UMEM Educational Pearls - Pediatrics

Category: Pediatrics

Title: Prepubertal Urethral Prolapse

Keywords: prepubertal vaginal bleeding, mass (PubMed Search)

Posted: 9/18/2020 by Jenny Guyther, MD (Updated: 8/17/2022)
Click here to contact Jenny Guyther, MD

- Urethral prolapse will appear as a protrusion of the distal urethra through the urinary meatus causing a “doughnut” sign.

- Risk factors include trauma, UTI, anatomical differences, and increased intraabdoiminal pressure from cough or constipation.  There is a higher incidence in people of African descent.

- The chief complaint may include urethral mass and vaginal bleeding.

- There is a bimodal age distribution (prepuberty and postmetapause) due to a relative estrogen deficiency.

-Treatment is with estrogen cream and sitz baths for 4- 6 weeks.

Show References


Category: Pediatrics

Title: Temporizing Measures for Button Battery Ingestions

Keywords: button battery, pediatrics, esophageal injuries (PubMed Search)

Posted: 9/4/2020 by Prianka Kandhal, MD
Click here to contact Prianka Kandhal, MD

Ingestion of a button battery is a can't-miss diagnosis with a very high risk for causing severe esophageal injury. There are about 3000 button battery ingestions per year, and this is increasing because electronics are becoming more and more prevalent.

Severe damage to the esophagus occurs within 2 hours. On your lateral view, the end with narrowing is the negative end, which triggers a hydrolysis reaction that results in an alkaline caustic injury and, ultimately, liquefactive necrosis.

Children can present with nonspecific symptoms and if the ingestion was not witnessed, they are at high risk for delays in diagnosis. Additionally, in the community setting, there can be further delays in definitive treatment (endoscopic removal) due to difficulty in calling teams in or transporting to other facilities.

Anfang et al. looked into ways to mitigate damage to esophageal tissue. They did an in vitro study on porcine esophageal tissue, measuring the pH with different substances applied. They tried apple juice, orange juice, gatorade, powerade, pure honey, pure maple syrup, and carafate. They then repeated the study in vivo on piglets with button batteries left in the esophagus and ultimately did gross and histological examination of the esophageal tissue.

Honey and carafate demonstrated protective effects both in vitro and in vivo. They neutralized pH changes, decreased full-thickness esophageal injury, and decreased outward extension of injury into deep muscle.

Take Home Point: If a child is found to have a button battery in the esophagus, while definitive management is still emergent endoscopic removal, early and frequent ingestion of honey (outside of the hospital) and Carafate (in the hospital) may help reduce the damage done to the tissue in the interim. The authors recommend 10ml every 10 minutes.

Show References


Category: Pediatrics

Title: Imperforate hymen

Keywords: Female GU, abdominal pain, missed period (PubMed Search)

Posted: 8/21/2020 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD

Definition: Congenital anomaly where the hymen is completely obstructing the vaginal opening

Demographic: Incidence 0.05-0.1% of females

History:  Most are asymptomatic and diagnosed on physical exam or incidentally when there is lack of menarche. Symptoms in adolescents can include: Abdominal pain (50%), urinary retention (20%), abnormal menstruation (14%), dysuria (10%), frequency, renal failure, UTI and back pain.

Physical exam: bulging, blueish hymenal membrane

Complications: Late detection can lead to infections, fertility problems, endometriosis, hydronephrosis, and rarely renal failure

ED treatment: If abdominal pain is significant or there is urinary obstruction, a urinary foley can be placed.  GYN should be consulted.

Definitive treatment: Hymenectomy, hymenotomy, carbon dioxide laser treatments or foley insertion through the hymen (done by a specialist).

Show References


Category: Pediatrics

Title: Risk factors for pediatric cervical spine injuries

Keywords: MVC, neck injury, neurological injury (PubMed Search)

Posted: 7/24/2020 by Jenny Guyther, MD (Updated: 8/17/2022)
Click here to contact Jenny Guyther, MD

There is no well validated clinical decision rule similar to NEXUS or the Canadian Cervical Spine rule in children for clearing the cervical spine.  Clinical clearance versus imaging first is a complicated decision.  Certain risk factors may predispose children to injury and should be taken into account when deciding about clinical clearance versus imaging (XR).

High Risk Criteria for Cervical Spine Injury in Pediatrics

Mechanism

 

High risk MVC

              Intrusion > 12 inches at the occupant site

              Intrusion > 18 inches at any site

              Partial or complete ejection

              Death in the same passenger compartment

              Vehicle telemetry consistent with high speed

Fall > 10 feet

Nonaccidental trauma

Diving injury

History

 

Down’s Syndrome

22.q11.2 deletion

Klippel-Fiel syndrome

Physical Exam

 

Altered mental status

Intoxication

Hypotension

Focal neurological exam

Neck pain

Torticollis

             

 

 

 

 

 

 

Show References


Takeaways

Every year, numerous children die of non-exertional heatstroke after being left in motor vehicles in the United States. Per data obtained from the national nonprofit KidsAndCars.org, the average number of pediatric vehicular heatstroke deaths is 39 per year since 1990. In 2018, this number peaked at 54 pediatric deaths. Prior studies show that the interior temperature of a closed vehicle rises quickly within minutes of closing the doors and windows. This rapid change occurs even on days with cooler ambient temperatures (20s °C/70s °F): the interior temperature of a car may still reach 117F within an hour.

Children, particularly infants and toddlers, are at increased risk for heat illness due to several physiologic and developmental factors:

-       Unable to escape hot environments or to self-hydrate

-       Lack mature thermoregulatory systems

o   Have lower rate of sweat production than adults

-       Have higher basal metabolic rates than adults

-       Have higher body surface area:mass ratio --> absorb heat faster in hot environments

Bottom line:  ED providers can be instrumental in giving anticipatory guidance on vehicular heatstroke in children during the warmer seasons:

-        Educate caregivers to “Look before you Lock”

-       Suggest that the caregiver place a valuable object (phone, employee badge, handbag) in the back seat when traveling with a child

-       Remind caregiver of the dangers of intentionally leaving a child in the car for any reason, even during cooler spring/summer days.

Show More In-Depth Information

Show References


Attachments

Hammett._Pediatric_Heatstroke_Fatalities_Caused_by_Being_Left_in_Cars.pdf (581 Kb)


Category: Pediatrics

Title: Failure to thrive in children in the ED

Keywords: weight loss, not eating, small, FTT (PubMed Search)

Posted: 6/19/2020 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD

Children will often present to the ED with concern for poor feeding or weight loss.  Be concerned about failure to thrive when: 2 or more growth percentile lines are crossed or weight or length is less than the 5th percentile for the patients chronological age.
Make sure to ask about feeding technique, type of formula, frequency of feeds and problems with feeding.
Keep a broad differential in the ED in children with weight concerns including non accidental trauma, congenital heart disease, genetic abnormalities, hyperthyroidism, and gastrointestinal abnormalities.  GI problems include cow's milk protein intolerance, celiac disease, pyloric stenosis and reflux.

Show References


Category: Pediatrics

Title: Pediatric Covid-19 Infection

Posted: 5/29/2020 by Rose Chasm, MD (Updated: 8/17/2022)
Click here to contact Rose Chasm, MD

  • Although significant data has been accumulated regarding Covid-19 infection in adults, the epidemiologic characters and clinical course descriptions in the pediatric population lags.
  • Studies to date report that children have mild self-limiting disease with low mortality, even in Immunocompromised children.
  • Less than half have fever.
  • However, recent reports of a severe illness similar to Kawasaki Disease and/or toxic shock syndrome have led to the newly dubbed Multisystem Inflammatory Syndrome in Children (MIS-C)
  • MIS-C CDC Criteria: <21 years of age, laboratory evidence of inflammation, clinically severe illness requiring hospitalization with multisystem involvement, no alternative diagnosis, and positive Covid-19 test or exposure within 4 weeks of presentation.
  • MIS-C seems to spare infants and toddlers, and is mostly described in school aged and adolescent groups.
  • MIS-C often begins with fever and GI symptoms (mild vague abdominal pain,diarrhea and/or vomiting). 
  • Telltale presentation of an erythematous rash that spares the limbs and is associated with conjunctival injection.  Hence the initial misdiagnosis of Kawasaki and Toxic Shock in the first reported cases.
  • MIS-C patients quickly decompensate to severe shock that is often refractory to typical treatments.
  • Providers should have a higher index of suspicion for MIS-C in any child who presents with concern for Covid-19 infection with these symptoms, and especially with abnormal vital signs. Closer monitoring of heart rate and blood pressure, which is often neglected is vital.

Show References


Category: Pediatrics

Title: When does a car seat need to be replaced?

Keywords: seat belt, car seats (PubMed Search)

Posted: 5/15/2020 by Jenny Guyther, MD (Updated: 8/17/2022)
Click here to contact Jenny Guyther, MD

NHTSA recommends that car seats be replaced following a moderate or severe crash. Car seats do not automatically need to be replaced following a minor crash.

A minor crash is one in which ALL of the following apply:

-The vehicle was able to be driven away from the crash site.
-The vehicle door nearest the car seat was not damaged.
-None of the passengers in the vehicle sustained any injuries in the crash.
-If the vehicle has air bags, the air bags did not deploy during the crash
-There is no visible damage to the car seat.

NEVER use a car seat that has been involved in a moderate to severe crash. Always follow manufacturer's instructions.

Show References


Category: Pediatrics

Title: Teen Driving Education in the Pediatric Emergency Department

Keywords: MVC, anticipatory guidance, seatbelts. (PubMed Search)

Posted: 4/17/2020 by Jenny Guyther, MD (Updated: 8/17/2022)
Click here to contact Jenny Guyther, MD

The leading cause of death in the US for those aged 16 to 24 years is motor vehicle collisions (MVCs).  Teen drivers are more likely than any other age group to be involved in an MVC that result in injury or fatality.  Texting while driving, nighttime driving, inexperienced driving, and driving under the influence of alcohol or drugs may play a role in these collisions.

Can anticipatory guidance related to safe driving be done in the ED?  YES!

This study implemented a toolkit that contained a copy of the driving law, a sample parent-teen driving contract and statistics on teen driving injuries. Post toolkit questionnaires showed that both teens and their guardians learned new information.

Bottom line: Engage in anticipatory guidance in the ED with teens and their parents about seatbelt use, the dangers of driving under the influence and local driving laws.

Show References


Category: Pediatrics

Title: SARS-CoV-2 Infection in Children

Keywords: pandemic, coronavirus, pediatric (PubMed Search)

Posted: 3/20/2020 by Jenny Guyther, MD (Updated: 8/17/2022)
Click here to contact Jenny Guyther, MD

New information is coming out each day.  Below is just a sample of some of the recent data in children.
 
SARS-CoV2 Infection in Children - Lu et al
- 1391 Children in China were tested between 1/28-2/26/20. 171 were positive. 
- Fever was present in 41.5 % of infected children at some time during their illness course
- 3 patients required ICU care
- 27 patients did not have any symptoms or pneumonia on chest xray
 
Infant COVID Study - Wei et al
-2 month retrospective review
-9 infants under 1 year tested positive for COVID during this time period
-3/9 asymptomatic, 4/9 fever only, 2/9 mild URI symptoms
 
Children COVID Study - Xai et al
-2 week retrospective review
-20 children, all inpatients 
-12/20 fever (60%), 13/20 cough (65%)
-Coinfection pathogens: influenza A, B, mycoplasma, CMV, RSV 
 
Bottom line: Children appear to be less severely affected than adults and with a different symptom pattern.  Coinfection with other respiratory viral pathogens can occur.

 

Show References


Category: Pediatrics

Title: Epinephrine administration in pediatric prehospital cardiac arrest

Keywords: cardiac arrest, prehospital, epinephrine (PubMed Search)

Posted: 2/21/2020 by Jenny Guyther, MD (Updated: 8/17/2022)
Click here to contact Jenny Guyther, MD

This was a population based observational study in Japan that enrolled pediatric patients age 8-17 years with out-of-hospital cardiac arrests (OHCA).  The primary end point was 1 month survival and secondary end points were favorable 1 month neurological outcomes and pre-hospital return of spontaneous circulation (ROSC).  In Japan, prehospital administration of epinephrine is allowed in children 8 years and older with appropriate training.
3961 pediatric OHCA were eligible (306 received epinephrine and 3655 patients did not).
There were no differences between the epinephrine and no epinephrine groups in regards to 1 month survival or favorable neurological outcome.  The epinephrine group had a slightly higher likelihood of achieving pre-hospital ROSC.

Show References


Category: Pediatrics

Title: Pelvic injury (submitted by Cheyenne Falat, MD)

Keywords: avulsion fracture, orthopedics, pelvic injury, trauma (PubMed Search)

Posted: 2/14/2020 by Mimi Lu, MD (Emailed: 2/15/2020) (Updated: 2/15/2020)
Click here to contact Mimi Lu, MD

Question

A 15 y.o. female presents to your emergency department with sudden onset hip pain after winding up to kick a soccer ball during her game today.  You see a well-developed female in obvious discomfort, with tenderness to palpation over her lateral hip and pain with passive ROM at the hip.  You obtain this x-ray.  What is your diagnosis?

 

 

 

Show Answer

Show References


Category: Pediatrics

Title: Post tonsillectomy complications

Keywords: ENT, post tonsillectomy bleeding, T and A (PubMed Search)

Posted: 1/17/2020 by Jenny Guyther, MD (Updated: 8/17/2022)
Click here to contact Jenny Guyther, MD

Tonsillectomy and adenoidectomy (T&A) is the second most common ambulatory surgery performed in the US.  Children younger than 3 years, children with craniofacial disorders or sleep apnea are typically admitted overnight as studies have shown an increase rate of airway or respiratory complications in this population.

The most common late complications include bleeding and dehydration.  Other complications include nausea, respiratory issues and pain.

Post-operatively, the overall 30-day emergency department return rate is up to 13.3%.  Children ages 2 and younger were more likely to present to the ED.  There is significantly higher risk of dehydration for children under 4 years.  Children over the age of 6 had significantly higher bleeding risk and need for reoperation for hemorrhage control.

Show References


Category: Pediatrics

Title: Urinary retention in children

Keywords: Urinary retention, formulas (PubMed Search)

Posted: 12/20/2019 by Jenny Guyther, MD (Updated: 8/17/2022)
Click here to contact Jenny Guyther, MD

Urinary retention in pediatrics is defined as the inability to void for more than 12 hours in the presence of a palpable bladder or a urine volume greater than expected for age.

Maximum urine volume calculation for age:  (age in years + 2) x 30ml.

Causes of urinary retention include mechanical obstruction, infection, fecal impaction, neurological disorders, gynecological disorders and behavioral problems.

The distribution is bimodal occurring between 3 and 5 years and 10 to 13 years.

Show References


Category: Pediatrics

Title: Acute Otitis Media

Posted: 11/29/2019 by Rose Chasm, MD (Updated: 8/17/2022)
Click here to contact Rose Chasm, MD

Antibiotic stewardship has led various organizations such as the AAP, AAFP, and IDSA to introduce two different approaches to the treatment of acute otitis media (AOM):

  • Immediate treatment with antibiotics versus
  • initial observation for 48-72 hours without antibiotics.

Immediate treatment with antibiotics should always include the following patients:

  • Children <6 months old
  • Toxic appearing
  • Severe signs/symptoms: otorhea, persistent pain, fever>39C, bilateral ear disease

The observation approach can be considered in the following very slect patient group:

  • Otherwise healthy children >2 years of age
  • Non-severe illness
  • Unilateral ear disease
  • Access to follow up within 48-72 hours
  • Parental comfort / Shared decision making

Often the issue with pediatric AOM isn't necessarily the overprescribing of antibiotics, but the inaccurate/inappropriate over diagnosis of acute otitis media.  An erythematous tympanic membrane does not equal AOM.  Crying and fever can result in a red TM. Fluid seen behind the TM, is often just serous otitis media, which isn't AOM. 

When antibiotics are warranted, first-line treatment is with high dose amoxicillin, 90 mg/kg per day divided into two doses; unless the child has received beta-lactam antibiotics in the previous 90 days and/or also has puruent conjunctivitis mandating amoxicillin-clavulanate instead.  In the later case, prescribing the Augment ES, 600 mg/5mL formlation with a lower clavulanic concentration lessening GI upset and diarrhea is prefered.

 

 

Show References


Category: Pediatrics

Title: At what age should I test for strep throat in children?

Keywords: Sore throat, strep throat (PubMed Search)

Posted: 11/15/2019 by Jenny Guyther, MD (Updated: 8/17/2022)
Click here to contact Jenny Guyther, MD

Streptococcal pharyngitis is common in the pediatric population however in children younger than 3 years, group A streptococcus (GAS) is a rare cause of sore throat and sequela including acute rheumatic fever are very rare.  Inappropriate testing leads to increased healthcare and unnecessary exposure to antibiotics.

The national guidelines published by the Infectious Diseases Society of America do NOT recommend GAS testing in children less than the age of 3 years unless the patient meets clinical criteria and has a home contact with documented GAS.

Show References


Category: Pediatrics

Title: Crystalloid fluid choice in Pediatric Sepsis

Keywords: lactated ringer, LR, normal saline, NS (PubMed Search)

Posted: 10/25/2019 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

  • Resuscitation with crystalloid fluid is a cornerstone of pediatric septic shock treatment.
  • Recent publication from the adult literature have suggested that balance crystalloid solutions may be better than 0.9% normal saline (NS) for select conditions.
  • Lactated Ringer's (LR) is a common balance crystalloid solution often used for fluid resuscitation and critically ill patients.
  • However whether resuscitation with balance fluids is associated with improved outcomes compared to NS in pediatric sepsis is unclear.
  • A matched retrospective cohort study of 12,529 pediatric patient with severe sepsis/septic shock at 382 US hospitals compared outcomes with versus without LR as a part of the initial resuscitation.
  • Outcomes includesd: 30-day hospital mortality, acute kidney injury, new dialysis, and length of stay.
  • After matching, mortality was not different between LR and NS groups. There were no differences in secondary outcomes except longer hospital length of stay in the LR groups.
  • The PRoMPT BOLUS randomized control trial pilot was a feasibility study designed to study the comparative effectiveness of LR versus NS fluid resuscitation for pediatic septic shock.  Completion of a more robust study may help provide answers to these ongoing questions. 

Bottom line: Balance fluid resuscitation with LR was not associated with improved outcomes compared to NS and pediatric sepsis. Selective LR use necessitates a prospective trial to definitively determine comparative effects among crystalloids.

Show References


Category: Pediatrics

Title: Autism in the ED

Keywords: sedation, autism spectrum disorder (PubMed Search)

Posted: 10/18/2019 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD

The emergency department care of a child with autism spectrum disorder (ASD) can be difficult due to problems with communication, social interaction and the patients problems with dealing with change. The often loud, hectic and unfamiliar environment does not help either.  Avoiding triggers, dimming lights, quiet rooms, using distractions and using home electronic devices may help.  Despite these interventions, these children may still require some type of sedation, even to be able to complete a routine exam.  There is not much research on ED sedation practices in this population.
The study cited was a retrospective chart review of 6020 patients with ASD seen over 8 years.  126 patients required sedation.  Laceration repair (24.6%), incision and drainage (17.5%), diagnostic imaging (14.3%) and physical exam (11.9%) were the leading reasons for sedation.  Half of the children received ketamine and half received midazolam.  Adverse effects were seen in 18% of patients with vomiting and desaturations being the most common.  Sedation was inadequate in 4 patients who received midazolam alone.  Physical restraint was used to complete some procedures due to patient resistance.
The use of sedation for painless procedures and exams is likely a consequence of communication impairments and sensory aversions.

Show References


Category: Pediatrics

Title: Pediatric Tibial tubercle avulsion fractures

Keywords: Orthopedics, compartment syndrome (PubMed Search)

Posted: 9/20/2019 by Jenny Guyther, MD (Updated: 8/17/2022)
Click here to contact Jenny Guyther, MD

-       Tibial tubercle avulsion fractures are rare and pediatrics, accounting for less than 3% of all epiphyseal injuries in children ages 11-17 years. 

-       The typical mechanism is a sudden forceful quadriceps contraction.  Patients present with sudden pain after sprinting or jumping with pain, bruising, deformity or swelling over the tibial tubercle and with a decrease ability to extend the leg. 

-       10 to 20% of cases result in anterior compartment syndrome related to the rupture of the anterior tibial recurrent artery.

-       Although directly measured intra-compartmental pressures can facilitate the diagnosis of compartment syndrome, interpretation of these values can be challenging with healthy children having higher average lower leg compartment pressures than adults.  Treatment of subsequent compartment syndrome is often based on a high index of suspicion.

Show References


Category: Pediatrics

Title: UTI Calculator

Keywords: UTIcalc, SBI, serious bacterial infection, febrile infant, urinary tract infection (PubMed Search)

Posted: 9/13/2019 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Question:  In febrile children younger than 2 years, what combination of clinical and laboratory variables best predicts the probability of a urinary tract infection?

Given that urinary tract infections (UTI) are the most common source of serious or invasive bacterial infections in young febrile infants, early identification and treatment has the potential to reduce poor outcomes.  Wouldn't it be great if there was an easy way to identify patients at highest risk?

Researchers from the Children’s Hospital of Pittsburgh formulated a calculator (UTICalc) that first estimates the probability of urinary tract infection (UTI) based on clinical variables and then updates that probability based on laboratory results.

  • The nested case-control study of 2,070 children aged 2 to 23 months with a documented temperature of 38°C or higher
  • In contrast with the American Academy of Pediatrics algorithm, the clinical model in UTICalc reduced testing by 8.1% (95% CI, 4.2%-12.0%) AND decreased the number of missed UTIs.

Bottom line:

The UTICalc calculator can be used to guide to tailor testing and treatment in children with suspected urinary tract infection with the hope of improving outcomes for children with UTI by reducing the number of treatment delays.

Go ahead and give it a click!! https://uticalc.pitt.edu/

Show References