An overweight 5 year old male presents with acute onset abdominal pain that localizes to the right lower quadrant. What are some causes of a limited or nondiagnostic ultrasound study in children?

Acute appendicitis is a time sensitive diagnosis. Ultrasound is frequently used as the initial diagnostic imaging in children. There are several reasons why the appendix may not be visualized, including retro-cecal location, normal appendix, perforation, and inflammation around the distal tip. An additional clinical predictor associated with poor or inconclusive ultrasound results in appendicitis is increased BMI (body mass index).

A study examining 263 pediatric patients found when BMI > 85th percentile and clinical probability of appendicitis was <50%, 58% of ultrasounds were nondiagnostic. Children with a BMI <85th percentile and clinical probability of appendicitis was <50%, had nondiagonstic scans 42% of the time. These trends were also mimicked in the patients with a higher clinical probability of appendicitis. In the child with a nondiagnostic ultrasound, options include observation and repeat ultrasound scan or CT scan, both of which have associated risks.

2013 AAP AOM Guidelines UPDATE

• Severe unilateral or bilateral AOM (>6mo): give antibiotics.  Severe AOM is defined as fever >102.2 (39 C), moderate/severe otalgia, or symptoms >48h.
• Nonsevere unilateral AOM (6-23 months): Advise the parents to consider a period of close observation and follow up (24-72h).  If the childs clinical status deteriorates give antibiotics.
• Nonsevere bilateral AOM (6-23 months): give antibiotics.
• Nonsevere unilateral or bilateral AOM (>24 months): Advise the parents to consider a period of close observation and follow up (24-72h).  If the childs clinical status deteriorates, give antibiotics.

Children frequently present with "pink eye" to the ED.  When they do, parents often expect antibiotics.  How many of these kids actually need them?  Previous studies have shown approximately 54% of acute conjunctivitis was bacterial, but antibiotics were prescribed in 80-95% of cases.

A prospective study in a suburban children's hospital published in 2007, showed that 87% of the cases during the study period were bacterial.  The most common type of bacteria was nontypeable H. influenza followed by S. pneumoniae.

Topical antibiotic treatment has been shown to improve remission rates by 6-10 days.

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You have diagnosed an infant or child with pneumonia.  How do you decide if they need admission?

The Pediatric Infectious Disease Society and the British Thoracic Society each have guidelines from 2011 to help with this decision.

In children, it is important to consider the maximum doses of local anesthetics when performing a laceration repair or painful procedure like abscess drainage. If there are multiple lacerations, or large lacerations, it may be possible to exceed those doses if one is not careful.

Max doses of common anesthetics

• Lidocaine WITHOUT epinephrine – 4 mg/kg (0.4 mL/kg of 1% lidocaine)
• Lidocaine WITH epinephrine – 7 mg/kg (0.7 mL/kg of 1% lidocaine)  
• Bupivicaine WITHOUT epinephrine – 2 mg/kg (0.8 mL/kg of 0.25% bupivicaine)
• Bupivicaine WITH epinephrine – 3 mg/kg (1.2 mL/kg of 0.25% bupivicaine)

For example, in a 20 kg child (an average 5-6 year old), the maximum doses would be:

• Lidocaine 1% - 8 ml
• Lidocaine 1% with epi – 14 ml
• Lidocaine 2% - 4 ml
• Bupivicaine 0.25% - 16 ml
• Bupivicaine 0.25% with epi - 24 ml

Pearls:

• For added safety, some advocate not exceeding 80% of the max dose in children < 8 years of age
• Higher concentration of lidocaine beyond 1% does not improve the time of onset or duration of action and may increases the risk of toxicity
• The addition of epinephrine increases the maximum dose and duration of action, but may be more painful during infiltration
• If the repair requires large amount of local anesthetic, consider doing an regional block

• Tinea capitis (ringworm of the scalp) is caused by dermatophytic fungi
• Trichophyton tonsurans is the most common species in the US, and does NOT flouresce under Wood's lamp
• Griseofulvin (20-25mg/kg/ day orally) is the standard first-line therapy in children older than 2 years, and has a good safety profile
• Both tablet and suspension formulations are available, and it should be taken with food that are high in fat to increase drug concentrations
• NO laboratory assessment of hepatic enzymes is required during the 8-week therapy course in children who have no history or clinical examination findings concerning for liver disease.
• Topical antifungal agents are ineffective because they do not penetrate sufficiently into the hair shaft.

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--The diagnosis and treatment of pediatric urinary tract infections (UTIs) can be broken down into different age groups. The AAP has recently updated its recommendations for children age 2 - 24 months.

--In ill-appearing febrile infants age 2 – 24 months, who require early initiation of antibiotics, clinicians should obtain urinalysis and urine culture by catheterization or suprapubic aspiration prior to administration of the first dose of antibiotics.

--Key components of diagnosing a UTI include: urinalysis with the presence of pyuria (>10 WBCs per µL) and bacteriuria. The ultimate diagnosis relies on identification of >50,000 CFUs per mL of a single urinary pathogen in culture.

--Treatment of most UTIs in well appearing infants 2-24 months can be done with oral antibiotics for a course of 7-14 days. Common antibiotics used include: amoxicillin-clavulanate, trimethoprim-sulfamethoxazole, or cephalosporins (cefpodoxime, cefixime) based on local patterns of susceptibility.

--Febrile infants with UTIs should undergo renal and bladder ultrasound (RBUS) to evaluate the renal parenchyma and identify complications of UTI in children who are not responding to treatment within 48 hours.

--Voiding cystourethrography (VCUG) to diagnose vesicoureteral reflux (VUR) as a cause of UTI should not be obtained routinely, but only in children with abnormal RBUS or with recurrent febrile UTIs.

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Luu JL, Wendtland CL, Gross MF, et al. Three percent saline administration during pediatric critical care transport. Ped Emerg Care 2011;27(12):1113-1117

This winter season has brought a rise in influenza and RSV activity in Maryland and in many parts of the country. It is also important to remember other potentially lethal infections that are prevalent in the winter and early spring months, such as Neisseria meningitidis. In fact, a recent study2 showed a potential increase in meningococcal disease when influenza and RSV activity is high.

What:
Encapsulated, gram-negative diplococcus
Where:
Found in nasopharyngeal secretions, carrier rates 2-30% in normal populations
Who:
Age of incidence has 2 peaks: children < 2 years old, teens 15-19 years old
Young adults who live in shared housing, such as college dorms and military recruits

Clinical Presentation:
Early non-specific symptoms of URI, fever, malaise, myalgias
Meningitis: non-specific prodrome + headache, stiff neck (not found in younger children who often present atypically with irritability and/or vomiting)
Meningococcemia: above symptoms + hypotension + petechial rash (>60% of patients)

Treatment:
Early (!) antibiotics: 3rd generation cephalosporins (<3mo: cefotaxime; older infants, children, and teens: ceftriaxone); PCN G is antibiotic of choice for susceptible isolates
Early and aggressive management of shock

Prevention:
Tetravalent vaccine, MCV4 (Menactra, Menveo), available for serogroups A, C, Y and W-135 is given routinely at age 11-12 years old with an additional booster at 16-17 years old. MCV4 does not protect against serogroup B which accounts for 30% of infections.
 

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Question

Patient:  A 10 year old female is brought to the ED after swallowing 2 beads (see image).  Based on the findings, what are your concerns and what is the disposition?

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• CDC recommends pediatric influenza antiviral treatment for those at higher risk for influenza complications, and include the following:

1. less than 2 years of age;
2. chronic diseases including: pulmonary (ie asthma), cardiovascular (except hypertension alone), renal, hepatic, hematologic (ie sickle cell disease), metabolic (ie diabetes), neurologic/neurodevelopmental (ie cerebral palsy, epilepsy), and intellectual disability (ie mental retardation)
3. immunosuppression (ie HIV)
4. less than 19 years of age and on chronic aspirin treatment;
5. morbid obesity (BMI>40)

• adamantanes (amantadine and rimantadine) should not be used due to high levels of resistance to influenza A
• neuraminadase inhibitors (oseltamivir and zanamivir) should be started within 48 hours of illness onset to reduce the duration and severity of disease
• oseltamivir can be used in children as young as 2 weeks of age at a dose of 3mg/kg twice daily for 5 days.

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Rotavirus is the leading cause of gastroenteritis worldwide and a leading cause of infant death in the developing world.

95% of U.S. children have had a rotavirus infection by the age of 5 years.

Most cases occur in late winter and early spring.

Route of transmission is mostly fecal-oral but may be airborne in cooler months.

Most common presenting signs and symptoms include fever (1/3 of cases), vomiting (in the first 1-2 days), and diarrhea (copious, watery, lasting 5-21 days).

Diagnosis is largely based on clinical manifestations, but antigen assays are available and may be useful in patients with extraintestinal complications, such as hepatitis, pneumonitis, or encephalopathy.

Treatment is largely supportive with efforts to maintain hydration.

Prevention is key to disease control and accomplished with good hand hygiene and widespread vaccination.

Newly implemented vaccine programs worldwide have proven to be effective in decreasing hospitalizations and deaths in developing countries.

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Parents bring in their child who placed a bead, seed, or other object up her nose.  What do you do?  Who should you call?

Research suggests that a decades-old home remedy (of sorts) known as the “mother’s kiss” may do the trick for children 1-8 years of age. It’s also much less invasive or frightening than some of the tools and techniques used in emergency departments with a success rate approaching 60%

What Is the “Mother’s Kiss”?

First described in 1965, here’s how the mother’s kiss technique works:

• The parent or caretaker places their mouth over their child’s mouth while holding the unaffected nostril closed with one finger.
• The parent or caretaker blows into the child’s mouth.
• The forceful breath may force the object out (warning: may want to wear protective covering as other things have been known to fly out as well!)

Epidemiology:

Trampoline injuries doubled between 1991 and 1996, increasing from 39,000 injuries per year to more then 83,000 injuries per year.  Injury rates and trampoline sales peaked in 2004 and have been decreasing since; however, hospitalization rates are still between 3% and 14%.

Risk Factors:

¾ of injuries occur when multiple people are on the trampoline at once

Smaller participants were 14x more likely to be injured then their heavier playmates

Falls account for 27-39% of all injuries

Springs and frames account for 20% of injuries

Up to ½ of injuries occur despite adult supervision

Injury types:

Lower extremity injuries are more common than upper extremity

Head and neck injuries accounted for 10-17% of trampoline injuries

Unique Injuries:

Proximal tibial fractures

Manubriosternal dislocations and sternal injuries

Vertebral artery dissection

Atlanto-axial subluxation

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Question

A 1 year old gets sent from their pediatrician’s office for rule out meningitis. They presented with fever for 2 days and neck rigidity. Your LP results are normal. What additional test should you consider?
 

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Conventional pediatric nasal cannula can safely deliver up to 4 lpm but are limited by cooling and drying of the airway. This leads to decreased airway patency, nasal mucosal injury, bleeding and possibly increase in coagulase negative staph infections.

HFNC delivers flow up to 40 lpm with 95-100% relative humidity at a controlled temperature. In infants, the initial flow rate is set between 2-4 lpm and can be increased to 8 lpm. Older children and can be started at 10 lpm and increased as high as 40 lpm. Oxygen is also adjustable.

Studies have shown improved comfort, respiratory rate and oxygenation compared to nasal CPAP.

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• approximately 1% of children in DKA have some degree of cerebral edema, and up to 25% of them may die
• known risk factors include the following:

1. younger children (especially <5 years)
2. new onset or newly diagnosed
3. increased BUN at presentation
4. severity of acidosis at presentation
5. bicarbonate therapy use
6. failure of sodium to improve following therapy

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We often ask our pediatric patients if there vaccines are up to date, but what does this mean?

Hepatitis B: birth, 2 and 6 months

Diphtheria/Tetanus and Acellular Pertussis: 2, 4 and 6 months

Pneumococcal vaccine: 2, 4 and 6 months

Haemophilus influenzae B : 2, 4 and 6 months

Polio: 2, 4 and 6 months

Rotavirus: 2 and 4 months or 2, 4 and 6 months depending on the brand. 

Influenza: 6 months and older

Children less than 8 years old should receive 2 doses of flu vaccine at least 4 weeks apart during the first flu season that they are immunized.  Children older than 2 years are eligible for the nasal vaccine if they do not have asthma, wheezing in the past 12 months or other medical conditions that predispose them to flu complications.

To see the full vaccine schedule including exact time frames between doses and catch up schedules, see: http://www.cdc.gov/vaccines/schedules/downloads/child/0-6yrs-schedule-pr.pdf

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