UMEM Educational Pearls - Pediatrics

Category: Pediatrics

Title: Coxsackie Virus Infections

Posted: 6/14/2013 by Rose Chasm, MD (Updated: 5/29/2024)
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 Jennifer Guyther, MD (Updated: 5/29/2024)
Click here to contact Jennifer 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 Jennifer Guyther, MD
Click here to contact Jennifer 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: 5/29/2024)
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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  • CDC recommends pediatric influenza antiviral treatment for those at higher risk for influenza complications, and include the following:
  1. less than 2 years of age;
  2. chronic diseases including: pulmonary (ie asthma), cardiovascular (except hypertension alone), renal, hepatic, hematologic (ie sickle cell disease), metabolic (ie diabetes), neurologic/neurodevelopmental (ie cerebral palsy, epilepsy), and intellectual disability (ie mental retardation)
  3. immunosuppression (ie HIV)
  4. less than 19 years of age and on chronic aspirin treatment;
  5. morbid obesity (BMI>40)
  • adamantanes (amantadine and rimantadine) should not be used due to high levels of resistance to influenza A
  • neuraminadase inhibitors (oseltamivir and zanamivir) should be started within 48 hours of illness onset to reduce the duration and severity of disease
  • oseltamivir can be used in children as young as 2 weeks of age at a dose of 3mg/kg twice daily for 5 days.


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Category: Pediatrics

Title: Rotavirus

Posted: 1/4/2013 by Lauren Rice, MD (Updated: 5/29/2024)
Click here to contact Lauren Rice, MD


Rotavirus is the leading cause of gastroenteritis worldwide and a leading cause of infant death in the developing world.

95% of U.S. children have had a rotavirus infection by the age of 5 years.

Most cases occur in late winter and early spring.

Route of transmission is mostly fecal-oral but may be airborne in cooler months.

Most common presenting signs and symptoms include fever (1/3 of cases), vomiting (in the first 1-2 days), and diarrhea (copious, watery, lasting 5-21 days).

Diagnosis is largely based on clinical manifestations, but antigen assays are available and may be useful in patients with extraintestinal complications, such as hepatitis, pneumonitis, or encephalopathy.

Treatment is largely supportive with efforts to maintain hydration.

Prevention is key to disease control and accomplished with good hand hygiene and widespread vaccination.

Newly implemented vaccine programs worldwide have proven to be effective in decreasing hospitalizations and deaths in developing countries.

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An 18-months old presents with classic symptoms of bronchiolitis.  A trial of Albuterol does not show any objective improvement. What are your other options?
- Nebulized epinephrine: 0.9mg/kg for racemic epi or 0.03 mL/kg of the 2.25% solution (diluted in 3mL) - improves oxygen saturation and respiratory rate, but does not affect admission rates
- Hypertonic saline (3%): decreases hospital length of stay and improves clinical scores, possibly by decreasing airway edema and mucus plugging
- Nasal CPAP: improves ventilation in children with bronchiolitis and hypercapnia
- Heliox: decreases respiratory distress, by reducing gaseous flow resistance and improving alveolar ventilation

Interventions that have shown no benefit and are not recommended:
- Anticholinergics
- oral and/or inhaled corticosteroids

Joesph, M. Evidence-Based Assessment and Management of Acute Bronchiolitis in the Emergency Department. Pediatric Emergency Medicine Practice 2011; 8(3)

Category: Pediatrics

Title: Nasal foreign body removal

Posted: 12/15/2012 by Mimi Lu, MD (Emailed: 12/21/2012) (Updated: 12/21/2012)
Click here to contact Mimi Lu, MD

Parents bring in their child who placed a bead, seed, or other object up her nose.  What do you do?  Who should you call?

Research suggests that a decades-old home remedy (of sorts) known as the “mother’s kiss” may do the trick for children 1-8 years of age. It’s also much less invasive or frightening than some of the tools and techniques used in emergency departments with a success rate approaching 60%

What Is the “Mother’s Kiss”?

First described in 1965, here’s how the mother’s kiss technique works:

  • The parent or caretaker places their mouth over their child’s mouth while holding the unaffected nostril closed with one finger.
  • The parent or caretaker blows into the child’s mouth.
  • The forceful breath may force the object out (warning: may want to wear protective covering as other things have been known to fly out as well!)


Cook S, Burton M, Glasziou P. Efficacy and safety of the "mother's kiss" technique: a systematic review of case reports and case series. CMAJ.2012 Nov 20;184(17):E904-12. doi: 10.1503/cmaj.111864. Epub 2012 Oct 15.



Trampoline injuries doubled between 1991 and 1996, increasing from 39,000 injuries per year to more then 83,000 injuries per year.  Injury rates and trampoline sales peaked in 2004 and have been decreasing since; however, hospitalization rates are still between 3% and 14%.

Risk Factors:

¾ of injuries occur when multiple people are on the trampoline at once

Smaller participants were 14x more likely to be injured then their heavier playmates

Falls account for 27-39% of all injuries

Springs and frames account for 20% of injuries

Up to ½ of injuries occur despite adult supervision

Injury types:

Lower extremity injuries are more common than upper extremity

Head and neck injuries accounted for 10-17% of trampoline injuries

Unique Injuries:

Proximal tibial fractures

Manubriosternal dislocations and sternal injuries

Vertebral artery dissection

Atlanto-axial subluxation

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Category: Pediatrics

Title: Fever and neck pain (submitted by Connor Lundy, MD)

Keywords: meningitis, neck pain, retropharyngeal abscess (PubMed Search)

Posted: 11/16/2012 by Mimi Lu, MD
Click here to contact Mimi Lu, MD


A 1 year old gets sent from their pediatrician’s office for rule out meningitis. They presented with fever for 2 days and neck rigidity. Your LP results are normal. What additional test should you consider?

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