UMEM Educational Pearls - Pediatrics

Category: Pediatrics

Title: Laceration Repair

Keywords: laceration, suture, absorbable (PubMed Search)

Posted: 8/17/2013 by Jenny Guyther, MD (Updated: 11/30/2023)
Click here to contact Jenny Guyther, MD

A facial laceration on a child can present a unique challenge which is not limited to the initial visit.  The traditional teaching has been to use nonabsorbable sutures and have the patient return in 5 days for removal.  A recent study compared the cosmetic outcome of linear facial lacerations 1 to 5 cm that were closed with either Ethicon fast absorbing surgical gut or monocryl nonabsorbable sutures.  Patients were randomized and returned to the ED in 4-7 days and 3-4 months. Scars were assessed by caregivers and blinded physicians.  Results showed that caregivers preferred absorbable sutures.  Visual analog scores as given by caregivers were not statistically different between the 2 groups at the 3 month mark.  The blinded physicians did give better cosmetic outcome scores to the absorbable suture group which differs from previous studies that had shown equivocal results.  Of note, all absorbable sutures were no longer visible after 14 days.

Bottom line:  Try absorbable sutures the next time you are suturing a child and the parents may be happier and you will not have to try and take out your sutures from a squirming, screaming child.

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Category: Pediatrics

Title: PECARN Head Injury Rule

Posted: 8/10/2013 by Rose Chasm, MD (Updated: 11/30/2023)
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Clinically important traumatic brain injuries are rare in children.  The PECARN study provides decision rules for when to avoid unnecessarily obtaining a CT for children who have suffered head trauma.

For children < 2 years old: <0.02% risk of clinically important TBI

  • Normal mental status
  • No scalp hematoma, except frontal
  • Loss of consciousness < 5 seconds
  • No palpalble skull fracture
  • Normal behavior
  • Nonsevere mechanism (fall < 3ft, pedestrian struck, rollover MVC)

For children > 2 years old: <0.05% risk of clinically important TBI

  • Normal mental status
  • No signs of basilar skull fracture
  • No loss of consciousness
  • No vomiting
  • No severe headache
  • Nonsever mechanism (fall < 5ft, pedestrian struck, rollover MVC)


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Category: Pediatrics

Title: Intranasal fentanyl (submitted by Ari Kestler, MD)

Keywords: sedation, pain management (PubMed Search)

Posted: 7/3/2013 by Mimi Lu, MD (Emailed: 7/26/2013) (Updated: 7/26/2013)
Click here to contact Mimi Lu, MD

Cringing at the thought of sewing up another screaming 2 year old?

Consider intranasal fentanyl.

Who: Young, otherwise healthy pediatric patients undergoing minor procedures (laceration repair, fracture reduction/splinting, etc...)

What: Fentanyl (2mcg/kg)

When: 5 minutes pre-procedure

Where: Intranasal

Why: More effective than PO, less invasive than IV while being equally efficacious.

How: Use an atomizer, splitting the dose between each nostril.


1) Use of Intranasal Fentanyl for the Relief of Pediatric Orthopedic Trauma Pain, Mary Saunders, MD Academic Emergency Medicine 2010, 17:1155-1161.
2) A Randomized Controlled Trial Comparing Intranasal Fentanyl to Intravenous Morphine for Managing Acute Pain in children in the Emergency Department, Meredith Borland, MBBS, FACEM, Annals of Emergency Medicine, March 2007, Vol. 49, No.3, 335-340
3) The Implementation of Intranasal Fentanyl for Children in a Mixed Adult and Pediatric Emergency
Department Reduces time to analgesic Administration, Anna Holdgate, MBBS, Academic Emergency Medicine 2010, 17:214-217.

Lactate is commonly used in the adult ED when evaluating septic patients, but there is a lack of literature validating its use in the pediatric ED.  Pediatric studies have suggested that in the ICU population, elevated lactate is a predictor of mortality and may be the earliest marker of death.
A retrospective chart review over a 1 year period showed that one elevated serum lactate correlated with increased pulse, respiratory rate, white blood cell count and platelets.  Serum lactate had a negative correlation with BUN, serum bicarbinate and age.  Elevated lactate levels were higher for admitted patients. However, the mean serum lacate level was not statistically different between those diagnosed with sepsis and those that were not.
The study included 289 patients less then 18 years who had both blood cultures and lactate drawn.  This community hospital had a sepsis protocol in place that automatically ordered a lactate with blood cultures.  Only previously healthy children were included.
The study is limited by its small sample size and overall low lactate levels.  Despite having a protocol in place, only 39% of patients who had blood cultures drawn had lactate levels available for analysis.  The mean serum lacate in this study was 2.04 mM indicating that the study population may not have been sick enough to determine mortality implications.  There were no serial measurements.

Bottom line:  Consider measuring serum lacate in your pediatric patient with suspected sepsis.  Pediatric ICU literature does suggest that an serum lactate as low as 3mM is associated with an increased mortality in the ICU.

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Category: Pediatrics

Title: Pediatric Appendicitis Score

Posted: 7/12/2013 by Rose Chasm, MD (Updated: 11/30/2023)
Click here to contact Rose Chasm, MD

Risk stratisfication score introducted by Maden Samuel in 2002.

The Pediatric Appendicitis Score had a sensitivity of 1, speciificity of 0.92, positive predictive value of 0.96, and negative predictive value of 0.99


  • Right lower quadrant tenderness = 2 points
  • Cough/Percussion/Hop RLQ tenderness = 1 point
  • Pyrexia = 1 point


  • RLQ migration of pain = 1 point
  • Anorexia = 1 point
  • Nausea/Vomiting = 1 point

Laboratory Values:

  • Leukocytosis = 2 points
  • Polymorphonuclear neutrophiia = 1 point

Scores of 4 or less are least likely to have acute appendicitis, while scores of 8 or more are most likely.

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Emergency physicians are often confronted with the child with acute respiratory failure.  Noninvasive ventilation (NIV) strategies such as continuous positive airway pressure (CPAP) and Bi-level positive airway pressure (BiPAP) can help support the child with reversible airway disease. Some children fail NIV and require endotracheal intubation and mechanical ventilation.
Certain clinical markers have been shown to predict failure of NIV in the ICU setting.  Early identification of failure can reduce the delay to definitive therapy and may further reduce morbidity and mortality.
Simply checking the level of FiO2 one hour after starting NIV can predict failure.  In one prospective cohort, an FiO2 > 80% after one hour reasonably predicted need for intubation in patients with a variety of underlying respiratory pathology.  In contrast, the responder group had mean oxygen requirement of 48% FiO2.
Najaf-Zadeh A, Leclerc F. Noninvasive positive pressure ventilation for acute respiratory failure in children: a concise review. Annals of Intensive Care 2001, 1:15.
Bernet et al. Predictive factors for the success of noninvasive mask ventilation in infants and children with acute respiratory failure. Pediatr Crit Care Med 2005, 6:6.

Category: Pediatrics

Title: Coxsackie Virus Infections

Posted: 6/14/2013 by Rose Chasm, MD (Updated: 11/30/2023)
Click here to contact Rose Chasm, MD

  • enterovirus which lives in digestive tract, and is highly contagious
  • outbreaks worse in summer and fall, but is a self-limited illness
  • causes mild flu-like symptoms such as fever, headache, muscle aches, sore throat. with fever usually lasting less than 3 days
  • hand, foot, and mouth disease: syndrome of painful blisters in oropharynx and plams of hands and soles of feet
  • herpangina: painful blisters in oropharynx, usually posterior in location
  • hemorrhagic conjunctivitis: eye pain with injected conjunctivia
  • serious complications include: viral meningitis and encephalitis, myocarditis, and secondary bacterial infections

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Infant lumbar puncture is often difficut and may require repeated attempts.  The traditional body positioning is lateral decubitus.  Previous studies have examined the saftey of having the patient in a sitting position, and neonatal studies have suggested that the subarachnoid space increases in size as the patient is moved to the seated position.  A study by Lo et al published last month looked to see if the same held true in infants.
50 healthy infants less then 4 months old had the subarachnoid space measured by ultrasound between L3-L4 in 3 positions: lateral decubitus, 45 degree tilt and sitting upright.
This study found that the size of the subarachnoid space did not differ significantly between the 3 positions.  Authors postulated that a reason for increase sitting LP success rate that had been reported in anestesia literature with tilt position could be due to other factors such as increased CSF pressure, intraspinous space widening or improved landmark identification.

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Ultrasound findings of appendicitis

  • noncompressible appendix with an outer diameter in any portion > 6mm
  • appendicolith
  • hyperechoic periappendiceal fat
  • loss of echogenic submucosal layer
  • increased blood flow of the appendix on color Doppler ultrasound scanning
  • periappendiceal collections seen in the absence of a visualized abnormal appendix

Ultrasound images:

  • diarrhea lasting less than 14 days
  • in children, almost all diarrhea is due to an infectious agent
  • most etiologies are self-limited and do not need further evaluation except in the following conditions:
  1. infants < 2 months of age
  2. gross blood in stool
  3. WBC's on microscopic exam of stool
  4. toxic-appearance
  5. immunocompromised child
  6. diarrhea developing while an inpatient
  • therapy is aimed at oral rehydration and providing nutrional needs
  • ORT is best with commerical formulations specific for this as most other clear liquids (juice, sodas) are hypertonic and have excess glucose resulting in ongoing diarrhea-like stools
  • after rehydration, resume the child's normal diet. 

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Category: Pediatrics

Title: Varicella-related stroke

Keywords: stroke, children, infection (PubMed Search)

Posted: 5/3/2013 by Jenny Guyther, MD (Updated: 11/30/2023)
Click here to contact Jenny Guyther, MD

Acute ischemic stroke occurs in 3.3/100,000 children per year.  Up to 30% of these are caused by varicella.  This can be diagnosed if the patient has had varicella infection within the past 12 months, has a unilateral stenosis of a great vessel, and has a positive PCR or IgG from the CSF.

Treatment includes anticoagulation, acyclovir for at least 7 days and steroids for 3-5 days.

Outcome is normally good and spontaneous improvement can be seen.

Inflammation of other arteries, including other areas of the brain, can also be seen.  Treatment options for this can include high dose glucocorticoids and possibly immunosuppresive agents.

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An overweight 5 year old male presents with acute onset abdominal pain that localizes to the right lower quadrant. What are some causes of a limited or nondiagnostic ultrasound study in children?

Acute appendicitis is a time sensitive diagnosis. Ultrasound is frequently used as the initial diagnostic imaging in children. There are several reasons why the appendix may not be visualized, including retro-cecal location, normal appendix, perforation, and inflammation around the distal tip. An additional clinical predictor associated with poor or inconclusive ultrasound results in appendicitis is increased BMI (body mass index).

A study examining 263 pediatric patients found when BMI > 85th percentile and clinical probability of appendicitis was <50%, 58% of ultrasounds were nondiagnostic. Children with a BMI <85th percentile and clinical probability of appendicitis was <50%, had nondiagonstic scans 42% of the time. These trends were also mimicked in the patients with a higher clinical probability of appendicitis. In the child with a nondiagnostic ultrasound, options include observation and repeat ultrasound scan or CT scan, both of which have associated risks.


Schuh S, et al. Predictors of non-diagnostic ultrasound scanning in children with suspected appendicitis. J Pediatr. 2011 Jan;158(1):112-8.

Category: Pediatrics

Title: Otitis Media (submitted by Ari Kestler, MD)

Keywords: antibiotics, wait and see (PubMed Search)

Posted: 4/19/2013 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

2013 AAP AOM Guidelines UPDATE

-AAP released a new clinical practice guideline for diagnosis and management of acute otitis media (AOM).
Key Action Statements:
Diagnosis if presence of middle ear effusion and
(1) moderate to severe bulging of tympanic membrane (TM) or new otorrhea or
(2) mild bulging of TM and recent ear pain or intense erythema of TM
Treatment options:
  • Severe unilateral or bilateral AOM (>6mo): give antibiotics.  Severe AOM is defined as fever >102.2 (39 C), moderate/severe otalgia, or symptoms >48h.
  • Nonsevere unilateral AOM (6-23 months): Advise the parents to consider a period of close observation and follow up (24-72h).  If the childs clinical status deteriorates give antibiotics.
  • Nonsevere bilateral AOM (6-23 months): give antibiotics.
  • Nonsevere unilateral or bilateral AOM (>24 months): Advise the parents to consider a period of close observation and follow up (24-72h).  If the childs clinical status deteriorates, give antibiotics.
Reference: Pediatrics Vol. 131 No. 3 March 1, 2013

Category: Pediatrics

Title: Conjunctivitis

Keywords: Conjunctivitis (PubMed Search)

Posted: 4/5/2013 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD

Children frequently present with "pink eye" to the ED.  When they do, parents often expect antibiotics.  How many of these kids actually need them?  Previous studies have shown approximately 54% of acute conjunctivitis was bacterial, but antibiotics were prescribed in 80-95% of cases.

A prospective study in a suburban children's hospital published in 2007, showed that 87% of the cases during the study period were bacterial.  The most common type of bacteria was nontypeable H. influenza followed by S. pneumoniae.

Topical antibiotic treatment has been shown to improve remission rates by 6-10 days.

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You have diagnosed an infant or child with pneumonia.  How do you decide if they need admission?

The Pediatric Infectious Disease Society and the British Thoracic Society each have guidelines from 2011 to help with this decision.

 The Pediatric Infectious Disease Society recommend inpatient therapy for the following
1) oxygen saturation <90%
2) infants less than 3-6 months of age with bacterial infection being the likely etiology
3) pneumonia from suspected or documented virulent pathogen such as CA-MRSA
4) children in whom home care is questionable, outpatient follow-up is not available or who cannot comply with outpatient therapy
The British Thoracic Society identify risk factors likely to require hospitalization:
1) oxygen saturation <92%
2) respiratory rate > 70 breaths/min (>50 breaths/min in older children)
3) significant tachycardia for level of fever
4) prolonged capillary refill time > 2 seconds
5) breathing difficulty
6) intermittent apnea or grunting
7) not feeding or signs of dehydration
8) chronic medical conditions/comorbidities
"The Management of Community-Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines bythe Pediatric Infectious Diseases Society and the Infectious Diseases Society of America"
"Guidelines for the management of community acquired pneumonia in children: update 2011" BTS

In children, it is important to consider the maximum doses of local anesthetics when performing a laceration repair or painful procedure like abscess drainage. If there are multiple lacerations, or large lacerations, it may be possible to exceed those doses if one is not careful.


Max doses of common anesthetics

  • Lidocaine WITHOUT epinephrine – 4 mg/kg (0.4 mL/kg of 1% lidocaine)
  • Lidocaine WITH epinephrine – 7 mg/kg (0.7 mL/kg of 1% lidocaine)  
  • Bupivicaine WITHOUT epinephrine – 2 mg/kg (0.8 mL/kg of 0.25% bupivicaine)
  • Bupivicaine WITH epinephrine – 3 mg/kg (1.2 mL/kg of 0.25% bupivicaine)


For example, in a 20 kg child (an average 5-6 year old), the maximum doses would be:

  • Lidocaine 1% - 8 ml
  • Lidocaine 1% with epi – 14 ml
  • Lidocaine 2% - 4 ml
  • Bupivicaine 0.25% - 16 ml
  • Bupivicaine 0.25% with epi - 24 ml



  • For added safety, some advocate not exceeding 80% of the max dose in children < 8 years of age
  • Higher concentration of lidocaine beyond 1% does not improve the time of onset or duration of action and may increases the risk of toxicity
  • The addition of epinephrine increases the maximum dose and duration of action, but may be more painful during infiltration
  • If the repair requires large amount of local anesthetic, consider doing an regional block

Category: Pediatrics

Title: Pediatric UTI (Age 2 - 24 Months)

Keywords: UTI, urinary tract infection (PubMed Search)

Posted: 3/8/2013 by Lauren Rice, MD (Updated: 11/30/2023)
Click here to contact Lauren Rice, MD


--The diagnosis and treatment of pediatric urinary tract infections (UTIs) can be broken down into different age groups. The AAP has recently updated its recommendations for children age 2 - 24 months.

--In ill-appearing febrile infants age 2 – 24 months, who require early initiation of antibiotics, clinicians should obtain urinalysis and urine culture by catheterization or suprapubic aspiration prior to administration of the first dose of antibiotics.

--Key components of diagnosing a UTI include: urinalysis with the presence of pyuria (>10 WBCs per µL) and bacteriuria. The ultimate diagnosis relies on identification of >50,000 CFUs per mL of a single urinary pathogen in culture.

--Treatment of most UTIs in well appearing infants 2-24 months can be done with oral antibiotics for a course of 7-14 days. Common antibiotics used include: amoxicillin-clavulanate, trimethoprim-sulfamethoxazole, or cephalosporins (cefpodoxime, cefixime) based on local patterns of susceptibility.

--Febrile infants with UTIs should undergo renal and bladder ultrasound (RBUS) to evaluate the renal parenchyma and identify complications of UTI in children who are not responding to treatment within 48 hours.

--Voiding cystourethrography (VCUG) to diagnose vesicoureteral reflux (VUR) as a cause of UTI should not be obtained routinely, but only in children with abnormal RBUS or with recurrent febrile UTIs.


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Management of the patient with intracranial hypertension represents one of the most challenging situations the emergency physician faces. Doing so in a community setting when the patient is a child is even more daunting. But devising therapies that can safely be given while the patient is being transferred to a tertiary center for definitive therapy is truly cringe-inducing. 
Fortunately, a recent study suggests that 3% saline fits this bill nicely. Given the risk of vasconstriction with hyperventilation and the risk of hypovolemia with mannitol, hypertonic saline has gained has emerged as beneficial therapy when trying to decrease intracranial pressure (ICP) in both children and adults. 
In late 2011, the Loma Linda University Medical Center published a retrospective analysis of their experience using 3% saline during transport of children at risk of elevated ICPs. While they found the expected rise in electrolytes such as sodium, chloride and bicarbonate, importantly they found no adverse effects (such as "local effects, renal abnormalities or central pontine myelinolysis") related to the administration of hypertonic saline, even though 96% of patients received the infusion through a peripheral line.
Bottom line: hypertonic saline appears to be a viable and safe option for use as therapy to decrease ICH during transport of children at risk for intracranial hypertension.

Luu JL, Wendtland CL, Gross MF, et al. Three percent saline administration during pediatric critical care transport. Ped Emerg Care 2011;27(12):1113-1117

This winter season has brought a rise in influenza and RSV activity in Maryland and in many parts of the country. It is also important to remember other potentially lethal infections that are prevalent in the winter and early spring months, such as Neisseria meningitidis. In fact, a recent study2 showed a potential increase in meningococcal disease when influenza and RSV activity is high.

Encapsulated, gram-negative diplococcus
Found in nasopharyngeal secretions, carrier rates 2-30% in normal populations
Age of incidence has 2 peaks: children < 2 years old, teens 15-19 years old
Young adults who live in shared housing, such as college dorms and military recruits

Clinical Presentation:
Early non-specific symptoms of URI, fever, malaise, myalgias
Meningitis: non-specific prodrome + headache, stiff neck (not found in younger children who often present atypically with irritability and/or vomiting)
Meningococcemia: above symptoms + hypotension + petechial rash (>60% of patients)

Early (!) antibiotics: 3rd generation cephalosporins (<3mo: cefotaxime; older infants, children, and teens: ceftriaxone); PCN G is antibiotic of choice for susceptible isolates
Early and aggressive management of shock

Tetravalent vaccine, MCV4 (Menactra, Menveo), available for serogroups A, C, Y and W-135 is given routinely at age 11-12 years old with an additional booster at 16-17 years old. MCV4 does not protect against serogroup B which accounts for 30% of infections.


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Category: Pediatrics

Title: Swallowed foreign body? (submitted by John Greenwood, MD)

Keywords: magnets, bowel perforation, ischemic necrosis, ingestion (PubMed Search)

Posted: 11/30/2012 by Mimi Lu, MD (Emailed: 1/18/2013) (Updated: 1/18/2013)
Click here to contact Mimi Lu, MD


Patient:  A 10 year old female is brought to the ED after swallowing 2 beads (see image).  Based on the findings, what are your concerns and what is the disposition?

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