UMEM Educational Pearls - Pediatrics

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

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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.

• both head tilting to one side and rotation of the chin toward the other side
• develops during infancy with episodes that last for hours to days
• idiopathic neurologic condition which wanes after 2 years and stops by 3 years
• mild delays in fine and gross motor skills are common along with family history of migraines
• no accepted medical treatment or therapy
• must have a normal physical and neurological examination that does not include abnormal/assymetric muscle tone, abnormal eye movements, or cranial nerve palsy

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Patellar dislocations:

• lateral displacement is the most common
• tender with limited range of motion
• caused by sudden twisting movement, either with or without contact
• more common in females and young adolescents
• reduction by extension of the knee and medial pressure on the patella
• knee immobilizer and crutches with orthopedics or sports medicine follow up
• recurrent cases usually require surgery for definitive repair

References:
1. http://emedicine.medscape.com/article/90068-overview
2. New England Musculoskeletal Institute. http://nemsi.uchc.edu/clinical_services/orthopaedic/knee/patellar_dislocation.html

Rashes that include palms/ soles

- Hand-Foot-Mouth Disease

- Kawasaki

- Erythema multiforme/ Stevens Johnson's Syndrome/ Toxic Epidermal Necrolysis

- Rocky Mountain Spotted Fever

- Scabies

- Syphillis

Rashes that have +Nikolsky's sign

- Scalded Skin Syndrome

- TEN

-  Pemphigus Vulgaris

Rashes that desquamate

- Scalded Skin Syndrome

- Toxic Shock Syndrome

- Scarlet Fever

- Kawasaki

- TEN

• acute gastroenteritis is a self-limited illness
• however, damage to the brush border of the small intestine mucosa where lactase is present may lead to a secondary lactase deficiency and subsequent inability to digest lactose properly
• partially or minimally digested lactose moves into the colon where it is fermented by enteric bacteria resulting in hydrogen, carbon dioxide, and acids
• these byproducts result in symptoms reported for those with lactase deficiency: cramps, abominal pain and distension, and flatulence
• the increased solute load in the large intestine leads to increased osmotic pressure, causing watery diarrhea
• early refeeding following gastroenteritis is recommended, but many clinicians recommend dairy restricted diets acutely

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Children & Appendicitis 

• Vomiting may be the first sign. 
• Children may not experience anorexia and may actually request food. 
• Most young children have perforation at the time of diagnosis.
• Children younger than 2 years of age may have generalized symptoms such as irritability and tachypnea. 
• Ultrasonography is useful in evaluation of thin children but is very operator dependent.
• CT with oral contrast and i.v. contrast may be needed to differentiate intraabdominal structures in thin children

• diagnosis of exclusion
• bilateral leg pain only in the evening/night
• should NOT have a limp, pain, or symptoms during the day
• completely normal physical exam
• no systemic symptoms, localizing signs, joint involvement, or limitation of activity
• look for something else if there is anything wrong on review of systems, examination, or imaging studies

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Potential Causes of Neonatal Apnea and Bradycardia

• Central nervous system  

Intraventricular hemorrhage, drugs maternal/fetal, seizures, hypoxic injury, herniation, neuromuscular disorders, brainstem infarction or anomalies (e.g., olivopontocerebellar atrophy), general anesthesia.

• Respiratory

Pneumonia, obstructive airway lesions, upper airway collapse, atelectasis, extreme prematurity  (<1,000 g), phrenic nerve paralysis, severe hyaline membrane disease, pneumothorax, hypoxia, malformations of the chest.

• Infectious

Sepsis, meningitis (bacterial, fungal, viral), RSV

• Metabolic

Hypoglycemia, hyper/hyponatrmia,  hyperammonemia, decreased organic acids, hypothermia.

• Cardiovascular

Hypotension/hypovolemia, heart failure, PDA, anemia, vagal tone.

There are limited direct comparisons of (intravenous (IV) vs. intramuscular (IM) ketamine for pediatric procedural sedation in the emergency department. The only RCT comparing IV and IM ketamine was by Roback et al. and compared an IV dose of 1mg/kg vs. IM 4mg/kg. The study authors reported less procedural pain with IM administration compared with IV.  However, vomiting occurred more frequently in the IM group, 26.3% compared to 11.9% in the IV group and recovery time was 49 minutes shorter with IV vs IM use.