Category: Pediatrics
Keywords: pediatrics, electrolyte, sodium (PubMed Search)
Posted: 7/5/2024 by Kathleen Stephanos, MD
(Emailed: 9/6/2024)
(Updated: 9/6/2024)
Click here to contact Kathleen Stephanos, MD
Continuing with the electrolyte derangements in children: Hyponatremia
Hyponatremia is defined as a Sodium of less than 135 mmol/L and does not depend on patient age.
This is the most common electrolyte abnormality in pediatric patients. Excessive free water is often the culprit and is usually thought of in the neonate or infant whose guardians are mixing formula incorrectly. * Additional causes include inappropriate ADH (Antidiuretic hormone) secretion, or in the case of dehydrated patients appropriate ADH secretion. Sodium wasting is rare.
Total body water (TBW) is important to consider, and preterm neonates have higher TBW (80%) than full term (70%) and 1 year old infants (~60%) putting them at higher risk of hyponatremia.
Recognizing the volume status of the patient aids in determining the etiology of the hyponatremia and allows for appropriate treatment. This may require obtaining urine sodium.
Treatment:
Hypertonic saline should be used only for patients with severe neurologic complications including seizures or altered mentation. In these patients, a hypertonic saline bolus should be given at 3-5 ml/kg of 3% NaCl over 10-15 minutes.
In hypovolemic patients without neurologic symptoms, fluid resuscitation is the mainstay with caution to increase sodium levels by no more than 6-8mmol/L/day. For euvolemic or hypervolemic patients, fluid restriction is advised.
Prevention:
Importantly, when children receive IV fluids, the choice should be made to select isotonic fluids (0.9% NaCl) rather than hypotonic fluids (0.45% NaCl) to avoid iatrogenic development of hyponatremia.
*Reminder: 2 ounces (about 60 ml) of water should be placed in the bottle, and then 1 full scoop of formula, unless directed to have higher caloric content by their doctor- in which case the amount of formula in the mixture should be higher
Saba L, Hanna C, Creo AL. Updates in hyponatremia and hypernatremia. Curr Opin Pediatr. 2024 Apr 1;36(2):219-227. doi: 10.1097/MOP.0000000000001324. Epub 2024 Jan 4. PMID: 38174733.
Brown DH, Paloian NJ. Hypokalemia/Hyperkalemia and Hyponatremia/Hypernatremia. Pediatr Rev. 2023 Jul 1;44(7):349-362. doi: 10.1542/pir.2021-005119. PMID: 37391630.
Category: Pediatrics
Keywords: pediatrics, electrolyte, potassium (PubMed Search)
Posted: 7/5/2024 by Kathleen Stephanos, MD
(Emailed: 8/2/2024)
(Updated: 8/2/2024)
Click here to contact Kathleen Stephanos, MD
Hyperkalemia is less common than hypokalemia in pediatric patients, though it is not uncommon to have hemolysis in patients who receive heel stick lab work.
The age of the patient is critical to determining the cutoff for hyperkalemia:
Typically, levels up 6.0mmol/L are well tolerated in children, unless the shift is rapid. For any child meeting age related hyperkalemia or who have a known lower prior potassium level should receive an ECG.
Treatment for hyperkalemia is similar to adults
Calcium Chloride (20mmg/kg - Max 1g) or Calcium Gluconate (0.5ml/kg - Max 20ml) is given for cardiac stability.
Albuterol can be given based on weight
Insulin and dextrose can be used with extreme caution and close monitoring for hypoglycemia. (Dextrose should be given as D10% in children under 5 years of age, D25% can be used if > 5 years old)
Brown DH, Paloian NJ. Hypokalemia/Hyperkalemia and Hyponatremia/Hypernatremia. Pediatr Rev. 2023 Jul 1;44(7):349-362. doi: 10.1542/pir.2021-005119. PMID: 37391630.
Category: Pediatrics
Keywords: pediatrics, electrolyte, potassium (PubMed Search)
Posted: 7/5/2024 by Kathleen Stephanos, MD
Click here to contact Kathleen Stephanos, MD
Hypokalemia is a common electrolyte abnormality found in pediatric patients. The cut off for low potassium is based on age, with young infants having higher baseline levels of potassium when compared to older children and adults. The most common cause of hypokalemia in children is GI losses (diarrhea), though other considerations include malnutrition, congenital adrenal hyperplasia, renal abnormalities and medication effects.
Typically, hypokalemia is well tolerated, and the focus of management is based on treating the underlying cause, rather than repleting the potassium.
Medications should ONLY be initiated in patients who have potassium levels < 3.0 mmol/L OR with those with levels < 3.5 mmol/L with ECG changes.
In patients receiving treatment, oral potassium administration is typically recommended unless any of the following criteria are met:
In these patients IV potassium should be given (typically KCl at 0.5-1mEq/kg/DOSE - Max of 40 mEq/dose).
Just like in adults, ALL patients require continuous cardiac monitoring when receiving potassium infusions.
Brown DH, Paloian NJ. Hypokalemia/Hyperkalemia and Hyponatremia/Hypernatremia. Pediatr Rev. 2023 Jul 1;44(7):349-362. doi: 10.1542/pir.2021-005119. PMID: 37391630.
Category: Pediatrics
Keywords: pediatrics, orthopedics, fracture (PubMed Search)
Posted: 6/6/2024 by Kathleen Stephanos, MD
(Emailed: 6/10/2024)
(Updated: 6/10/2024)
Click here to contact Kathleen Stephanos, MD
The supracondylar fracture is one of the most common pediatric fractures. It typically occurs due to a FOOSH injury and is a result of fracture through an area of high growth (and therefore weaker bone structure) in the pediatric distal humerus. Appearance on x-ray depends on the degree of displacement, however in cases without obvious displacement, providers must look for more subtle signs on x-ray. For example, a “sail sign” of the anterior fat pad and appearance of a posterior fat pad indicate a joint effusion and are suggestive of a fracture. However, there are often still equivocal x-rays in children with notable tenderness on exam, and failure to appropriately immobilize these fractures can result in pain and higher risk of injury resulting in displacement.
In 2021, Varga et al, looked into the ability to assess for supracondylar fractures with ultrasound. This prospective study evaluated 5 locations in the pediatric elbow for signs of fracture. Ultimately, this was able to identify more fractures than x-ray alone, and was a useful tool for equivocal cases. This is not an isolated study, but one of the most comprehensive, looking into ultrasound as a tool for supracondylar fracture identification.
It may be time to grab that ultrasound probe to look for fractures in pediatric patients with pain but an unclear elbow x-ray.
Varga M, Papp S, Kassai T, Bodzay T, Gáti N, Pintér S. Standardized sonographic examination of pediatric elbow injuries is an effective screening method and improves diagnostic efficiency. Injury. 2021 Mar;52 Suppl 1:S25-S30. doi: 10.1016/j.injury.2020.02.056. Epub 2020 Feb 28. PMID: 32173077.
Category: Pediatrics
Posted: 4/5/2024 by Kathleen Stephanos, MD
(Emailed: 5/10/2024)
(Updated: 5/10/2024)
Click here to contact Kathleen Stephanos, MD
Intranasal medications are an increasingly popular option for pediatric patients, particularly for analgesia and anxiolysis, with an increasing number of medications being used via the intranasal route of administration.
Fentanyl has been shown in prior studies to be a safe and effective pain management strategy for children, but is likely under utilized. In sickle cell patients, studies have shown that time to analgesia may improve outcomes including hospitalization.
In 2023, Rees et al. showed that in the sickle cell patient population IN fentanyl can be a very effective tool for patient's experiencing a Vaso-occlusive episode (VOE). This study looked at 400 children with a mean age of 14.6 years. Of these 19% received IN fentanyl.
Ultimately, the IN fentanyl patient population had a shorter time to initial administration of analgesia and a lower chance of admission to the hospital.
Notably, this was not a randomized study, so there is limitations in assessment of the causality of the lower discharge rates. However this is a tool that could likely be used more regularly in the pediatric sickle cell patient population to allow for more rapid pain management in the emergency department.
1. Payne J, Aban I, Hilliard LM, Madison J, Bemrich-Stolz C, Howard TH, Brandow A, Waite E, Lebensburger JD. Impact of early analgesia on hospitalization outcomes for sickle cell pain crisis. Pediatr Blood Cancer. 2018 Dec;65(12):e27420. doi: 10.1002/pbc.27420. Epub 2018 Aug 27. PMID: 30151977; PMCID: PMC6192851.
2. Rees CA, Brousseau DC, Ahmad FA, Bennett J, Bhatt S, Bogie A, Brown KM, Casper TC, Chapman LL, Chumpitazi CE, Cohen DM, Dampier C, Ellison AM, Grasemann H, Hatabah D, Hickey RW, Hsu LL, Bakshi N, Leibovich S, Patil P, Powell EC, Richards R, Sarnaik S, Weiner DL, Morris CR; SCD Arginine Study Group and PECARN. Intranasal fentanyl and discharge from the emergency department among children with sickle cell disease and vaso-occlusive pain: A multicenter pediatric emergency medicine perspective. Am J Hematol. 2023 Apr;98(4):620-627. doi: 10.1002/ajh.26837. Epub 2023 Feb 6. PMID: 36606705; PMCID: PMC10023395.
Category: Pediatrics
Keywords: Pediatrics, preparedness (PubMed Search)
Posted: 4/5/2024 by Kathleen Stephanos, MD
(Emailed: 4/12/2024)
(Updated: 4/12/2024)
Click here to contact Kathleen Stephanos, MD
In early 2023 Newgard et al published an article in JAMA which looked at pediatric readiness in ED's across the county. This study showed that there was a significant increase in pediatric mortality in patients who presented to EDs with lower readiness scores (<87 out of 100) when compared to those with higher readiness scores. And this translated to not just the time in the ED, but up to a year after they are seen in an ill-prepared ED. This number equated to an estimated total of 1,500 preventable deaths in children in the US each year.
Notably this does NOT look at what designation your hospital has for pediatrics (so being a level 1 pediatric trauma center does not automatically give you any points). This is based on having the physical materials needed for each age group, plans in place for specific patient age groups and evaluations (lower radiation doses for children in CT, using an US before CT for appendicitis evaluation, etc), and a person/people in place to review cases and ensure everyone is up to date on pediatric related training.
Want to check YOUR score? Go to https://www.pedsready.org/
Newgard CD, Lin A, Malveau S, et al. Emergency Department Pediatric Readiness and Short-term and Long-term Mortality Among Children Receiving Emergency Care. JAMA Netw Open. 2023;6(1):e2250941. doi:10.1001/jamanetworkopen.2022.50941
Category: Pediatrics
Keywords: pediatrics, fever, neonate, preterm (PubMed Search)
Posted: 2/9/2024 by Kathleen Stephanos, MD
Click here to contact Kathleen Stephanos, MD
It is an often asked question: should I consider the corrected or the chronologic age when determining the need for fever evaluation in a pediatric patient? The 2021 AAP guidelines for the well appearing febrile neonate are widely accepted and apply to neonates under 60 days. These highly practical guidelines are, unfortunately, not applicable to pre-term neonates. The question often becomes what age to use for a pre-term neonate- the age they actually are, or the age they would be if they had completed a full term gestation.
Hadhud et al attempted to clarify the age utilized in a retrospective review. This looked at febrile 448 pre-term neonates evaluated for fevers. It found that those patients with both a corrected and chronologic age over 3 months had a 2.6% rate of serious bacterial infections or SBI (UTI, bacteremia or meningitis), those with a corrected age under 3 months but a chronologic age over 3 months had a 16.7% rate of SBIs, and those with both a corrected and chronologic age of under 3 months had a 33.3% rate of SBI.
Overall, these rates of infection are higher than the typically reported in febrile neonates, supporting that pre-term neonates have a much higher risk of infections overall. Ultimately, pre-term neonates should be carefully assessed and a more thorough evaluation is typically warranted in this patient population even if they have reached the generally accepted 60 day marker by chronologic age- use the corrected age.
Hadhud M, Gross I, Hurvitz N, Ohana Sarna Cahan L, Ergaz Z, Weiser G, Ofek Shlomai N, Eventov Friedman S, Hashavya S. Serious Bacterial Infections in Preterm Infants: Should Their Age Be "Corrected"? J Clin Med. 2023 May 1;12(9):3242. doi: 10.3390/jcm12093242. PMID: 37176683; PMCID: PMC10178985.
Category: Pediatrics
Keywords: Pediatrics, procedures, sedation (PubMed Search)
Posted: 9/8/2023 by Kathleen Stephanos, MD
Click here to contact Kathleen Stephanos, MD
The literature is not completely new regarding the use of intranasal dexmedetomidine for pediatric sedation, with several articles confirming noninferiority to benzodiazepines. It is a potent a2- adrenergic receptor agonist, which allows for sedation without analgesic properties. It can be considered for patients who are undergoing PAINLESS procedures. A recent article gave further clarification for dosing considerations when selecting this option. This study assessed varying weight-based doses and found the best effect with doses of 3 to 4 mcg/kg
Importantly, there is limited data that suggests this may result in longer discharge, duration of procedure and total time in the department compared to other sedation methods. Additionally, this option is not always readily available and approved for pediatric patients in every hospital.
Overall, Dexmedetomidine may be an excellent option for painless procedures, such as CT imaging or even MRI based on the literature, when available.
Poonai N, Sabhaney V, Ali S, Stevens H, Bhatt M, Trottier ED, Brahmbhatt S, Coriolano K, Chapman A, Evans N, Mace C, Creene C, Meulendyks S, Heath A. Optimal Dose of Intranasal Dexmedetomidine for Laceration Repair in Children: A Phase II Dose-Ranging Study. Ann Emerg Med. 2023 Aug;82(2):179-190. doi: 10.1016/j.annemergmed.2023.01.023. Epub 2023 Mar 3. PMID: 36870890.
Tsze DS, Rogers AP, Baier NM, Paquin JR, Majcina R, Phelps JR, Hollenbeck A, Sulton CD, Cravero JP. Clinical Outcomes Associated With Intranasal Dexmedetomidine Sedation in Children. Hosp Pediatr. 2023 Mar 1;13(3):223-243. doi: 10.1542/hpeds.2022-007007. PMID: 36810939.
Lewis J, Bailey CR. Intranasal dexmedetomidine for sedation in children; a review. J Perioper Pract. 2020 Jun;30(6):170-175. doi: 10.1177/1750458919854885. Epub 2019 Jun 27. PMID: 31246159.
Category: Pediatrics
Keywords: Pediatrics, infectious disease, fever, bacteremia (PubMed Search)
Posted: 7/14/2023 by Kathleen Stephanos, MD
(Updated: 10/7/2024)
Click here to contact Kathleen Stephanos, MD
This study attempts to answer the age old question: What is the importance of fever in pediatric illnesses?
The authors' goal was to assess if response to antipyretics was associated with bacteremia. This article retrospectively reviewed 6,319 febrile children in whom blood cultures were sent and found that 3.8% had bacteremia. They then looked at the fever curve in response to antipyretics for these two groups in the emergency department over 4 hours. The study concluded that patients with bacteremia have a higher rate of persistent fever despite antipyretics. It is important to note the limitations of this study. As this was retrospective, it is unclear what clinical findings resulted in blood cultures being sent - most febrile children did not have any drawn (23,999 were excluded for this reason). They did not assess other vital signs, and did not address other bacterial infections (UTI, cellulitis, meningitis, otitis media, etc). Additionally, while patients with bacteremia did have a higher likelihood of fever, the majority of patients in both groups had fever resolution within 4 hours, and both groups had some children with persistent fevers.
Overall, this does seem to support the decision to consider obtaining further testing in those children with a persistent fever, but also emphasizes the importance of not using fever resolution alone as support for discharge to home or exclusion of bacteremia from the differential.
Baker AH, Monuteaux MC, Michelson KA, Neuman MI. Resolution of Fever in the Pediatric Emergency Department and Bacteremia. Clin Pediatr (Phila). 2023;62(5):474-480.
Category: Pediatrics
Keywords: glenohumoral dislocations, anterior shoulder, orthopedics, pediatrics (PubMed Search)
Posted: 11/6/2015 by Kathleen Stephanos, MD
Click here to contact Kathleen Stephanos, MD
- Anterior shoulder dislocations often require surgical management in young adults due to recurrence, but are less common in pediatric patients, particularly under age 10
- A study this year showed that 14-16 year olds are similar to 17-20 year olds in recurrence risk (around 38%- when non-operative management), and this is especially true of males.
- The recurrence rate is lower in the 10-13 age group, but there are also less dislocations in this group as well, making this group harder to assess
- Remember to consider both chronologic and bone age if you are deciding to refer a patient for outpatient surgery follow up, bone age is more accurate to determine healing and response to non-operative treatment
- Consider early referral for surgical management and counseling regarding recurrence risk in the 14-16 year age group after anterior shoulder dislocations
Leroux T, et al. The epidemiology of primary anterior shoulder dislocations in patients aged 10-16. Amer J of Sports Med. 2014; 42(2): 442-50.