Antibiotic stewardship has led various organizations such as the AAP, AAFP, and IDSA to introduce two different approaches to the treatment of acute otitis media (AOM):
Immediate treatment with antibiotics should always include the following patients:
The observation approach can be considered in the following very slect patient group:
Often the issue with pediatric AOM isn't necessarily the overprescribing of antibiotics, but the inaccurate/inappropriate over diagnosis of acute otitis media. An erythematous tympanic membrane does not equal AOM. Crying and fever can result in a red TM. Fluid seen behind the TM, is often just serous otitis media, which isn't AOM.
When antibiotics are warranted, first-line treatment is with high dose amoxicillin, 90 mg/kg per day divided into two doses; unless the child has received beta-lactam antibiotics in the previous 90 days and/or also has puruent conjunctivitis mandating amoxicillin-clavulanate instead. In the later case, prescribing the Augment ES, 600 mg/5mL formlation with a lower clavulanic concentration lessening GI upset and diarrhea is prefered.
Liebeerthal AS, et al. The diagnosis and management of acute otitis media. Pediatrics 2013; 131.
Shaikh N, et al. Development of an algorithm for the diagnosis of otitis media. Acad Pediatr 2012;12:214.
There is no standardized national reporting of dog bites in the US. Based on the reported figures, it is estimated that 2% of Americans are bitten annually, and children are affected disproportionately. With kids, it's usually the family dog, and occurs at home.
To avoid infection, usually from Pasturella species, many of us were taught never to primarily repair dog bites by suturing, and to always prescribe prophylactic antibiotic coverage with amoxicillin-clavulanate. However, the literature recommends otherwise in certain cases.
Bite wounds to the face and hands should have special considerations. In general, face wounds heal with lower rates of infection, but provide the greatest concern for cosmetic appearance. Hand wounds have notoriously higher rates of infection.
The latest recommendations for dog bites are as follows:
1. All dog bites should be copiously irrigated under high pressure.
2. Dog bites to the face should be primarily repaired when <8 hours old, as infection rates are not significantly different and cosmesis is greatly improved.
3. Injuries to the hands should be left open, unless function is in jeopardy or there are neurovascular concerns.
4. Prophylactic antibiotics do not always have to be prescribed, especially in low risk patients. Examples of high risk patients include, but are not limited to: primarily repaired bites, injuries in the hand, >8 hours old, deep or macerated or multiple bites, and the immunocompromised.
Paschos NK et al. Primary closure versus non-closure of dog bite wounds. A randomised controlled tira. Injury 2014 45(1): 23l7-40
Chen, HH et al. Analysis of Pediatric Facial Dog Bites. Cranomaxillofac Trauma Reconstr. 2013 Dec; 6(4):225-232
Ellis, R; Ellis, C (2014). "Dog and cat bites". American Family Physician. 90 (4): 239–43.
Hospitalization for Suicide Ideation or Attempt: 2008-2015. Pediatrics. Pelmons. 2018
Special Considerations in the Pediatric Psychiatric Population. Psychiatric Clinics. Santillanes 2017.
Sarah Edwards, DO. Medical & Program Director. Child and Adolescent Psychiatry. University of Maryland School of Medicine.
Davies, P., and I. Maconochie. “The relationship between body temperature, heart rate and respiratory rate in children.” Emergency Medicine Journal 26.9 (2009): 641-643.
Daymont, Carrie, Christopher P. Bonafide, and Patrick W. Brady. “Heart Rates in Hospitalized Children by Age and Body Temperature.” Pediatrics 135.5 (2015): e1173-e1181.d
The National Institute for Health and Care Excellence. Pediatric Fever Guidelines, 2007 and 2013
Bachur, R. Comparison of acute treatment regimens for migraine in the emergency department. Pediatrics.2015;135(2)232-238.
Gelfand, A. Treatment of pediatric migraine in the emregency department. Ped Neuro.2012;47(4)233-241.
Kacperski, J. The optimal management of headaches in chidlren and adolescents. Ther Adv Neuro Disor. 2016;9(1)53-68.
Sheridan, D. Pediatric Migraine: Abortive treatment in the emergency department. Headache. 2014;54(2):235-245.
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.
Therapeutic Hypothermia after Out-of-Hospital Cardiac Arrest in Children. Mosler FW, et al. N Eng J Med 2015; 372:1898-1908. May 2015
Debrovsky AS, Kempinska A, Bank I, Mok E. Accuracy of Ultrasonography for Determining Successful Realignment of Pediatric Forearm Fractures. Annals of Emergency Medicine. Vol 65;Number 3. March 2015.
Andolfatto G, et al. Intranasal ketamine for analgesia in theemergency department: a prospective observational study. Acad Emerg Med. 2013. Oct;20(10):1050-4.
Tsze DS, et al. Intranasal ketamine for procedural sedation in pediatric laceration repair: a preliminary report. Pediatr Emerg Care. 2012. August;28(8);767-70.
Hall D, et al. Intranasal ketamine for procedural sedation. Emerg Med J. 2014;31:789-90.
NMS Pediatrics. Lippincott Williams and Wilkins. 4th Edition. Paul Dworkin editor.
Bennett NJ, et al. Pediatric Pneumonia Treatment and Management. Medscape. April 2014.
AAP. Management of Communty-Acquired Pneumonia in Infants and Children Older than 3 Months of Age. Pediatrics. Vol 128 No 6 December 1, 2011.
Severe Respiratory Illness Associated With Enterovirus D68--Missouri and Illinois, 2014. CDC MMWR. Vol 63. September 2014.
Wolfe TR, Braude DA. Intranasal Medication Delivery for Children: A Review and Update. Pediatrics. 2010;126:532-7.
Mudd S. Intranasal fentanyl for pain management in children: a systematic review of the literature. J PediatrHealth Care 2011;25:316-22.
Chiaretti A, Barone G, Rigante D, et al. Intranasal lidocaine and midazolam for procedural sedation in children. Arch Dis Child 2011;96:160-3.
Cruz AT, Perry AM, Williams EA, et al. Implementaion of Goal-Directed Therapy for Children With Suspected Sepsis in the Emergency Department. Pediatrics 2011;127;e758.
Wang CJ, et al. Quality-of-care indicators for children with sickle cell disease. Pediatrics. 2011;128:484.
Berini JC, et al. Fatal hemolysis induced by Ceftriaxone in a child with sickle cell anemia. 1995;126:813.
Category: Airway Management
2012 PREP Self-Assessment. American Academy of Pediatrics