Roberto Velasco

Background: Early‐life skin barrier enhancement has been proposed as a strategy to prevent atopic dermatitis (AD), but results from emollient prevention trials have been inconsistent, and long‐term outcomes remain poorly defined. The STOP‐AD trial previously demonstrated a reduction in AD incidence following brief early emollient use in high‐risk infants. Whether these effects persist beyond infancy is unknown. Methods: This study reports the blinded five‐year follow‐up of the STOP‐AD single‐centre, randomised controlled trial. Term infants at high risk of AD were randomised within 4 days of birth to either twice‐daily whole‐body emollient application for the first 8 weeks of life or to standard routine skin care. At 5 years, participants underwent blinded, in‐person clinical assessment. AD was diagnosed using UK Working Party Diagnostic Criteria, and disease severity was assessed using SCORAD. Primary outcome was point prevalence of AD at 5 years. Secondary outcomes included AD severity. Complete‐case analyses were supplemented by multiple imputation to assess the impact of missing data. Results: A total of 177 children completed the five‐year follow‐up. The point prevalence of AD at 5 years was lower in the intervention group than in the control group (12.3% vs. 24.0%; RR 0.52, 95% CI 0.26–1.02; p = .048). Among children with AD, disease severity was also lower in the intervention group (median SCORAD 12.0 [IQR 8.2–15.2] vs. 19.6 [IQR 11.8–23.4]; p = .034). Multiple imputation to account for missing outcome data produced a similar treatment effect (OR 0.45, 95% CI 0.19–1.03; p = .060), although with greater uncertainty. Conclusions: Early, short‐term emollient use initiated in the neonatal period was associated with lower AD prevalence and severity at 5 years in high‐risk children. Although the effect estimate remained similar following multiple imputation, uncertainty due to attrition remained. These findings suggest that brief early‐life barrier support may influence longer‐term AD outcomes and support further investigation of the timing and formulation of preventive skin‐barrier interventions. image

Aim: To compare febrile infants aged 90 days or younger with Enterococcus spp. or Escherichia coli in urine cultures, overall and by urine dipstick findings. Methods: Matched cohort study in three Spanish paediatric emergency departments (2011–2023). Infants with Enterococcus spp. were matched 1:1 by age and sex with infants with E. coli and compared using paired tests; dipstick‐stratified analyses were exploratory. Results: Of 4006 febrile infants, 77 (1.9%) had Enterococcus spp. Abnormal dipstick findings were less frequent than with E. coli (27.3% vs. 80.5%; p < 0.001), and blood inflammatory markers were lower, largely reflecting the higher proportion of normal dipsticks. Abnormal voiding cystourethrogram findings were more frequent with Enterococcus spp., with abnormal (70.0% vs. 27.6%; p = 0.03) and normal dipsticks (33.3% vs. 0%; p = 0.04). With abnormal dipsticks, abnormal dimercaptosuccinic acid scans (6/11 vs. 0/17; p = 0.001) and recurrent urinary tract infections (33.3% vs. 8.1%; p = 0.009) were more frequent with Enterococcus spp. Conclusion: In these infants, Enterococcus spp. in urine usually had a normal dipstick but was associated with more urinary tract abnormalities than E. coli . Enterococcal infections with abnormal dipsticks were associated with more renal scan abnormalities and recurrences; the significance of isolates with normal dipsticks remains uncertain.

Background: The International Encephalitis Consortium (IEC) criteria are widely used to diagnose pediatric encephalitis, although their performance has not been evaluated. Objective: To evaluate IEC criteria in children with suspected encephalitis and identify prognostic factors associated with adverse outcomes. Methods: Secondary analysis of a retrospective multicenter study including children aged P < 0.001), focal neurologic deficits (aOR, 2.6; 95% CI, 1.3–5.2; P = 0.01), bacterial etiology (aOR, 2.7; 95% CI, 1.05–6.8; P = 0.03), seizures (aOR, 2.1; 95% CI, 1.0–4.5; P = 0.04) and microbiologic confirmation (aOR, 1.9; 95% CI, 1.0–3.6; P = 0.048). Conclusions: Children with altered mental status and an encephalitis-associated pathogen but only 1 minor IEC criterion may represent missed encephalitis cases. Microbiologic confirmation, particularly bacterial etiology, and 3 minor IEC criteria were independently associated with worse outcomes, with abnormal neuroimaging being the strongest predictor.

Background: Pediatric infectious encephalitis remains a significant cause of neurologic morbidity. Prompt antiviral treatment is recommended in patients with suspected herpes simplex virus (HSV) encephalitis. This study aimed to describe the epidemiology and outcomes of infectious encephalitis and to evaluate acyclovir use in children with suspected encephalitis presenting to the pediatric emergency department (PED). Methods: We conducted a multicenter, retrospective, cross-sectional study involving 10 Spanish PEDs (2017–2023), including children ≤18 years who underwent cerebrospinal fluid polymerase chain reaction testing as part of the evaluation of a possible central nervous system infection. Patients meeting the International Encephalitis Consortium (IEC) criteria for infectious encephalitis were analyzed, and acyclovir prescription rates were assessed. Results: We registered 446 episodes; 118 patients (26.5%) met the IEC criteria, and 88 (74.6%) had microbiologic confirmation. The most common pathogens were enterovirus (43.2%), influenza virus (18.2%) and HSV (9.0%). Thirty-seven patients (31.4%) had an adverse outcome, including 75% of those with HSV infection. Acyclovir was administered to 56.9% and 53.1% of patients with and without an altered mental status, respectively. All patients meeting IEC criteria presented with altered mental status and ≥1 minor criterion at evaluation in the PED. Conclusions: Enteroviruses were the leading cause of pediatric infectious encephalitis, whereas HSV infection was associated with the highest risk of adverse outcomes. Acyclovir use in the PED was suboptimal and poorly aligned with clinical criteria. Our findings suggest that empirical acyclovir should be considered in patients with altered mental status and at least one minor criterion, whereas it may be unnecessary in the absence of these features.

Background: Invasive bacterial infections (IBIs) in febrile infants ≤90 days are mostly caused by Escherichia coli and Streptococcus agalactiae . However, data on IBIs caused by other pathogens remain limited. Methods: We conducted a multicenter retrospective study of febrile infants aged ≤90 days diagnosed with IBI between 2008 and 2022 at 12 Spanish pediatric emergency departments. Epidemiology, clinical features, microbiology and outcomes of cases caused by pathogens other than E. coli / S. agalactiae were analyzed. Adverse outcomes included death, inotropic or respiratory support, acute complications, or sequelae. Results: Among 375 infants with IBI, 106 (28.3%) had infections caused by pathogens other than E. coli / S. agalactiae . The most frequent pathogens were Staphylococcus aureus (n = 30, 8.0%), Streptococcus pneumoniae (n = 15, 4.0%) and Enterococcus faecalis (n = 14, 3.7%). Most cases presented as isolated bacteremia (65.1%), followed by bacteremic urinary tract infection (18.9%) and meningitis (12.3%); 46.2% of infants with meningitis had a concomitant urinary tract infection. The distribution of pathogens varied according to age, with S. aureus being more frequent among younger infants and S. pneumoniae accounting for 8.6% of IBIs in infants aged 61–90 days. Listeria monocytogenes caused 1.3% of IBIs, with only 1 case identified in the last decade. Adverse outcomes occurred in 7.5% of infants with infections caused by other pathogens and 8.6% of those with E. coli / S. agalactiae (absolute risk difference, −1.0% [95% confidence interval, −7.1 to 5.0]). Conclusions: IBIs caused by pathogens other than E. coli / S. agalactiae accounted for a substantial proportion of cases and showed an age-dependent distribution. Most presented as isolated bacteremia, while meningitis was associated with a higher observed frequency of adverse outcomes.

Objective: To develop a national expert consensus on procedural sedation and analgesia practices in paediatric emergency departments in Spain and identify priority areas for standardisation, safety and implementation. Methods: We conducted a modified two‐round Delphi study with a panel of 28 clinicians with expertise in paediatric emergency care and procedural sedation from 23 centres in different regions of Spain. Participants rated key domains related to patient selection, fasting, monitoring, staffing, pharmacological strategies, training and safety standards. We used a predefined threshold of ≥ 70% agreement to establish consensus in both rounds. Results: The panel reached strong consensus across core domains of paediatric procedural sedation practice, including minimum safety requirements, monitoring standards, staff competencies and organisational priorities. Strong agreement supported the standardisation of procedural sedation processes. Areas of residual disagreement highlighted persistent variation in implementation and resource availability across departments. Pharmacological preferences differed according to the clinical scenario; ketamine was preferred for more painful procedures, but drug preferences for less invasive procedures or imaging procedures varied. Conclusion: This national Delphi consensus provides a pragmatic framework to support safer and more consistent procedural sedation practice in paediatric emergency departments. Although the study included only centres in Spain, it addressed operational and clinical challenges common worldwide, and its findings are likely relevant for all emergency departments seeking to improve paediatric sedation.

Background: Parapneumonic pleural effusion (PPE) is a frequent complication of pediatric pneumonia. Some cases progress to complicated PPE (cPPE), which is associated with greater morbidity, longer treatment, and a higher likelihood of need for pleural drainage. Early identification of children at risk of progression remains difficult at presentation, and pediatric evidence on early predictors is scarce and inconsistent. Methods: We conducted a retrospective observational study including children aged <18 years admitted with PPE between 2015 and 2025. cPPE was defined through standard laboratory and/or imaging criteria. Twenty clinical, laboratory, and radiological candidate predictors available at initial evaluation were assessed. After univariate screening, variables with statistical association and clinical relevance were entered into a multivariate logistic regression model. After model assessment, a simplified score was derived from the original model for bedside use. Results: A total of 122 children were included, 77 (63%) with cPPE and 45 (37%) with uncomplicated PPE. In univariate analyses, younger age, dyspnea, chest wall retractions, reduced lung sounds, C‐reactive protein, lower hemoglobin, pleural effusion thickness, and mediastinal shift were associated with cPPE. In the final multivariate model, five variables remained independently associated: age (OR 0.73, 95% CI 0.63–0.84), retractions (OR 3.23, 95% CI 1.16–8.95), C‐reactive protein ≥176.5 mg/L (OR 2.83, 95% CI 1.02–7.82), pleural effusion thickness (OR 2.16, 95% CI 1.27–3.70), and mediastinal shift (OR 10.75, 95% CI 2.24–51.64). The model showed good discriminatory performance, with an AUC of 0.883 (95% CI 0.817–0.948). The optimal probability threshold was 0.49, yielding a sensitivity of 92.2% and a specificity of 71.1%. A simplified additive clinical score derived from the model demonstrated similar performance, allowing stratification into four risk groups with progressively increasing observed rates of cPPE. Conclusions: Early risk stratification of pediatric PPE is feasible using a small set of readily available clinical, laboratory, and radiological variables. The proposed model and the adapted clinical score showed good discriminatory ability and may help identify children at increased risk of progression to cPPE who could benefit from closer monitoring and early optimized management. External validation is needed before routine clinical implementation.

Objective: To analyze the prevalence and characteristics of bacteremia in well-appearing children with prolonged fever attending a pediatric emergency department. Secondary objectives were to assess the prevalence and characteristics of other confirmed bacterial infections and to evaluate the diagnostic performance of additional investigations in this population. Methods: Retrospective observational study of well-appearing children ≤18 years presenting between October 2021 and September 2023 with fever ≥38°C lasting ≥5 days. Exclusion criteria: immunodeficiency, chronic conditions increasing infection risk, age Streptococcus pneumoniae in a child with complicated pneumonia and 1 due to Salmonella poona in an infant with acute gastroenteritis. Other confirmed or probable bacterial infections were diagnosed in 116 (15.6%): pneumonia (88, 11.9%), urinary tract infection (19, 2.5%), pharyngotonsillitis (7, 0.9%) and acute gastroenteritis (3, 0.4%). Blood tests were done in a subset: complete blood count (45.4%), C-reactive protein (46.6%) and procalcitonin (2.3%). Antibiotics were prescribed to 249 (33.6%) patients, including 24.0% without confirmed bacterial infection. Conclusions: The prevalence of bacteremia in well‑appearing children with prolonged fever was extremely low, indicating the limited utility of routine blood tests in this population. Most bacterial diagnoses were based on imaging, especially for pneumonia. Clinical assessment should remain central in decision‑making, reserving investigations for selected cases where they may meaningfully influence management.

Introduction: Early identification of invasive bacterial infections (IBI) in febrile infants under 90 days is essential, with blood biomarkers widely used for their risk evaluation. However, their diagnostic performance may vary by causative organism or type of IBI. Methods: We conducted a retrospective, multicenter study of infants ≤90 days with IBI treated in pediatric emergency departments of 18 hospitals (Spain and Latin America) from 2008 to 2022. IBI was defined by isolation or polymerase chain reaction (PCR) detection of a pathogenic bacterium in blood or cerebrospinal fluid. Sensitivity of standard biomarker cutoffs was analyzed by pathogen and IBI type, with multivariate regression adjusting for age, sex, temperature, symptom duration and clinical presentation. Results: Of 395 infants, Escherichia coli (45.6%) and Streptococcus agalactiae (25.6%) were the most frequently isolated bacteria, and bacteremia (43.8%) and bacteremic urinary tract infection (41.3%) were the most frequent IBI. Biomarker responses varied by organism and IBI type. E. coli IBIs showed higher white blood cell (WBC) and absolute neutrophil (ANC) counts and C-reactive protein levels than S. agalactiae IBIs. Only procalcitonin had high sensitivity for S. agalactiae IBIs. Standard cutoffs for WBC and ANC showed sensitivities below 50% for all pathogens and types of IBI. Conclusion: Biomarker levels in young febrile infants with IBIs depend on IBI type and causing bacteria. Increases in WBC, ANC and C-reactive protein are lower in isolated bacteremias than in bacteremic urinary tract infections. Procalcitonin is the best biomarker for ruling out S. agalactiae IBIs. These distinctions are key to interpreting lab tests and preventing underdiagnosis of invasive infections.

Aim: To analyse the relationship between fever severity and the rate of urinary tract infection (UTI) among well‐appearing febrile infants aged 61–90 days with fever without a source (FWS). Methods: We conducted a sub‐analysis of a multicentre retrospective study between 2011 and 2022. Results: 239 (21.4%) were diagnosed with UTI. UTIs were more common in males (odds ratio [OR]: 2.5; 95% confidence interval [CI]: 1.7–3.3), in infants with a longer fever duration (OR: 1.02; 95% CI: 1.01–1.03), and higher temperature (OR: 1.6; 95% CI: 1.2–2.2). The AUC for predicting a UTI based on fever degree was 0.59 (95% CI: 0.54–0.63). The prevalence of UTI was 22.3% (95% CI: 18.8%–26.1%) in infants with a temperature < 38.5°C, 12.5% (95% CI: 9.2%–16.4%) in infants with temperature 38.5°C–38.9°C, and 32.3% (95% CI: 26.5%–38.5%) in infants with temperature ≥ 39°C. The prevalence of invasive bacterial infection among patients diagnosed with UTI was 3.8% (95% CI: 1.7–7.0), with no significant differences across temperature categories. Conclusion: A urine dipstick test should be recommended for all well‐appearing infants aged 61–90 days with FWS regardless of the degree of fever. Blood culture should also be considered in infants with abnormal urine dipstick results, irrespective of fever severity.