UMEM Educational Pearls - Pediatrics

You are seeing a high school football player following a head injury.  After your exam or head CT, you determine the child to have had a mild traumatic brain injury (aka concussion).  You are ready to discharge him home when the parents or coach ask you when he can return to playing football.

A concussion is a form of functional, rather than structural, brain injury that displays no evidence of injury on structural neuroimaging.   Symptoms include transient loss of consciousness, amnesia, vomiting, headache, poor school work, sleep changes, and emotional lability.  Remember that children’s brains (even adolescents) are still developing, and are more prone to prolonged recovery following injury.

Recovery of symptoms usually follows a sequential course.  Current guidelines recommend a stepwise return to play (aka concussion rehabilitation) involving both physical and cognitive rest (e.g. no texting, video games, limited school work).  Once asymptomatic, the patient goes through each stage with at least 24 hours between stages.  If symptoms return during a stage, then the patient is expected to return to the previous stage for 24 hours before attempting the higher stage again. 

Return to Play Guidelines:

References:

1. Halstead ME, Walter KD, and The Council on Sports Medicine and Fitness.  Pediatrics. 2010;126:597-615.

• newborns have a thick right ventricle resulting in a mean QRS axis which points anteriorly and to the right demonstrating a right axis deviation (70-180degress) and large R waves in the precordium
• by 3 months of age, the QRS axis in the frontal plane shifts to the left with a mean of 65degress (0-125degress)
• by older childhood, the normal mean QRS axis is -30-100degress)
• thus, with age the R wave decreases in V1 and increases in V6
• take home:  right-axis deviation is often a normal finding in children and young adults when you see left-axis deviation in children consider tricuspid atresia, atrioventricular septal defects, and LVH as the most associated conditions

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Infantile botulism

1)      C-A-B for CPR. Now recommended to start compressions immediately instead of the conventional rescue breaths.

2)      Capnography during CPR. Continuous capnography recommended during CPR to guide the resuscitation, especially the effectiveness of chest compressions.

a.     If ETCo2 is less than 10 to 15 mm Hg consistently, focus your efforts on improving chest compressions.

3)      Etomidate for RSI induction.  Okay to use in infants and children, BUT not recommended for pediatric patients in septic shock.  Etomidate was not addressed in 2005 guidelines.

4)      Cuffed ET tubes. Acceptable to use in infants and children.

5)      Limit FiO2 after resuscitation.  Keep O2 sats ≥94%.  Avoid hyperoxia.

6)      Therapeutic hypothermia after cardiac arrest.  Recommendation based off of adult data, no pediatric prospective RCT done on this.  This is beneficial in adolescents with out-of-hospital VF arrest.

a.      Consider therapeutic hypothermia for infants and children.

b.      Cool to 32^oC-34^oC                                      

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Acute Poststreptococcal Glomerulonephritis (APSGN) is a sequela of group A beta-hemolytic streptococci (GAS) infection of the skin or pharynx with nephrogenic strains of GAS.  Damage to the kidneys is due to deposition of antigen-antibody complexes in the glomeruli. 

Presentation:

Testing:

Treatment:

Prognosis (favorable):

Reference:

Kit, Brian. Assess the volume status and electrolytes in children with poststreptococcal glomerulonephritis. Avoiding Common Pediatric Errors. 2008. p356-57.

You're called to bedside to evaluate a "lethargic" infant.  You wisely ask for a POCT glucose which returns at 35.  How much dextrose do you give (since you know it's not just "an amp" of D50?

Here's a simple mnemonic:

Rule of 50-100 = multiply type of dextrose solution by ____ factor (ml/kg) to total 50-100

D10 (neonate) x 5-10 ml/kg = 50-100

D25 (infant) x 2-4 ml/kg = 50-100

D50 (child/adolescent) x 1-2 ml/kg = 50-100

Now that summer is in full swing, the question is: Should the evaluation of the febrile young infant change during the summer and fall months?  And can that affect length of hospitalization and antibiotic use?

Two retrospective cohort studies from the Children’s Hospital of Philadelphia (CHOP) suggest yes!  The addition of enterovirus polymerase chain reaction (PCR) testing to cerebrospinal fluid (CSF) may improve the care of infants with fever during enterovirus season (early June through late October). 

Of note, at CHOP: 1) infants 56 days or younger routinely undergo lumbar puncture during evaluation for fever.  2) Most CSF enterovirus PCR test results (90%) were available within 36 hours; 95% of results were available within 48 hours.

In the King study, having positive enterovirus PCR CSF results decreased the length of hospitalization and the duration of antibiotic use for young infants less than 90 days, supporting the routine use of this test during periods of peak enterovirus season.  In multivariate
analysis, a positive CSF enterovirus PCR result was associated with a 1.54-day decrease in the length of stay and a 33.7% shorter duration of antibiotic use.

Bottom line: Consider adding enterovirus PCR testing to CSF obtained during the evaluation of febrile young infants during enterovirus season, as this may reduce length of hospitalization and duration of antibiotic use.  The effects, however, may be limited at institutions with slower lab turnaround times.

References:

1) King RL, Lorch SA, Cohen DM, Hodinka RL, Cohn KA, Shah SS. Routine cerebrospinal fluid enterovirus polymerase chain reaction testing reduces hospitalization and antibiotic use for infants 90 days or younger. Pediatrics. 2007 Sep;120(3):489-96. http://pediatrics.aappublications.org/content/120/3/489.full.pdf

2) Dewan M, Zorc JJ, Hodinka RL, Shah SS. Cerebrospinal fluid enterovirus testing in infants 56 days or younger. Arch Pediatr Adolesc Med. 2010 Sep;164(9):824-30.

• occurs when the small opening in the abdominal muscles which allows passage of umbilical cord does not completley close after birth
• allowing intestinal loops to pass through the opening
• 10% of all children are affected
• more common in blacks, girls, and premature infants
• most resolve by age 1year, but consider outpatient referral if becoming larger or still present after 2-3 years of age
• emergent consultation if not reducible, but rarely as most are harmless

• radial head subluxation
• usually 1-3 years of age
• often after sudden longitudinal traction on extended arm with wrist in pronation
• tearing of annular ligament attachment to radial neck, with detatched portion trapped between subluxed raidal head and capitellum
• children refuse to use affected arm and hold in a flexed pronated position
• traditionally, reduce by supination of forearm with elbow in 90degrees of flexion
• newer reduction technique, hyperpronation with elbow flexion has better success rateand less pain

• second most common vasculitis of childhood
• leading cause of acquired heart disease in children
• usually in children <5years old
• year-round with clusters in spring and winter
• highest incidence in children of asian decent
• clinical diagnosis requires fever for at least 5 days and a minimum of 4 of the following:

1. bilateral conjunctival injection without exudate
2. rash (often macular, polymorphous with no vesicles, most prominent in perineum followed by desquamation
3. changes in the skin of the lips and oral cavity (red pharynx, dry fissured lips, strawberry tongue)
4. changes in the extremities (edema, redness of hands and feet followed by desquamation)
5. cervical lymphadenopathy

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If there is a single truth of pediatric emergency medicine, it is that kids love to stuff things into their noses.  A particular danger (aside from batteries, covered in a previous pearl) is the magnet.  

Specifically, two magnets (as seen with magnet ear and nose rings, frequently worn by children and teens whose pesky parents won't allow piercings), attracted across the nasal septum can cause necrosis and perforation within hours.

Here's how to save yourself (and some noses):

1.  Place a strong magnet such a mechanic's pocket magnet (<$10), or a pacer inhibition magnet within 1.5cm of the magnets.  Be careful not to apply pressure to the septum.
2. Watch for the opposite side magnet to fall out of the nose.
3. Easily remove the second magnet, which is no longer stuck to anything...you can use the strong magnet from step 1 at the nare opening to assist.
4. Though this method is generally non-traumatic, you should pre-treat the nares with 4% lidocaine and 1:1,000 epinephrine spray to minimize potential bleeding.

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"Ear to sternal notch" positioning has gained wide acceptance in the emergency medicine and anesthesia literature.  Most often, this teaching is brought up with respect to obese adult patients whose large body habitus requires the raising of the neck and head to achieve airway alignment.

However, the correct anatomic positioning principle applies to all ages.  Specifically, with regard to neonates, a shoulder roll is often placed indiscriminately to put the patient into the now out-dated "sniffing position," usually worsening the view of the airway.  

Though this positioning is frequently misused, it can be easily adapted to apply ear to sternal notch positioning to neonates, whose misaligned airway is the result of a large occiput rather than a large torso.  In all ages, if you follow these positioning principles, you will improve your view of the airway:

1. Align the ear to the sternal notch

2. Keep the face parallel to the ceiling (do NOT hyperextend the neck, as in the sniffing position)

3. In adults, the head usually needs to be raised (Image 1), while in infants, the torso usually needs to be raised (image 3).

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Continuing the theme of endotracheal tube size pearls...  You get a box call for a pre-term baby delivered precipitously by mom at home and baby is blue.  EMS is bagging but unable to secure a definitive airway.  What size ETT do you reach for?  If you try to apply the formula "uncuffed ETT = (age/4) + 4", how much smaller than size 4 can you go?

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You decided to intubate a child and wisely remembered that you should also follow with an NG/ OG after intubation to decompress the stomach.  In order to avoid the blank stare when asked "what size"?  Here's a nice mneumonic about Pediatric "tube" sizes... easy as 1-2-3-4!!!  Please note ETT = endotracheal tube size.

• 1 x ETT = (age/4) + 4 (formula for uncuffed tubes)
• 2 x ETT = NG/ OG/ foley size
• 3 x ETT = depth of ETT insertion
• 4 x ETT = chest tube size (max, e.g. hemothorax)

So for example, a 4-year-old child would get intubated with a 5-0 ETT inserted to depth of 15 cm (3x ETT), a 10Fr NG/OG/foley (2x ETT), and a 20Fr chest tube (4x ETT).

Also, remember that you can use cuffed tubes in any child except neonates but the formula needs to be adjusted as follows: cuffed endotracheal tube ID (mm) = (age/4) + 3.5

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So the magnesium didn't work, and the baby is on the way!  You're prepared with everything you need for the delivery from bulb suction to a tripod for Dad's camera...  But what is going to special about this baby?  

Babies born to mothers who received magnesium therapy for any reason are at risk for hypotonia and severe respiratory depression.

• DO provide respiratory support as needed, as respiratory depression is the only dangerous side effect of hypermagnesemia in the neonate (be prepared to provide supplemental oxygen, positive pressure ventilation (PPV), and possibly intubation)
• DO recognize that generalized hypotonia may be a clue as to how significantly affected the neonate may be, however, don't let the hypotonia itself scare you - it will go away, and is not dangerous in and of itself
• DO follow neonatal resus guidelines (PPV for HR<100, CPR for HR<60), but remember that supportive measures will resolve all problems related to hypermagnesemia in the neonate...if there are other issues, don't blame the mag
• DO NOT give calcium as, in contrast to their mothers, these patients are not hypocalcemic (and the hypermagnesemia will spontaneously resolve in 48 hours)
• DO remember that these infants frequently require a brief NICU stay until they no longer require respiratory support

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• seborrheic dermatitis is most common in infants within the first two months of birth
• appears as  erythematous, greasy yellow scales most commonly on the scalp (cradle cap), and may also occur on the face
• most cases resolve spontaneously within weeks to months, but severe cases may be treated with 1% hydrocortisone cream, sahmpooing with selenium sulfide, and using an emollient to remove scales
• in extreme cases, consider hte possibility of Langerhans cell histicytosis, especially if atrophy, ulceration, or purpura are also present
• rarely occurs in children between 1 and 12 as they do not have active sebaceous glands, but will appear as dandruff in adolesecents
   

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Now that influenza season is in full swing, remember that early antiviral treatment can reduce the risk of complications in high-risk individuals. One of those high-risk groups is children <2 years, with the highest hospitalizations and mortality in infants <6 months.

According to the CDC website:
Recommended antiviral medications (neuraminidase inhibitors) are not FDA-approved for treatment of children aged <1 year (oseltamivir) or those aged <7 years (zanamivir). Oseltamivir was used for treatment of 2009 pandemic influenza A (H1N1) virus infection in children aged <1 year under an Emergency Use Authorization, which expired on June 23, 2010. Nevertheless,

•  3-11 months => Treatment: 3 mg/kg/dose BID, Chemoprophylaxis: 3 mg/kg/dose once daily
•  infants <3 months => Treatment: 3 mg/kg/dose BID, Chemoprophylaxis: not recommended
• newborns <14 days => 3 mg/kg/dose once daily
• treatment doses for children >1 year of age varies by weight:

•  <15 kg: 30 mg BID
• 15-23 kg: 45 mg BID
• 23-40 kg: 60 mg BID
• >40 kg: 75 mg BID

Current CDC guidance on treatment of influenza should be consulted; updated recommendations from CDC are available at http://www.cdc.gov/flu

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•  disorder in which the entire left side of the heart is underdeveloped
•  the right side of the heart is dilated and hypertrophied, and supports both the systemic and pulmonary circulations via PDA
•  accounts for nearly 1/4 of all cardiac deaths in the first year of life
•  infants present within the first days or weeks of life acutely ill with signs of CHF
• PE often shows cyanosis and poor pulses but hyperdynamic cardiac impulses
• CXR shows cardiac enlargement and prominent pulmonary vasculature
• EKG shows RA and RV hypertrophy
• echo is diagnostic
• acute treatment is PGE1 to maintain the PDA.

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