UMEM Educational Pearls - Pediatrics

 

  • TXA has been used for pediatric non-traumatic (surgical) bleeding with good evidence
  • Currently used in around 1/3 of pediatric trauma centers based on survey data
  • PED-TRAX (retrospective review of pediatric trauma admissions in a combat zone) showed an association between use of TXA and decreased mortality, with no increase in thromboembolic events
  • Dosing strategies in the literature and in practice have been variable (bolus at variable dosing versus bolus + infusion)
  • The TIC TOC trial was recently completed - a multicenter randomized pilot study looking at 2 dosing strategies of TXA versus placebo which demonstrated feasibility of a larger study and will hopefully serve as a model for further research to determine efficacy as well as ideal dosing

 

Bottom line: There is not clear evidence for efficacy, but trends are positive and the documented rates of adverse effects in this population are low. It is reasonable to give, especially in patients requiring massive transfusion or who are critically ill.

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Category: Pediatrics

Title: The Pediatric Pause - Introducing a Trauma Informed Care Protocol

Keywords: trauma informed care, pediatric resuscitation (PubMed Search)

Posted: 7/15/2022 by Jenny Guyther, MD (Updated: 8/17/2022)
Click here to contact Jenny Guyther, MD

Traumatic injuries are a leading cause of morbidity and mortality in pediatric patients.  Even in the setting of a full recovery, there can be negative psychological sequelae associated with the traumatic events.  The child's perceived risk of death and parental trauma related distress have both been associated with the development of post traumatic stress.
 
Previous studies have suggested the key components of trauma informed pediatric care include: minimizing potentially traumatic aspects of medical care and procedures, providing children and family with basic support and information, addressing child distress such as pain, fear, and loss,  promoting emotional support, screening children and families who might need support and providing anticipatory guidance about adaptive ways of coping.
 
The Pediatric PAUSE was introduced at a pediatric trauma center to help to reduce post traumatic stress.  
 
PAUSE stands for Pain/Privacy, Anxiety/IV access, Urinary Catheter/Rectal Exam/Genital Exam, Support for family or staff and Explain to patient/Engage the PICU team.  The article contains a table with a more detailed outline of the PAUSE.
 
This study evaluated the pediatric PAUSE to see if its implementation would interfere with the timeliness of the ACS/ATLS evaluation.  The PAUSE was inserted after the primary and ABCDE assessment (except in the unstable patient).  The use of this protocol did not prolong time between trauma bay arrival and critical imaging studies.

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  • Use of FAST is less common in pediatric trauma than in adult trauma
  • FAST in pediatric trauma has a lower negative predictive value than in adults
    • 1/3 of pediatric patients with hemoperitoneum on CT will have a negative FAST
    • Lowest sensitivity and specificity is in the under 2 years age group
  • A 2017 randomized clinical trial of ~900 patients showed no difference in clinical care, use of resources, or length of stay in hemodynamically stable children who received FAST + standard trauma evaluation versus standard trauma evaluation alone
  • There may be a role for FAST as a screening in patients with low suspicion for intraabdominal injury in conjunction with labs and physical exam, but this has not been fully explored

Bottom line: A positive FAST warrants further workup and may be helpful in the hemodynamically unstable pediatric trauma patient, but a negative FAST does not exclude intraabdominal injury and evidence for performing FAST in hemodynamically stable pediatric patients is limited.

 

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Category: Pediatrics

Title: What is the ideal length of treatment for pediatric community acquired pneumonia?

Keywords: PNA, pediatrics, duration of treatment (PubMed Search)

Posted: 6/17/2022 by Jenny Guyther, MD (Updated: 8/17/2022)
Click here to contact Jenny Guyther, MD

This was a randomized placebo controlled trial looking at 380 pediatric patients aged 6 months to 5 years who were diagnosed with nonsevere CAP and who showed early clinical improvement.  On day 6, one patient group was switched to a placebo while the other group continued with the antibiotics.
 
In this small study population, 5 days of a penicillin based antibiotic had a similar clinical response and antibiotic associated adverse effect profile compared to a 10 day course.  A 5 day course also reduced antibiotic exposure resistance compared to a 10 day course.  

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Category: Pediatrics

Title: Post fracture pain management in children.

Keywords: motrin, narcotics, oxycodone, fracture care (PubMed Search)

Posted: 5/20/2022 by Jenny Guyther, MD (Updated: 8/17/2022)
Click here to contact Jenny Guyther, MD

This was a prospective study done in a pediatric emergency department where 329 children ages 4-16 years with isolated fractures were included.  After casting, children were prescribed either ibuprofen or oxycodone.  Pain score and activity level were followed by phone for 6 weeks.  The reduction in pain was comparable for motrin and oxycodone.  However, the children who received motrin experienced less side effects and quicker return to baseline activities compared to oxycodone.
Bottom line: Ibuprofen is a safe and effective option for fracture related pain and has fewer adverse effects compared to oxycodone.

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Category: Pediatrics

Title: Environment Modifications for Autism in the ED

Keywords: autism spectrum disorder, neurodevelopmental disorder (PubMed Search)

Posted: 5/6/2022 by Rachel Wiltjer, DO (Updated: 8/17/2022)
Click here to contact Rachel Wiltjer, DO

 

  • Autism spectrum disorder and other neurodevelopmental disorders can predispose to challenging ED encounters secondary to difficulties with sensory processing and communication
  • Small changes to the environment can help to reduce stress, generally by decreasing stimulation
  • Use quieter areas of the ED when possible, decrease volume of alarms, and consider noise cancelling headphones or white noise if available
  • Consider dimming the lights, turning the monitor/computer screen away from the patient
  • Allow the patient to remain in their own clothing and consider whether restrictive items such as the monitor, pulse oximeter, and blood pressure cuff are necessary (but continue to use them when they are medically appropriate)
  • Offering distraction via electronics, fidget toys, or weighted blanket (or lead apron) may help with managing stress
  • Ask the patient or family which modifications would be helpful for the patient and ask child life for assistance where available

 

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In 2013, the Pediatric Emergency Care Applied Research Network developed a prediction rule to identify patients who were at low risk of requiring acute intervention after blunt abdominal trauma.  Interventions included laparotomy, embolization, blood transfusion or IV fluids for more than 2 nights with pancreatic or bowel injuries.
If ALL of the following are true, the patient is considered very low risk (0.1%) of needing an acute abdominal intervention:  
- No evidence of abdominal wall trauma or seat belt sign
- GCS 14 or 15
- No abdominal tenderness
- No thoracic wall trauma
- No abdominal pain
- No decreased breath sounds
- No vomiting
 
This prediction rule was externally validated in 2018 showing a sensitivity of 99%.  This rule should be used to decrease the rate of CT scans of the abdomen following blunt trauma.

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Category: Pediatrics

Title: Organic Acidemias - What you Need to Know in the ED

Keywords: inborn error of metabolism (IEM), organic acidemia (PubMed Search)

Posted: 4/1/2022 by Rachel Wiltjer, DO (Updated: 8/17/2022)
Click here to contact Rachel Wiltjer, DO

 

  • 2/3’s present in the neonatal period and can mimic conditions such as sepsis, gastroenteritis, and meningitis requiring careful consideration to prompt testing
  • Common symptoms are poor feeding, lethargy, irritability, vomiting, and encephalopathy
  • May be referred in if detected on newborn screen, but not all are tested on the newborn screen
  • Should look on labs for acidosis, elevated anion gap, hyperammonemia, lactic acidosis, ketosis/ketonuria, and hyper/hypoglycemia  
  • Emergent treatment includes: identification and treatment of any underlying triggers (such as infection), stopping any protein intake until situation can be clarified, providing fluids with glucose (requirements of 8-10 mg/kg/min of glucose in neonates), and genetics consultation

 

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In emergency departments in the US, the diagnosis of pneumonia is often made on chest xray.  In the outpatient setting, national guidelines focus on the clinical diagnosis of pneumonia and recommend against radiographs.  This study aimed to develop and validate a clinical tool that could be used to determine the risk of radiographic pneumonia.
The criteria in the Pneumonia Risk Score (PRS) evaluate for the presence of fever, rales, and wheeze and take into account age and triage oxygen saturation.  When developing this protocol, the investigators compared the patients who had pneumonia on chest xray with both clinical judgment and the PRS.  The PRS outperformed clinical judgment in predicting which patients would have pneumonia on chest xray.
Children who have a score of 2 or less were unlikely to have pneumonia on chest xray and would qualify for observation without an xray or empiric antibiotics use.  Children who had a score of 5 or greater were likely to have radiographic pneumonia and could be empirically treated with antibiotics. If the PRS score was 6, the specificity was 99.9%
This link https://links.lww.com/INF/E552. takes you to the excel spreadsheet where you can enter the patients clinical data and gives you a present probability of radiographic pneumonia.  (In case the link does not work, it is also found in the supplemental digital content.)
Bottom line: PRS outperforms clinical judgment when determining if pneumonia will be present on the pediatric chest xray.

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Category: Pediatrics

Title: SCIWORA in Pediatric Trauma Patients

Keywords: SCIWORA, trauma, pediatrics, myelopathy (PubMed Search)

Posted: 3/4/2022 by Natasha Smith, MD
Click here to contact Natasha Smith, MD

Pediatric spines are elastic in nature.

SCIWORA is a syndrome with neurological deficits without osseous abnormality on XR or CT.

Many patients with SCIWORA have myelopathy.

Mechanism of injury: Most commonly caused by hyperextension or flexion. Other possible mechanisms include rotational, lateral bending, or distraction.

Population: More common in younger children. This comprises 1/3 of pediatric trauma cases that have neuro deficits on exam. 

Severity depends on degree of ligamentous injury. It can be mild to severe, and cases have the potential to be unstable. 

Management: Immobilize cervical spine and consult neurosurgery. Patients often need prolonged spinal immobilization.

If the patient is altered and an adequate neurological exam cannot be obtained, a normal CT or XR of the cervical spinal is not sufficient to rule out spinal cord injury. It is important to continue monitoring neurological status. One possible etiology is spinal cord hemorrhage, and serial exams are essential. 

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This study looked at just over 10,000 children using the National Trauma Data Bank between 2011 and 2012. Patients were divided into two age groups: 0 to 14 years and 15 to 18 years. Primary outcomes were emergency department and inpatient mortality depending on whether they were taken to a pediatric versus adult trauma center. Secondary outcomes included hospital length of stay, complication rate, ICU length of stay and ventilator days.

Children in the 0-14 year age group had lower ED and inpatient mortality when treated at pediatric trauma centers. This age group was also more likely to be discharged home and have fewer ICU and ventilator days when treated at the pediatric trauma centers.

There was no difference in ED mortality or inpatient mortality in the 15 to18 year-old age group to pediatric and adult trauma centers. There were no differences in complication rates in any age group between pediatric and adult trauma centers. 
 
Bottom line: Children aged 0-14 should ideally be evaluated primarily at pediatric trauma centers.

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Acute facial palsy is common in children and while bell’s palsy is significant proportion, there are other more concerning etiologies that make up a number of cases. A retrospective cohort study of pediatric patients with an ED diagnosis of Bell’s palsy was done using the Pediatric Health Information System and showed an incidence of 0.3% (0.03% in control) for new diagnosis of malignancy within the 60 days following the visit at which bell’s palsy was diagnosed. Younger age increased the risk. There was also a subset of patient’s excluded for diagnosis of bell’s palsy as well as malignancy at the index visit.

These numbers are small but may be clinically significant. They likely do not warrant laboratory or imaging workup as a rule but do make a case for detailed history taking and thorough exam. Consider avoiding steroids which are used commonly but lack high quality data and may undermine later efforts at tissue diagnosis of malignancy or even worsen prognosis.

 

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Category: Pediatrics

Title: Risk factors for severe COVID in children

Keywords: pediatrics, COVID, vaccination, hospitalization (PubMed Search)

Posted: 1/21/2022 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD

This recently published study was conducted from May 2020 to May 2021 and included 3106 hospitalized pediatric patients with COVID 19 over 14 states.  2293 children were admitted due to their COVID symptoms.  30% of these patients had severe COVID (ICU admission, mechanical ventilation or death) and 0.5% died.
32.5% of admitted patients were younger than 2 years.  More than half of the patients had at least one medical condition.  The most common underlying conditions were obesity, chronic lung disease, neurologic disorders, cardiovascular disease and blood disorders.
Although this data was collected prior to the US presence of both the delta and omnicron variants and public availability of vaccination in 5-11 year olds, this study has identified children at potentially higher risk of severe COVID who may benefit from prevention efforts that include vaccination. 

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Category: Pediatrics

Title: Removal of Auricular Foreign Body

Keywords: foreign body, ear, insect, button battery (PubMed Search)

Posted: 1/7/2022 by Natasha Smith, MD (Updated: 8/17/2022)
Click here to contact Natasha Smith, MD

Many types of foreign bodies may be found in a child's ear. Some examples include: beads, cotton swabs, food, insects, and button batteries. 

Patients can be asymptomatic. However, they often have otalgia, pruritus, fullness, tinnitus, hearing loss, otorrhea, or bleeding. Obtain a history of the type of foreign body, when/how it entered the ear, and if there was a prior attempt at removal. Also ask if there are foreign bodies elsewhere, such as in the nose. Perform Rinne and Weber tests before and after removing the foreign body if the child is old enough to participate. 

Delayed presentation can result in edema and otitis externa. When the foreign body is sharp, there may be damage to the tympanic membrane (TM) and ossicles. 

Consult ENT when there is suspicion of damage to TM, when hearing loss is present, or when removal is especially challenging. Spherical foreign bodies are more difficult to remove. 

Remove foreign body if it can be visualized. Wax curettes, right-angled hooks, alligator forceps, and Frazier tip suctions can facilitate removal. Avoid additional trauma due to concern for edema, bleeding, TM perforation, or distal displacement of the object. Anxiety in the child will lead to increased difficulty with removal. 

A button battery in the ear is an emergency that can result in severe damage, including TM perforation, scarring or stenosis of the ear canal, and deeper injury. Seeds such as beans or peas and other absorptive material in the ear can expand, so do not irrigate when such foreign bodies are present. Living insects should be killed with alcohol, lidocaine, or mineral oil prior to performing foreign body removal. 

After removal, reassess ear canal and TM. Some foreign bodies require removal in the operating room. If the object has been successfully removed, evaluate for otitis externa or iatrogenic injury to the ear canal, and prescribe antibiotic otic drops when needed. When TM has perforated, refer for formal audiogram. ENT follow up is recommended for all patients.  

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  • 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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Category: Pediatrics

Title: Sever Disease - What a Heel

Keywords: peds ortho, calcaneus, stress injury (PubMed Search)

Posted: 12/3/2021 by Rachel Wiltjer, DO
Click here to contact Rachel Wiltjer, DO

Sever Disease

  • Calcaneal apophysitis – inflammation of the growth plate of the calcaneus
  • One of the most common causes of heel pain in adolescents, caused by repetitive stress (overuse injury)
  • Most common in those who are involved in sports, especially those with lots of running and jumping
  • Symptoms are heel pain and tenderness at/underneath the heel, with possible mild swelling
  • Pain is reproduced by squeezing the posterior calcaneus and standing on tip toes
  • Does not require imaging for typical presentation
  • Treat with reduction of activity (specifically avoid painful activities), NSAIDs, and stretching exercises

 

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Category: Pediatrics

Title: The dangers of monkey bars

Keywords: orthopedics, upper extremity fractures, playgrounds (PubMed Search)

Posted: 11/19/2021 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD

While playgrounds can be enjoyable for children, they are a land mine for possible injuries.  In a study looking at playground safety in Australia, monkey bars were the leading cause of upper extremity fractures.  The fractures caused by monkey bars were also more likely to require reduction or operative fixation.  The risk of fracture significantly increases after a fall above 1.5 meters.  Children ages 5-9 years were the most susceptible to playground falls.
Why does this matter?  Playgrounds have made modifications to prevent other types of injury (such as the modification of the playground surface to prevent head injuries).  Reduction in the height of monkey bars, may reduce or limit the severity of these upper extremity fractures.  

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Incidence of T1DM is 1.93/1000 of youth <20 years old in the United States, with a bimodal distribution of onset. Onset peaks from ages 4-6 and again at puberty. 

 

Prior to the development of DKA, diabetes often has an insidious onset with symptoms of polydipsia, polyphagia and polyuria with weight loss in children. It can also be asymptomatic. 

 

When DKA is present, symptoms will include neurological manifestations (confusion, lethargy), GI symptoms (abdominal pain, nausea, vomiting), or respiratory abnormalities (Kussmaul respirations.) Polyuria and polydipsia are frequently present as well.

 

Diagnosis of DKA includes: serum glucose of >200 mg/dL, serum or urine ketones, and a pH <7.30 or bicarbonate <15 mEq/L. 

 

DKA is classified as mild, moderate or severe:

Mild: pH 7.21-7.30, HCO3 11-15 mEq/L

Moderate: pH 7.11-7.20, HCO3 6-10 mEq/L 

Severe: pH < 7.10, HCO3 <5 mEq/L

 

Initial treatment is 10 ml/kg of isotonic fluid bolus to a max of 500 ml, then reassess. Continue to replace fluids gradually to cover maintenance fluids as well as to treat dehydration. Do NOT bolus insulin. Rather, start a drip at 0.05-0.1 units/kg/hr. Continue insulin until acidosis has completely resolved. Once the serum glucose falls below 250 mg/dL, start dextrose to prevent hypoglycemia until the gap closes. 

 

Cerebral edema can develop 4-12 hours after treatment has been initiated. Observe for change in mental status, posturing, decreased response to pain, cranial nerve palsy, bradycardia, or abnormal respiratory pattern. This is a clinical diagnosis! Although a head CT can be obtained, it is often negative and treatment with mannitol or hypertonic saline should be started as soon as there are clinical changes.

 

DKA has resolved when pH > 7.3 and HCO3 is >15.

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This was a retrospective, noninferiority analysis looking at patients 14 years old and younger treated for nontraumatic seizures by EMS with a midazolam dose of 0.1 mg/kg (regardless of route).  There were just over 2000 patients with a median age of 6 years included in the study.  Midazolam redosing occurred in 25% of patients who received intranasal midazolam versus only 14% who received midazolam via intramuscular, intravenous, or intraosseous routes.
Bottom line: In the prehospital setting, intranasal midazolam at a dose of 0.1 mg/kg was associated with an increased need to redose compared to other routes.  This dose may be subtherapeutic for intranasal administration.

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Category: Pediatrics

Title: AAP Guidelines on the Febrile Infant 2021

Keywords: febrile infant, neonatal fever (PubMed Search)

Posted: 10/1/2021 by Rachel Wiltjer, DO
Click here to contact Rachel Wiltjer, DO

What they are: Clinical practice guidelines put together by an AAP subcommittee over a span of several years based on changing bacteriology and incidence of illness, advances in testing, and evidence that has accumulated

Includes: Healthy infants 8 to 60 days of life with an episode of temperature greater than or equal to 38.0 C who at now at home after being born at home or after discharge from the newborn nursery, born between 37 and 42 weeks, without focal infection on exam (cellulitis, vesicles, etc)

Recommendations:

For the well appearing 8-21 day old:

  • Obtain UA (and culture if + UA), blood culture, CSF (including enterovirus PCR if pleocytosis in CSF or seasonal periods), inflammatory markers are optional
  • Start empiric antimicrobials regardless of results of UA/CSF or any inflammatory markers
  • Infant should be admitted

For well appearing 22- 28 day olds:

  • Obtain UA (and culture if +UA), blood culture, and inflammatory markers
    • procalcitonin preferred over CRP if available, ANC is helpful but less so than others
    • several studies used in making these guidelines used more than 1 inflammatory marker
      • Temp >38.5 is considered an inflammatory marker
  • If any inflammatory marker is abnormal:
    • Obtain CSF and start empiric antibiotics
      • CSF is optional if no inflammatory markers are abnormal (provider judgment/risk assessment)
    • If CSF is not obtained, infant should be hospitalized for observation
  • Discharge home is acceptable if all of the following are true: UA is normal, CSF is normal or enterovirus +, no obtained inflammatory marker is abnormal (or if abnormal they have subsequently had normal CSF testing), return precautions are discussed and follow up is assured within 24 hours for clinical re-examination
    • Infants being discharged home should receive empiric parental antibiotics prior to discharge
  • If the infant is hospitalized antibiotics should be started if: CSF with pleocytosis or uninterpretable or if UA is +
    • If workup is normal, antibiotics optional
    • If CSF not obtained, may start antibiotics but not required
  • Shared decision making with parents is recommended for decisions regarding LP and disposition in this group

For well appearing 29-60 day olds:

  • Obtain UA ( and culture if +UA), blood culture, and inflammatory markers
  • If inflammatory markers are normal LP does not need to be performed, antibiotics do not need to be administered (unless UTI present), and patient can be monitored closely at home with follow up in 24-36 hours
  • If positive UA in this group with normal inflammatory markers, obtain cath urine culture and start oral antibiotics
  • Consider obtaining CSF if abnormal inflammatory markers
  • If CSF obtained and normal antibiotics are optional, may be observed in hospital or closely at home
  • If CSF is not obtained or is uninterpretable with abnormal inflammatory markers, administer parenteral antibiotics
    • May be observed in hospital or closely at home

Notable changes:

  • UTIs have been differentiated from bacteremia and bacterial meningitis, the guideline discourages the use of the historic “serious bacterial illness”
  • A 2 step process where decision for catheretized urine culture is based on UA is suggested, UA to be obtained by bag or stimulated void

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