UMEM Educational Pearls - Pediatrics

Category: Pediatrics

Title: Magnets in noses...

Keywords: Magnet, Foreign body, pediatric, nose, nasal, perforation (PubMed Search)

Posted: 6/10/2011 by Adam Friedlander, MD (Emailed: 6/11/2011) (Updated: 6/11/2011)
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If there is a single truth of pediatric emergency medicine, it is that kids love to stuff things into their noses.  A particular danger (aside from batteries, covered in a previous pearl) is the magnet.  

Specifically, two magnets (as seen with magnet ear and nose rings, frequently worn by children and teens whose pesky parents won't allow piercings), attracted across the nasal septum can cause necrosis and perforation within hours.

Here's how to save yourself (and some noses):

  1.  Place a strong magnet such a mechanic's pocket magnet (<$10), or a pacer inhibition magnet within 1.5cm of the magnets.  Be careful not to apply pressure to the septum.
  2. Watch for the opposite side magnet to fall out of the nose.
  3. Easily remove the second magnet, which is no longer stuck to can use the strong magnet from step 1 at the nare opening to assist.
  4. Though this method is generally non-traumatic, you should pre-treat the nares with 4% lidocaine and 1:1,000 epinephrine spray to minimize potential bleeding.

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Category: Pediatrics

Title: Positioning in Pediatric Intubation

Keywords: Airway, Intubation, Pediatric, Positioning (PubMed Search)

Posted: 5/13/2011 by Adam Friedlander, MD (Updated: 8/28/2014)
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"Ear to sternal notch" positioning has gained wide acceptance in the emergency medicine and anesthesia literature.  Most often, this teaching is brought up with respect to obese adult patients whose large body habitus requires the raising of the neck and head to achieve airway alignment.

However, the correct anatomic positioning principle applies to all ages.  Specifically, with regard to neonates, a shoulder roll is often placed indiscriminately to put the patient into the now out-dated "sniffing position," usually worsening the view of the airway.  

Though this positioning is frequently misused, it can be easily adapted to apply ear to sternal notch positioning to neonates, whose misaligned airway is the result of a large occiput rather than a large torso.  In all ages, if you follow these positioning principles, you will improve your view of the airway:

1. Align the ear to the sternal notch

2. Keep the face parallel to the ceiling (do NOT hyperextend the neck, as in the sniffing position)

3. In adults, the head usually needs to be raised (Image 1), while in infants, the torso usually needs to be raised (image 3).



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Category: Pediatrics

Title: Pre-term tube sizes

Posted: 4/22/2011 by Mimi Lu, MD (Emailed: 5/6/2011) (Updated: 5/6/2011)
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Continuing the theme of endotracheal tube size pearls...  You get a box call for a pre-term baby delivered precipitously by mom at home and baby is blue.  EMS is bagging but unable to secure a definitive airway.  What size ETT do you reach for?  If you try to apply the formula "uncuffed ETT = (age/4) + 4", how much smaller than size 4 can you go?

Here's a nice mneumonic about guessing pre-term "tube" sizes.  Please note ETT = uncuffed endotracheal tube size.
20-25 week gestation: 2.5 ETT
25-30 week gestation: 3.0 ETT
30-35 week gestation: 3.5 ETT
35-40 week gestation: 4.0 ETT
Basically, a 25-week neonate gets a 2.5 tube, a 30-week neonate gets a 3.0 tube, etc.  As always, be prepared and have an additional ETT a 1/2 size smaller readily available.

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Category: Pediatrics

Title: Tube sizes

Posted: 4/22/2011 by Mimi Lu, MD (Emailed: 4/30/2011) (Updated: 4/30/2011)
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You decided to intubate a child and wisely remembered that you should also follow with an NG/ OG after intubation to decompress the stomach.  In order to avoid the blank stare when asked "what size"?  Here's a nice mneumonic about Pediatric "tube" sizes... easy as 1-2-3-4!!!  Please note ETT = endotracheal tube size.

  • 1 x ETT = (age/4) + 4 (formula for uncuffed tubes)
  • 2 x ETT = NG/ OG/ foley size
  • 3 x ETT = depth of ETT insertion
  • 4 x ETT = chest tube size (max, e.g. hemothorax)

So for example, a 4-year-old child would get intubated with a 5-0 ETT inserted to depth of 15 cm (3x ETT), a 10Fr NG/OG/foley (2x ETT), and a 20Fr chest tube (4x ETT).

Also, remember that you can use cuffed tubes in any child except neonates but the formula needs to be adjusted as follows: cuffed endotracheal tube ID (mm) = (age/4) + 3.5

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Category: Pediatrics

Title: Neonatal hypermagnesemia and respiratory depression

Keywords: magnesium toxicity, neonatal hypotonia, neonate, intubation, neonatal resuscitation (PubMed Search)

Posted: 4/8/2011 by Adam Friedlander, MD
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So the magnesium didn't work, and the baby is on the way!  You're prepared with everything you need for the delivery from bulb suction to a tripod for Dad's camera...  But what is going to special about this baby?  

Babies born to mothers who received magnesium therapy for any reason are at risk for hypotonia and severe respiratory depression.

  • DO provide respiratory support as needed, as respiratory depression is the only dangerous side effect of hypermagnesemia in the neonate (be prepared to provide supplemental oxygen, positive pressure ventilation (PPV), and possibly intubation)
  • DO recognize that generalized hypotonia may be a clue as to how significantly affected the neonate may be, however, don't let the hypotonia itself scare you - it will go away, and is not dangerous in and of itself
  • DO follow neonatal resus guidelines (PPV for HR<100, CPR for HR<60), but remember that supportive measures will resolve all problems related to hypermagnesemia in the neonate...if there are other issues, don't blame the mag
  • DO NOT give calcium as, in contrast to their mothers, these patients are not hypocalcemic (and the hypermagnesemia will spontaneously resolve in 48 hours)
  • DO remember that these infants frequently require a brief NICU stay until they no longer require respiratory support

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Category: Pediatrics

Title: Seborrhea

Posted: 3/25/2011 by Rose Chasm, MD (Updated: 12/8/2022)
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  • seborrheic dermatitis is most common in infants within the first two months of birth
  • appears as  erythematous, greasy yellow scales most commonly on the scalp (cradle cap), and may also occur on the face
  • most cases resolve spontaneously within weeks to months, but severe cases may be treated with 1% hydrocortisone cream, sahmpooing with selenium sulfide, and using an emollient to remove scales
  • in extreme cases, consider hte possibility of Langerhans cell histicytosis, especially if atrophy, ulceration, or purpura are also present
  • rarely occurs in children between 1 and 12 as they do not have active sebaceous glands, but will appear as dandruff in adolesecents

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Category: Pediatrics

Title: Influenza

Keywords: Influenza (PubMed Search)

Posted: 3/2/2011 by Mimi Lu, MD (Emailed: 3/5/2011) (Updated: 3/5/2011)
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Now that influenza season is in full swing, remember that early antiviral treatment can reduce the risk of complications in high-risk individuals. One of those high-risk groups is children <2 years, with the highest hospitalizations and mortality in infants <6 months.

According to the CDC website:
Recommended antiviral medications (neuraminidase inhibitors) are not FDA-approved for treatment of children aged <1 year (oseltamivir) or those aged <7 years (zanamivir). Oseltamivir was used for treatment of 2009 pandemic influenza A (H1N1) virus infection in children aged <1 year under an Emergency Use Authorization, which expired on June 23, 2010. Nevertheless,

  •  3-11 months => Treatment: 3 mg/kg/dose BID, Chemoprophylaxis: 3 mg/kg/dose once daily
  •  infants <3 months => Treatment: 3 mg/kg/dose BID, Chemoprophylaxis: not recommended
  • newborns <14 days => 3 mg/kg/dose once daily
  • treatment doses for children >1 year of age varies by weight:
  •  <15 kg: 30 mg BID
  • 15-23 kg: 45 mg BID
  • 23-40 kg: 60 mg BID
  • >40 kg: 75 mg BID

Current CDC guidance on treatment of influenza should be consulted; updated recommendations from CDC are available at


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Category: Pediatrics

Title: Hypoplastic Left Heart Syndrome

Posted: 2/25/2011 by Rose Chasm, MD (Updated: 12/8/2022)
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  •  disorder in which the entire left side of the heart is underdeveloped
  •  the right side of the heart is dilated and hypertrophied, and supports both the systemic and pulmonary circulations via PDA
  •  accounts for nearly 1/4 of all cardiac deaths in the first year of life
  •  infants present within the first days or weeks of life acutely ill with signs of CHF
  • PE often shows cyanosis and poor pulses but hyperdynamic cardiac impulses
  • CXR shows cardiac enlargement and prominent pulmonary vasculature
  • EKG shows RA and RV hypertrophy
  • echo is diagnostic
  • acute treatment is PGE1 to maintain the PDA.

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Category: Pediatrics

Title: To CT or not to CT, Part II

Keywords: head CT, trauma, pediatrics, head injury (PubMed Search)

Posted: 2/11/2011 by Adam Friedlander, MD (Updated: 12/8/2022)
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Head injuries in children over 2yo are stress provoking as well.  Here are the rules for that age group, piggy-backing on last week's pearl, based on a large (42,412 children, 31,694 >2yo) multi-center trial conducted by PECARN.
In children >2yo, if all of the following criteria are met, there is 99.95% chance that no clinically important traumatic brain injury exists (defined as an injury requiring intervention):
  • normal mental status
  • no loss of consciousness 
  • no vomiting
  • non-severe injury mechanism
  • no signs of basilar skull fracture
  • no severe headache
No children in either low risk group required neurosurgical intervention.

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Category: Pediatrics

Title: To CT or not to CT, Part I

Keywords: head CT, trauma, pediatrics, head injury (PubMed Search)

Posted: 2/4/2011 by Adam Friedlander, MD
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Head injuries in children under 2yo are stress provoking, particularly with regard to when you should be getting a head CT.  Luckily, a large (42,412 children, 10,718 <2yo) multi-center trial exists to guide your behavior.

In children <2yo, if the following criteria are met, there is a near 0% (95% CI) chance of a clinically important traumatic brain injury (defined as an injury requiring intervention):
  • normal mental status
  • no non-frontal scalp hematoma
  • no loss of consciousness, or LOC <5s
  • non-severe injury mechanism
  • no palpable skull fracture
  • acting normally according to the parents
Approximately 25% of the patients who had CTs, fit the low risk criteria above, and none had clinically significant brain injuries.  
In other words, just follow these simple rules to cut down the number of head CTs done on children <2yo by 25%.

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Category: Pediatrics

Title: Hypertonic Saline for the treatment of hyponatremic seizures in children

Keywords: hypertonic saline, seizures, hyponatremia, hyponatremic, encephalopathy, pediatric, children (PubMed Search)

Posted: 1/6/2011 by Adam Friedlander, MD (Emailed: 1/7/2011) (Updated: 1/7/2011)
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Hyponatremic seizures are a frightening entity.  Anticonvulsants don't work well, and will likely cause apnea well before they halt the seizure.  Hypertonic saline carries with it the fear of inducing central pontine myelinolysis (CPM) with overly rapid correction of the hyponatremia.  


  • CPM usually occurs at sodium level corrections of >8 mEq/L/day
  • Hyponatremic seizures are usually stopped with a correction of only 3-5 mEq/L

So, you can safely correct hyponatremia rapidly in the setting of seizures. Do it like this:

Give 2-3 mL/kg of 3% NaCl in rapid sequential boluses, until seizures stop.  A theoretical maximum dose is 100mL/kg, but recall that only a relatively small correction is required to stop the seizure.  
After you've stopped the seizure, correct the hyponatremia slowly, as you would otherwise.

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  • syndrome of hematuria at the END of urination
  • evidenced by spotting of blood in underwear
  • occurs only in boys
  • may last up to a year or longer
  • symptoms are usually intermittent and recurrent
  • physical examination is normal
  • renal ultrasound usually helps rule out structural anomalies, but will usually be normal
  • self-limited, with no specific therapy other than reassurance

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Category: Pediatrics

Title: Cuff Pressure in Pediatric Intubations

Keywords: Pediatric Intubation, Airway Control, Cuff Pressure (PubMed Search)

Posted: 12/10/2010 by Adam Friedlander, MD
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In the past several years it has become common practice to use cuffed tubes for pediatric intubations.  However, a recent study suggests that cuff pressures are not as well regulated in pediatric patients, particularly when the patients are quickly intubated prior to aeromedical transport. Cuff pressures >30 cm H2O are associated with tracheal damage, however, up to 41% of pediatric patients transferred had cuff pressures >30 cm H2O, and 30% of those had pressures >60 cm H2O!  


  • Check your cuff pressures in all patients, particularly prior to transport

  • Cuff pressures must be <30cm H2O

  • Recall that for years uncuffed tubes were the standard, so as long as effective ventilation is achieved, it is best to err on the low side...

If you work at a facility that routinely transfers out the sickest pediatric patients, you will save their life by securing an airway in this most stressful of circumstances, but careful attention to this seemingly small detail can save your patient from long term complications.

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Category: Pediatrics

Title: Do not flex the neck in pediatric LP positioning

Keywords: pediatric, lumbar puncture, positioning, interspinous space (PubMed Search)

Posted: 12/3/2010 by Adam Friedlander, MD
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We've all been there.  It's 2am, and a 4 week old with a temperature of 38.1 rolls in the door.  You grab the LP kit and your "best holder."  This person then holds the baby's head and neck flexed with one hand, while the other brings the bottom and legs up to the chest as much as possible...all, usually, without pulse oximetry monitoring.

Well, it's time for a change.  Here's why:
  • By ultrasound, the largest interspinous space is achieved in the upright, hips flexed position (ie. leaning forward).
  • In the lateral decubitus position (often preferred in young infants), neck flexion DOES NOT increase the interspinous space.
  • Furthermore, neck flexion increases the incidence of respiratory compromise and hypoxia. 
In other words,  NECK FLEXION SHOULD BE ABANDONED in the positioning for pediatric LP.


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Category: Pediatrics

Title: Newborn Pulmonary Hemorrhage

Posted: 11/26/2010 by Rose Chasm, MD (Updated: 12/8/2022)
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  • occurs in 1/1000 live births, but found in 15% of neonatal autopsies
  • usually weigh <2500 grams at birth with prematurity the most common risk factor
  • present with bleeding from the nose and mouth with severe respiratory distress
  • immediate treatment with tracheal suctioning, oxygen, and positive-pressure ventilation
  • ventilation goal is to maintain a high, positive expiratory pressure of at least 6-10cm H20
  • also check for and correct any underlying bleeding disorders
  • extremely high mortality, but no long-term pulmonary deficits if the infant survives

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Category: Pediatrics

Title: Necrotizing Enterocolitis

Posted: 10/28/2010 by Rose Chasm, MD (Emailed: 10/29/2010)
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Necrotizing Enterocolitis

  • NEC is an inflammatory lesion of bowel which can progress to intestinal gangrene, with perforation, and /or peritonitis
  • characterized by abdominal distension, feeding difficulties, and GI bleeding
  • mainly affects pre-term infants, and most commonly affects distal ileum and proximal colon
  • usually presents during the first 2 weeks of life, but may occur up to 3 months of age in infants who who born weighing <1000grams
  • classic finding on abdominal XR is pneumatosis intestinalis or air in the bowel wall (pathognomonic) and is present 50-75% of the time
  • treat emergently with nasogastric decompression, IVF recussitation, NPO, and IV antibiotics

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Category: Pediatrics

Title: Colic

Posted: 10/22/2010 by Rose Chasm, MD
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  • excessive, unexplained paroxysms of crying in an otherwise well-nourished normal infant
  • lasts >3 hours/day, and occurs >3 days/week...ughh!
  • usually occurs at the same time of the day or evening
  • usually resistant to most attempts to quell it
  • infant may have excess flatus and draw legs up during episodes (but don't change formulas)
  • beings in first week of life and ends by 4 months of age

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Category: Pediatrics

Title: Ondansetron and Oral Rehydration Therapy

Keywords: Ondansetron, Oral Rehydration, Therapy, vomiting, pediatrics (PubMed Search)

Posted: 10/15/2010 by Adam Friedlander, MD (Updated: 10/16/2010)
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You may already love ondansetron, but consider using it ORALLY followed by PO hydration in children with vomiting.

  • Improve ORT success
  • Decrease IV placements
  • Decrease admission rates
  • NOT cause any significant difference in the number of missed serious alternate diagnoses 

The size of the study that showed this: N of just under 35,000.

But don't skimp on dosing.  The dose is 0.1 - 0.15mg/kg, and you don't reach a max until 8mg.  To put this in perspective, a scrawny 115lb (about 53kg) middle school tennis player would get 8mg, an initial dose often reserved for chemo patients in the adult ED.

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Category: Pediatrics

Title: Subtle SCFE

Keywords: SCFE, slipped capitofemoral epiphysis (PubMed Search)

Posted: 10/1/2010 by Adam Friedlander, MD
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Slipped capito-femoral epiphysis (SCFE) is a favorite board exam topic, and typically involves a young early or pre-adolescent obese girl with hip pain and the classic "ice cream falling off the cone" appearance on hip radiographs. However, keep these three pearls in mind when thinking about SCFE:

  1. Girls > Boys, but boys may be older at presentation - don't forget 15 year old boys and SCFE.
  2. An early radiographic finding may only be physis widening, so consider comparison films - the ice cream may only be levitating, but not falling off.
  3. 23% of these children present with knee pain - think before diagnosing an obese 15 year old boy with a knee sprain from football. *bonus* Recall that this injury is non weight-bearing.

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Category: Pediatrics

Title: Bronchiolitis

Keywords: Bronchiolitis, RSV (PubMed Search)

Posted: 9/10/2010 by Adam Friedlander, MD
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As RSV season approaches, remember these key points in managing bronchiolitis:

  • Diagnosis is clinical - labs and XRays will not help you, unless you want to rule out a specific alternate diagnosis.  It's all about the H&P.
  • Supportive care, including bulb suction of secretions, placing the child in a position of comfort, and possibly providing humidified air, is the mainstay of treatment.
    • Ribavirin, corticosteroids, and antibiotics are not indicated.  Don't use them.
    • Bronchodilators have no benefit in bronchiolitis alone, and non-response to bronchodilators supports the diagnosis of bronchiolitis.  If a trial does work, know what you are treating - some children with bronchiolitis may have an underlying component of reactive airway disease, and should be treated accordingly.
  • Before disposition be sure that the child can tolerate PO.  A fussy, tachypneic child may require admission for IV hydration if they are unable to tolerate feeds - recall that infants are obligate nose breathers.
  • Finally, beware the RSV bronchiolitis bounceback - the peak incidence of respiratory failure in RSV bronchiolitis is after 3-4 days of illness, when most children should be improving.

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