UMEM Educational Pearls - By Kathleen Stephanos

It is an often asked question: should I consider the corrected or the chronologic age when determining the need for fever evaluation in a pediatric patient? The 2021 AAP guidelines for the well appearing febrile neonate are widely accepted and apply to neonates under 60 days. These highly practical guidelines are, unfortunately, not applicable to pre-term neonates. The question often becomes what age to use for a pre-term neonate- the age they actually are, or the age they would be if they had completed a full term gestation. 

Hadhud et al attempted to clarify the age utilized in a retrospective review. This looked at febrile 448 pre-term neonates evaluated for fevers. It found that those patients with both a corrected and chronologic age over 3 months had a 2.6% rate of serious bacterial infections or SBI (UTI, bacteremia or meningitis), those with a corrected age under 3 months but a chronologic age over 3 months had a 16.7% rate of SBIs, and those with both a corrected and chronologic age of under 3 months had a 33.3% rate of SBI. 

Overall, these rates of infection are higher than the typically reported in febrile neonates, supporting that pre-term neonates have a much higher risk of infections overall. Ultimately, pre-term neonates should be carefully assessed and a more thorough evaluation is typically warranted in this patient population even if they have reached the generally accepted 60 day marker by chronologic age- use the corrected age.

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The literature is not completely new regarding the use of intranasal dexmedetomidine for pediatric sedation, with several articles confirming noninferiority to benzodiazepines. It is a potent a2- adrenergic receptor agonist, which allows for sedation without analgesic properties. It can be considered for patients who are undergoing PAINLESS procedures. A recent article gave further clarification for dosing considerations when selecting this option. This study assessed varying weight-based doses and found the best effect with doses of 3 to 4 mcg/kg  

 

Importantly, there is limited data that suggests this may result in longer discharge, duration of procedure and total time in the department compared to other sedation methods. Additionally, this option is not always readily available and approved for pediatric patients in every hospital.  

 

Overall, Dexmedetomidine may be an excellent option for painless procedures, such as CT imaging or even MRI based on the literature, when available. 

 

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Category: Pediatrics

Title: Pediatric fever: Is response to antipyretics enough to discharge?

Keywords: Pediatrics, infectious disease, fever, bacteremia (PubMed Search)

Posted: 7/14/2023 by Kathleen Stephanos, MD (Updated: 2/23/2024)
Click here to contact Kathleen Stephanos, MD

This study attempts to answer the age old question: What is the importance of fever in pediatric illnesses?

The authors' goal was to assess if response to antipyretics was associated with bacteremia. This article retrospectively reviewed 6,319 febrile children in whom blood cultures were sent and found that 3.8% had bacteremia.  They then looked at the fever curve in response to antipyretics for these two groups in the emergency department over 4 hours. The study concluded that patients with bacteremia have a higher rate of persistent fever despite antipyretics. It is important to note the limitations of this study. As this was retrospective, it is unclear what clinical findings resulted in blood cultures being sent - most febrile children did not have any drawn (23,999 were excluded for this reason). They did not assess other vital signs, and did not address other bacterial infections (UTI, cellulitis, meningitis, otitis media, etc).  Additionally, while patients with bacteremia did have a higher likelihood of fever, the majority of patients in both groups had fever resolution within 4 hours, and both groups had some children with persistent fevers. 

Overall, this does seem to support the decision to consider obtaining further testing in those children with a persistent fever, but also emphasizes the importance of not using fever resolution alone as support for discharge to home or exclusion of bacteremia from the differential. 

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Category: Pediatrics

Title: Pediatric Shoulder Dislocations

Keywords: glenohumoral dislocations, anterior shoulder, orthopedics, pediatrics (PubMed Search)

Posted: 11/6/2015 by Kathleen Stephanos, MD
Click here to contact Kathleen Stephanos, MD

- Anterior shoulder dislocations often require surgical management in young adults due to recurrence, but are less common in pediatric patients, particularly under age 10

- A study this year showed that 14-16 year olds are similar to 17-20 year olds in recurrence risk (around 38%- when non-operative management), and this is especially true of males.

- The recurrence rate is lower in the 10-13 age group, but there are also less dislocations in this group as well, making this group harder to assess

- Remember to consider both chronologic and bone age if you are deciding to refer a patient for outpatient surgery follow up, bone age is more accurate to determine healing and response to non-operative treatment

- Consider early referral for surgical management and counseling regarding recurrence risk in the 14-16 year age group after anterior shoulder dislocations

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