UMEM Educational Pearls - Pediatrics

Children less than 8 years, and especially infants, are more susceptible to upper cervical spine injury.  Moreover, validated decision rules for suspected cervical spine injury imaging have not been proven to be as sensitive or specific for children less than 8 years of age.

The pediatric cervical spine has greater elasticity of the ligamentous structures, while the cartilaginous structures are less calcified. An infant's neck musculature is underdeveloped, with a disproportionally large head.  These factors increase the risk of cervical spine injury, and can make it difficult to properly place protective cervical collars in infants while assessing them for injury. 

In very young children, consider placing padding under the shoulders to prevent abnormal flexion that can occur with placement of a cervical collar, and consider having a lower threshold to image if mechanism history or exam is concerning.

Children are not little adults!  Clinicians must acknowledge the anatomic differences, varying age-related ability to cooperate with examination, pediatric specific injury mechanisms, and decreased reliability of validated decision rules for imaging in children, especially when younger than 8 years old.

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The peak age for croup is 6 months to 3 years.  The cornerstone of treatment is corticosteroids, traditionally dexamethasone.  With oral administration, the peak onset is 1-2 hours. Steroids shorten the duration of symptoms, reduce the need for nebulized epinephrine and decrease the need for intubation.

Racemic epinephrine has been used for moderate to severe croup and can show an improvement in patient symptoms for up to 120 minutes.  There is little evidence to suggest how long to observe the patient for recurrence of symptoms after racemic epinephrine was given.  Previous studies have suggested both 2 and 4 hour observation.

299 patients were included in this study.  136 patients were observed for 3.1 to 4 hours.  In the 3.1 to 4 hour group, 21 (7%) failed treatment, 19 of those patients required admission and 2 returned within 24 hours.  No patients who were discharged home after 4 hours returned to the emergency department within 24 hours.

Bottom Line: Consider a 4 hour period of observation after giving racemic epinephrine in order to decrease bounce backs.

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As we are approaching the winter in the northern hemisphere, the number of visits for ear pain or respiratory symptoms are expected to increase.  The occurrence of acute otitis media (AOM) will also increase, but are these two disease processes related?

Drs. Heikkinen and Chonmaitree published a systematic review of previously reported studies regarding the correlation of these two disease processes (1).  As far back as 1990, studies have shown that up to 94% of pediatric patients diagnosed with AOM have concomitant upper respiratory infection (URI) type symptoms at time of diagnosis (2).   The viral infections most commonly associated with AOM are respiratory syncytial virus, influenza virus, and adenovirus (3).

The most commonly taught risk factors for developing AOM include young age, male gender, multiple siblings, day care attendance, and passive smoking.  These factors are also related to the development of upper respiratory symptoms, and the development of AOM should be thought of as a complication of the upper respiratory infection (4). 

Koivunen et al noted the highest incidence of AOM at day 3 after the onset of an URI, and the median time to diagnosis was day 4 (5). If you see a patient in day 2-4 of an URI, who has started to develop an ear effusion, but not clinical AOM, you may want to consider a “Wait-to-see” treatment option if the patient meets treatment criteria (https://em.umaryland.edu/educational_pearls/2049/).

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In the US, there are an estimated 22.2 million users of cannabis based on the 2015 National Survey on Drug Use and Health.  The incidence of unintentional cannabis ingestion has increased in states that have legalized medical and recreational marijuana.  The cited article reviewed of 44 articles involving unintentional cannabis ingestion in children younger than 12 years.

The majority of intoxications were through cannabis resins followed by cookies and joints.

Lethargy was the most common presenting sign followed by ataxia.  Tachycardia, mydriasis and hypotonia were also noted.  Rarer but more serious presentations included respiratory depression and seizures.

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Some pediatric practitioners have adopted the oxygenation index (OI) ([FiO2 × mean airway pressure (Paw) × 100]/ PaO2) or oxygen saturation index (OSI) ([FiO2 × Paw × 100]/ SpO2) to assess hypoxemia in children instead of P/F ratios because of the less standardized approach to positive pressure ventilation in children relative to adults. 

OI can be used in pediatric patients to define severity of Acute Respiratory Distress Syndrome (ARDS) in patients receiving invasive mechanical ventilation and assess for potential ECMO treatment. 

In contrast, the P/F ratio should be used to diagnose Pediatric ARDS for patients receiving noninvasive continuous positive airway pressure [CPAP] or bilevel positive airway pressure [BiPAP]) with a minimum CPAP of 5 cm H2O.

Oxygen Index (OI) = FiO₂ x MAP x 100
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                                         PaO₂

• Mild ARDS: 4 ≤ OI ≤ 8
• Moderate ARDS: 8 ≤ OI < 16
• Severe ARDS: OI ≥ 16

• OI < 25: good outcome
• OI 25-40: >40% mortality
• OI > 40: Consider ECMO

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Within the first hour after administration, ondosterone, metoclopramide and bromopride were equally efficacious.  At the 6 hour and 24 hour period after receiving the initial dose of medication, ondansetron was statistically superior to bromopride (not available in the US) and metoclopramide.  There were no reported side effects in the ondansetron group (including diarrhea or sedation).

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Pediatric patients are at a higher risk of blunt renal injury due to multiple anatomic features, include relatively less protective perinephric fat and surrounding musculature, and larger size of the kidneys in relation to the abdomen compared to their adult counterparts (1). For this reason, it is important to keep a high clinical suspicion for renal injury in the pediatric patient with blunt abdominal trauma, particularly in those with lower rib fractures, direct injury, flank ecchymosis and/or tenderness, rapid deceleration injury, or other significant traumatic mechanism (2). Despite the risk of radiation exposure, the preferred imaging modality for the diagnosis of renal injury in pediatric patients is computed tomography (similar to adults). Studies evaluating the utility of renal ultrasound have demonstrated poor sensitivity with a decreased likelihood of diagnosing low-grade injuries. While ultrasound may be a useful screening tool to evaluate for severe injury, it should not be used to rule out traumatic injury (1). Take home point: Keep a high suspicion for renal injury in pediatric patients with blunt abdominal trauma and confirm the diagnosis with computed tomography of the abdomen and pelvis with contrast.

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Bronchiolitis season will soon be upon us. Here are some risk factors for children under 2 y/o with bronchiolitis, who may be more likely to suffer respiratory decompensation:

1. Age under 9 months

2. Black race

3. Hypoxia documented in the ED

4. Persisent accessory muscle use. 

Bottom Line: Consider providing respiratory support sooner than later in bronchiolitic infants with risk factors for decompensation. For HFNC, start at 1.5 - 2.0 L/kg/min, and titrate to work of breathing and  0₂ saturations. 

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Pathophysiology: Bronchiolitis is a disease process that leads to inflammation of lower airways, causing bronchiolar edema, epithelial hyperplasia, mucus plugging, and air trapping or atelectasis. Common viral causes include RSV, Human Metapneumovirus, Rhinovirus, Influenza, and Parainfluenza. 

Clinical Course: For most strains, the disease course is often 5-7 days with the worst days being 3-5. The disease process can last longer, especially in neonates. The predominant presenting symptoms are often rhinorrhea, low grade fevers, and cough, but apnea can be the primary symptom in younger infants. As a result of increased work of breathing, PO feeding tolerance decreases and leads to dehydration. 

Treatment: Primarily supportive care with suctioning, hydration, supplemental oxygen via standard NC, HFNC, and in severe cases BiPAP, CPAP or intubation. Trial of bronchodilator is often used, but there is no role for repeated bronchodilator use if no benefit is seen in pre and posttreatment respiratory effort. Hypertonic saline is not recommended for routine use in the ED. Corticosteroids have no role for routine use in viral bronchiolitis, either.

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Since the first description of acute respiratory distress syndrome (ARDS), various consensus conferences (including American-European Consensus Conference (AECC) and the Berlin Conference) have produced definitions focused on adult lung injury but have limitations when applied to children. 

This prompted the organization of the Pediatric Acute Lung Injury Consensus Conference (PALICC), comprised of  27 experts, representing 21 academic institutions and eight countries.  The goals of the conference were 1) to define pediatric ARDS (PARDS); 2) to offer recommendations regarding therapeutic support; and 3) to identify priorities for future research in PARDS.

Although there were several recommendations from the group, some notable ones, in contrast to the Berlin definition focused on adults, include: 1) use the Oxygenation Index (or, if an arterial blood gas is not available, the Oxygenation Severity Index) rather than the P/F ratio; 2) elimination of the requirement for “bilateral” pulmonary infiltrates (may be unilateral or bilateral) 3) elimination of  specific age criteria for PARDS.

Tune in next month for pearls on management for children with PARDS...

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Background:

There is an increased incidence of venous thromboembolic events (VTE) in pediatrics due to improved diagnosis and survival of children with VTE.

The mortality rate is estimated at 2%.

The most common etiologies vary by age - Central venous catheters in neonates and infants, and inherited thrombophilia in children and adolescents.

Learning Points:

1. With neonates and infants, carefully assess medical history from neonatal period. Umbilical lines? PICC? Broviac? History of these is likely to be the cause.

2. In children and adolescents, unprovoked VTE is most likely due to inherited thrombophilia, and can be DVT, PE, Portal venous thrombus, etc.

   1. Antithrombin deficiency: The first discovered inherited thrombophilia. The result is a lack of inhibition of coagulation factors – IIa, IXa, Xa, XIIa.

   2. Protein C or/and S deficiency: The result is lack of inhibition of activated Factor V.

   3. Factor V Leiden: Most common inherited thrombophilic defect. Resultant activated Factor V is resistant to normal Protein C and S activity.

   4. Prothrombin Mutation: Second most common inherited thrombophilia. The result is increased levels of prothrombin, which increases the half-life of factor Va.

3. Initial treatment of clinically significant VTE can start with enoxaparin (1-1.5 mg/kg q12-24h, while checking Anti-Xa levels 4 hours after administration for therapeutic dosing.)

 

Pearl: Testing for thrombophilia is not always appropriate when diagnosing pediatric patients with their first VTE, but in children and adolescents with first diagnosed, unprovoked VTE, it is worthwhile to send off the initial hypercoaguability work up as this can affect the duration of treatment and need for testing or evaluation. Enoxaparin is a recommended medication to start therapeutic treatment of VTE, even in pediatric patients.

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Bottom line:

There are no absolute contraindications (including age) for epinephrine in patients with anaphylaxis.  Give the initial dose IM into the anterolateral thigh.

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Febrile seizures occur in children 6 months through 5 year olds.  A complex febrile seizure occurs when the seizure is focal, prolonged (> 15 min), or occurs more than once in 24 hours.

The prevalence of bacterial meningitis in children with fever and seizure after the H flu and Strep pneumomoniae vaccine was introduced is 0.6% to 0.8%.  The prevalence of bacterial meningitis is 5x higher after a complex than simple seizure.

From the study referenced, those children with complex febrile seizures who had meningitis all had clinical exam findings suggestive of meningitis.  More studies are needed to provide definitive guidelines about when lumbar punctures are needed in these patients.

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The answer appears to be ... it depends.

Early Oseltamivir Treatment in Influenza in Children1-3 Years of Age: A Randomized Controlled Trial

A study in 2010 out of Finland by Heinonen, et al showed that if given in the first 12 hours of symptom onset to otherwise healthy pediatric patients between the age of 1-3 years:

-  decrease incidence of acute otitis media by 85%

-  no difference if given within 24 hours

Among children with influenza A, oseltamivir started within 24 hours of symptom onset

-  shortened medium time to resolution of illness by 3.5 days (3.0 versus 6.5) in all children

- shortened median time to resolution of illness by 4.0 days in UNvaccinated children

- Reduced parental work absenteeism by 3 days

*  no differences were seen in children with influenza B *

Limitations***

- Single Center study in Finland

- The authors received support from the drug manufacturer

- The sample size of children with confirmed influenza cases with small (influenza A: 79, influenza B: 19)

Takeaway:

If you have a patient between the age of 1-3 years with very early symptoms concerning for flu, a positive rapid influenza A test could allow you to cut her symptoms by 3 days, prevent complications, and allow parents to go back to work sooner.

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Ventricular shunt (VP) malfunction can be severe and life-threatening and evaluation has typically included a dry CT brain and a shunt series which includes multiple x-rays of the skull, neck, chest and abdomen.  The goal of this study was to decrease the amount of radiation used in the evaluation of these patients since these patients will likely present many times over their lifetime.  Several institutions have more towards a rapid cranial MRI, however, this modality may not be readily available.

This multidisciplinary team decreased the CT scan radiation dose from 250mA (the reference mA in the pediatric protocol at this institution) to 150 mA which allows for a balance between reducing radiation exposure and adequate visualization of the ventricular system.  They also added single view chest and abdominal x-rays.

The authors found that after implementing this new protocol, there was a reduction in CT radiation doses and number of x-rays ordered with no change in the return rate.

 

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Every year in the U.S., preventable poisonings in children result in more than 60,000 ED visits and around 1 million calls to poison centers.  Calls relating specifically to pet medication exposure and children have been on the rise.

A recent study in Pediatrics was the first was kind to characterize the epidemiology of such exposures.

This study is a call to arms for an increased effort on the part of public health officials, pharmacists, veterinarians, and physicians to improve patient education to prevent these exposures from occurring. 

Summary of major findings:

• Children less than or equal to age 5 are at greatest risk
• Ingestion accounted for the exposure route in 93% of cases. 
• Exploratory behavior(61.%) was the most common mechanism of exposure

Most commonly Implicated exposures:

• Pet medications with no human equivalent  (17.3%)
• Antimicrobials (14.8%
• Antiparasitic 14.6%)
• Analgesics (11.1%)

Key contributors to exposure risk:

• Lack of recognition by caregivers of potential hazards of pet medications
• Inappropriate or lack of home storage practices
• Inconsistent compliance by veterinary providers in terms of proper product labeling and child-resistant packaging

Take home point: Make sure your pet's medications are appropriately stored for safety!

 

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Chest injuries represent the second most common cause of pediatric trauma related death.  ATLS guidelines recommend CXR in all blunt trauma patients.  Previous studies have suggested a low risk of occult intrathoracic trauma; however, these studies included many children who were sent home.

Predictors of thoracic injury include: abdominal signs or symptoms (OR 7.7), thoracic signs of symptoms (OR 6), abnormal chest auscultation (OR 3.5), oxygen saturation < 95% (OR 3.1), BP < 5% for age (OR 3.7), and femur fracture (OR 2.5).

4.3 % of those found to have thoracic injuries did not have any of the above predictors, but their injuries were diagnosed on CXR.  These children did not require trauma related interventions.

Bottom line: There were still a number of children without these predictors that had thoracic injuries, so the authors suggest that chest xray should remain a part of pediatric trauma resuscitation.

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IM ziprasidone (Geodon) has a relatively quick onset of action with a half-life of 2-5 hours.  Although commonly used in adults, there has not been a study looking at an effective dose in pediatrics. Based on the study referenced, the suggested pediatric dose of ziprasidone is 0.2 mg/kg (max 20mg).

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Bottom line: Do not prescribe codeine or tramadol for cough or pain in children and breastfeeding moms.

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Predictive factors of asthma development in patients diagnosed with bronchiolitis include:

- Male sex (OR 1.3)

- Family history of asthma (OR 1.6)

- Age greater than 5 months at the time of bronchiolitis diagnosis (OR 1.4)

- More than 2 episodes of bronchiolitis (OR 2.4)

- Allergies (OR 1.6)

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