UMEM Educational Pearls - By Rose Chasm

• Pediatric acute gastroenteritis has always been a major cause of ED visits and hospitalizations.
• Pediatric complaints of vomiting and diarrhea have been on the rise, whether it be secondary to the new Omicron-variant of COVID-19, or norovirus and rotavirus which traditionally account for nearly 60% of all cases.
• Zofran (Ondansteron) 4mg for children 4-11yo weighing greater than 40kg, and up to 8mg for those older.
• Zofran prescription at discharge was associated with reduced rate of return at 72-hours and was not associated with masking alternative diagnosis like appendicitis and intussusception.
• Oral rehydration therapy (ORT) consisting of a low osmolarity solution containing sugar and salts along with zinc has also been shown to optimize treatment and diminish return visits. ORT is available in commercial packets, pre-mixed solutions, or can be made at home with table salt and sugar.
• Bottom Line: Consider providing a prescription of Zofran along with recommendations for oral rehydration therapy consisting of a low osmolarity solution containing sugar and salts to prevent outpatient treatment failure and return visits.

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• Testicular torsion is a straightforward diagnosis ultimately based on lack of blood flow to the affected painful, swollen testicle.
• Testicular torsion is the most common cause of acute unilateral testicular pain in peripubertal boys due to rapid increase in testicle size during puberty.
• Infarction begins as soon as after 2 hours of ischemia.
• There is nearly a 100% salvage rate if blood flow is re-established within 6 hours.
• Intermittent testicular torsion is challenging to diagnosis due to spontaneous resolution of symptoms and return of normal blood flow during ultrasound.
• Beware complaints of repeated episodes of acute unilateral testicular pain and swelling.
• Up to 50% of boys with testicular torsion reported at least one prior similar episode of acute pain and swelling. 
• Ultrasound findings of a whirlpool sign (spiral-like pattern of spermatic cord), boggy spermatic cord, and a psuedomass of the distal spermatic cord are concerning even in the setting of normal blood flow.
• Bottom Line: Peripubertal boys presenting with complaints of acute unilateral testicular pain and swelling should always be referred for urgent follow up even if their symptoms have resolved and when ultrasound may show normal blood flow as intermittent testicular torsion can not be ruled out.

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• Electronic cigarette (E-cigs) smoking (vaping) continues to be a major concern among adolescents and teens, who mistakenly think it is safer than smoking traditional cigarettes or don't consider it as smoking at all.
• Typically, they contain nicotine which is highly addictive and can cause harm in the developing brain, but can also contain other dangerous chemicals, flavorings and drugs.
• They often contain higher amounts and concentrations of nicotine. 1 JUUL pod can contain the equivalent of 20 packs of nicotine cigarettes.
• Inhaled aerosols of the various chemicals, flavorings, and heavy metals have resulted in lung disease and acute respiratory failure. Bilateral infiltrates on chest imaging is a common finding.
• Nicotine toxicity can also occur. Symptoms include vomiting, diarrhea, abdominal pain, salivation, headache, dizziness, confusion, and seizures. Hypertension and tachycardia acutely, followed by hypotension and bradycardia can be expected.
• Bottom Line: Ask specifically about electronic cigarette use in adolescents and teens who present with acute complaints. One study found that of those who regularly used and presented for evaluation of symptoms, 98% were respiratory, 81% were gastrointestinal, and 100% were constitutional in nature.

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The current COVID-19 pandemic and known aerosolized transmission has triggered many ED process changes, including the discouragement of utilizing nebulizers to administer inhaled bronchodilators such as albuterol for concern of spread. Historically, both patients and providers preferred the use of nebulizers as they are easier to use and the belief was that they were more effective than meterd dose inhalers. However, evidence based data has consistently shown that for both adult and pediatric patients that when MDI's are used WITH a spacer:

• There is NO significant difference in efficacy outcome.
• Nebs are associated with greater increase in tachycardia and tremors.
• Nebs are more costly overall.
• MDI's were associated with shorter ED stays and fewer hospital admissions for pediatric patients.

Albuterol:  2.5 mg nebulizer solution = 3-5 MDI puffs

Albuterol: 5 mg nebulizer solution = 5-10 MDI puffs

Ipratropium: 0.25 mg nebulizer solution = 2 MDI puffs

Ipratropium: 0.5 mg nebulizer solution = 4 MDI puffs

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• Although significant data has been accumulated regarding Covid-19 infection in adults, the epidemiologic characters and clinical course descriptions in the pediatric population lags.
• Studies to date report that children have mild self-limiting disease with low mortality, even in Immunocompromised children.
• Less than half have fever.
• However, recent reports of a severe illness similar to Kawasaki Disease and/or toxic shock syndrome have led to the newly dubbed Multisystem Inflammatory Syndrome in Children (MIS-C)
• MIS-C CDC Criteria: <21 years of age, laboratory evidence of inflammation, clinically severe illness requiring hospitalization with multisystem involvement, no alternative diagnosis, and positive Covid-19 test or exposure within 4 weeks of presentation.
• MIS-C seems to spare infants and toddlers, and is mostly described in school aged and adolescent groups.
• MIS-C often begins with fever and GI symptoms (mild vague abdominal pain,diarrhea and/or vomiting). 
• Telltale presentation of an erythematous rash that spares the limbs and is associated with conjunctival injection.  Hence the initial misdiagnosis of Kawasaki and Toxic Shock in the first reported cases.
• MIS-C patients quickly decompensate to severe shock that is often refractory to typical treatments.
• Providers should have a higher index of suspicion for MIS-C in any child who presents with concern for Covid-19 infection with these symptoms, and especially with abnormal vital signs. Closer monitoring of heart rate and blood pressure, which is often neglected is vital.

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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 versus
• initial observation for 48-72 hours without antibiotics.

Immediate treatment with antibiotics should always include the following patients:

• Children <6 months old
• Toxic appearing
• Severe signs/symptoms: otorhea, persistent pain, fever>39C, bilateral ear disease

The observation approach can be considered in the following very slect patient group:

• Otherwise healthy children >2 years of age
• Non-severe illness
• Unilateral ear disease
• Access to follow up within 48-72 hours
• Parental comfort / Shared decision making

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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• Pediatric visits for behavioral and mental health issues is on the rise.
• From 2008 to 2015, rates of PED visits for suicidal thoughts/attempts doubled.
• Shortage of pediatric psychiatrists:  8,300 nationwide with a need for 30,000.
• Deinstitionalized Movement of 1980's, has worsened this ED crisis-based culture.
• 50% of all mental illness begins by age 14.
• 1 in 5 children experience a mental disorder in a given year.
• Aggressive or agitated behavior in pediatric patients is different from adults.
• Children are more amenable to environmental and behavioral techniques, especially verbal de-escalation, once a trigger is identified.
• If not successful, avoid physical restraints and consider medications instead.
• Review current or previously prescribed medications, and consider extra/early/higher dosing. If naive to medications:
• First line is Diphenhydramine.
• Followed by Chlorpromazine, Risperidone, and Olanzapine
• Thorazine should be avoided in children under 12 years due to extra-pyramidal effects.
• Lorazapam not recommneded in children under 12 years, as it can cause disinhibition and worsen behavior.
• Avoid sedating children with neurodevelopmental disorders as they can have paradoxical reactions to diphenhydramine and benzodiazepines, and antipsychotics sometimes are not as effective.
• Boarding is common due to lack of resources, so starting treatment in the ED is imperative. 

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• No matter what the school nurse says, only a temperature >/= 100.4 F or 38 C is a fever.
• Routine use of rectal and oral routes to measure temperature are not required to document a fever in children.
• Use of electronic thermometers in the axilla is acceptable even in children under 5 years
• Forehead chemical thermometers are unreliable.
• Reported parental perception of fever should be considered valid and taken seriously.
• Measure heart rate, respiratory rate, and capillary refill as part of the assessment of a child with fever.
• Heart rate typically increases by 10, and respiratory rate increases by 7 for each 1 C temperature increase.
• If the heart rate or capillary refill is abnormal in a child with fever, measure blood pressure.
• Do not use height of temperature to identify serious illness.
• Do not use duration of fever to predict serious illness.
• Tepid sponging/bathing, underessing, and over-wrapping are not recommended in fever.
• Do not give acetaminophen and ibuprofen simultaneously.

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• Migraine diagnosis should only be made after other serious intracranial diagnoses have been ruled out.
• Pediatric migraine is a difficult diagnosis to make before the age of 7 years, due to communication difficulties
• Avoid opiates and barbiturates. They have not proven to be effective, and have been shown to decrease the effectiveness of future triptan treatments. 
• First line treatment for mild to moderate migraines is acetaminophen and/or NSAID's.  The addition of caffeine, has been shown to potentiate the analgesic effects of both.
• First line treatment for moderate to severe migraines is triptans.
• Most pediatric migraines presenting to the ED, are severe migraines that have failed the above abortive home treatments and have persisted for 24+ hours.  These patients often require intravenous therapy.
• Dopamine receptor antagonist, specifically Prochlorperazine, 0.15mg/kg, 10mg max, has demonstrated the greatest effectiveness. Consider administration with diphenhydramine, 1mg/kg, 50mg max to prevent dystonic reactions.
• Concomitant dexamethasone, 0.6mg/kg, 20mg max administration has been shown to decrease acute recurrence.
• If prochlorperazine fails, other alternatives include Sumatriptan, 5-20mg IN, 50-100mg PO and lidocaine, 0.5mL of 4% solution IN.
• IVF hydration, and reduction of light and sound stimuli may be helpful.

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• The rainy East coast spring has increased tick populations in endemic areas such as Maryland resulting in more tick bites.
• ED visits for known tick bites present acutely, often with parents bringing in the tick to be identified/tested.
• Routine serologic testing and antibiotic prophylaxis is not recommended after every tick bite.
• If an attached tick is engorged, identified as I. scapularis, and has been attached for >36 hours, then antibiotic prophylaxis for Lyme can be prescribed if started within 72 hours of tick removal in those patients > 8 years of age
• Prophylaxis: Single dose of doxycycline 4 mg/kg or 200mg max 
• If early Lyme Disese is present in the form of the classic rash of Erythema migrans, then treatment is doxycycline, 4 mg/kg or 100mg max BID for patients > 8 years of age or amoxicillin 50 mg/kg per day divided TID with 500 mg max TID in those < 8 years of age for 14 days 
• Serologic testing is false negative in the first month of testing, and unnecessary in the ED  for acute presentations. 

• Stevens-Johnsons like rash and mucositis
• Most common in children and adolescents, with a mean age of 12 years old
• More common in males than females, 2:1
• Prodromal symptoms of cough, fever, and malaise precede
• Mucositis far out of proportion to body rash, 90% vs 10%
• Mucositis is primarily oral > ocular > genital in distribution, and can be severe
• Body rash may involve palms and soles
• Complications: dehydration, GIB, epiglottitis, blindness, pericardial effusion
• Testing: PCR nasal wash/BAL; agglutination assays IgM/IgG
• Treatment: azithromycin and supportive care; occasionally steroids; rarely IVIG
• Unlike Stevens-Johnsons, prognosis is good.

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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• Evidence-based guidelines recommend therapeutic hypothermia in adults following resuscitation from cardiac arrest.
• Very few trials exist for children.
• The most recently published study on the subject (New England Journal of Medicine, May 2015) was of 295 children aged 2 days to 18 years old, at 38 different childrens hospitals who underwent targeted temperature management. 
• There was no significant difference in primary outcome between the hypothermia and normothermia groups.  One year survival and 28-day survival were similar, as were incidences of infection, serious arrhythmias, and use of blood products.
• "In comotose children who survived out-of-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia , did not confer a significant benefit in survival with a good functional outcome at 1 year."

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• Pediatric forearm fractures are common, and on the rise due to increasing sporting activity and increasing BMI.
• The most common mechanism is falling on an outstretched hand, which often leads to rotational displacement. 
• If not properly reduced, it leads to reduced range of motion.
• The majority do well with closed reduction, if properly reduced.
• A recent study (Debrovsky, et al. Ann of Emerg Med), found  the accuracy of bedside ultrasonography to determine when pediatric forearm fractures have been adequately realigned was comparable to fluoroscopy. 
• Consider using US for post-reduction evaluation of pediatric forearm fractures to reduce radiation exposure, cost, and time.

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• Ketamine popularity for procedural sedation is on the rise, again.  It provides pain relief, sedation, and memory loss while maintaining airway reflexes and has little effect on the heart. 
• Traditional administration has been the intravenous or intramuscular route, but consider intransal now. 
• Recent articles have touted the intranasal administration of ketamine for pediatric procedural sedation with good success.
• Admittedly, the number of patients enrolled in the studies to date have been small and the dosages have varied from 1 to 9 mg/kg/dose.  However, none of the studies have reported any bad outcomes or complications.
• So, consider IN ketamine for your next pediatric procedural sedation. 

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• Irregular bowel movements and constipation are a common complaint pediatric complaint.
• The majority of cases are functional, but providers should take extra care to rule out organic causes like Hirschsprung's disease particularly during the neonatal period. 
• 1 in 5000 incidence, with abnormal innervation of the distal colon resulting in tonic contraction, and obstruction of feces.
• In most cases, the agangionic segment is limited to the rectosigmoid area.
• Symptoms usually begin in the first month of life and consist of obstuctive complications such as abdominal distension, bilious vomiting, and poor feeding.
• Rectal examination should be done in all patients with constipation, and often reveals a narrowed high-pressure region adjacent to the anal sphincter.
• Barium enema, anal manometry, and rectal biopsy all aid in the diagnosis.

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• For uncomplicted community acquired pneumonia which is treated as an outpatient, high dose amoxicillin (80-90mg/kg/day) is the first-line antibiotic of choice.
• Macrolides and third-generation cephalosporins are acceptable alternatives, but are not as effective due to pneumococcal resistance and lower systemic absorption, respectivley.
• Hospitalization should be strongly considered for children younger than 2 months or premature due to an increased risk for apnea.
• Patients hospitalized only for pneumonia, should be treated with ampicillin while those who are septic should be treated with a combination of vancomycin along with a second- or third- generation cephalosporin.

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• The human enterovirus D68 is a rare virus closely related to the rhinovirus which causes the common cold.  However, there have been recent outbreaks throughout the midwest and the areas are rapidly expanding.
• Mild symptom onset of rhinorrhea and cough rapidly progress to hypoxia and respiratory distress.
• Key features are the rapid progression, presence of wheezing even without a history of reactive airway disease, and typically an absence of consolidation on chest XR.
• Children under 5 years and those with asthma are at the greatest risk for respiratory failure.
• There are a limited number of labs in the US which test specifically for EV-D68. At UMMC, the Luminex respiratory virus panel can be ordered using the kit form which includes a flocked swab and viral transport media.  Unfortunately, the panel does not differentiate between the closely related enterovirus and rhinovirus. 
• There is no definitive cure, rather only supportive care and low-threshold for admission/observation for high risk patients.

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• Only treat strep pharyngitis after confirmed via rapid antigen test or culture
• Remember the rapid antigen test has high specificity, but low sensitivity.  All negative rapid antigen tests should be followed up with a confirmatory culture
• Traditionally, strep pharyngitis was treated with penicillin V, 250mg PO tid for children and 500 mg tid for adolescents. This was then changed to bid dosing.
• Now, consider treating with amoxicillin, 50mg/kg once daily (max 1000mg). Once daily dosing and better taste improve compliance 

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