UMEM Educational Pearls - Pediatrics

Category: Pediatrics

Title: Post tonsillectomy complications

Keywords: ENT, post tonsillectomy bleeding, T and A (PubMed Search)

Posted: 1/17/2020 by Jennifer Guyther, MD (Updated: 6/24/2024)
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Tonsillectomy and adenoidectomy (T&A) is the second most common ambulatory surgery performed in the US.  Children younger than 3 years, children with craniofacial disorders or sleep apnea are typically admitted overnight as studies have shown an increase rate of airway or respiratory complications in this population.

The most common late complications include bleeding and dehydration.  Other complications include nausea, respiratory issues and pain.

Post-operatively, the overall 30-day emergency department return rate is up to 13.3%.  Children ages 2 and younger were more likely to present to the ED.  There is significantly higher risk of dehydration for children under 4 years.  Children over the age of 6 had significantly higher bleeding risk and need for reoperation for hemorrhage control.

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Category: Pediatrics

Title: Urinary retention in children

Keywords: Urinary retention, formulas (PubMed Search)

Posted: 12/20/2019 by Jennifer Guyther, MD (Updated: 6/24/2024)
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Urinary retention in pediatrics is defined as the inability to void for more than 12 hours in the presence of a palpable bladder or a urine volume greater than expected for age.

Maximum urine volume calculation for age:  (age in years + 2) x 30ml.

Causes of urinary retention include mechanical obstruction, infection, fecal impaction, neurological disorders, gynecological disorders and behavioral problems.

The distribution is bimodal occurring between 3 and 5 years and 10 to 13 years.

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Category: Pediatrics

Title: Acute Otitis Media

Posted: 11/29/2019 by Rose Chasm, MD (Updated: 6/24/2024)
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Antibiotic stewardship has led various organizations such as the AAP, AAFP, and IDSA to introduce two different approaches to the treatment of acute otitis media (AOM):

  • Immediate treatment with antibiotics versus
  • initial observation for 48-72 hours without antibiotics.

Immediate treatment with antibiotics should always include the following patients:

  • Children <6 months old
  • Toxic appearing
  • Severe signs/symptoms: otorhea, persistent pain, fever>39C, bilateral ear disease

The observation approach can be considered in the following very slect patient group:

  • Otherwise healthy children >2 years of age
  • Non-severe illness
  • Unilateral ear disease
  • Access to follow up within 48-72 hours
  • Parental comfort / Shared decision making

Often the issue with pediatric AOM isn't necessarily the overprescribing of antibiotics, but the inaccurate/inappropriate over diagnosis of acute otitis media.  An erythematous tympanic membrane does not equal AOM.  Crying and fever can result in a red TM. Fluid seen behind the TM, is often just serous otitis media, which isn't AOM. 

When antibiotics are warranted, first-line treatment is with high dose amoxicillin, 90 mg/kg per day divided into two doses; unless the child has received beta-lactam antibiotics in the previous 90 days and/or also has puruent conjunctivitis mandating amoxicillin-clavulanate instead.  In the later case, prescribing the Augment ES, 600 mg/5mL formlation with a lower clavulanic concentration lessening GI upset and diarrhea is prefered.

 

 

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Category: Pediatrics

Title: At what age should I test for strep throat in children?

Keywords: Sore throat, strep throat (PubMed Search)

Posted: 11/15/2019 by Jennifer Guyther, MD (Updated: 6/24/2024)
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Streptococcal pharyngitis is common in the pediatric population however in children younger than 3 years, group A streptococcus (GAS) is a rare cause of sore throat and sequela including acute rheumatic fever are very rare.  Inappropriate testing leads to increased healthcare and unnecessary exposure to antibiotics.

The national guidelines published by the Infectious Diseases Society of America do NOT recommend GAS testing in children less than the age of 3 years unless the patient meets clinical criteria and has a home contact with documented GAS.

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Category: Pediatrics

Title: Crystalloid fluid choice in Pediatric Sepsis

Keywords: lactated ringer, LR, normal saline, NS (PubMed Search)

Posted: 10/25/2019 by Mimi Lu, MD
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  • Resuscitation with crystalloid fluid is a cornerstone of pediatric septic shock treatment.
  • Recent publication from the adult literature have suggested that balance crystalloid solutions may be better than 0.9% normal saline (NS) for select conditions.
  • Lactated Ringer's (LR) is a common balance crystalloid solution often used for fluid resuscitation and critically ill patients.
  • However whether resuscitation with balance fluids is associated with improved outcomes compared to NS in pediatric sepsis is unclear.
  • A matched retrospective cohort study of 12,529 pediatric patient with severe sepsis/septic shock at 382 US hospitals compared outcomes with versus without LR as a part of the initial resuscitation.
  • Outcomes includesd: 30-day hospital mortality, acute kidney injury, new dialysis, and length of stay.
  • After matching, mortality was not different between LR and NS groups. There were no differences in secondary outcomes except longer hospital length of stay in the LR groups.
  • The PRoMPT BOLUS randomized control trial pilot was a feasibility study designed to study the comparative effectiveness of LR versus NS fluid resuscitation for pediatic septic shock.  Completion of a more robust study may help provide answers to these ongoing questions. 

Bottom line: Balance fluid resuscitation with LR was not associated with improved outcomes compared to NS and pediatric sepsis. Selective LR use necessitates a prospective trial to definitively determine comparative effects among crystalloids.

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Category: Pediatrics

Title: Autism in the ED

Keywords: sedation, autism spectrum disorder (PubMed Search)

Posted: 10/18/2019 by Jennifer Guyther, MD
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The emergency department care of a child with autism spectrum disorder (ASD) can be difficult due to problems with communication, social interaction and the patients problems with dealing with change. The often loud, hectic and unfamiliar environment does not help either.  Avoiding triggers, dimming lights, quiet rooms, using distractions and using home electronic devices may help.  Despite these interventions, these children may still require some type of sedation, even to be able to complete a routine exam.  There is not much research on ED sedation practices in this population.
The study cited was a retrospective chart review of 6020 patients with ASD seen over 8 years.  126 patients required sedation.  Laceration repair (24.6%), incision and drainage (17.5%), diagnostic imaging (14.3%) and physical exam (11.9%) were the leading reasons for sedation.  Half of the children received ketamine and half received midazolam.  Adverse effects were seen in 18% of patients with vomiting and desaturations being the most common.  Sedation was inadequate in 4 patients who received midazolam alone.  Physical restraint was used to complete some procedures due to patient resistance.
The use of sedation for painless procedures and exams is likely a consequence of communication impairments and sensory aversions.

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Category: Pediatrics

Title: Pediatric Tibial tubercle avulsion fractures

Keywords: Orthopedics, compartment syndrome (PubMed Search)

Posted: 9/20/2019 by Jennifer Guyther, MD (Updated: 6/24/2024)
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-       Tibial tubercle avulsion fractures are rare and pediatrics, accounting for less than 3% of all epiphyseal injuries in children ages 11-17 years. 

-       The typical mechanism is a sudden forceful quadriceps contraction.  Patients present with sudden pain after sprinting or jumping with pain, bruising, deformity or swelling over the tibial tubercle and with a decrease ability to extend the leg. 

-       10 to 20% of cases result in anterior compartment syndrome related to the rupture of the anterior tibial recurrent artery.

-       Although directly measured intra-compartmental pressures can facilitate the diagnosis of compartment syndrome, interpretation of these values can be challenging with healthy children having higher average lower leg compartment pressures than adults.  Treatment of subsequent compartment syndrome is often based on a high index of suspicion.

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Category: Pediatrics

Title: UTI Calculator

Keywords: UTIcalc, SBI, serious bacterial infection, febrile infant, urinary tract infection (PubMed Search)

Posted: 9/13/2019 by Mimi Lu, MD
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Question:  In febrile children younger than 2 years, what combination of clinical and laboratory variables best predicts the probability of a urinary tract infection?

Given that urinary tract infections (UTI) are the most common source of serious or invasive bacterial infections in young febrile infants, early identification and treatment has the potential to reduce poor outcomes.  Wouldn't it be great if there was an easy way to identify patients at highest risk?

Researchers from the Children’s Hospital of Pittsburgh formulated a calculator (UTICalc) that first estimates the probability of urinary tract infection (UTI) based on clinical variables and then updates that probability based on laboratory results.

  • The nested case-control study of 2,070 children aged 2 to 23 months with a documented temperature of 38°C or higher
  • In contrast with the American Academy of Pediatrics algorithm, the clinical model in UTICalc reduced testing by 8.1% (95% CI, 4.2%-12.0%) AND decreased the number of missed UTIs.

Bottom line:

The UTICalc calculator can be used to guide to tailor testing and treatment in children with suspected urinary tract infection with the hope of improving outcomes for children with UTI by reducing the number of treatment delays.

Go ahead and give it a click!! https://uticalc.pitt.edu/

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There is no standardized national reporting of dog bites in the US. Based on the reported figures, it is estimated that 2% of Americans are bitten annually, and children are affected disproportionately. With kids, it's usually the family dog, and occurs at home.

To avoid infection, usually from Pasturella species, many of us were taught never to primarily repair dog bites by suturing, and to always prescribe prophylactic antibiotic coverage with amoxicillin-clavulanate. However, the literature recommends otherwise in certain cases.

Bite wounds to the face and hands should have special considerations.  In general, face wounds heal with lower rates of infection, but provide the greatest concern for cosmetic appearance.  Hand wounds have notoriously higher rates of infection.  

The latest recommendations for dog bites are as follows:

1. All dog bites should be copiously irrigated under high pressure.

2. Dog bites to the face should be primarily repaired when <8 hours old, as infection rates are not significantly different and cosmesis is greatly improved. 

3. Injuries to the hands should be left open, unless function is in jeopardy or there are neurovascular concerns.

4.  Prophylactic antibiotics do not always have to be prescribed, especially in low risk patients.  Examples of high risk patients include, but are not limited to: primarily repaired bites, injuries in the hand, >8 hours old, deep or macerated or multiple bites, and the immunocompromised.

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Category: Pediatrics

Title: Rock Paper Scissors OK ! (submitted by Leen Ablaihed, MBBS, MHA)

Keywords: NV exam, neurovascular, upper extremity injury, orthopedics, hand, fracture, supracondylar (PubMed Search)

Posted: 5/24/2019 by Mimi Lu, MD (Emailed: 8/23/2019) (Updated: 8/23/2019)
Click here to contact Mimi Lu, MD

  • The assessment of peripheral nerves in children with upper limb injuries can be challenging. 
  • Neurovascular deficit was not documented in 25% of children presenting with upper extremity injury
  • BOAST (British Orthopedic Association Standards for Trauma) guidelines state that each of the Median, Ulnar, Radial, Anterior Interosseous Nerve exams must be individually documented in any supracondylar fracture
  • Dawson described an easy way to test and document your exam. Have the child play “Rock, Paper, Scissors, Ok”
    • Rock: tests the Median nerve
    • Paper: tests the Radial nerve
    • Scissors: tests the Ulnar nerve
    • Ok: tests the Anterior Interosseous nerve
  • This method increased proper documentation and reduced missed nerve injuries in upper extremity fractures.
  • Dr. Sarah Edwards and Dr. Hannah Lock created an easy infographic in the link below and found near 100% increase in NV documentation in their ED. Their poster won the prize for best infographic at the 2018 Emergency Medicine Educators' Conference (EMEC)
  • https://www.peminfographics.com/infographics/rock-paper-scissors-ok

 

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Category: Pediatrics

Title: Can an adult tourniquet be used on a pediatric patient?

Keywords: GSW, mass shooting, bleeding (PubMed Search)

Posted: 8/16/2019 by Jennifer Guyther, MD (Updated: 6/24/2024)
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Gunshot injuries are a leading cause of morbidity and mortality in the pediatric population.  The Pediatric Trauma Society supports the use of tourniquets in severe extremity trauma.  The Combat Application Tourniquet (CAT) that is commonly used in adults has not been prospectively tested in children.  This study used 60 children ages 6 through 16 years and applied a CAT to the upper arm and thigh while monitoring the peripheral pulse pressure by Doppler.  The CAT was successful in occluding arterial blood flow in all of the upper extremities and in 93% of the lower extremities.

Bottom line: The combat application tourniquet can stop arterial bleeding in the school aged child.

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Category: Pediatrics

Title: Status epilepticus medication management in children

Keywords: Keppra, Dilantin, status epilepticus (PubMed Search)

Posted: 7/20/2019 by Jennifer Guyther, MD (Updated: 6/24/2024)
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Question

-Benzodiazepines alone are effective in terminating status epilepticus in 40 to 60% of pediatric patients

-The guidelines for second line agents are based on observational studies and expert opinion

-Adverse effects of phenytoin include hepatotoxicity, pancytopenia, Stevens-Johnson syndrome, extravasation injuries, hypotension and arrhythmias

- Levetiracetam has a reduced risk of serious adverse events, greater compatibility with IV fluids and can be given in 5 minutes versus 20 minutes for phenytoin.

 

Bottom line: In a recent randomized control trial they found that levetiracetam was not superior to phenytoin as a second line agent for management of convulsive status epilepticus in children.  There was no difference between efficacy or safety outcomes between the two groups.

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Category: Pediatrics

Title: When to operate for complicated pediatric appendicitis

Keywords: appendicitis, hospitalization, operative management (PubMed Search)

Posted: 6/21/2019 by Jennifer Guyther, MD
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The 30-day adverse event rate is 11% after surgical removal of acute appendicitis.  Some experts believe that acute appendicitis actually consists of 2 types: Uncomplicated appendicitis and complicated appendicitis.  Complicated appendicitis can be broken down into appendicular abscess, appendicular phlegmon, and free perforated appendicitis with generalized peritonitis.
No consensus exists among surgeons regarding the optimal treatment of complicated acute appendicitis in children.  This study hoped to differentiate the complication rates between perforated appendicitis, appendicular abscess, and appendicular phlegmon with regards to early appendectomy versus conservative management.
14 studies were included in this meta-analysis for a total of 1288 patients. 
- Children with appendicular abscess and appendicular phlegmon had fewer complication rates and readmission rates if treated with nonoperative management.  
- Children with free perforated appendicitis showed lower complication rate and readmission rate if treated with operative management.  
- The costs were not significantly different between nonoperative management and operative management.

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Presentation:

- Prepubertal females are especially susceptible to urethral prolapse

- Can present incidentally is a painless mass found during bathing or on exam

- More commonly presents as urogenital bleeding, dysuria, or (rarely) urinary retention

 

Evaluation:

- Appears as a partial or circumferential "donut" of bright red, often friable prolapsed mucosa

- Typically occurs in the setting of UTI, cough, or constipation

- Need to rule out complications: UTI, urethral necrosis, and urinary retention

Treatment:

- Medical management start with sitz baths twice daily and addressing causative factors (treatment constipation, UTI, etc.)

- Can add either topical corticosteroid (hydrocortisone) or estrogen (Estrace or Premarin 0.01% twice daily)

- Urology follow-up necessary as many will require surgical resection of prolapsed mucosa



Category: Pediatrics

Title: Unintentional pediatric marijuana exposures

Keywords: ingestion, drug overdose, marijuana (PubMed Search)

Posted: 5/17/2019 by Jennifer Guyther, MD
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Washington state was one of the first states to legalize recreational marijuana use.  Toxicology call center data was collected on patient's 9 years old and younger with marijuana exposure between July 2010 and July 2016.  There were 161 cases during that time frame and of those 130 occurred after the legalization of recreational marijuana (over a 2.5 year period).  The median age range was 2 years old.  There were increasing cases noted after recreational marijuana was legalized and again after marijuana shops became legal.

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Category: Pediatrics

Title: Measles complications in hospitalized patients

Keywords: Measles, outbreak, complications (PubMed Search)

Posted: 4/19/2019 by Jennifer Guyther, MD (Updated: 6/24/2024)
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Measles outbreaks have been reported all over the globe, with the incidence increasing due to low immunization rates.  Italy experienced 5000 cases in 2017. This study was a retrospective multicenter observational study of children less than 18 years hospitalized for clinically and laboratory confirmed measles over a year and a half period from 2016-2017.

There were 263 cases of measles that required hospitalization during this time and 82% developed a complication with 7% having a severe clinical outcome defined by a permanent organ damage need for ICU care or death. A CRP value of greater than 2 mg/dL was associated with a 2-4 fold increased risk of developing complications. 23% developed pneumonia and 9.6% developed respiratory failure.  Hematologic involvement was seen in 48% of patients.  1.2% of hospitalized patients died.

Bottom line: Consider CRP, lipase and CBC at a minimum in your patients with suspected measles who require hospitalization.

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Over 630,000 children visit the ED every year with a diagnosis of concussion

Predictors of persistent post-concussive symptoms (PPCS):

  • female sex
  • age over 13 years
  • previous concussive symptoms lasting over 1 week
  • headache
  • sensistivity to noise
  • fatigue
  • slow response to questions.

Appromixately 1/3 of pediatric patients will have PPCS lasting over 2 weeks

Likelihood of PPCS increases to >50% in those with risk factors identified in the ED

Every state has a youth concussion law. The basic tenants are a) immediate removal from play b) written clearance from health professional to return to play c) education for athlete, parents, coaches.

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  • Pediatric visits for behavioral and mental health issues is on the rise.
  • From 2008 to 2015, rates of PED visits for suicidal thoughts/attempts doubled.
  • Shortage of pediatric psychiatrists:  8,300 nationwide with a need for 30,000.
  • Deinstitionalized Movement of 1980's, has worsened this ED crisis-based culture.
  • 50% of all mental illness begins by age 14.
  • 1 in 5 children experience a mental disorder in a given year.
  • Aggressive or agitated behavior in pediatric patients is different from adults.
  • Children are more amenable to environmental and behavioral techniques, especially verbal de-escalation, once a trigger is identified.
  • If not successful, avoid physical restraints and consider medications instead.
  • Review current or previously prescribed medications, and consider extra/early/higher dosing. If naive to medications:
  • First line is Diphenhydramine.
  • Followed by Chlorpromazine, Risperidone, and Olanzapine
  • Thorazine should be avoided in children under 12 years due to extra-pyramidal effects.
  • Lorazapam not recommneded in children under 12 years, as it can cause disinhibition and worsen behavior.
  • Avoid sedating children with neurodevelopmental disorders as they can have paradoxical reactions to diphenhydramine and benzodiazepines, and antipsychotics sometimes are not as effective.
  • Boarding is common due to lack of resources, so starting treatment in the ED is imperative. 

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Category: Pediatrics

Title: The Hyperoxia Test for the Cyanotic Infant (submitted by Nicholas Fern, MBBS)

Keywords: CCHD, congenital cardiac lesions, congenital heart disease (PubMed Search)

Posted: 2/23/2019 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

The hyperoxia-hyperventilation test (aka 100% Oxygen Challenge test) is used to differentiate the cause of central cyanosis in the sick neonate. The majority of neonatal cyanosis is caused by either cardiac or respiratory pathology.

Classically the test is performed as follows:

1. An ABG is obtained with the neonate breathing room air

2. The patient is placed on 100% FiO2 for 10 minutes

3. A repeat ABG is performed looking for an increase in PaO2 to >150 mmHg

 -   If the hypoxia is secondary to a respiratory cause, the PaO2 should increase to >150 mmHg.

-    If the hypoxia is secondary to a congenital cardiac lesion (i.e. secondary to a right-to-left cardiac shunt) the PaO2 is not expected to rise significantly. 

In practice, many physicians instead use pulse oximetry and monitor the SpO2 pre and post administration of 10 minutes of 100% FiO2.

-          If after 10min of 100% FiO2, if SpO2 is not ? 95% (some resources use 85%) then the central cyanosis is likely secondary to intracardiac shunt.

-          When this occurs, presume the sick neonate is symptomatic from a congenital cardiac lesion and initiate prostaglandin E-1 (PGE1) at 0.05-0.01 mcg/kg/min. Use caution as PGE1 may cause apnea.



Category: Pediatrics

Title: New pediatric maintenance fluid recommendations

Keywords: Maintenance fluids, D5, NS, hyponatremia (PubMed Search)

Posted: 2/15/2019 by Jennifer Guyther, MD (Updated: 6/24/2024)
Click here to contact Jennifer Guyther, MD

Hyponatremia is the most common electrolyte abnormality in hospitalized patients, affecting approximately 15-30% of patients.  Children have historically been given hypotonic maintenance IV fluids based off of theoretical calculations from the 1950s.  Multiple studies have shown complications related to iatrogenic hyponatremia, including increased length of hospital stay, seizures and death.

The American Academy of pediatrics completed a systematic review and developed an updated clinical practice guideline:

Patient's age 28 days to 18 years requiring maintenance IV fluids should receive isotonic solutions with the appropriate amount KCl and dextrose.

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