The PRoMPT BOLUS trial (Pragmatic Pediatric Trial of Balanced versus Normal Saline Fluid in Sepsis) is the largest randomized controlled trial to date comparing balanced crystalloids to 0.9% normal saline in children with septic shock. The primary outcome showed no significant difference in major adverse kidney events at 30 days between the two groups.  The secondary outcome showed  no significant difference in 30 or 90 day mortality.

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Low Magnesium in Children has a generally similar approach to adults, however the etiology may be different. 

Children can present with low magnesium levels due to many causes including but not limited to renal wasting (which may be drug related), malnutrition, malabsorption, refeeding syndrome, short gut syndrome, or genetic mutations

Hypomagnesemia is often coupled with hypocalcemia or hypokalemia which can be refractory until the magnesium is replaced. 

Symptoms may be vague particularly in younger patients, with neuromuscular irritability, though in extreme cases (typically <1.0mg/100ml) seizure activity may occur with severely low levels, and long QTc may cause dysrhythmia 

Oral replacement can be used for asymptomatic patients with levels greater than 1.0 mg/100mL

PO replacement:

Goal of 10-20mg/kg/dose (Max 2 g) elemental Magnesium

Magnesium oxide is the most common replacement but does come in pill form and is given up to four times daily 

IV replacement with Magnesium Sulfate (given over 2 -4 hours*):

Neonate: 25–50 mg/kg/dose every 8–12 hours 

Child: 25–50 mg/kg/dose every 4–6 hours (maximum 2 g/dose)

*In patients with life threatening hypomagnesemia such as those with seizures, a 50mg/kg dose given over 1-5 minutes is warranted.

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This was a metanalysis which included 5 studies of 3933 pediatric patients requiring seizure management without IV access, mostly in the prehospital setting.

Bottom line: IM midazolam appears superior to IN midazolam as a first-line non-IV benzodiazepine for pediatric seizures in the prehospital setting, though IN remains a clinically effective alternative — particularly when caregiver acceptability and ease of administration are prioritized.

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Bottom Line: In pediatric patients, identifying the underlying etiology of hypercalcemia is essential to guide appropriate long-term management.

Etiology: The causes of hypercalcemia in children are diverse and are broadly classified into parathyroid hormone (PTH)-mediated and non–PTH-mediated categories. Non–PTH-mediated causes include endocrine disorders, inborn errors of metabolism, medication-induced hypercalcemia, granulomatous diseases, immobilization, and malignancy.

Clinical Presentation: Symptoms vary depending on the severity of hypercalcemia. Mild hypercalcemia may be asymptomatic or present with findings such as shortened QT interval, polyuria, and constipation. Severe hypercalcemia can lead to significant complications, including seizures, altered mental status (e.g., hallucinations), dehydration, cardiac dysrhythmias, abdominal pain, and pancreatitis.

Management: In the emergency setting, the primary treatment is intravenous hydration, typically with 0.9% saline, to cause calcium dilution and increased urinary excretion of calcium. Loop diuretics should be used with caution in pediatric patients due to the risk of exacerbating dehydration. Additional pharmacologic therapies, including calcitonin, bisphosphonates, and glucocorticoids, may be indicated depending on the etiology and severity, and should be administered in consultation with a nephrologist and/or endocrinologist. In patients with contraindications to aggressive fluid management (e.g., renal or cardiac dysfunction), or in cases of severe, life-threatening hypercalcemia, dialysis may be required.

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US and International guidelines differ on the initial defibrillation dose in pediatric patients.  International, European, Australian and New Zealand guidelines had recommend an initial dose of 4 J/kg for the initial and all subsequent doses while the American Heart Association recommends an initial dose of 2-4J/kg (with 2 J/kg in the teaching algorithms) with subsequent shocks being at least at 4J/kg and no greater than 10 J/kg.   More recently, ILCOR suggested an initial dose of 2-4 J/kg.

This was a systemic review of 7 observational studies, mostly involving in hospital pediatric cardiac arrests.  Outcomes of termination of VF/pVT, ROSC and survival to hospital discharged were examined in relation to the initial J/kg dose that was used compared to initial doses of 2 J/kg.  Outcomes were neither better or worse with doses < 1.5 J/kg or > 2.5 J/kg.  Additional research is needed as this certainty of this evidence was considered “very low.”

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BOTTOM LINE: It is critical to recognize and treat symptomatic hypocalcemia in pediatric patients. 

Pediatric hypocalcemia has a variety of causes that should be considered. In the neonate congenital causes should be on the differential.

• In neonates, common causes include prematurity, infections, and maternal diabetes
• In infants and children vitamin D deficiency is most common, with rare causes including genetic etiologies, hyperparathyroidism and pseudohypoparathyroidism

Parathyroid hormone levels should be checked on all patients along with magnesium levels and ionized calcium.  

An ECG should also be obtained for prolonged QTc. 

Management is guided by acute symptoms (tetany, seizures, cramping, etc.) or other signs of critical illness (sepsis, trauma, etc.) in conjunction with low ionized calcium levels. 

For symptomatic patients give 20 mg/kg of elemental calcium IV over a 10–20 min period

• 2 ml/kg of 10% calcium gluconate OR
• 0.7 ml/kg of 10% calcium chloride

For asymptomatic patient oral calcium supplements are typically given. 

Failure to recognize concomitant hypomagnesemia may result in hypocalcemia that is resistant to treatment. 

Disposition: Those children receiving IV calcium should be admitted with every 4-to-6-hour calcium levels and typically require ICU level admission. Children being monitored with oral supplementation can often be observed on a pediatric floor presuming there are no ECG abnormalities.

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Pancreatic injury in pediatric blunt abdominal trauma is rare. 

This study was a secondary analysis of the data collected by the Pediatric Emergency Care Applied Research Network (PECARN) in the Intra-abdominal Injury Study Group. Of the children who had blunt abdominal trauma, 6% had intraabdominal injuries and 1% had pancreatitis.  A patient was considered as having traumatic pancreatitis if they had 2 of the following: 1) upper abdominal tenderness, 2) serum lipase of amylase > 3 x the upper limit of normal or 3) imaging study positive for pancreatitis.

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BOTTOM LINE:

• Use of VL and cuffed ETTs are appropriate for all ages
• Hyperangulated blades, LMAs and scopes should be available for rescue
• Apneic oxygenation is useful in neonates. 

A 2024 meta analysis from the European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia worked to develop joint guidelines for best practices for intubation of neonates and infants. 

While this guide is focused primarily on anesthesia and operative care, several of the recommendations have practical application to the EM and ICU as well. 

They focused on general guidance including ensuring appropriate anesthesia and analgesia during intubation. But also discussed that videolaryngoscopy with standard blades is the most appropriate first line for all intubations in this age group. It allows for appropriate visualization either directly or by video and for learners allows instructors to observe as well. 

When there are difficulties with intubation, hyperangulated blades have very high success rates, but LMA and video assisted intubation with a fiberoptic scope are also appropriate next steps for securing an airway. 

When intubating, uncuffed endotracheal tubes are acceptable in all infants though cuffed are also safe in infants over 3kg in weight.

Finally, while apneic oxygenation is regularly used in adults, it is also recommended in the neonatal period to avoid hypoxia.

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This was review of 24 studies across 21 years that aimed to look at the complications associated with pediatric intubation in the hospital.  The article also includes a list of all the articles with brief conclusions from each study for those interested. 

Among a combined 7135 patients, there was an 84.7% overall success rate with a 30.1% rate of complication.  There was a 69.8% first pass success rate.  Desaturations < 90% was the most common complication followed by mainstem intubation.  Studies also noted cardiac arrhythmia (55/3858 patients), hypotension (121/4536 patients) and cardiac arrest in 105/4836 patients).  Other adverse events included esophageal intubation, surgical airway management and airway trauma.

Indications for intubation from most to least common are: neurologic, respiratory, trauma, cardiac arrest, sepsis, shock, cardiac failure and intoxication.

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BOTTOM LINE: You are probably doing fine in your ED already, just delay cord clamping 60 seconds when possible.

The latest guidelines for neonatal resuscitation recommend a 60 second delay minimum in clamping the cord for neonates of all gestational ages who are stable. 
In those OVER 28 weeks for whom clamping cannot be delayed (due to maternal or neonatal factors), cord milking can be performed. 
DO NOT milk the cord in neonates under 28 weeks as this can increase the risk of intraventricular hemorrhage. 

Cord milking is performed by gently massaging the cord blood starting about 20cm away from the infant and moving toward the infant's body 3-4 times before clamping. This essentially allows for a transfusion before clamping occurs, increasing LV preload and allowing for improved oxygenation. 

Fortunately, in most EDs, the time to obtain the equipment for cord clamping likely takes more than 1 minute, so chances are in your practice you don't have to worry too much about this. But if you happen to have everything prepared, wait 60 seconds before clamping.

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Bottom line: Socioeconomic differences in outcomes of cardiac arrest are present in the pediatric population as well and CPR education and resources should be present in ALL communities.

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BOTTOM LINE: It is generally safe and effective to discharge vomiting pediatric patients with a prescription for ondansetron, and a recent study supported this common practice. 

While it has become common practice to prescribe ondansetron to children with emesis, a 2025 randomized controlled study showed that a prescription for ondansetron decreased the risk of moderate to severe gastroenteritis in the following 7 days. 

This study compared children 6 months to 18 years of age who received either ondansetron or placebo. They found a rates of moderate to severe gastroenteritis to be 5.1% in the ondansetron group versus 12.5% in the placebo group. 

*Note that ondansetron is NOT approved for children under 6 months of age or in those with prolonged QT.

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This was a retrospective study at a tertiary pediatric emergency department over a 10 year period.  Authors sought to determine the number of patients who developed radiographic pneumonia after an initial normal CXR. 

9957 patients with suspected pneumonia were included.  240 had an additional CXR within 14 days and 27 (11% of those with a 2nd CXR) had developed PNA on the CXR.  Overall, the rate was 1/370 children went on to have radiographic PNA in the next 14 days after an initial CXR.  Tachypnea, hypoxia and dehydration at the initial visit were shown to be associated with later development of PNA on CXR.

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In 2025, the AHA and AAP teamed up for the latest Cardiac arrest guides- worth a read overall, Peds had a couple tweaks which should be recognized.  

2-finger CPR is OUT. It has been shown to be ineffective, so the Two Thumb–Encircling Hands Technique should be used on ALL infants. 

Grab your AED early. While a staple of adult BLS, this is now being emphasized in pediatrics as well.  

For foreign body aspiration, remember to start with 5 back blows, but if the child is <1year old follow with chest thrusts, those who are older may receive abdominal thrusts. Repeat as needed. This has been in the literature for a while but was re-enforced due to potential injury to infants who receive abdominal thrusts.

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Pediatric CPR without an advanced airway in place requires 15 compressions to 2 ventilations per AHA and ILCOR guidelines.  This can lead to a 2-4 second pause in compressions due to the time the ventilations take.  The Maryland hiccup method is a novel description of two brief pauses for ventilations during the upstroke of compressions 14 and 15.  This method was shown to improve the compression fraction and compressions per minute with no significant differences between standard CPR and the Maryland hiccup method in ventilation volume or compression depth determined on simulation mannequins.  38 Maryland EMS clinicians participated in this study.

A video demonstration of the Maryland Hiccup method is linked in the article and also available at: https://www.youtube.com/watch?v=RvFxhj7hzsQ .

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Malrotation is estimated to occur in 1 in every 500 children, and while many are asymptomatic, volvulus can occur resulting in a high rate of morbidity and mortality from ischemic bowel. Most of these patients will present within the first month of life. 

Bilious emesis in an infant should immediately prompt consideration of this life-threatening condition, but what is the testing modality of choice? 

While Fluoroscopic Upper GI Series (UGIS) has historically been looked to as the gold standard there are many issues with this method. It requires contrast, radiation exposure and an in-house radiologist to perform the imaging, oftentimes necessitating a transfer. Due to this, many algorithms have moved to Ultrasound (US) as the first test for these patients. 

UGIS has a sensitivity for malrotation of 93-100%, but only as high as 89% for volvulus while US has a sensitivity and specificity of 94% and 100% respectively for midgut volvulus. 

US findings suggestive of volvulus include the classic “whirlpool sign” with twisting of the superior mesenteric vein around the superior mesenteric artery seen on Doppler, dilated proximal duodenum, or free fluid in the abdomen. 

So next time there is an infant presenting with bilious emesis, consider ultrasound as your first step to save a baby's bowel!

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A large-scale retrospective study of 3.7 million children found an association between radiation exposure from medical imaging and a small but significantly increased risk of developing hematologic cancers (primarily leukemia).

• Finding: Cancer risk increased with cumulative radiation dose

• Dose-Response: For the highest exposure group (50 to <100 mGy), the Relative Risk (RR) for hematologic cancer was 3.59 compared to no exposure.

  • Note: 13.7 mGy is roughly one head CT
     

• Attributable Risk: An estimated 10.1% of hematologic cancers in the cohort may have been attributable to medical imaging radiation, with CT scans being a major contributor.

• Vulnerability: Children are more susceptible to radiation-induced cancer due to their heightened radiosensitivity and longer life expectancy for the cancer to manifest.

Take Away:  Providers should critically assess the necessity of high-dose imaging like CT scans and use the lowest effective dose or possible alternative imaging (e.g. US, MRI, etc.) to prevent unnecessary cumulative exposure.

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Children account for up to 20% of emergency department visits.  In the US, up to 90% of children’s visits to emergency departments are to general EDs.  The weighted pediatric readiness score (WPRS) was developed to assess the level of readiness of emergency departments to care for pediatric patients. The last assessment was in 2013 showed a mean score of 68.9.  High readiness scores have been associated with decreased mortality.  The same holds true for children with injuries presenting to trauma centers.  The higher the WPRS score, the lower the risk of in hospital death.  There was no difference if the patient presented in cardiac arrest.  A 10 point increase in WPRS is associated with a lower odds of potentially avoidable transfers in both trauma and medical patients.  More recent data has been collected, but has not yet been published.  More information on pediatric readiness (for hospitals and EMS) can be found at: https://emscimprovement.center/domains/pediatric-readiness/. 

Bottom line: Being Pediatric Ready improves the care of children.

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A recent randomized control trial published in JAMA Pediatrics in January 2025 showed improvement in first attempt for IV access when using ultrasound in the pediatrics ED. 

This trial was performed at a quaternary pediatric hospital in Australia with a total of 164 patients (ages 18 and younger). Median age of the patients was 24 months. There was computerized system that randomized patients into either getting an IV by standard procedure vs ultrasound-guided. Those placing the ultrasound-guided IV had extensive training. Overall, the first time success rate was higher in the ultrasound group with about 85.7% compared to 32.5% in the standard group.

Main point: US IV decreases the number of sticks a child has to experience for IV access with a higher first stick success rate. Consider US IV training in your Pediatric Emergency Department in the future. Also use ultrasound guidance with first attempt IV access for your chronically ill children or for very anxious parents.

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Premature infants in the NICU are often given caffeine to help to prevent apneic episodes and this has been proven safe.  This study aims to determine if caffeine will help infants < 8 weeks with bronchiolitis, even if there is no concern for apnea. The current recommended treatment for bronchiolitis is supportive care.

2 French Hospitals with the same protocols and resources for bronchiolitis participated.  All infants admitted to each hospital with a diagnosis of bronchiolitis were included.  Infants who presented to Hospital A received caffeine and infants who presented to hospital B did not.  The remainder of their care was similar.  The caffeine was given as a bolus dose followed by a daily maintenance dose until there was clinical improvement.  The dose was the standard dose used in premature infants with apnea as recommended by the French National Authority for Health.  There were 26 patients at the study hospital that did not receive caffeine for an unknown reason.  65 patients received caffeine.

The study had several areas showing statistical significance:

In the subgroup of RSV + patients, those who did NOT receive caffeine had a higher incidence of requiring ventilatory support.  

The use of high flow nasal cannula was HIGHER in the group with NO caffeine.

The use of CPAP was HIGHER in the caffeine group BUT the duration of CPAP use was shorter compared to the NO caffeine group.

The need for nutritional support was higher in the NO caffeine group.

There were a few cases of temporary tachycardia and irritability in the caffeine group which resolved several hours after the medication was given.

A larger study is needed, but in this small group, there may be an indication for caffeine outside of the NICU for infants < 8 weeks.

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