UMEM Educational Pearls - Pediatrics

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

- 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


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.  

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.




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

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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.


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 (Updated: 5/21/2024)
Click here to contact Rose Chasm

  • 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

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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


2. New England Musculoskeletal Institute.

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


-  Pemphigus Vulgaris


Rashes that desquamate

- Scalded Skin Syndrome

- Toxic Shock Syndrome

- Scarlet Fever

- Kawasaki


Category: Pediatrics

Title: lactose intolerance after gastroenteritis

Posted: 3/9/2012 by Rose Chasm (Updated: 5/21/2024)
Click here to contact Rose Chasm

  • 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

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•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.
•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.
•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 (Updated: 5/21/2024)
Click here to contact Rose Chasm

  • 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
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


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 (Updated: 5/21/2024)
Click here to contact Rose Chasm

  • 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.
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.

  • 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

Show References

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…. 

Show References