UMEM Educational Pearls - Pediatrics

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: 8/15/2022)
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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

peds_pearl.jpg (504 Kb)


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: 8/15/2022)
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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: 8/15/2022)
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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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Category: Pediatrics

Title: Periumbilical rash (submitted by Greg Shamitko, MD)

Keywords: nickel dermatitis, contact irritant, allergy (PubMed Search)

Posted: 10/1/2016 by Mimi Lu, MD
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Question

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


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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.

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Inhaled nitrous oxide gas (N2O) or laughing gas, has a long history of use as anesthetics in dental and medical procedures, and can be used as a single agent for brief pediatric procedures. It has a short half-life of 5 minutes and is eliminated essentially non-metabolized through respirations.
Inhaled N2O has analgesic, anxiolytic, and amnestic properties. The mechanism of analgesia is hypothesized to be similar to that of opioids. Anxiolytic and sedative effect is similar to benzodiazepines and may involve GABA receptors.
The N2O is typically given as a mixture of 30% N2O with 70% O2, although 50:50 mixture is also safe. In the ED, it is usually given as monotherapy, as this meets criteria for minimal sedation. Nitrous oxide concentrations > 50% meet criteria for moderate sedation.
Complications are rare (most commonly, nausea/vomiting). Persistent use or abuse can be habit forming and has been associated with anemia and B12 deficiency. Rare side effects include asthma exacerbation, coughing, laryngospasm, cardiac events, and seizures. High nitrous concentrations can cause hypoxia and asphyxiation if sufficient oxygen isn’t supplied (FiO2 < 25%).

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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.

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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

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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.

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Category: Pediatrics

Title: Hypertensive crisis in children

Keywords: hypertension, pediatrics (PubMed Search)

Posted: 6/17/2016 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD

Hypertension is defined as a systolic or diastolic blood pressure > 95% for age, sex and height based on repeated measurements. There is no numeric blood pressure cut of for defining hypertensive emergency in pediatrics. Use a reference book such as Harriet Lane Handbook to determine percentiles. The proper size BP cuff should be used: bladder width that is at least 40% of the arm circumference at the midpoint of the upper arm and a length that is 80-100% of the arm circumference.
Hypertensive crisis in children younger than 6 years may present with: irritability, feeding disturbance, vomiting, failure to thrive, seizure, altered mental status, or congestive heart failure.
Treatment in the Emergency Setting
-Lower the BP to < 95 percentile in children with HTN and no signs of end organ dysfunction
-Lower the BP to < 90 percentile in children with end organ dysfunction or co-morbid conditions
-Start with IV if able
-Few anti hypertensive medications have been studied adequately in children.
-The cited article has a table of antihypertensive medications with doses to be used in children, but only 4 have FDA approved labeling for pediatrics (hydralazine, fenoldopam, sodium nitroprusside and minoxidil)

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