UMEM Educational Pearls - By Rachel Wiltjer

Sever Disease

• Calcaneal apophysitis – inflammation of the growth plate of the calcaneus
• One of the most common causes of heel pain in adolescents, caused by repetitive stress (overuse injury)
• Most common in those who are involved in sports, especially those with lots of running and jumping
• Symptoms are heel pain and tenderness at/underneath the heel, with possible mild swelling
• Pain is reproduced by squeezing the posterior calcaneus and standing on tip toes
• Does not require imaging for typical presentation
• Treat with reduction of activity (specifically avoid painful activities), NSAIDs, and stretching exercises

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What they are: Clinical practice guidelines put together by an AAP subcommittee over a span of several years based on changing bacteriology and incidence of illness, advances in testing, and evidence that has accumulated

Includes: Healthy infants 8 to 60 days of life with an episode of temperature greater than or equal to 38.0 C who at now at home after being born at home or after discharge from the newborn nursery, born between 37 and 42 weeks, without focal infection on exam (cellulitis, vesicles, etc)

Recommendations:

For the well appearing 8-21 day old:

• Obtain UA (and culture if + UA), blood culture, CSF (including enterovirus PCR if pleocytosis in CSF or seasonal periods), inflammatory markers are optional
• Start empiric antimicrobials regardless of results of UA/CSF or any inflammatory markers
• Infant should be admitted

For well appearing 22- 28 day olds:

• Obtain UA (and culture if +UA), blood culture, and inflammatory markers
  • procalcitonin preferred over CRP if available, ANC is helpful but less so than others
  • several studies used in making these guidelines used more than 1 inflammatory marker
    • Temp >38.5 is considered an inflammatory marker
• If any inflammatory marker is abnormal:
  • Obtain CSF and start empiric antibiotics
    • CSF is optional if no inflammatory markers are abnormal (provider judgment/risk assessment)
  • If CSF is not obtained, infant should be hospitalized for observation
• Discharge home is acceptable if all of the following are true: UA is normal, CSF is normal or enterovirus +, no obtained inflammatory marker is abnormal (or if abnormal they have subsequently had normal CSF testing), return precautions are discussed and follow up is assured within 24 hours for clinical re-examination
  • Infants being discharged home should receive empiric parental antibiotics prior to discharge
• If the infant is hospitalized antibiotics should be started if: CSF with pleocytosis or uninterpretable or if UA is +
  • If workup is normal, antibiotics optional
  • If CSF not obtained, may start antibiotics but not required
• Shared decision making with parents is recommended for decisions regarding LP and disposition in this group

For well appearing 29-60 day olds:

• Obtain UA ( and culture if +UA), blood culture, and inflammatory markers
• If inflammatory markers are normal LP does not need to be performed, antibiotics do not need to be administered (unless UTI present), and patient can be monitored closely at home with follow up in 24-36 hours
• If positive UA in this group with normal inflammatory markers, obtain cath urine culture and start oral antibiotics
• Consider obtaining CSF if abnormal inflammatory markers
• If CSF obtained and normal antibiotics are optional, may be observed in hospital or closely at home
• If CSF is not obtained or is uninterpretable with abnormal inflammatory markers, administer parenteral antibiotics
  • May be observed in hospital or closely at home

Notable changes:

• UTIs have been differentiated from bacteremia and bacterial meningitis, the guideline discourages the use of the historic “serious bacterial illness”
• A 2 step process where decision for catheretized urine culture is based on UA is suggested, UA to be obtained by bag or stimulated void

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• Generally a seasonal illness that circulates in fall/winter (Maryland’s season is October-April)
• Following low incidence since April 2020, there is current ongoing circulation outside of the normal seasonal patterns
• Updated regional trends are available via the National Respiratory and Enteric Virus Surveillance System (https://www.cdc.gov/surveillance/nrevss/rsv/index.html)
• Causes upper respiratory illness characterized by copious nasal secretions which may cause increased work of breathing and necessitate hospitalization
• Severity tends to peak at around day 5 of illness
• In infants younger than 6 months, may also present with poor feeding, lethargy, or apnea
• Risk of apnea is highest in premature infants (post conception age <48 weeks) and infants under 1 month of age
• Routine administration of albuterol has not been shown to have benefit, the most recent AAP guidelines have a recommendation against trial of albuterol (common practices continue to be variable). It should be noted that children with severe disease were excluded from the studies used to make this recommendation.
• Hypertonic saline administration has not shown to be helpful in the ED setting, but may decrease length of stay in patients being admitted
• Consider admission for persistent tachypnea, hypoxia, inability to adequately feed, moderate to severe increased work of breathing at rest, or apnea

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