UMEM Educational Pearls - Pediatrics

  • causes gastric outlet obstruction and vomiting
  • 1 in every 500 infants; with a 4:1 male-to-female ratio and a family history in another sibling
  • symptoms begin 2-4 weeks after birth, with projectile NON-bilious vomiting
  • firm, mobile, nontender, olive-shaped mass in right hypochondrium or epigastric area
  • diagnosis confirmed with US or upper GI series
  • treatment is a pyloromyotomy, but fluid and electrolyte replacement is vital in ED

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You just finished assessing a 6 month old in the Pediatric ED who can’t move his right leg.  You suspect child abuse.  You’re ready to order labs, a head CT, ophtho consult, skeletal survey and call Child Protective Services.   While your doing all of this, your medical student asks you, “What exactly are you looking for on the skeletal survey?”

A skeletal survey is mandatory for cases of suspected child abuse in children under the age of 2 years.  Approximately 60% of the fractures seen in abused children are younger than 18 months old.

When you are looking at a skeletal survey, carefully look for the following:

1. Multiple, healing fractures of various ages

2. Rib fractures, especially in the posterior ribs

3. Metaphyseal chip and buckle fractures

4. Spiral fractures in long bones (especially in children that can’t walk)

5. Skull fractures which are not simple and linear

6. Scapula fractures

 

More to come about child abuse…. 

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Most of us are at least vaguely familiar with Kawasaki Syndrome as an acute vasculitis of small and medium-sized vessels, predominantly occurring in patients aged 6 months to 5 years.

Classic Kawasaki is diagnosed by fever for greater than 5 days plus 4 out of 5 classic signs.

  • Mnemonic: “CRASH and burn”
  • Conjunctivitis (bilateral and nonexudative)
  • Rash (polymorphous, ie can look like anything)
  • Adenopathy (cervical, usually greater than 1.5cm and usually unilateral)
  • Strawberry tongue or other oral changes (lip swelling/fissuring/erythema/bleeding, oropharyngeal hyperemia)
  • Hands and feet (induration and erythema, desquamation is a late sign)
  • Burn = fever lasting for >5 days

But what about an 8 month-old with 6 days of fever plus nonexudative conjunctivitis, unilateral cervical adenopathy and a diffuse maculopapular rash?   Send some labs!

Incomplete Kawasaki is defined as fever for >5 days with 2 or more of the classic findings plus elevated ESR (>40mm/hr) and CRP (>3.0mg/dL).  It is most common in infants under 12 months of age. 

Disposition for the 8 month-old?

  • If ESR and CRP are not elevated, discharge to home with f/u in 24 hours to re-evaluate symptoms and for repeat labs if fever persists.
  • If ESR and CRP are elevated, the child needs an echo to evaluate for coronary artery aneurysms. 

 If the echo is normal, follow up in 24-48 hours and will need a repeat echo if fever persists.

TREAT kids with IVIG and aspirin (which generally means admission) if echo is positive, or with normal echo and the presence of 3 or more supplemental criteria:

  • Anemia for age
  • Elevated ALT
  • Albumin<3.0mg/dL,
  • Sterile Pyuria (>10 WBC/hpf)
  • Platelets >450K after 7 days
  • WBC >15,000
 
References:
1) Falcini F, Capannini S, Rigante D. Kawasaki syndrome: an intriguing disease with numerous unsolved dilemmas. Pediatric Rheumatology 2011;9:17
2) American Academy of Pediatrics. Kawasaki Disease. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009. 
 
 

Attachments

2009_Red_Book.doc (384 Kb)


Category: Pediatrics

Title: Child Passenger Safety

Keywords: Passenger Safety (PubMed Search)

Posted: 11/18/2011 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Child Passenger Safety.

Perhaps one of the greatest contributions emergency physicians can provide to society comes in the  form of anticipatory guidance. It is important to take the opportunity during the ED encounter to provide information to parents to prevent future injuries. Child passenger safety is one clear example. With over 330,000 pediatric visits to EDs  across the US annually attributed to motor vehicle collisions, the need to provide clear recommendations to parents on how to restrain their children in their vehicle is paramount. Despite a recent survey of over 1000 EPs in which 85% of respondents indicated child passenger safety should routinely be a part of pediatric MVC discharge instructions, only 36% of EPs knew the latest guidelines on child passenger safety.   The American Academy of Pediatrics provides such guidelines. These recommendations were recently adjusted in 2011.

(1) Infants up to 2 years must be in REAR-facing car seats
(2) Children through 4 years in forward-facing car safety seats
(3) Belt-positioning booster seat for children through at least 8 years old
(4) Lap-and-shoulder seat belts for those who have outgrown booster seats. How does one know when the child has outgrown the booster seat?
     a. Can the child sit with his/her knees bent at the edge of the seat?
     b. Does the shoulder belt lie across the middle of the chest/shoulder?
     c. Does the lap belt lie across the upper thighs and not the abdomen?
(5) Children younger than 13 should sit in the rear seats

Special Thanks to JV Nable, MD, EMT-P for writing this pearl.

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Category: Pediatrics

Title: Newborn Erb Paralysis

Posted: 11/11/2011 by Rose Chasm, MD (Updated: 12/8/2022)
Click here to contact Rose Chasm, MD

  • ocurs with significant lateral traction during vaginal delivery of an infant
  • results in damage to the upper part of the brachial plexus, especially the 5th and 6th cervical roots
  • results in paralysis of hte shoulder and arm
  • the affected arm is held in adduction and internal rotation
  • most resolve spontaneoulsy, but some may require physical therapy after 2 weeks
  • surgery is rarely required, and has poor results
  • always palpate for ipsilateral clavicel fractures!

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Category: Pediatrics

Title: Trick of the Trade: foreign body removal

Keywords: dermabond, glue, foreign body, (PubMed Search)

Posted: 10/21/2011 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Next time you have a small round foreign body that you can't grasp with alligator forceps in the nose or ear.  Advantages: non-traumatic and easy to use. Disadvantages: foreign body must be visualized, adhesion of glue to patient
 
Technique
- apply a small amount of cyanacrylate (e.g. Dermabond) to the wood or plastic end of of a cotton-tipped applicator 
 - under direct visualization, slowly advance the tip until contact is made with the foreign body and allow 30-60 seconds of dry time before extracting the object in a gentle smooth motion .
 
Helpful hints:
- This technique requires: a cooperative patient, good lighting, direct visualization and manual dexterity... if any of the these are missing, you may want to consider an alterative method.-
- The foreign body should be dry and easily visualized so that the risk of accidental contact with the mucosa or tympanic membrane is avoided.
 
Picture submitted by Dr. Adam Friedlander
 
 
Reference:
Davies P and Benger J. Foreign bodies in the nose and ear: a review of techniques for removal in the emergency department. J Accid Emerg Med 2000;17:91–94

Category: Pediatrics

Title: Cerebral Edema in Pediatric DKA

Posted: 10/14/2011 by Rose Chasm, MD (Updated: 12/8/2022)
Click here to contact Rose Chasm, MD

  • 0.3-1.5% of all pediatric DKA cases
  • 21-24% mortality rate
  • usually at 4-12 hours after therapy starts
  • risk factors:  <5years old, new onset diagnosis, increased BUN at presentation, severity of acidosis at presentation, bicarbonate use
  • have low threshold to diagnose and treat:  don't wait to treat for the CT!

Category: Pediatrics

Title: PD-associated peritonitis

Posted: 10/8/2011 by Vikramjit Gill, MD (Updated: 12/8/2022)
Click here to contact Vikramjit Gill, MD

Peritoneal dialysis (PD) is a commonly used form of dialysis for pediatric patients with end-stage renal disease, particularly in children less than five years of age.

One well known complication to this mode of dialysis is PD-associated peritonitis.

Children may present with fever, abdominal pain and a cloudy dialysate.

If peritonitis is suspected, obtain sample of dialysate fluid and send for cell count, Gram’s stain and culture.

Cell count in PD-associated peritonitis is usually WBC >100 with >50% neutrophils.

Both gram-positive and gram-negative organisms are involved with PD-associated peritonitis .  Keep both MRSA and Pseudomonas in mind.

In the ED, empiric therapy should cover both gram-positive and gram-negative organisms. Initiate antibiotic therapy with vancomycin and either a third-generation cephalosporin (ceftazidime) or aminoglycoside, respectively.

For PD-associated peritonitis, intraperitoneal (IP) administration of antibiotics is preferred over IV.

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Category: Pediatrics

Title: Pediatric Concussions - submitted by Mike Santiago

Keywords: Concussion, sports injury, TBI, return to play (PubMed Search)

Posted: 9/30/2011 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

You are seeing a high school football player following a head injury.  After your exam or head CT, you determine the child to have had a mild traumatic brain injury (aka concussion).  You are ready to discharge him home when the parents or coach ask you when he can return to playing football.

A concussion is a form of functional, rather than structural, brain injury that displays no evidence of injury on structural neuroimaging.   Symptoms include transient loss of consciousness, amnesia, vomiting, headache, poor school work, sleep changes, and emotional lability.  Remember that children’s brains (even adolescents) are still developing, and are more prone to prolonged recovery following injury.

Recovery of symptoms usually follows a sequential course.  Current guidelines recommend a stepwise return to play (aka concussion rehabilitation) involving both physical and cognitive rest (e.g. no texting, video games, limited school work).  Once asymptomatic, the patient goes through each stage with at least 24 hours between stages.  If symptoms return during a stage, then the patient is expected to return to the previous stage for 24 hours before attempting the higher stage again. 

 

Return to Play Guidelines:

Rehabilitation stage

Functional Exercise

  1. No activity

Complete physical and cognitive rest

  1.  Light aerobic activity

Walking, swimming, stationary cycling at 70% maximal heart rate, no resistance exercise

  1. Sport-specific exercise

Specific sport related drills but no head impact

  1. Noncontact training drills

More complex drills, may start light resistance training

  1. Full-contact practice

After medical clearance, participate in normal training

  1. Return to play

Normal game play

 

References:

  1. Halstead ME, Walter KD, and The Council on Sports Medicine and Fitness.  Pediatrics. 2010;126:597-615.

Category: Pediatrics

Title: FAST in blunt pediatric abdominal trauma - submitted by John Greenwood, MD

Keywords: ultrasound, intra-abdominal injury, free fluid, blunt trauma (PubMed Search)

Posted: 9/23/2011 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Focused assessment of sonography in trauma (FAST) has been shown useful to detect clinically significant hemoperitoneum in adults, but not in children.  Several studies, including a meta-analysis have attempted to assess the performance of FAST in identifying children with intra-abdominal injuries (IAIs) from blunt abdominal traumas (BAT).
 
In a prospective observational study on 357 children with blunt abdominal trauma, FAST sensitivity = 52% for significant hemoperitoneum, specificity = 96%, PPV = 48%; NPV = 97%.  In the meta-analysis, the identification of hemoperitoneum using FAST protocol (for intra-peritoneal fluid only) the pooled estimate of sensitivity was 80% and specificity 96%.  For the identification of any IAI using FAST protocol the pooled estimate of sensitivity was 66% and specificity was 93%.
 
 
Bottom line:
In children with BAT, FAST has a low to moderate sensitivity but high specificity to detect clinically important free fluid.  While a positive FAST suggests hemoperitoneum and abdominal injury, a negative FAST cannot be used to reliably rule out IAI.

 

References:
1. Holmes J F, Gladman A, Chang C H. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. Journal of Pediatric Surgery 2007; 42(9): 1588-1594.
2. Fox JC, Boysen M, et al. Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg Med. 2011 May;18(5):477-82. 

Category: Pediatrics

Title: Pediatric ECG

Posted: 9/9/2011 by Rose Chasm, MD (Updated: 12/8/2022)
Click here to contact Rose Chasm, MD

  • newborns have a thick right ventricle resulting in a mean QRS axis which points anteriorly and to the right demonstrating a right axis deviation (70-180degress) and large R waves in the precordium
  • by 3 months of age, the QRS axis in the frontal plane shifts to the left with a mean of 65degress (0-125degress)
  • by older childhood, the normal mean QRS axis is -30-100degress)
  • thus, with age the R wave decreases in V1 and increases in V6
  • take home:  right-axis deviation is often a normal finding in children and young adults when you see left-axis deviation in children consider tricuspid atresia, atrioventricular septal defects, and LVH as the most associated conditions

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Category: Pediatrics

Title: Ipratropium in severe asthma

Keywords: severe asthma, decreased hospitalization (PubMed Search)

Posted: 8/26/2011 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Ipratropium bromide (IB, Atrovent) is most efficacious in improving symptoms and preventing hospital admissions due to severe asthma exacerbations when used early and aggressively.  Even in patients with mild to moderate exacerbations, there is also benefit in symptom reduction, decreased number of treatments and duration of treatment, and improved lung function.
 
The National Asthma Education and Prevention Program (NAEPP) consensus recommends multidose protocol of IB every 20 minutes (either 250 or 500 Kg per dose) for 3 doses, during the initial management of severe exacerbations. For those institutions who prefer to give IB by metered dose inhaler (18 Kg per puff, with face mask and spacer for children younger than 4 years),
 
 
Bottom line:
Give ipratropium bromide (atrovent) early and aggressively to decrease hospitalization rates in severe asthma exacerbation.
 
 
References:
1. Dotson K et al. Ipratropium bromide for acute asthma exacerbations in the emergency setting. PediatrEmergCare. 2009 Oct;25(10):687-92; Review.
2. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (Summary Report 2007). In: BusseW, ed. J Allergy Immunol. 2007;120(5):S94Y138. National Institutes of Health National Heart Lung, and Blood Institute.

Category: Pediatrics

Title: Infantile botulism

Keywords: weakness, constipation (PubMed Search)

Posted: 8/20/2011 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Infantile botulism

- acute weakness in previously well infant < 6 months of age
- due to intestinal colonization by Clostridium botulinum, which produces neurotoxin
- spores found in soil, agricultural products and honey
 
Presentation:
initial constipation, followed by lethargy and feeding difficulties
 
Physical:
hypoactive deep tendon reflexes, decreased suck and gag, poorly reactive pupils, bilateral ptosis, oculomotor palsies, and facial weakness.
 
Diagnosis:
C. botulinum toxin in feces or isolation in stool culture (less sensitive)
 
Management:
supportive, admission to observe for respiratory compromise (77% require eventual intubation), antitoxin has resulted in anaphylaxis in infants, no additional benefit with antibiotics (although often used)

1)      C-A-B for CPR. Now recommended to start compressions immediately instead of the conventional rescue breaths.

2)      Capnography during CPR. Continuous capnography recommended during CPR to guide the resuscitation, especially the effectiveness of chest compressions.

a.     If ETCo2 is less than 10 to 15 mm Hg consistently, focus your efforts on improving chest compressions.

3)      Etomidate for RSI induction.  Okay to use in infants and children, BUT not recommended for pediatric patients in septic shock.  Etomidate was not addressed in 2005 guidelines.

4)      Cuffed ET tubes. Acceptable to use in infants and children.

5)      Limit FiO2 after resuscitation.  Keep O2 sats ≥94%.  Avoid hyperoxia.

6)      Therapeutic hypothermia after cardiac arrest.  Recommendation based off of adult data, no pediatric prospective RCT done on this.  This is beneficial in adolescents with out-of-hospital VF arrest.

a.      Consider therapeutic hypothermia for infants and children.

b.      Cool to 32oC-34oC                                      

            

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Acute Poststreptococcal Glomerulonephritis (APSGN) is a sequela of group A beta-hemolytic streptococci (GAS) infection of the skin or pharynx with nephrogenic strains of GAS.  Damage to the kidneys is due to deposition of antigen-antibody complexes in the glomeruli

Presentation:

- Onset of APSGN averages 10 days after pharyngitis and 3 weeks following cellulitis.
- Nephritic syndome - hematuria (classically "coa-colored"), mild proteinuria, edema (periorbital), hypertension
- Additional symptoms: orthopnea, dyspnea (volume overload), lethargy, vomiting, fever, headache

Testing:

- Urinalysis (hematuria, proteinuria), creatinine (with subsequent hyperkalemia, acidosis)
- Bacterial cultures of skin or pharynx not useful as rarely positive at time of presentation
- Antistreptolysin O (ASO) titer elevated if preceding pharyngitis but rarely skin infections
- Antideoxyribonuclease B (anti-DNAse B) titers typically elevated in both
- Suppressed C3 level

Treatment:

- Predominately symptomatic: salt an water restriction
- Treatment of hyperkalemia, hypertension (loop diuretics)
- Antibiotics vs GAS (although does not affect clinical course of APSGN, eradicates GAS in individual and reduces transmission of nephrogenic GAS to community
- Profound renal failure may require hemodialysis or peritoneal dialysis

Prognosis (favorable):

- Hypertension and gross hematuria resolve over weeks (microscopic may last years)
- Proteinuria resolves over months
- Creatinine returns to baseline over 3-4 weeks

 

Reference:

Kit, Brian. Assess the volume status and electrolytes in children with poststreptococcal glomerulonephritis. Avoiding Common Pediatric Errors. 2008. p356-57.


You're called to bedside to evaluate a "lethargic" infant.  You wisely ask for a POCT glucose which returns at 35.  How much dextrose do you give (since you know it's not just "an amp" of D50?

Here's a simple mnemonic:

Rule of 50-100 = multiply type of dextrose solution by ____ factor (ml/kg) to total 50-100

D10 (neonate) x 5-10 ml/kg = 50-100

D25 (infant) x 2-4 ml/kg = 50-100

D50 (child/adolescent) x 1-2 ml/kg = 50-100


Category: Pediatrics

Title: Enterovirus Meningitis

Keywords: Enterovirus, infant, CSF (PubMed Search)

Posted: 7/15/2011 by Mimi Lu, MD (Updated: 7/22/2011)
Click here to contact Mimi Lu, MD

Now that summer is in full swing, the question is: Should the evaluation of the febrile young infant change during the summer and fall months?  And can that affect length of hospitalization and antibiotic use?

Two retrospective cohort studies from the Children’s Hospital of Philadelphia (CHOP) suggest yes!  The addition of enterovirus polymerase chain reaction (PCR) testing to cerebrospinal fluid (CSF) may improve the care of infants with fever during enterovirus season (early June through late October). 

Of note, at CHOP: 1) infants 56 days or younger routinely undergo lumbar puncture during evaluation for fever.  2) Most CSF enterovirus PCR test results (90%) were available within 36 hours; 95% of results were available within 48 hours.

In the King study, having positive enterovirus PCR CSF results decreased the length of hospitalization and the duration of antibiotic use for young infants less than 90 days, supporting the routine use of this test during periods of peak enterovirus season.  In multivariate
analysis, a positive CSF enterovirus PCR result was associated with a 1.54-day decrease in the length of stay and a 33.7% shorter duration of antibiotic use.


Bottom line: Consider adding enterovirus PCR testing to CSF obtained during the evaluation of febrile young infants during enterovirus season, as this may reduce length of hospitalization and duration of antibiotic use.  The effects, however, may be limited at institutions with slower lab turnaround times.

 

References:

1) King RL, Lorch SA, Cohen DM, Hodinka RL, Cohn KA, Shah SS. Routine cerebrospinal fluid enterovirus polymerase chain reaction testing reduces hospitalization and antibiotic use for infants 90 days or younger. Pediatrics. 2007 Sep;120(3):489-96. http://pediatrics.aappublications.org/content/120/3/489.full.pdf

2) Dewan M, Zorc JJ, Hodinka RL, Shah SS. Cerebrospinal fluid enterovirus testing in infants 56 days or younger. Arch Pediatr Adolesc Med. 2010 Sep;164(9):824-30.


  • occurs when the small opening in the abdominal muscles which allows passage of umbilical cord does not completley close after birth
  • allowing intestinal loops to pass through the opening
  • 10% of all children are affected
  • more common in blacks, girls, and premature infants
  • most resolve by age 1year, but consider outpatient referral if becoming larger or still present after 2-3 years of age
  • emergent consultation if not reducible, but rarely as most are harmless

Category: Pediatrics

Title: Nursemaid's Elbow

Posted: 7/1/2011 by Rose Chasm, MD (Updated: 12/8/2022)
Click here to contact Rose Chasm, MD

  • radial head subluxation
  • usually 1-3 years of age
  • often after sudden longitudinal traction on extended arm with wrist in pronation
  • tearing of annular ligament attachment to radial neck, with detatched portion trapped between subluxed raidal head and capitellum
  • children refuse to use affected arm and hold in a flexed pronated position
  • traditionally, reduce by supination of forearm with elbow in 90degrees of flexion
  • newer reduction technique, hyperpronation with elbow flexion has better success rateand less pain

  • second most common vasculitis of childhood
  • leading cause of acquired heart disease in children
  • usually in children <5years old
  • year-round with clusters in spring and winter
  • highest incidence in children of asian decent
  • clinical diagnosis requires fever for at least 5 days and a minimum of 4 of the following:
  1. bilateral conjunctival injection without exudate
  2. rash (often macular, polymorphous with no vesicles, most prominent in perineum followed by desquamation
  3. changes in the skin of the lips and oral cavity (red pharynx, dry fissured lips, strawberry tongue)
  4. changes in the extremities (edema, redness of hands and feet followed by desquamation)
  5. cervical lymphadenopathy

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