Keywords: Bronchiolitis, asthma (PubMed Search)
Predictive factors of asthma development in patients diagnosed with bronchiolitis include:
- Male sex (OR 1.3)
- Family history of asthma (OR 1.6)
- Age greater than 5 months at the time of bronchiolitis diagnosis (OR 1.4)
- More than 2 episodes of bronchiolitis (OR 2.4)
- Allergies (OR 1.6)
This was a retrospective study of 1991 children younger than 2 years that presented between 2000-2010 who were diagnosed with bronchiolitis. Primary care records were reviewed 1 year after their visit to the ED to see if the patient had a primary care diagnosis of asthma.
Of the initial study population, 817 patients had received a diagnosis of asthma at 1 year.
Since these patients were only followed up at 1 year, the amount of children who were later diagnosed with asthma may be underestimated.
Waseem et al. Factors Predicting Asthma in children with Acute Bronchiolitis. Pediatric Emergency Care. March 2017. Epub ahead of print.
Keywords: Pediatrics, urinary tract infection, urine concentration (PubMed Search)
A recent study suggests that using a lower cut off value of white blood cells in dilute urine, may have a higher likelihood of detecting a urinary tract infection in children.
In dilute urine (specific gravity < 1.015), the optimal white blood cell cut off point was 3 WBC/hpf (Positive LR 9.9). With higher specific gravities, the optimal cut off was 6 WBC/hpf (Positive LR 10). Positive leukocyte esterase has a high likelihood ratio regardless of the urine concentration.
This was a retrospective study of 2700 infants < 3 months old who were evaluated for urinary tract infections (UTI). The UTI prevalence in this group was 7.8%. A UTI was defined as at least 50,000 colony forming units/mL from a catheterized specimen. Test characteristics looked at white blood cell and leukocyte esterase cut-offs, dichotomized into specific gravities: dilute (<1.015) and concentrated (>/=1.015).
Keywords: pediatric, sepsis, infection, infants, children (PubMed Search)
Sepsis remains the most common cause of death in infants and children worldwide, with pneumonia being the most common cause of pediatric sepsis overall.
Strikingly, however, the mortality rate in pediatric sepsis is significant lower in children (10-20%) as compared to adults (35-50%).
The management of pediatric sepsis has been largely influenced by and extrapolated from studies performed in adults, in part due to difficulties performing clinical trial data in children with critical illness, including sepsis.
A major difference in management of children vs. adults with refractory septic shock with or without refractory hypoxemia from severe respiratory infection is the dramatic survival advantage of children when ECMO rescue therapy is used as compared to adults.
Bottom line: Consider ECMO for refractory pediatric septic shock with respiratory failure – in kids, survival is improved dramatically – consider it early!
For respiratory distress and hypoxia: Infants have a lower FRC and can desaturate very quickly!
Supplemental O2 should be delivered via face mask or nasal cannula or other devices such as high flow nasal cannula or nasopharyngeal CPAP, even if O2 saturation levels appear normal with peripheral monitoring devices
For improved circulation: utilize peripheral IO early
Peripheral IV or IO access can be used for fluid resuscitation, inotrope infusion, and antibiotic delivery when central access is not readily available or obtainable
Initial therapeutic resuscitative end points: hypotension and poor capillary refill may portend imminent cardiovascular collapse!
Antibiotics and source control: Early and aggressive source control is key, just as in adults!
Fluid resuscitation: Support the pump, and fill, but don’t overload the tank!
Inotropes and vasopressors: not just Levo for all!
Extracorporeal Membrane Oxygenation (ECMO)
Consider ECMO for refractory pediatric septic shock with respiratory failure – in kids, survival is improved dramatically – consider it early!
Randolph AG & McCulloh RJ. Pediatric sepsis: important considerations for diagnosing and managing severe infections in infants, children, and adolescents. Virulence. 2014: 1;5(1):179-89. doi: 10.4161/viru.27045.
Keywords: rash, fingertip, bulla, nail disorder (PubMed Search)
2) Cohen R, Levy C, Cohen J, Corrard F, Deberdt P, Béchet S, Bonacorsi S, Bidet P. Diagnostic of group A streptococcal blistering
Keywords: unicameral bone cyst, fracture (PubMed Search)
A 12 year old with arm pain after doing push ups during gym class. What is the diagnosis?
Diagnosis: Pathologic fracture with a unicameral bone cyst
Unicameral bone cysts are benign lesions that mainly affect children and adolescents. On xray the cyst is noted to be a mildly expansile, lytic, thin walled lesion without periosteal reaction. The most common sites are the proximal humerus and femur. These lesions can resolve spontaneously, but there is a risk of pathologic fracture. If fracture is detected, then the fracture site should be treated as any other fracture in the area. These lesions can also be found incidentally in which case they should be referred to orthopedics for outpatient follow up.
Kadhim, M, Thacker M, Kadhim A and Holmes L. Treatment of unicameral bone cyst: systemic review and meta analysis. J Child Orthop. 2014 Mar; 8(2): 171-191.
Mascard E, Gomez-Brouchet A, Lambot K. Bone cysts: Unicameral and aneurysmal bone cyst. Orthop Traumatol Surg Res. 2015 Feb; 101.
Keywords: epinephrine, auto-injector (PubMed Search)
As a follow up to Dr. Winter’s Pearl on Anaphylaxis on 1/24/2017, here’s a handy pearl for pediatric anaphylaxis (part 1).
Anaphylaxis: rapid and potentially life-threatening involvement of at least 2 systems following exposure to an antigen.
Medications (max: adult doses)
Get it?!?! Easy right? Instead of fumbling through an app or reference card during your next case of pediatric anaphylaxis, be a rock star "EM DR" by remembering the “Rule of 2’s”.
(Can't help it...ya'll know I love my mnemonics!!)
Keywords: Nail bed injuries, wound closure (PubMed Search)
More studies are needed, but the existing data shows that medical adhesives may be quicker without impacting cosmetic and functional outcome.
Nail bed injuries occur in 15-24% of children with fingertip injuries.
In 1997, medical adhesive was first used to secure the avulsed nail plate back to the nail bed instead of suturing back into place. By 2008, there were small studies looking at the utility of using medical adhesive to close the laceration of the nail bed. The studies were small, but there was a tendency towards shorter repair times and no difference between pain, cosmetic outcome or function.
A total of 6 articles were included in this review – 2 using histoacryl and 4 using demabond.
Edwards, S, Parkinson L. Is Fixing Pediatric Nail Bed Injuries with Medical Adhesives as Effective as Suturing? A Review of the Literature. Pediatric Emergency Care. 2016.
In pediatrics, providers typically prescribe 10 mg/kg (max 500 mg) and 5 mg/kg daily x 4 (max 250 mg) for treatment of pneumonia, but this dosing regimen is NOT recommended for all azithromycin usage. There are other dosing regimens that are important to keep in mind during the respiratory season:
1) Pharyngitis/ tonsillitis (ages 2-15 yr): 12 mg/kg daily x 5 days (max 500 mg/ 24 hr)
3) Acute sinusitis >/= 6 months: 10 mg/kg daily x 3 days
Tschudy MM, Arcara KM. The Harriet Lane Handbook 19th edition. Elsevier Mosby; 2012
Keywords: fever, diarrhea, urinary tract infection (PubMed Search)
After 4 months old, the answer MAY be no.
80 children between 4 months and 6 years of age with fever > 101 degress F and watery stools (> 3 episodes) were evaluated for hydration status using urine samples. The urine was collected either by catheterization or clean catch, depending on age. All urine cultures were negative.
Nibhanipudi KV. A Study to determine the Incidence of Urinary Tract Infections in Infants and Children Ages 4 months to 6 Years with Febrile Diarrhea. Glob Pediatr Health. 2016. Published online Sept 12, 2016.
Keywords: septic shock, cold shock, vasopressor, dopamine, epinephrine (PubMed Search)
Which first-line vasoactive drug is the best choice for children with fluid-refractory septic shock? A prospective, randomized, blinded study of 120 children compared dopamine versus epinephrine in attempts to answer this debated question in the current guidelines for pediatric sepsis.
Bottom line: Dopamine was associated with an increased risk of death and healthcare–associated infection. Early administration of peripheral or intraosseous epinephrine was associated with increased survival in this population.
This was a small double-blind, prospective randomized controlled trial of 120 children with fluid-refractory septic shock in a PICU in Brazil. The primary outcome was to compare the effects of dopamine or epinephrine in severe sepsis on 28-day mortality; secondary outcomes were the rate of healthcare–associated infection, the need for other vasoactive drugs, and the multiple organ dysfunction score. Dopamine was associated with death (OR, 6.5; 95% CI, 1.1–37.8; p = 0.037) and healthcare–associated infection (odds ratio, 67.7; 95% CI, 5.0–910.8; p = 0.001). The use of epinephrine was associated with a survival odds ratio of 6.49. Further multicenter trials or single-center studeis are necessary to verify the reproducibiltiy of these results.
Ramaswamy KN, Singhi S, Jayashree M, Bansal A, Nallasamy K. Double-Blind Randomized Clinical Trial Comparing Dopamine and Epinephrine in Pediatric Fluid-Refractory Hypotensive Septic Shock.Pediatr Crit Care Med. 2016 Nov;17(11):e502-e512.
Keywords: Ketamine, conscience sedation, pharmacology, pediatrics (PubMed Search)
Using 1.5 mg/kg or 2 mg/kg of IV ketamine led to less redosing compared to using 1 mg/kg IV.
This was a prospective, double blinded, randomized controlled trial of children 3-18 years. 125 children were included in the study. They compared 1mg/kg, 1.5 mg/kg and 2 mg/kg doses. All doses were IV. Adequate sedation was achieved with all 3 doses of ketamine, and there was no increased risk of adverse events with the higher doses. However, using 1.5mg/kg or 2 mg/kg required less redosing.
Previous studies suggested a higher risk of adverse events if the initial dose was greater than 2.5 mg/kg or the total dose was more than 5 mg/kg.
Kannikeswaran et al. Optimal dosing of intravenous ketamine for procedural sedation in children in the ED – a randomized control trial. American Journal of Emergency Medicine 24 (2016) 1347-1353.
Keywords: sickle cell, acute chest syndrome, pneumonia (PubMed Search)
Typically, empiric treatment for lobar community acquire pneumonia (CAP) in immunized < 5 year olds (preschool) is amoxicillin (45mg/kg BID or 30 mg/kg TID for resistant S. pneumoniae) for outpatient and ampicillin or ceftriaxone for inpatient. Additional coverage with azithromycin is typically recommended for school age and adolescent patients (>= 5 years), but not necessarily for younger children unless there is a particular clinical suspicion for atypical pneumonia with history, xray findings, or sick contacts.
However, in sickle cell patient with suspicion for acute chest syndrome, azithromycin is recommended for all ages groups, as atypical bacteria such as Mycoplasma are a common cause of acute chest syndrome in patients of all ages with sickle cell disease even young children. In a prospective series of 598 children with acute chest syndrome, 12% of the 112 cases in children less than 5 had positive serologic testing of M. pneumoniae (9% of all cases had M. pneumoniae) (Neumayr et al, 2003).
1) Bradley et al. The Management of Community-Acquired Pneumonia in infants and children older than 3 months of age: Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin. Infect. Dis. 53:617-630 (2011)
2) Miller, S. How I treat acute chest syndrome in children with sickle cell disease. Blood 117:5297-5305 (2011)
3) Neumayr L, et al. Mycoplasma disease and acute chest syndrome in sickle cell disease. Pediatrics 1212:87-95 (2003)
Keywords: Fluid resuscitation, gastroenteritis, dehydration (PubMed Search)
Plasma-Lyte A outperformed 0.9% NaCl for rehydration in children with acute gastroenteritis showing a more rapid improvement in serum bicarbonate levels and dehydration scores.
This was a prospective randomized double blinded study in 8 pediatric emergency departments. Patients were at least 6 months old and younger than 11 years. To be included they had to have at least 3 episodes of vomiting or diarrhea in the previous 12 hours and a Gorelick score of at least 4. 100 children were included. Serum bicarbonate was measured at 0 and 4 hours and dehydration scores were reassessed. There was a change of bicarbonate of 1.6 mEq/L for plasma-lyte A (PLA) and no change for sodium chloride. There as an improvement in the dehydration score at 2 hours for the PLA group, but the dehydration scores were not statistically significant between the 2 groups at the 4 hours mark.
Allen et al. A randomized trial of Plasma-Lyte A and 0.9% sodium chloride in acute pediatric gastroenteritis. BMC Pediatrics 2016 16:117.
Keywords: nickel dermatitis, contact irritant, allergy (PubMed Search)
A 12 year old male who recently started middle school presents to the ED with a rash in the periumbilical region that has been developing over the last few weeks. The rash is scaly, somewhat itchy, but otherwise benign appearing. The patient has no known medical conditions other than eczema, and is otherwise well. What is the diagnosis?
Picture courtesy of Mara Haseltine, MD
-Nickel allergy dermatitis is a type of allergic contact dermatitis common in skin tests in 8-16% of the pediatric population. Unlike irritant dermatitises (such as exposure to poison ivy), it usually takes repeated exposure over time to develop. In this case, the back of the button on a pair of blue jeans was the offending agent, though belt buckles, earrings, watches, piercings, and any other metal that touches skin can also cause a similar reaction. -The process is a delayed type hypersensitivity reaction mediated by T cells. Topical steroids can help clear up the rash, but the best treatment is to remove contact with the offending agent. One simple method is to apply clear nail polish to the back of the metal button or otherwise cover it with a piece of cloth. -Between 10 and 16 percent of blue jean buttons may contain nickel according to two studies. -Commercial test kits are available to help determine what metal components contain nickel -Known metal allergies should be communicated and documented as it can complicate orthopedic appliances or cardiac stents
1. T. Suneja, K. Flanagan and D. Glaser, "Blue-jean button nickel; prevalence and prevention of its release from buttons," Dermatitis, vol. 18, no. 4, pp. 208-211, December 2007 .
2. T. Byer and D. Morrell, "Periumbilical Allergic Contact Dermatitis: Blue Jeans or Belt Buckles?," Pediatric Dermatology, vol. 21, no. 3, pp. 223-226, May-June 2004.
3. J. Brasch and J. Geier, "Patch Test REsults in Schoolchildren. Results from the Information Netowrk of Departments of Dermatology (IVDK) and the German Contact Dermatitis Group (DKG)," Contact Dermatitis, vol. 37, pp. 286-93, 1997.
4. W. Weston, J. Weston and J. Kinoshita, "Prevalence of Positive Epicutaneous Tests Among Infants, Children, and Adolescents," Pediatrics, vol. 78, pp. 1070-1074, 1986.
Keywords: Bronchiolitis, ETCO2 (PubMed Search)
114 children with bronchiolitis had end tidal carbon dioxide (ETCO2) measured on presentation to the ED. The ETCO2 levels did not differ significantly between admitted and discharged patients. In the subset of admitted patients, there was no correlation with ETCO2 on admission and days of oxygen requirement or length of stay.
Bottom line: Initial ETCO2 does not predict outcome for patients with bronchiolitis.
Jacob R, Bentur L, Brik R, Shavit I and Hakim F. Is capnometry helpful in children with bronchiolitis? Respir Med 2016; 113:37-41.
Keywords: procedural sedation (PubMed Search)
Alai, A. Nitrous Oxide Administration. Medscape/emedicine. http://emedicine.medscape.com/
Guideline for Monitoring and Management of Pediatric Patients During and After Sedation Diagnostic and Therapeutic Procedures. American Academy of Pediatrics. 2011
Clinical Policy: Critical Issues in the Sedation of Pediatric Patients in the Emergency Department. Annals of Emergency Medicine, 51(4):378-399 (2008)
Keywords: Trampoline, injury patterns (PubMed Search)
From 2010-2014 ED visits in the US for injuries from trampoline parks (TPI) increased from 581 visits per year to 6932 visits per year. There was no change in the number of injuries related to home trampoline use. TPI were more likely to involve the lower extremity, be a dislocation and warrant admission and less likely to involve the head.
Bottom line: TPIs are increasing and have a different injury pattern compared to home trampolines.
Kasmire K, Rogers S and Sturm J. Trampoline Park and Home Trampoline Injuries. Pediatrics 2016: 138 (3).
Keywords: airway. mac (PubMed Search)
The pediatric epiglottis is more "U" shaped, often overlies the glottic opening, and is "less in line with the trachea."1 Because of this, it has traditionally been taught that a Miller blade is the ideal laryngoscope.
Varghese et al compared the efficacy of the Macintosh blade and the Miller blade when placed in the vallecula of children between the ages of 1 and 24 months. The blades provided similar views and suffered similar failure rates. When the opposite blade was used as a backup, it had a similar success rate as the opposing blade.2 Passi et al also compared these two blades, this time placing the Miller blade over the epiglottis. Again, similar views were achieved.3
1. Harless J, Ramaiah R, Bhananker S. Pediatric airway management. Int J. Crit Illn Inj Sci. 2014;4(1):65-70.
2. Varghese E, Kundu R. Does the Miller blade truly provide a better laryngoscopic view and intubating conditions than the Macintosh blade in small children? Paediatr Anaesth. 2014;24:825-829.
3. Passi Y, Sathyamoorthy M, Lerman J, et al. Comparison of the laryngoscopy views with the size 1 Miller and Macintosh laryngoscope blades lifting the epiglottis or the base of the tongue in infants and children <2 yr. of age. Br J Anaesth. 2014;113(5):869-874.
Keywords: Intranasal vaccine, immunizations (PubMed Search)
Although it is summer, preparations are being made for the 2016-2017 influenza season. The Center for Disease Control (CDC) no longer recommends the live attenuated influenza vaccine (LAIV4). The American Academy of Pediatrics has supported this statement.
The LAIV4 (the only intranasal vaccine available) was offered to patients over the age of 2 years without respiratory problems. Observational studies during the 2013-2015 seasons have shown that the LAIV4 has an adjusted vaccine efficacy of 3% compared to 63% for the inactivated vaccine (intramuscular). Children who received the intranasal vaccine were almost 4 times more likely to get the flu compared to children who received the injection.
Bottom line: Only the intramuscular shot is recommended for this upcoming season. This is causing many primary care practices to scramble to obtain enough vaccine.
Bernstein HH and Kimberlin DW. Intranasal FluMISSED its target. AAP News. July 2016.
Chung J et al. Seasonal Effectiveness of Live Attenuated and Inactivated Influenza Virus. Pediatrics 2016: 137 (2).
Keywords: hypertension, pediatrics (PubMed Search)
Stein DR, Ferguson MA. Evaluation and treatment of hypertensive crisis in children. Integr Blood Press Control 2016; 9:49-58.