The gold standard for confirming ETT position is a chest xray, but this can often be delayed while the patient is stabilized. Many physicians will estimate ETT insertion depth to be 3x the ETT size, but this is based on selection of the correct tube. There are several other published formulas, including the PALS guidelines [age in years/2 + 12] which applies to children older than one year. In 1982, there was an article published that cited the formulas of [Height (cm) x 0.1 +5] or [Weight(kg)/5 + 12].
This was a retrospective study where the ideal position of cuffed ETT (from the front teeth) was determined by looking at post intubation xrays of 167 patients between 28 days and 18 years. The individual optimal ETT insertion depth was plotted against age, weight and height for all children. This study showed that there is not a fully linear relationship between age, height or weight which is a flaw of all of these formulas. Calculations using the patients’ weight performed the worst. Age based and height formulas performed the best.
You've heard of one kill pills such as calcium channel blockers, beta blockers, sulfonylureas, anti-malarials, but less commonly known is benzonatate, or tessalon perles.
Tessalon perles are not recommended for children under the age of 10. 1-2 capsules of benzonatate in children <2 years old have been reported to cause serious side effects including restlessness, tremors, convulsions, coma and even cardiac arrest rapidly after ingestion (within 15-20 minutes and death within a couple of hours). It is attractive to young children as it somewhat resembles a jelly bean.
Pearls on Tessalon Perles:
BACM stands for benign acute childhood myositis which is typically a benign, viral induced self limiting illness. This was a retrospective study looking at 65 patients in Italy to further characterize the characteristics of the disease.
In this study, the median patient age was 6 years with a male predominance. The incidence of BACM peaked in winter with a second peak in the fall. Patients presented with prodromal symptoms including fever, cough, coryza, sore throat and vomiting. The exam showed difficulty walking and myalgias with reproducible calf tenderness and preserved reflexes. Influenza B and A, COVID and other viral pathogens have been detected in these patients.
Lab work may show an elevated creatinine kinase, AST and potassium. WBC and CRP may also be elevated. The median CK value was 943 U/L and on average normalized within one week. Other studies have shown median CK values in the 3300s. Treatment includes hydration to promote CK clearance and prevent complications including acute kidney injury related to rhabdomyolysis. Recurrent myositis or CK values > 5000 U/L should have screening tests for muscular dystrophy and metabolic disorders.
It is an often asked question: should I consider the corrected or the chronologic age when determining the need for fever evaluation in a pediatric patient? The 2021 AAP guidelines for the well appearing febrile neonate are widely accepted and apply to neonates under 60 days. These highly practical guidelines are, unfortunately, not applicable to pre-term neonates. The question often becomes what age to use for a pre-term neonate- the age they actually are, or the age they would be if they had completed a full term gestation.
Hadhud et al attempted to clarify the age utilized in a retrospective review. This looked at febrile 448 pre-term neonates evaluated for fevers. It found that those patients with both a corrected and chronologic age over 3 months had a 2.6% rate of serious bacterial infections or SBI (UTI, bacteremia or meningitis), those with a corrected age under 3 months but a chronologic age over 3 months had a 16.7% rate of SBIs, and those with both a corrected and chronologic age of under 3 months had a 33.3% rate of SBI.
Overall, these rates of infection are higher than the typically reported in febrile neonates, supporting that pre-term neonates have a much higher risk of infections overall. Ultimately, pre-term neonates should be carefully assessed and a more thorough evaluation is typically warranted in this patient population even if they have reached the generally accepted 60 day marker by chronologic age- use the corrected age.
Revisits back to the ED within 3 days of the initial visit represent a standard quality measure. A critical ED revisit was defined as an ICU admission or death within 3 days of ED discharge. This study looked at 16.3 million children who were discharged from various EDs over a 4 year period and found that 0.1% (18,704 patients) had a critical revisit and 0.00001% (180 patients) died.
The most common diagnosis at the initial visit of those patients coming back with a critical revisit included: Upper respiratory infections, gastroenteritis/nausea/vomiting and asthma.
The most common critical revisit diagnosis were: asthma, pneumonia, cellulitis, bronchiolitis, upper respiratory infections, respiratory failure, seizure, gastroenteritis/nausea/vomiting, appendectomy and sickle cell crisis. Among the patients who died, 48.9% were younger than 4 years. Patients with complex medical problems and patients seen at a high volume center were more likely to have a critical ED visit.
Bottom line: These ED revisits may not have been related to missed diagnosis (with the exception of appendicitis), but rather due to the natural progression of certain disease processes. Patients with these diagnoses may benefit from careful reassessment, targeted patient education, more specific return precautions and closer outpatient follow up.
Urinary tract infection (UTI) is the leading cause of fever without a source in infants younger than 3 months. This data was collected from patients who presented to the emergency department with fever without a source over a 16 year period. Out of 2850 patients, 20.8% were diagnosed with a UTI, the majority of which grew E coli. Of those patients who were diagnosed with UTI, these patients were more likely to have a history of renal/GU problems, have a fever of at least 39C (38% vs 29%) or poor feeding (13% vs 8.7%). However, 48% had none of these risk factors. Also 6.1% of patients with a febrile UTI had another invasive bacterial infection. These patients were more likely to be < 1 month, be "irritable" per parents and have an elevated procalcitonin and CRP.
Bottom line: A lack of risk factors can not exclude a UTI in febrile infants < 3 months. A diagnosis of UTI also does not definitively exclude an additional invasive bacterial infection in a subset of these children.
Since Christmas is coming up, let's talk about Hemophilia A (factor VIII deficiency) and Hemophilia B (factor IX deficiency, also known as Christmas disease)
Deficiencies in Factors VIII and IX are the most common severe inherited bleeding disorders.
Pathophysiology:
Clinical Manifestations:
Lab findings and diagnosis
Genetics
Classification
trauma to induce bleeding
Treatment
Summary:
Since Christmas is coming up, let's talk about Hemophilia A (factor VIII deficiency) and Hemophilia B (factor IX deficiency, also known as Christmas disease)
Deficiencies in Factors VIII and IX are the most common severe inherited bleeding disorders.
Pathophysiology:
Clinical Manifestations:
Lab findings and diagnosis
Genetics
Classification
trauma to induce bleeding
Treatment
Summary:
Acute bronchiolitis (AB) is a common cause of respiratory tract infections in infants. A recent study looked at the application of Point-of-Care Lung Ultrasound (LUS) in infants <12 months who presented with symptoms of AB.
They scored infant lungs using a cumulative 12-zone system. With the below scale:
0 - A lines with <3 B lines per lung segment.
1 - ≥3 B lines per lung segment, but not consolidated.
2 - consolidated B lines, but no subpleural consolidation.
3 - subpleural consolidation with any findings scoring 1 or 2.
They found that infants with higher LUS scores had increased rates of hospitalization and length of stay.
Here are some tips for ultrasounding a pediatric patient:
Term? Tone? Tantrum?
Immediately after delivery, your initial neonatal assessment should evaluate for:
- Appearance of full or late pre-term gestation (>34 weeks)
- Appropriate tone (flexed extremities, not floppy)
- Good cry and respiratory effort
Newborns meeting this criteria should not require resuscitation. They can be placed skin to skin on mother and allowed to breastfeed. Delayed cord clamping for 60 seconds is recommended, as data shows improved neurodevelopmental outcomes and iron stores in first year of life.
Neonates not meeting these criteria should be brought to the warmer for resuscitation, with the focus being on:
- Warm - via radiant warmer. Maintain temps 36.5 C – 37.5 C
- Dry - Neonates have thin skin and lose heat readily from evaporative loses
- Stim - tactile stimulation on the head, midline of the back and extremities to provoke a cry and encourage respiratory effort
Avoid routinely bulb-suctioning unless there is significant obstructing mucous, as this can increase vagal tone and result in bradycardia. If bulb suctioning is used, first suction the mouth before the nose.
Majority of resuscitations do not require additional support, however if heart rate is <100 or there is poor respiratory effort, the physician should initiate PPV.
PPV settings: PIP 20 PEEP 5 FiO2 21% Rate of 60 breaths per minute
Improvement in the neonate’s HR is the primary indicator of effective PPV!
If HR poorly responding (remains <100), ensure appropriate mask size, reposition, suction, and increase PIP (max 35) and FiO2.
If HR drops below 60, intubate with uncuffed ETT
- Prioritize adequate ventilation as this is the highest priority in neonatal resuscitation
- Initiate compressions at rate of 120/min.
- Epi dosing is 0.01-0.03 mg/kg q3-5 min
- ETT size estimation by gestational age:
25 weeks = 2.5, 30 weeks = 3.0, 35 weeks = 3.5, 40 weeks = 4.0
- Magnets move through the GI tract at different rates and become lodged in adjacent loops of intestine. Adjacent bowel segments can stick together when the magnets attract each other through the bowel walls which can cause obstruction, perforation, fistula formation, and necrotic bowel.
- Obtain xray to identify ingested metallic object(s)
- Any object lodged in the esophagus should be emergently removed by a pediatric gastroenterologist.
- Once an object is past the stomach and beyond the reach of endoscopy, affected patients need to be watched carefully for signs of obstruction or peritonitis, either occurrence requiring the prompt consultation of a pediatric surgeon.
- Enhancement of magnet movement through the GI tract may be aided by a laxative such as polyethylene glycol, but there is no clear data that this approach speeds the passage of the magnet. There is no clear guidance on how frequently to obtain abdominal radiographs to determine movement or passage of ingested magnets.
- More frequently lodge in esophagus due to seize and cause electric urn on contact
- Complications include perforation or fistula formation
- Honey or liquid ulcer medication carafate can slow extent of esophageal injury
- Current recommendations from National Button Battery Hotline: caregiver to give 2 teaspoons of honey every 10 minutes while en route to hospital
- Causes caustic contact to vocal cords, which leads to acute laryngospasm
- Airway compromise, if to occur, occurs rapidly. If after brief obs period, it does not appear, it is very unlikely to be a late occurance.
- Corrosive on GI tract. pH of detergents range from 7-9.
- Any child with difficulty swallowing, drooling, stridor, and recurrent vomiting should have GI consulted for endoscopy
Tiki Torch Oil
- Tiki torch oil looks like apple juice (the container looks similar too)
- Lamp oil ingestion (hydrocarbons) can cause excessive drowsiness, lung injury, difficulty breathing
- Preventing accidental tiki torch oil ingestion: NEVER use torch fuels near area where food or drinks are served, keep out of reach and out of sight of young children, and only buy bottle of torch fuels with child-resistant cap and make sure to replace cap securely after every single use
Hydrogen Peroxide
- 35% hydrogen peroxide has become more popular as food-grade or nutraceutical product (food additive purportedly used for medicinal purposes)
- When hydrogen peroxide reacts with HCl in the stomach, it liberates large volumes of oxygen causing immediate frothy emesis and systemic absorption of oxygen. Gastric oxygen, once absorbed, passes through the portal vein to liver causing gas embolisms in liver
- Preferred evaluation of kids with known ingestion and acute vomiting should image by noncontrast limited upper abdominal CT (to reduce radiation exposure) to assess bubble burden.
- There is no consensus on what is considered a significant air embolism burden that would require hyperbaric treatment
- A single tablet of buprenorphine, or a single dissolvable gel strip of its formulation as Suboxone has been lethal to children.
- Prescribing intranasal naloxone spray to the family of patients on buprenorphine (and methadone as well) is potentially lifesaving to the patient, should they take too much, but also for children in their homes who may accidentally eat a single tablet or chew on what appears to be a “gummy” product, a dissolvable formulation of Suboxone.
- Pediatricians doing anticipatory safety guidance to parents at the 9-month-old to 1-year-old health supervision visit should ask about opiates and medication-assisted therapy present in the home or used by caregivers (especially grandparents) and should offer to write a prescription for naloxone nasal spray
Kids eat everything (except perhaps carefully prepared and balanced meals). While button battery ingestions are feared, there is more to worry about. Magnet ingestions – especially rare earth metal magnet ingestions – can lead to high morbidity and mortality.
When more than one magnet (or a magnet and another metallic object) are ingested, they can become stuck together through walls in the GI tract, creating risk for obstruction, erosion, fistula formation, and perforation. Sharp metallic foreign objects can be particularly dangerous as they can do much damage while being moved around by the magnet.
If there is concern for magnet ingestion, care should be taken to try to determine the number ingested (if parents have the magnets, you can compare the size of an object on xray to the size of the magnets as it can otherwise sometimes be difficult to differentiate if it is one magnet or more than one stuck together).
Higher risk features of ingestion include:
Ingestions should prompt consultation with pediatric GI and surgery when isolated as many will require either endoscopic or surgical removal. This may include need for referral and transfer.
The literature is not completely new regarding the use of intranasal dexmedetomidine for pediatric sedation, with several articles confirming noninferiority to benzodiazepines. It is a potent a2- adrenergic receptor agonist, which allows for sedation without analgesic properties. It can be considered for patients who are undergoing PAINLESS procedures. A recent article gave further clarification for dosing considerations when selecting this option. This study assessed varying weight-based doses and found the best effect with doses of 3 to 4 mcg/kg
Importantly, there is limited data that suggests this may result in longer discharge, duration of procedure and total time in the department compared to other sedation methods. Additionally, this option is not always readily available and approved for pediatric patients in every hospital.
Overall, Dexmedetomidine may be an excellent option for painless procedures, such as CT imaging or even MRI based on the literature, when available.
It's back to school season which means back to school injuries!
Scalp lacerations often require suturing or staple closure, but what if you can close the wound without any sharps that scare the kiddos? Consider using the Hair Apposition Technique (HAT)!
What is HAT?
- A very quick and easy technique for superficial scalp laceration closure made by twisting hair on each side of the laceration and sealing the twist with a small dot of glue for primary closure.
When do I consider HAT?
- For linear, superficial lacerations that are <10cm in length
- Laceration has achieved adequate hemostasis
- Patient has hair on both sides of the laceration
What are contraindications to HAT?
- Hair strands are less than 3cm in length
- Laceration is longer than 10cm in length
- Active bleeding from laceration despite hair apposition
- Significant wound tension
- Laceration is highly contaminated
How do I perform HAT?
- Debride wound as you normally wound for any laceration
- Take approximately 5 strands of hair on one side of the laceration and twist them together to make one twisted bundle
- Take approximately 5 strands of hair directly on the other side of the laceration and twist them together to make another twisted bundle
- Then take each bundle and intertwine the two bundles until the wound edges appose.
- Place a drop of glue on the twist
- Repeat along the length of the laceration until laceration is closed
Benefits of HAT:
- Based on a RCT from Singapore that compared suturing to HAT for superficial scalp lacerations that were <10cm, patient's were more satisfied, had less scaring, lower pain scores, shorter procedure tiems, adn less wound breakdown in the HAT group compared to the sutured group.
- A follow up study by the same group also assessed cost-effectievness of HAT compared to suturing (by taking into account staff time, need for staple/suture removal, treatment of complications, materials, etc) and found that HAT saved $28.50 USD when compared to suturing.
Modified hair apposition of scalp wounds- UpToDate
Bottom Line:
- Consider Hair Apposition Technique (HAT) for linear, superficial scalp lacerations, especially in pediatric patients as it is much more well tolerated (can also do this in adults!)
This was a retrospective study involving several hospitals in Italy. 135 patients who had drowned (the term used in the article) were included. 4.5% of patients died. Most drowning occurred in July and August. The most common comorbidity was epilepsy in about 10% of patients. Several patients were also witnessed to have trauma and syncope. Early resuscitation, either by bystanders or trained professionals, was paramount in survival.
Children who are conscious at presentation and have mild or no respiratory distress have the best prognosis. A well appearing child should be observed for 6-8 hours, given that 98% of children will present with symptoms within the first 7 hours. A chest xray is not indicated in the asymptomatic patient. Patients who are submerged greater than 25 minutes or without ROSC after 30 minutes have a poor prognosis.
Bottom line: Never swim alone and everyone should be trained in bystander CPR.
This study attempts to answer the age old question: What is the importance of fever in pediatric illnesses?
The authors' goal was to assess if response to antipyretics was associated with bacteremia. This article retrospectively reviewed 6,319 febrile children in whom blood cultures were sent and found that 3.8% had bacteremia. They then looked at the fever curve in response to antipyretics for these two groups in the emergency department over 4 hours. The study concluded that patients with bacteremia have a higher rate of persistent fever despite antipyretics. It is important to note the limitations of this study. As this was retrospective, it is unclear what clinical findings resulted in blood cultures being sent - most febrile children did not have any drawn (23,999 were excluded for this reason). They did not assess other vital signs, and did not address other bacterial infections (UTI, cellulitis, meningitis, otitis media, etc). Additionally, while patients with bacteremia did have a higher likelihood of fever, the majority of patients in both groups had fever resolution within 4 hours, and both groups had some children with persistent fevers.
Overall, this does seem to support the decision to consider obtaining further testing in those children with a persistent fever, but also emphasizes the importance of not using fever resolution alone as support for discharge to home or exclusion of bacteremia from the differential.
