UMEM Educational Pearls - Pediatrics

BOTTOM LINE: You are probably doing fine in your ED already, just delay cord clamping 60 seconds when possible.

The latest guidelines for neonatal resuscitation recommend a 60 second delay minimum in clamping the cord for neonates of all gestational ages who are stable. 
In those OVER 28 weeks for whom clamping cannot be delayed (due to maternal or neonatal factors), cord milking can be performed. 
DO NOT milk the cord in neonates under 28 weeks as this can increase the risk of intraventricular hemorrhage. 

Cord milking is performed by gently massaging the cord blood starting about 20cm away from the infant and moving toward the infant's body 3-4 times before clamping. This essentially allows for a transfusion before clamping occurs, increasing LV preload and allowing for improved oxygenation. 

Fortunately, in most EDs, the time to obtain the equipment for cord clamping likely takes more than 1 minute, so chances are in your practice you don't have to worry too much about this. But if you happen to have everything prepared, wait 60 seconds before clamping.

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Bottom line: Socioeconomic differences in outcomes of cardiac arrest are present in the pediatric population as well and CPR education and resources should be present in ALL communities.

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BOTTOM LINE: It is generally safe and effective to discharge vomiting pediatric patients with a prescription for ondansetron, and a recent study supported this common practice. 

While it has become common practice to prescribe ondansetron to children with emesis, a 2025 randomized controlled study showed that a prescription for ondansetron decreased the risk of moderate to severe gastroenteritis in the following 7 days. 

This study compared children 6 months to 18 years of age who received either ondansetron or placebo. They found a rates of moderate to severe gastroenteritis to be 5.1% in the ondansetron group versus 12.5% in the placebo group. 

*Note that ondansetron is NOT approved for children under 6 months of age or in those with prolonged QT.

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This was a retrospective study at a tertiary pediatric emergency department over a 10 year period.  Authors sought to determine the number of patients who developed radiographic pneumonia after an initial normal CXR. 

9957 patients with suspected pneumonia were included.  240 had an additional CXR within 14 days and 27 (11% of those with a 2nd CXR) had developed PNA on the CXR.  Overall, the rate was 1/370 children went on to have radiographic PNA in the next 14 days after an initial CXR.  Tachypnea, hypoxia and dehydration at the initial visit were shown to be associated with later development of PNA on CXR.

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In 2025, the AHA and AAP teamed up for the latest Cardiac arrest guides- worth a read overall, Peds had a couple tweaks which should be recognized.  

2-finger CPR is OUT. It has been shown to be ineffective, so the Two Thumb–Encircling Hands Technique should be used on ALL infants. 

Grab your AED early. While a staple of adult BLS, this is now being emphasized in pediatrics as well.  

For foreign body aspiration, remember to start with 5 back blows, but if the child is <1year old follow with chest thrusts, those who are older may receive abdominal thrusts. Repeat as needed. This has been in the literature for a while but was re-enforced due to potential injury to infants who receive abdominal thrusts.

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Pediatric CPR without an advanced airway in place requires 15 compressions to 2 ventilations per AHA and ILCOR guidelines.  This can lead to a 2-4 second pause in compressions due to the time the ventilations take.  The Maryland hiccup method is a novel description of two brief pauses for ventilations during the upstroke of compressions 14 and 15.  This method was shown to improve the compression fraction and compressions per minute with no significant differences between standard CPR and the Maryland hiccup method in ventilation volume or compression depth determined on simulation mannequins.  38 Maryland EMS clinicians participated in this study.

A video demonstration of the Maryland Hiccup method is linked in the article and also available at: https://www.youtube.com/watch?v=RvFxhj7hzsQ .

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Malrotation is estimated to occur in 1 in every 500 children, and while many are asymptomatic, volvulus can occur resulting in a high rate of morbidity and mortality from ischemic bowel. Most of these patients will present within the first month of life. 

Bilious emesis in an infant should immediately prompt consideration of this life-threatening condition, but what is the testing modality of choice? 

While Fluoroscopic Upper GI Series (UGIS) has historically been looked to as the gold standard there are many issues with this method. It requires contrast, radiation exposure and an in-house radiologist to perform the imaging, oftentimes necessitating a transfer. Due to this, many algorithms have moved to Ultrasound (US) as the first test for these patients. 

UGIS has a sensitivity for malrotation of 93-100%, but only as high as 89% for volvulus while US has a sensitivity and specificity of 94% and 100% respectively for midgut volvulus. 

US findings suggestive of volvulus include the classic “whirlpool sign” with twisting of the superior mesenteric vein around the superior mesenteric artery seen on Doppler, dilated proximal duodenum, or free fluid in the abdomen. 

So next time there is an infant presenting with bilious emesis, consider ultrasound as your first step to save a baby's bowel!

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A large-scale retrospective study of 3.7 million children found an association between radiation exposure from medical imaging and a small but significantly increased risk of developing hematologic cancers (primarily leukemia).

• Finding: Cancer risk increased with cumulative radiation dose

• Dose-Response: For the highest exposure group (50 to <100 mGy), the Relative Risk (RR) for hematologic cancer was 3.59 compared to no exposure.

  • Note: 13.7 mGy is roughly one head CT
     

• Attributable Risk: An estimated 10.1% of hematologic cancers in the cohort may have been attributable to medical imaging radiation, with CT scans being a major contributor.

• Vulnerability: Children are more susceptible to radiation-induced cancer due to their heightened radiosensitivity and longer life expectancy for the cancer to manifest.

Take Away:  Providers should critically assess the necessity of high-dose imaging like CT scans and use the lowest effective dose or possible alternative imaging (e.g. US, MRI, etc.) to prevent unnecessary cumulative exposure.

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Children account for up to 20% of emergency department visits.  In the US, up to 90% of children’s visits to emergency departments are to general EDs.  The weighted pediatric readiness score (WPRS) was developed to assess the level of readiness of emergency departments to care for pediatric patients. The last assessment was in 2013 showed a mean score of 68.9.  High readiness scores have been associated with decreased mortality.  The same holds true for children with injuries presenting to trauma centers.  The higher the WPRS score, the lower the risk of in hospital death.  There was no difference if the patient presented in cardiac arrest.  A 10 point increase in WPRS is associated with a lower odds of potentially avoidable transfers in both trauma and medical patients.  More recent data has been collected, but has not yet been published.  More information on pediatric readiness (for hospitals and EMS) can be found at: https://emscimprovement.center/domains/pediatric-readiness/. 

Bottom line: Being Pediatric Ready improves the care of children.

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A recent randomized control trial published in JAMA Pediatrics in January 2025 showed improvement in first attempt for IV access when using ultrasound in the pediatrics ED. 

This trial was performed at a quaternary pediatric hospital in Australia with a total of 164 patients (ages 18 and younger). Median age of the patients was 24 months. There was computerized system that randomized patients into either getting an IV by standard procedure vs ultrasound-guided. Those placing the ultrasound-guided IV had extensive training. Overall, the first time success rate was higher in the ultrasound group with about 85.7% compared to 32.5% in the standard group.

Main point: US IV decreases the number of sticks a child has to experience for IV access with a higher first stick success rate. Consider US IV training in your Pediatric Emergency Department in the future. Also use ultrasound guidance with first attempt IV access for your chronically ill children or for very anxious parents.

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Premature infants in the NICU are often given caffeine to help to prevent apneic episodes and this has been proven safe.  This study aims to determine if caffeine will help infants < 8 weeks with bronchiolitis, even if there is no concern for apnea. The current recommended treatment for bronchiolitis is supportive care.

2 French Hospitals with the same protocols and resources for bronchiolitis participated.  All infants admitted to each hospital with a diagnosis of bronchiolitis were included.  Infants who presented to Hospital A received caffeine and infants who presented to hospital B did not.  The remainder of their care was similar.  The caffeine was given as a bolus dose followed by a daily maintenance dose until there was clinical improvement.  The dose was the standard dose used in premature infants with apnea as recommended by the French National Authority for Health.  There were 26 patients at the study hospital that did not receive caffeine for an unknown reason.  65 patients received caffeine.

The study had several areas showing statistical significance:

In the subgroup of RSV + patients, those who did NOT receive caffeine had a higher incidence of requiring ventilatory support.  

The use of high flow nasal cannula was HIGHER in the group with NO caffeine.

The use of CPAP was HIGHER in the caffeine group BUT the duration of CPAP use was shorter compared to the NO caffeine group.

The need for nutritional support was higher in the NO caffeine group.

There were a few cases of temporary tachycardia and irritability in the caffeine group which resolved several hours after the medication was given.

A larger study is needed, but in this small group, there may be an indication for caffeine outside of the NICU for infants < 8 weeks.

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As we enter cold and flu season, sinus issues become commonplace in the ED. What do we need to know about pediatric sinusitis?

First, it is important to know when pneumatization of the sinuses occur (so we don't look for symptoms where they can't be present). Completion of their development does not occur until around age 21 years. 

• Ethmoid and Maxillary sinus- present at birth continue to develop over time
• Frontal sinus- does not develop until around age 7 years
• Sphenoid sinus- not present until the teen years

Sinusitis should be a clinical diagnosis and does not require imaging unless there is concern for abscess development, cellulitis or other complications, or in cases where symptoms are not improving despite treatment.

In most otherwise healthy children, acute sinusitis is typically viral in nature, regardless of the color of nasal discharge, and can be managed with symptomatic care, including saline sprays, humidifiers, warm compresses and monitoring. 

There are strict criteria for otherwise healthy children regarding when to initiate antibiotics including:

• patients with persistent symptoms of pain over the sinuses and nasal drainage for at least 10 days
• patients with URI symptoms AND purulent discharge AND high fever for 3 days
• patients with biphasic worsening of symptoms

 The antibiotic of choice is high-dose amoxicillin with or without clavulanic acid (cefpodoxime or cefdinir can be considered in penicillin allergic patients)

Antibiotic stewardship is critical in these patients, as unnecessary antibiotics can result in resistance or undesired side effects. There should be a clear conversation about return precautions with parents including education about the importance of symptomatic management over antibiotics in the first 10 days.

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In the pediatric ED, intranasal midazolam is a common choice among providers for procedural sedation. However, with widely varying recommendations, the ideal dose remains a topic of debate.

A recent randomized clinical trial published in JAMA Pediatrics involving 101 children, ages 6 months to 7 years, sought to determine the best dose of intranasal (IN) midazolam for sedation during laceration repair. Researchers compared four different doses: 0.2, 0.3, 0.4, and 0.5 mg/kg.

The primary outcome was achieving adequate sedation for at least 95% of the procedure. Secondary outcomes included the level of sedation, how quickly it took effect, recovery time, satisfaction of clinicians and caregivers, and any negative side effects.

What did they find?

The lower doses (0.2 and 0.3 mg/kg) were found to be less effective and were removed from the study early.

The two higher doses (0.4 and 0.5 mg/kg) both provided similar, adequate sedation for about two-thirds of the children.

Sedation took effect quickly, within a few minutes, and children recovered fast.

Adverse events were rare and not serious.

Satisfaction among both clinicians and caregivers was high across the board.

Bottom line: Consider reaching for higher doses of intranasal midazolam (0.4 to 0.5 mg/kg) for pediatric patients requiring procedural sedation.

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This was a European study examining a screening tool to be used in the ED to indicate the need for further investigation into the concern for possible abuse.  Four questions were taken from other commonly used abuse screening tools that were used outside of the ED.  SCAN questions are as follows:

1. Is the injury compatible with the history, and does it correspond to the child's developmental level?

2. Was there an unnecessary delay in seeking medical help?

3. Is the behavior/interaction of the child and caregivers appropriate?

4. Are there other signals that make you doubt the safety of the child or family?

Any positive answer triggered further evaluation, starting with a complete head to toe assessment and complete history with additional tests added as warranted.  This is only a screening tool and positive answers do NOT mean that abuse has occurred, but should cause you to pause and think further.

These questions showed a "moderate" performance among close to 25000 patients and the questions were comparable in children < 5 years to other/longer screening tools used in Europe.

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Evidence shows the effectiveness of inhaled corticosteroids during pediatric asthma attacks.

A metanalysis from 2020 reviewed 7 different studies between 2009 to 2018 that included patients < 18 years.  The studies compared the use of inhaled corticosteroids to placebo, inhaled corticosteroids compared to systemic corticosteroids, and inhaled corticosteroids in addition to systemic corticosteroids.  Please note that in the studies children were still being treated with albuterol.

The results showed:

-Inhaled corticosteroids would significantly reduce the hospital admission rate when compared to placebo (by about 83%). 

-Inhaled corticosteroids reduced hospital admission rates when compared to systemic steroids only (by 27%) for mild to moderate asthma. 

-When combining systemic steroids with inhaled corticosteroids, the hospital admission rate would be reduced by 25% compared to using only systemic steroids for moderate to severe asthma attacks.  

Bottom line: Consider administering inhaled corticosteroids in pediatric asthma patients.

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The first attempt success rates for neonatal intubation is less than 50%.  Video laryngoscopy (VL) has been shown to improve state first pass success compared to direct laryngoscopy (DL) in both children and adults, but few studies have looked at the neonatal population.

This study was a randomized control trial.  There was a 74% first pass success rate for VL compared to a 45% first pass success rate for DL.  There were no differences in secondary outcomes which include hypoxia, bradycardia, epinephrine administration, oral trauma and correct positioning.

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Trauma is a leading cause of death in pediatric patients.  The  Pediatric Traumatic Hemorrhagic Shock Consensus Conference Recommendations have stated that blood products are better than crystalloid and recommend the use of low titer type O whole blood (LTOWB) over individual components for pediatric traumatic resuscitation.

This study used the Trauma Quality Improvement Program Database to look at 1122 pediatric patients (< 18 years) over a 3 year period to retrospectively examine the impact of the ratio of whole blood and blood products given during the resuscitation of these patients. When at least 30% of the blood products delivered within the first 4 hours of resuscitation were low titer O whole blood, survival improved at the 6, 12 and 24 hour time mark.
 

The authors concluded that the observed survival benefit supports the greater availability and use of LTOWB during pediatric trauma resuscitation.

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Intranasal (IN) midazolam is often used for anxiolysis in pediatrics prior to procedures.  In this study, 0.2 mg/kg of IN midazolam (up to 6 mg total dose) was given prior to laceration repair in children 2-10 years.

90% of children were at least minimally sedated at the start of the procedure and these children also displayed less anxiety when measured on a standardized anxiety scale.  

Children's whose procedure started 10-20 minutes after IN medication compared to 25-35 minutes had significantly lower anxiety.

IN midazolam can be successful as an anxiolytic, but careful attention should be directed at the timing of the procedure.

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As the weather warms up, remember that pediatric patients have some physiologic factors that increase their risk of heat related complications. Approximately 37 infants die in cars annually, with risk of vehicular related heat illness starting with outdoor temperatures as low 72°F (32°C). Approximately 9,000 high school athletes require treatment for heat related illness annually with approximately 2 deaths per year. 

Physiology:

Infants and young children have physiologically limited thermoregulation. They also may lack developmental abilities to impact their environment (they cannot ask for water, remove clothing or a seat belt, or move themselves to a cooler environment). 

Older children take longer to acclimate to environments than their adult counterparts- requiring 10-14 days to adjust to work outs in higher temperatures (a gradual approach of increasing gear over time has been recommended for outdoor sports requiring padding or heavy equipment)

Management:

Heat exhaustion/stroke- focus on cooling the patient with temperatures being monitored with a core measurement. In teens and older children this can be done in a similar manner to adults- with removal of clothes, emersion therapy for heat stroke. In infants and young children, some experts favor evaporative management over emersion due to reflex bradycardia as well as patient compliance. 

There are no recommended medications for use during heat stroke. Benzodiazepines may be utilized to present shivering or to treat seizures only if needed.  

Prevention:  

For athletes steps should include encouraging hydration (flavored drinks have been shown to increase consumption and improve hydration), developing strategies for acclimatization for athletes, and have materials present (ice baths) to intervene quickly for players with symptoms. For infants and young children car alarms or reminders, and practicing placing a needed item in the back seat can prevent parents from inadvertently leaving a child in a car.

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While there are numerous evidence-based recommendations for the management of febrile infants, there are not clear guidelines for the management of hypothermic infants (0-90 days).

A recent review article offered the following summary points from the literature:

The World Health Organization defines hypothermia as a temperature < 36.4 degrees Celsius while the International Pediatric Sepsis Consensus Conference uses < 36.0 degrees Celsius.  A multicenter study attempted to empirically derive a threshold for hypothermia but was not successful.

One study looking at the age of presentation of hypothermic patients showed that > 50% of the infants that presented were < 7 days old.

There are numerous reasons that an infant can be hypothermic, including bacterial infections such as urinary tract infections, bacteremia or meningitis, viral infections (herpes simplex virus) or environmental factors.  Premature infants can also have temperature instability as can those with insufficient caloric intake.

Serious bacterial infection (defined as urinary tract infections, bacteremia or meningitis ) occurred less frequently in hypothermic infants compared to febrile infants, but the rates of invasive bacterial infections (defined as bacteremia and meningitis) were the same between the two groups.

In 112 patients with neonatal HSV, 5.2% of the cases were hypothermic, 30.9% had fever and 63.9% had no change in temperature.

Important questions/exam findings to raise suspicion for a pathological cause of hypothermia:

Perinatal history: Gestational age, GBS and HSV status of mom, perinatal antibiotics, and potential exposures to HSV.

Weight change, activity change, interest in feeding, abnormal movements, changes in breathing pattern, ill appearance

Some institutions will group the evaluation of hypothermic infants into the febrile infant guidelines, but there are currently no evidence-based pathway's.  Striking a balance between over testing and not missing a serious bacterial infection is difficult and an area that requires additional research.

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