Spanish Peditric Academy
NEJM 2020; 382:1663-1665
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.
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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.
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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.
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