Keywords: Asthma, pediatrics, fluid (PubMed Search)
Fluid overload (defined in this study as (fluid input-output)/weight)) is associated with longer hospital stays, longer treatment duration and oxygen use.
Bottom line: Treat dehydration appropriately but try not to over resuscitate the asthmatic. Further studies are needed before definitive recommendations are made.
This was a retrospective cohort study over 7 years at a single children’s hospital. Children included were older than 6 years and were admitted with no pneumonia or history of chronic lung disease. Fluid intake and output were collected for the initial 72 hours of hospitalization or discharge. The study included 1175 encounters. On average, 1% increase in fluid overload was associated with about a 7 hour increase in hospital stay, 6 hours longer of beta agonist and 2 hours longer of supplemental oxygen. Fluid overload of more than 7% was determined to be clinically meaningful showing an increased risk of requiring supplemental oxygen and non-invasive pressure ventilation. One of the limitations of this study that the authors mention is that the weight they used is the admission weight and the patient may already be dehydrated, thereby overestimating fluid overload.
Kantor et al. Fluid balance is Associated with Clinical Outcomes and Extravascular Lung Water in Children with Acute Asthma Exacerbation. American Journal of Respiratory and Critical Care Medicine. Epub ahead of print, Jan 9, 2018.
Keywords: foreign body, choking (PubMed Search)
Patient: 11 month old with trouble breathing and color change after a family member sprayed air freshener. Symptoms have since resolved.
What are you concerned about in the attached xrays?
Answer: Radiolucent foreign body
Bilateral decubitus lateral films allow assessment of air trapping. The expectation is that the dependent lung will collapse partially in the normal patient. When a foreign body is present, there will be air trapping and hyperlucency in the dependent lung. In older patients, you can also obtain expiratory films to look for air trapping.
The patient had a food/mucus plug that was taken out of the right mainstem on bronchoscopy.
Foreign body aspiration is the 4th most common cause of accidental death in children younger than 3 years. Coughing and choking are the most common presenting symptoms.
CXRs are negative in > 50% of tracheal foreign bodies and 25% of bronchial foreign bodies.
More than 75% of foreign bodies in children less than 3 years are radiolucent.
Indirect signs of radiolucent foreign bodies include unilateral hyperinflation, atelectasis, consolidation and bronchiectasis (if presentation is delayed).
Bottom line: Consider bilateral lateral decubitus xrays in patients with a history concerning for foreign body.
Baram et al. Trachoebronchial Foreign Bodies in Children: The Role of Emergency Rigid Bronchoscopy. Global Pediatric Health. 2017: 1-5.
Keywords: Kawasaki's disease, SJS, TEN, dermatitis (PubMed Search)
Case: 5 year old presents to the ED with 2 weeks of fever. She has extensive cracked, bleeding lips and a rash on her hands and feet. She was recently diagnosed with “walking pneumonia” and hand, foot and mouth disease this week. Her pediatrician sent her in for further workup after she was found to have an elevated CRP on outpatient labs. A similar picture appears in the link below:
What's the diagnosis?
The diagnosis of Mycoplasma pneumonia-induced rash and mucositis (MIRM) was recently termed in the 2015 Journal of American Academy of Dermatology. It is characterized by mucocutaneous eruptions with prominent mucosal involvement. 94% of patients in the reviewed cases had extensive oral lesions that can range from erosions, ulcers or vesiculobullous lesions. 82% of patients had ocular involvement characterized by purulent bilateral conjunctivitis. In 63% of cases, patients were found to have urogenital lesions. Almost all of these patients had prodromal symptoms of cough and fever preceding the eruption by 1 week. The disease was found to be most prominent with young (11.9 ± 8.8 years) and with a 66% male predominance. The treatment is antibiotics such as azithromycin and oral corticosteroids with a minority of patients requiring IVIG. These patients have a good prognosis.
Bottom Line: Consider MIRM in patients with extensive mucosal disease that do not completely fit the criteria of Kawasaki’s or Stevens-Johnson Syndrome/ Toxic Epidermal Necrolysis.
Canavan TN, Mathes EF, Frieden I, Shinkai K. Mycoplasma pneumoniae-induced rash and mucositis as a syndrome distinct from Stevens-Johnson syndrome and erythema multiforme: a systematic review. J Am Acad Dermatol. 2015
Keywords: Pediatrics, Abdominal Pain (PubMed Search)
Your patient is an18 months old female with intermittent abdominal pain for the last 4-5 days. She has history of constipation and soy allergy, seen at an outside hospital three days ago for the same. She had an xray and was discharged home with instructions for at home clean out with diagnosis of constipation.
Mother is bringing her to your ED because the pain is back. The laxatives helped somewhat, but her symptoms have returned. She reports that the patient cries spontaneously, lasting 1-2 minutes, then completely resolves. These episodes happen at multiple times during the day.
ROS: Decreased appetite and energy, but NO fevers, vomiting, diarrhea, bloody stool, abdominal distension, hematuria, or lethargy.
Intussusception classically presents with colicky abdominal pain, palpable mass, and currant jelly stools, but in less than 50% of patients. The clinical presentation of intussusception actually occurs on a spectrum. Children who present early in their course may look well with intermittent, unexplained crying episodes, while others may be febrile, dehydrated, with bloody stools, and be septic. The diagnosis can be missed in up to 60% of children presenting for initial evaluation. Identified risk factors include any syndrome or abnormality causing a lead point, ie Meckel's Diverticulum, Familial Polyposis, lymphoma and Henoch-Scholein Purpura, as well as GI infections, bacterial and viral, (Adenovirus, Rotavirus, and HHV6, etc.)
On exam, our patient's abdomen was soft but hard to evaluate due to behavior. Flat plate AXR demonstrated a circular hyperdensity in the RUQ, which on ultrasound, corresponded to a large ileocolic intussusception. She was successfully treated with air enema reduction, which in recent review has the lowest recurrence rate of intussusception.
Bottom Line -
In children with intermittent abdominal pain or unexplained crying episodes, consider intussusception on your differential, as more than half are missed on initial presentation, which can be subtle. Late presentations can include bowel perforation, peritonitis, sepsis, and shock. If diagnosed, arrange for enema reduction or transfer to a facility with this capability.
Waseem M, Rosenberg HK. Intussusception. Pedi Emer Care. Nov 2008, 24(11): 793-800.
Gluckman S, Karpelowsky J, Webster AC, McGee RG. Management for intussusception in children. Cochrane Review of Systematic Databases. 2017; Issue 6.
Keywords: Pain control in children, opiates, NSAIDS, motrin, orthopedic (PubMed Search)
Bottom line: Oral morphine was not superior to ibuprofen and both drugs decreased pain with no difference in efficacy. Morphine was associated with more adverse events.
Poonai et al. Oral Morphine versus ibuprofen administered at home for postoperative orthopedic pain in children: a randomized controlled trial. CMAJ 2017. 189: E1252-E1258.
Keywords: NAT, non-accidental trauma, abusive head trauma, intra-abdominal injury, burns (PubMed Search)
In addition to suspicion of NAT with traumatic brain injury and burns, remember these other high risk injuries and features:
- Duodenal injuries in children <4 y/o
- Frena injuries in non-ambulating children
- Proximal and midshaft humeral fractures > supracondylar fractures
- Any bruising on the trunk, ears, neck, or with larger size or pattern
- Delay in seeking care, inconsistent history, mechanism inconsistent with developmental age, and blame of a sibling or other child inflicting harm are all historical features also high risk.
Non-accidental trauma (NAT) continues to be a sad, but prevelant pathology in the United States. It is estimated that one million children in the US have been victims of maltreatment. As high as one third of children with NAT had the abuse missed on prior medical evaluation. There are several screening tools and clinical prediction rules that have been developed for clinical use, but none are to be used as substitutes for full skeletal survey and CT scan when indicated.
TEN-4 (clinical prediction rule): 97% sensitivity, 84% specificity with regards to NAT in the setting of bruising by age, location and characteristic.
PEDIBIRN (clinical prediction rule): 96% sensitive, 43% specificity with regards to abusive head trauma in children less than 3 years old.
PredAHT (clinical prediction rule): 72% sensitive, 86% specificity, also for abusive head trauma less than 3 years old.
PIBIS (screening tool): scoring system for well appearing infants presenting with brief resolved unexplained event (BRUE), previously called apparent life threatening event or ALTE.
Escobar, MA, et al. The association of nonaccidental trauma with historical factors, examination findings, and diagnostic testing during the initial trauma evaluation. Journal Trauma Acute Care Surgery. 2017; 82(6).
Children less than 8 years, and especially infants, are more susceptible to upper cervical spine injury. Moreover, validated decision rules for suspected cervical spine injury imaging have not been proven to be as sensitive or specific for children less than 8 years of age.
The pediatric cervical spine has greater elasticity of the ligamentous structures, while the cartilaginous structures are less calcified. An infant's neck musculature is underdeveloped, with a disproportionally large head. These factors increase the risk of cervical spine injury, and can make it difficult to properly place protective cervical collars in infants while assessing them for injury.
In very young children, consider placing padding under the shoulders to prevent abnormal flexion that can occur with placement of a cervical collar, and consider having a lower threshold to image if mechanism history or exam is concerning.
Children are not little adults! Clinicians must acknowledge the anatomic differences, varying age-related ability to cooperate with examination, pediatric specific injury mechanisms, and decreased reliability of validated decision rules for imaging in children, especially when younger than 8 years old.
Murray BL, Cordle RJ: Pediatric Trauma, in Walls RM, Hockberger RS, Gausche-Hill M, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 9. Philadelphia, Elsevier 2018, (Ch) 165:p 2042-2057.
Leonard JR, Jaffe DM, Kuppermann N, et al. Cervical spine injury patterns in children. Pediatrics 2014; 133:e1179.
Keywords: Croup, epinephrine, discharge, observation (PubMed Search)
The peak age for croup is 6 months to 3 years. The cornerstone of treatment is corticosteroids, traditionally dexamethasone. With oral administration, the peak onset is 1-2 hours. Steroids shorten the duration of symptoms, reduce the need for nebulized epinephrine and decrease the need for intubation.
Racemic epinephrine has been used for moderate to severe croup and can show an improvement in patient symptoms for up to 120 minutes. There is little evidence to suggest how long to observe the patient for recurrence of symptoms after racemic epinephrine was given. Previous studies have suggested both 2 and 4 hour observation.
299 patients were included in this study. 136 patients were observed for 3.1 to 4 hours. In the 3.1 to 4 hour group, 21 (7%) failed treatment, 19 of those patients required admission and 2 returned within 24 hours. No patients who were discharged home after 4 hours returned to the emergency department within 24 hours.
Bottom Line: Consider a 4 hour period of observation after giving racemic epinephrine in order to decrease bounce backs.
Smith S, Giordano K, Thompson A and DePiero A. Failure of Outpatient Management With Different Observation Times After Racemic Epinephrine for Croup. Clinical Pediatrics. Epub ahead of print. Accessed October 2017.
Keywords: URI, AOM, wait-and-see, antibiotic stewardship (PubMed Search)
As we are approaching the winter in the northern hemisphere, the number of visits for ear pain or respiratory symptoms are expected to increase. The occurrence of acute otitis media (AOM) will also increase, but are these two disease processes related?
Drs. Heikkinen and Chonmaitree published a systematic review of previously reported studies regarding the correlation of these two disease processes (1). As far back as 1990, studies have shown that up to 94% of pediatric patients diagnosed with AOM have concomitant upper respiratory infection (URI) type symptoms at time of diagnosis (2). The viral infections most commonly associated with AOM are respiratory syncytial virus, influenza virus, and adenovirus (3).
The most commonly taught risk factors for developing AOM include young age, male gender, multiple siblings, day care attendance, and passive smoking. These factors are also related to the development of upper respiratory symptoms, and the development of AOM should be thought of as a complication of the upper respiratory infection (4).
Koivunen et al noted the highest incidence of AOM at day 3 after the onset of an URI, and the median time to diagnosis was day 4 (5). If you see a patient in day 2-4 of an URI, who has started to develop an ear effusion, but not clinical AOM, you may want to consider a “Wait-to-see” treatment option if the patient meets treatment criteria (https://em.umaryland.edu/
(1) Heikkinen T, Chonmaitree T. Importance of Respiratory Viruses in Acute Otitis Media. Clinical Microbiology Reviews. 2003;16(2):230-241.
Keywords: Marijuana, symptoms, overdose (PubMed Search)
In the US, there are an estimated 22.2 million users of cannabis based on the 2015 National Survey on Drug Use and Health. The incidence of unintentional cannabis ingestion has increased in states that have legalized medical and recreational marijuana. The cited article reviewed of 44 articles involving unintentional cannabis ingestion in children younger than 12 years.
The majority of intoxications were through cannabis resins followed by cookies and joints.
Lethargy was the most common presenting sign followed by ataxia. Tachycardia, mydriasis and hypotonia were also noted. Rarer but more serious presentations included respiratory depression and seizures.
Richards JR, Smith NE, Moulin AK. Unintentional Cannabis Ingestion in Children: A Systemic Review. The Journal of Pediatrics. 2017. Epub ahead of print.
Keywords: ARDS, oxygenation index, OI, PALICC, acute lung injury, respiratory distress, PARDS (PubMed Search)
Some pediatric practitioners have adopted the oxygenation index (OI) ([FiO2 × mean airway pressure (Paw) × 100]/ PaO2) or oxygen saturation index (OSI) ([FiO2 × Paw × 100]/ SpO2) to assess hypoxemia in children instead of P/F ratios because of the less standardized approach to positive pressure ventilation in children relative to adults.
OI can be used in pediatric patients to define severity of Acute Respiratory Distress Syndrome (ARDS) in patients receiving invasive mechanical ventilation and assess for potential ECMO treatment.
In contrast, the P/F ratio should be used to diagnose Pediatric ARDS for patients receiving noninvasive continuous positive airway pressure [CPAP] or bilevel positive airway pressure [BiPAP]) with a minimum CPAP of 5 cm H2O.
Oxygen Index (OI) = FiO2 x MAP x 100
Keywords: Vomiting, pediatric, medication (PubMed Search)
Within the first hour after administration, ondosterone, metoclopramide and bromopride were equally efficacious. At the 6 hour and 24 hour period after receiving the initial dose of medication, ondansetron was statistically superior to bromopride (not available in the US) and metoclopramide. There were no reported side effects in the ondansetron group (including diarrhea or sedation).
This was a randomized control trial of children 1 year to 12 years seen in the pediatric emergency department in Brazil for vomiting and given intramuscular bromopride (0.15mg/kg to a maximum of 10 mg), metoclopramide (0.15mg/kg to a maximum of 10 mg), or ondansetron (0.15mg/kg to a maximum of 8 mg). 175 children were included.
Epifanio et al. Bromopride, metoclopramide, or ondansetron for the treatment of vomiting in the emergency in the pediatric emergency department: a randomized control trial. J Pediatr 2017. Article in Press.
Keywords: Trauma, hematuria, kidney injury (PubMed Search)
Keywords: Pediatrics, Bronchiolitis, Respiratory Decompensation, Risk factors (PubMed Search)
Bronchiolitis season will soon be upon us. Here are some risk factors for children under 2 y/o with bronchiolitis, who may be more likely to suffer respiratory decompensation:
1. Age under 9 months
2. Black race
3. Hypoxia documented in the ED
4. Persisent accessory muscle use.
Bottom Line: Consider providing respiratory support sooner than later in bronchiolitic infants with risk factors for decompensation. For HFNC, start at 1.5 - 2.0 L/kg/min, and titrate to work of breathing and 02 saturations.
Pathophysiology: Bronchiolitis is a disease process that leads to inflammation of lower airways, causing bronchiolar edema, epithelial hyperplasia, mucus plugging, and air trapping or atelectasis. Common viral causes include RSV, Human Metapneumovirus, Rhinovirus, Influenza, and Parainfluenza.
Clinical Course: For most strains, the disease course is often 5-7 days with the worst days being 3-5. The disease process can last longer, especially in neonates. The predominant presenting symptoms are often rhinorrhea, low grade fevers, and cough, but apnea can be the primary symptom in younger infants. As a result of increased work of breathing, PO feeding tolerance decreases and leads to dehydration.
Treatment: Primarily supportive care with suctioning, hydration, supplemental oxygen via standard NC, HFNC, and in severe cases BiPAP, CPAP or intubation. Trial of bronchodilator is often used, but there is no role for repeated bronchodilator use if no benefit is seen in pre and posttreatment respiratory effort. Hypertonic saline is not recommended for routine use in the ED. Corticosteroids have no role for routine use in viral bronchiolitis, either.
Keywords: ARDS, oxygenation index, OI, PALICC, acute lung injury (PubMed Search)
Since the first description of acute respiratory distress syndrome (ARDS), various consensus conferences (including American-European Consensus Conference (AECC) and the Berlin Conference) have produced definitions focused on adult lung injury but have limitations when applied to children.
This prompted the organization of the Pediatric Acute Lung Injury Consensus Conference (PALICC), comprised of 27 experts, representing 21 academic institutions and eight countries. The goals of the conference were 1) to define pediatric ARDS (PARDS); 2) to offer recommendations regarding therapeutic support; and 3) to identify priorities for future research in PARDS.
Although there were several recommendations from the group, some notable ones, in contrast to the Berlin definition focused on adults, include: 1) use the Oxygenation Index (or, if an arterial blood gas is not available, the Oxygenation Severity Index) rather than the P/F ratio; 2) elimination of the requirement for “bilateral” pulmonary infiltrates (may be unilateral or bilateral) 3) elimination of specific age criteria for PARDS.
Tune in next month for pearls on management for children with PARDS...
Pediatric Acute Respiratory Distress Syndrome: Consensus Recommendations from the Pediatric Acute Lung Injury Consensus Conference. Pediatric Acute Lung Injury Consensus Conference Group. Pediatr Crit Care Med. 2015 Jun;16(5):428-39
Collaborators: Jouvet P, Thomas NJ, Wilson DF, Erickson S, Khemani R, Zimmerman J, Dahmer M, Flori H, Quasney M, Sapru A, Cheifetz IM, Rimensberger PC, Kneyber M, Tamburro RF, Curley MA, Nadkarni V, Valentine S, Emeriaud G, Newth C, Carroll CL, Essouri S, Dalton H, Macrae D, Lopez-Cruces Y, Quasney M, Santschi M, Watson RS, Bembea M.
Keywords: Sedation, URI, adverse events (PubMed Search)
Elective surgeries with general anesthesia are often cancelled when the child has an upper respiratory tract infection. What are the adverse events when procedural sedation is used when the child has an upper respiratory tract infection?
Recent and current URIs were associated with an increased frequency of airway adverse events (AAE). The frequency of AAEs increased from recent URIs, to current URIs with thin secretions to current URIs with thick secretions. Adverse events not related to the airway were less likely to have a statistically significant difference between the URI and non-URI groups
AAEs for children with no URI was 6.3%. Children with URI with thick/green secretions had AAEs in 22.2% of cases. Children with URIs did NOT have a significant increase in the risk of apnea or need for emergent airway intervention. The rates of AAEs, however, still remains low regardless of URI status.
Data was collected on over 83,000 patients retrospectively from a voluntary database, The Pediatric Sedation Research Consortium. Children with URIs (no fever) who underwent procedural sedation for things such as imaging or hematology/oncology procedures were included. Propofol, dexmedetomidine, ketamine and opiates were the most commonly used agents.
AAEs included wheezing, secretions requiring treatment, cough, stridor, desaturations, obstruction, snoring, laryngospasm, and apnea.
Mallory et al. Upper Respiratory Infections and Airway Adverse Events in Pediatric Procedural Sedation. Pediatrics. 2017; 140 (1): 1-10.
Keywords: VTE, Thrombophilia, Enoxaparin, Children, Thromboembolism (PubMed Search)
There is an increased incidence of venous thromboembolic events (VTE) in pediatrics due to improved diagnosis and survival of children with VTE.
The mortality rate is estimated at 2%.
The most common etiologies vary by age - Central venous catheters in neonates and infants, and inherited thrombophilia in children and adolescents.
With neonates and infants, carefully assess medical history from neonatal period. Umbilical lines? PICC? Broviac? History of these is likely to be the cause.
In children and adolescents, unprovoked VTE is most likely due to inherited thrombophilia, and can be DVT, PE, Portal venous thrombus, etc.
Antithrombin deficiency: The first discovered inherited thrombophilia. The result is a lack of inhibition of coagulation factors – IIa, IXa, Xa, XIIa.
Protein C or/and S deficiency: The result is lack of inhibition of activated Factor V.
Factor V Leiden: Most common inherited thrombophilic defect. Resultant activated Factor V is resistant to normal Protein C and S activity.
Prothrombin Mutation: Second most common inherited thrombophilia. The result is increased levels of prothrombin, which increases the half-life of factor Va.
Initial treatment of clinically significant VTE can start with enoxaparin (1-1.5 mg/kg q12-24h, while checking Anti-Xa levels 4 hours after administration for therapeutic dosing.)
Pearl: Testing for thrombophilia is not always appropriate when diagnosing pediatric patients with their first VTE, but in children and adolescents with first diagnosed, unprovoked VTE, it is worthwhile to send off the initial hypercoaguability work up as this can affect the duration of treatment and need for testing or evaluation. Enoxaparin is a recommended medication to start therapeutic treatment of VTE, even in pediatric patients.
Van Ommen CH, Nowak-Gottl U. Inherited Thrombophilia in Pediatric Venous Thromboembolic Disease: Why and Who to Treat. Frontiers in Pediatrics. 2017: 5(20).
The Harriet Lane Handbook, 20th edition. Chapter 29: Drug Dosages. 2015
Keywords: allergic reaction, anaphylaxis, auto-injector, epi-pen (PubMed Search)
Anaphylaxis is a life threatening emergency with mortality of up to 2% . Early recognition is imperative and administration of timely Epinephrine is the single most important intervention . While providers may be hesitant to administer epinephrine in older patients due to fear of precipitating adverse cardiovascular events, they may also hesitate in younger patients due to fear of overdose.
Iimmediate administration with any dose available is recommended because:
There are no absolute contraindications (including age) for epinephrine in patients with anaphylaxis. Give the initial dose IM into the anterolateral thigh.
1- Bock SA, Muñoz-Furlong A, Sampson HA. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol. 2001 Jan. 107(1):191-3. [Medline].
4- Wood JP, Traub SJ, Lipinski C. Safety of epinephrine for anaphylaxis in the emergency setting. World Journal of Emergency Medicine. 2013;4(4):245-251. doi:10.5847/wjem.j.issn.1920-