UMEM Educational Pearls - Pediatrics

Category: Pediatrics

Title: Bacterial Meningitis in Pediatric Complex Febrile Seizures

Keywords: Febrile seizure, meningitis (PubMed Search)

Posted: 8/18/2017 by Jenny Guyther, MD (Updated: 12/7/2022)
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Takeaways

Febrile seizures occur in children 6 months through 5 year olds.  A complex febrile seizure occurs when the seizure is focal, prolonged (> 15 min), or occurs more than once in 24 hours.

The prevalence of bacterial meningitis in children with fever and seizure after the H flu and Strep pneumomoniae vaccine was introduced is 0.6% to 0.8%.  The prevalence of bacterial meningitis is 5x higher after a complex than simple seizure.

From the study referenced, those children with complex febrile seizures who had meningitis all had clinical exam findings suggestive of meningitis.  More studies are needed to provide definitive guidelines about when lumbar punctures are needed in these patients.

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Takeaways

The answer appears to be ... it depends.

Early Oseltamivir Treatment in Influenza in Children1-3 Years of Age: A Randomized Controlled Trial

A study in 2010 out of Finland by Heinonen, et al showed that if given in the first 12 hours of symptom onset to otherwise healthy pediatric patients between the age of 1-3 years:

-  decrease incidence of acute otitis media by 85%

-  no difference if given within 24 hours

Among children with influenza A, oseltamivir started within 24 hours of symptom onset

-  shortened medium time to resolution of illness by 3.5 days (3.0 versus 6.5) in all children

- shortened median time to resolution of illness by 4.0 days in UNvaccinated children

- Reduced parental work absenteeism by 3 days

*  no differences were seen in children with influenza B *

Limitations***

- Single Center study in Finland

- The authors received support from the drug manufacturer

- The sample size of children with confirmed influenza cases with small (influenza A: 79, influenza B: 19)

Takeaway:

If you have a patient between the age of 1-3 years with very early symptoms concerning for flu, a positive rapid influenza A test could allow you to cut her symptoms by 3 days, prevent complications, and allow parents to go back to work sooner.

 

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Category: Pediatrics

Title: Reducing radiation exposure in evaluation of ventricular shunt malfunctions in children

Keywords: CT scans, radiation exposure, pediatrics (PubMed Search)

Posted: 7/21/2017 by Jenny Guyther, MD (Updated: 12/7/2022)
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Ventricular shunt (VP) malfunction can be severe and life-threatening and evaluation has typically included a dry CT brain and a shunt series which includes multiple x-rays of the skull, neck, chest and abdomen.  The goal of this study was to decrease the amount of radiation used in the evaluation of these patients since these patients will likely present many times over their lifetime.  Several institutions have more towards a rapid cranial MRI, however, this modality may not be readily available.

This multidisciplinary team decreased the CT scan radiation dose from 250mA (the reference mA in the pediatric protocol at this institution) to 150 mA which allows for a balance between reducing radiation exposure and adequate visualization of the ventricular system.  They also added single view chest and abdominal x-rays.

The authors found that after implementing this new protocol, there was a reduction in CT radiation doses and number of x-rays ordered with no change in the return rate.

 

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Takeaways

Every year in the U.S., preventable poisonings in children result in more than 60,000 ED visits and around 1 million calls to poison centers.  Calls relating specifically to pet medication exposure and children have been on the rise.

A recent study in Pediatrics was the first was kind to characterize the epidemiology of such exposures.

This study is a call to arms for an increased effort on the part of public health officials, pharmacists, veterinarians, and physicians to improve patient education to prevent these exposures from occurring. 

Summary of major findings:

  • Children less than or equal to age 5 are at greatest risk
  • Ingestion accounted for the exposure route in 93% of cases. 
  • Exploratory behavior(61.%) was the most common mechanism of exposure

Most commonly Implicated exposures:

  • Pet medications with no human equivalent  (17.3%)
  • Antimicrobials (14.8%
  • Antiparasitic 14.6%)
  • Analgesics (11.1%)

Key contributors to exposure risk:

  • Lack of recognition by caregivers of potential hazards of pet medications
  • Inappropriate or lack of home storage practices
  • Inconsistent compliance by veterinary providers in terms of proper product labeling and child-resistant packaging

Take home point: Make sure your pet's medications are appropriately stored for safety!

 

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Category: Pediatrics

Title: Pediatric blunt trauma and the need for chest xray

Keywords: Blunt thoracic trauma, pediatric trauma, chest xray (PubMed Search)

Posted: 6/16/2017 by Jenny Guyther, MD
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Takeaways

Chest injuries represent the second most common cause of pediatric trauma related death.  ATLS guidelines recommend CXR in all blunt trauma patients.  Previous studies have suggested a low risk of occult intrathoracic trauma; however, these studies included many children who were sent home.

Predictors of thoracic injury include: abdominal signs or symptoms (OR 7.7), thoracic signs of symptoms (OR 6), abnormal chest auscultation (OR 3.5), oxygen saturation < 95% (OR 3.1), BP < 5% for age (OR 3.7), and femur fracture (OR 2.5).

4.3 % of those found to have thoracic injuries did not have any of the above predictors, but their injuries were diagnosed on CXR.  These children did not require trauma related interventions.

Bottom line: There were still a number of children without these predictors that had thoracic injuries, so the authors suggest that chest xray should remain a part of pediatric trauma resuscitation.

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Takeaways

IM ziprasidone (Geodon) has a relatively quick onset of action with a half-life of 2-5 hours.  Although commonly used in adults, there has not been a study looking at an effective dose in pediatrics. Based on the study referenced, the suggested pediatric dose of ziprasidone is 0.2 mg/kg (max 20mg).

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Takeaways

The FDA recently announced restrictions on the use of Tramadol and Codeine in children and breastfeeding mothers due to possible harm in infants.  Essentially, codeine will now be contraindicated for the treatment of cough and/or pain, and tramadol contraindicated to treat pain for children under age 12 years. Tramadol will be also be contraindicated in children younger than 18 years for treatment of pain after tonssillectomy/ adenoidectomy. 
 
These medicines carry serious risks, including slowed or difficulty breathing and death. These medicines also should be limited in some older children.
 
Additional warnings apply for children 12 to 18 years who are obese, have severe lung disease, or sleep apnea as they may increase the risk of serious breathing problems. 
 
Please be aware of these new restrictions to protect the health and safety of our patients.
 
A summary statement from the American Hospital Association (AHA) is posted below.

Bottom line: Do not prescribe codeine or tramadol for cough or pain in children and breastfeeding moms.

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Takeaways

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)

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Category: Pediatrics

Title: Does urine concentration effect the diagnosis of urinary tract infection?

Keywords: Pediatrics, urinary tract infection, urine concentration (PubMed Search)

Posted: 4/14/2017 by Jenny Guyther, MD (Updated: 12/7/2022)
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Takeaways

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. 

 

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Category: Pediatrics

Title: Pediatric Sepsis (submitted by Lauren Grandpre, MD)

Keywords: pediatric, sepsis, infection, infants, children (PubMed Search)

Posted: 3/31/2017 by Mimi Lu, MD
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Takeaways

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!

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Category: Pediatrics

Title: Blistering Distal Dactylics (submitted by Nicole Cimino-Fiallos, MD)

Keywords: rash, fingertip, bulla, nail disorder (PubMed Search)

Posted: 3/24/2017 by Mimi Lu, MD
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Who- Mostly seen in children, but sometimes in immunocompromised adults
What- Peri-ungal infection of the fingerpad with pus-filled blister with erythematous base
Cause- May result from thumb or finger sucking. Staph and strep are the most common bugs, but it can be caused by MRSA.
DDx- herpetic whitlow, paronychia/felon, friction blister, insect bite
Treatment-
1. De-roof the blister
2. Send drainage for culture
3. Treat for staph and strep- no indication to treat for MRSA initially unless strong suspicion
4. 10 day course of antibiotics recommended
For additional information and image: http://www.medscape.com/viewarticle/718695_3

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Question

A 12 year old with arm pain after doing push ups during gym class.  What is the diagnosis?

 

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Attachments

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Category: Pediatrics

Title: Pediatric Anaphylaxis "Rule of 2's"

Keywords: epinephrine, auto-injector (PubMed Search)

Posted: 1/27/2017 by Mimi Lu, MD
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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)

  • Epinephrine auto-injector (2 doses): 0.15 mg and 0.3 mg
  • Methylprednisolone (IV) or prednisone (PO): 2 mg/kg
  • Diphenhydramine: 1-2 mg/kg
  • Ranitidine: 2 mg/kg

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!!)


Category: Pediatrics

Title: Can you glue a pediatric nail bed laceration?

Keywords: Nail bed injuries, wound closure (PubMed Search)

Posted: 1/20/2017 by Jenny Guyther, MD (Updated: 12/7/2022)
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Takeaways

More studies are needed, but the existing data shows that medical adhesives may be quicker without impacting cosmetic and functional outcome.

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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)

2) Pertussis

3) Acute sinusitis >/= 6 months: 10 mg/kg daily x 3 days

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Category: Pediatrics

Title: Do older infants with fever and diarrhea need a UA and culture?

Keywords: fever, diarrhea, urinary tract infection (PubMed Search)

Posted: 12/16/2016 by Jenny Guyther, MD (Updated: 12/7/2022)
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Takeaways

After 4 months old, the answer MAY be no.

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Category: Pediatrics

Title: Vasopressor of choice in pediatric sepsis?

Keywords: septic shock, cold shock, vasopressor, dopamine, epinephrine (PubMed Search)

Posted: 11/25/2016 by Mimi Lu, MD
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Takeaways

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.

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Category: Pediatrics

Title: What is the optimal dosing for IV ketamine for moderate sedation in children?

Keywords: Ketamine, conscience sedation, pharmacology, pediatrics (PubMed Search)

Posted: 11/18/2016 by Jenny Guyther, MD
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Takeaways

Using 1.5 mg/kg or 2 mg/kg of IV ketamine led to less redosing compared to using 1 mg/kg IV.

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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).

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Category: Pediatrics

Title: Plasma-Lyte A versus 0.9% NaCl for rehydration in the pediatric patient

Keywords: Fluid resuscitation, gastroenteritis, dehydration (PubMed Search)

Posted: 10/21/2016 by Jenny Guyther, MD
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Takeaways

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.

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