Keywords: prepubertal vaginal bleeding, mass (PubMed Search)
- 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.
McCaskill A, Inabinet C, Tomlin K et al. Prepubertal Genital Bleeding: Examination and Differential Diagnosis in Pediatric Female Patients. The Journal of Emergency Medicine 2018; 55(4): 97-100.
Keywords: button battery, pediatrics, esophageal injuries (PubMed Search)
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.
Anfang RR, Jatana KR, Linn RL, et al. pH-Neutralizing Esophageal Irrigations as a Novel Mitigation Strategy for Button Battery Injury. The Laryngoscope. 2019; 129:49-57.
Keywords: Female GU, abdominal pain, missed period (PubMed Search)
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).
Lee K, Hong J, Jung H et al. Imperforate Hymen: A Comprehensive Systematic Review. J Clin Med 2019; 8(56): 1-14.
Keywords: MVC, neck injury, neurological injury (PubMed Search)
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
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
Altered mental status
Focal neurological exam
Gopinathan N, Viswanathan V, Crawford A. Cervical Spine Evaluation in Pediatric Trauma: A Review and an Update of Current Concepts. Indian J Orthop 2018;52(5):489-500.
Leonard J, Browne L and Ahmed F et al. Cervical Spine Injury Risk Factors in Children with Blunt Trauma. Pediatrics 2019;144 (1):e20183221.
Kliegman R, Stanton B, St Geme J et al. Nelson Textbook of Pediatrics. 20th edition Vol 1 and 2. 2016. Elsevier. P 549-550, 3299-3300, 3352.
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.
A recent retrospective cohort study (Hammett et al.) of 554 pediatric victims (aged <14 years) who died of heatstroke in a motor vehicle was conducted using KidsAndCars.org data. This study is the largest to date to describe this US subset of pediatric fatalities.
- Nearly half of the cases occurred when the ambient temperature was >90°F. However, 10% cases occurred when the ambient temperature was < 80°F.
- Most incident cases (~40%) occurred in home parking areas > nonresidential parking areas> daycare centers parking.
- The mean victim age was 16.4 months. Most (99%) victims were less than 5 years of age.
- Male children were more common victims (54% cases) than female children.
- Most victims (78%) were left unknowingly in vehicles by their caregivers. For those victims left intentionally in vehicles, caregivers’ reasons for leaving the child in the vehicle were the caregivers’ need to attend work or school or desire to allow the child to keep sleeping.
- A single caregiver was most commonly responsible for leaving the child in the vehicle (89% cases), with the victim’s mother being the most often responsible.
Hammett, D. L., Kennedy, T. M., Selbst, S. M., Rollins, A. & Fennell, J. E. Pediatric Heatstroke Fatalities Caused by Being Left in Motor Vehicles. Pediatric Emergency Care, (2020).
Keywords: weight loss, not eating, small, FTT (PubMed Search)
Calleo V, Surujdeo R and Thabet A. Emergency Department Management of Patients with Failure to Thrive. EB Medicine. March 2020.
Spanish Peditric Academy
NEJM 2020; 382:1663-1665
Keywords: seat belt, car seats (PubMed Search)
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.
Car Seat Use After a Crash. https://www.nhtsa.gov/car-
Keywords: MVC, anticipatory guidance, seatbelts. (PubMed Search)
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.
Spears et al. Teen driving education in the pediatric emergency department: effectiveness of a tool kit. Southern Medical Journal 2019; 112(11): 562-565.
Keywords: pandemic, coronavirus, pediatric (PubMed Search)
Keywords: cardiac arrest, prehospital, epinephrine (PubMed Search)
Matsuyama et al. Pre-Hospital Administration of Epinephrine in Pediatric Patients with Out-of-Hospital Cardiac Arrests. JACC: 75 (2); 2020.
Keywords: avulsion fracture, orthopedics, pelvic injury, trauma (PubMed Search)
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?
Answer: Avulsion fracture of the anterior superior iliac spine.
An avulsion fracture of the anterior superior iliac spine is an uncommon injury seen almost exclusively in adolescent athletes.
They mostly result from a sudden, forceful, and/or unbalanced contraction of the attached musculotendinous unit (sartorius muscle or tensor fascia lata) during the starting phase of running, jumping, kicking, etc.
The most implicated sports include soccer, running, and ice hockey.
The patient may report sudden shooting pain referred to the involved tuberosity.
Physical exam may include localized edema and tenderness to palpation and pain on passive ROM at the hip.
The iliac crest is the weakest component of the pelvic ring during adolescence.
The avulsed fragment is usually displaced distally and laterally.
Conservative therapy includes 2-3 weeks of limited activity and walking with partial weight bearing restrictions and crutches. May also include bed rest with the affected lower extremity positioned with the hip and knee in flexion to ensure minimal tension of the muscles attaching to the ASIS. This is considered for minimally displaced fractures in younger children.
Surgical management generally consists of ORIF with a lag screw, and is generally recommended for patients with fracture fragments > 3cm or severely displaced fragments that cause compression of the lateral cutaneous nerve resulting in meralgia parasthetica.
Rossi F, S. Acute avulsion fractures of the pelvis in adolescent competitive athletes: prevalence, location and sports distribution of 203 cases collected. Skeletal . 2001;30(3):127-31.
J, T, V. Comparison of conservative against surgical treatment of anterior-superior iliac spine avulsion fractures in children and adolescents. Int . 2014;38(7):1495-8.
Keywords: ENT, post tonsillectomy bleeding, T and A (PubMed Search)
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.
Lindquist NR, Feng Z and Mukerji SS. Age-related causes of emergency department visits after pediatric adenotonsillectomy at a tertiary pediatric referral center. International Journal of Pediatric Otorhinolaryngology 2019; 127: 109668.
Keywords: Urinary retention, formulas (PubMed Search)
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.
Nevo A, Mano R, Livne P, Sivan B and Ben-Meir. Urinary Retention in Children. Urology 2014; 84(6):1475-1479.
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 should always include the following patients:
The observation approach can be considered in the following very slect patient group:
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.
Liebeerthal AS, et al. The diagnosis and management of acute otitis media. Pediatrics 2013; 131.
Shaikh N, et al. Development of an algorithm for the diagnosis of otitis media. Acad Pediatr 2012;12:214.
Keywords: Sore throat, strep throat (PubMed Search)
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.
Ahluwalia et al. Reducing streptococcal testing in patients less than 3 years old in an emergency department. Pediatrics 2019;144:4.
Keywords: lactated ringer, LR, normal saline, NS (PubMed Search)
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.
1. Weiss SL, Keele L, Balanmuth F, Vendetti N, Ross R, Fitzgerald JC, Gerber JS. Crystalloid Fluid Choice and Clinical Outcomes in Pediatric Sepsis: A Matched Retrospective Cohort Study. J Pdatr.207 Mar:182:304-310.
2. Balamuth F, Kittick M, McBride P, Woodford AL, Vestal N, Casper TC, Metheney M, Smith K, Atkin NJ, Baren JM, Dean JM, Kuppermann N, Weiss SL. Pragmatic Pediatric Trial of Balanced versus Normal Saline Fluid in Sepsis: The PRoMPT BOLUS Randomized Controlled Trial Pilot Feasibility Study. Acad Emerg Med. 2019 Jun 10
Keywords: sedation, autism spectrum disorder (PubMed Search)
Brown et al. Procedural sedation in children with autism spectrum disorders in the emergency department. Am J Emerg Med. 2019 Aug;37(8):1404-1408.
Keywords: Orthopedics, compartment syndrome (PubMed Search)
- 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.
Yue et al. Bilateral tibial tubercle avulsion fractures: Pediatric orthopedic injury at high risk for compartment syndrome. The American Journal of Emergency Medicine. Available online May 2019.
Keywords: UTIcalc, SBI, serious bacterial infection, febrile infant, urinary tract infection (PubMed Search)
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 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/
Shaikh N, Hoberman A, Hum SW, Alberty A, Muniz G, Kurs-Lasky M, Landsittel D, Shope T. Development and Validation of a Calculator for Estimating the Probability of Urinary Tract Infection in Young Febrile Children. JAMA Pediatr. 2018 Jun 1;172(6):550-556.