UMEM Educational Pearls - Pediatrics

Children account for up to 20% of emergency department visits.  In the US, up to 90% of children’s visits to emergency departments are to general EDs.  The weighted pediatric readiness score (WPRS) was developed to assess the level of readiness of emergency departments to care for pediatric patients. The last assessment was in 2013 showed a mean score of 68.9.  High readiness scores have been associated with decreased mortality.  The same holds true for children with injuries presenting to trauma centers.  The higher the WPRS score, the lower the risk of in hospital death.  There was no difference if the patient presented in cardiac arrest.  A 10 point increase in WPRS is associated with a lower odds of potentially avoidable transfers in both trauma and medical patients.  More recent data has been collected, but has not yet been published.  More information on pediatric readiness (for hospitals and EMS) can be found at: https://emscimprovement.center/domains/pediatric-readiness/. 

Bottom line: Being Pediatric Ready improves the care of children.

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A recent randomized control trial published in JAMA Pediatrics in January 2025 showed improvement in first attempt for IV access when using ultrasound in the pediatrics ED. 

This trial was performed at a quaternary pediatric hospital in Australia with a total of 164 patients (ages 18 and younger). Median age of the patients was 24 months. There was computerized system that randomized patients into either getting an IV by standard procedure vs ultrasound-guided. Those placing the ultrasound-guided IV had extensive training. Overall, the first time success rate was higher in the ultrasound group with about 85.7% compared to 32.5% in the standard group.

Main point: US IV decreases the number of sticks a child has to experience for IV access with a higher first stick success rate. Consider US IV training in your Pediatric Emergency Department in the future. Also use ultrasound guidance with first attempt IV access for your chronically ill children or for very anxious parents.

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Premature infants in the NICU are often given caffeine to help to prevent apneic episodes and this has been proven safe.  This study aims to determine if caffeine will help infants < 8 weeks with bronchiolitis, even if there is no concern for apnea. The current recommended treatment for bronchiolitis is supportive care.

2 French Hospitals with the same protocols and resources for bronchiolitis participated.  All infants admitted to each hospital with a diagnosis of bronchiolitis were included.  Infants who presented to Hospital A received caffeine and infants who presented to hospital B did not.  The remainder of their care was similar.  The caffeine was given as a bolus dose followed by a daily maintenance dose until there was clinical improvement.  The dose was the standard dose used in premature infants with apnea as recommended by the French National Authority for Health.  There were 26 patients at the study hospital that did not receive caffeine for an unknown reason.  65 patients received caffeine.

The study had several areas showing statistical significance:

In the subgroup of RSV + patients, those who did NOT receive caffeine had a higher incidence of requiring ventilatory support.  

The use of high flow nasal cannula was HIGHER in the group with NO caffeine.

The use of CPAP was HIGHER in the caffeine group BUT the duration of CPAP use was shorter compared to the NO caffeine group.

The need for nutritional support was higher in the NO caffeine group.

There were a few cases of temporary tachycardia and irritability in the caffeine group which resolved several hours after the medication was given.

A larger study is needed, but in this small group, there may be an indication for caffeine outside of the NICU for infants < 8 weeks.

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As we enter cold and flu season, sinus issues become commonplace in the ED. What do we need to know about pediatric sinusitis?

First, it is important to know when pneumatization of the sinuses occur (so we don't look for symptoms where they can't be present). Completion of their development does not occur until around age 21 years. 

• Ethmoid and Maxillary sinus- present at birth continue to develop over time
• Frontal sinus- does not develop until around age 7 years
• Sphenoid sinus- not present until the teen years

Sinusitis should be a clinical diagnosis and does not require imaging unless there is concern for abscess development, cellulitis or other complications, or in cases where symptoms are not improving despite treatment.

In most otherwise healthy children, acute sinusitis is typically viral in nature, regardless of the color of nasal discharge, and can be managed with symptomatic care, including saline sprays, humidifiers, warm compresses and monitoring. 

There are strict criteria for otherwise healthy children regarding when to initiate antibiotics including:

• patients with persistent symptoms of pain over the sinuses and nasal drainage for at least 10 days
• patients with URI symptoms AND purulent discharge AND high fever for 3 days
• patients with biphasic worsening of symptoms

 The antibiotic of choice is high-dose amoxicillin with or without clavulanic acid (cefpodoxime or cefdinir can be considered in penicillin allergic patients)

Antibiotic stewardship is critical in these patients, as unnecessary antibiotics can result in resistance or undesired side effects. There should be a clear conversation about return precautions with parents including education about the importance of symptomatic management over antibiotics in the first 10 days.

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In the pediatric ED, intranasal midazolam is a common choice among providers for procedural sedation. However, with widely varying recommendations, the ideal dose remains a topic of debate.

A recent randomized clinical trial published in JAMA Pediatrics involving 101 children, ages 6 months to 7 years, sought to determine the best dose of intranasal (IN) midazolam for sedation during laceration repair. Researchers compared four different doses: 0.2, 0.3, 0.4, and 0.5 mg/kg.

The primary outcome was achieving adequate sedation for at least 95% of the procedure. Secondary outcomes included the level of sedation, how quickly it took effect, recovery time, satisfaction of clinicians and caregivers, and any negative side effects.

What did they find?

The lower doses (0.2 and 0.3 mg/kg) were found to be less effective and were removed from the study early.

The two higher doses (0.4 and 0.5 mg/kg) both provided similar, adequate sedation for about two-thirds of the children.

Sedation took effect quickly, within a few minutes, and children recovered fast.

Adverse events were rare and not serious.

Satisfaction among both clinicians and caregivers was high across the board.

Bottom line: Consider reaching for higher doses of intranasal midazolam (0.4 to 0.5 mg/kg) for pediatric patients requiring procedural sedation.

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This was a European study examining a screening tool to be used in the ED to indicate the need for further investigation into the concern for possible abuse.  Four questions were taken from other commonly used abuse screening tools that were used outside of the ED.  SCAN questions are as follows:

1. Is the injury compatible with the history, and does it correspond to the child's developmental level?

2. Was there an unnecessary delay in seeking medical help?

3. Is the behavior/interaction of the child and caregivers appropriate?

4. Are there other signals that make you doubt the safety of the child or family?

Any positive answer triggered further evaluation, starting with a complete head to toe assessment and complete history with additional tests added as warranted.  This is only a screening tool and positive answers do NOT mean that abuse has occurred, but should cause you to pause and think further.

These questions showed a "moderate" performance among close to 25000 patients and the questions were comparable in children < 5 years to other/longer screening tools used in Europe.

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Evidence shows the effectiveness of inhaled corticosteroids during pediatric asthma attacks.

A metanalysis from 2020 reviewed 7 different studies between 2009 to 2018 that included patients < 18 years.  The studies compared the use of inhaled corticosteroids to placebo, inhaled corticosteroids compared to systemic corticosteroids, and inhaled corticosteroids in addition to systemic corticosteroids.  Please note that in the studies children were still being treated with albuterol.

The results showed:

-Inhaled corticosteroids would significantly reduce the hospital admission rate when compared to placebo (by about 83%). 

-Inhaled corticosteroids reduced hospital admission rates when compared to systemic steroids only (by 27%) for mild to moderate asthma. 

-When combining systemic steroids with inhaled corticosteroids, the hospital admission rate would be reduced by 25% compared to using only systemic steroids for moderate to severe asthma attacks.  

Bottom line: Consider administering inhaled corticosteroids in pediatric asthma patients.

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The first attempt success rates for neonatal intubation is less than 50%.  Video laryngoscopy (VL) has been shown to improve state first pass success compared to direct laryngoscopy (DL) in both children and adults, but few studies have looked at the neonatal population.

This study was a randomized control trial.  There was a 74% first pass success rate for VL compared to a 45% first pass success rate for DL.  There were no differences in secondary outcomes which include hypoxia, bradycardia, epinephrine administration, oral trauma and correct positioning.

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Trauma is a leading cause of death in pediatric patients.  The  Pediatric Traumatic Hemorrhagic Shock Consensus Conference Recommendations have stated that blood products are better than crystalloid and recommend the use of low titer type O whole blood (LTOWB) over individual components for pediatric traumatic resuscitation.

This study used the Trauma Quality Improvement Program Database to look at 1122 pediatric patients (< 18 years) over a 3 year period to retrospectively examine the impact of the ratio of whole blood and blood products given during the resuscitation of these patients. When at least 30% of the blood products delivered within the first 4 hours of resuscitation were low titer O whole blood, survival improved at the 6, 12 and 24 hour time mark.
 

The authors concluded that the observed survival benefit supports the greater availability and use of LTOWB during pediatric trauma resuscitation.

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Intranasal (IN) midazolam is often used for anxiolysis in pediatrics prior to procedures.  In this study, 0.2 mg/kg of IN midazolam (up to 6 mg total dose) was given prior to laceration repair in children 2-10 years.

90% of children were at least minimally sedated at the start of the procedure and these children also displayed less anxiety when measured on a standardized anxiety scale.  

Children's whose procedure started 10-20 minutes after IN medication compared to 25-35 minutes had significantly lower anxiety.

IN midazolam can be successful as an anxiolytic, but careful attention should be directed at the timing of the procedure.

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As the weather warms up, remember that pediatric patients have some physiologic factors that increase their risk of heat related complications. Approximately 37 infants die in cars annually, with risk of vehicular related heat illness starting with outdoor temperatures as low 72°F (32°C). Approximately 9,000 high school athletes require treatment for heat related illness annually with approximately 2 deaths per year. 

Physiology:

Infants and young children have physiologically limited thermoregulation. They also may lack developmental abilities to impact their environment (they cannot ask for water, remove clothing or a seat belt, or move themselves to a cooler environment). 

Older children take longer to acclimate to environments than their adult counterparts- requiring 10-14 days to adjust to work outs in higher temperatures (a gradual approach of increasing gear over time has been recommended for outdoor sports requiring padding or heavy equipment)

Management:

Heat exhaustion/stroke- focus on cooling the patient with temperatures being monitored with a core measurement. In teens and older children this can be done in a similar manner to adults- with removal of clothes, emersion therapy for heat stroke. In infants and young children, some experts favor evaporative management over emersion due to reflex bradycardia as well as patient compliance. 

There are no recommended medications for use during heat stroke. Benzodiazepines may be utilized to present shivering or to treat seizures only if needed.  

Prevention:  

For athletes steps should include encouraging hydration (flavored drinks have been shown to increase consumption and improve hydration), developing strategies for acclimatization for athletes, and have materials present (ice baths) to intervene quickly for players with symptoms. For infants and young children car alarms or reminders, and practicing placing a needed item in the back seat can prevent parents from inadvertently leaving a child in a car.

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While there are numerous evidence-based recommendations for the management of febrile infants, there are not clear guidelines for the management of hypothermic infants (0-90 days).

A recent review article offered the following summary points from the literature:

The World Health Organization defines hypothermia as a temperature < 36.4 degrees Celsius while the International Pediatric Sepsis Consensus Conference uses < 36.0 degrees Celsius.  A multicenter study attempted to empirically derive a threshold for hypothermia but was not successful.

One study looking at the age of presentation of hypothermic patients showed that > 50% of the infants that presented were < 7 days old.

There are numerous reasons that an infant can be hypothermic, including bacterial infections such as urinary tract infections, bacteremia or meningitis, viral infections (herpes simplex virus) or environmental factors.  Premature infants can also have temperature instability as can those with insufficient caloric intake.

Serious bacterial infection (defined as urinary tract infections, bacteremia or meningitis ) occurred less frequently in hypothermic infants compared to febrile infants, but the rates of invasive bacterial infections (defined as bacteremia and meningitis) were the same between the two groups.

In 112 patients with neonatal HSV, 5.2% of the cases were hypothermic, 30.9% had fever and 63.9% had no change in temperature.

Important questions/exam findings to raise suspicion for a pathological cause of hypothermia:

Perinatal history: Gestational age, GBS and HSV status of mom, perinatal antibiotics, and potential exposures to HSV.

Weight change, activity change, interest in feeding, abnormal movements, changes in breathing pattern, ill appearance

Some institutions will group the evaluation of hypothermic infants into the febrile infant guidelines, but there are currently no evidence-based pathway's.  Striking a balance between over testing and not missing a serious bacterial infection is difficult and an area that requires additional research.

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2024 brought us an excellent new decision tool to prevent excessive radiation for children. NOTE: These are vastly different than adult criteria.  

In children with traumatic injuries, most will NOT require CT imaging.  

This study included over 22,000 patients (age 0-17 years) who were evaluated following blunt trauma. A rate of <1% were found to have c-spine injuries. Excluded from the study were strangulation patients, intoxicated patients, and predisposing conditions including prior fracture. 

Indications for considering CT C-spine include ANY of the following: 

• GCS 3-8 
• AVPU = U 
• Abnormal ABCs 
• Focal Neuro Deficits

Indications for consider C-spine XRs include ANY of the following: 

• GCS 9-14 
• AVPU = V or P 
• Self-reported neck pain 
• Neck tenderness 
• Substantial head or torso injuries (requiring observation or OR)

Abnormal XR findings should receive further evaluation as per standard of care.  

The remaining patients may have their c-spine cleared.

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Have you been wondering what the latest pediatric emergency medicine lecture says?

See the attached table from this review which highlights the 10 top articles from 2024 with their key findings!

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Attachments

• Top 10 PEM articles 2024-67ebfc5c9db41.pptx (238 Kb)

Presentation:

JME is a common cause of juvenile/adolescent seizures. 
Patients typically present between 12-18 years of age with a combination of myoclonic movements, absence seizures and generalized tonic-clonic seizures. 
This diagnosis is often mistaken for morning clumsiness due to the myoclonic movements and asking about myoclonic movements can help make the diagnosis.

Diagnosis:

Diagnosis is primarily based on history. Myoclonic seizures are required to make the diagnosis. Patients with consistent history can receive outpatient EEG to confirm the diagnosis. 
No ED images or tests needed with the correct clinical history and return to baseline. (even outpatient with appropriate history imaging is not needed as it is usually normal)
 

Treatment:

Valproic acid is typically the treatment of choice for patients though must be used with caution in women of childbearing age. Other common treatment options include levetiracetam and lamotrigine. With the correct clinical history, these can be started in the ED. 

Be sure to discuss good sleep hygiene and avoidance of alcohol with patients as these can be triggers.

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This was a retrospective analysis of pediatric cardiac arrests that occurred out of hospital in Japan, where no pediatric termination of resuscitation is allowed.  1007 arrests were included.  Patients that were placed on ECMO were excluded.  This study included both medical and traumatic arrests looking at a primary outcome of 1 month moderate or better neurological disability.  CPR time for both EMS and the hospital prior to ROSC were included.  Bystander CPR was not included in these calculations.  Possible downtime prior to CPR was not taken into consideration.

Overall, less than 1% of pediatric patients exhibited one-month moderate disability or better neurological outcome when total CPR duration is more than 64 minutes.

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Simple Febrile Seizures are a very common cause for presentation to the Emergency Department. 

Up to 5% of children will have one in their lifetime, and a single febrile seizure increases risk of recurrence. 

Definition:

• Age 6 months to 60 months (5 years)
• <15 minutes of seizure activity
• No focal seizure activity
• Fever of >100.4 within 24 hours
• 1 seizure within 24 hours
• Return to baseline with no focal deficits
• No history of seizures without fever (this is provoked

While not part of the formal definition, the following details are critical to obtain on history, and high risk features that should not be missed on initial evaluation:

• Antibiotics use (within 48 hours of the seizure)
• Vaccination status

Evaluation and Management:

Consider a finger stick

Most patients can be discharged to home after a period of observation - most use a 2-4 hour minimum. More recent literature suggests considering a longer observation period in patients who have seizures at lower core body temperatures (<39°C) or those with a history of recurrent simple febrile seizures (2 simple febrile seizures within 24 hours with return to baseline in between)

Obtain a lumbar puncture in all patients with symptoms of meningitis 

Consider a lumbar puncture, lab evaluation, and prolonged observation in patients who are under-vaccinated/unvaccinated/unknown vaccination status between 6 months and 12 months of age, or received antibiotics within the last 48 hours

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This was a retrospective cohort study of the national trauma data bank that included about 64000 pediatric trauma patients in the derivation group and the same amount in the validation group.  The authors empirically created upper and lower cut off values for the shock index based on age.  They compared the shock index based on age cut offs with major trauma as defined by the standardized triage assessment tool criteria.  

The empirically derived age adjusted values had a sensitivity of 43.2% and a specificity of 79.4% for major trauma.  The sensitivity of the pediatric shock index (PSI) in that same group was 33.9% with a specificity of 90.7%. The pediatric-adjusted shock index (SIPA) had a 37.4% sensitivity and 87.8% sensitivity for 4-16 year olds.

Shock index = (Heart Rate / Systolic BP)  

• Shock Index, Pediatric Adjusted (SIPA)
  • 4-6 years = 1.2
  • 6-12 years = 1
  • > 12 years = 0.9
  • Patients with an elevated SIPA had a 3.82 odds of major trauma compared to those with a normal SIPA.

Pediatric Shock Index (PSI)

For children age 1-12 years

SI > 1.55 - (0.5) x (age in years)

Patients with an elevated shock index had a 5.02 greater odds of major trauma in this study.  

This study used age specific cut offs such as:

1 yr to < 3 years = lower limit of 0.73 and an upper limit of 1.40

(see article for a full table).

Patients with a shock index below the lower limit had a 1.55 greater offs of major trauma and patients with a shock index above the upper limit had a 3.97 greater risk of major trauma.  

Bottom line: Shock index alone has a limited role in the identification of major trauma in children.  Of these three methods for calculating/interpreting shock index, PSI seemed to do better.

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PECARN, in 2012, published a decision tool aimed at helping avoid unnecessary abdominal CT scans in children with blunt torso trauma. While a prior retrospective validation was done, the tool had not been prospectively validated and generally has not been in widespread use as a standalone, although the original paper may have helped to influence development of local pediatric trauma protocols. Recent prospective validation may make the tool more applicable for broader usage.  

The tool is useful as a rule out given that when all criteria are negative, the risk of intraabdominal injury requiring intervention is less than 0.1%.  The criteria are: 

• Evidence of abdominal wall trauma or seatbelt sign 
• GCS <14 and blunt abdominal trauma 
• Abdominal tenderness 
• Evidence of thoracic wall trauma 
• Abdominal pain 
• Decreased breath sounds 
• Vomiting

If using the rule, it is important to note that the presence of one or more of the criteria does not indicate that the patient needs a CT. Patients who do not rule out should be evaluated based on local pediatric trauma protocols and/or in collaboration with the local pediatric trauma center, which often will involve a stepwise approach based on historical information, laboratory workup, and physical exam findings.

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This was a retrospective, multicenter cross-sectional study of pediatric sedations over 3 years using the Pediatric Sedation Research Consortium database.

85,599 pediatric sedations were included.  These sedations did include the operating rooms.  

8.7% of sedations required an intervention for airway/breathing/circulation in patients who did NOT have procedural oxygenation while 10.1% of patients in the group that did have procedural oxygenation required an intervention.  The majority of these interventions were minor, ie airway repositioning.  The group that did have procedural oxygenation did have a lower rate of hypoxia compared to the group without procedural oxygenation (2.5% vs 4.5%).

The authors concluded that preemptive procedural oxygenation did NOT decrease the overall need for interventions in the ABCs compared to no procedural oxygenation.

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