Practice Pearls

Educational Objectives

The goals of this program are to improve management of conditions (eg, respiratory syncytial virus [RSV]) recently up­dated in the American Academy of Pediatrics 2009 Red Book, and to improve the management of common pediatric inju­ries and maternal and congenital cytomegalovirus (CMV) infection. After hearing and assimilating this program, the clinician will be better able to:

1.   Explain the changes in the Red Book recommendations for the use of palivizumab in the prevention of RSV.

2.   Describe the 2 currently available meningococcal vaccines and recommendations for their use.

3.   Effectively manage common pediatric trauma, including injuries to the head, upper extremities, wrist, and an­kle, as well as burns and animal bites.

4.   Recognize signs of sexual abuse when evaluating pediatric injuries.

5.   Discuss some of the challenges and pitfalls in the diagnosis of maternal and congenital CMV infection.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee 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 and the planning committee re­ported nothing to disclose. In her lecture, Dr. Fowler discusses the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Brady spoke at 27th Annual Pediatric Infectious Disease Pearls Conference, in cooperation with the 2009 Allergy, Immu­nology, Dermatology Pearls Conference, held September 17, 2009, in Columbus, OH, and sponsored by Nationwide Chil­dren’s Hospital, Section of Infectious Diseases, and Nationwide Children’s Hospital Education Institute, Section of Allergy and Immunology. Dr. Hutchings was recorded at 5th Annual Gulf Coast Update in Pediatrics, held June 14-16, 2009, in Biloxi, MS, and sponsored by Ochsner Medical Center for Children. Dr. Fowler spoke at 11th Annual Frontiers in Pediatrics, held De­cember 5-7, 2008, in Charleston, SC, and sponsored by the Medical University of South Carolina, Department of Pediatrics, Office of Continuing Education, and the Office of Continuing Nursing Education, College of Nursing. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Red Book Update 2009

Michael T. Brady, MD, Chair, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH

Introductory remarks: American Academy of Pediatrics (AAP) 2009 Red Book released in June 2009 (available as hard copy or online); contains >1000 pages; has »92 changes

Prevention of respiratory syncytial virus (RSV): currently in use  —  RSV immunoglobulin intravenous (RSV-IGIV [RespiGam]), polyclonal globulin; palivizumab [Synagis], humanized mouse monoclonal antibody

Palivizumab: administration during RSV season in preterm infants and in children with hemodynamically significant congenital heart disease (CHD) shown to reduce hospitalizations for RSV disease, number of RSV hospital days, and days requiring oxygen (but did not reduce need for mechanical ventilation or mortality); Food and Drug Ad­ministration (FDA) indication  —  for prevention of serious lower respiratory tract disease (RTD) caused by RSV in pediatric patients at high risk for RSV disease; 2009 Red Book recommendations  for  32 to 35 wk gestation cohort  —  updates change cohort to 32 wk 0 days, to 34 wk, 6 days, and recommend palivizumab for infants with congenital airway abnormality or severe neuromuscular disease, age £90 days during RSV season, and 1 of 2 risk factors (school-age sibling or child care attendance); maximum recommended doses 3; no doses at >90 days of age)

RSV season: varies geographically, but duration of peak season 5 mo, regardless of onset date; 5-dose maximum for RSV prophylaxis in any location

Neisseria meningitides: ³13 serogroups (A, B, C, Y, and W-135 of most concern); primary clinical syndromes of N meningitidis infection meningitis and bacteremia; peak ages for meningococcal disease in pediatric patients <2 yr of age and late adolescence; distribution of cases by serogroup varies by time and age group (»65% of cases in chil­dren <1 yr of age in 1996-2008 caused by serogroup B [not included in vaccine]); risk factors for meningococcal disease  —  functional or anatomic asplenia, HIV, tobacco smoke, crowding, and upper respiratory tract infections

Meningococcal vaccines: meningococcal polysaccharide vaccine (MPSV4)  —  contains serogroups A, C, Y, and W-135; approved for persons ³2 yr of age; not recommended for routine vaccination; use only in persons >55 yr of age who are at increased risk for N meningiditis infection or if conjugate vaccine unavailable; meningococcal con­jugate vaccine (MCV4)  —  quadrivalent polysaccharide vaccine conjugated to diphtheria toxoid; approved for per­sons 2 through 55 yr of age; recommended for all children at 11 to 12 yr of age, unvaccinated children 12 to 18 yr of age, and for other persons 2 to 55 yr of age who are at increased risk for invasive meningococcal disease; revac­cination may be indicated for person who continues to be at increased risk for infection 5 yr after receiving MPSV4 (MCV4 recommended for revaccination, although use of MPSV4 acceptable)

Haemophilus influenzae type b (Hib): Hib disease nearly eliminated in countries with widespread use of Hib conju­gate vaccines; 4 vaccines currently available; Hiberix recently received accelerated FDA approval for booster dose in children 15 mo through 4 yr of age; reemergence of 5 cases of Hib disease in Minnesota in 2008 (3 of 5 children unvaccinated due to parental refusal)

Erythromycin ophthalmic ointment (0.5%) shortage: recommendations for prophylaxis of ophthalmia neonatorum  —  if available, reserve erythromycin ointment for newborns; for other children, can use azithromycin ophthalmic solution 1% (not FDA-approved, but recommended); other options  —gentamicin 0.3%, tobramycin 0.3%, or ciprofloxacin 0.3%; if alternative regimen used, recheck patient 48 to 72 hr after discharge; test for gonor­rhea if conjunctivitis present

Rabies prophylaxis: number of vaccine doses recently changed; previous schedule for postexposure prophylaxis 5 doses at 0, 3, 7, 14 and 28 days; new schedule 4 doses at 0, 3, 7, and 14 days; immunocompromised individuals still need 5 doses and need to be tested for rabies virus neutralizing antibodies after fifth dose to ensure response 

Management of Common Childhood Injuries

Rebecca Hutchings, MD, Director of Pediatric Emergency Services, Ochsner Medical Center, New Orleans, LA

Head injuries: minor head trauma  —  take detailed history; do thorough neurologic examination; provide reassurance for parents; indications for immediate discharge  —  fall from <3 ft; no loss of consciousness (LOC) or seizure; as­ymptomatic ³2 hr after event; no frontal scalp hematoma; normal mental status and neurologic examination; no ev­idence of skull fracture; no preexisting neurologic condition; 6 hr of observation  —vomiting after incident; lethargy or irritability initially; behavioral change; skull fracture >24 hr old; injury caused by high force; unwitnessed trauma; indications for computed tomography (CT)  —  prolonged LOC; child amnestic to event; seizure; Glasgow Coma Scale <15; acute skull fracture or bulging fontanelle; focal neurologic findings; scalp bruise or swelling in child <1 yr of age; significant mechanism of injury; persistent vomiting (>3 episodes); altered mental status; suspi­cion of abuse; underlying condition (eg, osteogenesis imperfecta)

Cervical spine injuries: can involve bones, ligaments, blood vessels, or spinal cord; immobilize cervical spine while performing work-up; bony tenderness requires imaging; neurologic deficits require immediate imaging and neuro­surgical consultation

Clavicle fractures: »50% of all clavicle fractures occur in children <7 yr of age; management  —  clavicle x-ray; sling and swath, or clavicle sling for uncomplicated fractures; chest x-ray if pneumothorax suspected; angiography if vascular injury suspected; orthopedic consultation for open or displaced fractures

Common hand injuries: broken finger  —  x-ray; buddy tape or metal finger splint; dislocated finger  —  x-ray; digital block; reduction; laceration  —  neurovascular examination; repair; orthopedic consultation for neurovascular defi­cits

Wrist injuries: sprain  —  treat with rest, ice, elevation, and Velcro splint; distal radius and ulna  —  nondisplaced (safely treated with Velcro splint); displaced fracture  —orthopedic consultation for reduction and splinting

Torus fracture: common in children; buckle fracture; can be treated with Velcro wrist splint

Comminuted intra-articular fracture: complicated; high probability of disability if not reduced or treated by ortho­pedist

Subluxation of radial head: most common elbow injury in children  ; occurs between 1 and 4 yr of age (peaks at 2-3 yr); recurrence rate 27% to 39%; technique for reduction  —supinate patient’s hand; flex arm; with thumb on radial head, guide back into place

Straddle injuries: often unilateral and superficial; generally involve anterior portion of genitalia in both boys and girls

Urogenital injuries: in girls  —  usually involve mons, clitoral hood, anterior labia minora, or area lateral to hymen; vulvar hematoma (treat with ice packs and pain management); vulvar lacerations (heal by secondary intent when possible; conscious sedation for any necessary sutures); vaginal injuries (generally do not require intervention); sig­nificant injuries should be managed under anesthesia by gynecologist experienced with children; in boys  —  urethral injuries (diagnosis can be made by retrograde urethrography [RUG]; anterior injuries managed with 7 to 10 days of catheterization and antibiotics; posterior injuries occur with more extensive trauma; testicular and scrotal injuries (order ultrasonography [US]); if no injury to testicle, treat with ice, compression, and pain control; repair lacera­tions under conscious sedation; if testicles involved or laceration extends beyond dartos, consult urologist); penile injuries (repair lacerations under adequate sedation; evaluate urethra with RUG; consult urologist); be suspicious of sexual abuse in children with any genital injury

Toddler fractures: seen in children 9 mo to 3 yr of age; present with acute onset of limp or refusal to bear weight; nondisplaced spiral fracture of distal tibia

Ankle injuries: palpate laterally, medially, and posteriorly; any bony tenderness or inability to bear weight warrants x-ray; management of sprains  —  rest; ice; elevation; place in elastic wrap (eg, Ace bandage), air cast, or splint; non­weightbearing for »1 wk; refer to orthopedist if pain continues; management of fracture  —  same as for sprain, but use posterior splint; consider stirrup splint for bimaleolar fracture; Maisonneuve (high ankle) fracture  —  highly un­stable; surgery usually required; Jones fracture  —  presents between 9 and 14 yr of age; avulsions and displaced fractures should be referred to orthopedic surgeon

Burns: categorized by thickness; deep burns more common in children than in adults because skin thinner ; manage­ment decisions (ie, when to transfer to burn center) determined by size and site of burn; hospital admission; minor burns  —  partial-thickness burns over <10% of total body surface area (TBSA) in patients >10 yr of age or <5% of TBSA in patients <10 yr of age, or full-thickness burns over <2% of TBSA in any patient without other injury; must be isolated injury not involving face, hands, perineum, or feet, must not cross major joints or be circumferen­tial

Burn management: stop burning process; burnt clothing and jewelry should be removed unless stuck to patient; de­bride sloughed or necrotic skin and ruptured blisters; cover skin with topical antibiotic to prevent infection; cover burn area with clean sheet or blanket to reduce pain and keep child warm; use nonadhesive dressing to keep area clean and dry; give tetanus immunization to any child with burns deeper than superficial thickness and without booster in >5 yr; burns require significant pain management; follow-up  —  day after injury, adjust pain medications, assess competence of dressing change, debride wound, and look for signs of infection, scarring and contracture; subsequent follow-up can be done weekly until wound epithelialization occurs; all suspected burn infections war­rant aggressive management

Lacerations: cyanoacrylate  —  high-viscosity skin adhesive; use on facial injuries  —  position patient so any run-off of adhesive avoids eye; eye should be closed and protected with gauze and/or petroleum jelly or antibiotic ointment around eye

Dog bites: comprise 80% to 90% of all animal bites; management  —  irrigate profusely; leave open when possible; use loose sutures when closure necessary; close facial wounds for cosmesis; give tetanus booster if needed; prophy­lactic amoxicillin/clavulanate for 5 days for high-risk bites; consider rabies prophylaxis in unprovoked attack when animal cannot be captured

Cat bites: infection commonly caused by Pasteurella multocida (develops rapidly, with erythema, swelling, and in­tense pain as early as 12-24 h,r after bite); systemic infection occurs in <20% of bites; first-line treatment amoxicil­lin/clavulate (clindamycin for penicillin-allergic patients)

Rodent bites: rat most common rodent bite; most occur in children £5 yr of age, on face or hands, and at night; usu­ally do not require treatment

Human bites: fight bites  —  injury overlying metacarpophalangeal joints; management  —  wound should be carefully explored to identify injury to underlying structures; if foreign body or fracture suspected, obtain x-ray; deep-com­partment infection and tendonitis frequent; suspect if pain occurs on finger motion; paronychia in infants can result from parent biting rather than cutting child’s nails; bites to breasts and genitals can occur during sexual activity or assault; bite mark that has intercanine distance >3 cm probably came from adult and should raise concerns about child abuse

CMV: What’s New for the Neonate?

Sandra L. Fowler, MD, MSc, Associate Professor of Pediatrics, Medical University of South Carolina, Charleston

Symptomatic cytomegalovirus (CMV) infection: mani-festations  —  infant small for gestational age; microceph­aly; calcifications; hepatosplenomegaly; anemia; cytopenia; seizures; “blueberry muffin spots”; natural history  —    infection transmitted from infected mother through placenta to infant; of mothers who have primary CMV infec­tion during pregnancy, »50% of fetuses infected, but only 10% of those symptomatic at birth

Pitfalls in diagnosis of maternal CMV infection: most CMV infections in adults asymptomatic; development of congenital infection strongly dependent on whether mother has primary (much higher risk of transmission), sec­ondary, or recurrent CMV infection; pregestation IgG rarely available; sensitivity and specificity of IgM assays poor; maternal blood polymerase chain reaction (PCR) and viral cultures not useful; question whether maternal anti-CMV IgM due to acute infection or reactivation

Anti-CMV IgG avidity index: as CMV infection evolves, IgG antibody response and avidity of antibody for antigen mature; low avidity associated with recent infection (also true for IgM antibody); presence of low-avidity antibody associated with high attack rate for congenital CMV infection (helps predict probability of transmission to infant)

Diagnosis of fetal infection: detection of CMV in amniotic fluid by viral culture or quantitative PCR (qPCR) assay  — in recent study, almost all infected infants had positive virology testing; viral culture and qPCR assay have very high predictive values for determining if fetus has CMV infection in utero, but cannot predict if infant will be symptomatic at birth 

Outcomes of congenital CMV infection: study of long-term outcomes  —  50 infants followed for 12 mo; of those as­ymptomatic at birth (70%), only one developed sequelae; of those symptomatic at birth, 80% developed long-term sequelae; hearing outcomes in screened infants  —  study identified 74 infants with CMV infection; 3 of 4 symptom­atic at birth had hearing tested; 1 had sensorineural hearing loss (SNHL); of 60 of 70 asymptomatic infants, 21% had SNHL; recent study showed that newborns with high CMV viral load much more likely to develop long term sequelae of infection

Effect of ganciclovir on outcome: 12-mo study of infants with symptomatic CMV disease who received 6 wk of in­travenous (IV) ganciclovir or no treatment; results found treated infants much more likely to have improvement or no worsening of best hearing, and much less likely to have progressive hearing loss; however, therapy and study flawed  

Collaborative Antiviral Study Group (CASG) trial 112: phase III new trial of 6 wk vs 6 mo of oral valganciclovir (oral prodrug of ganciclovir); will include infants with symptomatic CMV disease 30 days of age and ³1800 g at enrollment, and gestational age ³32 wk; subjects to be followed to 5 yr of age; outcomes  —hearing, safety, and neu­rodevelopmental assessment

Suggested Reading

Carson S et al: Pediatric upper extremity injuries. Pediatr Clin North Am 53:41, 2006; Centers for Disease Control and Pre­vention (CDC): Licensure of a Haemophilus influenzae type b (Hib) vaccine (Hiberix) and updated recommendations for use of Hib vaccine. MMWR Morb Mortal Wkly Rep 58:1008, 2009; Centers for Disease Control and Prevention (CDC): Up­dated recommendation from the Advisory Committee on Immunization Practices (ACIP) for revaccination of persons at pro­longed increased risk for meningococcal disease. MMWR Morb MortalWkly Rep 58:1042, 2009; Dowd MD et al: The interpretation of urogenital findings in children with straddle injuries. J Pediatr Surg 29:7, 1994; Fowler SL: A light in the darkness: predicting outcomes for congenital cytomegalovirus infections. J Pediatr 137:4, 2000; Gill MA, Welliver RC: Mo­tavizumab for the prevention of respiratory syncytial virus infection in infants. Expert Opin Biol Ther 9:1335, 2009; Kaye AE et al: Pediatric dog bite injuries: a 5-year review of the experience at the Children's Hospital of Philadelphia. Plast Reconstr Surg 124:551, 2009; Lanari M et al: Neonatal cytomegalovirus blood load and risk of sequelae in symptomatic and asymp­tomatic congenitally infected newborns. Pediatrics 117:1467, 2006; Lazzarotto T et al: New advances in the diagnosis of con­genital cytomegalovirus infection. J Clin Virol 41:192, 2008; Merritt DF: Genital trauma in the pediatric and adolescent female. Obstet Gynecol Clin North Am 36:85, 2009; O'Brien SP, Billmire DA: Prevention and management of outpatient pe­diatric burns. J Craniofac Surg 19:1034, 2008; Schutzman SA et al: Pediatric minor head trauma. Ann Emerg Med 37:65, 2001; Smith JL et al: Management of cervical spine injuries in youngchildren: lessons learned. J Neurosurg Pediatr 4:64, 2009.