UMEM Educational Pearls - Pediatrics

Precedex (Dexmedetomidine) - Great for pediatric imaging procedures

Alpha-2 agonist with sedative properties

No analgesic effect alone, but shown to decrease the amount of opioids required for a painful procedure

Benefits pts go to sleep and awake in a more natural state.  Caregivers tend to prefer this as opposed to other sedatives.  Short recovery time- about 30 minutes

Adverse effects include bradycardia and hypotension.  Not recommended in any child with cardiac abnormalities.  Paradoxical hypertension with loading dose has also been observed

Effective for MRI or CT scans at loading doses of 2mcg/kg over ten minutes, then maintenance of 1mcg/kg/hr

Residents can gain experience with Precedex with Peds sedation on M,W,F mornings with sedation team, contact me to arrange a time for you to participate.

The umbilical site normally heals by 1 month of age. 

Any fluid draining after this period suggests an abnormal connection between the surface of the abdomen and the underlying structures, and requires further investigation.  Clear yellow fluid could represent a persistent connection of the bladder with the umbilicus called a patent urachus. The fluid that leaks is actually urine. The treatment is surgical closure of the connection.

Pus oozing from the umbilical stump would imply infection, especially if there is concomitant redness of the skin around the umbilicus.  An omphalitis can be life-threatening, and requires admission for invtravenous antibiotics.

Umbilical hernias are common in infants, and are usually noted with diastasis of the rectus muscles.  Most umbilical hernias resovle by school age, and do not require surgical intervention.

An umbilical granuloma is a small piece of bright red, moist flesh that remains in the umbilicus after cord separation. It is scar tissue, usually on a stalk, that did not become normally covered with skin cells. It contains no nerves and has no feeling. Most can be simply cauterised with silver nitrate.

Pediatric Constipation is a common presentation to PED and large percentage of GI clinic patient volume

Defined as less than 2 stools per week for two weeks with hard, large pellet like stools

Broad Differential includes functional constipation (most common), stricture, obstruction, celiac disease, Hirschsprung, hypothyroid, Cow's milk protein allergy, CF and spina bifida.  Always inspect the spine and perform rectal

Success of treatment is based on the aggressive nature of treatment and timing of treatment.  Ttreatment is longer and more difficult if patient has to wait on referral to GI specialist.

• Clean out with enema and stool softener (miralax BID for two days, followed by daily maintenance regimen is most common)
• Cheaper and effective regimens include mineral oil, kondremul or lactulose
• Encourage behavioral therapy with routine toilet time and rewards
• Increase fiber in diet to 8-10 grams for toddlers, 12-14 preschool and 14-16 for school age
• Initial treatment is safe and does not require electrolyte monitoring.
• Failed treatment and bounceback may require GI consult, inpatient Golytely therapy with electrolyte monitoring

Hyperleukocytosis is often seen in acute presentations childhood leukemias, and is defined as a WBC count of greater than 30-50K.  Complications usually arise at counts greater than 300, however, keep in mind that automated cell counters may underestimate very high white counts.

Complications include:

• Hyperviscosity Syndrome / Leukostasis
  • Risk of CVA, PE, Mesenteric Ischemia, etc.
• Tumor Lysis Syndrome (TLS)
  • Risk of fatal arrhythmia, may monitor with K, LDH, Uric Acid
• Disseminated Intravascular Coagultion (DIC)

Treatment:

• EMERGENT LEUKOREDUCTION APHERESIS, aka Leukopheresis
• This is a true emergency - if you are at a facility without leukopheresis capability, the fastest transport mode possible is indicated - fly, don't drive
• Temporizing measures include fluids, fluids, and fluids
• Allopurinol / Rasburicase may be considered, but not if this will delay transport, especially if there is no evidence of TLS - this decision may be made in consultation with the pediatric heme/onc specialist who is helping to arrange for leukopheresis

Meningitis Prophylaxis in Children

While H1N1 and garden-variety influenza have been taking the spotlight lately, we can't forget about other disease processes.  Meningitis is still a severe, life-threatening/altering process which occurs in various social groups (e.g. military cadets, college students).

However, with more of our parents working out of the home, child care is more often the norm, and as such, you may find yourself dealing with cases of children who have been in proximity to another child or caregiver diagnosed with meningitis.  What do you do?

The causative agent will often dictate your choice of management.

Neisseria meningitidis - nursery/child care contacts should receive chemoprophylaxis and the Menactra vaccine (if they have not already received it) within 7 days of onset;  casual school or work contacts do NOT require prophylaxis

Streptococcus pneumoniae - no chemoprophylaxis or vaccination required (unless series was not continued)

Haemophilus influenzae - if only one case reported, no intervention;  if 2 or more cases within a 60-day period, Hib vaccination and chemoprophylaxis with rifampin for BOTH children and caregivers (especially if the center cares for young children who have not completed their Hib series)

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After seeing all the electrical and extension cords supplying various seasonal holiday decorations, I thought this would be appropriate.

• most commonly occurs once children establish a grasp at 4months and 4 years when children finally learn not to touch cords, but most common from 1-2 years
• not surprisingly, more common in boys (60%)
• moist oral cavity creates a short circuit and electric arc which produces enough heat (up to 1371C/2500F) to cause a low-voltage electric burn
• 5% may suffer cardiac/respiratory arest
• electrical mouth burns result in significant soft tissue damage which forms an eschar
• beware sloughing of the nonviable eschar from the underlying viable tissue around week 2, that results in labial artery hemmorhage

• 4-5% of Prepubertal Vaginal Complaints are the result of foreign body.
• Vaginal bleeding is the most sensitive (93%), and specific (82%)
• Discharge usually foul-smelling is only seen in 18% of patients
• Undiagnosed symptoms may be chronic, (case reports lasting years).
• Complications of delayed removal include infection, toxic shock syndrome, fistulas, adhesions and even infertility
• Exam in knee chest position, and removal with irrigation or tissue forceps.
• Failure to remove FB may require exam under anesthesia.

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The Emergency Department is often the first line in detecting the sexual abuse of a child.  Unfortunately, what you do or don't say/ask/test can significantly affect the legal protection of the abused child.

1. Know your region's dedicated sexual abuse center, if one exists.  These centers have personnel trained in interviewing and forensic evidence collection.  There may be different centers for children of different ages.

2. Know your state laws regarding what is and is not admissible as evidence of sexual abuse.  GC/CT urine testing (NAAT), though more sensitive than swab cultures, is not currently admissible as evidence in many states.

3. Withhold prophylactic antibiotic treatment when possible - antibiotics work well, and often eliminate evidence.  Withholding antibiotics is acceptable if the child is asymptomatic or only has very mild symptoms.

4. Any sexually transmitted disease in a child warrants further workup and investigation.  Primary genital HSV in a young child warrants testing for Gonorrhea and Chlamydia, and appropriate referral as well as police involvement.

5. Finally, if trained personnel is available to conduct the interview of a child, limit the questions you ask the child directly.  Any evidence in your note that you may have suggested something to the child in your line of questioning could negate the validity of their testimony.

Ductal-Dependent Cardiac Lesions in the Neonate

• Often present in the first 1-2 weeks of life (children born prematurely tend to be at the upper end of the spectrum as they may have delayed closure of the ductus arteriosus)
• May present with tachypnea, sudden onset of cyanosis or pallor (often worse with crying), diaphoresis with feeds, lethargy, or failure to thrive
• Oxygen challenge - place baby on 100% 02 via NRB;  10% improvement in SpO2 (or 30mmHg increase in PaO2 on ABG) suggests a pulmonary issue;  no or minimal change suggests a congenital heart defect
• If congenital heart disease is suspected, start PGE-1 infusion at a rate of 0.05-0.1ug/kg/minute;  improvement may be drastic and is usually seen within 15 minutes
• Side effects of PGE-1 infusion include apnea, fever, hypotension, and seizures;  have your code cart and intubation equipment ready to go prior to beginning infusion

Ring-removal is a dreaded problem in pediatric hand and finger injuries.  Removal can be difficult and time consuming.  The relatively recent introduction of Tungsten into the jewelry market has further complicated this problem:

• The hardest metal used in jewelry - cannot be scratched, much less cut, by common tools
• Cheap, easy to buy online, attractive to adolescents

However, it is:

• Extremely brittle
• May be safely and quickly broken with locking pliers (also cheap), by sequentially, gradually tightening the locking plier grip

This video explains how.  Of course, this works on adults as well.

http://www.youtube.com/watch?v=poM423pewRE

_{I have no relationship with the copany which made this video - it was simply chosen for its clear explanation of the solution described in this pearl.}

Conjunctivitis in Children:

• Usually a self-limiting process, very common in school-aged children and children in daycare or group home settings
• Crusting/swelling treated with warm compresses
• Antibiotics are not necessary outside of the neonatal period, but they do speed recovery
• Neonates with conjunctivitis - send cultures (gonococcal ophthalmia neonatorum);  all others - no cultures necessary
• Treatment with erythromycin ointment, Polytrim solution, ciprofloxacin solution (usually practicioner preference unless dealing with a recurrent/resistant case)

HOWEVER... remember to consider other common etiologies of a red eye in a child!

• Corneal abrasions
• Acute angle closure glaucoma (sickle cell patients)
• Allergic sources

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• comprehensive history and thorough external genital exam (often without direct visualization of the cervix) will lead to appropriate diagnosis
• estrogen withdrawal following birth or ingestion of oral contraceptives
• vaginal foreign bodies (such as toilet paper, small toys)
• bacterial infections (strep and shigella)
• trauma from sexual abuse or straddle injuries
• vascular lesions such as hemangiomas
• be careful to differentiate urethral bleeding from vaginal bleeding

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• characterized by paroxysms of severe vomiting without apparent cause separated by periods of complete health
• typically begins between 3 and 7 years of age
• family or patient history of migraine or irritable bowel syndrome often noted
• intentse vomiting with lethargy, fever, and headache preceding the onset of emesis
• episodes last up to 48 hours (but may last up to one week) with 4-12 episodes per hour, and end suddenly often after sleep
• two thirds of children become so dehydrated they require intravenous fluids
• most patients have stereotypic patterns of onset and triggering events
• rapid treatment with IVF and glucose, along with migraine treatments such as cyproheptadine, propanolol, and TCA's
• antiemetics often not effective

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While it is often ok to defer removal of pesky nasal foreign bodies until ENT follow up, if the foreign body may be a button battery, emergent identification and removal is indicated.

Damage can occur in 3 hours, and by 24 hours, near complete necrosis of turbinates and ala has been described.

• If the object may be a button battery, consider a plain film - if it doesn't show up, it isn't a battery, and you are in the clear.
• If you can clearly see the button battery, you can try to remove it - consider using a magnet if one is available - more on that in a future pearl.
• Lastly, if you cannot visualize the battery, if there is any evidence of content leakage, or if there is any tissue damage, emergently consult ENT for assistance - this is a surgical emergency.

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While breastfeeding is still the preferred source of infant nutrition by the AAP, a little-known fact is that breastfeeding may expose the nursing infant to environmental pollutants to which they might not normally be exposed.  If you have a mother that appears ill due to exposure to any of these agents, don't forget to have the infant examined as well for signs of intoxication.

• Breastmilk can contain approximately 20% of the maternal toxin load, which can produce more severe effects in the infant due to the vastly different dose/weight ratio
• Toxin load is usually due to the lipid solubility of agents
• Formulas are safe due to the nature of their fat sources;  cows usually have a much lower exposure rate to pollutants, and those that are ingested are much more dilute due to the volume of milk produced in comparison to a human female;  also, with non-cows'-milk formulas, the lipid components are usually plant-derived and thus also with a lower risk of exposure
• Common offending agents include:  DDT, PCBs, Dioxin, hexachlorobenzene, Halothane, carbon disulfide, nicotine, lead, methylmercury, Heptachlor, Chlordane, and tetrachloroethylene

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• although newborn screening for PKU has been routine throughout North America since the 1960's, it is not routine in undeveloped countries (beware immigrants, foreign visitors)
• PKU is caused by phenylalanine hydroxylase (PAH) deficiency which catalyzes the conversion of phenylalanine to tyrosine
• neonates with PKU typically show no physical signs of hyperphenylalaninemia
• children with untreated PKU have impaired brain development with poor brain growth, seizures, behavior problems, and severe mental retardation
• affected individuals exude a pungent, musty odor due to elevated phenylalanine levels which also causes skin conditions such as eczema
• because there is absent tyrosine production with reduced tyrosinase, the hair and skin are very lightly pigmented
• early diagnosis and management with a low-phenylalanine diet eliminates these complications; and once treated, affected children are healthy and do not require hosopitalizations

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• Although rare, it is a serious life threatening entity of pediatric emergency medicine
• Must be in the differential of those with signs of increased intracranial pressure or focal deficit and hx of sinusitis, mastoiditis or cyanotic congenital heart disease.
• Investigation and diagnosis primarily with CT scan
• CSF studies demonstrate sterile fluid with elevated protein, and mildly elevated WBC
• Antibiotic coverage should be broad Naficillin/Vanc + Ceftriaxone + Metronidazole, until speciation and susceptibilities obtained from surgical specimen
• Steroids reserved only in cases of imminent herniation
• Controversy exists over prophylactic anticonvulsants
• Mortality recently <10% attributed to early diagnosis and appropriate antibiotic coverage.

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You've probably long been taught that Sickle Cell Trait is an irrelevant piece of the PMH, unless you are a genetic counselor.  Well, thanks to Dr. Rolnick and a literature search, I (and now you) know that that is incorrect.

Though Sickle Cell Trait (SCT) does not cause exactly the same pathologies as Sickle Cell Disease (SCD), there are believed to be a variety of RBC abnormalities associated with HgbS (such as measurably lower RBC deformability, and low levels of sickling under extreme heat and exercise conditions) which contribute to increased exercise-related sudden death.  In one NEJM study of all deaths among 2 million (MILLION) military recruits over a 4 year period, the relative risk of otherwise unexplained sudden death for black recruits with HgbAS vs. black recruits without HgbS was 27.6 (p<0.001), and 39.8 (p<0.001) for all recruits (HgbAS vs. no HgbS).

I must say that this topic is not controversy-free, however, I should also note that my search for "Sickle Cell Trait and Sudden Death" turned up quite a few articles directed at plaintiff's attorneys. 

The take-home point is that SCT is likely not a benign condition, and you must be cautious in telling patients that it is.  Again, this phenomenon is best described in patients undergoing extreme physical exertion, but hopefully this will change how you think about SCT.

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Infantile Spasms (West Syndrome):

• Are brief contractions of the neck, trunk, arm, and leg muscles that last 2-10 seconds
• Are NOT seizures, but 86% of children with infantile spasms go on to develop a seizure disorder before 1 year of age
• Usually occur as the child is going to sleep or waking up
• Most commonly seen between 3 and 8 months of age
• Often mistakenly diagnosed as colic
• Poor prognosis as infantile spasms usually indicate an underlying genetic, metabolic, or developmental abnormality

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• Status epilepticus is defined as either a continuous convulsion or serial convulsions without loss of consciousness that lasts 30 minutes.
• First line treatment:  benzodiazepine because it is absorbed rapidly into the nervous system; lorazepam (0.05 to 0.1 mg/kg) is preferred over diazepam (0.2 to 0.5 mg/kg) because of its longer half-life in the CNS; rectal administration of the intravenous formulation or the commercially available gel at the same doses may be subsitutued if no IV is attainable.
• if seizure activity persists beyond 10 - 15 min, a longer acting anticonvulsant such as phenytoin (18 -20 mg/kg), fosphenytoin, or phenobarbital (18 - 20 mg/kg) is administered; they take longer to penetrate the CNS, but have much longer half-lives than the benzodiazepines.  Phenobarbital is given to infants while phenytoin or fosphenytoin is given to older children.
• Fosphenytoin, a prodrug to phenytoin, increasingly is replacing phenytoin as the drug of choice.  It can be administered at two to three times the rate of phenytoin and is less caustic to skin in teh event of vein extravasation.  It can als be given intramuscularly, while phenytoin can't.

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