (pyelonephritis) and possibly the bloodstream (bacteremia). Pyelonephritis may lead to renal scarring and long-term complications such as hypertension and chronic renal failure.

Frequency

United States

Prevalence and incidence of UTIs varies based on age, sex, and gender. Overall, UTIs are estimated to affect 2.4-2.8% of all children every year. As many as 5% of all children younger than 2 years who present to the emergency department with fever have a UTI. An approach using low-risk criteria for febrile infants younger than 3 months who have temperature of more than 38 º C is shown in the image below.

Application of low-risk criteria and approach for the febrile infant: A reasonable approach for treating febrile infants younger than 3 months who have a temperature of greater than 38°C.

International

International prevalence and incidence is difficult to accurately assess, especially in developing countries, but is assumed to be similar to that in the United States. 

Mortality/Morbidity

Bacteremia or urosepsis may develop from UTI. This risk is highest in neonates and very young infants. Simple cystitis may progress to pyelonephritis. Predicting which patients will develop pyelonephritis is difficult, although evidence suggests that genetics may play a role. Approximately 10-30% of children with UTIs develop renal scarring. Severe and/or recurrent cases of pyelonephritis may lead to kidney damage. This may cause hypertension, renal insufficiency, or renal failure.

Race

Studies indicate that nonblacks have a higher incidence of UTI than blacks.

Sex

Uncircumcised males have a significantly higher incidence of UTIs than circumcised males. Uncircumcised male infants have a higher incidence of UTI than female infants during the first year of life. After the first year of life, females have a much higher incidence of UTIs than males. Incidence is highest in sexually active adolescent females.

Age

Prevalence of UTIs in the first 3 months of life is estimated to be as high as 7.5%. During the first year of life, males have an incidence of UTIs of 2.7% compared with 0.7% for girls. For children older than 1 year, females have a 1-2% incidence of UTIs and males have a 0.1-0.2% incidence of UTIs. In sexually active teenaged females, the incidence of UTIs approaches 10%.

Clinical

History

History varies with the age of the patient with urinary tract infection (UTI) and is often nonspecific for younger children.

• Neonates
  • Jaundice
  • Fever
  • Failure to thrive
  • Poor feeding
  • Vomiting
  • Irritability
• Infants
  • Poor feeding
  • Fever
  • Vomiting
  • Strong-smelling urine
  • Abdominal pain
  • Irritability
• Preschoolers
  • Vomiting
  • Abdominal pain
  • Fever
  • Strong-smelling urine
  • Enuresis
  • Urinary symptoms (dysuria, urgency, frequency)
• School-aged children
  • Fever
  • Vomiting, abdominal pain
  • Flank/back pain
  • Strong-smelling urine
  • Urinary symptoms (dysuria, urgency, frequency)
  • Enuresis
  • Incontinence
• Adolescents
  • Adolescents are more likely to present with typical urinary symptoms.
  • Adolescent girls are more likely to have vaginitis (35%) than UTI (17%). Those diagnosed with cystitis frequently have a concurrent vaginitis.

Physical

• Hypertension should raise suspicion of hydronephrosis or renal parenchyma disease.
• Costovertebral angle (CVA) tenderness
• Abdominal tenderness to palpation
• Suprapubic tenderness to palpation
• Palpable bladder
• Dribbling, poor stream, or straining to void
• Examine external genitalia for signs of irritation, pinworms, vaginitis, trauma, or sexual abuse.

Causes

• Bacterial infections are the most common cause of UTIs.
  • E coli is the most frequent pathogen, causing 75-90% of UTIs.
  • Klebsiella species
  • Proteus species
  • Enterococcus species
  • Staphylococcus saprophyticus, especially among sexually active females
  • Streptococcus group B, especially among neonates
  • Pseudomonas aeruginosa
• Fungi (Candida species), especially after instrumentation of the urinary tract
• Adenovirus (rare)

Differential Diagnoses

Other Problems to Be Considered

Cystitis
Pregnancy 
Urolithiasis
Vesicoureteral reflux

Workup

Laboratory Studies

• The criterion standard for diagnosing urinary tract infections (UTIs) is the isolation of a pathogen from a urine culture obtained via suprapubic aspiration.^{[2 ]}
• Although suprapubic aspiration is the criterion standard method for obtaining urine, catheterization is the most commonly used technique in infants and younger children. More than 50,000 CFU/mL in a catheterized specimen is defined as a UTI, although some experts recommend 10,000 CFU/mL as the cutoff.
• Midstream clean catch urine specimens are also adequate for older children who can provide them. More than 100,000 CFU/mL in a midstream clean catch urine specimen is defined as a UTI.
• Bagged urine specimens are of no value for the diagnosis of UTIs due to high rates of false-positives, and their use should be discouraged.
• Although urine culture is the criterion standard for diagnosis UTIs, it may take as long as 48 hours for cultures to be positive. Therefore, evaluation of urinalysis is often needed to help make the initial diagnosis of a UTI.
  • A urine specimen that is found to be positive on dipstick for nitrite, leukocyte esterase, or blood may indicate a UTI.
  • Dipstick tests have sensitivities approaching 85-90%.
  • Microscopic examination of spun urine can evaluate for presence of WBCs, RBCs, bacteria, casts, and skin contamination (eg, epithelial cells).
  • With regards to a suprapubic aspirate, 5 or more WBC/high power field suggests an infection.
  • Hemacytometer measures cells per volume and has been found to be more sensitive and specific than standard microscopic examination.^{[3,4 ]}
  • With regards to a suprapubic aspirate, 10 or more WBC/μL is consistent with infection.^{[3,4 ]}
  • Gram stain of unspun urine may reveal organisms.
  • A combination of hemacytometer cell count and Gram stain has been shown in studies to have a sensitivity approaching 95%.
• In pediatric patients, urine cultures should be sent to the laboratory even if urinalysis results are inconclusive.
  • Approximately 10-20% of pediatric patients with UTIs have normal urinalyses results.
  • Multiple organisms may be present if structural abnormalities are present.
• Hematological studies do not tend to help in the diagnosis of UTIs, although they should be obtained in patients that appear ill.
• In patients with suspected bacteremia or urosepsis, blood cultures should be obtained.
• Renal function can be measured by serum creatinine and BUN levels and may be elevated in severe disease.
• Electrolyte abnormalities may be present.

Imaging Studies

• Imaging is recommended by the American Academy of Pediatrics for patients aged 2 months to 2 years old with febrile UTIs.
• The recommendation is for a renal ultrasonography and a voiding cysto-urography (VCUG). The purpose is to identify those with vesicoureteral reflux (VUR).
  • Renal ultrasonography allows for the identification of anatomical abnormalities (ie, duplication) and hydroureter/nephrosis. It does not allow for definitive diagnosis of VUR, although it can suggest it.
  • VCUG allows for anatomical definition of urethra and bladder and grading of VUR, if present.
• Although still the standard of care, many question the use and effectiveness of the current imaging recommendations, especially in light of recent trends to minimize exposure to ionizing radiation.
• Neither renal ultrasonography nor VCUG can evaluate for pyelonephritis or renal scarring, which could lead to long-term complications.
• Tc 99m dimercaptosuccinic (DMSA) is the criterion standard to detect pyelonephritis and renal scarring.
  • DMSA involves injecting a radionuclide that binds to renal proximal tubular cells.
  • Decreased uptake represents abnormal or damaged cells.
  • Some experts recommend screening with DMSA during the acute UTI with the reasoning that if no kidney involvement is noted during the acute phase no risk of renal scarring and further complication is noted and further imaging is unnecessary.

Procedures

• Transurethral catheterization of the urinary bladder is the most common procedure performed in the evaluation of UTIs. Catheterization may introduce pathogens.
• A suprapubic bladder aspiration may also be performed to obtain urine and is the criterion standard despite the potential for gross or microscopic hematuria. Risk of infection is lower than with transurethral catheterization, and complications are low.

Treatment

Prehospital Care

• Prehospital care is rarely applicable in patients with urinary tract infections (UTI), although patients who are uroseptic and in shock may present via EMS, in which case, standard supportive measures for septic patients should be followed.

Emergency Department Care

The primary goal should be to identify UTIs and begin appropriate treatment.

• Patients with a nontoxic appearance may be treated with oral fluids and antibiotics.
• Toxic-appearing patients must be aggressively treated with intravenous fluids and parenteral antibiotics.
• Toxic-appearing patients must be admitted for continued parenteral therapies.

Consultations

• Consultation with a urologist is not typically required at presentation unless obstruction of the urinary tract is evident.
• Consultation with an infectious disease specialist may be useful if drug resistant or an unusual organism is suspected.

Medication

Start antibiotics after urinalysis and culture are obtained in patients with urinary tract infections (UTIs). A 10-day course of antibiotics is recommended, even for uncomplicated infection. Typical short course treatments should be reserved for non-toxic-appearing adolescent females with UTIs. Be aware of increasing rates of antibiotic resistance and to choose antibiotic therapy accordingly.

Antibiotics

Empiric antibiotics should be chosen for coverage of the most common uropathogens, namely E coli and Enterococcus, Proteus, and Klebsiella species. For suspected pyelonephritis, parenteral antibiotics are recommended. Recent evidence indicates that oral antibiotics are adequate therapy for febrile UTIs in young infants and children; short-term (fever) and long-term (renal scarring) outcomes are comparable to that with parenteral therapy. For uncomplicated cystitis, oral antibiotic therapy is generally adequate. The possibility of antibiotic resistance must be considered when choosing empiric therapy, especially ampicillin. Knowledge of the local antibiotic resistance helps in guiding antibiotic choice.

Ampicillin (Omnipen, Principen)

Provides bactericidal activity against susceptible organisms. Administered parenterally and used in combination with gentamicin or cefotaxime.

Dosing

Adult

1-2 g/d IV/IM divided q6h

Pediatric

100-200 mg/kg/d IV/IM divided q6h

Interactions

Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of PO contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction; caution in cephalosporin allergy.
Resistance rates are high.

Gentamicin (Garamycin)

Aminoglycoside antibiotic for gram-negative coverage. Provides synergistic activity with ampicillin against gram-positive bacteria including enterococcal species. Inhibits protein synthesis by irreversibly binding to bacterial 30S and 50S ribosomes. Dosing regimens are numerous; adjust dose based on CrCl and changes in volume of distribution. May be administered IV/IM.

Dosing

Adult

3-5 mg/kg IV qd; alternatively, 1 mg/kg IV q8h

Pediatric

<5 years: 2.5 mg/kg/dose IV/IM q8h
>5 years: 1.5-2.5 mg/kg/dose IV/IM q8h

Interactions

Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents thus prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)

Contraindications

Documented hypersensitivity; non–dialysis-dependent renal insufficiency

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment

Cefotaxime (Claforan)

Third-generation cephalosporin with gram-negative spectrum. Lower efficacy against gram-positive organisms. Used as initial parenteral therapy for pediatric patients with acute complicated pyelonephritis. May be used for neonates or jaundiced patients. Requires dosing at q6-8h intervals.

Dosing

Adult

1-2 g IV/IM q6-8h

Pediatric

100-200 mg/kg/d IV/IM divided q6-8h

Interactions

Probenecid may increase levels; coadministration with furosemide and aminoglycosides may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe renal impairment; has been associated with severe colitis; caution in penicillin allergy

Amoxicillin (Amoxil, Trimox)

Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria. Activity against gram-positive and some gram-negative bacteria.

Dosing

Adult

250-500 mg PO q8h

Pediatric

30-50 mg/kg/d PO divided q8h

Interactions

Reduces the efficacy of PO contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment; caution in cephalosporin allergy

Trimethoprim and sulfamethoxazole (Bactrim DS, Septra)

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Antibacterial activity of TMP-SMZ includes common urinary tract pathogens, except Pseudomonas aeruginosa.

Dosing

Adult

160 mg TMP/800 mg SMZ PO bid (ie, 1 double-strength tab bid)

Pediatric

<2 months: Not recommended
>2 months: 5-10 mg/kg/d PO divided q12h, based on TMP component

Interactions

May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine

Contraindications

Documented hypersensitivity; megaloblastic anemia due to folate deficiency; age <2 mo

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not use during last trimester of pregnancy due to potential toxicity to newborn (eg, jaundice, hemolytic anemia, kernicterus); discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBC counts frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, administer 5-15 mg/d leucovorin); caution in folate deficiency (eg, persons with chronic alcoholism, elderly persons, those receiving anticonvulsant therapy, those with malabsorption syndrome); hemolysis may occur in individuals with G-6-PD deficiency; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation

Cephalexin (Keflex)

First-generation cephalosporin that inhibits bacterial replication by inhibiting bacterial cell wall synthesis. Bactericidal and effective against rapidly growing organisms forming cell walls.
Resistance occurs by alteration of penicillin-binding proteins. Effective for treatment of infections caused by streptococcal or staphylococci, including penicillinase-producing staphylococci. Used PO when outpatient management is indicated.

Dosing

Adult

250-1000 mg PO q6h for 10-14 d; not to exceed 4 g/d

Pediatric

25-50 mg/kg/d PO divided q6h; not to exceed 3 g/d

Interactions

Probenecid increases serum concentrations; coadministration with aminoglycosides increases nephrotoxic potential

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Documented hypersensitivity with penicillin; colitis; dosage modification required with renal impairment

Cefixime (Suprax)

Third-generation PO cephalosporin with broad activity against gram-negative bacteria. By binding to one or more of the penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial growth. Has shown poor activity against staphylococcal and enterococcal species. Cefixime compared favorably to a quinolone in one study.

Dosing

Adult

400 mg PO qd

Pediatric

8 mg/kg PO qd; not to exceed 400 mg/d

Interactions

Probenecid increased serum concentration; coadministration of aminoglycosides increase nephrotoxicity; possible increase in serum carbamazepine concentration

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Documented hypersensitivity to penicillin; impaired renal function; colitis; dosage modification needed with impaired renal function

Ciprofloxacin (Cipro)

Fluoroquinolone that inhibits bacterial DNA synthesis and, consequently, growth, by inhibiting DNA gyrase and topoisomerases, which are required for replication, transcription, and translation of genetic material. Quinolones have broad activity against gram-positive and gram-negative aerobic organisms. Has no activity against anaerobes. Continue treatment for at least 2 d (7-14 d typical) after signs and symptoms have disappeared.

Dosing

Adult

250-500 mg PO bid for 7-14 d

Pediatric

<1 year: Not established
1-17 years: Consult with specialist, evidence suggest use appears safe, although not first choice in children
PO: 10-20 mg/kg/dose PO bid for 10-21 d; not to exceed 750 mg/dose
IV: 6-10 mg/kg/dose IV q8h for 10-21 d; not to exceed 400 mg/dose
>18 years: Administer as in adults

Interactions

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations
May increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Not drug of first choice in pediatrics due to increased incidence of adverse events compared to controls, including arthropathy; no data exist for dose for pediatric patients with renal impairment (ie, CrCl <50 mL/min)

Follow-up

Further Inpatient Care

• Hospitalization is necessary for the following individuals with urinary tract infection (UTI):
  • Patients who are toxemic or septic
  • Patients with signs of urinary obstruction or significant underlying disease
  • Patients unable to tolerate adequate oral fluids or medications
  • Infants younger than 3 months with febrile UTI (presumed pyelonephritis)
  • All infants younger than 1 month with suspected UTI even if not febrile

Further Outpatient Care

• The American Academy of Pediatrics recommends all infants and young children (2 months to 2 years of age) with first UTI have a urinary tract ultrasonography and voiding cysto-urography (VCUG). These tests should be acquired promptly if patients fail to show expected clinical response within 2 days of treatment.
• All patients should have close follow-up to evaluate response to antibiotics.
• Repeat urinalysis and/or urine cultures are not needed if the patient’s condition responds to therapy as expected.

Inpatient & Outpatient Medications

• Most non-toxic-appearing patients with uncomplicated cystitis will do well on oral antibiotics.
• Any patient with suspected pyelonephritis should be started on parenteral antibiotics and then transitioned to oral antibiotics once afebrile for more than 24 hours.
• Neonates should be kept on parenteral antibiotics for 3-4 days before being transitioned to oral antibiotics.

Deterrence/Prevention

• Prevention of UTI is focused on the identification and correction of structural abnormalities.
• Prophylactic antibiotics is controversial though widely practiced for patients with vesicoureteral reflux (VUR) and recurrent infections. Prophylactic antibiotics are associated with increased risk of resistant infection.

Complications

• Dehydration is the most common complication of UTI in the pediatric population. Intravenous fluid replacement is necessary in more severe cases. Treat febrile UTI as pyelonephritis, and consider parenteral antibiotics and admission for these patients.
• Untreated UTI may progress to renal involvement with systemic infection (eg, urosepsis).
• Long-term complications include renal parenchyma scarring, hypertension, decreased renal function, and, in severe cases, renal failure.

Prognosis

• Most cases of uncomplicated UTI respond readily to outpatient antibiotic treatments without further sequelae.
• Appropriate treatment, imaging, and follow-up prevent long-term sequelae in patients with more severe cases or chronic infections.
• Low-grade VUR usually resolves without permanent damage.
• High-grade VUR may require surgical correction.

Patient Education

• For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also, see eMedicine's patient education article Urinary Tract Infections.

Miscellaneous

Medicolegal Pitfalls

• Failure to have a high index of suspicion for urinary tract infections (UTIs), especially in neonates and febrile infants
• Failure to diagnosis and aggressively treat pyelonephritis to avoid acute and chronic complications
• Failure to insist on proper collection of urine sample (ie, avoid bagged specimens)
• Failure to initiate proper antibiotic treatment in a timely fashion
• Failure to emphasize/arrange for appropriate follow-up and imaging

Special Concerns

• Pregnancy must be considered in adolescent girls who present with symptoms of UTI and/or vaginitis and who are sexually active.
• Antibiotic resistance among uropathogens is increasing dramatically.

Multimedia

Media file 1: Application of low-risk criteria and approach for the febrile infant: A reasonable approach for treating febrile infants younger than 3 months who have a temperature of greater than 38°C.

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Keywords

urinary tract infection, UTI, urinary tract infection in kids, urinary tract infection in infants, UTI in children, cystitis, UTI in infants, urosepsis, pyelonephritis, treatment, diagnosis, symptoms

Contributor Information and Disclosures

Author

Stephen L Thornton, MD, Attending Physician, Department of Emergency Medicine, St John's Hospital
Stephen L Thornton, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

David S Howes, MD, Residency Program Director, Professor of Medicine, Section of Emergency Medicine, University of Chicago/Pritzker School of Medicine
David S Howes, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians-American Society of Internal Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Grace M Young, MD, Associate Professor, Department of Pediatrics, University of Maryland Medical Center
Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Terrance K Egland, MD, and Ann G Egland, MD, to the development and writing of this article.

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