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.
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
Keywords: Enterovirus, infant, CSF (PubMed Search)
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.
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
Pediatrics Board Review, 2004
Keywords: Magnet, Foreign body, pediatric, nose, nasal, perforation (PubMed Search)
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):
Keywords: Airway, Intubation, Pediatric, Positioning (PubMed Search)
"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).
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?
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.
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
Keywords: magnesium toxicity, neonatal hypotonia, neonate, intubation, neonatal resuscitation (PubMed Search)
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.
Special thanks to Dr. Mimi Lu for the reference above
Pediatrics Board Review Core Curriculum, 1st edition
Keywords: Influenza (PubMed Search)
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,
Current CDC guidance on treatment of influenza should be consulted; updated recommendations from CDC are available at http://www.cdc.gov/flu
Pediatrics Board Review Core Curriculum
MedStudy 1st edition, Book 3
Keywords: head CT, trauma, pediatrics, head injury (PubMed Search)
Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study.
Keywords: head CT, trauma, pediatrics, head injury (PubMed Search)
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.
Keywords: hypertonic saline, seizures, hyponatremia, hyponatremic, encephalopathy, pediatric, children (PubMed Search)
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.
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.
Pediatrics Board Review
Keywords: Pediatric Intubation, Airway Control, Cuff Pressure (PubMed Search)
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.
Tollefsen, William W. et al. Endotracheal Tube Cuff Pressures in Pediatric Patients Intubated Before Aeromedical Transport. Pediatric Emergency Care: May 2010 - Volume 26 - Issue 5 - pp 361-363
Keywords: pediatric, lumbar puncture, positioning, interspinous space (PubMed Search)
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.