UMEM Educational Pearls - By Mimi Lu


The answer appears to be ... it depends.

Early Oseltamivir Treatment in Influenza in Children1-3 Years of Age: A Randomized Controlled Trial

A study in 2010 out of Finland by Heinonen, et al showed that if given in the first 12 hours of symptom onset to otherwise healthy pediatric patients between the age of 1-3 years:

-  decrease incidence of acute otitis media by 85%

-  no difference if given within 24 hours

Among children with influenza A, oseltamivir started within 24 hours of symptom onset

-  shortened medium time to resolution of illness by 3.5 days (3.0 versus 6.5) in all children

- shortened median time to resolution of illness by 4.0 days in UNvaccinated children

- Reduced parental work absenteeism by 3 days

*  no differences were seen in children with influenza B *


- Single Center study in Finland

- The authors received support from the drug manufacturer

- The sample size of children with confirmed influenza cases with small (influenza A: 79, influenza B: 19)


If you have a patient between the age of 1-3 years with very early symptoms concerning for flu, a positive rapid influenza A test could allow you to cut her symptoms by 3 days, prevent complications, and allow parents to go back to work sooner.


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Every year in the U.S., preventable poisonings in children result in more than 60,000 ED visits and around 1 million calls to poison centers.  Calls relating specifically to pet medication exposure and children have been on the rise.

A recent study in Pediatrics was the first was kind to characterize the epidemiology of such exposures.

This study is a call to arms for an increased effort on the part of public health officials, pharmacists, veterinarians, and physicians to improve patient education to prevent these exposures from occurring. 

Summary of major findings:

  • Children less than or equal to age 5 are at greatest risk
  • Ingestion accounted for the exposure route in 93% of cases. 
  • Exploratory behavior(61.%) was the most common mechanism of exposure

Most commonly Implicated exposures:

  • Pet medications with no human equivalent  (17.3%)
  • Antimicrobials (14.8%
  • Antiparasitic 14.6%)
  • Analgesics (11.1%)

Key contributors to exposure risk:

  • Lack of recognition by caregivers of potential hazards of pet medications
  • Inappropriate or lack of home storage practices
  • Inconsistent compliance by veterinary providers in terms of proper product labeling and child-resistant packaging

Take home point: Make sure your pet's medications are appropriately stored for safety!



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The FDA recently announced restrictions on the use of Tramadol and Codeine in children and breastfeeding mothers due to possible harm in infants.  Essentially, codeine will now be contraindicated for the treatment of cough and/or pain, and tramadol contraindicated to treat pain for children under age 12 years. Tramadol will be also be contraindicated in children younger than 18 years for treatment of pain after tonssillectomy/ adenoidectomy. 
These medicines carry serious risks, including slowed or difficulty breathing and death. These medicines also should be limited in some older children.
Additional warnings apply for children 12 to 18 years who are obese, have severe lung disease, or sleep apnea as they may increase the risk of serious breathing problems. 
Please be aware of these new restrictions to protect the health and safety of our patients.
A summary statement from the American Hospital Association (AHA) is posted below.

Bottom line: Do not prescribe codeine or tramadol for cough or pain in children and breastfeeding moms.

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Category: Pediatrics

Title: Pediatric Sepsis (submitted by Lauren Grandpre, MD)

Keywords: pediatric, sepsis, infection, infants, children (PubMed Search)

Posted: 3/31/2017 by Mimi Lu, MD
Click here to contact Mimi Lu, MD


Sepsis remains the most common cause of death in infants and children worldwide, with pneumonia being the most common cause of pediatric sepsis overall.

Strikingly, however, the mortality rate in pediatric sepsis is significant lower in children (10-20%) as compared to adults (35-50%).

The management of pediatric sepsis has been largely influenced by and extrapolated from studies performed in adults, in part due to difficulties performing clinical trial data in children with critical illness, including sepsis.

A major difference in management of children vs. adults with refractory septic shock with or without refractory hypoxemia from severe respiratory infection is the dramatic survival advantage of children when ECMO rescue therapy is used as compared to adults.

Bottom line: Consider ECMO for refractory pediatric septic shock with respiratory failure – in kids, survival is improved dramatically – consider it early!

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Category: Pediatrics

Title: Blistering Distal Dactylics (submitted by Nicole Cimino-Fiallos, MD)

Keywords: rash, fingertip, bulla, nail disorder (PubMed Search)

Posted: 3/24/2017 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Who- Mostly seen in children, but sometimes in immunocompromised adults
What- Peri-ungal infection of the fingerpad with pus-filled blister with erythematous base
Cause- May result from thumb or finger sucking. Staph and strep are the most common bugs, but it can be caused by MRSA.
DDx- herpetic whitlow, paronychia/felon, friction blister, insect bite
1. De-roof the blister
2. Send drainage for culture
3. Treat for staph and strep- no indication to treat for MRSA initially unless strong suspicion
4. 10 day course of antibiotics recommended
For additional information and image:

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Category: Pediatrics

Title: Pediatric Anaphylaxis "Rule of 2's"

Keywords: epinephrine, auto-injector (PubMed Search)

Posted: 1/27/2017 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

As a follow up to Dr. Winter’s Pearl on Anaphylaxis on 1/24/2017, here’s a handy pearl for pediatric anaphylaxis (part 1).

Anaphylaxis: rapid and potentially life-threatening involvement of at least 2 systems following exposure to an antigen.

Medications (max: adult doses)

  • Epinephrine auto-injector (2 doses): 0.15 mg and 0.3 mg
  • Methylprednisolone (IV) or prednisone (PO): 2 mg/kg
  • Diphenhydramine: 1-2 mg/kg
  • Ranitidine: 2 mg/kg

Get it?!?!  Easy right?  Instead of fumbling through an app or reference card during your next case of pediatric anaphylaxis, be a rock star "EM DR" by remembering the “Rule of 2’s”. 

(Can't help it...ya'll know I love my mnemonics!!)

In pediatrics, providers typically prescribe 10 mg/kg (max 500 mg) and 5 mg/kg daily x 4 (max 250 mg) for treatment of pneumonia, but this dosing regimen is NOT recommended for all azithromycin usage. There are other dosing regimens that are important to keep in mind during the respiratory season:

1) Pharyngitis/ tonsillitis (ages 2-15 yr): 12 mg/kg daily x 5 days (max 500 mg/ 24 hr)

2) Pertussis

3) Acute sinusitis >/= 6 months: 10 mg/kg daily x 3 days

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Category: Pediatrics

Title: Vasopressor of choice in pediatric sepsis?

Keywords: septic shock, cold shock, vasopressor, dopamine, epinephrine (PubMed Search)

Posted: 11/25/2016 by Mimi Lu, MD
Click here to contact Mimi Lu, MD


Which first-line vasoactive drug is the best choice for children with fluid-refractory septic shock?  A prospective, randomized, blinded study of 120 children compared dopamine versus epinephrine in attempts to answer this debated question in the current guidelines for pediatric sepsis.

Bottom line: Dopamine was associated with an increased risk of death and healthcare–associated infection. Early administration of peripheral or intraosseous epinephrine was associated with  increased survival in this population.

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Typically, empiric treatment for lobar community acquire pneumonia (CAP) in immunized < 5 year olds (preschool) is amoxicillin (45mg/kg BID or 30 mg/kg TID for resistant S. pneumoniae) for outpatient and ampicillin or ceftriaxone for inpatient. Additional coverage with azithromycin is typically recommended for school age and adolescent  patients (>= 5 years), but not necessarily for younger children unless there is a particular clinical suspicion for atypical pneumonia with history, xray findings, or sick contacts.

However, in sickle cell patient with suspicion for acute chest syndrome, azithromycin is recommended for all ages groups, as atypical bacteria such as Mycoplasma are a common cause of acute chest syndrome in patients of all ages with sickle cell disease even young children. In a prospective series of 598 children with acute chest syndrome, 12% of the 112 cases in children less than 5 had positive serologic testing of M. pneumoniae (9% of all cases had M. pneumoniae) (Neumayr et al, 2003).

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Category: Pediatrics

Title: Periumbilical rash (submitted by Greg Shamitko, MD)

Keywords: nickel dermatitis, contact irritant, allergy (PubMed Search)

Posted: 10/1/2016 by Mimi Lu, MD
Click here to contact Mimi Lu, MD


A 12 year old male who recently started middle school presents to the ED with a rash in the periumbilical region that has been developing over the last few weeks. The rash is scaly, somewhat itchy, but otherwise benign appearing. The patient has no known medical conditions other than eczema, and is otherwise well. What is the diagnosis?

Picture courtesy of Mara Haseltine, MD

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Inhaled nitrous oxide gas (N2O) or laughing gas, has a long history of use as anesthetics in dental and medical procedures, and can be used as a single agent for brief pediatric procedures. It has a short half-life of 5 minutes and is eliminated essentially non-metabolized through respirations.
Inhaled N2O has analgesic, anxiolytic, and amnestic properties. The mechanism of analgesia is hypothesized to be similar to that of opioids. Anxiolytic and sedative effect is similar to benzodiazepines and may involve GABA receptors.
The N2O is typically given as a mixture of 30% N2O with 70% O2, although 50:50 mixture is also safe. In the ED, it is usually given as monotherapy, as this meets criteria for minimal sedation. Nitrous oxide concentrations > 50% meet criteria for moderate sedation.
Complications are rare (most commonly, nausea/vomiting). Persistent use or abuse can be habit forming and has been associated with anemia and B12 deficiency. Rare side effects include asthma exacerbation, coughing, laryngospasm, cardiac events, and seizures. High nitrous concentrations can cause hypoxia and asphyxiation if sufficient oxygen isn’t supplied (FiO2 < 25%).

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The pediatric epiglottis is more "U" shaped, often overlies the glottic opening, and is "less in line with the trachea."1 Because of this, it has traditionally been taught that a Miller blade is the ideal laryngoscope.

Varghese et al compared the efficacy of the Macintosh blade and the Miller blade when placed in the vallecula of children between the ages of 1 and 24 months. The blades provided similar views and suffered similar failure rates. When the opposite blade was used as a backup, it had a similar success rate as the opposing blade.2 Passi et al also compared these two blades, this time placing the Miller blade over the epiglottis. Again, similar views were achieved.3

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Category: Pediatrics

Title: Neonatal Jaundice (submitted by Brad Cotter, MD)

Posted: 4/29/2016 by Mimi Lu, MD (Emailed: 4/30/2016) (Updated: 4/30/2016)
Click here to contact Mimi Lu, MD

Neonatal jaundice- Incidence ~85% of term newborns

Bili levels are EXPECTED to rise during first 5 days of life

Be aware of CONJUGATED hyperbilirubinemias (biliary atresia, infection)

Majority of cases due to increase in unconjugated (indirect) bilirubin 2/2 residual fHgb breakdown and insufficient capacity of hepatic conjugation

Severe hyperbilirubinemia (Tbili >20mg/dL) <2% of term infants 

Acute bilirubin encephalopathy(ABE)- Hypertonia, arching, opisthotonos, fever, high pitched cry


Kernicterus (5% of ABE)-CP, MR, auditory dysfunction, upward gaze palsy


When to refer for phototherapy/exchange transfusion

  1. Reference published guides (attached)
  2. Online calculator-


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1604300118_F3.large.jpg (259 Kb)

Category: Pediatrics

Title: Perianal Group A Strep (submitted by Michele Callahan, MD)

Posted: 2/26/2016 by Mimi Lu, MD (Emailed: 2/27/2016) (Updated: 2/27/2016)
Click here to contact Mimi Lu, MD

Perianal Group A Strep is an infectious dermatitis seen in the perianal region that is caused by Group A beta-hemolytic Strep. Children will have a characteristic rash with a sharply-demarcated area of redness, swelling, and irritation around the perianal region. There may be associated swelling and irritation of the vulva and vagina (in girls) and penis in boys. Patients can have bleeding or itching during bowel movements.

The age range is often <10 years of age. There is often an absence of fever or other systemic symptoms.The diagnosis can be confirmed by obtaining a Rapid Strep swab from the area of interest. You can also collect a bacterial culture of the area.

Treatment requires a 14 day course of penicillin. Amoxicillin (40 mg/kg/day divided TID) and clarithromycin are alternative treatments. The additional of topical bactroban (mupirocin) can be effective, but it should not be used as monotherapy. Re-occurrence is common, so close follow-up is key.


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Category: Pediatrics

Title: Pediatric Urinary Tract Infections (UTI) (submitted by Marina Kloyzner, MD)

Keywords: UTI, Fever, febrile, AAP, clinical practice guideline (PubMed Search)

Posted: 10/23/2015 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Fever is the most common presenting symptoms to pediatric emergency departments 10-20%

Of these, 2%-7% have a final diagnosis of a urinary tract infection (UTI).
Timely diagnosis and treatment of UTI is important in the pediatric population as it can progress to pyelonephrits which can lead to scarring of the renal parenchyma and end stage renal disease.
A challenge for the ED physician is whether or not to pursue the diagnosis of UTI in a febrile child with viral URI. However, multiple studies have shown that having a documented URI does not significantly decrease the chance of having a concomitant UTI. Furtheremore, there is a correletion betweent having RSV bronchiolitis with fever and a concurrent UTI.
The latest definition of UTI from the American Academy of Pediatrics (AAP) requires both a urinalysis with pyuria or bacteria and a urine culture with more than 50,000 CFU/mL. 
Methods for collecting urine include urethral catheterization, suprapubic aspiration, clean catch collection and sterile urine bag.
Contamination rates for these methods are as follows:
  • Urine bag 46%
  • Clean catch 14-26%
  • Catheterization 12-14%
  • Suprapubic aspiration 1-9%
Because of the significant rates of contamination, catheterization and suprapubic aspiration are the recommended methods of obtaining urine in children younger than 3 years old.

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Making the wee patient pee – a non invasive urinary collection technique in the newborn

Obtaining a urinary sample in a neonate can be challenging and time consuming. The most commonly used non-invasive technique is urine collection using a sterile bag. This technique is limited by patient discomfort and contamination of the urinary sample. Catheterisation and needle aspiration are other options, but are more invasive.

A prospective feasibility and safety study enrolled 90 admitted infants aged under 30 days who needed a urine sample into the study [1]. They performed the following stimulation technique.


1.     Feed the baby through breast-feeding or an appropriate amount of formula for their age and weight.

2.     Wait twenty-five minutes. After twenty-five minutes clean the infant’s genitals thoroughly with warm water and soap. Dry with sterile gauze.

3.     Have an assistant hold a sterile urine container near the infant

4.     Hold the baby under their armpits with their legs dangling (if short handed, parents can do this)

5.     Gently tap the suprapubic area at a frequency of 100 taps or blows per minute for 30 seconds

6.     Massage the lumbar paravertebral zone lightly for 30 seconds

7.     Repeat both techniques until micturition starts. Collect midstream urine in the sterile container

In the study, success was defined as obtaining a midstream urinary sample within 5 minutes after initiation of the stimulation procedure. There was a 86% success rate (n=69/80). Mean time to sample collection was 57 seconds. There were no complications, but controlled crying occurred in 100% of infants.  The study was limited by the lack of a control group. Previous studies have described longer collection times with traditional non invasive techniques, up to over an hour [2].


Consider the above mentioned stimulation technique to obtain a urinary sample in the neonate.


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Post- streptococcal glomerulonephritis (PSGN) is an inflammatory reaction of the kidneys following infection with group A strep, and can occur sub clinically or have a severe presentation requiring admission, Nephrology consult, and careful management.

This diagnosis should be considered in any child between ages 2-12, or adults over 60, presenting with sudden unexplained hematuria or brown urine.  Patients may also present with generalized edema secondary to urinary protein loss, hypertension, and acute kidney injury.  Since kidney involvement usually trails the throat injection by 2-3 weeks or more, the patient and their family may not relate the two symptoms.  A previous or current diagnosis of strep throat is not necessary to consider a patient for PSGN, since they may test negative by throat culture at the time of urinary and renal symptoms

When considering this diagnosis, the EM physician should order the following lab tests:
- Urinalysis (for casts and protein)
- Creatinine
- ASO Titer (or full streptozyme assay of 5 tests including ASO)
- Complement C3, C4, C50

Treatment is primarily supportive, and many cases will be mild enough to discharge home with pediatrician or Nephrology follow up.  However, some cases may warrant admission for AKI, pulmonary edema, or cerebral edema.  Edema can be managed with sodium restriction and loop diuretics.  Hypertension can be managed with anti hypertension medications.

Renal biopsy can confirm the diagnosis with the presence of epithelial crescents in the glomeruli, but this is only necessary in severe cases where it is important to determine the etiology of the nephritis.

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  • Large vascular supply to the tonsil and the surrounding tissues that do not compress on themselves which can lead to hemorrhage
  • 2 types of hemorrhage - primary and secondary
    • primary - within 24 hours
    • secondary - after 24 hours
      • most commonly POD 5-10
      • median time to bleed is POD 7
  • Bleeding occurs as the fibrin clot sloughs off from the tonsillar pillar (which occurs on day 5-10)
  • Surgery in older children and acute peritonsillar abscess are at increased risk for bleeding
  • Due to the proximity to arteries and the possibility of pseudoaneurysm formation, bleeding post-procedure can result in significant, life-threatening hemorrhage.
  • When assessing these patients, start with the ABCs
    • Assess the airway for compromise, some patients have heavy bleeding that requires intubation to secure the airway
    • Obtain access if needed due to the concern for exsanguination from these areas
  • Patients that have active bleeding or a clot should be referred to surgery (ENT) for cautery of bleeding area
  • Most patients are not bleeding when they reach the ED. If a patient presents with a history of bleeding, they should be observed (no standardized time frame)
  • If the patient has severe bleeding and awaiting the OR, can place gauze soaked with lidocaine with epinephrine on the bleeding area with Magill forceps
  • Topical hemostatic agents may help with bleeding, however, more severe bleeding requires surgery


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Category: Pediatrics

Title: Pediatric DKA (submitted by Anthony Roggio, MD)

Keywords: diabetic ketoacidosis, DKA (PubMed Search)

Posted: 3/27/2015 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

ISPAD (International Society for Pediatric and Adolescent Diabetes) Updated their Guidelines for Pediatric Diabetic Ketoacidosis (DKA) in 2014



·       Begin fluid repletion with 10-20ml/kg of 0.9% NS over 1-2 hours

·       Estimate losses (mild DKA <5%, moderate 5-7%, severe ~10%) and replete evenly over 48 hours

o   Use NS, Ringers or Plasmalyte for 4-6 hours

o   Afterwards use any crystalloid, tonicity at least 0.45% NaCl

·       Add 5% glucose to IV fluid when glucose falls below 250-300mg/dL



·       No bolus

·       Low dose 0.05 - 0.1U/kg/hr AFTER initiating fluid therapy

o   higher incidence of cerebral edema in patients given insulin in 1st hour

·       Short acting subQ insulin lispro or aspart can be substituted for drip in uncomplicated mild DKA

·       Give long acting subQ insulin at least 2 hours before stopping infusion to prevent rebound



·       If K low (< 3.3): add 40mmol/L with bolus IV fluids (20mmol/L if rate > 10ml/kg/hr)

·       if K normal (3.3-5): add 40mmol/L when insulin is started

·       If K high (> 5):  add 40mEq/L after urine output is documented



·       No role for bicarbonate in treatment of Pediatric DKA

o   No benefit, possibility of harm (paradoxical CNS acidosis) 

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Cyanotic (right to left shunt) Congenital Heart Disease (CHD) lesions can be easily remembered with the 1,2,3,4,5 method.

1- Truncus Arteriosis (ONE trunk)

2- Transposition of the Great Vessels (TWO vessels flipped)

3- TRIcuspid Atresia

4-TETRAlogy of Fallot

5- Total Anomolous Pulmonary Venous Return (TAPVR=5 words/letters)

A few other important DUCTAL-DEPENDENT lesions: Coarctation of the Aorta, Hypoplastic Left Heart Syndrome, and Pulmonary Atresia.

Patients present to the emergency department within the first week of life in severe distress, including hypoxia, tachypnea, and hypotension.  The above cyanotic CHD all reflect DUCTAL-DEPENDENT lesions, meaning they need a widely open PDA (which closes in the first week of life) to maintain sufficient oxygenation for viability.

These patients will not survive without timely intervention with prostaglandin (PGE1), so be sure to initiate this life-saving medication as soon as possible!  Side effects include apnea…be prepared to intubate your neonate!