UMEM Educational Pearls - Pediatrics

• 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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In children with known congenital heart disease, BNP measurements are higher in those patients with heart failure compared to those without heart failure.

The utility of BNP in differentiating a cardiac from pulmonary pathology in patients with respiratory distress has been studied in pediatrics. In one study involving 49 infants with respiratory distress, the patients with a final diagnosis of heart failure had a higher mean BNP concentration than those patients with other causes.  Also, there is a suggestion that the relative change in NT proBNP levels may be useful in patients with underlying pulmonary hypertension.  However, currently there is not enough literature to support the routine use of BNP or NT proBNP in acute management.

Bottom line: BNP can be useful in your patient with congenital heart disease who is decompensating and may be used in a patient where there is difficulty in differentiating a primary respiratory from cardiac etiology.

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Despite a lack of formal guidelines and evidence, lactate measurement has become a component of many pediatric emergency sepsis quality programs, with one survey showing that up to 68% of responding pediatric emergency medicine providers routinely measured it.

The Surviving Sepsis Campaign, last updated in February 2020, could not make a recommendation on the use of lactate in pediatric patients with suspected shock. The authors did state that lactate levels are often measured during the evaluation of septic shock if the lab can be obtained rapidly. However, lactate levels alone would not be an appropriate screening test.

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Young infants (0-90 days) have immature immune systems and are at higher risk for serious bacterial infections, particularly urinary tract infections, bacterial meningitis, and bacteremia. Infants less than 90 days old have an incidence of bacterial infections between 8 to 12.5%, while infants less than or equal to 28 days old have almost a 20% incidence.

Risk-stratification of this group has been a huge focus of research over the past couple of decades to help identify which patients require a full sepsis work-up, particularly in well-appearing infants if a source of fever is identified early. Recent studies have explored the utility of biomarkers in risk stratification in this population. A better ability to discriminate would hopefully decrease unnecessary lumbar punctures, antibiotic use, and hospital admission. Multiple studies have shown procalcitonin is able to outperform CRP for prediction of serious bacterial infections. Kuppermann et al developed a tool to identify low risk febrile infants < 60 days using procalcitonin and ANC. Their prediction rule gave a 97.7% sensitivity, 60% specificity, and 99.6% NPV for serious bacterial infection.  There have been several other studies that have looked harder to detect infections such as osteomyelitis or septic arthritis across all pediatric patients and the data has not been as promising.

Bottom line: Procalcitonin shows promise as part of a risk stratification tool in infants younger than 60 days.  Other studies have failed to show its relevance as a screening tool for osteomyelitis, septic arthritis, renal abscess or community acquired pneumonia.

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Several studies have described factors associated with peri-intubation cardiac arrest in the adult population. Factors such as pre-intubation hypotension, elevated BMI, and elevated shock index (HR/SBP) have been associated with cardiac arrest following intubation in adult ED patients. Given the differences in anatomy and physiology in children, one may expect risk factors for peri-intubation cardiac arrest to differ in children.

A number of studies have examined factors associated with peri-intubation cardiac arrest in the pediatric population, but these have remained limited to the inpatient setting. These studies have found that, in hospitalized and PICU patients, the factors of hemodynamic instability, hypoxemia, history of difficult airway, pre-existing cardiac disease, and higher number of intubation attempts are associated with peri-intubation cardiac arrest. A paucity of literature exists on this airway complication in pediatric ED patients.

Pokrajac et al. provide the first study on risk factors for peri-intubation cardiac arrest in pediatric ED patients. These authors conducted a retrospective nested case-control study of pediatric patients (ages <18 years) who presented to a tertiary children’s hospital in San Diego from 2009-2017. Cases included patients who had a cardiac arrest within 20 minutes after the start of endotracheal intubation. Authors selected a number of predictors to examine, including age-adjusted hemodynamic variables, capillary refill, pulse oximetry, patient characteristics, intubation-related factors, and pre-intubation interventions.

The authors found the following:

-       Demographic characteristics:

o   Patients with peri-intubation cardiac arrest were significantly younger (<1 year of age), shorter, and more likely to have history of preexisting pulmonary disease.

-       Incident characteristics:

o   Patients with peri-intubation cardiac arrest were more likely to have:

       -Low or unobtainable SBP or DBP

       -Delayed capillary refill time

       -Low (<92%) or unobtainable pre-intubation SpO2

        -More than 1 intubation attempt than controls

        -No paralytic or sedative agent prior to intubation

o   Patients with peri-intubation cardiac arrest were NOT more likely to have increases in age-adjusted HR or pediatric shock index in comparison to controls.

o   The strongest clinical predictor for peri-intubation cardiac arrest was pre-intubation hypoxia or unobtainable SpO2. This fact is supported by children’s increased metabolic rate and thus increased oxygen consumption. This physiologic finding explains the shorter amount of time it takes children to develop acute hypoxia, particularly in the peri-intubation setting.

Bottom line: If planning to intubate a pediatric patient in the ED, keep in mind that pre-intubation systolic or diastolic hypotension, delayed capillary refill time, multiple intubation attempts, and hypoxia in particular may increase the risk for peri-intubation cardiac arrest. Consider providing apneic oxygenation to minimize hypoxemia prior to intubation.

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To determine if the child is prepubescent, look for the lack of pubic hair, clitoral size, configuration of the hymen, breast development, and axillary hair growth. A Tanner stage of 1 would be consistent with prepuberty.

The proper positioning for the physical exam will allow the child to be comfortable and the examiner to obtain an adequate view including up to one-third of the vagina.

If the child is small enough, they can lay in the parent’s lap. For a larger child, you can have the parent sit in the bed with the patient or stand near the child’s head. Engage child life if available.

The frog leg position with gentle downward and outward traction of the labia at the 5- and 7-o’clock positions provides the optimal view.

The knee to chest position is helpful when further evaluation is needed.

A rectovaginal exam is useful for evaluation of masses or foreign body only and is not routinely needed. Place the examiner’s little finger in the rectum and the other hand on the abdomen and palpate.

The use of a vaginal speculum is rarely needed in prepubertal children; if it is needed, perform the exam under anesthesia.

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The current COVID-19 pandemic and known aerosolized transmission has triggered many ED process changes, including the discouragement of utilizing nebulizers to administer inhaled bronchodilators such as albuterol for concern of spread. Historically, both patients and providers preferred the use of nebulizers as they are easier to use and the belief was that they were more effective than meterd dose inhalers. However, evidence based data has consistently shown that for both adult and pediatric patients that when MDI's are used WITH a spacer:

• There is NO significant difference in efficacy outcome.
• Nebs are associated with greater increase in tachycardia and tremors.
• Nebs are more costly overall.
• MDI's were associated with shorter ED stays and fewer hospital admissions for pediatric patients.

Albuterol:  2.5 mg nebulizer solution = 3-5 MDI puffs

Albuterol: 5 mg nebulizer solution = 5-10 MDI puffs

Ipratropium: 0.25 mg nebulizer solution = 2 MDI puffs

Ipratropium: 0.5 mg nebulizer solution = 4 MDI puffs

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A labial adhesion is defined as a thin avascular clear plane, a raphe, between the labia minora. These adhesions which can be caused by minor trauma or infection in the absence of estrogen  can cause varying degrees of obstruction.  

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Acute appendicitis is the most common etiology requiring urgent abdominal surgery in children in the United States. Peak incidence occurs in the second decade of life, with male patients being more commonly affected than female patients. Classic manifestations of appendicitis occur in school-aged children and adolescents, but are often absent in younger children. Infants and young children <5 years are more likely to present with nonspecific or atypical findings, resulting in delays in diagnosis and higher rates of perforation.

Diagnosis is aided by clinical factors, lab findings, and ultrasound (+/- CT or MRI if ultrasound is equivocal).

Historically, the standard of care for acute appendicitis has been urgent operative management. However, in the past several years, there has been increasing literature supporting nonoperative management (antibiotics only) in adult patients with acute uncomplicated appendicitis. Additionally, there is a growing body of evidence demonstrating the safety and efficacy of nonoperative management for uncomplicated appendicitis in children.

Hartford and Woodward provide a review of the current literature on the nonoperative management of uncomplicated appendicitis in children. They conclude:

-       The majority of recent prospective studies demonstrate early treatment success (0-30 days) of approximately 90% in pediatric patients undergoing nonoperative management.

-       Factors associated with failure of nonoperative management in pediatric appendicitis: longer duration of symptoms (>48 hours), younger age (<5 years), and presence of appendicolith.

-       Nonoperative management has been associated with

o   Lower healthcare costs at 1 year

o   Fewer disability days at 1 year

o   No significantly different rate of complicated appendicitis

-       Most trials to date involve a 24-48 hour initial course of broad spectrum IV antibiotics followed by oral antibiotics for a total of >/= 7 days as nonoperative management. Currently, there is no consensus on antibiotic regimen.

Bottom Line: Given the current evidence, nonoperative management may be a viable treatment option for low risk pediatric patients with uncomplicated appendicitis. The literature is not conclusive, thus we as medical providers in conjunction with our surgical colleagues, should consider numerous factors when discussing treatment options for acute appendicitis with patients and their families.

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- 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.

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