PEDIATRIC LITERATURE UPDATE
From the 16th Annual Emergency Medicine Conference, sponsored by Kaiser Permanente
Richard M. Cantor, MD, Associate Professor of Emergency Medicine and Pediatrics, Director, Pediatric Emergency
Department, and Medical Director, Central New York Poison Control Center, Upstate Medical University, Syracuse,
NY
Infectious Diseases
| Antipyretic treatment in young children: 464 subjects received acetaminophen, ibuprofen, or both alternating q4h
for 3 days after standard dose; conclusion—alternating regimen more effective (lower mean temperature, more rapid reduction
of temperature, less antipyretic used, and less absenteeism)
|
| Acetaminophen dose accuracy: over 1 wk, 25% of children received acetaminophen; study showed rectal route associated
with most dosage errors
|
| Pneumococcal vaccine, polyvalent (Pneumovax 23)
|
 | Epidemiology of bacteremia: study looked at blood cultures in children <3 yr of age over 5 yr; implementation of pneumococcal
vaccine resulted in 84% less bacteremia caused by Streptococcus pneumoniae; overall reduction 67%; rates
same for contaminants (7 in 10 blood cultures showed contaminants); total blood cultures decreased by 35% in outpatient
departments, but not in emergency departments (EDs); one third of pathogenic organisms Escherichia coli, one
third nonvaccine serotypes of pneumococcus, and remaining one third other organisms; in this study, white blood cell
(WBC) count of 15,000/µL poor predictor of bacteremia
|
| Analysis of blood cultures: restrospective study over 8 yr of pediatric blood cultures in community hospital ED in postpneumococcal
vaccine era; all children <3 yr of age with fever; incidence of bacteremia 3.5%; prevalence of true positives 0.7%
(20% of positives; 80% of remaining positives contaminants); false positives take longer time (1.5 days) to positivity; false-
positive culture group had lower WBC counts and lower mean presenting temperatures
|
| Blood culture contamination: study looked at role of patient’s age and physician’s experience in determining contamination
rates; conclusion—young age of patient and lack of experience of physician drawing specimen increase risk for contamination
|
| Methicillin-resistant Staphylococcus aureus (MRSA): study of whether changes have occurred in frequency and
susceptibility of community-acquired (CA)-MRSA; data collected over 1 yr compared to data collected 1990 to 2001;
1000 cases of MRSA identified, of which 93% CA-MRSA; usually starts as abscess in perirectal area in children; teaching
points—emergence of CA-MRSA causing infections in children has reached epidemic proportions; must culture abscess
|
| Impact of rapid influenza testing at triage: febrile children <3 yr of age; intervention group tested for influenza in
triage, other group not tested; conclusion—triage protocol for rapid influenza testing decreased additional testing, time
in ED, and medical charges in children who tested positive for influenza
|
| Prevalence of serious bacterial infections (SBIs) in infants <3 mo of age with influenza: retrospective
study; subjects tested over 4 flu seasons; 700 subjects, of whom 25% influenza-positive (IP) and 75% influenza-negative
(IN); results showed only 1 of IP subjects had bacteremia, while 23 of IN subjects bacteremic; 2 of 110 IP subjects had
urinary tract infections (UTIs), while 10% of IN subjects had UTIs; 13 of 51 IP subjects had pneumonia, while 41% of IN
subjects had pneumonia; none had meningitis; 16 (9.8%) SBIs in IP group, 28% in IN group; conclusion—lower incidence
of bacteremia, UTI, pneumonia, and SBI in IP subjects
|
| Bacterial conjunctivitis: study to identify rates of Haemophilus influenzae, S pneumoniae, and Moraxella catarrhalis
in cases of bacterial conjunctivitis and define antibiotic resistance rates; 2-yr prospective study of 428 children;
found nontypeable influenza, pneumococcus, and Moraxella; results showed 55% of cultures had ≥1 pathogen; H influenzae
and pneumococcus grown, with β-lactamase production in one third of H influenzae isolates; penicillin nonsusceptibility
in 60% of pneumococcal isolates; conjunctivitis-otitis syndrome found in 32% of subjects (82% of
cultures H influenzae); conclusion—resistance rates high; look for conjunctivitis-otitis syndrome
|
| Management of herpetic gingivostomatitis: survey of what physicians using for treatment; cocktail of calcium
carbonate (Maalox) and diphenhydramine (Benadryl) one example; anecdotal evidence of efficacy; speaker cautious with
Benadryl; mucosa of oral cavity absorbs drug well; absorption also enhanced by open lesions; has resulted in anticholinergic
crisis; study points out unclear instructions, variable dosing, and underuse of acyclovir; speaker states that by time
lesion appears, acyclovir no longer effective
|
| Oral dexamethasone for pharyngitis: randomized double-blind controlled trial of children 5 to 18 yr of age with severe
pharyngitis; given oral dexamethasone or placebo; of 125 patients, those who received dexamethasone had earlier
pain relief and resolution; study recommended giving oral dexamethasone for pharyngitis; another study found one dose as
effective as 3-day course
|
| Urine collection methods: study of diagnosis of UTI in young febrile infants; 3000 subjects; 70% of specimens obtained
by catheterization (remainder by bag); infection rates similar for both methods; ambiguous cultures more common
in bag specimens; if done correctly, bag method good (can obtain clean catch); bag method leading cause of anuria
|
| Clinical and demographic factors associated with UTI: febrile infants <60 days old; 1000 subjects enrolled;
10% had UTI with fever; in uncircumcised infant boys, 21% (lower rates in circumcised boys and in girls); boys <6 mo
of age more likely to have UTIs (associated with high-grade fever and not being circumcised); many UTIs resolve spontaneously,
but need to be more vigilant in infants (obtain urine culture and check for renal anomalies)
|
| Procalcitonin (PCT) as diagnostic aid: PCT elevated in bacterial infections, low in viral infections; used to screen
for osteoarthritis (OA) and septic joints in limping children; 44 children evaluated; 25% had OA; PCT elevated in 50% of
children with OA and in 3 with septic arthritis; PCT normal in other diagnoses (inflammatory joints, noninfectious joints,
and viral syndromes); conclusion—PCT useful marker for bone infections but not joint infections
|
| Characteristics of Kawasaki disease in infants <6 mo of age: studied infants <6 mo of age and those >6 mo of
age; looking for differences in presentation; incomplete presentation in younger infants; higher coronary involvement
and less treatment because diagnosis missed; teaching point—consider diagnosis in infant with fever of unknown
source for 4 days
|
Respiratory
| Fall school opening and ED visits for asthma: study of whether school or time of year associated with increased
ED visits; preschool and early school-age groups; conclusion that confined-space activity factor in these children
|
| Vomiting of liquid corticosteroids in children with asthma: double-blind clinical trial of children ≥6 yr of age
on generic prednisolone or Orapred; taste score obtained using 5-point Hedonic face scale; 17% in generic group vomited
vs 5% in Orapred group; conclusion—Orapred tastes better
|
| Levalbuterol (Xopenex) vs racemic albuterol: children with moderate to severe asthma exacerbations; double-
blind prospective study; peak flow rates measured; all subjects (70) in both groups showed improvement in all parameters;
no statistical difference between rate of breathing, O2 saturation, and peak flow; conclusion—levalbuterol not more
effective than racemic albuterol
|
| Helium-oxygen mixture (Heliox): effective for severe asthma
|
| Child life intervention: study looked at angiocatheter insertion in pediatric ED, comparing IV insertion in presence or
absence of child life intervention; looked at customer satisfaction, anticipatory panic, and procedural satisfaction in 149
subjects; improvement noted in intervention group, especially in anticipation phase
|
| Ethnic differences in parent preference: survey of 300 black, white, and Hispanic parents about preferences for remaining
in room during painful medical procedures; up to 81% preferred to be present in room for critical resuscitation,
with few ethnic differences
|
| Young children’s perception of physicians’ attire: customary medical attire (scrub suit and white coat) preferred
|
| Effect of clowns on preoperative anxiety: 40 subjects in minor day-surgery center; found those accompanied by
clown and parent in preoperative room less anxious
|
| Prescription-writing errors in pediatric ED: 6-mo review looking at severity of errors; discharge instructions collated;
360 prescriptions eligible, of which 60% had minor errors; minor omissions most common (eg, incomplete or unclear
directions about dose and quantity to be dispensed); frequency of errors 81% for emergency medicine residents, less
for pediatric residents
|
| Outcome of out-of-hospital cardiorespiratory arrest: study of 95 children 7 days to 16 yr of age; overall initial
survival rate 50%, less at 1 yr; mortality higher in children <1 yr of age; survival of patients with respiratory arrest 82%,
lower for cardiac arrest; higher survival rate for patients initially resuscitated by lay persons; mortality higher in patients
who presented with slow rhythm rather than ventricular fibrillation; concluded that mortality rates high (but lower if CPR
started by lay person), and duration of CPR best indicator of mortality
|
| Anemia in apparent life-threatening events (ALTEs): 2-yr study to determine how often anemia found in children
presenting with ALTEs; 108 patients with ALTEs matched to control patients; rate of anemia in recurrent ALTE patients
21%, less in single-ALTE or control patients; conclusion—anemia common in children with recurrent ALTEs;
speaker’s point not whether anemia causes ALTE but rather to screen for anemia in patient with recurrent ALTEs
|
| Signs and symptoms of cerebrospinal fluid (CSF) shunt malfunction: retrospective study by speaker found
that average child 15 yr of age with shunt has had computed tomography (CT) of head ≥ 20 times
|
| Management of esophageal coins: immediate endoscopic removal vs observation; randomized prospective study of
subjects <21 yr of age; sent for endoscopy or observation with repeat radiography 16 hr later; in observation group, 77% required
endoscopy, compared to 70% in surgical group; conclusion—observation not protective; more likely to pass foreign
body spontaneously if older in age and if foreign body in distal third of esophagus; decision made by otolaryngologist (most
favor immediate removal)
|
| Ultrasonography (US) and patient description in foreign body detection: prospective study (131 subjects);
patients asked whether they had foreign body sensation, bedside US performed, and patient explored; low percentage of
foreign bodies (10%); US as good as plain radiography to detect foreign body
|
| Gastrointestinal symptoms associated with orthostatic intolerance: complete resolution of abdominal pain
with volume resuscitation
|
| Early analgesia for children with acute abdominal pain: double-blind randomized placebo trial; 108 subjects received
IV morphine or saline; no differences in number of appendicitis diagnoses and number of children who had laparotomies;
reduction in pain score better with morphine; confidence of ED physicians and surgeons not affected; conclusion—can
give morphine
|
Trauma
| Seat belt sign and intra-abdominal injury (IAI): study to determine whether sign reliable indicator of IAI; patients
with sign more commonly had IAIs, including pancreatic injuries; none of 6 patients with sign but without abdominal
pain had IAIs; in and of itself, sign not enough to indicate injury, but presence should prompt further investigation
|
| ED visits for sledding injuries: 57000 ED visits annually due to injuries; of these, 71% in patients ≤19 yr of age,
mostly male; most caused by falls or collisions; injury to head or neck in younger patients, and extremities in older patients;
90% had traumatic brain injuries; many areas for sledding not policed
|
| Childhood soccer injuries: common injuries decrease with age; sprains and strains increased in older population
|
| All-terrain vehicle (ATV)–related nonfatal injuries: 108,000 children treated annually for nonfatal injuries
(25% increase over 3 yr); boys account for 52%; children ≤5 yr of age most likely to injure face; leg and foot injuries in
older children; fractures most common diagnosis, and almost all serious
|
Sedation
| Adverse events with procedural sedation and analgesia: survey of frequency and severity of adverse effects
with certain drug combinations; 2500 patients; 2200 received drugs IV; subjects 19 days to 32 yr of age; 4 combinations,
including ketamine and midazolam, midazolam and fentanyl, and midazolam alone; 450 adverse effects; respiratory effects
(20%); vomiting (ketamine caused most vomiting)
|
| Topical anesthesia for IV insertion: eutectic mixture of local anesthetics (EMLA) cream has place in care practice
model; speaker also uses EMLA for lumbar puncture
|
| Adverse effects in ketamine sedations with or without morphine pretreatment: data do not support use of
midazolam and ketamine (although commonly used); in 800 sedations, no difference found in number and type of adverse
events when morphine used
|
| Effect of etomidate on intracranial pressure (ICP): study found etomidate lowered mean ICP
|
| Pain perception during reduction of subluxation of radial head: supination-flexion method vs forced pronation;
randomized 32 children to 2 groups; no difference in perception of pain, but parents and nurses felt forced pronation
method less painful
|
| Sedation and analgesia for fracture reduction: Cochrane trial registry; found that ketamine and midazolam
caused less distress during reduction and fewer airway interventions than propofol and fentanyl
|
Educational Objectives
| The goal of this program is to educate the listener about updates in the pediatric literature on infectious diseases, respiratory
issues, trauma, and sedation. After hearing and assimilating this program, the clinician will be better able to:
|
| 1. Identify methicillin-resistant Staphylococcus aureus in children.
|
| 2. Exercise vigilance in cases of urinary tract infections in children.
|
| 3. Avoid common prescription-writing errors.
|
| 4. Manage abdominal pain in children.
|
| 5. Recognize and manage the adverse effects of sedating agents.
|
Suggested Reading
Abanses JC et al: Impact of rapid influenza testing at triage o.management of febrile infants and young children.
Pediatr Emerg Care 22:145, 2006; Black KJ et al: Pediatric intravenous insertion in the emergency department:
bevel up or bevel down? Pediatr Emerg Care 21:707, 2005; Bramwell KJ et al: The effect of etomidate on intracranial
pressure and systemic blood pressure in pediatric patients with severe traumatic brain injury. Pediatr Emerg
Care 22:90, 2006; Butbul-Aviel Y et al: Procalcitonin as a diagnostic aid in osteomyelitis and septic arthritis. Pediatr
Emerg Care 21:828, 2005; Faden H: Management of primary herpetic gingivostomatitis in young children.
Pediatr Emerg Care 22:268, 2006; Faden H: Mastitis in children from birth to 17 years. Pediatr Infect Dis J
24:1113, 2005; Fein JA et al: The decision to use topical anesthetic for intravenous insertion in the pediatric emergency
department. Acad Emerg Med 13:264, 2006; Epub 2006 Feb 22. Green DA et al: Randomized comparison of
pain perception during radial head subluxation reduction using supination-flexion or forced pronation. Pediatr Emerg
Care 22:235, 2006; Green R et al: Early analgesia for children with acute abdominal pain. Pediatrics 116:978,
2005; Hardasmalani MD et al: Levalbuterol versus racemic albuterol in the treatment of acute exacerbation of
asthma in children. Pediatr Emerg Care 21:415, 2005; Migita RT et al: Sedation and analgesia for pediatric fracture
reduction in the emergency department: a systematic review. Arch Pediatr Adolesc Med 160:46, 2006; Pitetti
RD et al: Prevalence of anemia in children presenting with apparent life-threatening events. Acad Emerg Med
12:926, 2005; Sarrell EM et al: Antipyretic treatment in young children with fever: acetaminophen, ibuprofen, or
both alternating in a randomized, double-blind study. Arch Pediatr Adolesc Med 160:197, 2006; Schroeder AR et
al: Choice of urine collection methods for the diagnosis of urinary tract infection in young, febrile infants. Arch Pediatr
Adolesc Med 159:915, 2005; Silverman RA et al: The relationship of fall school opening and emergency department
asthma visits in a large metropolitan area. Arch Pediatr Adolesc Med 159:818, 2005; Skarbek-Borowska
S et al: Emergency department visits for sledding injuries in children in the United States in 2001/2002. Acad Emerg
Med 13:181, 2006; Epub 2006 Jan 25. Sokolove PE et al: Association between the “seat belt sign” and intra-abdominal
injury in children with blunt torso trauma. Acad Emerg Med 12:808, 2005; Taylor BL et al: Prescription
writing errors in the pediatric emergency department. Pediatr Emerg Care 21:822, 2005; Waltzman M: Management
of esophageal coins. Pediatr Emerg Care 22:367, 2006.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
the faculty reported nothing to disclose.
Dr. Cantor was recorded at the 16th Annual Emergency Medicine Conference, held September 13-16, 2006, in Las Vegas,
NV, and sponsored by Kaiser Permanente. The Audio-Digest Foundation thanks Dr. Cantor and Kaiser Permanente
for their cooperation in the production of this program.
|
