UMEM Educational Pearls - Pediatrics

Category: Pediatrics

Title: Intussusception

Keywords: abdominal pain, vomiting, bloody stool, altered mental status, lethargy (PubMed Search)

Posted: 6/22/2012 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

 

Intussusception is the telescoping or prolapse of one portion of the bowel into an immediately adjacent segment.

  • age: 3 months to 6 years, most common among 3-12 months (although case reports exist in adults)
  • after constipation, most common cause of abdominal pain in infants and pre-school aged children
  • classic triad: colicky abdominal pain, vomiting, and red currant jelly stools
    • occurs in only 10% -20% of cases
  • although colicky pain is the most common symptom, 15-20% experience no pain
  • vomiting is often the earliest symptom, but may be absent in 30-40% cases
  • most patients (75%) without grossly bloody stool, may be positive for occult blood
  • plain abdominal radiographs may be normal in 30% of cases
  • consider in differential for intants with altered mental status/ lethargy
    • TIPS AEIOU - one of the "I"s is for intussusception
  • choice of radiographic evaluation is institution-dependent
    • ultrasound may be diagnostic but is not therapeutic
    • air or contrast enema can diagnose and treat
    • both are operator dependent

 


Category: Pediatrics

Title: Supracondylar fractures in children (submitted by Mike Santiago, MD)

Keywords: orthopedics, fracture, reduction, elbow (PubMed Search)

Posted: 6/15/2012 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Definition: Fracture of the humerus just proximal to the epicondyles.

-Classification of fracture based on mechanism:
  • Extension type (majority >80%; distal fx segment displaced posteriorly)
  • Flexion type (distal fx segment displaced anteriorly)
-Assessment should be made for neurovascular injuries.
  • Any diminished pulsations or capillary refill should cause concern for vascular compromise (arterial compression, tear, or compartment syndrome).
  • Place a continuous pulse oximetry probe on the affected hand to monitor bloodflow.
  • The radial, median, or ulnar nerves may be affected and should be assessed.
-Look for accompanying fractures of the forearm and wrist and xray those areas if suspected.
-Nondisplaced fractures may follow up with orthopedics within 1 week after posterior long arm splinting (elbow at 90 degrees & forearm in neutral position)
-Displaced fractures require prompt pediatric orthopedic consultation for closed reduction in OR vs operative repair.
-Obtain emergent orthopedic consultation for compartment syndrome, neurovascular compromise, or open fracture.
-Partial reductions in ED likely just increase soft tissue swelling and delay definitive reduction and should be reserved for rare cases of vascular compromise.


References:
Wheeless, CR.  Pediatric Supracondylar Fractures of the Humerus.  Wheeless’ Textbook of Orthopedics.  [Accessed online 4/22/12.] http://www.wheelessonline.com/ortho/pediatric_supracondylar_fractures_of_the_humerus
Ryan, LM.  Evaluation and management of supracondylar fractures in children.  UpToDate.  [Accessed 4/22/2012].  http://www.uptodate.com/contents/evaluation-and-management-of-supracondylar-fractures-in-children

 


Category: Pediatrics

Title: Newborn feeding (submitted by JV Nable, MD)

Keywords: breastfed, formula, obesity, weight gain (PubMed Search)

Posted: 5/25/2012 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Proper Feeding of the Newborn

The emergency physician must be comfortable with providing anticipatory guidance to parents of newborn, especially with regards to proper feeds of the neonate.

Newborns will lose some weight in the first 5-7 days of life. A 5% weight loss is considered normal for a formula fed newborn. A 7%-10% loss is considered normal for the breastfed baby. Most babies regain their birth weight by days10-14 of life. During the first 3 months, infants gain about an ounce a day (30 g) or 2 pounds a month (900 g).  By age 3-4 months, healthy term infants have doubled their birth weight.

Breast-fed Neonates:
- Should be fed every 2-3 hours while awake
- 5-20 minutes of sucking per breast
- May gain weight slower than formula-fed counterparts

Formula-fed Neonates:
- 0.5-1 ounces per feeding every 3-4 hours for the 1st week
- Then 1-3 ounces per feeding every 3-4 hours
- Typical formula contains 20 cal/ounce

In general, overfeeding during the neonatal period has been associated with adult obesity. The American Academy of Pediatrics recommends exclusive breastfeeding for at least the 1st 6 months of life. Earlier switches to formula has been associated with atopy, diabetes and obesity


References:
- Fleischer DM. “Introducing formula and solid foods to infants at risk for allergenic disease.” UptoDate;2012.
- Hammer LD, et al. “Development of feeding practices during the first 5 years of life.”  Nutrition;1999;189-194.
- Philips SM and Jensen C. “Dietary history and recommended dietary intake in children.” UptoDate;2011.
- Prior LJ and Armitage JA. “Neonatal overfeeding leads to developmental programming of adult obesity.” J Physiol;2009:2419.

 

Category: Pediatrics

Title: ALTE (submitted by Jim Lantry, MD)

Keywords: apparent life threatening event (PubMed Search)

Posted: 5/18/2012 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

There has been no link found between Sudden Infant Death Syndrome (SIDS) and an Acute Life Threatening Event (ALTE)

There are several factors that dispute previous claims of each being manifestations of the same disease state:

1)      Timing: approx 75-80% of  SIDS deaths occur between midnight and 6 AM; 80-85% of  ALTE occur between 8 AM and 8 PM 

2)      Prevention: Interventions to prevent SIDS (ex, “back to sleep”) have not resulted in a decreased incidence of ALTE

3)      Risk factors:

a.       SIDS: prone sleeping, bottle feeding, maternal smoking

b.      ALTE: repeated apnea, pallor, history of cyanosis, feeding difficulties

 

BONUS PEARL: A thorough history and physical will lead to the diagnosis for the source of the ALTE in 21%

Pertinent historical items: detailed bystander history of event (parents, EMS), activity and behavior prior to event and any past medical issues or medications (focus on GERD and pulmonary)

Pertinent physical exam: detailed neurological and cardiopulmonary system eval with focus on signs of non-accidental trauma (retinal hemorrhaging, bulging fontanel, bruising) as up to 10% of ALTEs involve some form of abuse

 

References:
1) Blair, PS. Et. Al. Major epidemiological changes in sudden infant death syndrome: a 20-year population-based study in the UK. The Lancet. 2006; 367(9507):314-319
2) Moon, RY, Horne, RSC, Hauck, FR.  Sudden Infant Death Syndrome. The Lancet. 2007; 370(9598):1578-1587
3) McGovern MC, Smith MBH. Causes of apparent life threatening events in infants: a systematic review. Archive Diseases of Childhood. 2004; 89:1043-8.
4) U Kiechl-Kohlendorfer,U, Hof, D, Pupp Peglow, U, Traweger-Ravanelli, B, Kiechl.  Epidemiology of apparent life threatening events. Archive of Diseases of Childhood. 2005; 90:297-300

Category: Pediatrics

Title: Submersion injuries (submitted by Floyd Howell, MD)

Keywords: drowning, submersion, seizure, intubation (PubMed Search)

Posted: 4/27/2012 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Submersion injuries are the 2nd leading cause of accidental death in children with 1/3 of survivors sustaining significant neurologic sequelae.  50% of drownings occur from May to August.

40% of all drowning victims are children under age 4, with males affected 3 times as often as females.  Most drownings occur with 10 feet of safety.  Infants and toddlers drown most often in bathtubs (especially if <1 year old), buckets, toilets, pools and hot tubs (most often the pools are in-ground).  Those with seizure disorders have a 10-14 fold higher likelihood of drowning.

Aspiration of as little as 1-3ml/kg of fluid may cause pulmonary edema, surfactant inactivation or washout, pulmonary shunting with resulting V/Q mismatching, or direct injury to the alveolar membrane. 

Immediate and adequate resuscitation, including intubation, is the single most important factor determining survival.  Always check body temperature as hypothermia is common.  In general, prophylactic antibiotics and steroids are not indicated unless drowning occurred in grossly contaminated water/sewage.  

 
References: 
1. Stewart, C. Pediatric Submersion Injuries: New Definitions and Protocols. Pediatric Emergency Medicine Practice, Apr 2006;3:1-20.
2. Burford, AE, et al. Drowning and Near-Drowning in Children and Adolescents. Pediatric Emergency Care, 2005. 21:9.

Category: Pediatrics

Title: Transfusion guidelines

Keywords: transfusion, anemia, hemoglobin (PubMed Search)

Posted: 4/20/2012 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Children are at higher risk for complications related to the transfusion of blood products compared with adults. So when should we consider transfusion?

 

Normal hemoglobin values:

- highest at birth (14 - 24 g/dL),

- decreasing to 8 to 14 g/dL at 3 months,

- increasing to 10 to 14 g/dL at age 6 months to 6 years, 11 to 16 g/dL at age 7 to 12 years, and 11.5 to 18 g/dL in adulthood.

- Although the number of platelets are in the normal range at birth, their function is impaired.

 

For infants younger than 4 months, thresholds for red blood cell transfusions:

- hemoglobin levels are 12 g/dL for preterm infants or term infants born anemic,

- 11 g/dL for chronic oxygen dependency,

- 12 to 14 g/dL for severe pulmonary disease,

- 7 g/dL for late anemia in a stable infant,

- 12 g/dL for acute blood loss exceeding 10% of estimated blood volume.

 

For infants older than 4 months, thresholds for red blood cell transfusions:

- hemoglobin levels are 7 g/dL in a stable infant,

- 7 to 8 g/dL in a critically unwell infant or child,

- 8 g/dL in an infant or child with perioperative bleeding,

- 9 g/dL in an infant or child with cyanotic congenital heart disease (increased oxygen demand).

- 9 g/dl in children with thalassemia major (to slow bone marrow stimulation)

 

For children with sickle cell disease (SCD):

- threshold is 7 to 9 g/dL, or more than 9 g/dL if the child has previously had a stroke.

- perioperatively for major surgery: 9 to 11 g/dL, and sickle hemoglobin should be less than 30%, or less than 20% for thoracic or neurosurgery.

 

Bottom line:

A threshold of 7 g/dL is indicated for the transfusion of packed red blood cells in most children.

 

 

Reference:

1) Transfusion guidelines in children. Anasethesia and Intensive Care Medicine. 2012;13(1);20–23.

2) Medscape clinical education briefs


  • usually in preschool or early school-age children presenting with tea-colored urine
  • most commonly is postinfectious (following URI)
  • may also have periorbital edema and high blood pressure
  • UA shows blood, and microscopy shows RBC's and RBC casts
  • no definitive emergent treatment, but prognosis is usually good with resolution of symptoms over 8-10 weeks

Show References


It is likely that during ones career in Emergency Medicine, one will be faced with how to work up a child presenting to the ER following exposure to common house electrical current.  The older recommendations were such that all children exposed, received a screening EKG and were admitted to telemetry for monitoring.  However, a relatively recent article in the Annals of Emergency Medicine suggests otherwise.

In fact, after reviewing several studies the authors conclude that, although there is not enough literature to support evidence based practice “guidelines”, there appears to enough evidence to support that practice of “safely discharging these children without an initial EKG evaluation or inpatient cardiac monitoring after a common household current exposure.” This includes both 120V and 220 V exposures.

Clearly, some patients may require work up and/or admission based on other injuries or clinical presentation.

 

References:
Chen E H, Sareen A, Do Children Require ECG Evaluation and Inpatient Telemetry After Household Electrical Exposures? Ann Emerg Med. 2007;49:64-67.


Category: Pediatrics

Title: Paroxysmal Torticollis of Infancy

Posted: 3/31/2012 by Rose Chasm, MD (Updated: 12/8/2022)
Click here to contact Rose Chasm, MD

  • both head tilting to one side and rotation of the chin toward the other side
  • develops during infancy with episodes that last for hours to days
  • idiopathic neurologic condition which wanes after 2 years and stops by 3 years
  • mild delays in fine and gross motor skills are common along with family history of migraines
  • no accepted medical treatment or therapy
  • must have a normal physical and neurological examination that does not include abnormal/assymetric muscle tone, abnormal eye movements, or cranial nerve palsy

Show References


Patellar dislocations:

  • lateral displacement is the most common
  • tender with limited range of motion
  • caused by sudden twisting movement, either with or without contact
  • more common in females and young adolescents
  • reduction by extension of the knee and medial pressure on the patella
  • knee immobilizer and crutches with orthopedics or sports medicine follow up
  • recurrent cases usually require surgery for definitive repair

 

References:
1. http://emedicine.medscape.com/article/90068-overview
2. New England Musculoskeletal Institute. http://nemsi.uchc.edu/clinical_services/orthopaedic/knee/patellar_dislocation.html


Rashes that include palms/ soles

- Hand-Foot-Mouth Disease

- Kawasaki

- Erythema multiforme/ Stevens Johnson's Syndrome/ Toxic Epidermal Necrolysis

- Rocky Mountain Spotted Fever

- Scabies

- Syphillis

 

Rashes that have +Nikolsky's sign

- Scalded Skin Syndrome

- TEN

-  Pemphigus Vulgaris

 

Rashes that desquamate

- Scalded Skin Syndrome

- Toxic Shock Syndrome

- Scarlet Fever

- Kawasaki

- TEN


  • acute gastroenteritis is a self-limited illness
  • however, damage to the brush border of the small intestine mucosa where lactase is present may lead to a secondary lactase deficiency and subsequent inability to digest lactose properly
  • partially or minimally digested lactose moves into the colon where it is fermented by enteric bacteria resulting in hydrogen, carbon dioxide, and acids
  • these byproducts result in symptoms reported for those with lactase deficiency: cramps, abominal pain and distension, and flatulence
  • the increased solute load in the large intestine leads to increased osmotic pressure, causing watery diarrhea
  • early refeeding following gastroenteritis is recommended, but many clinicians recommend dairy restricted diets acutely

Show References


•Hemophilia A is the deficiency of factor VIII, hemophilia B, the deficiency of factor IX.  In this disease, thrombin is not formed by VIIIa or Ixa
•Emergent presentations are due to bleeding. Hemophiliac joints have a higher tendency to bleed, because synovial cells make more tissue factor pathway inhibitor, and so have higher Xa inhibition.
•Especially in severe hemophilia, alloantibodies can develop that neutralize factor VIII.  Presence of an inhibitor may mean decreased responsiveness to treatment with factor concentrate.  Factor VIII in high doses may overcome this.
Labs:
•Hemoglobin, hematocrit, platelets, PT, INR are likely to be normal.  PTT may be normal or prolonged, it is more likely prolonged in severe disease. Draw 2 extra blue-top tubes to be spun and frozen for inhibitor assays.
Management:
•Several studies have shown the safety and efficacy of NSAIDs for pain control for arthritis in hemophiliacs.  However, these studies tend to be small and in select groups of hemophiliacs, under careful supervision.
•DDAVP can be useful in mild hemophilia.  FFP and cryoprecipitate are not used, due to concerns for volume overload and viral transmission.  Recombinant FVIII concentrates are the treatment of choice.  1U/kg will increase plasma levels by 2%.   The severity of the bleeding dictate the goal serum percentage (30-100%) and the time (hours –days) it should be kept at this level.  
•Consult the blood bank and hematology early, for optimal management.

Children & Appendicitis 

  • Vomiting may be the first sign. 
  • Children may not experience anorexia and may actually request food. 
  • Most young children have perforation at the time of diagnosis.
  • Children younger than 2 years of age may have generalized symptoms such as irritability and tachypnea
  • Ultrasonography is useful in evaluation of thin children but is very operator dependent.
  • CT with oral contrast and i.v. contrast may be needed to differentiate intraabdominal structures in thin children

Category: Pediatrics

Title: Growing Pains

Posted: 2/10/2012 by Rose Chasm, MD (Updated: 12/8/2022)
Click here to contact Rose Chasm, MD

  • diagnosis of exclusion
  • bilateral leg pain only in the evening/night
  • should NOT have a limp, pain, or symptoms during the day
  • completely normal physical exam
  • no systemic symptoms, localizing signs, joint involvement, or limitation of activity
  • look for something else if there is anything wrong on review of systems, examination, or imaging studies

Show References


Potential Causes of Neonatal Apnea and Bradycardia

• Central nervous system  

Intraventricular hemorrhage, drugs maternal/fetal, seizures, hypoxic injury, herniation, neuromuscular disorders, brainstem infarction or anomalies (e.g., olivopontocerebellar atrophy), general anesthesia.

• Respiratory

Pneumonia, obstructive airway lesions, upper airway collapse, atelectasis, extreme prematurity  (<1,000 g), phrenic nerve paralysis, severe hyaline membrane disease, pneumothorax, hypoxia, malformations of the chest.

• Infectious

Sepsis, meningitis (bacterial, fungal, viral), RSV

• Metabolic

Hypoglycemia, hyper/hyponatrmia,  hyperammonemia, decreased organic acids, hypothermia.

• Cardiovascular

Hypotension/hypovolemia, heart failure, PDA, anemia, vagal tone.


Category: Pediatrics

Title: Omphalitis (submitted by Jim Lantry, MD)

Keywords: infectious disease, neonatal infections, umbilical disorders (PubMed Search)

Posted: 1/20/2012 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Omphalitis is an infection of the umbilical cord that progresses to invade the surrounding subcutaneous tissue, fat and abdominal wall musculature.  Anatomical defects such as a patent urachus or immulogical defects (LAD or neutropenia) should be suspected for severe, protracted omphalitis or for failure of cord separation beyond 2 weeks of life.
o   Incidence: developed countries the incidence is 0.5-1% of births; mean age of 3.2 days of life
o   Risk factors: a non-sterile delivery, maternal genital tract infection, prolonged rupture of membranes, prematurity, low birth weight, umbilical vein catherization and inappropriate stump hygiene.
o   Signs: periumbilical edema, erythema, tenderness and/or discharge
o   Pathogens: Staph epidermis, group A or group B Strep (perinatally), E-coli, Klebsiella or Pseudomonas. Tetanus is a possibility in developing countries
o   Complications: necrotizing fasciitis, myonecrosis, peritonitis, portal vein thrombosis, abscess, spontaneous bowel evisceration          
o   Treatment: septic work-up with culture of all fluids (urine, blood CSF) and implementation of broad spectrum antibiotics and aggressive fluid resuscitation
 
References:
1) Lee PPW, Lee TL, Ho MHK, Chong PCY, So CC, Lau YL. An Infant with Severe Congenital Neutropenia Presenting with Persistent Omphalitis: Case Report and Literature Review. Hong Kong Journal of Pediatrics. 2010. 15(4): 289-298
2) Louie JP. Essential Diagnosis of Abdominal Emergencies in the First Year of Life. Emergency Medicine Clinics of North America. 2007. 25:1009-1040

There are limited direct comparisons of (intravenous (IV) vs. intramuscular (IM) ketamine for pediatric procedural sedation in the emergency department. The only RCT comparing IV and IM ketamine was by Roback et al. and compared an IV dose of 1mg/kg vs. IM 4mg/kg. The study authors reported less procedural pain with IM administration compared with IV.  However, vomiting occurred more frequently in the IM group, 26.3% compared to 11.9% in the IV group and recovery time was 49 minutes shorter with IV vs IM use.

 
Bottom line: Ketamine may be administered via both IM and IV routes.  IM administration is associated with higher incidence of vomiting, may require repeat dosing, and is associated with longer recovery times.  Age greater than 5 years may predispose to a higher incidence of vomiting.  However, it may be useful for minor procedures where IV access may be difficult or traumatic for the patient. 
 

Route          Onset          Duration             Dose

  IM            3-5 min         20-30min         3-5 mg/kg

  IV             1 min            5-10 min          1-2 mg/kg

 

References: 
1) Deasy C, Babl F. Intravenous vs intramuscular ketamine for pediatric procedural sedation by emergency medicine specialists: a review. Pediatric Anesthesia 2010; 20:787--96.
2) Clinical Procedures in Emergency Medicine, 4th Edition (2004).
3) Green SM et al. Intramuscular ketamine for pediatric sedation in the emergency department: safety profile in 1,022 cases. Ann Emerg Med. 1998 Jun;31(6):688-97.
4) McGlone R. Emergency sedation in children. Utility of low dose ketamine. BMJ. 2009 Dec 22;339.
5) Roback MG et al. A randomized, controlled trial of i.v. versus i.m. ketamine for sedation of pediatric patients receiving emergency department orthopedic procedures. Ann Emerg Med. 2006 Nov; 48(5):605-12.

Category: Pediatrics

Title: Bechet Disease

Posted: 12/30/2011 by Rose Chasm, MD (Updated: 12/8/2022)
Click here to contact Rose Chasm, MD

  • vasculitis of small vessels with neutrophilic infiltration of venules and arterioles
  • classic triad:  painful recurrent oral and genital ulcers with inflammatory eye disease
  • key finding of recurrent buccal apthous ulcers (nearly 100% of patients)
  • diagnosis is made when recurrence of oral ulceration occurs at least 3 times in 1 year plus 2 of the following: recurrent genital ulceration , eye lesions, skin lesions, or positive pathergy test.
  • initial ED treatment is corticosteroids (oral or topical).  Reserve colchicine and pentoxifylline for ulcerative maifestations.

Show References


Category: Pediatrics

Title: Pediatric forearm fractures (submitted by Emilie Cobert, MD, MPH)

Keywords: Bayonet, fracture reduction technique, radius (PubMed Search)

Posted: 12/16/2011 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Pediatric forearm fractures:

- 75% occur at the distal forearm, often include both radius and ulna
- Risk factor for failure of closed management: increased initial fracture displacement
- Increasing use of operative management for these unstable fractures due to unsuccessful closed reduction
- Bayoneted fracture (two fracture fragments that lie next to each other rather than in end-to-end contact) often require pin repair.
- Attempt closed reduction in ED with such maneuvers as traction-countertraction, can be aided by finger traps.
- Other newer techniques include Lower Extremity-aided Fracture Reduction (LEAFR) maneuver (Eichinger, 2011) which utilizes the unaided single provider's lower extremity to place counter-traction on the arm while using dominant hand of provider for traction and the free second hand of provider to realign the deformity (place your flexed knee interlocked just proximal to patient's flexed elbow)
- Splint distal forearm fractures in pronation in long-arm cast.
 
Bottom line: The LEAFR is a newer clinically effective technique for reduction of bayoneted distal radius fractures in children for single providers resulting in decreased rates of operative management.
 
 
References:
Eichinger, JK, et al. A New Reduction Technique for Completely Displaced Forearm and Wrist Fractures in Children: A Biomechanical Assessment and 4-year Clinical Evaluation. J Pediatr Orthop. 2011 Oct-Nov;31(7):e73-9.