UMEM Educational Pearls - Pediatrics

• sleep disruption silimar to a nightmare, but much more dramatic most often between 4-12 years
• sudden fear reaction which occurs during the transition to and from deep non-REM sleep while nightmares occur during REM sleep
• occurs 2-3 hours after falling asleep when the child suddenly awakens in distress and may thrash about, scream, cry
• child returns to sleep with no memory of the event the following morning
• often occurs when a child is stressed, overtired, on new medication, or sleeping in a new environment
• do not awaken the child during the event but rather allow them to calm on their own

If concern arises on screening assessment, keep child in hard cervical collar and image (may start with x-ray and progress to CT if still concerned and x-rays negative).

If imaging negative, but persistent suspicion based on neurological deficits consider SCIWORA (Spinal Cord Injury WithOut Radiographic Abnormality) which exists in up to 50% of children with cervical cord injury, and may require MRI to further identify injury.

Types:
- Uniphasic anaphylaxis: occuring immediately after exposure to allergen, resolves over minutes to hours and does not recur
- Biphasic anaphylaxis: occuring after apparent resolution of symptoms typically 8 hours after the first reaction. Occur in up to 23% of adults and up to 11% of children with anaphylaxis

Treatment:
1. First line: IM epinephrine 1:1000 solution
   - vasoconstrictor effects on hypotension and peripheral vasodilation; bronchodilator effects on upper respiratory obstruction
   - NO absolute contraindication for use in anaphylaxis
   - Dosage: Adult: 0.3 - 0.5mg; Peds: 0.01mg/kg (max 0.3mg)
   - can be repeated every 5-15 minutes
2. Adjunctive therapy:
   - H1 Blocker: diphenhydramine 1-2mg/kg up to 50mg IV
   - H2 Blocker: ranitidine 1-2mg/kg
   - Corticosteroid: 1-2 mg/kg for prevention of biphasic reactions
   - Bronchodilator: Albuterol for bronchospasm
   - Glucagon: for refractory hypotension or if patient is on beta blocker
          - Dosage: Adult: 1-5 mg; Peds 20-30microgm/kg
          - Dose may be repeated or followed by infusion of 5-15 mg/min
   - place patient in recumbent position if tolerated with lower extremities elevated
   - supplemental O2
   - IV fluids for hypotension

Fatalities: typically seen with peanut or treenut ingestions from cardiopulmonary arrest. Associated with delayed or inappropriate epinephrine dosing

Disposition:
   - Mild reaction with symptom resolution: observe for 4-6 hrs (ACEP, AAP)
   - Recurrent symptoms or incomplete resolution: admit

Reference:
1. World Allergy Organization Guidelines for the Assessment and Management of Anaphylaxis, Feb 2011
2. Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID-Sponsored Expert Panel Oct 2010

If you have a patient who meets (or has had close exposure to someone meeting) the clinical case definition of pertussis (a cough lasting at least 2 weeks with one of the following: paroxysms of coughing, inspiratory “whoop,” or post-tussive vomiting) here are some important points to keep in mind:

Vaccination

• Be wary that children younger than 7 might not be “up to date” for pertussis vaccination.
  • The recommended schedule is four primary doses of DTap at 2, 4, 6 and 15-18 months, and a fifth DTap booster at 4- 6 years old. ACIP now recommends kids 7 and older get a Tdap booster if their immunizations were previously incomplete.

Testing

• The available testing modalities for routine surveillance are culture and/or PCR (from a posterior nasopharyngeal swab or aspirate) and serologic testing.
  • Serologic results are not currently accepted as laboratory confirmation for purposes of national surveillance, but may be more useful for testing patients in the convalescent stage.

Treatment

• The CDC recommends treatment of clinical or confirmed cases with one of these regimens:
  • Azithromycin daily x 5 days
  • Clarithromycin BID x 7 days
  • Erythromycin QID x 14 days
  • Trimethoprim/sulfamethoxazole (Bactrim) BID x 14 days if resistance or allergy to macrolides
    • However, a 2011-updated Cochrane review showed that short-term antibiotics (azithromycin for 3-5 days, or clarithromycin or erythromycin for 7 days) were as effective as long-term (erythromycin for 10-14 days)  (RR 1.01) (95% CI  0.98-1.04). Trimethoprim/sulfamethoxazole for seven days was also effective.
• Insufficient evidence to decide whether there is clear benefit for treating healthy contacts, but the CDC does recommend prophylactic treatment of close contacts and family members.

References:

Altunaiji SM, Kukuruzovic RH, Curtis NC, Massie J. Antibiotics for whooping cough (pertussis). Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD004404. DOI: 10.1002/14651858.CD004404.pub3

http://www.cdc.gov/vaccines/pubs/surv-manual/chpt10-pertussis.html

• small growth of grainy pink/redish tissue that forms on an area of the umbilical stump which is inflamed and produces a sticky mucous dishcarge not allowing normal tissue to grow on top of it
• caused by abnormal tissue healing after the remaining umbilical cord dries up and falls off
• treatment is painless as the granuloma lacks innervation, and requires applying chemical silver nitrate directly to the granumloma to burn the tissue off
• although rare, careful examination of the tissue is needed to enssure the tissue is not intestinal or bladder in origin

Henoch-Schonlein Purpura (aka. Anaphylactoid purpura) is a small vessel vasculitis.

Background:

• most commonly diagnosed vasculitide in childhood
• age range 3-15 years, mean age 4yo, mostly <7yo (75% cases)
• more cases in Winter and Spring months
• boys more commonly than girls (2:1)
• IgA-mediated leukoclastic vasculitis

Clinical Features:

• Rash: progresses to petechiae, purpura; occurs on lower extremities and buttocks in dependent areas
• Joints: arthritis/arthralgia mainly of large joints (knees, ankles)
• GI: colicky abdominal pain, may occur with melena (33%) or less likely, hematemesis; ultrasound for intussusception (2-14%)
• Renal: microscopic hematuria with/without proteinuria; usually transient but may lead to progressive renal disease in patients with more severe, persistent symptoms
• Orchitis and/or angioedema may also occur

Etiology:

• unknown
• preceding URI (50%)
• associated with bacteria (Strep pyogenes, Legionella, Mycoplasma), viruses (EBV, CMV, parvovirus), drugs (penicillin, cephalosporins), and insect bites

Diagnosis:

• clinical features
• lab studies that are helpful but nonspecific: high WBC, high ESR, high IgA, normal platelet and coagulation studies

Treatment:

• supportive care, may last up to 4 weeks
• steroids may be helpful but evidence has not shown true benefit
• recurrence happens in 40% of cases

Bonus pearl:  Types of Jaundice by Age

• congenital disorder which is the most common cause of stridor in infancy
• larynx appears disproportionately small, and supporting structures are abnormally soft
• stridor begins within the first 4 weeks of life, and accentuates with increased ventilation (crying, excitement, URI, etc.)
• stridor usually resolves by 12 months but may recur with URI until about 3 years of age
• diagnosis is by fiberoptic bronchoscopy or direct laryngoscopy
• therapy is usually not needed, but rarely laser therapy of redundant tissue or traceostomy when stridor occurs with failure to thrive or apnea

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Submitted by Dr. Lauren Rice

The summertime can be full of lots of fun activities (beach, fireworks, cookouts, and campfires) that can put children at risk of burns. 

Burn depth classification:

1. Superficial (first-degree): red and blanching with minor pain, resolves in 5-7 days 

2. Partial thickness (second-degree): red and wet with blisters, very painful, resolves in 2-5 weeks

Treatment: clean with soap and water twice daily, and apply silvadene wrap with gauze, kerlex

3. Full thickness (third-degree): dry and leathery without pain, no resolution after 5-6 weeks, may require graft

Treatment:  wound debridement and dressings as above

Parkland formula: 4ml/kg/%TBSA in 1^st 24 hours with 50% of total volume in 1^st 8 hours

 Calculate burn surface area:

-SAGE: free computerized burn diagram available at www.sagediagram.com

-Rule of Nines > 14 years old

-Rule of Palm <10 years old

Burn Center Referral

-Extent: partial thickness of >30% TBSA or full thickness of >10-20%

-Site: hands, feet, face, perineum, major joints

-Type: electrical, chemical, inhalation

Show References

Pathology at the umbilicus can manifest as inflammation, drainage, a palpable mass, or herniation.

Omphalitis - A cellulitis of the umbilicus. Mild cases often respond to local application of alcohol to clean the area, but due to the possibility of rapid progression and abdominal wall necrotizing fasciitis, admission for observation and IV antibiotics is usually warranted. Cover staph, strep, and GNRs.

Umbilical granuloma - As the umbilical ring closes and the cord sloughs off, granulation tissue formation is a normal part of umbilical epithelialization. There is sometimes an overgrowth of granulation tissue which can be treated once or twice with silver nitrate. Should the tissue not regress after a 1-2 treatments, the patient should be referred to pediatric surgery for excision and evaluation of other pathology (urachal or vitelline remnants).

Umbilical fistula - This is a patent vitelline duct and is characterized by persistent drainage that is bilious or purulent. A fistulogram using a small catheter and radio opaque dye can sometimes be helpful in determining the source of drainage (dye should be seen in the small bowel).

Umbilical polyp - Often confused with an umbilical granuloma with its glistening cherry red appearance, this is actually a vitelline duct remnant and contains small bowel mucosa. It does not regress with silver nitrate.

Vesicoumbilical fistula/sinus - The urachal versions of the umbilical fistula. This are a failure of complete closure of the urachus, resulting in persistent drainage of urine from the umbilicus, and infection (including recurrent UTIs). A fistulogram can be helpful for diagnosis. 

Intussusception is the telescoping or prolapse of one portion of the bowel into an immediately adjacent segment.

• age: 3 months to 6 years, most common among 3-12 months (although case reports exist in adults)
• after constipation, most common cause of abdominal pain in infants and pre-school aged children
• classic triad: colicky abdominal pain, vomiting, and red currant jelly stools
  • occurs in only 10% -20% of cases
• although colicky pain is the most common symptom, 15-20% experience no pain
• vomiting is often the earliest symptom, but may be absent in 30-40% cases
• most patients (75%) without grossly bloody stool, may be positive for occult blood
• plain abdominal radiographs may be normal in 30% of cases
• consider in differential for intants with altered mental status/ lethargy
  • TIPS AEIOU - one of the "I"s is for intussusception
• choice of radiographic evaluation is institution-dependent
  • ultrasound may be diagnostic but is not therapeutic
  • air or contrast enema can diagnose and treat
  • both are operator dependent

Definition: Fracture of the humerus just proximal to the epicondyles.

Proper Feeding of the Newborn

The emergency physician must be comfortable with providing anticipatory guidance to parents of newborn, especially with regards to proper feeds of the neonate.

Newborns will lose some weight in the first 5-7 days of life. A 5% weight loss is considered normal for a formula fed newborn. A 7%-10% loss is considered normal for the breastfed baby. Most babies regain their birth weight by days10-14 of life. During the first 3 months, infants gain about an ounce a day (30 g) or 2 pounds a month (900 g).  By age 3-4 months, healthy term infants have doubled their birth weight.

Breast-fed Neonates:
- Should be fed every 2-3 hours while awake
- 5-20 minutes of sucking per breast
- May gain weight slower than formula-fed counterparts

Formula-fed Neonates:
- 0.5-1 ounces per feeding every 3-4 hours for the 1st week
- Then 1-3 ounces per feeding every 3-4 hours
- Typical formula contains 20 cal/ounce

In general, overfeeding during the neonatal period has been associated with adult obesity. The American Academy of Pediatrics recommends exclusive breastfeeding for at least the 1st 6 months of life. Earlier switches to formula has been associated with atopy, diabetes and obesity


References:
- Fleischer DM. “Introducing formula and solid foods to infants at risk for allergenic disease.” UptoDate;2012.
- Hammer LD, et al. “Development of feeding practices during the first 5 years of life.”  Nutrition;1999;189-194.
- Philips SM and Jensen C. “Dietary history and recommended dietary intake in children.” UptoDate;2011.
- Prior LJ and Armitage JA. “Neonatal overfeeding leads to developmental programming of adult obesity.” J Physiol;2009:2419.

There has been no link found between Sudden Infant Death Syndrome (SIDS) and an Acute Life Threatening Event (ALTE)

There are several factors that dispute previous claims of each being manifestations of the same disease state:

1)      Timing: approx 75-80% of  SIDS deaths occur between midnight and 6 AM; 80-85% of  ALTE occur between 8 AM and 8 PM 

2)      Prevention: Interventions to prevent SIDS (ex, “back to sleep”) have not resulted in a decreased incidence of ALTE

3)      Risk factors:

a.       SIDS: prone sleeping, bottle feeding, maternal smoking

b.      ALTE: repeated apnea, pallor, history of cyanosis, feeding difficulties

BONUS PEARL: A thorough history and physical will lead to the diagnosis for the source of the ALTE in 21%

Pertinent historical items: detailed bystander history of event (parents, EMS), activity and behavior prior to event and any past medical issues or medications (focus on GERD and pulmonary)

Pertinent physical exam: detailed neurological and cardiopulmonary system eval with focus on signs of non-accidental trauma (retinal hemorrhaging, bulging fontanel, bruising) as up to 10% of ALTEs involve some form of abuse

Submersion injuries are the 2nd leading cause of accidental death in children with 1/3 of survivors sustaining significant neurologic sequelae.  50% of drownings occur from May to August.

40% of all drowning victims are children under age 4, with males affected 3 times as often as females.  Most drownings occur with 10 feet of safety.  Infants and toddlers drown most often in bathtubs (especially if <1 year old), buckets, toilets, pools and hot tubs (most often the pools are in-ground).  Those with seizure disorders have a 10-14 fold higher likelihood of drowning.

Aspiration of as little as 1-3ml/kg of fluid may cause pulmonary edema, surfactant inactivation or washout, pulmonary shunting with resulting V/Q mismatching, or direct injury to the alveolar membrane. 

Immediate and adequate resuscitation, including intubation, is the single most important factor determining survival.  Always check body temperature as hypothermia is common.  In general, prophylactic antibiotics and steroids are not indicated unless drowning occurred in grossly contaminated water/sewage.  

Children are at higher risk for complications related to the transfusion of blood products compared with adults. So when should we consider transfusion?

Normal hemoglobin values:

- highest at birth (14 - 24 g/dL),

- decreasing to 8 to 14 g/dL at 3 months,

- increasing to 10 to 14 g/dL at age 6 months to 6 years, 11 to 16 g/dL at age 7 to 12 years, and 11.5 to 18 g/dL in adulthood.

- Although the number of platelets are in the normal range at birth, their function is impaired.

For infants younger than 4 months, thresholds for red blood cell transfusions:

- hemoglobin levels are 12 g/dL for preterm infants or term infants born anemic,

- 11 g/dL for chronic oxygen dependency,

- 12 to 14 g/dL for severe pulmonary disease,

- 7 g/dL for late anemia in a stable infant,

- 12 g/dL for acute blood loss exceeding 10% of estimated blood volume.

For infants older than 4 months, thresholds for red blood cell transfusions:

- hemoglobin levels are 7 g/dL in a stable infant,

- 7 to 8 g/dL in a critically unwell infant or child,

- 8 g/dL in an infant or child with perioperative bleeding,

- 9 g/dL in an infant or child with cyanotic congenital heart disease (increased oxygen demand).

- 9 g/dl in children with thalassemia major (to slow bone marrow stimulation)

For children with sickle cell disease (SCD):

- threshold is 7 to 9 g/dL, or more than 9 g/dL if the child has previously had a stroke.

- perioperatively for major surgery: 9 to 11 g/dL, and sickle hemoglobin should be less than 30%, or less than 20% for thoracic or neurosurgery.

Bottom line:

A threshold of 7 g/dL is indicated for the transfusion of packed red blood cells in most children.

Reference:

1) Transfusion guidelines in children. Anasethesia and Intensive Care Medicine. 2012;13(1);20–23.

2) Medscape clinical education briefs

• usually in preschool or early school-age children presenting with tea-colored urine
• most commonly is postinfectious (following URI)
• may also have periorbital edema and high blood pressure
• UA shows blood, and microscopy shows RBC's and RBC casts
• no definitive emergent treatment, but prognosis is usually good with resolution of symptoms over 8-10 weeks

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It is likely that during ones career in Emergency Medicine, one will be faced with how to work up a child presenting to the ER following exposure to common house electrical current.  The older recommendations were such that all children exposed, received a screening EKG and were admitted to telemetry for monitoring.  However, a relatively recent article in the Annals of Emergency Medicine suggests otherwise.

In fact, after reviewing several studies the authors conclude that, although there is not enough literature to support evidence based practice “guidelines”, there appears to enough evidence to support that practice of “safely discharging these children without an initial EKG evaluation or inpatient cardiac monitoring after a common household current exposure.” This includes both 120V and 220 V exposures.

Clearly, some patients may require work up and/or admission based on other injuries or clinical presentation.

References:
Chen E H, Sareen A, Do Children Require ECG Evaluation and Inpatient Telemetry After Household Electrical Exposures? Ann Emerg Med. 2007;49:64-67.