PEDIATRIC UPDATE 2007
Highlights from Topics in Emergency Medicine, sponsored by the University of California, San Francisco, School of
Medicine
Andrea Marmor, MD, Assistant Clinical Professor of Pediatrics, University of California, San Francisco, School of
Medicine, and San Francisco, General Hospital
| Case: 6-yr-old girl; developed upper respiratory infection (URI) few days earlier; coughing and troubled breathing since
then, despite using albuterol q4h; known asthmatic; past medical history—asthma since age 3 yr; no hospitalizations,
but 2 emergency department (ED) visits in last year; prescribed prednisone but always throws it up; vital signs—O2 saturation
normal; respiratory rate slightly high for age; afebrile; on examination—alert and awake; signs of acute airway
obstruction consistent with asthma; treatment—start with 3 back-to-back doses of albuterol and ipratropium (Atrovent);
anti-inflammatory agent indicated, but not oral prednisone
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| Bronchodilator delivery by metered dose inhaler (MDI) and spacer: multiple studies show equivalent dose
of broncho-dilator by MDI and spacer as effective as (or more effective than) dose by nebulizer in very young infants and
children, even in acute exacerbations; cost effectiveness varies, de-pending on setting; MDI and spacer preferred by parents;
recommendations—use MDI and spacer to deliver bronchodilator in ED whenever possible; benefits (reinforces
use of drug for parent; may be cost-effective; 8 puffs equivalent to single 2.5-mg dose from nebulizer); all patients should
learn MDI and spacer technique before leaving ED; technique—child in parent’s lap; get good seal with mask over nose
and mouth; one puff at a time; wait 30 sec between puffs; count 5 breaths of child, not 5 sec
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| Systemic steroids: effective and safe in children with acute asthma exacerbations; prevent hospitalization; reduce duration of
symptoms; most effective when given early; oral and intravenous (IV) or intramuscular (IM) routes equal in efficacy;
problem—oral prednisone poorly tolerated in children; dexamethasone—longer half-life than prednisone; safety well established;
can give IV form orally; 2 doses (0.6 mg/kg) 24 to 36 hr apart as effective as 5-day course of prednisone; no evidence inhaled
corticosteroids (ICS) effective in treatment of acute asthma exacerbations
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| Continuation of case: despite initial management with oral dexamethasone and continuous inhaled bronchodilators, patient’s
condition worsens, progressing to status asthmaticus; treatment options—single dose of magnesium sulfate administered
slowly (randomized controlled trial [RCT] data show efficacy and safety in children; most beneficial in severe
asthmatics); theophylline (still good drug to keep in mind; shown effective in children with status asthmaticus; when compared
to terbutaline, equally safe and effective, and more cost-effective)
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| Continuation of case: patient responds to theophylline and magnesium sulfate; admitted to pediatric intensive care unit
and discharged after 3 days; returns 2 wk later with much milder exacerbation that responds well to inhaled bronchodilators
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| Traditional model of asthma care: focuses on stabilization of acute exacerbation in ED and referral to primary care
physician (PCP) for long-term management; model failing (especially children at highest risk, who are most likely to use
ED for episodic care and lack PCP); in addition, many PCPs not up-to-date on guidelines for long-term management of
asthma and may not be aware of patient’s history
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| Initiation of long-term daily corticosteroid treatment: should be done in ED, accompanied by education; evidence
supporting long-term management of chronic asthma in ED; National Heart, Lung, and Blood Institute (NHLBI) guidelines
state that ICS first-line medication for persistent asthma in children; Cochrane review found that initiation of ICS at
discharge from ED reduced relapses and hospitalizations; effective, safe, and indicated in children with persistent asthma
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| Effective ED-based education should include: action plan; focus on—asthma as chronic condition; use of anti-inflammatory
drugs; role of rescue drugs; techniques for delivery of medications (CART mnemonic); follow-up educational
intervention for highest-risk patients; referrals to PCP or specialty clinic
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| Recommendations: classify asthma severity in all patients (start those with persistent asthma on inhaled corticosteroid
at appropriate dose for age); give all patients action plan; provide appropriate education; arrange follow-up and schedule
follow-up visit or telephone call if possible; rule of 2s—if child has >2 daytime symptoms per week or >2 nighttime
symptoms per month or >2 ED visits or hospitalizations in last year, child has persistent asthma and should be placed on
ICS
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| FEVER WITHOUT SOURCE (FWS)
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| Case: 5-mo-old boy brought into ED with 2 days of fever; on examination—well appearing; well hydrated; temperature
39.2°C; no source found on examination or history; child fully immunized for age (including second dose of 7-valent
pneumococcal conjugate vaccine [PCV-7])
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| Significance of FWS: nearly 20% of febrile children have FWS; small proportion, although well appearing, have occult
serious bacterial infection (SBI) or urinary tract infection (UTI)
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| Role of PCV-7: Streptococcus pneumoniae most common cause of SBI in children; PCV-7 approved for all children
and part of recommended immunization schedule; contains isolates known to cause 85% to 97% of invasive pneumococcal
disease (IPD); efficacy—in large prelicensure RCT, PCV-7 almost 100% effective against IPD from vaccine serotypes in
fully vaccinated children and 94% effective in children receiving ≥1 dose of vaccine, 90% effective against IPD from any
pneumococcal serotype in children receiving ≥1 dose; since vaccine—multiple studies support expected reduction in IPD
in vaccinated and unvaccinated populations (80% drop in IPD in children <2 yr of age); overall rate of IPD from nonvaccine
serotypes has not increased as result of vaccine, but percentage of IPV caused by nonvaccine serotypes slightly
higher; SBI can still occur, even in vaccinated children; partial vaccination efficacious; risk for SBI in vaccinated children
<0.5%, regardless of white blood cell (WBC) count
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| Management of FWS: immediately stabilize ill- or toxic-appearing febrile child; unvaccinated children—WBC
count should be done to stratify risk for SBI; screening for UTI essential in children at high risk (based on age and circumcision
status); vaccinated, well-appearing children >4 mo of age—at low risk for IPD; screening blood tests unlikely
to change management
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| Possible role of viral testing: studies conclude—infants with FWS who have positive viral test less likely to have concurrent
SBI or UTI; viral testing affects ED management (results in reduced blood testing, hospitalizations, and use of antibiotics
but does not result in missed SBI); recommendation—positive rapid viral testing (RVT) significantly reduces
probability of SBI or UTI (negative predictive value best in child who already has low or moderate probability); RVT recommended
when results will change management; infants at high risk should still be tested for UTI, regardless of viral diagnosis
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| CORTICOSTEROIDS FOR MENINGITIS
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| Case: 4-mo-old boy whose parents do not believe in immunizations; presents with fever of 40.1°C, irritability, vomiting,
and poor feeding; noted on examination—full fontanelle, inconsolable, nuchal rigidity
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| Steroids for meningitis: severity of inflammation principal predictor of outcome in experimental models of meningitis;
neuronal injury caused primarily by inflammation, rather than direct bacterial invasion; evidence—meta-analysis of trials
since 1988 found reduction in long-term sequelae in children with Haemophilus influenzae or S pneumoniae meningitis
when steroids given before or with antibiotics; recent trials suggest benefit greatest when meningitis due to H
influenzae or S pneumoniae, diagnosis and treatment prompt, and steroids given before or with first dose of antibiotics;
no studies have shown worse outcomes or adverse events in children receiving dexamethasone; no data to support use of
corticosteroids in neonates or for other causes of meningitis, eg, Neisseria meningitidis; neonates <6 mo of age—
insufficient evidence to recommend use; infants and children >6 mo of age—steroids recommended as adjunct to antibiotics
against suspected or proven meningitis due to H influenzae or S pneumoniae; initiate therapy as soon as possible
and continue for 4 days; discontinue in cases of significant side effects (extremely rare in children) or culture-proven
bacteriologic diagnosis other than H influenzae or S pneumoniae
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| Antibiotics for pediatric meningitis: as pneumococcus still major cause of pediatric meningitis in United States, recommended
regimen third-generation cephalosporin (eg, ceftriaxone) plus vancomycin (combination induces more rapid bacteriolysis
than either agent alone); evidence—nonbacteriolytic antibiotics associated with decreased inflammation and
mortality in animal studies; one RCT showed delay in administration of vancomycin by >2 hr resulted in significant reduction
in hearing loss and other adverse events, with no increase in mortality or morbidity
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| Case presentation: 3-yr-old boy; presents to ED after vomiting and diarrhea for 24 hr; parents report child throwing up
everything he eats; 3 loose stools yesterday and 3 today; has had slightly decreased urine output, but had wet diaper this
morning; on examination—heart rate 120 beats/min; skin cool but well perfused; capillary refill slightly delayed; mouth
slightly tacky; boy appears tired, but alert and responsive; belly “totally benign”; parents report patient’s sister had stomach
flu last week
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| Oral hydration: American Academy of Pediatrics (AAP) and Centers for Disease Control and Prevention (CDC) recommend
oral hydration as first-line treatment for children with mild-to- moderate dehydration due to presumed acute gastroenteritis
(AGE); ED physicians and pediatricians “somewhat reluctant” to use oral hydration; evidence—IV vs oral
rehydration in moderately dehydrated children evaluated in several RCTs; findings in study of infants 3 to 36 mo of age
(compared IV vs nasogastric [NG] tube or oral hydration; equivalent in all clinical outcomes, but NG or oral hydration superior
in cost-effectiveness and reducing complications; routine laboratory tests did not alter treatment or help with diagnosis);
study of older children showed equivalent success rate (oral hydration associated with decreased time in ED);
recommendations—minimize blood draws and IV lines; consider oral or NG hydration
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| Medications and nutritional supplements for the vomiting child
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 | Evidence: ondansetron—several recent RCTs look at ondansetron in children with AGE; results vary; reduces vomiting in
ED and may speed oral rehydration, but does not decrease hospitalization rates; loperamide—contraindicated in children
(associated with increased morbidity and mortality); zinc supplementation—primarily studied in developing countries; results
show improved intestinal permeability and decreased severity of diarrhea; however, role in developed countries
and optimal mode of delivery unknown; probiotics—while several studies show probiotics safe and effective in treatment
of infectious and antibiotic-associated diarrhea, doses used too large to be practical (unclear whether smaller
doses equally effective, but worth considering)
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| Recommendations: mainstays of therapy oral rehydration and restoring proper nutrition; some medications (eg, ondansetron)
may be safe for children, but add to cost and may add to risk (unlikely to add significant benefit by reducing
hospitalizations); nutritional supplements mostly safe, may be used in moderation
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| Restoration of diet: restore age-appropriate diet as soon as possible; breast milk always acceptable; formula does not
need to be diluted; avoid full-strength juices and milk in some patients
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| IMAGING AFTER MINOR HEAD TRAUMA IN YOUNG INFANTS
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| Case: 9-mo-old boy; brought in by babysitter immediately after being knocked over in high chair by family dog; on
examination—child somewhat fussy but consolable; drinks from bottle; nonfocal neuroexamination; 2-cm by 2-cm red
mark on right occiput; options for next step—computed tomography (CT); plain skull films; head ultrasonography; observation
for 4 to 6 hr; discharge if caregiver reliable
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| Background: intracranial injury (ICI) occurs in 3% to 6% of young infants and children with apparently minor head
trauma; goals of selective imaging to identify those with clinically significant ICI, and to minimize unnecessary radio-
graphy, sedation, and hospital admissions; head imaging guidelines often recommend lower threshold for children <2 yr
of age (ICI may be asymptomatic; infants at higher risk for skull fractures, and skull fractures associated with ICI; infants
at higher risk for nonaccidental trauma); however, important to minimize unnecessary imaging in these infants (higher
risk for side effects from sedation and radiation)
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| Predictors of ICI in infants <2 yr of age: risk factors for significant ICI include altered mental status; focal neurologic
findings; skull fracture; loss of consciousness (LOC) and vomiting not good independent predictors of ICI
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| Asymptomatic ICI: more prevalent in younger children (especially those <3-6 mo of age); 1998 study of infants with
minor head trauma found 19% incidence of asymptomatic ICI (all in infants <1 yr of age; 95% also had skull fractures)
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| Skull fracture and ICI: incidence of fracture 6% to 30% (highest in younger age group); skull fracture better predictor
of ICI in young infants than clinical symptoms (positive predictive value 15%-30%; sensitivity best in young infants);
scalp hematoma 80% to 100% sensitive for associated skull fracture (more sensitive in older infants)
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| Algorithm for imaging: high risk (symptomatic)—children with clinical findings (eg, significant vomiting; long periods
of LOC; acute fractures; irritability; unwell appearance) require CT; intermediate risk—subdivided into patients
with potential indicators of ICI (moderate versions of high-risk symptoms, eg, vomiting, LOC, skull fracture >24 hr old)
and those who have additional risk factors due to mechanism of injury; occult ICI most likely in children <6 mo of age,
those with scalp hematoma, skull fracture, higher-force mechanism of injury, unwitnessed trauma, signs or symptoms of
head trauma but no history of trauma (at risk for nonaccidental trauma); imaging or observation over 4 to 6 hr reasonable
strategies; low risk—children who are asymptomatic and without risk factors may be safely discharged and monitored
by appropriate caregiver
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Suggested Reading
Atherly-John YC et al: A randomized trial of oral vs intravenous rehydration in a pediatric emergency department.
Arch Ped Adol Med 156:1240, 2002; Baraff LJ: Management of fever without source in infants and children. Ann
Emerg Med 36:602, 2000; Buckingham SC: Early vancomycin therapy and adverse outcomes in children with pneumococcal
meningitis. Pediatrics 117:1688, 2006; Byington CL, Rene Enriquez F: Serious bacterial infections in febrile
infants 1-90 days old with and without viral infections. Pediatrics 113:1662, 2004; Centers for Disease Control
and Prevention (CDC): Direct and indirect effects of routine vaccination children with 7-valent pneumococcal conjugate
vaccine on incidence of invasive pneumococcal disease—United States, 1998-2003. MMWR Weekly 54:893, 2005;
Chaudhuri A: Adjunctive dexamethasone treatment in acute bacterial meningitis. The Lancet Neurology 3:54, 2004;
Delgado A et al: Nebulizers vs metered-dose inhalers with spacers for bronchodilator therapy to treat wheezing in children
aged 2 to 24 months in a pediatric emergency department. Arch Pediatr Adolesc Med 157:76, 2003; Freedman
SB: Oral ondansetron for gastroenteritis in a pediatric emergency department. N Engl J Med 354:1698, 2006; Goldblatt
D: Immunogenicity and boosting after a reduced number of doses of a pneumococcal conjugate vaccine in infants and toddlers.
Pediatr Infect Dis J 25:312, 2006; Greenes DS, Harper MB: Low risk of bacteremia in children with recognizable
viral syndromes. Pediatr Infec Dis J 18:258, 1999; Greenes DS, Schutzman SA: Clinical indicators of
intracranial injury in head-injured infants. Pedatrics 104:861, 1999; McIntyre PB et al: Dexamethasone as adjunctive
therapy in bacterial meningitis: meta-analysis of randomized clinical trials since 1988. JAMA 278:925, 1997; Nager AL,
Wang VJ: Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with acute dehydration.
Pediatrics 109:566, 2002; Osmond M: Evidence-based emergency medicine: Nebulizers vs inhalers with spacers
for acute asthma in pediatrics. Ann Emerg Med Mar 43:413, 2004; Qureshi F et al: Comparative efficacy of oral dexamethasone
versus oral prednisone in acute pediatric asthma. J Pediatr 139:20, 2001; Ream RS: Efficacy of IV theophylline
in children with severe status asthmaticus. Chest 119:1480, 2001; Schutzman SA et al: Evaluation and
management of children younger than two years old with apparently minor head trauma: proposed guidelines. Pediatrics
107:983, 2001; Singer AJ et al: A call for expanding the role of the emergency physician in the care of patients with
asthma. Ann Emerg Med Mar 45:295, 2005; Thiessen ML, Woolridge DP: Pediatric minor closed head injury. Pediatr
Clin N Amer 53:1, 2006; Tung GA et al: Comparison of accidental and nonaccidental traumatic head injury in children
on noncontrast computed tomography. Pediatrics 118:626, 2006; Wheeler DS: Theophylline vs terbutaline in
treating critically ill children with status asthmaticus: a prospective, randomized, controlled trial. Ped Crit Care Med Mar
6:142, 2005.
Educational Objectives
| The goal of this program is to improve the management of pediatric emergencies. After hearing and assimilating this program,
the clinician will be better able to:
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| Utilize a metered dose inhaler and spacer in the management of acute asthma exacerbations.
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| Explain the role and impact of the 7-valent pneumococcal conjugate vaccine in the management of fever without
source.
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| Administer corticosteroids in the management of proven or suspected pediatric meningitis.
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| Describe and follow the recommended treatment guidelines for the mild-to-moderately dehydrated child with suspected
acute gastroenteritis.
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| Evaluate infants and children <2 yr of age with head trauma and determine whether imaging is necessary.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose
relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any
identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Dr. Marmor spoke at Topics in Emergency Medicine, held November 6-9, 2006, in San Francisco, CA, and sponsored
by the University of California, San Francisco, School of Medicine. The Audio-Digest Foundation thanks Dr. Marmor
and the UCSF School of Medicine for their cooperation in the production of this program.
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