UMEM Educational Pearls - Pediatrics

Acute facial palsy is common in children and while bell’s palsy is significant proportion, there are other more concerning etiologies that make up a number of cases. A retrospective cohort study of pediatric patients with an ED diagnosis of Bell’s palsy was done using the Pediatric Health Information System and showed an incidence of 0.3% (0.03% in control) for new diagnosis of malignancy within the 60 days following the visit at which bell’s palsy was diagnosed. Younger age increased the risk. There was also a subset of patient’s excluded for diagnosis of bell’s palsy as well as malignancy at the index visit.

These numbers are small but may be clinically significant. They likely do not warrant laboratory or imaging workup as a rule but do make a case for detailed history taking and thorough exam. Consider avoiding steroids which are used commonly but lack high quality data and may undermine later efforts at tissue diagnosis of malignancy or even worsen prognosis.

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Many types of foreign bodies may be found in a child's ear. Some examples include: beads, cotton swabs, food, insects, and button batteries. 

Patients can be asymptomatic. However, they often have otalgia, pruritus, fullness, tinnitus, hearing loss, otorrhea, or bleeding. Obtain a history of the type of foreign body, when/how it entered the ear, and if there was a prior attempt at removal. Also ask if there are foreign bodies elsewhere, such as in the nose. Perform Rinne and Weber tests before and after removing the foreign body if the child is old enough to participate. 

Delayed presentation can result in edema and otitis externa. When the foreign body is sharp, there may be damage to the tympanic membrane (TM) and ossicles. 

Consult ENT when there is suspicion of damage to TM, when hearing loss is present, or when removal is especially challenging. Spherical foreign bodies are more difficult to remove. 

Remove foreign body if it can be visualized. Wax curettes, right-angled hooks, alligator forceps, and Frazier tip suctions can facilitate removal. Avoid additional trauma due to concern for edema, bleeding, TM perforation, or distal displacement of the object. Anxiety in the child will lead to increased difficulty with removal. 

A button battery in the ear is an emergency that can result in severe damage, including TM perforation, scarring or stenosis of the ear canal, and deeper injury. Seeds such as beans or peas and other absorptive material in the ear can expand, so do not irrigate when such foreign bodies are present. Living insects should be killed with alcohol, lidocaine, or mineral oil prior to performing foreign body removal. 

After removal, reassess ear canal and TM. Some foreign bodies require removal in the operating room. If the object has been successfully removed, evaluate for otitis externa or iatrogenic injury to the ear canal, and prescribe antibiotic otic drops when needed. When TM has perforated, refer for formal audiogram. ENT follow up is recommended for all patients.  

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• Pediatric acute gastroenteritis has always been a major cause of ED visits and hospitalizations.
• Pediatric complaints of vomiting and diarrhea have been on the rise, whether it be secondary to the new Omicron-variant of COVID-19, or norovirus and rotavirus which traditionally account for nearly 60% of all cases.
• Zofran (Ondansteron) 4mg for children 4-11yo weighing greater than 40kg, and up to 8mg for those older.
• Zofran prescription at discharge was associated with reduced rate of return at 72-hours and was not associated with masking alternative diagnosis like appendicitis and intussusception.
• Oral rehydration therapy (ORT) consisting of a low osmolarity solution containing sugar and salts along with zinc has also been shown to optimize treatment and diminish return visits. ORT is available in commercial packets, pre-mixed solutions, or can be made at home with table salt and sugar.
• Bottom Line: Consider providing a prescription of Zofran along with recommendations for oral rehydration therapy consisting of a low osmolarity solution containing sugar and salts to prevent outpatient treatment failure and return visits.

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Sever Disease

• Calcaneal apophysitis – inflammation of the growth plate of the calcaneus
• One of the most common causes of heel pain in adolescents, caused by repetitive stress (overuse injury)
• Most common in those who are involved in sports, especially those with lots of running and jumping
• Symptoms are heel pain and tenderness at/underneath the heel, with possible mild swelling
• Pain is reproduced by squeezing the posterior calcaneus and standing on tip toes
• Does not require imaging for typical presentation
• Treat with reduction of activity (specifically avoid painful activities), NSAIDs, and stretching exercises

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Incidence of T1DM is 1.93/1000 of youth <20 years old in the United States, with a bimodal distribution of onset. Onset peaks from ages 4-6 and again at puberty. 

Prior to the development of DKA, diabetes often has an insidious onset with symptoms of polydipsia, polyphagia and polyuria with weight loss in children. It can also be asymptomatic. 

When DKA is present, symptoms will include neurological manifestations (confusion, lethargy), GI symptoms (abdominal pain, nausea, vomiting), or respiratory abnormalities (Kussmaul respirations.) Polyuria and polydipsia are frequently present as well.

Diagnosis of DKA includes: serum glucose of >200 mg/dL, serum or urine ketones, and a pH <7.30 or bicarbonate <15 mEq/L. 

DKA is classified as mild, moderate or severe:

Mild: pH 7.21-7.30, HCO3 11-15 mEq/L

Moderate: pH 7.11-7.20, HCO3 6-10 mEq/L 

Severe: pH < 7.10, HCO3 <5 mEq/L

Initial treatment is 10 ml/kg of isotonic fluid bolus to a max of 500 ml, then reassess. Continue to replace fluids gradually to cover maintenance fluids as well as to treat dehydration. Do NOT bolus insulin. Rather, start a drip at 0.05-0.1 units/kg/hr. Continue insulin until acidosis has completely resolved. Once the serum glucose falls below 250 mg/dL, start dextrose to prevent hypoglycemia until the gap closes. 

Cerebral edema can develop 4-12 hours after treatment has been initiated. Observe for change in mental status, posturing, decreased response to pain, cranial nerve palsy, bradycardia, or abnormal respiratory pattern. This is a clinical diagnosis! Although a head CT can be obtained, it is often negative and treatment with mannitol or hypertonic saline should be started as soon as there are clinical changes.

DKA has resolved when pH > 7.3 and HCO3 is >15.

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This was a retrospective, noninferiority analysis looking at patients 14 years old and younger treated for nontraumatic seizures by EMS with a midazolam dose of 0.1 mg/kg (regardless of route).  There were just over 2000 patients with a median age of 6 years included in the study.  Midazolam redosing occurred in 25% of patients who received intranasal midazolam versus only 14% who received midazolam via intramuscular, intravenous, or intraosseous routes.
Bottom line: In the prehospital setting, intranasal midazolam at a dose of 0.1 mg/kg was associated with an increased need to redose compared to other routes.  This dose may be subtherapeutic for intranasal administration.

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What they are: Clinical practice guidelines put together by an AAP subcommittee over a span of several years based on changing bacteriology and incidence of illness, advances in testing, and evidence that has accumulated

Includes: Healthy infants 8 to 60 days of life with an episode of temperature greater than or equal to 38.0 C who at now at home after being born at home or after discharge from the newborn nursery, born between 37 and 42 weeks, without focal infection on exam (cellulitis, vesicles, etc)

Recommendations:

For the well appearing 8-21 day old:

• Obtain UA (and culture if + UA), blood culture, CSF (including enterovirus PCR if pleocytosis in CSF or seasonal periods), inflammatory markers are optional
• Start empiric antimicrobials regardless of results of UA/CSF or any inflammatory markers
• Infant should be admitted

For well appearing 22- 28 day olds:

• Obtain UA (and culture if +UA), blood culture, and inflammatory markers
  • procalcitonin preferred over CRP if available, ANC is helpful but less so than others
  • several studies used in making these guidelines used more than 1 inflammatory marker
    • Temp >38.5 is considered an inflammatory marker
• If any inflammatory marker is abnormal:
  • Obtain CSF and start empiric antibiotics
    • CSF is optional if no inflammatory markers are abnormal (provider judgment/risk assessment)
  • If CSF is not obtained, infant should be hospitalized for observation
• Discharge home is acceptable if all of the following are true: UA is normal, CSF is normal or enterovirus +, no obtained inflammatory marker is abnormal (or if abnormal they have subsequently had normal CSF testing), return precautions are discussed and follow up is assured within 24 hours for clinical re-examination
  • Infants being discharged home should receive empiric parental antibiotics prior to discharge
• If the infant is hospitalized antibiotics should be started if: CSF with pleocytosis or uninterpretable or if UA is +
  • If workup is normal, antibiotics optional
  • If CSF not obtained, may start antibiotics but not required
• Shared decision making with parents is recommended for decisions regarding LP and disposition in this group

For well appearing 29-60 day olds:

• Obtain UA ( and culture if +UA), blood culture, and inflammatory markers
• If inflammatory markers are normal LP does not need to be performed, antibiotics do not need to be administered (unless UTI present), and patient can be monitored closely at home with follow up in 24-36 hours
• If positive UA in this group with normal inflammatory markers, obtain cath urine culture and start oral antibiotics
• Consider obtaining CSF if abnormal inflammatory markers
• If CSF obtained and normal antibiotics are optional, may be observed in hospital or closely at home
• If CSF is not obtained or is uninterpretable with abnormal inflammatory markers, administer parenteral antibiotics
  • May be observed in hospital or closely at home

Notable changes:

• UTIs have been differentiated from bacteremia and bacterial meningitis, the guideline discourages the use of the historic “serious bacterial illness”
• A 2 step process where decision for catheretized urine culture is based on UA is suggested, UA to be obtained by bag or stimulated void

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• Watch out for Streptococcus pneumoniae sepsis! Patients can look well for several hours, then suddenly decline, leading to shock or death.
• Note that nearly half of patients with HgSS will have diminished spleen function by 1 year of age
• Start antibiotics early, even if patients are immunized or are taking prophylactic penicillin
• Antibiotic recommendations: long-acting cephalosporin +/- Vancomycin 
• Order CBC, reticulocyte count, blood culture, CXR, and other testing as needed based on presentation
• Admit patients with high fever, toxic appearance, infiltrate on CXR, hypoxia, tachypnea not explained by fever, poor intake/dehydration, severely abnormal CBC, history of S. pneumoniae sepsis, pain crisis + fever

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- A higher metabolic rate, reduced capacity for sweating, greater thermolability, and a larger body surface-to-volume ratio make infants and young children more susceptible to hyperthermia.

- Temperatures can rise rapidly within enclosed vehicles, reaching maximum temperatures within 5 minutes. In an open area with an ambient temp of 98 F (36.8 C), interior temperatures reach 124-152 F (51 to 67 C) within 15 minutes of closing the car doors.

- Texas leads the country in the numbers of pediatric heatstroke fatalities due to unattended children left in cars, followed by Florida and California.

- Most heatstroke victims (78.2%) were unknowingly left in vehicles by their caregivers.

- Most organizations interested in child safety issues recommend placing a phone, briefcase, or handbag in the back seat when traveling with a child as one way to prevent heatstroke fatalities.

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• Generally a seasonal illness that circulates in fall/winter (Maryland’s season is October-April)
• Following low incidence since April 2020, there is current ongoing circulation outside of the normal seasonal patterns
• Updated regional trends are available via the National Respiratory and Enteric Virus Surveillance System (https://www.cdc.gov/surveillance/nrevss/rsv/index.html)
• Causes upper respiratory illness characterized by copious nasal secretions which may cause increased work of breathing and necessitate hospitalization
• Severity tends to peak at around day 5 of illness
• In infants younger than 6 months, may also present with poor feeding, lethargy, or apnea
• Risk of apnea is highest in premature infants (post conception age <48 weeks) and infants under 1 month of age
• Routine administration of albuterol has not been shown to have benefit, the most recent AAP guidelines have a recommendation against trial of albuterol (common practices continue to be variable). It should be noted that children with severe disease were excluded from the studies used to make this recommendation.
• Hypertonic saline administration has not shown to be helpful in the ED setting, but may decrease length of stay in patients being admitted
• Consider admission for persistent tachypnea, hypoxia, inability to adequately feed, moderate to severe increased work of breathing at rest, or apnea

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• Testicular torsion is a straightforward diagnosis ultimately based on lack of blood flow to the affected painful, swollen testicle.
• Testicular torsion is the most common cause of acute unilateral testicular pain in peripubertal boys due to rapid increase in testicle size during puberty.
• Infarction begins as soon as after 2 hours of ischemia.
• There is nearly a 100% salvage rate if blood flow is re-established within 6 hours.
• Intermittent testicular torsion is challenging to diagnosis due to spontaneous resolution of symptoms and return of normal blood flow during ultrasound.
• Beware complaints of repeated episodes of acute unilateral testicular pain and swelling.
• Up to 50% of boys with testicular torsion reported at least one prior similar episode of acute pain and swelling. 
• Ultrasound findings of a whirlpool sign (spiral-like pattern of spermatic cord), boggy spermatic cord, and a psuedomass of the distal spermatic cord are concerning even in the setting of normal blood flow.
• Bottom Line: Peripubertal boys presenting with complaints of acute unilateral testicular pain and swelling should always be referred for urgent follow up even if their symptoms have resolved and when ultrasound may show normal blood flow as intermittent testicular torsion can not be ruled out.

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During cardiac arrest, metabolic acidosis develops because of hypoxia-induced anaerobic metabolism and decreased acid excretion caused by inadequate renal perfusion.  Sodium bicarbonate (SB) administration was considered as a buffer therapy to correct metabolic acidosis.  However,  SB has several side effects such as hypernatremia, metabolic alkalosis, hypocalcemia, hypercapnia, impairment of tissue oxygenation, intracellular acidosis, hyperosmolarity, and increased lactate production.  The 2010 Pediatric Advanced Life Support (PALS) guideline stated that routine administration of SB was not recommended for cardiac arrest except in special resuscitation situations, such as hyperkalemia or certain toxidromes.  An evidence update was conducted in the 2020 Pediatric Life Support (PLS) guideline and the recommendations of 2010 remain valid.  This article was a systematic review and meta-analysis of observational studies of pediatric in hospital cardiac arrests.  The primary outcome was the rate of survival to hospital discharge after in hospital cardiac arrests. The secondary outcomes were the 24-hour survival rate and neurological outcomes.   

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• Electronic cigarette (E-cigs) smoking (vaping) continues to be a major concern among adolescents and teens, who mistakenly think it is safer than smoking traditional cigarettes or don't consider it as smoking at all.
• Typically, they contain nicotine which is highly addictive and can cause harm in the developing brain, but can also contain other dangerous chemicals, flavorings and drugs.
• They often contain higher amounts and concentrations of nicotine. 1 JUUL pod can contain the equivalent of 20 packs of nicotine cigarettes.
• Inhaled aerosols of the various chemicals, flavorings, and heavy metals have resulted in lung disease and acute respiratory failure. Bilateral infiltrates on chest imaging is a common finding.
• Nicotine toxicity can also occur. Symptoms include vomiting, diarrhea, abdominal pain, salivation, headache, dizziness, confusion, and seizures. Hypertension and tachycardia acutely, followed by hypotension and bradycardia can be expected.
• Bottom Line: Ask specifically about electronic cigarette use in adolescents and teens who present with acute complaints. One study found that of those who regularly used and presented for evaluation of symptoms, 98% were respiratory, 81% were gastrointestinal, and 100% were constitutional in nature.

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Even though acute myocardial ischemia (AMI) does not present as commonly in the pediatric patient as in the adult and the literature is limited, it is reasonable to obtain a troponin when acute cardiac ischemia is suspected based on the history and physical exam. 

Recreational drugs including cocaine, amphetamine, cannabis, Spice, and K2 (cannabis derivatives) have been shown to result in myocardial injury including AMI. Coronary vasospasm secondary to drug use is well documented in the pediatric population. While cocaine use is a known risk factor for coronary vasospasm, the same condition has been reported in pediatric patients after marijuana use.

In a study of pediatric patients with blunt chest trauma, 3 of 4 patients with electrocardiographic or echocardiographic evidence of cardiac injury had elevations in troponin I above 2.0 ng/mL. Cardiac troponins are an accurate tool for screening for cardiac contusion after blunt chest trauma in pediatric patients even with limited data.

Cardiac troponins are also useful in the evaluation for myocarditis. In one study, myocarditis was the most common diagnosis (27%) in pediatric ED patients presenting with chest pain and an increased troponin. Eisenberg et al showed a 100% sensitivity and an 85% specificity for myocarditis using a troponin of 0.01 ng/mL or greater as a cut off.  A normal troponin using this cutoff can be used to exclude myocarditis. Abnormal troponin in the first 72 hours of hospitalization in pediatric patients with viral myocarditis is associated with subsequent need for extracorporeal membrane oxygenation and IVIg.

Bottom line: Troponin can be used in pediatric patients with clinical concern for cardiac ischemia, cardiac contusion and myocarditis

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