UMEM Educational Pearls - Pediatrics

Show References

Head injuries in children under 2yo are stress provoking, particularly with regard to when you should be getting a head CT.  Luckily, a large (42,412 children, 10,718 <2yo) multi-center trial exists to guide your behavior.

Show References

Hyponatremic seizures are a frightening entity.  Anticonvulsants don't work well, and will likely cause apnea well before they halt the seizure.  Hypertonic saline carries with it the fear of inducing central pontine myelinolysis (CPM) with overly rapid correction of the hyponatremia.  

However:

• CPM usually occurs at sodium level corrections of >8 mEq/L/day
• Hyponatremic seizures are usually stopped with a correction of only 3-5 mEq/L

So, you can safely correct hyponatremia rapidly in the setting of seizures. Do it like this:

Give 2-3 mL/kg of 3% NaCl in rapid sequential boluses, until seizures stop.  A theoretical maximum dose is 100mL/kg, but recall that only a relatively small correction is required to stop the seizure.  

After you've stopped the seizure, correct the hyponatremia slowly, as you would otherwise.

Show References

• syndrome of hematuria at the END of urination
• evidenced by spotting of blood in underwear
• occurs only in boys
• may last up to a year or longer
• symptoms are usually intermittent and recurrent
• physical examination is normal
• renal ultrasound usually helps rule out structural anomalies, but will usually be normal
• self-limited, with no specific therapy other than reassurance
   

Show References

In the past several years it has become common practice to use cuffed tubes for pediatric intubations.  However, a recent study suggests that cuff pressures are not as well regulated in pediatric patients, particularly when the patients are quickly intubated prior to aeromedical transport. Cuff pressures >30 cm H2O are associated with tracheal damage, however, up to 41% of pediatric patients transferred had cuff pressures >30 cm H2O, and 30% of those had pressures >60 cm H2O!  

So:

Show References

We've all been there.  It's 2am, and a 4 week old with a temperature of 38.1 rolls in the door.  You grab the LP kit and your "best holder."  This person then holds the baby's head and neck flexed with one hand, while the other brings the bottom and legs up to the chest as much as possible...all, usually, without pulse oximetry monitoring.

Show References

• occurs in 1/1000 live births, but found in 15% of neonatal autopsies
• usually weigh <2500 grams at birth with prematurity the most common risk factor
• present with bleeding from the nose and mouth with severe respiratory distress
• immediate treatment with tracheal suctioning, oxygen, and positive-pressure ventilation
• ventilation goal is to maintain a high, positive expiratory pressure of at least 6-10cm H20
• also check for and correct any underlying bleeding disorders
• extremely high mortality, but no long-term pulmonary deficits if the infant survives

Show References

Necrotizing Enterocolitis

• NEC is an inflammatory lesion of bowel which can progress to intestinal gangrene, with perforation, and /or peritonitis
• characterized by abdominal distension, feeding difficulties, and GI bleeding
• mainly affects pre-term infants, and most commonly affects distal ileum and proximal colon
• usually presents during the first 2 weeks of life, but may occur up to 3 months of age in infants who who born weighing <1000grams
• classic finding on abdominal XR is pneumatosis intestinalis or air in the bowel wall (pathognomonic) and is present 50-75% of the time
• treat emergently with nasogastric decompression, IVF recussitation, NPO, and IV antibiotics

Show References

Colic

• excessive, unexplained paroxysms of crying in an otherwise well-nourished normal infant
• lasts >3 hours/day, and occurs >3 days/week...ughh!
• usually occurs at the same time of the day or evening
• usually resistant to most attempts to quell it
• infant may have excess flatus and draw legs up during episodes (but don't change formulas)
• beings in first week of life and ends by 4 months of age

Show References

You may already love ondansetron, but consider using it ORALLY followed by PO hydration in children with vomiting.

• Improve ORT success
• Decrease IV placements
• Decrease admission rates
• NOT cause any significant difference in the number of missed serious alternate diagnoses 

The size of the study that showed this: N of just under 35,000.

But don't skimp on dosing.  The dose is 0.1 - 0.15mg/kg, and you don't reach a max until 8mg.  To put this in perspective, a scrawny 115lb (about 53kg) middle school tennis player would get 8mg, an initial dose often reserved for chemo patients in the adult ED.

Show References

Slipped capito-femoral epiphysis (SCFE) is a favorite board exam topic, and typically involves a young early or pre-adolescent obese girl with hip pain and the classic "ice cream falling off the cone" appearance on hip radiographs. However, keep these three pearls in mind when thinking about SCFE:

1. Girls > Boys, but boys may be older at presentation - don't forget 15 year old boys and SCFE.
2. An early radiographic finding may only be physis widening, so consider comparison films - the ice cream may only be levitating, but not falling off.
3. 23% of these children present with knee pain - think before diagnosing an obese 15 year old boy with a knee sprain from football. *bonus* Recall that this injury is non weight-bearing.

Show References

As RSV season approaches, remember these key points in managing bronchiolitis:

• Diagnosis is clinical - labs and XRays will not help you, unless you want to rule out a specific alternate diagnosis.  It's all about the H&P.
• Supportive care, including bulb suction of secretions, placing the child in a position of comfort, and possibly providing humidified air, is the mainstay of treatment.
  • Ribavirin, corticosteroids, and antibiotics are not indicated.  Don't use them.
  • Bronchodilators have no benefit in bronchiolitis alone, and non-response to bronchodilators supports the diagnosis of bronchiolitis.  If a trial does work, know what you are treating - some children with bronchiolitis may have an underlying component of reactive airway disease, and should be treated accordingly.
• Before disposition be sure that the child can tolerate PO.  A fussy, tachypneic child may require admission for IV hydration if they are unable to tolerate feeds - recall that infants are obligate nose breathers.
• Finally, beware the RSV bronchiolitis bounceback - the peak incidence of respiratory failure in RSV bronchiolitis is after 3-4 days of illness, when most children should be improving.

Show References

• most common cause of low platelets in children
• immune-mediated destruction of circulating platelets
• acute ITP peak incidence between 2-5 years of age; chronic ITP peaks in adolescence
• recent history (1-6 weeks) of viral infection or immunization is common
• no hepatosplenomegaly
• low platelets with megathrombocytes on smear, with normal hemoglobin (which differentiates from TTP, HUS, and DIC)
• nearly 90% of children will have normal platelet counts in 6 months
• treatment reserved for platelet counts <20,000 or significant bleeding:  IVIG (best response rate of 95%), corticosteroids (79% resposne rate), anti-rH (D) immunoglobulin (82% reesponse reate)

Show References

A common debate on the topic of pediatric burns is whether or not blisters should be debrided.  ALL PEDIATRIC BURN BLISTERS SHOULD BE DEBRIDED.  There are two reasons for this:

1. Without debridement of burn blisters, the depth of a burn cannot be assessed, and such an assessment will certainly affect treatment and disposition.
2. There is conflicting (poor) evidence that blister fluid provides both protective and damaging properties, however, there is excellent evidence that ruptured blisters, or large blisters which are likely to rupture, carry a higher risk of infection if not debrided. Therefore, all blisters should be debrided. 

The best method for debriding blisters uses sterile gauze soaked in saline, and it is important to note that pain is almost universally decreased after debridement. 

The "1, 2, 3 Ouch!" technique is exactly what it sounds like (count to three with the child, and then wipe quickly, like tearing off a bandage), and works well in older children with smaller burn areas.  Sedation may be necessary for extensive debridements, and these children may need to be taken to the OR for debridement under anesthesia.  Some burn centers utilize non-operating room anesthesia (NORA) areas for such debridements that may be prolonged or painful, but do not require the full resources of an operating room.

Show References

Pediatric Ethanol Ingestion

A young child is brought to you after accidentally drinking a shot of alcohol at a wedding party. Here is what you need to consider:

• Infants and young children who have ingested enough ethanol to cause a peak serum level ≥50 mg/dL (11 mmol/L) are at risk for profound hypoglycemia, in addition to the other effects of alcohol seen in adults The key is that the dangerous serum level is MUCH lower in children than in adults, and children require FAR smaller volume than what may be considered dangerous by adults.
• Supportive care is the key to good outcomes, with particular focus on treating hypoglycemia - check your D-sticks early and often.
• Consider child protective services involvement in every case of pediatric intoxication, and consider measurement of serum acetaminophen levels as well as other possible toxic ingestion candidates.
• Activated charcoal cannot adsorb ethanol and should only be used if other substances are being considered.
• Children who are asymptomatic for six hours, and have a safe home environment, may be discharged.

Show References

• autossomal dominant disorder most commonly in Scandinavian and British descent due to deficiency of HMB-synthetase
• most heterozygotes are asymptomatic unless some factor increases the production of pyrogens, usually medications
• common drugs include steroids, alcohol, low calorie diets, and drugs (barbituates, sulfonamide antibiiotics, grisefulvin, and synthetic estrogens (birth-control)
• attacks of abdominal pain lasting several hours is the most common symptom and may be secondary to ileus or distension, but tenderness on exam and fever are absent
• peripheral neuropathy and muscle weakness improves over days, but may take years to return to normal
• diagnose: gold standard test measures RBC HMB-synthetase, screening test of normal PBG (porphobilinogen) level in urine rules out the condition
• treatment: narcotics, IV glucose (300g/day), and IV heme (4g/day)
   

Show References

Current American Burn Association guidelines state that any child with a greater than 10% total body surface area (TBSA) burn should be admitted to a center capable of caring for pediatric burns, rather than being discharged after wound management.  However, physician use of TBSA% estimation techniques is variable.  An excellent free tool for estimating TBSA is available online, allows for automatic weight based calculation, and allows printing of your diagram.  The diagram is available at http://www.sagediagram.com/.  More to come...

Show References

Hyperpronation: This reduction technique for a nursemaid's elbow (radial head subluxation)  has been found to have better first attempt success than classic supination/flexion technique.  (Pediatrics July '98).  Support the elbow with a finger on the radial head, and forcefully hyperpronate.  

• Technique may be less painful as well.  
• Reexamine after five minutes, and normal function should be returned
• Xrays are generally unnecessary unless history and physical are not consistent with nursemaid's elbow, symptoms for greater than 12 hours, or reductions attempts are unsuccessful
• Supination/Flexion may be attempted after two failed hyperpronation attempts 

Attachments

• 1005212340_Hyperpronation_technique.jpg (54 Kb)

Once you've made the presumptive diagnosis of cerebral edema in Pediatric DKA (refer to part 1), here's what's next:

• DO NOT GET A HEAD CT - this will only waste your time, recall that most children with DKA have subclinical cerebral edema
• Reduce the fluid rate by at least half
• Start mannitol at 0.25-1g/kg IV over 20 minutes (may repeat in 2 hours)
• OR (not and) 3% saline at 5-10mL/kg over 30 minutes (slightly less used and supported)
• If you intubate, DO NOT HYPERVENTILATE.  A pCO2 < 22 mmHg is associated with poorer outcomes, presumably secondary to ischemia from reduced bloodflow...

Mortality from cerebral edema in DKA is 20-25%, and 15-35% of survivors have permanent disability. 

The best strategy is to do your best to avoid cerebral edema in the first place, but if you do recognize it, this is a clinical diagnosis, and you should not delay treatment for radiographic studies.

Show References

• seizure disorder occuring in infants and children <1 year of age
• mostly occur between ages 4-8 months
• classic spasm is sudden, simultaneous flexion of the head and trunk with felxion and adduction of the extremities (salaam attack Blitz-krampf)
• occurs in clusters of diminishing severity
• initiated or aggrevated by transition from sleep to wakefulness or emotions
• EEG demonstrates hypsarrhythmia: high-voltage, irregular, slow waves occuring out of synch with multiple foci
• most resolve over time without therapy, but most children have some level of mental retardation or other seizure disorder