UMEM Educational Pearls - By Jennifer Guyther

Category: Pediatrics

Title: Pediatric Migraine Therapy

Keywords: migraine, sodium valproate, headache (PubMed Search)

Posted: 6/19/2015 by Jennifer Guyther, MD
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Sodium valproate (VPA) had been studied and found to be effective in the adult population for migraines, but not in the pediatric population.  This article was a small (12 patient) retrospective study of pediatric migraine patients looking at pain scores before and after VPA administration.  Prior to VPA, patients received NSAIDs, dopamine antagonists, IV fluids and narcotics.  Mean pain reduction prior to VPA was 17%.  After VPA, pain scores were reduced by an additional 36%.

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Lice are spread through direct contact as they crawl. Indirect contact (through brushes or hats) is less likely. One study showed that live lice were found in only 4% of infested volunteers pillowcases.

During an initial infestation, lice can reside on the head for up to 4 to 6 weeks before becoming symptomatic. Therefore, when lice are detected at school, there is no need to send the child home (or to the ED). Children also do not need to be kept out of school while receiving treatment.

Bonus: First line treatment is 1% Permethrin applied on day 0 and 9. The patient should wash their hair first with a non conditioned shampoo, apply Permethrin for 10 minutes and then rinse.

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Category: Pediatrics

Title: Traumatic Lumbar Punctures in Infants 1 to 2 months

Keywords: Traumatic lumbar punctures, fever, infants (PubMed Search)

Posted: 4/17/2015 by Jennifer Guyther, MD
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Approximately ¼ of lumbar punctures (LP) are traumatic or unsuccessful in infants.  What is the implication of this?

A retrospective cross sectional study over a 10 year period at Boston Children’s Hospital looked at infants aged 28 to 60 days who had blood cultures sent from the Emergency Department and who had LPs performed. The ED clinicians at this facility routinely follow the “Boston Criteria” to identify infants at low risk for spontaneous bacterial infection (SBI).  Traumatic LPs were defined as CSF red cell count greater than or equal to 10x10^9 cells/L while an unsuccessful LP was defined as one where no CSF was available for cell counts.  A small portion of the unsuccessful LPs did not have CSF cultures sent.

173 infants had traumatic or unsuccessful LPs.  The SBI rate did not differ between the normal LP and the traumatic and unsuccessful LP infants.  Median hospital charges were higher in the traumatic or unsuccessful LPs compared to the normal LP group ($ 5117 US dollars versus $ 2083 US dollars).

Bottom Line:  Traumatic or unsuccessful LPs lead to higher hospital charges.

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Upper gastrointestinal (UGI) bleeds accounts for only 0.2% of complaints for children presenting to the pediatric emergency department. However, these children can present in significant distress. In fact, critically ill children with UGI bleeds while in the ICU had an increase mortality rate compared to those without UGI bleeds.
There is a long differential for the cause of the bleeding, although age may be a clue. In the first month of life, consider maternal blood ingestion or vitamin K deficiency. In infants and toddlers, think of reflux esophagitis or ingestion. In older children, consider ulcer disease.
Remember to ask about different food ingestions that may mimic blood: licorice, red drinks, red fruits and vegetables, spicy/hot flavored snacks, bismuth, and iron.
Key points to remember in the management of pediatric patients:
-Gastroccult (NOT hemoccult)
-Apt-Downey test (looking for maternal blood)
-XRs indicated only for concern of ingestion
-NG lavage are done in 3 to 5 ml/kg aliquots
-If your patients have a G-tube, lavage through this may lead to false-negative findings or underestimation of the severity of the bleeding.

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This study is a case control study of the association of congenital heart disease (CHD) and stroke using a base population of 2.5 million Kaiser patients in California. 412 cases of stroke were identified and compared to 1236 controls. Of these stroke patients, 11/216 ischemic strokes and 4/196 hemorrhagic strokes were attributed to CHD (both cyanotic and acyanotic lesions). CHD was found in 7/1236 controls.

Children with CHD and history of cardiac surgery had the strongest risk of stroke (31 fold over the control group). Many of these children had strokes years after their surgery. Children with CHD who did not have cardiac surgery had a trend towards elevated stroke risk, but the confidence intervals included the null. More children without CHD history presented with headache.

Bottom line: Stroke risk (both hemorrhagic and ischemic) extend past the immediate postoperative period in patients with CHD.

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Of pediatric patients who have anteroposterior (AP) pelvic xrays (XR), there is a 4.6% rate of pelvic fracture or dislocation, compared to 10% in adults.

This study is a sub analysis of a prospective observational cohort of children with blunt torso trauma conducted by PECARN. 7808 patients had pelvic imaging, with 65% of them having an AP XR. The XR sensitivity ranged from 64-82% (based on age groups) for detecting fractures. All but one patient with a pelvic fracture not detected on XR had a CT scan. The CT scan detected all but 2 fractures both of which were picked up later as healing fractures on repeat pelvic XR. Some of the patients who had a missed fracture on XR were hemodynamically unstable or wound up requiring operative intervention.

The authors support the following algorithm:

-With hemodynamically unstability children, obtain a pelvic XR

-For hemodynamically stable children when the physician is planning to get a CT, there is no indication for XR

Bottom line: Consider using AP pelvic radiographs in the hemodynamically stable patient with a high suspicion for fracture or dislocation who are not undergoing CT.

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Category: Pediatrics

Title: Respiratory season is here

Keywords: Bronchiolitis, wheezing (PubMed Search)

Posted: 12/19/2014 by Jennifer Guyther, MD
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Now that respiratory season is upon us, we are faced with an increasing number of bronchiolitis children. The updated clinical practice guidelines for managing these kids were recently published and emphasize supportive care only.

Some of the key points:

-When clinicians diagnose bronchiolitis on the basis of history and physical examination, radiographic or laboratory studies should not be obtained routinely.

-Medications such as albuterol, nebulized epinephrine or steroids should not be administered routinely in children with a diagnosis of bronchiolitis.

-Nebulized hypertonic saline should not be administered to infants with a diagnosis of bronchiolitis in the emergency department

-Clinicians may choose not to administer supplemental oxygen if the oxyhemoglobin saturation exceeds 90% in infants and children with a diagnosis of bronchiolitis

-Clinicians may choose not to use continuous pulse oximetry for infants and children with a diagnosis of bronchiolitis.

Check out the full guidelines for the quality of evidence and rational behind these recommendations.

The bottom line is that not much really works, and we just need to support their respiratory effort and ensure hydration.

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Category: Pediatrics

Title: Home medication errors in children

Keywords: Medications, overdose, pediatric, over the counter (PubMed Search)

Posted: 11/21/2014 by Jennifer Guyther, MD
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This study looked at the National Poison Database System with regards to out of hospital medication errors in children under the age of 6 over a 10 year period.
-This type of error occurs to 1 child every 8 minutes.
-Analgesics were most common followed by cough and cold preparations, antihistamines and antibiotics.
-27% of errors were due to being given the medication twice, 17.8% were the incorrect dose and 8.2 % were confusion over units of measure.
-Errors occur more often during winter months.
-Serious adverse affects were rare.
Bottom line: Make sure to review the appropriate dose and interval of all medications, including common over the counter supplements

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Category: Pediatrics

Title: Lactate use in pediatrics

Keywords: Lactate (PubMed Search)

Posted: 10/17/2014 by Jennifer Guyther, MD (Updated: 5/29/2024)
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The world of pediatrics is still working on catching up to adult literature in terms of lactate utilization and its implications.  The study referenced looked at over 1000 children admitted to the pediatric intensive care unit. Lactate levels were collected  2 hours after admission and a mortality risk assessment was calculated within 24 hours of admission (PRISM III).  Results showed that the lactate level on admission was significantly associated with mortality after adjustment for age, gender and PRISM III score.

Bottom line:  In your critically ill pediatric patient, lactate may be a useful predictor of mortality.  

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Category: Pediatrics

Title: Cervical spine clearance in pediatrics

Keywords: cervical spine, pediatrics, NEXUS (PubMed Search)

Posted: 9/19/2014 by Jennifer Guyther, MD (Updated: 5/29/2024)
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The NEXUS criteria is widely applied to adults who present with neck pain due to trauma.  While this study did include about 2000 pediatric patients, there were not enough young children to draw definitive conclusions.  For more information on the evaluation of the cervical spine, see Dr. Rice's pearl from 9/7/12.  A 2003 study piloted an algorithm for cervical spine clearance in children < 8 years.

Patients were spine immobilized if: unconscious, abnormal neurological exam, history of transient neurological symptoms, significant mechanism of injury, neck pain, focal neck tenderness or inability to assess based on distracting injury (extremity or facial fractures, open wound, thoracic injuries, or abdominal injuries), physical exam findings of neck trauma, unreliable exam due to substance abuse, significant trauma to the head or face, or inconsolable children.

When the 2 pathways (see attached) were implemented, there was a decrease in time to cervical spine clearance.  There were no missed injuries in the study period prior to implementation of the pathway or once it was implemented.  There was no significant difference in the amount of xrays, CT scans or MRIs.

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1409192317_Cspine_clearence_pathway.docx (52 Kb)

6-7% of kids presenting with upper respiratory symptoms will meet the definition for ABS.

The American Academy of Pediatrics (AAP) reviewed the literature and developed clinical practice guideline regarding the diagnosis and management of ABS in children and adolescents.

The AAP defines ABS as: persistent nasal discharge or daytime cough > 10 days OR a worsening course after initial improvement OR severe symptom onset with fever > 39C and purulent nasal discharge for 3 consecutive days.

No imaging is necessary with a normal neurological exam.

Treatment includes amoxicillin with or without clauvulinic acid (based on local resistance patterns) or observation for 3 days.

Optimal duration of antibiotics has not been well studied in children but durations of 10-28 days have been reported.

If symptoms are worsening or there is no improvement, change the antibiotic.

There is not enough evidence to make a recommendation on decongestants, antihistamines or nasal irrigation.


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Category: Pediatrics

Title: Acute Otorrhea in Children with PE tubes

Keywords: tympanostomy tubes, antibiotics, otorrhea (PubMed Search)

Posted: 7/18/2014 by Jennifer Guyther, MD
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Up to 26% of patients with tympanostomy tubes (PE tubes) can suffer from clinically manifested otorrhea.  This is thought to be the result of acute otitis media that is draining through the tube. Previous small studies suggested that antibiotic ear drops are as effective or more effective and with less side effects for its treatment.  This study compared treatment with antibiotic/glucocorticoid ear drops (hydrocortisone-bacitracin-colistin) to oral Augmentin (30 mg/kg/TID) to observation for 2 weeks.

Study population: Children 1-10 years with otorrhea for up to 7 days in the Netherlands
Exclusion criteria included: T > 38.5 C, antibiotics in previous 2 weeks, PE tubes placed within 2 weeks, previous otorrhea in past 4 weeks, 3 or more episodes of otorrhea in past 6 months
Patient recruitment: ENT and PMD approached pt with PE tubes and they were told to call if otorrhea developed and a home visit would be arranged
Study type: open-label, pragmatic, randomized control trial
Primary outcome: Treatment failure defined as the presence of otorrhea observed otoscopically
Secondary outcome: based on parental diaries of symptoms, resolution and recurrence over 6 months

Results: After 2 weeks, only 5% of the ear drop group compared to 44% of the oral antibiotic group and 55% of the observation group still had otorrhea.  There was not a significant difference between those treated with oral antibiotics and those that were observed.  Otorrhea
lasted 4 days in the ear drop group compared to 5 days with oral antibiotics and 12 days with observation (all statistically significant).

Key differences:  The antibiotic dosing and choice of ear drops are based on availability and local organism susceptibility.

Bottom line:  For otorrhea in the presence of PE tubes, ear drops (with a non-aminoglycoside antibiotic and a steroid) may be more beneficial than oral antibiotics or observation.

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Category: Pediatrics

Title: Indeterminate ultrasound results in kids

Keywords: Ultrasound, pediatrics, appendicitis (PubMed Search)

Posted: 6/20/2014 by Jennifer Guyther, MD
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Ultrasound is gaining favor as a radiation free tool for evaluating appendicitis.  However, we are all faced with a challenge when the ultrasound is unable to visualize the appendix. What is the next step? Do we CT these kids? Observe them?  MRI them? Admit to surgery? Certainly some of these decisions are made by the institution where you practice, but one study looked at the clinical outcomes in kids where the "appendix was not fully visualized."
 -Retrospective chart review in a tertiary Canadian hospital of kids 2-17 who had US for suspected appendicitis (968 pts)
 -526 kids had incompletely visualized appendices:
           55 went to the OR
           160 were observed
                   -105 were discharged home with no return visits
                   - 55 had appendectomies
                    -39 had appendicitis confirmed by pathology
 -311 went home
          58 bounced-back
          1 had appendicitis confirmed by pathology
-442 kids had fully visualized appendices
           232 were consistent with appendicitis
Bottom line: 15% of kids with an incompletely visualized appendix have appendicitis, so serial reexamination is imperative.  If repeat clinical exams are reassuring, then the miss rate (for this study) was <0.3%.

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Category: Pediatrics

Title: Pediatric Mental Health Screening

Keywords: Psychiatric clearance, pediatric (PubMed Search)

Posted: 5/16/2014 by Jennifer Guyther, MD
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Mental health-related visits account for 1.6–6% of ED encounters.  Patients with acute psychosis are often brought to the ED for clearance prior to psychiatric evaluation.  Is this necessary?

Background: Several adult studies have shown that only 0–4% of patients with isolated psychiatric complaints have organic diagnoses requiring urgent treatment.  Routine ED laboratory testing in adults is low yield still, with one study identifying abnormalities in only 2 of 352 patients—both mild hypokalemia.  A pediatric study found that 207 of 209 patients were medically cleared.

This study was a retrospective review of pediatric psychiatric patients presenting to a an urban California hospital.  They examined 798 patients who had an involuntary psychiatric hold placed by a psychiatric mobile response team.

  • 72 (9.1%) were determined to require medical screening (based on patient complaints).
  • Only 35 (4.4%) holds were found to require further medical care prior to psychiatric hospitalization.
  • Total charges for laboratory assessments, secondary ambulance transfers and wages for sitters were $1,241,295 or US$17,240 per patient requiring a medical screen.
  • Patients were in the ED for an average of 7 h with a cumulative time of 5538 hours.

The authors concluded that few pediatric patients brought to the ED on an involuntary hold required a medical screen and perhaps use of basic criteria in the prehospital setting to determine who required a medical screen (altered mental status, ingestion, hanging, traumatic injury, unrelated medical complaint, sexual assault) could have led to significant savings.

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Scabies is considered by the WHO to be one of the main neglected diseases with approximately 300 million cases worldwide each year. One third of cases of scabies seen by dermatologists are in kids less than 16 years old. The belief had been that presentation varies by age.  One French study reported a first time miss rate of more than 41% and an overall diagnostic delay of 62 days.

A prospective, multi center observational study of patients with confirmed scabies sought to determine common phenotypes in children. All patients were seen by dermatologists in France and administered standard questionnaires.  They were divided into 3 age groups, <2 years, 2-15 years and > 15 years.  323 patients were included.

The study found that: 
-infants were more likely to have facial involvement and nodules, especially on the back and axilla
-relapse was more common in < 15 year olds - this was hypothesized to be due to poor compliance with treatment to the head
-family members with itch, or planter or scalp involvement were independently associated with diagnosis of scabies in kids < 2 years
-burrows were seen in 78%, nodules in 67% and vesicles of 43% of patients (see photo)
-itching was absent in up to 10% of patients

Bottom line:  Have a high suspicion for scabies in any rash.



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1404180657_scabies_figures.docx (1,793 Kb)


Parents will often bring children to the ED for evaluation after a minor head injury.  Vomiting has been considered a risk factor for traumatic brain injury (TBI).  Is isolated vomiting clinically significant?
A PECARN study looked at children < 18 years.
Isolated vomiting with minor head trauma was defined as: No history of LOC, GCS of 15, no altered consciousness (ie sleepiness, agitation), no palpable skull fracture or signs of basilar skull fracture, acting
normally per parent/guardian, no scalp hematoma or other traumatic scalp finding (ie abrasion or laceration), no headache (for patients 2-18 y), no seizure after the head trauma, no neurological deficits
(eg, motor or sensory abnormalities) and no amnesia (for patients 2-18 y).
42,112 children were enrolled.
5,557 (13.2%) had a history of vomiting, of whom 815 of 5,392 (15.1%) with complete data had isolated vomiting.
Clinically important TBI (death, neurosurgical procedure, intubation for at least 24 hours for TBI, or hospitalization for 2 or more nights because of the head trauma in association with TBI on cranial CT) occurred in 2 of 815 patients with isolated vomiting compared with 114 of 4,577 with non isolated vomiting.
Of patients with isolated vomiting for whom CT was performed, TBI on CT occurred in 5 of 298 compared with 211 of 3,284 with non isolated vomiting
There was no association found with timing of onset or time since the last episode of vomiting.
Bottom line: TBI on CT is uncommon and clinically important traumatic brain injury is very uncommon in children with minor blunt head trauma when vomiting is their only sign or symptom. Observation in the emergency department before determining the need for CT appears appropriate for these children to observe for deterioration.

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Category: Pediatrics

Title: Passive Leg Raise in Children

Keywords: Passive leg raise, hypotension (PubMed Search)

Posted: 2/21/2014 by Jennifer Guyther, MD (Updated: 5/29/2024)
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Passive leg raise (PLR) has been studied in adults as a bedside tool to predict volume responsiveness (see previous pearls from 5/7/13 and 6/17/2008). Can this be applied to children?
A single center prospective study looked at 40 intensive care patients ranging in age from 1 month to 12.5 years.  They used a noninvasive monitoring system that could measure heart rate, stroke volume and cardiac output.  These parameters were measured at a baseline, after PLR, after another baseline and after a 10 ml/kg bolus.
Overall, changes in the cardiac index varied with PLR.  However, there was a statistically significant correlation in children over 5 years showing an increase in cardiac index with PLR and with a fluid bolus.
Bottom line:  In children older then 5 years, PLR can be a quick bedside tool to assess for fluid responsiveness, especially if worried about fluid overload and in an under served area.

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Category: Pediatrics

Title: Maintenance Sodium in the Pediatric Patient

Keywords: hyponatremia, maintenance fluid (PubMed Search)

Posted: 1/17/2014 by Jennifer Guyther, MD (Updated: 5/29/2024)
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What sodium base should be given to children who are unable to eat?  Recent studies have suggested that the traditional teaching of 0.45% normal saline (NS), 0.33% NS or 0.2% NS may cause iatrogenic hyponatremia when compared to an isotonic solution (0.9% NS, Ringers lactate or Hartmann's solution).  
A meta-analysis of 8 studies with 855 patients examined the rate of hyponatremia when using hypotonic versus isotonic solutions.
-Studies included were randomized controlled trials with children age 1 month to 17 years.
-Children needing any type of resuscitation were excluded.
-Hyponatremia was defined as a sodium < 136 mmol/L.
-There is a higher risk when using hypotonic fluids for developing hyponatremia (RR 2.24) and severe hyponatremia (RR 5.29).
-The decrease in sodium was greater when hypotonic solutions were used.
-No significant difference in the rate of hypernatremia (Na>150 mmol/L)
-The type of fluid given (not rate) correlated with the risk of hyponatremia.
-Conclusions could not be drawn on the clinical significance of the iatrogenic hyponatremia
Bottom line: Make a conscience decision about maintenance fluids.  Be sure to monitor Na levels for patients that you place on maintenance fluids and who are in your ED for prolonged periods of time.

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Please see below for the correct information.
-Birth weight doubles by 4 months, triples by 12 months and quadruples by 24 months
-After age 2, normal weight gain averages 5 pounds per year until adolescence
-Birth length increases by 50% at 1 year
-Birth length doubles by 4 years and triples by 13 years
-After age 2, average height increases by 2 inches per year until adolescence

Category: Pediatrics

Title: Abdominal pain and fever

Keywords: Intussusception, abdominal pain, fever (PubMed Search)

Posted: 11/10/2013 by Jennifer Guyther, MD (Emailed: 11/15/2013) (Updated: 11/16/2013)
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Case: A 3 year 9 month female presents with fever to 39.4 C and intermittent abdominal pain worsening over 2 days.  The patient had been tolerating food and had no change in her bowel habits.  Based on the imaging below, what is your diagnosis and treatment?

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