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Every summer there seems to be one organism that reminds us why not every child with prolonged diarrhea has “viral gastroenteritis.” With more than 1,000 cases reported during the current multistate outbreak, this is a good time to revisit Cyclospora. Persistent watery diarrhea lasting more than a week, especially during the summer, should make you think of it. Just remember that routine ova and parasite testing may miss the diagnosis unless you specifically ask the lab to look for it.

What is Cyclospora?Cyclospora cayetanensis is a coccidian parasite transmitted through contaminated food or water. In the United States, outbreaks are most commonly associated with imported fresh produce including cilantro, basil, lettuce, salad mixes, and berries. Unlike many diarrheal pathogens, direct person-to-person transmission is unlikely because oocysts passed in stool require days to weeks in the environment before they become infectious. Children, particularly those under 5 years of age, are among the most susceptible populations. Most infections occur during the spring and summer months.

Clinical PresentationThe incubation period averages about 7 days, so exposures are often forgotten by the time symptoms develop. The classic presentation includes:

• Persistent watery diarrhea, often large volume or explosive
• Waxing and waning symptoms
• Abdominal cramping
• Bloating
• Nausea
• Anorexia
• Fatigue
• Low-grade fever
• Weight loss or poor weight gain

Unlike viral gastroenteritis, symptoms frequently persist for weeks if untreated. Many children have already seen another healthcare provider before the diagnosis is considered. A pediatric study from Colombia found that children with cyclosporiasis commonly presented with high-volume watery diarrhea, abdominal pain, and an alkaline stool pH. Younger children and immunocompromised patients generally have more severe disease.

When Should You Suspect It?Cyclospora should be in your differential when a child has:

• Watery diarrhea lasting longer than 7 days
• Symptoms that improve briefly before returning
• Weight loss or dehydration
• Summer presentation
• Recent travel or fresh produce exposure
• Negative bacterial stool studies

One important teaching point: Cyclospora is not spread directly from one person to another. Fresh stool is not immediately infectious because the oocysts must sporulate in the environment before they can infect another host.

DiagnosisA routine ova and parasite examination does not reliably detect Cyclospora, and many laboratories will not specifically look for it unless requested. Depending on your institution, diagnostic options include:

• Gastrointestinal multiplex PCR panel that includes Cyclospora
• Dedicated Cyclospora PCR
• Modified acid-fast stain
• UV autofluorescence microscopy

On modified acid-fast stain:

• Oocysts measure approximately 8 to 10 μm
• Staining is variable
• Some oocysts stain bright red
• Others appear as clear “ghost” organisms

This variable staining pattern helps distinguish Cyclospora from Cryptosporidium, whose smaller oocysts stain more uniformly. If microscopy is used and suspicion remains high, collect multiple stool specimens separated by 2 to 3 days because oocyst shedding is intermittent.

TreatmentTrimethoprim-sulfamethoxazole (TMP-SMX) remains the treatment of choice. 5 mg/kg/day plus SMX 25 mg/kg/day, divided twice daily for 7 days Most children begin improving within 24 to 48 hours, and oocyst shedding rapidly decreases after treatment begins. Immunocompromised children often require a longer treatment course followed by secondary prophylaxis because relapse is common.

If a child has a true sulfa allergy (not a just family history of allergy where a parent is worried) no alternative has proven as effective as TMP-SMX. Potential options include:

• Nitazoxanide
• Ciprofloxacin (generally avoided in children unless benefits clearly outweigh risks)

Both have lower success rates than TMP-SMX. Consultation with infectious diseases is reasonable for patients with severe sulfonamide allergy.

Supportive CareTreatment should also include:

• Aggressive oral rehydration when possible
• IV fluids for moderate or severe dehydration
• Electrolyte replacement
• Nutritional support for prolonged illness

Routine repeat stool testing is unnecessary once symptoms have resolved.

ComplicationsMost immunocompetent children recover completely. More severe disease occurs in immunocompromised patients and may include:

• Prolonged diarrhea
• Relapsing infection
• Significant weight loss
• Severe dehydration

Rare extraintestinal complications have been reported, including:

• Reactive arthritis
• Acalculous cholecystitis
• Ocular inflammation
• Guillain-Barré syndrome

| Cyclospora | Giardia | Cryptosporidium | | --- | --- | --- | | Organism | Coccidian protozoan | Flagellated protozoan | Protozoan | | Infective form | Oocyst (8-10 μm) | Cyst (8-12 μm) | Oocyst (4-6 μm) | | Transmission | Contaminated fresh produce or water; oocysts require days to weeks outside the body before becoming infectious | Fecal-oral; contaminated water or food; cysts immediately infectious when shed | Fecal-oral; contaminated water or food; oocysts immediately infectious when shed | | Person-to-person spread | Rare | Common | Common | | Incubation | ~7 days | 7-14 days | ~7 days | | Typical diarrhea | Watery, often explosive, waxing and waning | Greasy, foul-smelling, fatty stools (steatorrhea) | Profuse watery diarrhea | | Associated symptoms | Cramping, bloating, nausea, weight loss, low-grade fever | Bloating, flatulence, cramping, nausea | Cramping, nausea, vomiting, low-grade fever | | Untreated course | Days to weeks; may last >1 month | 2-6 weeks; may become chronic | Usually self-limited in 2-3 weeks | | Seasonality | Summer; produce-associated outbreaks | Summer through fall | Year-round with summer peaks | | Best diagnostic test | Stool PCR or modified acid-fast stain | Stool antigen or PCR | Stool antigen or PCR | | Treatment | TMP-SMX | Metronidazole, tinidazole, or nitazoxanide | Supportive care (nitazoxanide in selected immunocompetent patients) |

Take Home Points* Persistent watery diarrhea lasting more than a week is not always viral. * Cyclospora should be considered during the summer months and during recognized outbreaks. * Routine ova and parasite testing may miss the diagnosis unless Cyclospora testing is specifically requested. * PCR is the most sensitive diagnostic method when available. * TMP-SMX remains the treatment of choice and usually produces rapid clinical improvement. * Unlike many enteric pathogens, person-to-person spread is extremely unlikely.

Bottom LineCyclospora is uncommon enough that it’s easy to forget, but common enough during outbreaks that it belongs on the differential for prolonged watery diarrhea. The presentation is fairly characteristic, the diagnosis requires the right stool test, and treatment is highly effective. As summer progresses, don’t let persistent diarrhea get dismissed as “just another viral gastroenteritis.”

References Stobbe M. Outbreak of diarrhea-causing parasite grows to more than 1,000 cases. ABC News. Published July 8, 2026. Accessed July 10, 2026. * Bilung LM, Tahar AS, Yunos NE, et al. Detection of Cryptosporidium and Cyclospora oocysts from environmental water for drinking and recreational activities in Sarawak, Malaysia. Biomed Res Int. 2017;2017:4636420. doi:10.1155/2017/4636420. * Giangaspero A, Gasser RB. Human cyclosporiasis. Lancet Infect Dis. 2019;19(7):e226-e236. doi:10.1016/S1473-3099(18)30789-8. * Pyzocha N, Cuda A. Common intestinal parasites. Am Fam Physician.* 2023;108(5):487-493. * Centers for Disease Control and Prevention. Clinical care of cyclosporiasis. Updated March 8, 2024. Accessed July 10, 2026.

AI Disclosure: ChatGPT (OpenAI) was used to assist with editorial revisions and to generate the stylized header artwork depicting the word “Cyclospora” formed from lettuce leaves. All medical content was written, reviewed, and approved by the author, who assumes full responsibility for the final article.

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Fishhook injuries are common, usually straightforward, and surprisingly under-discussed in emergency medicine education. Most of us learn fishhook removal by watching another clinician do one, removing a few ourselves, and slowly accumulating preferences over time. There are relatively few comparative studies, no major practice-changing trials, and not much formal teaching. Yet if you work in pediatric emergency medicine, urgent care, sports medicine, or primary care long enough, eventually somebody is walking into your room with a fishhook in a finger.

This post accompanies the latest episode of PEM Currents and reviews practical fishhook removal techniques, pain management, procedural considerations, and post-removal care in children.

Initial AssessmentFishhook injuries in children most commonly involve the hands and head and can generally be managed in the emergency department or urgent care setting with local anesthesia and basic equipment. The first step is not choosing a removal technique, it is understanding the injury.

Questions I think through before touching the hook include: Is this a single hook or a treble hook? Is the hook barbed? How deeply embedded is it? Is this near a tendon, joint, nerve, vessel, or the eye? Was the injury sustained in freshwater, saltwater, or out of water entirely? Has anyone already attempted removal?

A treble hook deserves special mention because it changes procedural planning. Treble hooks consist of three individual hook points and barbs fused to a single shank and eye. Even when only one point is embedded, the additional exposed hooks create opportunities for secondary injury to both patient and clinician during removal.

If there is concern for globe injury, stop. Fishhook injuries involving the eye are not routine emergency department procedures and warrant ophthalmology involvement.

Fishhook Removal TechniquesThere is not one “correct” fishhook removal technique. Four classic approaches are described in the literature and each has advantages depending on the anatomy and characteristics of the hook.

Retrograde TechniqueRetrograde removal is the simplest conceptually and is usually what families expect. Pull the hook back out the same direction it entered. This works best for barbless hooks or very superficial hooks where the barb has not fully engaged tissue. Unfortunately, most hooks encountered clinically are barbed. Once the barb catches tissue, simple backward traction usually increases pain and tissue distortion without successfully removing the hook. Because of that limitation, retrograde removal is often less successful for embedded fishhooks.

Advance-and-Cut TechniqueThis is probably the technique I use most often. Advance-and-cut sounds counterintuitive when you explain it to families because the plan is to continue advancing the hook rather than removing it immediately. Mechanically, however, it makes excellent sense. The hook is advanced through the skin until the barb exits completely. Heavy wire cutters are then used to remove the barb, allowing the remaining smooth portion of the hook to be withdrawn back through the original tract. The obvious tradeoff is creation of a second puncture wound. In practice, however, this additional wound is often less traumatic than repeated unsuccessful attempts at extraction. Children generally tolerate one good attempt significantly better than multiple failed attempts.

String-Yank TechniqueThe string-yank technique is widely demonstrated online and occasionally performed in field settings. String or heavy suture is looped around the bend of the hook while downward pressure is applied to disengage the barb. A quick pull parallel to the hook shaft removes the hook. When successful, removal is nearly instantaneous. The challenge in pediatrics is cooperation. This approach becomes more difficult in anxious children, younger children, deeply embedded hooks, and treble hooks.

Needle-Cover TechniqueThe needle-cover method receives less attention but remains useful in selected situations. An 18-gauge needle is inserted alongside the hook until the bevel covers the barb, and both are withdrawn together. The main advantage is minimizing tissue trauma and avoiding creation of a second puncture site. The downside is technical complexity. Maintaining alignment between the needle and hook can be challenging, particularly in smaller children.

Pain Management and Procedural SupportMost fishhook removals in children can be performed with local anesthesia alone. Lidocaine 1% with or without epinephrine is usually adequate. Depending on location, digital blocks or field blocks may be preferable to local infiltration because infiltration itself can distort tissue planes and complicate removal. One practical strategy worth considering is topical anesthetic before injection. LMX or EMLA can reduce the discomfort of local infiltration, particularly in anxious children. The limitation is timing. These agents generally require approximately 40 to 60 minutes for meaningful effect, so they only help if procedural planning starts early.

In children, procedural success is rarely determined by analgesia alone. Child life support, distraction, parental coaching, videos, music, and procedural preparation frequently determine whether a straightforward removal stays straightforward. Most children do not require procedural sedation, although anxiolysis with midazolam or inhaled nitrous oxide can be extremely helpful. Ketamine remains an excellent option for selected cases involving failed attempts, difficult anatomy, or children who cannot tolerate removal safely.

Antibiotics and AftercareFishhook removal does not automatically require antibiotics. A prospective study of 100 fishhook injuries found prophylactic antibiotics unnecessary for uncomplicated soft tissue injuries not involving cartilage or tendon. Situations where antibiotics deserve consideration include delayed presentation, gross contamination, tendon involvement, joint involvement, water exposure, or signs of established infection. Freshwater exposure raises concern for organisms such as Aeromonas. Saltwater injuries introduce consideration of Vibrio species and occasionally Mycobacterium marinum.

Once the hook is removed, wound management is generally simple. Irrigate the area, inspect for retained fragments, reassess neurovascular status and range of motion, apply a basic dressing, and review tetanus status. Families often ask when their child can fish again. Usually sooner than they expect. Maybe just avoid standing directly behind whoever is casting.

Take-Home Points* Fishhook removal is usually straightforward but benefits from deliberate technique selection. * Advance-and-cut is broadly reliable and often my preferred approach in children. * Local anesthesia is sufficient for most patients, though procedural planning and anxiolysis frequently determine success. * Routine antibiotics are unnecessary for uncomplicated injuries. * And if the hook involves the eye, that is no longer a fishhook removal problem, it is an ophthalmology problem.

ReferencesGammons MG, Jackson E. Fishhook removal. Am Fam Physician. 2001;63(11):2231–2236.

Prats M, O’Connell M, Wellock A, Kman NE. Fishhook removal: case reports and a review of the literature. J Emerg Med. 2013;44(6):e375-e380. doi:10.1016/j.jemermed.2012.11.058

Doser C, Cooper WL, Ediger WM, et al. Fishhook injuries: a prospective evaluation. Am J Emerg Med. 1991;9(5):413–415. doi:10.1016/0735-6757(91)90204-w

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Well, probably not.

For years there has been this lingering idea in pediatric emergency medicine that maybe some preschool wheezers are different. Maybe some of these kids are not “just viral.” Maybe there is a subgroup with bacterial colonization, airway inflammation, or some overlapping phenotype where azithromycin actually helps. And honestly, it was not a completely bogus theory.

Earlier studies found higher rates of bacteria like Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae in children with recurrent wheezing. Macrolides also have anti-inflammatory effects. So it was pretty easy to justify giving azithromycin to a miserable wheezing 3-year-old in the ED.

The new AZ-SWED trial from PECARN in the New England Journal of Medicine gives us the clearest answer we have had so far.

Spoiler alert: Azithromycin probably does not help.

What Was the Study?AZ-SWED was a multicenter, randomized, double-blind, placebo-controlled trial from PECARN looking at preschool children with moderate-to-severe wheezing presenting to the emergency department.

Children 18 to 59 months of age received either:

• Azithromycin for 5 days
• Matching placebo

The investigators also specifically looked at whether bacterial carriage changed outcomes. That is important because a lot of the enthusiasm around azithromycin has centered around the idea that maybe certain bacteria are contributing to these wheezing episodes.

The primary outcome was symptom severity over 5 days using the Asthma Flare-up Diary for Young Children (ADYC).

So Did It Work?Nope – There was no meaningful difference in symptom severity between the azithromycin group and the placebo group. Even when they separated kids into bacterial-positive and bacterial-negative groups, the results were basically identical.

Bacterial-positive subgroup:

• Azithromycin: 10.34
• Placebo: 10.39

Bacterial-negative subgroup:

• Azithromycin: 9.76
• Placebo: 9.83

But Wait, There’s More… (Sort of)Azithromycin did exactly what you would expect an antibiotic to do, it reduced bacterial carriage. But those kids did not actually get better. Respiratory viruses were identified in 86.1% of participants, and rhinovirus showed up in nearly three quarters of cases. Azithromycin also substantially increased bacterial clearance at follow-up. But none of that translated into improved symptom scores, shorter illness duration, or better clinical outcomes.

In retrospect, the bacteria may have just been along for the ride. Treating bacterial carriage did not really change the clinical course. And it also raises an interesting question: if you already clinically think the child has a viral wheezing illness, how much should airway bacterial testing change management in the first place?

Why AZ-SWED MattersThis is a great example of a useful “negative” trial. Recruitment was actually discontinued early for futility. Preschool wheezing is common, frustrating, heterogeneous, and exhausting for families. When a child keeps wheezing, keeps coming back, and keeps needing albuterol, there is a strong temptation to try something else. Azithromycin became one of those “maybe this helps” therapies in a lot of places. AZ-SWED pushes back on that practice.

The study does not support routine azithromycin use for established acute preschool wheezing in the emergency department. Which is important for:

• antibiotic stewardship
• cost
• side effects
• and avoiding treatments that sound biologically plausible but do not actually improve patient-centered outcomes

The Final WordOne of the most important things in medicine is learning to separate interventions that make us feel better from interventions that make patients better. Azithromycin changed the bacteria. But the bacteria was probably just there, minding its own business. It just didn’t change the child in front of you.

The wheezing toddler still needs good supportive care, bronchodilators when appropriate, reassessment, caregiver education, and thoughtful follow-up. But this study makes it harder to justify routinely prescribing azithromycin once the child is already in the ED with an established wheezing episode. It also helps us think about swabbing noses for infectious causes in the first place… But that’s an issue for another day.

That’s why they do the studies!

ReferencesDenninghoff KR, Casper TC, Zorc JJ, Ruddy RM, Satola S, Wendt W-J, Morris CR, et al; for the PECARN AZ-SWED Trial Study Group. Azithromycin for preschoolers with wheezing in the emergency department. N Engl J Med. Published online May 18, 2026. doi:10.1056/NEJMoa2516505.

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This is the only non-medical post I publish each year. The annual anniversary video that I plan, film, edit, and produce for my wife. I’ve been making them since our third anniversary. This is number 19.

OK, so once again, I’m going to have to apologize to Kerri for not making time to buy the perfect anniversary card from Hallmark. I’ve been really busy, so busy, in fact, that I asked AI to write this message. So here goes.

Year 19 — and still no Hallmark card. At this point it’s a system — a tradition — a feature, not a bug. Three songs — three moods — one story:

“Wild Wild Life” — Talking Heads

“Reckoner” — Radiohead

“Let My Love Open the Door” — Pete Townshend

Nineteen years — three kids — a lifetime of moments compressed into minutes. What started as a backup plan became a ritual — a timeline — a living archive of us. No card — no store aisle — no perfect prewritten message. Just this — every year — on repeat — but different. Kerri — still my favorite person — still the whole point. Happy Anniversary — I love you!

OK, that was terrible. Well, Happy 19th Anniversary, Kerri. Here’s a video I made for you:

A YouTube playlist with all of the previous anniversary videos: https://www.youtube.com/playlist?list=PLAh5F9d2aT_tzwTTME7UoDcmxUv8ekPuG

A website with all of the previous anniversary videos: https://bradsobolewski.com/anniversaryvideos/

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Croup is a clinical syndrome of upper airway obstruction defined by barking cough, stridor, and hoarseness. Management hinges on severity assessment, universal corticosteroid use, and selective epinephrine. The key clinical task is distinguishing typical croup from high-risk mimics that require urgent airway intervention.

Learning Objectives1. Differentiate croup from other causes of pediatric upper airway obstruction using key historical and physical exam features. 2. Apply a severity-based approach to croup management, including appropriate use of corticosteroids and nebulized epinephrine. 3. Recognize clinical features that suggest alternative or life-threatening diagnoses requiring escalation of care.

References1. Cooke A, Conway S, Griffin L. Croup: Rapid Evidence Review. Am Fam Physician. 2026;113(3):254-258. 2. Gates A, Johnson DW, Klassen TP. Glucocorticoids for Croup in Children. JAMA Pediatr. 2019;173(6):595-596. doi:10.1001/jamapediatrics.2019.0834 3. Bjornson CL, Klassen TP, Williamson J, et al. A Randomized Trial of a Single Dose of Oral Dexamethasone for Mild Croup. N Engl J Med. 2004;351(13):1306-1313. doi:10.1056/NEJMoa033534 4. Bjornson CL, Johnson DW. Croup. Lancet. 2008;371(9609):329-339. doi:10.1016/S0140-6736(08)60170-1 5. Bjornson C, Russell K, Vandermeer B, Klassen TP, Johnson DW. Nebulized Epinephrine for Croup in Children.Cochrane Database Syst Rev. 2013;(10):CD006619. doi:10.1002/14651858.CD006619.pub3

TranscriptThis transcript was generated using Descript and subsequently reviewed and lightly edited for spelling, grammar, and clarity. Minor inaccuracies may remain, and the audio recording should be considered the definitive version of this content.

Welcome to PEM Currents: The Pediatric Emergency Medicine Podcast. As always, I’m your host, Brad Sobolewski. And today we’re gonna talk about croup. We’re gonna focus on diagnosis, severity based management, and how to differentiate it from scarier high risk conditions that may present similarly, but behave very differently.

So croup is best understood as a clinical syndrome of upper airway obstruction caused by inflammation at the level of the larynx and subglottis. So in most cases this is viral laryngotracheitis, most commonly due to parainfluenza virus. But as you’d expect multiple viruses can cause it. The subglottis is the narrowest portion of the pediatric airway.

So even small amounts of edema create large increases in airway resistance. So that’s why the clinical picture is so consistent. You’ve got inspiratory stridor, hoarseness, and that characteristic barking cough, which either sounds like a seal or a dog, and yes, of course, I know the difference between the two coughs because I was a biology major.

This is primarily a disease of children between six months and three years of age with a peak incidence in the second year of life. It’s really, really common, like one and a half percent of all ED visits, maybe 350,000 visits a year, and 85% of these kids have mild disease. Hospitalization is rare. The range is variable, about two to 8% of cases, and return visits occur in about three to 5%. Fewer than 1% of children, a lot fewer, require intensive care or airway intervention. Honestly, most kids do really well. The ones who don’t can get sick very quickly, and that’s been my clinical experience.

In the Northern Hemisphere, we see croup throughout the fall and winter, usually starting in around November and sort of tapering off by April. But that being said, I’ve seen croup-like symptoms every month of the year over the past couple of decades.

Croup is absolutely a classic clinical diagnosis. A typical case begins with 12 to 48 hours of viral prodrome, you know, body aches, fever, congestion, cough, followed by often abrupt nighttime onset of barky cough and stridor. Symptoms fluctuate, and they’re generally worse with agitation and get better when the kid is calm. That variability is the key feature.

So what you’ll have is a child who wakes up after sleeping for a few hours with a barky cough and then noisy stridor. This freaks parents out, and this is not hyperbole. There’s this little center in the back of your brain that’s like, please don’t stop breathing and die. So appropriately, they’re worried about the kid, they call emergency medical services, they bring them to the emergency department, and by and large, by the time they get there, the stridor has resolved. The kid is calm, and parents will say, I swear he looked a lot worse at home. Trust me, we believe you parents, this is what croup does.

When I’m taking a history of croup, I get all of these details. Are there any sick contacts? If the parents are worried about a foreign body inhalation or ingestion, then I’m worried about a foreign body inhalation or ingestion. Listen to the lungs, inspect their airway. Always check the ears for concomitant otitis and I’ll feel their trachea. I’ll actually grab and hold the trachea and move it. Kids with croup really don’t have a painful trachea. Kids with bacterial tracheitis, aside from looking more toxic, actually have a lot of pain when they move their trachea.

Testing for croup is generally unnecessary. Labs and viral studies do not change management, and imaging is really reserved for atypical presentations or when you’re considering an alternative diagnosis like a foreign body. If you do get an X-ray, what you’re looking for is the classic steeple sign on the AP view. It is seen in croup, but it’s not 100% sensitive nor specific.

Once you’ve made the diagnosis of croup, it’s important to assess severity, and remember that I said that most kids are mild. So mild croup is defined by the absence of stridor at rest. So they may have some stridor when they’re upset or even a little bit of hoarseness or noise. It’s important to listen to many, many children with croup to get a sense of this.

Moderate croup includes stridor at rest with mild to moderate retractions. So at rest means that the child is in a position of comfort. They’re calm with a parent, and they’ve generally been that way for about 10 to 15 minutes. Sometimes that’s how long it can take for the stridor to dissipate once you get the kid calm.

Severe croup, which is fortunately rare, involves marked work of breathing, agitation, fatigue, need for oxygen, altered mental status, and this aligns with the Westley croup score. It formalizes stridor, retractions, air entry, cyanosis, and mental status. But really, in practice, most of us get very good at bedside assessment of croup.

Management of croup starts with corticosteroids. This is one of the highest-yield interventions that we have in pediatric emergency medicine. Every child with croup should receive dexamethasone. Typically 0.6 milligram per kilogram as a single dose up to a maximum of 10 milligrams. Some places will use 0.15 milligram per kilogram.

Locally, we often give the IV formulation orally. It’s 10 milligrams per mL. Tastes bad, but pairs reasonably well with apple juice. The oral suspension is 1 milligram per mL, tastes terrible, and pairs nicely with being spit on the ground by toddlers.

The evidence behind dexamethasone is very robust. The main benefit is that it reduces return visits and hospital readmissions by about half, and those return visits include doctor’s offices and emergency departments. In a Cochrane review of 1,679 children, glucocorticoids reduce return visits or readmissions with a risk ratio of 0.52, so that translates to a number needed to treat of seven.

I’ve certainly seen seven or more croup kids during one shift, so for every seven children treated with dexamethasone, one return visit is prevented. Symptom improvement begins within about two hours and lasts at least 24 hours, but maybe up to a couple of days. Hospital length of stay for kids that get steroids is reduced by an average of 15 hours as well. Serious adverse events are rare. It’s well tolerated, and other than the taste, kids do fine with it. And importantly, the benefit is consistent across all severities of croup, mild, moderate, and severe.

So when you explain this to families who are very scared about their kids, but now their kid is looking better and you’re only giving them a single medicine, not doing any tests or X-rays or anything, I think you have to frame the medicine in terms of what it’s going to do for them over the next couple of days.

So one way of explaining this to families would be to say something like this is a steroid called dexamethasone. It reduces the swelling in your child’s airway that’s causing the barky cough and noisy breathing. Most children start feeling better within a couple of hours, and the benefit lasts at least a full day, if not longer.

Without this medicine, about one in five children need to come back because symptoms get worse again. You really get two bad days with croup in most cases. With this medicine, the risk of returning drops to about one in 10, so it cuts the chance of coming back in half.

We can expect your child’s cough to start improving over the next day or two. Most children are feeling a lot better within 48 hours, though a little bit of hoarseness and cough can last for a week to about 10 days.

So it’s possible that when your child goes to sleep later tonight, they may experience that barking cough and noisy breathing again. They’re almost certainly going to be upset. The steroid blunts enough of the swelling so that you are much more likely to have them free of distress and stridor, that noisy breathing, once you get them calm.

So if they’re upset, get them calm, and if in about 10 minutes the stridor and noisy breathing get better, that’s the dexamethasone doing its job and you can safely stay home.

For children with moderate or severe croup, we’re gonna use nebulized racemic epinephrine. It works fast by reducing airway edema by constricting inflamed blood vessels. You’ll see improvement in stridor and work of breathing often within 30 minutes. The effect is transient and largely gone by about two hours, and you need to do a structured reassessment at about 30 minutes after the racemic epinephrine.

If the child’s clearly better, continue that observation for up to two hours. If they’re unchanged or worse, repeat the epinephrine and start thinking more carefully about your diagnosis and disposition. Because it’s got such a short duration, that two hours after treatment is the most common time period, though some institutions and some children will need to be observed a little bit longer.

If they remain well appearing with no stridor at rest, normal oxygenation, minimal work of breathing, and they can tolerate oral fluids, they can be discharged. If symptoms recur, they require repeated epinephrine, or they fail to improve, then you may have to escalate care and consider admission.

Honestly, with croup, supportive care is still one of the most important things. You gotta keep kids calm by minimizing agitation. Parents are experts at this with their own children. Agitation worsens airway obstruction. Airway resistance is fourfold greater when the kid’s upset.

Give oxygen if the kid’s hypoxic. Fortunately, this is rare. Antipyretics and fluids are great, do them. Humidified air has not been shown to provide meaningful benefit, and obviously we should avoid sedatives because they can suppress respiratory drive without improving airway patency.

Many parents will say that their kid was better when they were exposed to cool air or mist in the shower. Those can help, but honestly, don’t stick your kid’s head in the freezer if it upsets them. Keep them calm, hold them, and comfort them.

Alright, croup, barking cough, stridor, variable symptoms, easy, right? There are some other diagnoses that can mimic this or overlap that you shouldn’t miss.

Spasmodic croup is a related phenotype. You’ve got sudden nighttime onset, often minimal prodrome, and recurrent episodes. These kids are typically well between episodes, and the pattern becomes more apparent over time. Some kids will bark with every mild cold or stuffy nose up until about eight or nine, but they usually don’t have stridor and respiratory distress.

Bacterial tracheitis is progression to a more severe and dangerous airway infection. These children often start with viral symptoms and then rapidly worsen. They’ve got a high fever, they appear toxic. Most importantly, they fail to respond to standard croup therapy. Toxic appearance plus lack of response should immediately shift your diagnostic reasoning.

These kids may have a lot of pain when you grab and move their trachea. The cough can be more junky because again, they’ve got purulent mucus in their trachea.

Epiglottitis is defined by the absence of barking cough and the presence of drooling, dysphagia, and tripod positioning. These children are very anxious, they’re very ill, their airway is at risk, and so your immediate priority is keeping them calm and having the airway managed in the safest environment, generally the operating room.

Deep neck space infections, including retropharyngeal cellulitis and abscesses and peritonsillar abscesses, present with fever, neck stiffness, sometimes even torticollis, and lymphadenopathy. Kids won’t really have a barky cough and the exam localizes to the neck rather than the airway alone.

Acute foreign body aspiration presents with sudden onset symptoms, no viral prodrome, no barking cough, and sometimes some asymmetric exam findings. The diagnosis is frequently missed when clinicians anchor too early on croup.

If you have an esophageal foreign body, remember that 70% of these get stuck at the thoracic inlet. So always think about a kid who sounded like they had croup and got croup treatments, but also has some swallowing issues and is the right age to put things in their mouth. This is when you see coins and button batteries and other things stuck not in the upper airway, but in the esophagus right behind it.

Alright, now when it comes to disposition, most kids with croup are gonna be sent home. Children who improve, they have no stridor at rest, minimal work of breathing, can be discharged home with clear return precautions. Those with persistent symptoms, need for repeated racemic epinephrine, hypoxia, or concerning features should be admitted.

For kids who continue to worsen despite standard therapy, escalation includes high-flow nasal cannula, noninvasive ventilation as a bridge. Heliox can be used as a temporizing measure to reduce work of breathing.

Fortunately, needing to intubate a child with croup is rare, but when it’s needed, it can be challenging due to subglottic narrowing. You need the best proceduralists, and you should downsize your endotracheal tube by 0.5 to 1 millimeter smaller than usual.

And I’ll reiterate this again. The natural course of croup is really favorable for most kids. The fear’s not gonna go away for the parents, this is a scary diagnosis, but I think with some reassurance, we can help them understand that this is something that is unlikely to cause significant problems and will get better.

Most kids improve significantly within 48 hours, though like any other respiratory illness, symptoms can persist for a week or so. Severe outcomes are fortunately rare, and they almost always occur in children whose severity or alternative diagnosis was not recognized early.

So again, here’s my take-home points. Croup is a clinical diagnosis. Severity determines your management. Steroids, dexamethasone, should be given to all patients. Racemic epinephrine is used for moderate to severe disease with mandatory reassessment and observation. And most importantly, always reassess the diagnosis when the presentation does not fit the expected patterns.

Things can get rough when you’re barking up the wrong tree and thinking it’s croup when it’s actually something else.

Well, I hope you enjoyed this episode on honestly one of the most classic conditions that we see in the pediatric emergency department. If you’ve got any feedback on the episode, send it my way.

As the kids would say, like, rate, and review. I would love it if you left a review on your favorite podcast site. It helps more people find the show. I do this as a labor of love because I enjoy teaching, and I think that this is a wonderful way to reach my colleagues and learners.

If you’ve got suggestions on other topics or episodes, I’d love to hear them.

For PEM Currents: The Pediatric Emergency Medicine Podcast, this has been Brad Sobolewski. See you next time.

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Every flu season, the question comes up, “Is the vaccine actually helping this year?” This year according to the CDC flu MMWR, the answer is yes, even with a drifted strain, and the details matter.

What the Data ShowAcross U.S. surveillance networks this season:

• 24%–36% reduction in flu-related medical visits
• 31% reduction in flu-related hospitalizations

In children:

• 38% lower likelihood of a flu-related medical visit
• 48% lower likelihood of hospitalization

These are meaningful reductions, particularly in hospitalization, which is where the biggest impact is for pediatric patients.

The Strain MismatchMost of the circulating viruses this season have been influenza A(H3N2) subclade K, which is antigenically different from the strain used in the vaccine. That mismatch matters. It lowers overall vaccine effectiveness and explains why we are still seeing a lot of flu. However, vaccination is still reducing the likelihood of needing care and the likelihood of hospitalization. That’s consistent with what we would expect biologically, partial immune recognition still translates into less severe disease.

The Bigger Issue: UptakeAs of February 22, 2026, fewer than half of children and adults in the U.S. have received a flu vaccine this season. So while it’s easy to focus on the circulating virus mismatch, the larger issue is that many patients remain unvaccinated. In the Emergency Department, we should continue to recommend vaccination. Even late in the season, there is benefit as long as influenza is circulating.

We should also use antivirals appropriately. While the reduction in symptom duration, roughly a day, may not be clinically meaningful for many otherwise healthy children, there are groups where treatment matters because of higher risk for complications. In those patients, oseltamivir should be part of routine management. Specifically:

• Children being admitted with influenza
• Children younger than 2 years
• Children who are immunocompromised
• Children with chronic medical conditions, especially asthma and other cardiopulmonary disease

The Bottom LineThis is not a perfectly matched vaccine year, but the vaccine is still reducing visits and hospitalizations, especially in children. The dominant circulating strain, A(H3N2) subclade K, has drifted, but protection against severe outcomes remains. Vaccination rates remain suboptimal, and improving uptake likely has more impact than any incremental change in strain match.

ReferenceMaloney P, Reeves EL, Wielgosz K, et al. Interim Estimates of 2025–26 Seasonal Influenza Vaccine Effectiveness — United States, September 2025–February 2026. MMWR Morb Mortal Wkly Rep 2026;75:116–123. DOI: http://dx.doi.org/10.15585/mmwr.mm7509a2.

Note: This post was edited with the assistance of artificial intelligence (ChatGPT, OpenAI GPT-5.3). The content, interpretation, and final wording were reviewed and approved by the author. And, oh yeah, AI also helped make the banner image because I’m not that good at drawing.

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You could just touch the fluorescein strip to the patient’s inner eyelid when trying to diagnose a corneal abrasion. But then you could cause a corneal abrasion, which is an ouroboros of terribleness from which there is no escape. So why don’t you try making a dropper instead, as detailed in this video. All you need is:

• one saline flush
• one angiocath
• one fluorescein strip

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Take Home Point: Early stylet removal is a technique that results in a greater success rate on lumbar punctures performed on infants

Note: This post is an update from 2014 – yes, I’ve been blogging that long

There are numerous techniques that we can use to improve our likelihood of success in performing a lumbar puncture. There is one that has a bit of nuance to it that I thought would be an excellent theme for a Why We Do What We Do post. So, without further ado, let’s talk about early stylet removal. Somehow it got the nickname “The Cincinnati Method” – but this was well before my time in the Queen City.

How does one actually perform it?1. Insert the spinal needle with the stylet in place 2. Advance completely past the epidermis and dermis (<1cm in most children) 3. Remove the stylet 4. Advance forward until reflux of CSF noted 5. Reinsert the stylet and withdraw the needle

Here is a video tutorial on lumbar puncture that I produced for the AAP’s PediaLink platform. Skip ahead to 4:27 wish if you want to go to the early stylet removal part.

So, why does this technique actually make a difference?In short, you avoid overshooting the subarachnoid space and hitting the vascular plexus of the ventral epidural space. Interestingly, you can measure the depth to the subarachnoid space if you’re interested by using the following calculation which I promise to never, ever ask anyone to do on a shift:

MATH ALERT!!! Depth of LP = 0.77cm + (2:56 × BSA [in meters squared]) MATH ALERT!!!I think this diagram is really the most helpful in showing why early stylet removal is beneficial.

As you can see in the diagram above, with the stylet still in place if you enter in the midline perpendicular to the CSF target you have the maximum space from which to get fluid. But, if your angle of entry is slightly off (only a few degrees will do it) you can see that the angle becomes more magnified. Using early stylet removal will allow you to see reflux of fluid into the spinal needle the instant you enter the space, thus giving you confirmation before you “back wall” the needle into a venous plexus.

Are there any risks?Those of us who have been performing LPs for a loooong time may recall an epoch where butterfly needles were used to perform LPs. Those procedures left patients at risk for intraspinal epidermoid tumors – late appearing intraspinal masses after an unstyleted needle pushing epidermal cells into the intraspinal space. These can create a mass effect. See this case series from a while back for more information on how they presented. Fortunately, the use of styleted needles mitigated this risk. Theoretically the early stylet removal technique could cause the same risks if the stylet was removed before passing through the dermis – fortunately the best practice technique specifies that you should not remove the stylet until you have passed through the epidermis and dermis. There is no evidence – case series or otherwise –

What’s the evidence?You wouldn’t want me to recommend something without supporting evidence would you? Well, in 2006 Baxter et al. published their findings of a prospective observational study in PEDIATRICS. They reviewed 428/594 (72%) infant LPs – 377 of which were performed by trainees. Seventy-four percent (279/377) of the trainee LPs were successful. Amongst other factors local anesthesia was used for 280 (74%), and 225 (60%) were performed with early stylet removal. They found the following;

• LPs were more likely to be successful in infants >12 weeks of age – OR=3.1 (95% CI 1.2-8.5)
• Local anesthetic use showed increased odds of success OR=2.2 (95% CI 1.04-4.6)
• In infants ≤12 weeks of age, early stylet removal improved success rates – OR=2.4 (95% CI 1.1-5.2)
• Position (upright vs side-lying), drape use, and year of training were not significant predictors of success

So, as you can see – there is evidence and it stands firmly in the camp of those patients under the age of 12 weeks. However, that being said, I use this technique no matter the age of the patient. I do think that this is an example of where understanding a little bit more about why a certain technique is used will make a difference.

ReferencesBaxter et al. Local anesthetic and stylet styles: factors associated with resident lumbar puncture success. Pediatrics. 2006 Mar;117(3):876-81. PMID: 16510670.

Bonadio, Pediatric lumbar puncture and cerebrospinal fluid analysis. J Emerg Med. 2014 Jan;46(1):141-50. PMID: 24188604.

Ziv et al. Iatrogenic intraspinal epidermoid tumor: two cases and a review of the literature. Spine (Phila Pa 1976). 2004 Jan 1;29(1):E15-8. PMID: 14699293.

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Psychogenic nonepileptic seizures, or PNES, are common, frequently misunderstood, and increasingly encountered in pediatric Emergency Departments. These events closely resemble epileptic seizures but are not caused by abnormal electrical activity in the brain. When misidentified or poorly communicated, PNES can lead to unnecessary testing, medication exposure, ICU admissions, and long-term harm.

This post reviews how to recognize PNES in children and adolescents and provides a practical, evidence-based Emergency Department approach to diagnosis, management, and communication.

Podcast EpisodeWhat Are PNES?PNES are paroxysmal events that resemble epileptic seizures but occur without epileptiform EEG correlates. They are best understood as a subtype of functional neurological symptom disorder, specifically functional or dissociative seizures. Historically, these events were often referred to as “pseudo-seizures.” That term still appears in clinical conversations and documentation but is outdated and misleading. “Pseudo” implies that the events are fake or voluntary, which is incorrect. PNES events are real, involuntary, and distressing, even though they are not epileptic.

Preferred terminology includes psychogenic nonepileptic seizures (PNES), functional seizures, and dissociative seizures. PNES is not a diagnosis of exclusion and does not require identification of psychological trauma or psychiatric disease. Diagnosis is based on positive clinical features and careful semiology analysis.

EpidemiologyPNES are not rare, and their recognition in pediatric populations has increased over time. Population-based studies estimate an incidence of approximately 7.4 per 100,000 person-years among children and adolescents aged 5 to 17 years. Prevalence estimates range from 23.8 per 100,000 when all clinically diagnosed cases are included to 10.6 per 100,000 when limited to video-EEG confirmed cases.

Among children undergoing video-EEG monitoring for suspected seizures, 15 to 19 percent are ultimately diagnosed with PNES. In tertiary epilepsy monitoring units, paroxysmal non-epileptic events account for roughly 15 to 20 percent of monitored patients. Age has a strong influence on prevalence. PNES become more common with increasing age, with the highest prevalence seen in adolescents aged 15 to 19 years. Adolescents account for nearly half of pediatric PNES cases seen in monitoring units. Younger children under 6 years still represent approximately one quarter to one third of cases.

Comorbid epilepsy is common and clinically important. Between 14 and 46 percent of pediatric patients with PNES also have epilepsy, which frequently delays diagnosis and complicates management. Overall, PNES are common, often coexist with epilepsy, and the ED is frequently the first setting where the pattern becomes apparent.

PathophysiologyPNES are best conceptualized as a disorder of abnormal brain network functioning rather than structural disease. Current models emphasize altered attention and expectation, impaired integration of motor control and awareness, and dissociation during events. Psychological and psychosocial stressors are common but not required for diagnosis and may be less prevalent in pediatric populations than in adults. PNES are brain-based events. They are not conscious behavior, not malingering, and not under voluntary control.

Risk Factors* Children and adolescents with PNES have significantly higher rates of psychiatric comorbidities and psychosocial stressors compared to both healthy controls and youth with epilepsy alone. * Psychiatric disorders are present in approximately 40 percent of pediatric PNES patients. Anxiety is present in about 58 percent, depression in 31 percent, and ADHD in 35 percent. * Compared to youth with epilepsy, the risk of psychiatric disorders in PNES is nearly doubled. Compared to healthy controls, the risk is five to eight times higher. * A distinct somatopsychiatric profile strongly predicts PNES. This includes multiple medical complaints, psychiatric symptoms, high anxiety sensitivity, and solitary emotional coping. When present together, this profile carries an odds ratio of approximately 15 for PNES. * Comorbid epilepsy occurs in 14 to 23 percent of pediatric PNES cases and is associated with intellectual disability and prolonged diagnostic delay. Across all demographic groups, anxiety is the most consistent predictor of PNES.

Clinical Features and Seizure SemiologyNo single feature diagnoses PNES. Instead, patterns of semiology and context are key. Semiological features with high specificity for PNES include long event duration, typically greater than three minutes, fluctuating or asynchronous limb movements, pelvic thrusting or side-to-side head movements, ictal eye closure often with resisted eyelid opening, ictal crying or vocalization, recall of ictal events, and rare association with injury.

Age-related patterns are common. Younger children more often present with unresponsiveness, while adolescents more commonly demonstrate prominent motor activity. In pediatric cohorts, the most frequent semiology includes rhythmic motor activity in approximately 27 percent of cases and complex motor movements and dialeptic events in approximately 18 percent each. Features that argue against PNES include sustained cyanosis with hypoxia, true lateral tongue biting, stereotyped events that are identical each time, clear postictal confusion or lethargy, and epileptic EEG changes during events.

DiagnosisVideo-EEG monitoring is the diagnostic gold standard, capturing typical events without epileptiform activity. However, video-EEG is not feasible for every patient. A diagnosis of probable PNES can be made based on a detailed clinical history, careful seizure semiology, and reassuring interictal EEG findings. Normal laboratory tests and imaging do not establish the diagnosis. Psychiatric comorbidities are not required. PNES is diagnosed using positive clinical features rather than by exclusion.

Emergency Department ApproachInitial management should always prioritize stabilization of airway, breathing, and circulation. Patients should be protected from injury using seizure precautions. If the patient is protecting their airway, oxygenating, and hemodynamically stable, avoid reflexive escalation of care. Repeated benzodiazepines, intubation, and reflexive loading with antiseizure medications should be avoided unless clearly indicated. A focused history is essential. Key elements include prior epilepsy diagnosis, prior EEG or epilepsy monitoring, event triggers, psychiatric history, school stressors or family conflict, and recent illness or injury. Laboratory testing and imaging should be ordered only when clinically indicated. EEG is rarely available or diagnostic in the Emergency Department.

Avoid telling families that the event is “not real,” that it is “all psychological,” or implying that the patient is faking symptoms. A helpful communication framework includes validating the experience, naming the diagnosis, explaining the mechanism, emphasizing treatability, and outlining next steps. Explain that the events look like seizures but are not caused by abnormal electrical activity, that they represent a functional seizure where the brain temporarily loses control of movement and awareness, that the episodes are real and involuntary, and that early treatment is effective.

Management and PrognosisCBT-based psychotherapy is the standard of care for PNES. Typical treatment involves 12 to 14 sessions focused on identifying triggers, modifying maladaptive cognitions, and developing coping strategies. Outcomes with appropriate treatment are encouraging. Approximately 59 to 65 percent of patients achieve full remission, 21 to 28 percent achieve partial remission, and combined improvement rates approach 90 percent at 12 months. Early diagnosis and treatment are critical. Connection to counseling within one month of diagnosis is the strongest predictor of remission. PNES duration longer than 12 months before treatment significantly reduces the likelihood of remission. Video-EEG confirmation alone does not predict outcomes. Healthcare utilization decreases substantially after diagnosis and treatment, with large reductions in Emergency Department visits and ambulance use.

Take-Home PointsPNES are common and increasingly recognized in children and adolescents. The term “pseudo-seizure” is outdated and misleading. PNES are real, involuntary, brain-based events. Diagnosis relies on positive clinical features rather than normal tests. Communication in the Emergency Department directly influences long-term outcomes. Early recognition and rapid referral to cognitive behavioral therapy can change patients’ lives.

References1. Sawchuk T, Buchhalter J, Senft B. Psychogenic Nonepileptic Seizures in Children-Prospective Validation of a Clinical Care Pathway & Risk Factors for Treatment Outcome. Epilepsy & Behavior. 2020;105:106971. (PMID: 32126506) 2. Fredwall M, Terry D, Enciso L, et al. Outcomes of Children and Adolescents 1 Year After Being Seen in a Multidisciplinary Psychogenic Nonepileptic Seizures Clinic. Epilepsia. 2021;62(10):2528-2538. (PMID: 34339046) 3. Sawchuk T, Buchhalter J. Psychogenic Nonepileptic Seizures in Children – Psychological Presentation, Treatment, and Short-Term Outcomes. Epilepsy & Behavior. 2015;52(Pt A):49-56. (PMID: 26409129) 4. Labudda K, Frauenheim M, Miller I, et al. Outcome of CBT-based Multimodal Psychotherapy in Patients With Psychogenic Nonepileptic Seizures: A Prospective Naturalistic Study. Epilepsy & Behavior. 2020;106:107029. (PMID: 32213454)

Note: This post was written by Brad Sobolewski. Editorial assistance and revisions were provided using ChatGPT (OpenAI), model GPT-5.2, to support clarity, organization, and accuracy. All clinical content, interpretation, and final responsibility rest with the author.

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For more than four decades, the default approach to febrile infants ≤28 days old has been routine lumbar puncture, empiric antibiotics, and hospital admission, driven by the catastrophic consequences of missed bacterial meningitis. A new international study published in JAMA provides the strongest evidence to date that this paradigm may be safely challenged for a carefully selected subset of neonates.

In a large pooled analysis, Burstein and colleagues evaluated the updated Pediatric Emergency Care Applied Research Network (PECARN) prediction rule specifically for bacteremia and bacterial meningitis in febrile infants 0–28 days old, separating these high-stakes outcomes from more common infections like UTI

What question were they asking?Can a clinical prediction rule using urinalysis, procalcitonin, and absolute neutrophil count, without lumbar puncture, accurately identify febrile neonates at very low risk for bacteremia or bacterial meningitis?

This matters because most current guidelines still recommend routine LP in this age group, despite advances in biomarkers and risk stratification.

Study design, at a glance Pooled analysis of 4 prospective cohorts * 6 countries, pediatric ED settings * 1,537 infants ≤28 days old in primary analysis * Secondary analysis included >2,500 infants * All infants were previously healthy, full-term, and non-ill-appearing* * Low-risk defined as: + Negative urinalysis or urine dipstick + Procalcitonin ≤0.5 ng/mL + ANC ≤4,000/mm³

Key ResultsAmong infants meeting low-risk criteria:

• Sensitivity for invasive bacterial infection: 94.2%
• Negative predictive value: 99.4%
• Sensitivity for bacterial meningitis: 100%
• Missed meningitis cases: Zero

These findings held in both the primary international analysis and the larger secondary analysis that included the original PECARN derivation and validation cohorts.

Put another way: no infant classified as low risk had bacterial meningitis.

How this adds to what we already knowThis analysis succeeds where earlier work could not because of:

• Scale: the largest dataset ever assembled for febrile infants ≤28 days
• International collaboration, improving generalizability
• Modern biomarkers, particularly procalcitonin
• Outcome focus on meningitis, not diluted by UTI prevalence

The authors estimate that at a meningitis prevalence of ~1%, the number needed to LP to prevent one missed case exceeds 2,000, with a very wide confidence interval, highlighting how rare the event is in low-risk infants.

What this means for you in the EDThis study does not say that lumbar puncture should never be done in febrile neonates. Instead, it supports several important shifts:

1. Routine LP is no longer the only defensible approach for all 0–28-day-old infants.
2. A substantial minority (~40%) of well-appearing neonates may meet objective low-risk criteria.
3. This creates space for true shared decision-making with families, using quantitative risk estimates rather than fear-based framing.
4. The “ill vs non-ill appearing” distinction remains critical, and HSV risk assessment is separate and unchanged by this rule.

Limitations All infants were evaluated in pediatric EDs with access to rapid procalcitonin. * Results may not generalize to non-pediatric settings. * This study is practice-informing, not guideline-replacing. * Clinicians must still follow local pathways, institutional policies, and specialty guidance*.

For the first time, we have high-quality, international evidence suggesting that some febrile infants in the first month of life can safely avoid lumbar puncture when objective low-risk criteria are met. This study challenges decades of dogma and provides the data needed to support nuanced, family-centered conversations about risk.

Guidelines will take time to catch up. And you should still adhere to local best practices and guidelines, but the times they are a changing. And besides, even pop culture is taking notice: PECARN’s work was name-checked on the Season Two premiere of The Pitt, underscoring the real-world impact of pediatric emergency research beyond academic journals.

ReferenceBurstein B, Waterfield T, Umana E, et al. Prediction of Bacteremia and Bacterial Meningitis Among Febrile Infants Aged 28 Days or Younger. JAMA. Published online December 8, 2025. doi:10.1001/jama.2025.21454

Note: This post was edited with the assistance of artificial intelligence (ChatGPT, OpenAI GPT-5.2). The content, interpretation, and final wording were reviewed and approved by the author.

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IntroductionObservation periods after epinephrine treatment for pediatric anaphylaxis vary widely across emergency departments. While prolonged stays are often intended to catch biphasic reactions, they can also lead to unnecessary admissions and extended ED length of stay. This multicenter retrospective study aims to provide evidence-based guidance by determining when the risk of repeat epinephrine administration becomes acceptably low.

What Did They Do?Researchers conducted a retrospective cohort study across 30 US and 1 Canadian pediatric emergency departments, analyzing data from 5641 children (ages 6 months to 17 years) treated with epinephrine for an acute allergic reaction between 2016 and 2019.

The primary outcome was the time from first to last epinephrine dose, whether given before arrival, in the ED, or during hospitalization. The investigators used Kaplan-Meier analyses and a semiparametric cure model to identify the observation threshold after which the cumulative incidence of repeat epinephrine was less than 2 percent. Patients were stratified by initial severity:

• No respiratory or cardiovascular involvement
• Respiratory involvement only
• Cardiovascular involvement

Key FindingsOverall* 4.7 percent of children received repeat epinephrine after 2 hours * 1.9 percent after 4 hours.

Cumulative Incidence of Repeat Epinephrine by Time

| Time After Initial Epinephrine | % Receiving Repeat Epinephrine | | --- | --- | | 2 hours | 4.7% | | 4 hours | 1.9% | | 6 hours | 1.1% | | 8 hours | 0.8% |

Threshold for <2 percent risk of repeat epinephrine

| Severity Group | Observation Time (minutes) | % Receiving Repeat Epinephrine After Threshold | | --- | --- | --- | | All patients | 115 (95% CI 105–122) | 5.0% | | No respiratory or cardiovascular symptoms | 105 (95% CI 54–135) | 4.1% | | Respiratory involvement, no CV involvement | 109 (95% CI 98–118) | 5.2% | | Cardiovascular involvement | 161 (95% CI 125–249) | 4.4% |

Discharge safety* 95.3 percent of the cohort could have been safely discharged at 2 hours * 98.1 percent could have been safely discharged at 4 hours

Predictors of repeat epinephrine included:* Severe respiratory or cardiovascular symptoms * History of severe anaphylaxis * Prehospital epinephrine * ED steroid administration

Why Does This Matter?This is the largest study to date addressing the optimal observation period after epinephrine in children with anaphylaxis. By linking observation time to a quantifiable clinical risk threshold, the findings offer an evidence-based approach to streamline care.

These results could support ED protocols that prioritize risk-stratified observation, reduce variability in practice, limit unnecessary admissions, and improve patient and caregiver experience without compromising safety.

Bottom LineA 2-hour observation period after epinephrine is likely sufficient for most pediatric patients with anaphylaxis who do not have cardiovascular involvement. For those with cardiovascular symptoms, a 4-hour window is likely appropriate. Risk of repeat epinephrine drops significantly beyond those time points, suggesting diminishing returns with longer observation. Shared decision-making, access to epinephrine autoinjectors, and allergist follow-up remain essential.

ReferencesDribin TE, Sampson HA, Zhang Y, et al. Timing of repeat epinephrine to inform paediatric anaphylaxis observation periods: a retrospective cohort study. Lancet Child Adolesc Health. 2025;9(7):484-496. doi:10.1016/S2352-4642(25)00139-7

This post was edited with assistance from ChatGPT-4o.

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What you can expect to learn from this article:* Recognize signs of end-organ injury when BP is ≥ 95th percentile + 30 mmHg. * Lower blood pressure slowly — no more than 25% in the first 8 hours — to avoid ischemic injury. * Use IV labetalol or nicardipine continuous drips to lower blood pressure. * Look for the underlying cause — renal disease leads the list in kids. * All kids with hypertensive emergency need ICU-level care. Clinical CaseYou are a senior resident working in the busy emergency department on an overnight shift. A 12-year-old girl is roomed with a chief complaint of “headache and nausea.” Per the ESI (Emergency Services Index), she was triaged a Level 2. On rapid chart review, you note that her BMI is well above the 99th percentile, and she has a history of elevated triglycerides. Upon entering the room, you find the patient’s nurse at the bedside already in mid-conversation with the patient’s parent. The child has become more sleepy over the past couple of hours, and a manual BP confirmed the elevated triage reading of 190/120, which is well above the 95th percentile for age (120/78) + 30!

Before your blood pressure rises as well, know that this PEMBlog article is here to provide an overview of the recognition and management of hypertensive emergencies.

Hypertension Epidemiology & Definition The increasing prevalence of obesity among children and adolescents has been identified as a significant contributor to the rising rates of hypertension, often accompanied by associated comorbidities. Hypertension is categorized as follows:

• Elevated BP: > or = 90th percentile and < 95th percentile (age 1-12 years old); 120-129/<80 (age 13+ years old)
• Stage 1 hypertension: > or = 95th percentile and < 95th percentile + 12 mm Hg, or 130/80-139/89 (age 1-12 years old); 130-139/80-89 (age 13+ years old)
• Stage 2 hypertension: > or = 95th percentile + 12 mm Hg, or > or = 140/90 (age 1-12 years old); > or = 140/90 (age 13+ years old).

Hypertensive emergency is a clinical diagnosis characterized by a sudden and severe elevation in blood pressure accompanied by signs of acute end-organ dysfunction. In pediatric patients, this condition should be considered when blood pressure exceeds the 95th percentile for age, height, and sex by more than 30 mm Hg, or reaches levels above 180/120 mm Hg in older adolescents. However, the presence of end-organ damage is the defining feature of a hypertensive emergency, rather than the absolute blood pressure value alone.

In the case presented, the patient’s blood pressure was significantly elevated, and she exhibited symptoms indicative of end-organ involvement, including altered mental status, headache, and nausea. These neurological manifestations suggest hypertensive encephalopathy, a form of end-organ damage. While elevated blood pressure readings are critical data points, the presence of symptoms and signs of end-organ dysfunction are paramount in diagnosing a hypertensive emergency (Kamat 2024).

Recognizing Hypertensive Emergencies The end-organ dysfunction component of this diagnosis presents as particular symptoms, physical exam findings, or laboratory and imaging results. Hypertensive encephalopathy which is the most acute subcategory of hypertensive emergency, is characterized by seizures, altered mental status, focal neurological findings, and visual changes (Kamat 2024).

Hypertensive emergencies can result either from primary or secondary hypertension. Secondary hypertension is the more common cause of the two and is related to renal, cardiac, pulmonary, oncologic, endocrine, or autoimmune pathologies, in addition to medication side effects. Within the category of secondary hypertension, kidney disease (ie reflux nephropathy, glomerular disease, renovascular disease, obstructive uropathy, hemolytic uremic syndrome) is the leading etiology (Bertazza 2022). While elucidating the underlying cause of the hypertensive emergency is important for a patient’s ongoing care, your role in the pediatric ED is to: 1) stabilize airway, breathing, circulation; 2) minimize worsening end-organ dysfunction by acutely lowering blood pressure; and, 3) start work up to evaluate cause (Patel 2012).

Physical Exam Pearls & Initial ED Workup Crucial, focused physical exam findings on initial assessment include:

• Four extremity blood pressures and pulse checks
• Abdominal exam to evaluate for hepatomegaly, abdominal bruit, or masses
• Fundoscopy to assess for hemorrhage, infarct, or papilledema
• Neurologic exam to assess for focality, mental status
• Cardiac exam to evaluate for gallop, rate, murmur
• Signs of fluid overload, such as crackles on lung exam or peripheral edema.

Evaluation consists of lab studies, including CBC, CMP, BNP, troponin, UA, UDS, TSH with reflex to T4, and urine pregnancy test for individuals with a uterus. If available at your institution, urine NGAL, Neutrophil Gelatinase-Associated Lipocalin, is an excellent early marker for acute kidney injury (as this protein is released directly by the kidney). A value of > or = 50 ng/mL is considered abnormal. Additional lab testing can be completed to account for the broader differential diagnoses. This includes assessing for urine catecholamines, peripheral blood smear, complement levels, ANA, renin, and angiotensin. Imaging and other diagnostic studies can consist of chest x-ray, EKG, renal ultrasound with doppler, voiding cystourethrography, renal arteriography, echocardiogram, and MRI/MRA/CT of the brain/neck if neurologic complications are involved (Kamat 2024; Patel 2012).

| Organ System | Signs/Symptoms | Workup | | Neurologic | Headache, nausea, vomiting, seizure, altered mental status (AMS) | CT head (consider MRI especially if concerned for PRES, posterior reversible encephalopathy syndrome) | | Ophthalmologic | Blurry vision; papilledema, hemorrhage on fundoscopy | Consult ophthalmology | | Cardiac | Signs of heart failure (peripheral or pulmonary edema, gallop), hepatomegaly; four extremity blood pressures and pulse checks with discrepancies | Labs: troponin, BNP; imaging: CXR, EKG, consider echocardiogram (POCUS for bedside function assessment, Cardiology consult for formal evaluation) | | Renal | Decreased urine output; peripheral edema, abdominal bruit | Urinalysis to assess for proteinuria; CMP to evaluate creatinine; NGAL, if available (early marker of AKI); renal ultrasound with doppler |

Pharmacologic Management & Disposition Intravenous medications, in the form of continuous drips, are the preferred method for lowering the patient’s blood pressure. The initial medications of choice include labetalol and nicardipine with the plan to decrease blood pressure by less than or equal to 25% of the initial blood pressure reading over the first eight hours of treatment. Patients with hypertensive emergency will require ICU admission for close hemodynamic monitoring and drip titration.

• Labetalol dosing: 0.2-1 mg/kg bolus dose (maximum 40 mg/dose), then a continuous drip at 0.25-3 mg/kg/hr; onset of action is less than 5 minutes, and the duration of medication lasts between 2-6 hours.
• Nicardipine dosing: bolus at 30 mcg/kg/bolus (maximum 2 mg/dose), then a continuous drip at 0.5-4 mcg/kg/min; onset of action is less than 5 minutes.

The goal is to achieve blood pressures around the 90th percentile for age, weight, and height over approximately 24 to 48 hours after the initial 8 hour time period. It is important to lower blood pressure readings slowly over an extended period of time to avoid possible hypoperfusion injury in patients with hypertensive emergency (Kamat 2024; Bertazza 2022).

Previously, sodium nitroprusside was one of the most commonly used IV agents in acutely lowering blood pressure. However, for children whose hypertensive emergencies are secondary to renal or hepatic pathology, toxic metabolites (cyanide and thiocyanate) from medication breakdown can accumulate; therefore, sodium nitroprusside is contraindicated in this population (Bertazza 2022). Additionally, hydralazine is another agent that was previously utilized in pediatric hypertensive emergencies. Due to the potent vasodilator properties and effect on the RAS system, this medication requires renal dosing adjustment for patients with chronic kidney disease.

The Pediatric Intensive Care Unit is the most appropriate destination for patients being treated for hypertensive emergency with continuous IV medications and frequent blood pressure monitoring. For providers in community hospital settings, it is crucial to engage pediatric nephrology or intensive care unit providers as soon as possible to guide management and facilitate transfer to other institutions.

References: Bertazza Partigiani N, Spagnol R, Di Michele L, et al. Management of Hypertensive Crises in Children: A Review of the Recent Literature. Front Pediatr. 2022;10:880678. Published 2022 Apr 15. doi:10.3389/fped.2022.880678.

Deepak M. Kamat, Kim Huynh Piburn; Hypertensive Emergencies. Quick References 2024; 10.1542/aap.ppcqr.396258.

Patel NH, Romero SK, Kaelber DC. Evaluation and management of pediatric hypertensive crises: hypertensive urgency and hypertensive emergencies. Open Access Emerg Med. 2012 Sep 5;4:85-92. doi: 10.2147/OAEM.S32809. PMID: 27147865; PMCID: PMC4753979.

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Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with protean manifestations. In pediatric patients, complications can evolve rapidly and carry significant morbidity and mortality. Emergency medicine providers should maintain a high index of suspicion for these entities in children and adolescents with known or suspected SLE. Below is a focused overview of key lupus-related emergencies, with attention to ED-relevant presentations, diagnostics, and treatment strategies.

Renal Disease (Lupus Nephritis)Signs & Symptoms: Children may present with new-onset hypertension, edema, or decreased urine output. ED referrals are often prompted by incidental findings of proteinuria or hematuria, or clinical concerns for hypertensive encephalopathy or PRES.

Laboratory Findings:

• Hypoalbuminemia
• Metabolic acidosis
• Anti-dsDNA antibody positive

Treatment:

• Induction: Corticosteroids + cyclophosphamide or mycophenolate mofetil
• Maintenance: Azathioprine or mycophenolate
• All patients: Hydroxychloroquine unless contraindicated

Pearls:

• Urinalysis with microscopy remains the cornerstone of initial evaluation.
• Spot urine protein:creatinine ratio provides rapid assessment of proteinuria.
• Kidney biopsy is essential for staging and guiding treatment in persistent proteinuria or renal insufficiency.

Hemolytic Anemia and ThrombocytopeniaSigns & Symptoms: Common presentations include fatigue, pallor, petechiae, mucosal bleeding, or abnormal labs found during fever workup. Cross-matching may be difficult due to autoantibodies.

Laboratory Findings:

• Elevated LDH
• Low haptoglobin
• Positive Coombs test
• Cytopenias

Treatment:

• First-line: High-dose corticosteroids
• Adjunct: IVIg for thrombocytopenia
• Refractory: Rituximab

Pearls:

• Evans syndrome or isolated ITP may precede SLE diagnosis.
• Avoid transfusion unless clinically necessary.

Macrophage Activation Syndrome (MAS)Signs & Symptoms: MAS may mimic sepsis or malignancy. Presenting features include persistent fever, hepatosplenomegaly, and altered mental status. Rapid clinical deterioration is common.

Laboratory Findings:

• Hyperferritinemia
• Cytopenias
• Elevated liver enzymes and triglycerides
• Decreased ESR with rising CRP

Treatment:

• High-dose corticosteroids
• Escalation: Cyclosporine or anakinra for refractory cases

Pearls:

• Early recognition is critical—delays increase mortality.
• Always evaluate for infectious triggers.

Pulmonary Embolism and Venous ThromboembolismSigns & Symptoms: Acute dyspnea, pleuritic chest pain, or hypoxia. DVT symptoms or syncope may precede PE diagnosis. Risk is elevated in the context of nephrotic syndrome or APL antibodies.

Laboratory Findings and Risk Factors:

• Hypocomplementemia
• Anti-dsDNA and APL antibodies
• Nephrotic-range proteinuria

Treatment:

• Anticoagulation: LMWH, transitioning to oral agents
• Lifelong anticoagulation may be indicated with persistent APL antibodies

Pearls:

• Consider CAPS in cases with thrombosis and multi-organ dysfunction.

Neuropsychiatric InvolvementSigns & Symptoms: Children may present with seizures, psychosis, mood lability, persistent headache, or focal deficits. Differential includes infection, medication toxicity, and primary psychiatric illness.

Laboratory Findings and Risk Factors:

• Positive anti-neuronal and anti-ribosomal antibodies

Treatment:

• Severe disease: High-dose corticosteroids + cyclophosphamide
• Refractory: Rituximab
• Symptomatic management: Anticonvulsants, antipsychotics as indicated

Pearls:

• MRI, EEG, and CSF analysis are key diagnostic tools.
• Symptoms may precede formal SLE diagnosis.

Pulmonary HemorrhageSigns & Symptoms: Sudden onset hemoptysis and hypoxia with bilateral infiltrates. May be misdiagnosed as pneumonia or pulmonary edema.

Laboratory Findings:

• Drop in hemoglobin
• Thrombocytopenia

Treatment:

• High-dose corticosteroids
• Cyclophosphamide in severe/recurrent disease
• Supportive care, including respiratory support

Pearls:

• Strongly associated with lupus nephritis or APL syndrome.
• Requires prompt recognition and immunosuppression.

Cardiac Involvement – Pericarditis and MyocarditisSigns & Symptoms: Chest pain, dyspnea, palpitations, or fatigue. Infants and toddlers may present with nonspecific signs such as irritability or feeding difficulty.

Laboratory and Diagnostic Findings:

• EKG: Diffuse ST elevations (pericarditis); ST depressions, T wave inversions, conduction delay (myocarditis)
• Elevated BNP and troponin
• Echo: Effusion, wall motion abnormalities

Treatment:

• NSAIDs for mild pericarditis
• Corticosteroids for myocarditis or tamponade physiology
• IVIG or immunosuppressants in refractory myocarditis

Pearls:

• Cardiac MRI aids in myocarditis diagnosis.
• Myocarditis can be rapidly progressive and fatal.

Final ThoughtsRecognition of SLE-related emergencies in the ED requires familiarity with atypical presentations and thoughtful use of diagnostics. Many complications mimic other pathologies such as sepsis, malignancy, or psychiatric disease. A multidisciplinary approach involving rheumatology, nephrology, critical care, and hematology is often essential for optimal care. Education, psychosocial support, and long-term follow-up remain critical in improving outcomes for children with cSLE.

ReferencesBrunner HI, Huggins J, Klein-Gitelman MS. Pediatric SLE–towards a Comprehensive Management Plan. Nature Reviews. Rheumatology. 2011;7(4):225-33. doi:10.1038/nrrheum.2011.15. PMID: 21386795.

Gültekingil Keser A, Ertuğrul İ, Tekşam Ö, et al. Unusual Presentations of Childhood Systemic Lupus Erythematosus to the Emergency Department. Pediatric Emergency Care. 2017;33(10):e100-e102. doi:10.1097/PEC.0000000000000829. PMID: 27977505.

Campbell EJ, Clarke AE, Ramsey-Goldman R. Systemic Lupus Erythematosus: A Case-Based Presentation of Renal, Neurologic, and Hematologic Emergencies. Expert Review of Clinical Immunology. 2018;14(10):803-816. doi:10.1080/1744666X.2018.1518132. PMID: 30173578.

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Community-acquired pneumonia (CAP) remains a high-volume driver of ED visits, and yet, risk stratification tools tailored to well-resourced emergency departments are limited. A new study from the Pediatric Emergency Research Network (PERN) aimed to change that.

Published in The Lancet Child & Adolescent Health, this prospective cohort study of over 2200 children across 73 Emergency Departments in 14 countries developed and validated clinical prediction models to help clinicians distinguish mild CAP from moderate or severe cases, and ultimately guide decisions about hospital admission.

What Did They Do? Population: Children 3 months to <14 years with clinically diagnosed CAP (radiographic confirmation not required). * Setting: 73 EDs across 14 countries (primarily high-income nations). * Exclusions: Children with complex chronic conditions or severe disease evident in the first 4 hours of ED care. * Primary Outcome: A three-tiered pneumonia severity classification (mild, moderate, severe) based on clinical interventions and outcomes within 7 days. * Analytic Approach*: Logistic regression with bootstrap validation, converted into a user-friendly point-based risk score.

Key FindingsOut of 1901 children with complete data:

• 53.2% had mild CAP
• 40.6% had moderate CAP
• 6.2% had severe CAP

Eight clinical variables independently predicted moderate or severe CAP:

| Predictor | Adjusted Odds Ratio | Point Value | | --- | --- | --- | | Chest retractions | 2.86 | +3 | | Oxygen saturation <90% | 13.39 | +6 | | Oxygen saturation 90–92% | 3.24 | +3 | | Respiratory rate >95th %ile | 1.63 | +1 | | Heart rate >95th %ile | 1.64 | +1 | | Refusal to drink | 1.57 | +1 | | Abdominal pain | 1.52 | +1 | | Antibiotics before ED visit | 1.64 | +1 | | Rhinorrhea/congestion | 0.59 | −1 |

Model performance was excellent:

• c-statistic = 0.82, both in the general cohort and in those with radiographic CAP.
• Point thresholds performed well for both sensitivity (92.6% at score ≥1) and specificity (92.0% at score ≥6).

Why Does This Matter?This study’s risk models:

• Were built using objective and widely available data (no labs required).
• Distinguish mild from moderate/severe disease to inform ED disposition decisions.
• Are pragmatic enough to integrate into clinical decision support tools (apps, EHRs).
• May outperform clinician gestalt (model c-statistic 0.82 vs clinician 0.75 in previous studies).

Importantly, these models also showed consistent performance in children with radiographic pneumonia, with additional predictors such as multifocal opacities and decreased breath sounds.

Bottom LineThis PERN study delivers a robust, externally relevant tool for risk stratifying pediatric CAP in the ED. The scoring system can help avoid unnecessary hospitalizations and ensure that higher-risk children get the care they need sooner. While external validation is still needed, the groundwork is set for incorporating this evidence into practice.

ReferenceFlorin TA, Tancredi DJ, Ambroggio L, et al. Predicting paediatric pneumonia severity in the emergency department: a multinational prospective cohort study of the Pediatric Emergency Research Network. Lancet Child Adolesc Health. 2025;9(6):383–92. DOI: 10.1016/S2352-4642(25)00094-X

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In this episode of PEM Currents: The Pediatric Emergency Medicine Podcast, Brad Sobolewski discusses advanced imaging in pediatric emergency care with Dr. Jennifer Marin (jennifer.marin@chp.edu) from UPMC Children’s Hospital of Pittsburgh. They explore the evidence behind ultrasound, CT, and MRI, strategies to reduce low-value imaging, and the role of shared decision-making in selecting the appropriate diagnostic test.

Learning Objectives1. Demonstrate the ability to use shared decision-making strategies when discussing imaging options with families of pediatric patients presenting to the Emergency Department. (Bloom’s: Apply; Kirkpatrick Level 2 – Learning) 2. Evaluate the risks and benefits of ultrasound, CT, and MRI for common pediatric emergencies and identify appropriate imaging modalities based on clinical guidelines discussed in the podcast. (Bloom’s: Analyze; Kirkpatrick Level 3 – Behavior): 3. Assess the impact of implementing strategies for reducing low-value imaging in the pediatric emergency department on patient care outcomes, including diagnostic accuracy, radiation exposure, and healthcare costs. (Bloom’s: Evaluate; Kirkpatrick Level 4 – Results)

Listen
Advanced Imaging of Children in the ED: Ultrasound, CT, and MRI – Brad Sobolewski, MD, Med – PEM Currents: The Pediatric Emergency Medicine Podcasthttp://www.pemcincinnati.com/podcastsSubscribe* Apple Podcasts * Spotify * YouTube

References1. Marin JR, Lyons TW, Claudius I, et al; American Academy of Pediatrics Committee on Pediatric Emergency Medicine, Section on Radiology; American College of Emergency Physicians Pediatric Emergency Medicine Committee; American College of Radiology. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Policy Statement. Pediatrics. 2024;154(1):e2024066854. doi:10.1542/peds.2024-066854. PubMed 2. Marin JR, Lyons TW, Claudius I, et al; American Academy of Pediatrics Committee on Pediatric Emergency Medicine, Section on Radiology; American College of Emergency Physicians Pediatric Emergency Medicine Committee; American College of Radiology. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. Pediatrics. 2024;154(1):e2024066855. doi:10.1542/peds.2024-066855. PubMed

TranscriptNote: This transcript was partially completed with the use of the Descript AI and the Chat GPT 4o AI

Welcome to PEM Currents: The Pediatric Emergency Medicine Podcast. As always, I’m your host, Brad Sobolewski, and in today’s episode, we are diving into a critical topic that every clinician in the emergency department encounters: we are talking about advanced imaging. Wait, so is this like an upper-level college course?

No. Advanced imaging, according to the American Academy of Pediatrics, the American College of Emergency Physicians, and the American College of Radiology, refers to diagnostic modalities like ultrasound, computed tomography or CT, and magnetic resonance imaging or MRI that provide detailed visualization of the internal structures of our patients to aid in the evaluation and management of the kids that we see in the ED.

So it’s the name for all of the cool imaging studies that we order on all of our patients, and they are essential for doing our daily jobs and identifying serious conditions like traumatic brain injuries, appendicitis, and stroke. There’s also risks. We’re talking about radiation exposure, having to sedate patients, false positive results, incidental findings that we have to deal with, and the obvious increase in healthcare costs, and there certainly is a rise in CT and MRI use.

And how do we actually strike the right balance between obtaining essential diagnostic information and avoiding unnecessary imaging? So here to help us navigate these complex decisions is Dr. Jennifer Marin. She’s an emergency department director of imaging at UPMC, Children’s Hospital of Pittsburgh, my hometown, a Yinzer, and a leading voice in pediatric emergency imaging.

She’s been at the forefront of research into imaging optimization. Focusing a lot on when to image, when not to image, and how to communicate imaging decisions effectively with families. In this episode, which we recorded as a discussion on May 12th, 2025, we will explore the latest evidence and guidelines, discuss practical strategies for reducing low-value imaging, and highlight how shared decision-making can help ensure that every scan is the right scan.

Jen, let’s start broadly. What are the most common injuries or conditions in children that require advanced imaging in the ED? And what are some of the trends that you’re seeing regarding how often we’re performing these studies? You know, reordering more imaging just because it’s more readily available because our patients and families expect it.

Or is there something else going on here? Thanks, Brad, and thanks so much for having me. It’s an honor to be on your podcast. To answer your first question, I think really the most common things that we see patients being imaged for would be suspected appendicitis. The kid who comes in with belly pain, you don’t wanna miss an appendicitis.

So we’re doing a lot of abdominal ultrasounds in those cases. Head trauma, um, of course people don’t wanna miss a bleed. So we do imaging for closed head injury. Those patients with minor head trauma, cervical spine trauma, abdominal trauma. And then I would say also children who come in with headaches. Uh, and those who also have seizures, those would be probably the most common reasons why we image kids.

So these studies are all readily available. We can get them sort of whenever we want. Really. What are some of the trends that we’re seeing in terms of ordering practices? Yeah, there’s definitely been studies that have shown that over time we are using more advanced imaging modalities. And I, I like to say to the residents and trainees, if you build it, they will come. And so as we now have more availability of these tests, when I started training, we did not have 24 hour ultrasound. We certainly didn’t have MRI available in the ED. But now that we have 24 hour ultrasound, it’s much easier to just get the ultrasound, or at least that’s the perception, right?

So it’s relatively cheap when you talk about ultrasound compared to other advanced imaging modalities, it isn’t usually painful. It’s no radiation and it’s fairly quick. So I think that when we, our threshold to order tests like this have gone way down simply because of the availability. Do you feel like sometimes we just assume that a patient or family wants an imaging test in order to figure out what’s going on?

Sometimes we do think that. I think we think that probably more than they actually do. And I’ve actually started, instead of assuming that a family is expecting imaging, I’ve started asking, what are you worried about? And what do you think should be done? And a lot of times I’m very surprised when I explain to the families why imaging isn’t necessary, if in fact they are expecting it. Most of the time it’s very well received.

Right. And I feel like we used to see a kid who would come in with a day and a half, two days of pain, right? So it was a little bit easier. Um, but now they’ll come in with a few hours of pain. And the reality is that if you get an ultrasound in early appendicitis, you’re probably not even gonna see the appendix. And so the test really isn’t gonna be that useful. And I go into that a little bit with families and I think it really resonates with them and has them understanding why we’re not doing the ultrasound.

That’s a wonderful point. And I don’t think there’s any such thing as a perfect test. There’s almost nothing that’s a binary yes-no. There’s false positives and false negatives for everything. And if you are born with your appendix behind your cecum, no ultrasonographer in the universe is going to be able to get it to come out to take a picture. Do you think that medical-legal concerns also play a role?

Is it different in taking care of children versus adults? I think medical-legal implications do play a role, and there’s been studies on that, but it’s mostly in the general EM literature, not as much in pediatrics. But I think that it’s something that is probably there that we think about. Nobody wants to miss an appendicitis. Nobody wants to miss a head bleed, right? We don’t wanna miss anything. And I think that when we’re faced with a child who has one of these diagnoses, that’s where we need to weigh the risks and benefits. And in some cases have a conversation with the family because sometimes it’s clear-cut that they need imaging. Other times it’s clear that they don’t need imaging, but there’s a lot of gray.

And you mentioned in your intro, shared decision-making, and I think that shared decision-making plays a really important role with imaging in a lot of these scenarios.

So I’m gonna shift gears just a tiny bit. You talked a few moments ago about some of the more common conditions in which we get imaging. I’m gonna ask specifically about CT scans and radiation. And it’s a topic that comes up again and again and we’re learning more and more over time about the risks of radiation, particularly in growing children where we really don’t understand the long-term risks. Can you talk about safer alternatives? How we should approach the risk of CT scan with families and some of the decisions around that?

Absolutely. So there is a risk of radiation. We know this. What we don’t know is what exactly is that risk. And a lot of the studies that have been done were done on patients who received imaging on much older equipment. And the equipment that we use now is much more sophisticated, much more high-tech, and does have the ability to deliver much lower radiation doses. So the explanation that I give to families, especially when I’m in a shared decision-making situation or in a scenario where I’m recommending a CT and the family is a bit hesitant, you know, I’ll say the benefits of this scan very likely outweigh any of the risks.

We don’t know what that risk is. We know that any radiation can be potentially harmful, but when you’re getting imaged at a children’s hospital, for example, and this is a kid who’s not getting imaged every month or every year like some of our adult patients are, then the risks really are generally outweighed by the benefits when you have a high pretest probability of disease.

CT does get the lion’s share of concerns about risk and advanced imaging. But there’s two other modalities that we’re talking about today. Really, on one end we’ve got ultrasound, which there’s no ionizing radiation whatsoever. It’s readily available and it’s first line for things like appendicitis, kidney stones, and soft tissue infections. And then at the other end we have MRI, and it’s not just set it and forget it. Now we have rapid protocols and other things. Can you talk specifically about some of these Rapid MRI protocols and how they may supplant CT scans?

Yes, so Rapid MRI protocols have really exploded, I would say in the last decade. We actually have four different rapid protocols depending on the scenario, depending on the imaging question, and it’s a wonderful test. I think that there are limitations to it, right? So one is going to be the speed with which you can get it, and our MRI scanners, you know, we don’t have an infinite number, and so we are competing with other patients around the hospital who need MRIs and sometimes kids have to wait two, three plus hours to get it.

The other thing though that’s important is a lot of times, you know, the CT gives us good information and it’s fast, but it may not be the best test. And so MRI is going to give us more information depending on the scenario. So I’m thinking about maybe a seizure patient, where an MRI might be a better test than a CT. And so getting the CT is to some extent, only delaying the inevitable because the patient’s ultimately going to need the MRI.

So what I initially learned about MRI, it was like this two hour long test. You had to lay in this big machine. It made a ton of noise. You had to put headphones on. When you talk about rapid MRI, like how fast can these patients be in and out of the scanner?

So these tests are very fast. They’re not as fast as CT scans. You can get a head CT probably in under two minutes, but you can get a rapid MRI in five to seven minutes. In some cases, if you’re doing a shunt protocol, for example, some of them take a little bit longer, 10 minutes, 12 minutes. But still, to your point, Brad, it’s not this hour long scan that we’re used to seeing and most patients tolerate it well.

But – and I’ll go back to your earlier question – one of the limitations of MRI is you can get a scan down to three minutes, but if you’re a 19-month-old who doesn’t want to lay still, it’s not going to happen. So that risk of sedation really becomes something to consider when we’re getting a rapid MRI in a particular age group.

Locally, we will not do MRIs on ED patients below six years of age.

When I started residency way back in the day, I said to one of my mentors, ‘What am I gonna do about two-year-olds?’ And I was told, ‘Nothing.’ And that has held true all throughout my career.

Yes, and so thinking about these imaging modalities, I keep coming back to the fact that most of the time when we’re ordering one, it’s because we’re thinking about what’s next from a management standpoint for the patient. That often involves our subspecialty colleagues, whether that’s our surgeons, our subspecialist surgeons, or other pediatric subspecialties. How are we collaborating with these pediatric specialists to ensure that we’re triaging and effectively making decisions and integrating these decisions into the overall treatment plan for the children we’re caring for in the emergency department?

Subspecialists are key, right? And I think that getting multidisciplinary collaboration when we are figuring out what is the best imaging strategy for X is critical. We have clinical effectiveness guidelines, as I’m sure many know, and many pediatric emergency departments have these. These are multidisciplinary guidelines that have been put together that really take into account all the relevant stakeholders and what’s the best imaging test to get the answer that we’re interested in.

We’ve collaborated with general surgery, radiology, and all different specialties depending on the scenario, so that we’re imaging in the right way and not having to redo the study. We have different protocols like for kidney stones, where we do a very low dose CT, and we have parameters around which we decide whether to do that CT in lieu of ultrasound for certain patients.

None of that would be possible without earlier collaboration with all the relevant stakeholders first.

You think about all the different points in your system where the decision could go wrong. You just mentioned a CT protocol for stones. You could order another version of a, you know, abdominal CT and get a study that also looked at the kidneys but wasn’t specific for it. And they’re all on that giant menu. So you have to think from top to bottom in your system and get everybody involved and on board. And I would agree with you completely that I found that’s the only way to drive decisions toward the preferred imaging modality. Everybody that’s a stakeholder has to agree. And you can’t just snap your fingers and make that happen.

And we are working in children’s hospitals with tons of resources, world experts, and the availability of tests. But the majority of our patients do not initially seek care in our facilities. We know that nine out of ten children that go to the ER do not go to children’s hospital ERs. And I think some of the concern about low-value imaging or imaging with high risks has to be directed at our children who may receive imaging outside of children’s hospitals.

So what can pediatric emergency medicine physicians specifically do to reduce the use of low-value imaging being performed at non-children’s hospitals?

You’re absolutely right, Brad. And I always say that I do not envy my emergency medicine colleagues, particularly those practicing in community settings. We really do have so many resources at our disposal, and it is very hard for them to know everything about kids and adults while practicing in locations where they don’t have these consultants available 24/7.

I think it’s very important, almost an obligation, for us to provide outreach and education to our community ED colleagues so that they are given the tools needed to provide the right imaging to the right patient at the right time.

So I’ll give you a couple of examples. At UPMC, we have many hospitals as part of our system, but only one pediatric children’s hospital. And so we routinely do outreach with our community providers. There’s an education series, a lecture series, and I had the opportunity to give a talk on this very topic to those providers. It was all these medical directors at other hospitals who then had the opportunity to cascade down the message about low-value imaging, when to image, when not to image. We provided resources, which I’ll talk about in a little bit, and, you know, hopefully that will lead to less low-value imaging in the community setting.

Another recommendation that I have is regarding transport calls. We all take transport calls when we’re practicing at the ‘mothership.’ Patients are getting transferred, and I think having a conversation with the doc at the point of care, even if imaging has already been done — and maybe it was low-value or could have been avoided — I think it’s important to talk to the provider and say, ‘Hey, you know what? Just so you know, next time you have a kid like this, don’t feel like you have to image them. We are happy to take this kid without imaging.’

It’s going to save time, it’s going to save us having to upload the disc that may or may not be corrupted. It’s going to save the patient, potentially, another scan because they were moving all over the table because the techs at the referring hospital aren’t used to trying to manage a wriggling infant.

I almost empower them to not necessarily do imaging because I think that there is this common misconception in the community setting that you can’t transfer a patient unless you know what the diagnosis is or unless you have imaging available. And that’s really not the case at all.

Talking about some of the resources in the guidelines that we published, the policy statement and technical report that we published in Pediatrics and in some other journals, statements on advanced imaging in children who present to the emergency department. It was authored by the American Academy of Pediatrics, the American College of Emergency Physicians, and the American College of Radiology. Those statements were published, and one of the documents that I think is very useful is the supplement to the technical report, which includes several publicly available clinical effectiveness guidelines from various children’s hospitals all over the country.

These can be used at the point of care to help with decision-making so that we’re providing high-value care and performing high-value imaging.

Before we bring this episode to a close, there’s one other subject I wanted to talk a little bit more about, and it’s incidental findings. You know, it’s when we get a study right, and we discover something that we weren’t expecting to see. I think, colloquially, it’s gotten the name ‘Incidentaloma.’ How do you suggest we approach when we discover something that we weren’t expecting to see? What does that mean for patients and families? And is there a cascade of decisions that happen because of that that could have been avoided?

Absolutely. Yeah. I don’t think we talk about these enough because we don’t have to deal with them in the ED. So an incidental finding is something that a radiologist sees on the imaging study that means nothing. It doesn’t cause the patient any harm, and it’s certainly not the reason for their symptoms. But when you tell someone that they have a nodule, let’s say, on their lung from a CT PE study, that then sparks what we call ‘care cascades.’

And they have to follow up on that. It’s an extra visit, time off work, time out of school, an extra cost, anxiety-provoking. And maybe they need to follow it up every three months. It’s a real burden on families and on the healthcare system more broadly and probably something that doesn’t get enough attention in emergency medicine.

So, I would encourage folks when they’re ordering tests, particularly if the pretest probability is very low, to think about the risks, including incidental findings and how they’re really not insignificant.

Before we end our conversation, what final words of advice do you have for someone who’s going to have a shift soon after they listen to this episode? What’s one thing that they can take to the bedside in an upcoming discussion with a patient and their family?

Understanding that imaging isn’t always necessary to make a diagnosis, and that’s something that I think today’s trainees need to hear, and also some of the families need to hear. There’s so much information available online, as you know, and Facebook groups and resources and ‘My friend, my grandmother,’ etc., and it can be overwhelming.

Taking the time to explain to families, especially those who are expecting imaging or have questions about imaging, why we aren’t doing imaging and the risks associated with it, which are very real — I think that that carries a lot of weight.

What about other healthcare teams that interface with our patients when they may be requesting tests that we’re concerned pose additional risks or costs to patients? How do we have a collaborative discussion with them when there’s a difference of opinion about what best to do for a patient?

Yes. I think you answered it, actually, Brad — having a collaborative discussion. A lot of times when we consult a service, it’s a resident who might be at another hospital. They have to come to our hospital. They’re just reflexively asking for imaging. I say to the resident, ‘I’m going to call that resident back.’ And I’ll say, ‘You know what? I would really love for you to just see the patient before we talk about getting a CT because I don’t think the kid needs a CT.’

Most of the time, that works really well. Sometimes they’ll say, ‘Well, here’s why I want the CT,’ and I’ll say, ‘Oh, that’s really helpful. We’ll go ahead and get it.’ So I think having a conversation and questioning in a very respectful way can be eye-opening on both sides.

And that is a conversation that is best had by voice or face-to-face. It can be uncomfortable to feel like you’re going to have a disagreement with somebody. But ultimately, everybody’s goal is the same — just to do what’s right for the kid and their family.

And the other people that are really smart and amazing and wonderful are radiologists. We should always be willing to call them on the phone. They’re not just the test referral center. You don’t just put in the test and get it. Sometimes we should be calling them and saying, ‘Here’s the problem I have at hand. What’s the best way that we can safely image this child?’

Jen, thank you so much. Tons of fascinating information. As I mentioned before, I will put links to all of these excellent resources in the show notes. I hope that in listening today, you will come up with some new ways to approach these issues with patients and families, as well as the folks we collaborate with. And don’t be afraid to have those discussions with folks calling in from other institutions. We all have the same goal. And ultimately, it’s on us working in pediatric emergency departments to disseminate that best information.

Jen, thank you very much.

Brad, thank you so much. It was such an honor. I had a really nice time. Thank you.

Alright, that’s all for this episode. I hope you now understand what the term ‘advanced imaging’ encompasses — ultrasound, CT, MRI — the radiologic studies that we use to make diagnoses every day in the emergency department on children. Sometimes these tests are necessary; sometimes they’re not. We have to collaborate with patients, families, our radiology colleagues, the other specialists we collaborate with, and providers working at community EDs to decide whether to image and, if we do, to get the right test that will get us the most accurate results with the least risk.

So if you liked this episode, share it with a colleague, leave a review on your favorite podcast site, or send me a comment via email, on the blog, or via social media.

For PEM Currents: The Pediatric Emergency Medicine Podcast, I’m Brad Sobolewski. See you next time.

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This session was co-hosted by the AAP SOEM Education Subcommittee and the Point-of-Care Ultrasound (POCUS) Special Interest Group and was originally held on Zoom on Monday, May 12, 2025. This interactive session explored the landscape of pediatric POCUS through the lens of education, curriculum development, and sustaining quality. Our expert presenters shared practical guidance, challenges, and updates based on national recommendations from the AAP, ACEP, and others.

Need more convincing to watch? Well, you can seek out answers to questions such as, “why is my division making everyone learn how to do ultrasound? and “how did they make the decisions on what scans we have to learn and how many do we need to have?” and even “won’t Radiology get mad if we take their money?”

Agenda and PresentersEducation Recommendations and Guidelines: Diagnostics and ProceduresJennifer Marin, MD
Professor of Pediatrics, Emergency Medicine, and Radiology
Medical Director, Point-of-Care Ultrasound, UPMC Children’s Hospital of Pittsburgh
Emergency Medical Imaging Director, Division of Pediatric Emergency Medicine

Quality Assurance – What Works to Maintain a ProgramPatrick C. Drayna, MD
Associate Professor of Pediatrics – Division of Emergency Medicine
Medical Director of Point-of-Care Ultrasound, Children’s Wisconsin
Medical College of Wisconsin

Implementation – Curriculum Development and BarriersMarjan (Zahra) Ghazi-Askar, MD
Clinical Associate Professor
Director, Pediatric Ultrasound Education, Department of Emergency Medicine
Stanford University School of Medicine

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In this episode, we tackle the clinical mischief of Parvovirus B19, a common viral infection with a surprisingly wide range of manifestations—from the classic “slapped cheek” rash of erythema infectiosum to aplastic crises in children with hemolytic anemias and fetal hydrops in pregnant contacts. We’ll break down the virology, epidemiology, clinical presentation, and complications of Parvovirus B19. You’ll also learn how to manage exposures in the emergency department, especially when the child has a pregnant caregiver, and why isolation isn’t always necessary once the rash shows up.

Learning Objectives* Describe the classic and atypical clinical presentations of Parvovirus B19 infection in pediatric patients, including erythema infectiosum, arthropathy, transient aplastic crisis, and chronic anemia in immunocompromised hosts. * Understand the epidemiology and transmission timeline of Parvovirus B19, especially its seasonal peaks and viral shedding period. * Recognize key diagnostic features that help differentiate Parvovirus B19 from other viral exanthems and systemic illnesses. * Formulate an evidence-based management plan for patients with suspected or confirmed Parvovirus B19, including those with underlying hemolytic disease or immunocompromise. * Counsel families and caregivers—including pregnant household contacts—on the risks, exposures, and infection control considerations related to Parvovirus B19.

ListenParvovirus B19 (Fifth Disease) – Brad Sobolewski – PEM Currents: The Pediatric Emergency Medicine Podcasthttp://www.pemcincinnati.com/podcastsSubscribe* Apple Podcasts * Spotify * YouTube

ReferencesJordan, Jeanne A. “Treatment and Prevention of Parvovirus B19 Infection.” UpToDate, Jun. 14, 2024. https://www.uptodate.com/contents/treatment-and-prevention-of-parvovirus-b19-infection

Edwards, Morven S. “Clinical Manifestations and Diagnosis of Parvovirus B19 Infection.” UpToDate, Jun. 14, 2024. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-parvovirus-b19-infection

Macri, Angela, and Crane, Jonathan S. “Parvoviruses.” StatPearls, NCBI Bookshelf, Jun. 28, 2023. https://www.ncbi.nlm.nih.gov/books/NBK482245/

Kostolansky, Sean, and Waymack, James R. “Erythema Infectiosum.” StatPearls, NCBI Bookshelf, Jul. 31, 2023. https://www.ncbi.nlm.nih.gov/books/NBK513309/

“Parvovirus B19 Infection and Pregnancy.” Centers for Disease Control and Prevention. https://www.cdc.gov/parvovirusb19/pregnancy.html

TranscriptNote: This transcript was partially completed with the use of the Descript AI and the Chat GPT 4o AI

Welcome to PEMCurrents, the Pediatric Emergency Medicine Podcast. As always, I’m your host, Brad Sobolewski, and today we are covering Parvovirus B19—a common but clinically diverse viral infection that you will definitely encounter in pediatrics, and not just in the form of a rash. Parvovirus B19 is best known for causing fifth disease, but in certain patients it can lead to some serious complications like aplastic crises, fetal hydrops, or chronic anemia.

So as you can see, this virus does a lot of stuff. But what is it? Well, let’s get nerdy. It is a non-enveloped, single-stranded DNA virus in the Parvoviridae family. There are some forms of parvo that infect other mammals, but Parvovirus B19 is only for humans, and it loves erythroid progenitor cells. It was discovered by accident back in 1975, so a little bit before I was born, and it was labeled B19 because of the sample number in a Hepatitis B screening panel. Since then it has been identified as the cause of several syndromes. I’ll go over those as we move along here.

Parvovirus B19 is spread via respiratory droplets, much less commonly by blood products or vertical transmission. The incubation period is typically four to fourteen days. Viremia peaks at days five through ten after exposure, and that’s when the patient is most contagious. The classic rash and joint symptoms appear later, and at that point, the patient is actually no longer infectious. So that detail’s key—because when a kid shows up with a slapped cheeks rash, you no longer need to isolate them.

So the classic presentation that’s on every board exam ever is called erythema infectiosum, or fifth disease. This is the most well-known manifestation, seen primarily in school-aged children, especially in the spring and early summer. Again, it’s also known as fifth disease—this is one of the six classic childhood exanthems. These are a group of viral rash-causing illnesses that were originally numbered in the late 19th and early 20th centuries based on their order of description.

So: first disease was measles or rubeola, which obviously we don’t see as much anymore. Second disease was scarlet fever from group A Streptococcus. Third disease was rubella, or German measles. Fourth disease was Dukes’ disease, now believed to be a misclassified form of scarlet fever or staphylococcal scalded skin syndrome. Fifth disease is erythema infectiosum caused by Parvovirus B19. Sixth disease is roseola infantum, caused by HHV-6, and sometimes HHV-7.

Honestly, fifth disease is a historical happenstance—and I just think it’s fun to know that. Sometimes I share it with patients and families.

Here’s how it typically plays out. Phase one is the viral prodrome. This occurs during peak viremia. About 50% of symptomatic patients experience nonspecific flu-like symptoms: low-grade fever, malaise, myalgias, headache, coryza, nausea, and sometimes even diarrhea. This lasts about two to three days.

Phase two is the classic rash. This appears two to five days after the prodrome. You get an erythematous malar rash with circumoral pallor—the classic slapped cheeks appearance. You can also see a lacy, reticular rash on the trunk and extremities, which follows the slapped cheek rash about one to three days later. This rash can fade within a week or two, or it can wax and wane for weeks, especially worsening with sun, exercise, or stress. By the time the rash appears, viremia has resolved and the patient usually feels well.

Only about 25% of infected individuals will have this classic rash syndrome. Another 50% will only have mild flu-like illness, and 25% remain completely asymptomatic.

Let’s talk about the joint symptoms. These are seen in about one out of ten children. More commonly, adults—especially women—have joint symptoms, affecting up to 60% of them. Typically, joint symptoms are symmetric and affect the small joints of the hands, wrists, knees, and feet. The joint pains can last about one to three weeks. Chronic arthropathy occurs in a very small subset of patients and can last for months or more. Importantly, there’s no joint destruction—it hurts, but the joints are fine afterwards.

A serious manifestation of Parvovirus B19 infection that you do not want to miss is called transient aplastic crisis. This occurs when Parvovirus B19 halts erythropoiesis in patients with underlying hemolytic disorders like sickle cell disease, thalassemia, or hereditary spherocytosis. In one study of just over 300 patients with homozygous sickle cell disease, Parvovirus B19 infection caused transient aplastic crisis about 80% of the time.

Presenting symptoms are those of anemia: pallor, fatigue, tachycardia, weakness. You’ll often see a hemoglobin drop of greater than 30% from baseline, an undetectable reticulocyte count, and possibly leukopenia and thrombocytopenia. This often requires hospitalization and transfusion—in one series, 87% of children with transient aplastic crisis required packed red blood cell transfusions.

In immunocompromised children, B19 can also cause chronic infection, with persistent viremia and pure red cell aplasia. You’ll see this in transplant patients, patients with leukemia, or advanced HIV. These patients don’t get rash or joint symptoms—those are immune-mediated—and these kids have compromised immune systems. Diagnosis is confirmed with PCR, often as part of a viral panel, or via characteristic bone marrow findings. Treatment is with IVIG and, if possible, reduction of immunosuppression, though this can be tricky. These patients often need admission and careful care.

Let’s talk about fetal infection. Parvovirus B19 is not routinely screened for in pregnancy, but vertical transmission can cause hydrops fetalis, stillbirth, and severe fetal anemia. The risk is highest in the second trimester. The overall rate of fetal loss after maternal infection is around 2 to 6%, but it may be higher depending on timing and fetal response.

Now, let’s talk about a wonderfully named manifestation: papular purpuric gloves and socks syndrome. This is why pediatrics is great—we have the best names for things. This is a rare manifestation of Parvovirus B19, often seen in adolescents or young adults. You get painful, pruritic petechiae and purpura of the hands and feet, with a sharp demarcation at the wrists and ankles. You may also see mucosal erosions. You’re probably thinking, this sounds like mycoplasma or other viral illnesses—and it does. But unlike fifth disease, patients are contagious when this rash appears.

Finally, let’s talk about some rare neurologic complications. These include encephalitis, Guillain-Barré syndrome, and brachial plexopathy. One review identified about 129 cases of parvovirus-related neurologic complications between 1970 and 2012, with encephalitis making up about two-thirds of those cases. These are rare, but something to keep in mind—especially if you’re in a large academic children’s hospital.

So how do we diagnose Parvovirus B19? It’s usually a clinical diagnosis—especially in cases of typical erythema infectiosum. In more complicated cases or in immunocompromised children, you can check IgM antibodies (which appear about 7 to 10 days after exposure and peak at 2 to 3 weeks). IgG indicates past infection. PCR is most useful in immunocompromised patients or when evaluating possible fetal infection.

Management of erythema infectiosum is supportive care only—antipyretics, hydration, and reassurance. The rash can be itchy; use moisturizers or antihistamines like cetirizine. Explain to families that the rash may last for days to weeks and can worsen with sunlight. I’ve seen a lot of visits in urgent care where this is the main concern during outbreaks.

For joint symptoms, use NSAIDs. A patient with transient aplastic crisis will likely need hospitalization and red blood cell transfusion, especially if unstable. In immunosuppressed patients with chronic infection, treat with IVIG and carefully consider immunosuppressive management.

What if the child has a pregnant caregiver? The child is most contagious before the rash appears—during the viral prodrome—so it’s easy to mistake for another virus. Once the rash appears, the child is no longer infectious. If a pregnant household contact was exposed during the contagious period—especially in the first or second trimester—they should contact their OB provider for serologic testing (IgG and IgM). If seronegative, serial ultrasound may be recommended to monitor for fetal hydrops.

Isolation of the child is not necessary after the rash appears. If they are in the viremic phase, then hand hygiene and respiratory precautions are important to limit household spread.

Take-home points:
Parvovirus B19 can cause a range of presentations—from slapped cheeks to life-threatening anemia. It’s a clinical diagnosis, especially in typical cases. If you’re not familiar with the rash, look it up—so you’ll recognize it in the ED. In patients with red cell disorders or immunosuppression, use PCR or serology. Don’t miss a transient aplastic crisis in a child with sickle cell. And remember: once the rash appears, the child is no longer contagious. The virus spreads during the early, flu-like phase.

Thank you for listening to this episode. If you found it helpful, let me know. Leave a review, shoot me a message on social media or email, and share it with your colleagues and learners. And as my 13-year-old would like to remind me: like and subscribe.

For PEM Currents, this has been Brad Sobolewski. See you next time.

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This is the only non-medical post I make every year. The annual Anniversary Video that I plan, film, edit, and produce for my wife. I’ve been sharing them with her every year since our third anniversary. This is number 18.

Maybe someday I will get my act together and buy a nice card from Hallmark with a heartfelt message on it for my wife. They still sell those I’m told. If I ever got off my butt and drove to a store I would probably be browsing the aisles for quite a while. It’s so hard to find the right message for someone so wonderful. What if I found a nice card on some thick embossed paper with flowers and a bird and a message like…

“Turns out all those cheesy love songs were onto something. Happy Anniversary to the woman who makes my ordinary days extraordinary.”

or maybe…

“Every love story is beautiful, but ours is my favorite — mostly because you agreed to put up with me.”

I didn’t buy a card like that. But I did make this video. Happy Anniversary Kerri. I love you!

And here are all of the previous Anniversary Videos! https://bradsobolewski.com/anniversaryvideos/

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I’ve you’ve been keeping track (and I know you haven’t) this is the 52nd straight week I’ve posted a “Medical Music Mondays” – this was always the plan of course. As AI matures – and I keep writing fun educational songs I’ll post more – just not on a weekly basis. I’ll end this run with a rap battle – two tracks – who is superior, Ibuprofen or Acetaminophen?N-SAID “Aceta-Dope”Is Ibuprofen better than Acetaminophen? Many parents would say so. Not only will it treat aches and pains better, but it also gives you about 20 minutes longer of fever control. Plus it won’t hurt your liver as easily. Ibuprofen for the win.

LyricsTo say I ain’t anti-inflammatory is quite defamatory
I’m best for pain and your fever and there’s more to the story

I do hepatic metabolism without boxing the liver
Post fracture pain evidence based care I deliver

I can treat all your ailments, the list is complete
headaches, menstrual cramps, arthritis from your arms to your feet

toothaches and back pain, all strains and sprains
I’m better than you at treating your pain

And frankly my impact on bleeding is overrated
I might irritate your stomach but not with appetites sated

And yeah, I treat fever, you think you got an advantage
Common colds, flu, and infection symptoms I’ll manage

Fever control? twenty minutes longer I achieve
Add that on top of all the pain I relieve!

VERSUSAPAP “IBU-FAUX-FEN”Many will choose Acetaminophen over Ibuprofen? Why? There’s flexible dosing. It won’t affect bleeding (at least according to surgeons). It’s got flexible every 4 to 6 hour dosing. And it’s approved for babies under 6-months-old. Take that Ibuprofen!

LyricsI’m more than quite adequate as an acute pain reliever
A versatile treatment why aren’t you a believer?

First recommended by doctors for treating fever in babies
Approved under six months? There ain’t no maybes

My dosing is flexible, every four to six hours
I’m gentle on stomachs, even the most sour

There’s something spectacular about the way that I work
To suggest I’m inferior just means you’re a jerk

Fabricate competition means you’ve got an inferiority complex
We coexist on the store shelves, brand awareness? It’s complex?

Both metabolized in the liver, it’s most certainly true
And surgeons they tremble at the bleeding risk that you’ll do

Let’s face it I’m better, or at least I’m the same?
To suggest you’re the victor is boastful and lame

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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Autism spectrum disorder (ASD) is common—affecting approximately 1 in 68 children—and increasingly recognized in pediatric emergency departments (EDs). While we pride ourselves on providing high-quality care for all children, we must acknowledge that the noisy, fast-paced, and unpredictable environment of the ED can be especially distressing for autistic patients. For many children with ASD, the ED is not just unfamiliar—it’s overwhelming.

A study by Nicholas et al. brings forward the voices of parents, ED clinicians, and administrators, and outlines practical steps to make EDs more compassionate and accessible for children with ASD. Here are six key takeaways and what you can do starting today.

Know Before They Go: ASD-Focused PreparednessEmergency care often begins at triage—but for children with ASD, success may hinge on what happens before that.

What you can do:

• Implement brief screening tools at registration to identify communication needs, sensory triggers, and calming strategies.
• Encourage families to bring “All About Me” sheets or care cards that summarize critical accommodations.
• Digitize and integrate this into your EHR for quick reference.

Manage Wait Times with IntentionalityLong, unstructured waits are hard for all kids—but especially for autistic children who rely on routine and predictability.

What you can do:

• Offer sensory-friendly spaces or quiet rooms with calming tools like weighted blankets, noise-canceling headphones, or fidget toys.
• Borrow from the restaurant world: Use pagers or texting systems to allow families to wait in less stimulating environments (e.g., their car).
• Communicate wait times clearly, and check in often.

Tailor Sedation and Restraint ApproachesSedation and physical restraint can be traumatic for children with ASD and their caregivers.

What you can do:

• Ask families what’s worked (or hasn’t) in the past.
• Discuss options like oral medications, intranasal routes, or the presence of trusted caregivers during procedures.
• Avoid “default” restraint approaches. Be intentional, and when possible, preventive.

Bring in the Experts: Child Life and BeyondDevelopmentally appropriate support is a game-changer—especially during painful or anxiety-provoking procedures.

What you can do:

• Involve Child Life whenever possible to support procedural preparation and coping strategies.
• Stock your department with a sensory cart, calming visuals, or social stories to help kids understand what to expect.
• Orient new staff to these resources early and often.

Build Capacity Across Your TeamWe don’t expect every clinician to be an autism specialist—but we can all do better with a little training.

What you can do:

• Incorporate ASD care into simulation scenarios, staff onboarding, and continuing education.
• Offer tip sheets on communication strategies, de-escalation, and non-verbal pain assessment.
• Create quick-access resources (digital or physical) in high-traffic care areas.

Plan for What Comes NextA visit to the ED shouldn’t be the end of the road—or the start of a revolving door.

What you can do:

• Partner with outpatient providers to ensure follow-up is arranged for behavioral, medical, or developmental concerns.
• Work with your hospital’s care coordination team to create pathways for kids with recurrent ED visits.
• Advocate for transition planning resources as patients age out of pediatric care.

Final ThoughtsCompassionate care for children with ASD in the ED is possible—and necessary. It begins with listening to families, adapting our environments, and equipping our teams. As Nicholas et al. emphasize, “Heightened ASD competence in care may prevent children from being triggered into meltdowns and the need for greater resource infusion.” In short, good care is not just kinder—it’s smarter.

ReferencesPatient- And Family-Centered Care in the Emergency Department for Children With Autism. Nicholas DB, Muskat B, Zwaigenbaum L, et al. Pediatrics. 2020;145(Suppl 1):S93-S98. doi:10.1542/peds.2019-1895L.

Medical Management of Children With Autism in the Emergency Department.. Wolpert KH, Kim SJ, Kodish I, Uspal NG. Pediatric Emergency Care. 2022;38(7):332-336. doi:10.1097/PEC.0000000000002751.

Youth With Autism Spectrum Disorder in the Emergency Department. Lytle S, Hunt A, Moratschek S, Hall-Mennes M, Sajatovic M. The Journal of Clinical Psychiatry. 2018 May/Jun;79(3):17r11506. doi:10.4088/JCP.17r11506.

Note: I used ChatGPT 4.o to help edit this content and generate the image for the header

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Hypertrophic pyloric stenosis is such a down home diagnosis. You bring your baby home and then their weight goes down. Also the ultrasound measurements are a muscle wall greater than 3mm thick and a channel length greater than 14mm. 3 and 14 – 3.14, pi. Get it? Did you read this far?

Lyrics[verse]Across the room
The vomit goes
It’s on the wall
And my clothes
Have a slice of pie – it’s on the menu
Projectile emesis – does that offend you?
More Firstborn males for some reason
Pal-pa-bull olives? They’re in season

[chorus]Hypertrophic Pyloric Stenosis
Nothings getting through!
An Ultrasound will diagnose
A Pyloromyotomy we will do!

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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Did you know that post tonsillectomy bleeding occurs approximately 3 to 5% of the time, most often at days 5 to 7 after the surgery? Of course you did. Unstable children with active bleeding may need a trip to the OR. Otherwise ENT can help determine management.

LyricsNasty strep or OSA
Take those tonsils out today
Remove adenoids just in case
Now there’s blood all over the place

Post T&A bleeds frequently
now you call ENT
If active bleed resuscitate
maybe operate on this date

If not bleeding look for clots
if there’s one ENT takes a shot
But if they are very stable
discharge home you might be able

[Chorus]TNA Bleed,
TNA Bleed!
Yeah!
TNA Bleed
Call ENT!
Now!

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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IntroductionAcute gastroenteritis affects millions of children in the U.S. every year, leading to emergency department visits and hospitalizations. Probiotics, particularly Lactobacillus rhamnosus GG (LGG), have been commonly used as a treatment, but evidence supporting their effectiveness has been limited. A new study conducted by the Pediatric Emergency Care Applied Research Network (PECARN) aimed to determine whether LGG could reduce the severity of gastroenteritis in children. The trial found that LGG did not significantly improve outcomes compared to placebo.

Why is this important for patients and caregivers?

| The study clarifies that probiotics, particularly LGG, may not be as beneficial as previously thought for treating acute gastroenteritis in children.This can help caregivers make informed decisions about the use of probiotics during their child’s illness.Reducing unnecessary treatments can also reduce medical costs and the burden of administering non-beneficial interventions. Parents often use probiotics, like Lactobacillus rhamnosus GG, hoping to reduce the severity of their child’s gastroenteritis. However, this large study shows that probiotics do not significantly shorten illness duration, improve symptoms, or reduce the need for additional medical visits. By using the latest research, parents can focus on more effective treatments like hydration. |

Study questionDoes administering Lactobacillus rhamnosus GG to children with acute gastroenteritis reduce the incidence of moderate-to-severe disease compared to placebo?

Study designThis randomized, double-blind, placebo-controlled trial included 971 children between the ages of 3 months and 4 years who presented to 10 U.S. emergency departments. The children received either LGG or a placebo for five days, and their symptoms were monitored for two weeks.

ResultsThe study found no significant difference between the LGG and placebo groups in terms of moderate-to-severe gastroenteritis (11.8% vs. 12.6%, respectively). There were also no differences in the duration of diarrhea or vomiting, day-care absenteeism, or household transmission of symptoms.

CautionWhile this study provides important insights, it is worth noting that probiotics may still play a role in other health contexts. However, for pediatric gastroenteritis, the evidence suggests they do not provide significant benefits.

A brief message from the principal investigator

We studied close to a thousand patients with acute gastroenteritis in ten U. S. hospitals. We found that probiotics did not improve patient outcomes when compared to placebo. We looked at every outcome we could think of, combined gastroenteritis severity score, duration and severity of diarrhea and vomiting, duration of fever, unplanned healthcare visits, household transmission rates, daycare and work absenteeism. And we also looked in every subgroup we could think of, young versus older, on and off antibiotics, viral or bacterial gastroenteritis, patients that were exclusively breastfed versus not, and the answer was always the same. There were absolutely no differences between the probiotic and the placebo groups.

David Schnadower, MD, MPH

Take Home Points

| Lactobacillus rhamnosus GG does not reduce the severity or duration of gastroenteritis symptoms in children.Caregivers should prioritize hydration and symptomatic care over probiotics for managing gastroenteritis.The findings may shift the approach to treating pediatric gastroenteritis in both clinical and home settings. |

ReferencesSchnadower D, Tarr PI, Casper TC, Gorelick MH, Dean JM, O’Connell KJ, Mahajan P, Levine AC, Bhatt SR, Roskind CG, Powell EC, Rogers AJ, Vance C, Sapien RE, Olsen CS, Metheney M, Dickey VP, Hall-Moore C, Freedman SB. Lactobacillus rhamnosus GG versus Placebo for Acute Gastroenteritis in Children. N Engl J Med. 2018 Nov 22;379(21):2002-2014. doi: 10.1056/NEJMoa1802598. PMID: 30462938; PMCID: PMC6358014.

Freedman et al. Multicenter Trial of a Combination Probiotic for Children with Gastroenteritis. N Engl J Med 2018; 379:2015-2026. DOI: 10.1056/NEJMoa1802597.

Parker et al. Rapid adoption of Lactobacillus rhamnosus GG for acute gastroenteritis. Pediatrics, 2013.

Szajewska et al. Meta-analysis: Lactobacillus GG for treating acute gastroenteritis in children–updated analysis of randomised controlled trials. Aliment Pharmacol Ther. 2013 Sep;38(5):467-76. doi: 10.1111/apt.12403. Epub 2013 Jul 10.

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Night terrors are super scary. And the kid doesn’t even remember them! They’re more like sleep walking than nightmares and parents are often worried that it’s a seizure or something more serious.

Lyrics[verse]Woke up late at night flailing and crying
Couldn’t wake him up though the parents were trying
Oh why the unstoppable fussing and screamin’
Could it be a seizure or possession by a demon?

[chorus]No, It’s a night terror
So just relax
They happen all the time
And those are the facts
You keep the kid safe
And the crying will end
Until the next time
That it happens again!

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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Pinworms! Ahhhhh! They itch at night and they’re scary. Fortunately they are easy to treat and eradicate. They’re still gross.

Lyrics[Intro]Pinworms makin me itch
Pinworms son of a…
WOAH!

[Verse]Nocturnal anal pruritus
Emergence of the white worm
Even steadfast parents
Are beginning to squirm

But fret not and don’t cry
There’s a treatment for you
Pyrantel pamoate and repeat in two weeks
That’s what we’ll do!

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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Duchenne Muscular Dystrophy (DMD) is a complex and progressive disease requiring highly specialized care, especially in emergency situations. The condition affects multiple organ systems—muscular, cardiac, and respiratory—leading to a myriad of clinical complications. When patients with DMD present in the Emergency Department (ED), an understanding of the nuanced aspects of their care is essential for optimal management. Below are key considerations based on current best practices.

Steroid Use and AmbulationSteroids are a mainstay in DMD management, typically starting around ages 3 to 4. They are effective in delaying the loss of ambulation, although progression is inevitable. Once patients become non-ambulatory, they often develop secondary complications like lymphedema, which further complicates their care.

Cardiac Complications: A Unique CardiomyopathyCardiac dysfunction in DMD differs from typical dilated cardiomyopathy. Hearts in DMD patients often have small ventricular volumes and are replaced by fatty tissue, leading to unpredictable cardiac stress responses. Importantly, while cardiac function deteriorates, the heart does not dilate, making echocardiography less reliable. MRI is preferred, particularly with late gadolinium enhancement (LGE), which helps assess scarring and the extent of remaining cardiac muscle.

For cardiac biomarkers, NT-proBNP is used instead of BNP, as valsartan and entresto can affect BNP levels. NT-proBNP values in children with DMD should be below 50, whereas levels above 125-150 in adults indicate concern. You will often observe a longitudinal trend of increasing NT-proBNP and high-sensitivity troponin levels due to ongoing “demand-based injury.” Troponin levels should ideally remain below 2.

In terms of hemodynamics, normal wedge pressures should be in single digits, with elevated values above 12-13 indicating potential cardiac dysfunction. Central venous pressure (CVP) should also stay in the single digits.

Respiratory Management: Vigilance with HypercarbiaRespiratory failure is a critical concern in DMD. Progressive diaphragmatic weakness and fatty infiltration lead to severely diminished lung volumes, sometimes reduced to just two rib spaces. Administering oxygen alone can mask the underlying hypercarbia. Instead, prioritize non-invasive ventilation, such as BiPAP, especially for patients lying flat, which can exacerbate their respiratory insufficiency.

In cases where imaging like a CT scan is necessary, frequent blood gases should be monitored. If sedation is required, ensure careful use of BiPAP to prevent further respiratory decline.

Orthopedic Risks: Watch for Fat EmbolismDMD patients are prone to fat embolisms following fractures due to the fatty infiltration of their bone marrow. Any trauma that results in fractures should raise immediate concern for fat embolism syndrome, which can present rapidly and lead to respiratory and cardiovascular complications.

Renal and Liver Function MonitoringRenal function is best assessed with Cystatin C rather than creatinine, as muscle mass in DMD patients is so low that creatinine levels may not accurately reflect kidney function. If an older patient presents with measurable creatinine levels, consider the possibility of acute kidney injury (AKI).

Liver function tests (AST/ALT) are usually elevated in DMD due to muscle breakdown. However, these elevations do not indicate liver dysfunction. Instead, bilirubin levels should be used to assess actual liver health.

Managing Fluids and HemodynamicsPatients with DMD often have resting tachycardia, even before the onset of overt cardiac dysfunction. Be cautious with intravenous fluids (IVF), as patients are prone to rapid volume overload. Fluid boluses should be administered with care, as they can quickly induce cardiac failure.

In cases of hypotension, start with epinephrine, and consider milrinone if blood pressure remains low but manageable. Additional vasoactive support may be needed, including vasopressin, but only after achieving a stable blood pressure baseline. Always consider the risk of arrhythmia, which can occur despite relatively normal ECG findings.

Imaging: Prioritize MRI Over EchoMRI is the gold standard for cardiac evaluation in DMD patients, particularly for assessing myocardial scarring and function through LGE. Echocardiograms, while frequently used, tend to overestimate cardiac function compared to MRI. DMD patients often receive yearly MRIs to monitor their cardiac health, as discrepancies between MRI and echo findings are common.

Emergency Care Plans and Advanced DirectivesMany DMD patients will arrive with comprehensive emergency care plans or letters from their providers. These documents should be reviewed promptly upon presentation, as they often contain critical information about the patient’s DNR status, preferred ventilation strategies, and other key management instructions. If the patient is in an advanced stage of the disease, these care plans can guide decision-making, particularly around goals of care and interventions.

Conclusion: Holistic, Multidisciplinary CareEmergency care for DMD patients requires a comprehensive understanding of their multi-system disease. The interplay between cardiac, respiratory, and musculoskeletal complications necessitates a highly coordinated approach. By carefully managing fluid status, ventilatory support, and orthopedic risks, and by relying on advanced imaging techniques, emergency providers can deliver the best possible care for these complex patients.

Always review the latest care plans, assess longitudinal trends in cardiac biomarkers, and consult with specialists when needed to ensure that each patient receives individualized and optimal care.

AcknowledgementsThank you to Dr. Michelle Eckerle for the meticulous lecture notes that were the backbone of this post, and Chat GPT 4o for help with editing.

ReferencesCrisafulli S, Sultana J, Fontana A, Salvo F, Messina S, Trifirò G. Global epidemiology of Duchenne muscular dystrophy: an updated systematic review and meta-analysis. Orphanet J Rare Dis. 2020 Jun 5;15(1):141. doi: 10.1186/s13023-020-01430-8. PMID: 32503598; PMCID: PMC7275323.

Buddhe S, Cripe L, Friedland-Little J, Kertesz N, Eghtesady P, Finder J, Hor K, Judge DP, Kinnett K, McNally EM, Raman S, Thompson WR, Wagner KR, Olson AK. Cardiac Management of the Patient With Duchenne Muscular Dystrophy. Pediatrics. 2018 Oct;142(Suppl 2):S72-S81. doi: 10.1542/peds.2018-0333I. PMID: 30275251; PMCID: PMC6566852.

Venugopal V, Pavlakis S. Duchenne Muscular Dystrophy. [Updated 2023 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482346/

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Did you know that pancreatitis is mostly caused by viruses in kids? They don’t drink alcohol or get gallstones like grown ups. Also, scorpion bites apparently cause it. But that’s silly and only something you see in board review books. Anyway, this would be a better Broadway musical than most retreads of 1980s & 90s movies.

Lyrics[Verse]Pancreatitis calls out my name
The pain the intensity, I cannot explain
My mom said I ate too many wings
My dad told me to focus on more pleasant things
But the vomiting ceaseless an unremitting ache
I told them, I mean it, This isn’t fake!

[Chorus]I came in with Pancreatitis now!
My lipase was like 6,000 wow!
I’t probably just a viral cause
Guess my diet will have to take a pause

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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Children with Hemophilia who present to the ED need to get a dose of Factor First! Don’t delay and give their home factor if they have it.

LyricsFactor First!
Factor First!

Bleeding hemophiliac
What’s the plan of attack?

Factor first!
Factor first!

Factor VIII or Factor IX
Use home factor everytime

Factor first!
Factor first!

IV access nice and quick
Hopefully one needle stick

Factor first!
Factor first!

Hematology call can wait
Factor dose can not be late

Factor first!
Factor first!

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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In this episode of PEM Currents: The Pediatric Emergency Medicine Podcast, I explore the complexities of gastroesophageal reflux (GER) and gastritis in children and adolescents. I’ll make the important distinction between gastritis – which is diagnosed only via endoscopy – and dyspepsia, the term best used to describe the symptoms many patients experience. I’ll dive into the latest clinical practice guidelines and discuss evidence-based approaches to diagnosis and treatment.

Topics covered include:

• The pathophysiology of GER and GERD in the pediatric population.
• Understanding dyspepsia and its clinical presentation.
• Diagnostic strategies and when to consider further evaluation.
• The role of lifestyle and dietary modifications in management.
• Pharmacological interventions, including the use of proton pump inhibitors (PPIs), H2 blockers, and antacids.
• Current controversies and updates in pharmacological treatments.
• Management of gastritis and the consideration of Helicobacter pylori infection.

Join me as I scope out the nuances of gastroesophageal reflux and gastritis and provide practical insights for clinicians in the emergency setting.

Listen http://www.pemcincinnati.com/podcasts

Subscribe* Apple Podcasts * Spotify * YouTube

ReferencesRosen R, Vandenplas Y, Singendonk M, et al. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr.2018;66(3):516-554. doi: 10.1097/MPG.0000000000001889

Lightdale JR, Gremse DA; Section on Gastroenterology, Hepatology, and Nutrition. Gastroesophageal Reflux: Management Guidance for the Pediatrician. Pediatrics. 2013;131(5):e1684-1695. doi: 10.1542/peds.2013-0421

Tighe M, Afzal NA, Bevan A, et al. Pharmacological Treatment of Children with Gastro-oesophageal Reflux. Cochrane Database Syst Rev. 2014;2014(11):CD008550. doi: 10.1002/14651858.CD008550.pub2

Sintusek P, Mutalib M, Thapar N. Gastroesophageal Reflux Disease in Children: What’s New Right Now? World J Gastrointest Endosc. 2023;15(3):84-102. doi: 10.4253/wjge.v15.i3.84

TranscriptNote: This transcript was partially completed with the use of the Descript AI

Welcome to PEMCurrents, the pediatric emergency medicine podcast. As always, I’m your host, Brad Sobolewski, and today’s episode will focus on gastro esophageal reflux and gastritis in children and adolescents. Both conditions can present with similar symptoms. They do, though, have distinct pathophysiologies and management strategies.

So we’re going to discuss the evidence based approaches to diagnosis and treatment, and I will talk about why it is presumptive to call things gastritis before definitive diagnosis, even though I put it in the title of the episode. Alright, let’s scope things out. I’m going to begin by making a brief distinction between gastroesophageal reflux and gastroesophageal reflux disease.

So, reflux itself is a common physiologic process, especially in infants, that usually resolves by 12 to 18 months, when the gastroesophageal sphincter gets tighter, and kids spend more of their life on it. upright. Gastroesophageal reflux disease is when the patients have severe symptoms that persist and cause long term issues.

Now, either way, this is due to reflux of the stomach contents into the esophagus. Now, gastroesophageal reflux is incredibly common in infants with up to 50 percent of b cells. babies under three months regurgitating daily. This typically peaks at about four months of age and improves as the infant grows.

Gastroesophageal reflux disease is less common, but still affects about 10 percent of children and up to 10 to 20 percent of adolescents. Adolescents with GERD often present similarly to adults with heartburn and regurgitation as the primary complaints. Now there are some risk factors for GERD.

Gastroesophageal reflux and reflux disease in children. A main one is neurological impairment. So kids with cerebral palsy or other neurologic disorders have delayed gastric emptying and poor esophageal motility, increasing the risk of GERD. Children with respiratory conditions and chronic lung disease like asthma are more prone to GERD as well.

And reflux itself can exacerbate the existing respiratory symptoms either through microaspiration or vagal mediated bronchospasm. Prematurity and congenital conditions like esophageal atresia also obviously increase the risk. So gastroesophageal reflux and reflux disease result from transient relaxation of the lower esophageal sphincter.

That allows acidic gastric contents to flow back into the esophagus. Now, the lower esophageal sphincter is supposed to prevent this reflux from happening. In GERD, the sphincter relaxes too frequently or incompletely, which can lead to symptoms building up over time. Other factors like delayed gastric emptying and abnormal esophageal motility can worsen problems in general.

And the presentation for GERD varies by age. Infants will have frequent spitting up or vomiting after feeds, irritability during or after feeds, especially in the more significant cases where the esophagus is irritated. Uh, infants may start to refuse to feed due to the discomfort. They can have poor weight gain or even failure to thrive in more severe cases.

And they can have Sandefur syndrome, which is the arching of the back and dystonic posturing that occurs during or after feeds as a response to discomfort from acid reflux. This is sometimes misidentified as seizures. In older children and adolescents, heartburn is the most common symptom. It’s a burning sensation in the chest or epigastrium, and that is the classic symptom in this age group.

You can also see regurgitation, acid or food regurgitating into the mouth, leading to a sour taste. uh, ill defined epigastric or chest pain, and it’s often worse by eating or lying down after meals. And some other symptoms that you gotta think about in reflux, chronic cough, hoarseness, or even asthma like symptoms.

These extra esophageal manifestations can occur due to irritation of the upper airways by the gastric contents. Now, in the pediatric emergency department, the diagnosis of reflux is primarily clinical. You just got to take a good history and do a physical examination, especially when the symptoms are typical, like regurgitation, heartburn, or epigastric pain in an older child or adolescent.

You want to take a good history on feeding or dietary habits. In infants, you want to know the amount and frequency of feeding, especially because baby stomachs are small and no newborn stomach can hold six ounces. So, the parents may say, well, he Doesn’t ever seem full. Well, baby doesn’t know how to be full.

So really, you need to learn how much a baby can take and follow weight gain appropriately. Overfeeding a baby will lead to increased spitting up and reflux. You should also ask about older children and adolescents eating trigger foods like spicy things, caffeinated beverages, and acidic beverages like pop.

These can all exacerbate reflux. You want to ask about nocturnal symptoms. So if the kid has symptoms that are worse at night or immediately upon waking up, this may indicate reflux exacerbated by lying down, especially after meals. Red flags that you should always ask about include hematemesis, melana, dysphagia, and Unintentional weight loss, these all need further investigation for complications like esophagitis or another diagnosis such as EOE or peptic ulcer disease.

If any of those red flags are present, you should definitely consider a further diagnostic workup. Again, otherwise the diagnosis is based on history and physical examination. So if you see failure to thrive or poor weight gain, again, vomiting blood or passing black tori stools, signs of esophagitis such as painful swallowing or difficulty swallowing.

They need more workup often via GI. So diagnostic testing centers around endoscopy. That’s the gold standard and ultimately getting a camera in there. Taking a look for strictures or ulcers and taking a biopsy of the esophageal and gastric mucosa will make the diagnosis and evaluate for other things like eosinophilic esophagitis or helicobacter pylori infection.

Also get a pH monitoring and impedance probe. This measures both acid and non acid reflux events. It’s kind of like a Holter monitor for reflux. This is obviously ordered by a gastroenterologist, but But the probe itself measures reflux, and then the patient can press a button for an event monitor. And this is particularly useful in children with atypical symptoms or extra esophageal manifestations like cough or asthma, and especially in those that have had a normal endoscopy.

Contrast radiography, like a barium swallow, has much lower sensitivity and specificity than scopes or, in certain situations, even impedance probes and pH monitors. Now, that being said, imaging can be helpful if you suspect hypertrophic pyloric stenosis or other causes of obstruction such as duodenal atresia or antral webs.

But again, you should suspect these based on a detailed history and physical. A management of gastroesophageal reflux is largely dependent on the severity of symptoms and the patient’s age. And most cases of GERD in a pediatric ED can be managed conservatively with feeding or lifestyle modifications and short term pharmacotherapy.

So in infants, you want to recommend smaller, more frequent feeds. Again, overfeeding is a common contributor to reflux in infants. Maybe parents will have to thicken the feeds, but I do not recommend this in the emergency department. Um, and this practice adds rice cereal to the formula or express breast milk that may reduce regurgitation.

Again, this should only really be done under supervision of the child’s pediatrician, keeping infants upright for a half hour after feeds, can let gravity be your friend and reduce reflux episodes. And in older Children and adolescents, the first and most important thing to do is to do dietary modifications like avoiding trigger foods, caffeine, chocolate, spicy foods and acidic beverages like pop.

Large fatty meals should also be avoided, especially in the two to three hours before bedtime. You should encourage older children to avoid lying down immediately after meals, and in some cases, elevating the head of the bed by 30 degrees can reduce night time symptoms. If you feel that you do need to do pharmacologic management, The most effective drugs are proton pump inhibitors like omeprazole and lansoprazole.

They can reduce gastric acid production and help heal the esophagus. A 4 8 week trial of PPIs is recommended for children with moderate to severe GERD, especially those with esophagitis. So you could start that in the emergency department if the symptoms are severe enough, provided that they have primary doctor follow ups.

You may need to wean these PPIs off if symptoms improve because long term use could be associated with risks such as malabsorption of calcium and magnesium or maybe even an increased risk of GI infections such as C. difficile. H2 blockers or H2 formatidine can be used as an alternative to PPIs in milder cases of GERD.

They start working faster. Again, the PPI’s take three to four days to start working. H2’s work immediately. They do reduce acid production to a lesser degree. In older children and adolescents, antacids can provide symptomatic relief of heartburn, but they don’t address underlying acid production. And then there’s things for infants like myelocon and gas drops.

And if you want to try them, go ahead, but they ain’t gonna stop the physiologic process of reflux. And I’ll touch on surgical management briefly before moving on to part two. In rare, severe cases where GERD is refractory to medical management, surgical interventions like fundoplication may be considered, especially in kids with neurologic impairments or life threatening aspiration.

All right, let us shift gears to gastritis. So gastritis is inflammation of the gastric mucosa and can result from infections such as H. pylori, H. pylori, medication overuse, particularly NSAIDs or other stressors. Children with gastritis often present with epigastric pain, nausea, and vomiting, particularly after meals.

And yes, these symptoms do overlap with gastroesophageal reflux and gastroesophageal reflux disease, but they are separate entities. Now there’s a big caveat here. I know that I’m using the word gastritis. And it’s even in the title of the episode. But technically, this diagnosis is only made after endoscopy and biopsy.

Trust me, I asked a gastroenterologist about this directly. So therefore, if you’re seeing this kid for the first time and there’s no established diagnosis, it’s more accurate, especially when an endoscopy has not yet happened, to diagnose them and label that diagnosis based on their symptoms, such as abdominal pain, nausea, early satiety, endoscopy.

Or, you can label it as dyspepsia, also known as indigestion. This refers to a condition characterized by discomfort or pain in the upper abdomen. Typically manifests as fullness, bloating, nausea, or burning in the stomach, especially after eating. And as noted throughout this episode, dyspepsia can be caused by several factors that overlap with GERD and even a kid who gets an ultimate diagnosis of gastritis, like overeating, spicy or fatty food, stress, or underlying conditions.

And technically, the most common cause is functional dyspepsia. Now, I know that’s a lot to digest, and you might be starting to churn, but let’s talk now about the relationship between eating and pain. A key feature of gastritis is the timing of pain. Pain in gastritis typically occurs shortly after eating, as food stimulates gastric acid production, which can irritate the inflamed stomach lining.

You want to ask detailed questions about the timing in pain in relation to meals. Again, that pain is mostly shortly after eating. The foods that cause more symptoms are the ones you’d expect. Spicy, fatty, acidic, or caffeinated items. A detailed dietary history is one of the first steps to making the diagnosis.

You also want to take a detailed history of medication use, especially NSAIDs. Chronic NSAID use for often comorbid symptoms such as headache can damage the gastric mucosa leading to gastritis. The red flag symptoms, as expected, are similar to GERD. Look for signs of GI bleeding, such as hematemesis or melanoma.

or somebody who appears pale, dehydrated, in severe pain, or worse, even in shock. So if you think a kid has dyspepsia, or maybe even eventually gastritis, it’s the history and physical alone which will make the diagnosis. Now a GI cocktail, which is antacid plus viscous lidocaine, could modify the patient’s current symptoms and help sort of convince them where the pain is coming from.

It has been called into question recently by the adult literature. And probably with good cause, as In an older adult with GI symptoms, you should be worried about myocardial infarction or other causes and if you alleviate or mask the pain then you may be moving yourself away from a more important diagnosis.

There also is the worry about rapid systemic absorption of the lidocaine. In general, I’ve not found them to be incredibly helpful in children, but if you’re not worried about other causes, and you need to modify the kid’s pain to sort of help them convince that it’s their stomach and esophagus as a source of the pain, then it could be worth trying.

I mentioned again that the diagnosis is based on history and physical. If they’ve been dealing with chronic symptoms, And there’s an abrupt worsening, or again, the child has red flag symptoms, then you probably do want to get some labs, such as the CBC, check the HNH, lipase, renal panel, liver profile, and ESR and CRP.

Like a kid with normocytic anemia and an ESR of 140, that ain’t gastritis. I’d be worried about inflammatory bowel disease, for instance. Plain films are generally not helpful unless you suspect obstruction or foreign body ingestion. And then, only a radiopaque foreign body. A CT scan can show some signs of liver disease or pancreatitis, but the HNP followed by targeted labs is a more safe and judicious approach.

Now, ultrasound is useful if you suspect gallbladder disease, but the patient needs to be NPO for six to eight hours before the procedure. This will that the gallbladder is distended, which improves the accuracy of the ultrasound in visualizing gallstones or sludge or other abnormalities. So, a kid with mild symptoms, and you want to rule out gallbladder disease?

Like, you can totally order this as an outpatient. You don’t need to make them wait in the ED for six to eight hours. Have a detailed discussion with the patient and family and do shared decision making in terms of interventions, the GI does, and again, these will be the gold standards. Endoscopy, upper GI and endoscopy is the gold standard for diagnosing gastritis.

You see direct visualization of the gastric mucosa and you take biopsies, which can rule out helicobacter pylori or eosinophilic esophagitis or eosinophilic gastritis. Non invasive H. pylori testing, like stool antigens or a urea breath test, can be helpful for diagnosing H. pylori, especially in cases of chronic or recurrent symptoms.

But, being on a PPI can make these tests less accurate. So really, scope is still the way to go. In the end, the most common diagnoses are All of these kids with gastritis like symptoms are going to end up is functional dyspepsia. This is chronic or recurrent pain and discomfort centered in the left upper abdomen without any identifiable structural or biochemical abnormalities upon medical examination.

Gastritis is, once again, inflammation of the stomach lining, which is only truly identified with endoscopy and biopsy. And yes, I called this episode gastroesophageal reflux and gastritis because it’s a colloquial term, but it’s important to make the distinction that ultimately these kids should be labeled as their symptom or dyspepsia in the ED and then followed up with their primary doctor or GI if necessary.

And many of us will ask about H. pylori. And it’s more common in adults, but it’s actually pretty rare in kids. So unless someone living in the home with a kid has an active infection is being treated. it’s probably not going to be H. pylori in the kid. And still, GI would recommend that we don’t start empiric antibiotic treatment in the emergency department anyway, because it’s best to diagnose that with a scope.

So in the odd, rare scenario where you have a family member being treated for H. pylori and a kid with symptoms, I wouldn’t actually start them on a PPI and instead refer to GI for definitive diagnosis. Other things on the differential include peptic ulcer disease, Again, that’s something that really you’ll pick up on endoscopy, but a kid looks like they’re bleeding out, I’d be worried about it, and they are coming in.

It’s also worth mentioning that gastroparesis and delayed gastric emptying can also cause symptoms of dyspepsia. So what are some other important causes of abdominal pain that you should differentiate from dyspepsia and gastritis? And by differentiate, I mean both ask the right questions and tell the family that you are not worried about them.

First, pancreatitis. So the pain in pancreatitis is typically more severe, constant, can radiate to the back, unlike the more intermittent pain of gastritis. Patients will have more nausea and vomiting and some systemic signs like fever or tachycardia. Elevated lipase can make the diagnosis, though Ultrasound or CT can show some pancreatic inflammation.

Gallstones can be seen in adolescence. Pain in the right upper quadrant or epigastric pain. It’s often described as colicky, worsened by fatty meals. Ultrasound, as I noted before, is the diagnostic test of choice. And peptic ulcer disease from duodenal ulcers improves with food, but then worsens several hours later.

Whereas gastric ulcers may worsen shortly after eating, similar to gastritis. Endoscopy will make the diagnosis. And then there’s celiac disease. So celiac disease can cause dyspepsia symptoms as well. Celiac disease is a true autoimmune disorder triggered by the ingestion of gluten. It’s a protein found in wheat, barley, and rye.

In individuals with celiac disease, gluten intake leads to an immune mediated inflammatory response that damages the small intestine’s mucosal lining, specifically the villi. It kind of blunts them down. This impairs nutrient absorption and can lead to a variety of GI symptoms. So if somebody says, I’m not eating gluten because I don’t feel like it or because I want better hair.

Maybe I should try that. That’s not celiac disease. Celiac disease is an immune process. So dyspepsia is a symptom that can occur in celiac disease, and so if you take a history that things worsen upon eating gluten, or what happens if the patient has eliminated gluten from their diet, which is something that I’ve seen many families do on their own.

And it’s not within the scope of this episode, but the anti tissue transglutaminase antibodies, TTG, IgA, that’s the most sensitive and specific initial test for celiac. All right, let’s start to talk about now the management of dyspepsia and gastritis. Dietary and lifestyle changes are the first line treatment.

They can significantly improve symptoms. It’s important that we communicate to patients and families how optimistic we are that these can make a difference. So avoid trigger foods, spicy and fatty foods, acidic foods and beverages like citrus fruits and carbonated drinks. Caffeine and chocolate, and even dairy products if you suspect lactose intolerance.

You want to encourage eating of small, frequent meals. That allows you to digest the gastric contents a little more efficiently. Chew your food thoroughly. Don’t swallow things like a snake. That reduces the swallowing of air and aids digestion. And avoid late night eating, especially two to three hours before bedtime.

No bedtime snacks for these kids. Kids should stay well hydrated, adequate water intake, and limit sugary drinks like juice and pop that can irritate the stomach. Gatorade. That’s a big offender that I’ve run up against. Stress management is really important because stress can exacerbate symptoms, deep breathing, meditation, biofeedback, regular physical activity promotes healthy digestion, and avoiding secondhand smoke because tobacco smoke can irritate the stomach lining.

If you want some symptomatic relief, you can use antacids. They neutralize stomach acid and provide quick relief from symptoms. So Tums, or calcium carbonate, you chew it and it neutralizes existing stomach acid. It’s quick, short term relief. If you take way too many of them, you can get constipation or hypercalcemia.

Maalox, which is aluminum hydroxide and magnesium hydroxide, it’s two antacids, and it can balance side effects maybe, I don’t know. That also provides symptomatic relief. It’s a little bit gritty, but you drink it. And there are pediatric formulations. If you take a lot of it, magnesium can cause diarrhea, and aluminum can cause constipation.

I don’t know if those balance out at all. I haven’t tried it. Then you have your H2 receptor antagonists, or H2 blockers. These medications reduce stomach acid production by blocking histamine receptors in the stomach lining cells. So you’ve got things like famotidine or pepsid. Runitidine or Zantac was commonly used, but it’s been withdrawn from the market due to some safety concerns.

Lomatidine will decrease acid secretion, and it’s effective for mild to moderate symptoms, and it starts shortly after taking it, and is generally well tolerated. The next step up are proton pump inhibitors. These are more potent acid suppressants, and they block the enzyme responsible for acid secretion itself, as opposed to just the pump.

You’ve got drugs like Prilosec, which is Omeprazole, Prevacid, which is Lansoprazole, or Nexium, Esomeprazole. They all work fine and there’s some pediatric formulations which you can look up and sometimes insurances will take one and not the other, again, beyond the scope of this episode. These are prescribed for more severe symptoms or when H2 blockers are ineffective.

Follow pediatric weight based dosing and know that it does take three to four days before the suppression starts working. Long term use could affect nutrient absorption of like magnesium or vitamin B12. And being on a PPI as opposed to being on an H2 blocker can, as I mentioned earlier, alter the results of an endoscopy.

So if you think a kid’s going to need a scope, don’t start a PPI. Or you can stop the PPI if they’re going to get a scope within the next one to two weeks. Let me talk about one more medication that I’ve used occasionally. And so it’s sucrophate or carophate. This kind of acts like a protective barrier over the stomach lining that can aid in healing.

It’s kind of like putting, like, spackle over the stomach. It just kind of blocks everything up and tamps down the symptoms. It’s a viscous, adhesive substance, and it can adhere to ulcer sites as well. This is really short term treatment for more severe pain. You would administer this on an empty stomach, usually an hour before meals, or when a child is having severe symptoms not around the time of meals.

If you use a lot of it, it can cause constipation or interfere with the absorption of other daily medications. So fortunately, most of the kids with dyspepsia, or kids that you think will ultimately be diagnosed with gastritis, will be able to be discharged home. So first and foremost, recommend dietary and lifestyle modifications.

For You could start a daily proton pump inhibitor and explain to the family that it takes three to four days before it starts working. If they want more immediate relief or the symptoms are mild, you consider using an H2 blocker instead. For mild intermittent symptoms, consider adding Tums if they like to chew a tablet or Maalox if they’d rather drink a liquid.

And for a step up to more severe symptoms, suggest the use of sucrophate and intermittently and judiciously. You should have the child follow up with their primary care doctor often after about 10 to 14 days on the acid blocking regimen that you prescribed. If they’re doing better and they’ve made diet and lifestyle modifications, the primary doctor at that point can discuss how long to maintain therapy and develop an exit strategy.

A trial of four to eight weeks would be reasonable. But if they’re not improving, And that could be a cause for referral to gastroenterology. It’s important in the ED to not over promise that, oh yeah, you’re going to see GI. Kids can get better on what we recommend. You should trust that. So don’t immediately refer to GI unless you’re worried about a bleeding ulcer or another diagnosis like inflammatory bowel disease or celiac or eosinophilic esophagitis because every time they swallow chicken and steak it gets stuck in their esophagus.

Remember, our community pediatricians, family medicine doctors, are brilliant. They can handle this problem. But if a child has those red flags, or if you’re concerned they need immediate intervention, by all means, get them to a pediatric center for admission and GI evaluation imminently. And again, I will say it yet one more time, because most of these kids have not yet had endoscopy with biopsy, I would not recommend using the diagnosis gastritis.

And I did put it in the title, but it’s what most people call it, and perhaps this was a bridge to education. Use symptoms as your diagnosis. Abdominal pain, nausea, early satiety, or probably most appropriately, call it dyspepsia. These kids are having indigestion. Don’t minimize it. It is having a significant impact on their daily lives.

They kept whining about it. They came to the ED. And it is tempting to call it gastritis because it seems more significant or impactful, but Avoiding making a presumptive diagnosis does not minimize the symptoms the child is having. Instead, use this as a teachable moment and link your interventions with your expected symptom improvement.

Alright, so we know that gastroesophageal reflux and gastritis are linked. really dyspepsia, are common yet distinct causes of GI symptoms in pediatric patients. Recognizing the key features of these conditions and differentiating them from other causes of epigastric pain, such as pancreatitis, gallstones, and ulcers, is crucial in providing appropriate management.

Thank you for listening to this episode. I hope you were able to pick up some new pearls that you can take back to your next clinical shift. If you have any feedback on this episode or would like to suggest content for a future episode, send it my way. I’ll take an email, a comment on the blog, a direct message on X or another social media platform.

And my kids will remind me to say, like, rate, and review. That’s so more people can find the show and continue to learn. For PEM Currents, the Pediatric Emergency Medicine Podcast, this has been Brad Sobolewski. See you next time.

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Cannabis Hyperemesis Syndrome can make habitual smokers miserable! They will got some relief from hot showers – but many need fluids, ondansetron, topical capsaicin, and even Haldol.

Lyrics[Chorus]Don’t fear the reefer?
Cannabis hyper-emesis syndrome says you do
Intractable vomiting, many hot showers
What, oh what, will we do?

[Verse]You didn’t think this would happen
You just decided to smoke
Now you’re puking your guts up
Is this some sick kind of joke?

Hot showers may help a little
Ondansetron may help some more
Topical Capsaicin applied to the trunk?
Then Haldol you might explore

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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EmergiQuiz is an annual case-based presentation sponsored by the AAP Section on Emergency Medicine that challenges the audience to think through the differential diagnosis for four amazing cases. Traditionally these cases are presented live at the AAP National Conference and Exhibition. Since 2020 the AAP Section on Emergency Medicine has also been sponsoring the publication of online cases on EmergiQuiz.com.

The cases are presented in two parts. First the fellow will present the case. Then one week later the diagnosis will be revealed. This year the schedule is as follows.

Part 1: Case Presentations – Today (Tuesday, September 24th)

Part 2: Diagnosis Revealed – Thursday, September 26th

Here are the 4 cases, each linked to their individual page. Check out all of this year’s cases as well as the previous online cases at EmergiQuiz.com!

Don’t Make Any Rash Decisions – Victoria Quinn, DOPreparing for the Fallout – Margaret Barton, MDHot and Bothered – Joseph Bartoletti, MDHead, Shoulders, Knees & Toes – Morgan Weyant-Cheeseman, MDCheck out this year’s cases as well as the previous online cases at EmergiQuiz.com!

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PEMPix is the American Academy of Pediatrics Section on Emergency Medicine’s annual visual diagnosis competition. This year, in addition to the 10 finalists Maneesha Agarwal will be presenting at the National Conference and Exhibition we will be sharing four cases online in advance of the conference. This is the last of the four cases.

This case was submitted by
Dr. Inbar PlautPEM Fellow at UMASS Chan Medical School | UMASS Memorial Children’s Medical Center

IG handle(s): @inbar.y, @umasspem
Co-author: Zachary Binder

The CaseA 2-month-old male presents with 2-days of reluctance to move the right lower extremity. The mother describes the upper leg as feeling swollen and tense, and the patient cries when the area is touched. She denies any associated redness, warmth, or bruising to the area as well as any trauma or falls. He has otherwise been afebrile and acting at his baseline with normal oral intake and urine output. No recent illnesses or any other symptoms.

He does have a history of prematurity, born via vaginal delivery at 34 weeks due to maternal pre-eclampsia. He required external cephalic version for breech presentation. He spent 2 weeks in the NICU for respiratory distress but was discharged home after 2 weeks on room air and oral feeds. He has been doing well since discharge.

On exam, the child has normal vital signs and is generally well appearing. His right lower extremity is the only major abnormality. He is holding the hip in flexion with minimal movement of the right lower extremity. He has tenderness to palpation of the right thigh with minimal edema, but there is no overlying redness, warmth, or bruising. He has full passive range of motion of the right hip. The remainder of the right lower extremity is nontender to palpation and without abnormality. Additionally, he has full range of motion of the right knee and ankle.

Labs Calcium 10.6 [Reference Range 8.7-10.7 mg/dL] * Phosphorus 6.7 [Reference Range 3.2-6.2 mg/dL] * Alk Phos 663 [Reference Range 150-350 U/L * AST: 34 [ Reference Range 30-80 U/L] * ALT: 29 [Reference Range 5-50 U/L] * Vitamin D, 25-Hydroxy: 24* [Reference Range: 30-100 ng/mL]​ * PTH 26 [Reference Range 8-70 pg/mL]

Femur X-Rays are pictured below:

What’s the Diagnosis?A. Congenital syphilisB. Healing femur fractureC. OsteomyelitisD. ScurvyE. Infantile cortical hyperostosisTap/Click here to reveal the correct answerE. Infantile Cortical HyperostosisThe child protection team and orthopedics were consulted due to concern for possible healing femur fracture. A skeletal survey was completed and revealed smooth bridging calluses of the radii bilaterally. CT head showed focal right parietal bone thickening and sclerosis with widening of the diploic space. Given multiple areas of cortical hyperostosis in the absence of healing or acute fracture, a diagnosis of infantile cortical hyperostosis was made that was later confirmed with genetic testing. Orthopedics has continued to follow patient who has done well, including normal growth and no further episodes of pain.

Infantile cortical hyperostosis, also known as Caffey’s disease, is an autosomal dominant genetic condition linked to a mutation in the COL1A1 gene which encodes type I collagen. It causes changes in bones which typically begin in infancy and self-resolve by two years of age. Clinical presentation can include subperiosteal bone hyperplasia, swelling of the overlying soft tissue as well as associated fever and irritability. It most often affects the mandible and long bones. Patients typically present in infancy with pain with movement of limbs but are otherwise well-appearing with no associated symptoms. Elevations in white blood cell count, ESR, and alkaline phosphatase are common lab abnormalities[i]. These patients are often followed by orthopedics to ensure proper remodeling and growth of affected limbs, but the natural course is favorable with no intervention.

Congenital syphilis can present with “pseudo-paralysis” where infants do not move a limb due to pain. Bony changes often involve the metaphysis and diaphysis of the long bones. In addition, congenital syphilis will have other clinical manifestations including cutaneous lesions, jaundice, anemia, and snuffles. Infants whose mothers received regular prenatal care are unlikely to develop congenital syphilis as it is routinely screened for during pregnancy.

A healing femur fracture was a strong consideration in this case however there was no healing fracture line and the callus was longer than would be expected. Additionally, one would expect more acute pain immediately after the fracture and an improvement in pain as it heals, which does not align with this clinical presentation of concurrent new onset pain and callus formation on X-ray.

Infants with osteomyelitis could present similarly to our patient, although given it is an infection of the bone, one would expect the patient to have a fever, and other signs of infection such as erythema and warmth of the affected limb. Findings on XR are often seen later in the course and it would be unlikely for a patient to be well-appearing and afebrile at the time of evaluation for pain.

Ascorbic acid deficiency or scurvy can present with bone pain due to periosteal reaction. It is unlikely in an infant who is fed breastmilk or formula as Vitamin C is found in both. Scurvy will also have other clinical manifestations such as gingival hemorrhage, peri-follicular hemorrhage, and coiled, fragmented hair.

ReferencesGlorieux FH. Caffey disease: an unlikely collagenopathy. J Clin Invest. 2005;115(5):1142-1144. doi:10.1172/JCI25148

CAFFEY J. (1957). Infantile cortical hyperostosis; a review of the clinical and radiographic features. Proceedings of the Royal Society of Medicine, 50(5), 347–354.

Gensure, R. C., Mäkitie, O., Barclay, C., Chan, C., Depalma, S. R., Bastepe, M., Abuzahra, H., Couper, R., Mundlos, S., Sillence, D., Ala Kokko, L., Seidman, J. G., Cole, W. G., & Jüppner, H. (2005). A novel COL1A1 mutation in infantile cortical hyperostosis (Caffey disease) expands the spectrum of collagen-related disorders. The Journal of clinical investigation, 115(5), 1250–1257. https://doi.org/10.1172/JCI22760

Stafford IA, Workowski KA, Bachmann LH. Syphilis Complicating Pregnancy and Congenital Syphilis. N Engl J Med. 2024;390(3):242-253. doi:10.1056/NEJMra2202762

Pan, T., Hennrikus, E. F., & Hennrikus, W. L. (2021). Modern Day Scurvy in Pediatric Orthopaedics: A Forgotten Illness. Journal of pediatric orthopedics, 41(3), e279–e284. https://doi.org/10.1097/BPO.0000000000001731

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PEMPix is the American Academy of Pediatrics Section on Emergency Medicine’s annual visual diagnosis competition. This year, in addition to the 10 finalists Maneesha Agarwal will be presenting at the National Conference and Exhibition we will be sharing four cases online in advance of the conference. This is the third of the four cases.

This case was submitted by
Dr. Niharika Goparaju
Pediatric Emergency Medicine Fellow at the University of Texas – Austin | Dell Children’s Medical Center

Instagram: @ngoparaj, @atxpemsquad, @dellmedschool, @cat_yee
Co-author: Catherine Yee, MD

The CaseA 12-year-old male with trisomy 21 presents with one week of right eye swelling and three days of clear eye drainage. Initially, the patient was self-inflicting trauma to the eye with his thumb. At the time, parents noted redness of the eye. Since then, patient has had progressive eyelid swelling leading to the inability to open the right eye altogether. Three days prior to presentation, the parents noted clear drainage from the right eye. The day prior to presentation, the parents flushed the right eye with water and applied castor oil to the eyelid.

The patient has had no fever, decreased appetite, emesis, cough, congestion, known foreign body in the eye, or chemical exposure. In addition to trisomy 21, the patient has a history of autism, intermittent alternating esotropia with horizontal nystagmus, constipation, and dysphagia. He’s had a prior strabismus surgery. He is completely unimmunized and on supplemental vitamins.

His exam is notable for features consistent with trisomy 21 and unremarkable other than his eye exam.

Left eye: Blinks to light, EOM intact, intraocular pressures unable to assess, visual fields unable to assess, no proptosis, cornea is clear, lens visualized, unable to assess IOP and visual fields.

Right eye: (exam limited by cooperation) mild upper and lower lid swelling, eye does not open spontaneously, cornea opacified – difficult to assess pupil, +conjunctival injection; negative fluorescein, unable to assess IOP and visual fields

Right EyeLeft EyeWhat’s the Diagnosis?A. Post traumatic cataractB. Bacterial keratitisC. Fuchs endothelial dystrophyD. Open globeE. Acute corneal hydropsTap/Click here to reveal the correct answerE. Acute corneal hydropsThe patient was seen by ophthalmology who recommended admission for medical management to prevent further self-inflicted trauma via clear plastic shields and initiate eye drops including atropine, prednisolone, and hypertonic saline. Once parents were comfortable administering drops at home, the patient was discharged a few days later with close out-patient ophthalmology follow-up. Eventually ophthalmic losartan was added with great improvement. It took two months for the patient to completely recover.

The term “hydrops” originates from the ancient Greek word “húdōr,” which means “water,” and is used in medicine to refer to any abnormal accumulation of serous fluid in a tissue or cavity. In the case of acute corneal hydrops, there is a break in the Descment membrane and endothelium, and aqueous humor influxes causing corneal edema. Conditions that weaken the cornea increase the risk of this condition and includes keratoconus (progressive thinning and cone-like steepening of the cornea. Patients with trisomy 21, atopic disease, learning disabilities, corneal anatomical variances, steep keratometry, and elevated intraocular pressure are also at increased risk of acute corneal hydrops. Eye rubbing also increases risk.

Symptoms of acute corneal hydrops includes sudden onset of decreased visual acuity, photophobia, pain, and a translucent milky-white appearance to the cornea. Diagnosis is made based on history and slit lamp findings. Medical management includes hypertonic saline drops to draw fluid from the epithelium, topical antibiotics to prevention secondary infection, antiglaucoma medications to reduce hydrodynamic forces, as well as cycloplegics, NSAIDs, and steroids to help with symptoms. Surgical treatment may also play a role and include intracameral gas injection, compression corneal sutures, and penetrating keratoplasty. While most cases spontaneously resolve in 2- 4 months, complications may include vision-debilitating scarring, infection, pseudocyst formation, and corneal perforation.

ReferencesMudgil T, Nagpal R, Goel S, Basu S. Acute Corneal Hydrops: Etiology, Risk Factors, and Management. In: Das S, ed. Keratoconus. Singapore: Springer; 2022. doi:10.1007/978-981-19-4262-4_12.

Barsam A, Petrushkin H, Brennan N, et al. Acute corneal hydrops in keratoconus: a national prospective study of incidence and management. Eye (Lond). 2015;29(4):469-474. doi:10.1038/eye.2014.333

Barsam A, Brennan N, Petrushkin H, et al. Case-control study of risk factors for acute corneal hydrops in keratoconus. Br J Ophthalmol. 2017;101(4):499-502. doi:10.1136/bjophthalmol-2015-308251

McMonnies CW. Mechanisms for acute corneal hydrops and perforation. Eye Contact Lens. 2014;40(4):257-264. doi:10.1097/ICL.0000000000000048

Fan Gaskin JC, Patel DV, McGhee CN. Acute corneal hydrops in keratoconus – new perspectives. Am J Ophthalmol. 2014;157(5):921-928. doi:10.1016/j.ajo.2014.01.017

Maharana PK, Sharma N, Vajpayee RB. Acute corneal hydrops in keratoconus. Indian J Ophthalmol. 2013;61(8):461-464. doi:10.4103/0301-4738.116062

García de Oteyza G, Bregliano G, Sassot I, Quintana L, Rius C, García-Albisua AM. Primary surgical options for acute corneal hydrops: A review. Eur J Ophthalmol. 2021;112067212110378. doi:10.1177/11206721211037833

Ocular Trauma: Acute Evaluation, Cataract, Glaucoma. EyeWiki.https://eyewiki.org/Ocular_Trauma:_Acute_Evaluation,_Cataract,_Glaucoma. Accessed June 18, 2024.

Bacterial Keratitis. EyeWiki. https://eyewiki.aao.org/Bacterial_Keratitis#References. Published June 3, 2021. Accessed June 18, 2024.

Fuchs’ Endothelial Dystrophy. EyeWiki.https://eyewiki.aao.org/Fuchs%E2%80%99_Endothelial_Dystrophy#:~:text=Disease-,Fuchs’%20endothelial%20dystrophy%20is%20a%20non%2Dinflammatory%2C%20sporadic%20or,halos%2C%20and%20reduced%20visual%20acuity. Accessed June 18, 2024.

American Academy of Ophthalmology. Acute Anterior Uveitis. EyeWiki.https://eyewiki.aao.org/Acute_Anterior_Uveitis. Accessed June 20, 2024.

Wilson SE. Topical Losartan: Practical Guidance for Clinical Trials in the Prevention and Treatment of Corneal Scarring Fibrosis and Other Eye Diseases and Disorders. J Ocul Pharmacol Ther. 2023;39(3):191-206. doi:10.1089/jop.2022.0174

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EmergiQuiz is an annual case-based presentation sponsored by the AAP Section on Emergency Medicine that challenges the audience to think through the differential diagnosis for four amazing cases. Traditionally these cases are presented live at the AAP National Conference and Exhibition. Since 2020 the AAP Section on Emergency Medicine has also been sponsoring the publication of online cases on EmergiQuiz.com.

The cases are presented in two parts. First the fellow will present the case. Then one week later the diagnosis will be revealed. This year the schedule is as follows.

Part 1: Case Presentations – Today (Tuesday, September 24th)

Part 2: Diagnosis Revealed – Thursday, September 26th

Here are the 4 cases, each linked to their individual page. Check out all of this year’s cases as well as the previous online cases at EmergiQuiz.com!

Don’t Make Any Rash Decisions – Victoria Quinn, DOPreparing for the Fallout – Margaret Barton, MDHot and Bothered – Joseph Bartoletti, MDHead, Shoulders, Knees & Toes – Morgan Weyant-Cheeseman, MD

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PEMPix is the American Academy of Pediatrics Section on Emergency Medicine’s annual visual diagnosis competition. This year, in addition to the 10 finalists Maneesha Agarwal will be presenting at the National Conference and Exhibition we will be sharing four cases online in advance of the conference. This is the second of the four cases.

This case was submitted by
Dr. Mary Muffly
Pediatric Resident at Emory University | Children’s Healthcare of Atlanta

Instagram: @emorypedsresidency, @emorypemfellows, @emoryrad, @marymuffly, @dgreenks, @itsanjali,
Co-authors: Anjali Prasad MD, Erica Riedesel MD, David Greenky MD

The CaseAn 8-year-old male with mild intermittent asthma and G6PD deficiency presents with three days of fatigue and nightly cough. He initially presented to his pediatrician two months prior with 10 days of cough and unexplained fevers. At that time, a chest x-ray revealed a left lower lobe consolidation that was treated with a 5-day course of amoxicillin. Two weeks later, he returned to his pediatrician with persistent fevers; a repeat chest x-ray at that time continued to show a left lower lobe opacity. This time, he was treated with a 5-day course of azithromycin. However a third chest x-ray obtained two weeks to evaluate for improvement demonstrated an evolving left lower lobe consolidation with a loculated effusion. At that point, he was referred to pulmonology who started the patient on albuterol, manual chest physiotherapy, and a steroid inhaler with a plan for a fourth chest x-ray four weeks later.

However, he developed the fatigue and cough prompting today’s presentation to the ED. On arrival, the patient was febrile to 38.3C. He was saturating 100% on room air. He had easy work of breathing, and physical exam was only notable for decreased breath sounds over the left lower lobe.

A CBC, CRP, and CMP were obtained and notable for a leukocytosis (18,500/µL) with a neutrophilic predominance (86.6%), elevated platelets (481/µL), anemia (10.7 g/dL), elevated C-reactive protein (6.5 mg/dL, normal <0.1 mg/dL), and hyponatremia (131 mEq/L). His chest x-ray revealed persistent opacity in the left lower lobe, shown below. Further evaluation with computed tomography (CT) chest was obtained with representative cuts shown and a 3D reconstruction shown as well.

What’s the Diagnosis?A. Aspirated foreign bodyB. Bronchopulmonary sequestrationC. LymphomaD. Congenital pulmonary airway malformationE. TuberculosisTap/Click here to reveal the correct answerB. Bronchopulmonary sequestrationOur patient was diagnosed with bronchopulmonary sequestration (BPS). His chest CT showed large caliber systemic arterial vessels arising from the celiac trunk below the diaphragm which were supplying an abnormal portion of the left lower lobe, suggestive of previously undiagnosed BPS. The CT also showed normal pulmonary venous return via the left lower pulmonary vein. Additionally, the CT revealed findings most consistent with necrotizing pneumonia within the sequestered portion of the lung and a small left pleural effusion. It is believed that this sequestered portion of his lung placed him at an elevated risk for infections as this is a known complication of bronchopulmonary sequestration.

Bronchopulmonary sequestration is a rare type of congenital lung malformation (CLM) in which a section of lung tissue is nonfunctional and does not communicate with the normal tracheobronchial tree. With improved access to prenatal care and ultrasounds, CLMs are commonly detected prenatally. Some cases will become symptomatic in the newborn period with presentations such as infection, respiratory distress, or high-output heart failure, however a smaller portion of patients with BPS are not diagnosed prenatally and either become symptomatic later in life (such as our patient) or remain asymptomatic and are incidentally noted on imaging. Congenital lung malformations are seen in about 1 in 2,500 to 8,000 live births, and BPS accounts for 0.15 to 6.4% of all CLMs. Other forms of CLMs include congenital pulmonary airway malformation, bronchogenic cysts, congenital lobar emphysema, and bronchial atresia.

This patient was admitted to the general pediatrics service and initially started on ceftriaxone and clindamycin. After one day he was transitioned to oral levofloxacin and clindamycin to complete a 2-week antibiotic course. He remained off respiratory support and was discharged on day 3 of admission to complete the remainder of his antibiotic course at home. Pulmonology and surgery were consulted during his hospital stay, and he has since had a left lower lobectomy after healing from his pneumonia.

An important point from this case is to consider CT imaging when a child has persistent or recurrent pneumonia. Most patients are afebrile by the third day of treatment and clinically improved within two weeks. In addition to CLMs, the differential diagnosis for these patients includes an airway obstruction, aspirated foreign body serving as an infectious nidus, and immunologic disorder.

ReferencesPalla J, Sockrider MM. Congenital Lung Malformations. Pediatr Ann. 2019 Apr 1;48(4):e169-e174. doi: 10.3928/19382359-20190326-02. PMID: 30986318.

Hegde BN, Tsao K, Hirose S. Management of Congenital Lung Malformations. Clin Perinatol. 2022 Dec;49(4):907-926. doi: 10.1016/j.clp.2022.08.003. PMID: 36328607.

Chakraborty RK, Modi P, Sharma S. Pulmonary Sequestration. 2023 Jul 24. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 30335347.

Savic B, Birtel FJ, Tholen W, Funke HD, Knoche R. Lung sequestration: report of seven cases and review of 540 published cases. Thorax. 1979 Feb;34(1):96-101. doi: 10.1136/thx.34.1.96. PMID: 442005; PMCID: PMC471015.

Marrie TJ, Beecroft MD, Herman-Gnjidic Z. Resolution of symptoms in patients with community-acquired pneumonia treated on an ambulatory basis. J Infect. 2004 Nov;49(4):302-9. doi: 10.1016/j.jinf.2003.11.013. PMID: 15474628.

Metlay JP, Atlas SJ, Borowsky LH, Singer DE. Time course of symptom resolution in patients with community-acquired pneumonia. Respir Med. 1998 Sep;92(9):1137-42. doi: 10.1016/s0954-6111(98)90408-5. PMID: 9926169.

Singh J, Dalal P, Rattan KN. Congenital pulmonary airway malformation mimicking as pulmonary tuberculosis in five paediatric patients: a diagnostic dilemma. Trop Doct. 2018 Jul;48(3):247-250. doi: 10.1177/0049475518765305. Epub 2018 Apr 6. PMID: 29621946.

Lyon SM, Rossman MD. Pulmonary Tuberculosis. Microbiol Spectr. 2017 Jan;5(1). doi: 10.1128/microbiolspec.TNMI7-0032-2016. PMID: 28185620.

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PEMPix is the American Academy of Pediatrics Section on Emergency Medicine’s annual visual diagnosis competition. This year, in addition to the 10 finalists Maneesha Agarwal will be presenting at the National Conference and Exhibition we will be sharing four cases online in advance of the conference. This is the first of the four cases.

This case was submitted by
Dr. Andrea De Jesús Martínez
Chief PEM Fellow at Baylor College of Medicine | Texas Children’s Hospital

Instagram: @bcm_pemfellows

Co-author: Benjamin Silva, MD, MPH

The CaseA 4-year-old male with no significant past medical history presents with headache and vomiting. About 2 weeks prior, he had an ED evaluation after a 2-3 foot fall onto a carpeted floor with subsequent vomiting. At that visit, his physical exam was normal. He had a CT scan (depicted below) that was reviewed by the neurosurgery team, and he was cleared for discharge home.

During this ED visit, the family notes that the child has had 1 week of vomiting whenever he eats. They also note that he has been waking up in the early morning with a headache that is self-resolving and occasional associated vomiting. The patient has had improving activity and energy since his fall and initial ED evaluation 2 weeks prior.

During this second ED visit, his physical exam including vital signs and mental status remains normal. His neurologic exam reveals an alert child with GCS of 15. No facial asymmetry. Moves all extremities equally against gravity. Intact sensation to light touch bilaterally. No CN II-XII deficits noted. A second CT scan is obtained with relevant cuts depicted below.

What’s the Diagnosis?A. Epidermoid cystB. Non-accidental traumaC. Ruptured arachnoid cystD. Mega cisterna magnaE. Post-traumatic leptomeningeal cystTap/Click here to reveal the correct answerC. Ruptured Arachnoid CystArachnoid cysts are benign extra-axial cystic lesions that are filled with cerebrospinal fluid (CSF). They are usually incidental findings that are completely asymptomatic. However, these cysts can rupture (occurrence rate ~2-6%) and cause subdural hygromas, an accumulation of CSF in the subdural space due to separation of the arachnoid layer from the dura. Cysts larger than 5cm in size increases the risk of rupture, which can be precipitated by even minor head trauma.

Rarely, an arachnoid cyst rupture with subsequent subdural hygroma will result in increased intracranial pressure (occurrence rate <1%). Symptoms typically evolve in the following days to weeks after rupture. Increased intracranial pressure is an indication for surgical intervention.

This patient had a subsequent brain MRI that also revealed papilledema. He also developed hypertension with bradycardia prompting surgical intervention. He initially underwent a right craniotomy with cyst fenestration. He then developed a large pseudocyst requiring placement of a permanent ventriculoperitoneal shunt.

ReferencesAlmousa, Abdulelah S et al. “Spontaneous Rupture of Arachnoid Cyst in a Child: A Rare Case Report.” Cureus vol. 15,1 e33652. 11 Jan. 2023, doi:10.7759/cureus.33652

de Araújo Neto, Francisco Barbosa et al. “Post-traumatic intraosseous leptomeningeal cyst.” Radiologia brasileira vol. 51,2 (2018): 126-128. doi:10.1590/0100-3984.2016.0166

Furtado, Leopoldo Mandic Ferreira et al. “Intracranial arachnoid cyst rupture after mild TBI in children: have we underestimated this risk?.” BMJ case reports vol. 12,4 e228790. 30 Apr. 2019, doi:10.1136/bcr-2018-228790

Jafrani, Ryan et al. “Intracranial arachnoid cysts: Pediatric neurosurgery update.” Surgical neurology international vol. 10 15. 6 Feb. 2019, doi:10.4103/sni.sni_320_18

Khilji, Muhammad Faisal et al. “Spontaneous Arachnoid Cyst Rupture with Subdural Hygroma in a Child.” Case reports in emergency medicine vol. 2016 (2016): 6964713. doi:10.1155/2016/6964713

Kim, Ga-Eun et al. “Radiologic Follow-up of Ruptured Arachnoid Cysts With or Without Hemorrhage: Five Case Reports and a Review of the Literature.” Brain tumor research and treatment vol. 11,3 (2023): 210-215. doi:10.14791/btrt.2023.0013

Rajesh, A et al. “Traumatic rupture of arachnoid cyst with subdural hygroma.” Journal of pediatric neurosciences vol. 7,1 (2012): 33-5. doi:10.4103/1817-1745.97620

Shrestha, Rajendra, and Chao You. “Spontaneous chronic subdural hematoma associated with arachnoid cyst in children and young adults.” Asian journal of neurosurgery vol. 9,3 (2014): 168-72. doi:10.4103/1793-5482.142739

White, Matthew L. and Joe M. Das. “Arachnoid Cysts.” StatPearls, StatPearls Publishing, 2 February 2024.

Wittschieber, D et al. “Understanding Subdural Collections in Pediatric Abusive Head Trauma.” AJNR. American journal of neuroradiology vol. 40,3 (2019): 388-395. doi:10.3174/ajnr.A5855

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What if the Fab Four from Liverpool sang about Henoch-Schönlein purpura – AKA IgA vasculitis. Wouldn’t that be neat? Probably not. Anyway. Listen to this song, it’s fun.

Lyrics
H-S-P
Palpable purpura and swelling of the knee
protein in the pee
hypertension is a thing that you might see
If the urine and B-P are okay
You can send them home to be seen on another day[chorus]H-S-P
I-G-A vasculitis of the kidney
know the rash, catch some pee, get a BP

Lyrics[Verse]HSP
Palpable purpura and swelling of the knee
protein in the pee
hypertension is a thing that you might see
If the urine and BP are okay
You can send them home to be seen on another day

[Chorus]HSP
IGA vasculitis of the kidney
know the rash, catch some pee, get a BP

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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Acquired torticollis is a self limited spasm of the neck muscles – often he sternocleidomastoid – that responds well to ibuprofen, heat, and gentle massage and stretching exercises. I thought you’d appreciate the “wry” sense of humor in the album cover… You’d think I’d write a song about asthma and a child that’s a “Weezer?”

Lyrics[Verse]The world has turned and I’m stuck here
I’ve got torticollis it does appear
A Sternocleidomastoid spasm has now set in
Heat, ibuprofen, and rest – my prescription

[Chorus]Turn, turn, turn
And I can’t turn back
It’s an acquired wry neck
Torticollis attack!

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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Dewdrops on a rose petal describes the classic appearance of the lesions in varicella infections. Chicken pox is preventable by vaccines you know…

Lyrics[Chorus]Dewdrops on a rose petal
Vaccines test your mettle
it’s chicken pox
you silly fox!

[Verse]prodrome fever, body hurts
then the rash arrives in spurts
Varicella’s itchy lesions
most on trunk for some reason
scabbing over, different stages
once all crusted, not contagious

[Chorus]Dewdrops on a rose petal
Vaccines test your mettle

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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In honor of the return of football season I decided to post this tune…

Concussions are nothing to mess around about – and sometimes you don’t know you have one until a bit later. So a conservative plan involves resting until symptoms improve and following up with your doctor. No one knows if listening to “bro country” worsens symptoms.

LyricsWoke up this morning
with a pounding head
Last night’s memories clouded
everything’s blurry instead
Got tackled hard
Got me a TBI
Never thought I’d be that guy

Blindsided and crushed
All the spectators hushed
The game must go on just without me
Just another concussion and some CTE!

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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Ondansetron is an antiemetic that reduces vomiting episodes in many illnesses. It also helps reduce the risk of IV fluids and admission in children with acute gastroenteritis. Also, AI images are weird and why did I end up with a picture of a Bruno mars look a like sitting on the toilet?

LyricsIt might seem crazy what I’m ’bout to say
Vomiting and diarrhea all throughout the day
Norovirus from some jerk’s kid at daycare
Dehydration is now on the way

Yeah, he’s got gastro
Crap all day long and you feel like you gotta puke
Yes he’s got gastro
Ondansetron if you want to stop the puke

Yeah he’s got gastro
Give zofran if you wanna reduce the risk of IV fluids
Yeah it’s just gastro
Yeah they might puke but the risk of admission is reduced too

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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This episode of PEM Currents discusses ECPR (Extracorporeal Cardiopulmonary Resuscitation), an advanced procedure used in cases of cardiac arrest when traditional CPR fails. ECPR involves using ECMO (Extracorporeal Membrane Oxygenation) to take over heart and lung functions, offering a last-resort option that is becoming more common in large pediatric hospitals. While ECPR shows promise in improving survival rates, particularly in pediatric patients with conditions like congenital heart disease, it is resource-intensive and carries significant risks. Establishing an ECPR program requires robust infrastructure, multidisciplinary teamwork, and extensive training. The episode highlights the importance of understanding eCPR as a critical therapy for both in-hospital and out-of-hospital cardiac arrests.

ListenECPR – PEM Currents: The Pediatric Emergency Medicine Podcast – by: Brad Sobolewski, MD, MEdhttp://www.pemcincinnati.com/podcastsSubscribe* Apple Podcasts * Spotify * YouTube

ReferencesGajkowski EF, Herrera G, Hatton L, et al. ELSO guidelines for adult and pediatric extracorporeal membrane oxygenation circuits. ASAIO J. 2022; 68:133–152.

Stratton, M., & Edmunds, K. (2024). Extracorporeal Cardiopulmonary Resuscitation. Pediatric Emergency Care, 40(8), 618-622.

ECC Committee, Subcommittees, and Task Forces of the American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2005;112(suppl):IV1–IV203.

Yannopoulos D, Kalra R, Kosmopoulos M, et al. Rationale and methods of the advanced R2Eperfusion STrategies for refractory cardiac ARREST (ARREST) trial. Am Heart J. 2020;229:29–39.

Bartos JA, Yannopoulos D. Starting an extracorporeal cardiopulmonary resuscitation program: success is in the details. Resuscitation. 2023; 187:109792.

TranscriptNote: This transcript was partially completed with the use of the Descript AI

Welcome to PEMCurrents, the Pediatric Emergency Medicine Podcast. As always, I’m your host, Brad Sobolewski, and this episode is all about eCPR, an emerging, resource intensive, but life saving technique that can be activated in situations where there was a witnessed out of hospital cardiac arrest with continuous CPR in process or an in hospital cardiac arrest.

Now, I know that this isn’t readily available, but it is becoming more common in large children’s hospitals, and I thought that this would be a good time to share an overview. So, eCPR, extracorporeal cardiopulmonary resuscitation, is an advanced medical procedure used in cases of cardiac arrest where traditional CPR has failed.

Refractory CPR is a situation where the team has not obtained return to spontaneous circulation in 30 minutes. Now, some centers are using 15 minutes in their guidelines, but 30 is what I’m familiar with. And here’s a basic overview of the eCPR process. So first, the patient has ongoing, high quality CPR.

Some sample objective markers of high quality CPR could include an end tidal CO2 greater than 10 millimeters of mercury, and or pH greater than 7, and or intermittent organized breathing. cardiac rhythms. If the patient meets criteria, then the multidisciplinary ECMO, extracorporeal membrane oxygenation team, is activated.

The patient will undergo cannulation, where large catheters are inserted into an artery and vein, like the femoral, to connect them to the heart lung machine. ECMO will take over the function of the heart and lungs, circulating and oxygenating the blood externally. The patient will remain on ECMO while the underlying causes of the cardiac arrest are addressed.

These could include severe sepsis. asthma, heart failure, and more. If the patient’s heart function recovers, they’re gradually weaned off of ECMO. If not, further interventions, including potential transplantation, may be considered. eCPR is typically performed in specialized centers with highly trained personnel in well coordinated teams.

It is a last resort for patients who would otherwise have a very low chance of survival. Now the evidence behind the benefits of eCPR are encouraging. There are some observational studies and meta analyses which generally support its use, showing increased survival rates in cases of refractory cardiac arrest.

One of the landmark studies, the ARREST trial, compared traditional CPR with early eCPR in adults and found significantly improved survival rates among those treated with eCPR. Now, this study did take place in a single center with a mature eCPR system already in place. So eCPR itself is not a standalone intervention.

It’s part of a comprehensive system of care that requires robust infrastructure and and coordination. When we turn the focus to pediatric patients, the data is unsurprisingly more limited, but compelling. For instance, eCPR is well established as a bridge therapy in pediatric patients with congenital heart disease and increasingly used in in hospital cardiac arrests.

One review of pediatric eCPR cases demonstrated a 73 percent survival rate, and the majority of these survivors maintained their pre arrest neurological baseline. And ultimately, Most of the data thus far is in in hospital arrest. And that makes sense. It’s easier, if easy is a relative term, to coordinate ECMO initiation when the patient is already in the hospital.

It’s much more logistically difficult when the patient arrests out of the hospital and then presents to the emergency department with CPR ongoing via EMS personnel and then to get transitioned to ECMO. And because this process is so resource intensive, It’s important to consider the risks, which are significant.

The process of cannulation itself, which again involves placing large bore catheters in arteries and veins to connect to the ECMO circuit, can lead to complications such as distal ischemia, thrombosis, and hemorrhage. Maintaining the ECMO circuit requires continuous monitoring on anticoagulation, adding additional layers of complexity and the concern of intracranial hemorrhage.

So again, that’s why eCPR is reserved for specific cases where the potential benefits clearly outweigh the risks and the patient meets the standardized criteria accepted by the facility in which it’s deployed. Now, where I work, we have eCPR available, but you may work at a place in which it’s not yet available or currently being developed.

The first and most obvious step is that the facility has to have an established ECMO center. Then developing an eCPR program involves building a comprehensive system of care that extends out into the community as well. So we need to include pre hospital providers, the emergency medicine teams. ECMO proceduralists, the ECMO perfusionists, and intensive care unit clinicians.

One of the key lessons from existing eCPR programs is the importance of rigorous training and simulation. So for instance, large scale simulation programs have been shown to improve adherence to activation protocols and reduce activation times. Of course, both of those are critical to the success of eCPR.

These simulations focus on the coordination of care across multiple divisions within the hospital, ensuring that everyone involved knows their role and can act swiftly when times of the essence. Looking forward, the future of eCPR is bright, but it needs to be available in more centers. We need to refine our systems of care and develop more precise inclusion criteria.

And to spread what has already been learned, about the rigorous simulation and systems based training. And of course, there needs to be more data on outcomes in pediatrics. Future prospective studies should focus on outcomes across a broad array of pediatric patients. This will provide the evidence needed for institutions to support the monumental financial and resource cost to set up eCPR programs in the first place.

Well, that’s all for this episode on extracorporeal cardiopulmonary resuscitation, eCPR. I hope that it provided a basic overview and some context. for this emerging therapy. eCPR is becoming more readily available, and we should all have an understanding of why it is such a pivotal therapy for in and out of hospital cardiac arrest in children.

If you have any feedback on this episode, or the show in general, send them my way. I’ll take an email, a direct message on X, or you can, as the kids say, send Like, rate, and leave a review, or if you found the content helpful, just share it with a colleague. And most of all, thank you for listening. I have been producing this podcast for a dozen years, and I continue to enjoy sharing new knowledge with all of you.

For PEMCurrents, the Pediatric Emergency Medicine Podcast, this has been Brad Sobolewski. See you next time.

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Scabies is everywhere! It’s also very treatable with permethrin topically. It’s also important to remember that patients and families feel unclean and stigmatized by this common infection – but they shouldn’t! Also “Scabies for the Babies” will be stuck in your head. I promise…

Lyrics[chorus]It’s scabies for the babies
Woo hoo
We got scabies for the babies
Do you?
I hate scabies on the babies
And I know that you should too!

[verse]He’s got a rash so itchy
All over the place
On the limbs and the trunk
But spares the face
There’s a surefire cure
Yes one can dream
If you diagnose scabies
Prescribe Permethrin cream

[chorus]It’s scabies for the babies
Oh yeah!

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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Intranasal dexmedetomidine is one of the latest sedative options that’s gaining traction, especially for non-painful procedures. Let’s take a closer look at what makes this medication so useful, particularly when given intranasally.

What is Dexmedetomidine?Dexmedetomidine, often known by its brand name Precedex, is a fascinating medication. It’s a highly selective central alpha-2 agonist that’s able to induce a state of sedation that closely mimics natural sleep. What’s particularly interesting about dexmedetomidine is that it offers “cooperative” sedation, meaning that patients are calm and comfortable but can still respond if you need them to. This makes it different from other sedatives that might make a patient too drowsy or unresponsive.

Plus, it’s versatile! You can give dexmedetomidine in several ways, including intranasally, which is really handy when an IV isn’t the best option.

Safe and PredictableOne of the big selling points of dexmedetomidine is its safety. At the doses we’re talking about for minimal sedation (1-2 mcg/kg intranasally), side effects are pretty rare. The most common things you might see are bradycardia and hypotension, but these are usually mild and easy to manage. And unlike some other sedatives, like benzodiazepines, dexmedetomidine doesn’t cause those paradoxical reactions where a patient might get agitated or overly excited, which is a big plus.

Fast-Acting and FlexibleWhen given intranasally, dexmedetomidine kicks in relatively quickly – typically within 7 to 15 minutes. The duration of its effects can vary depending on the dose, but you can expect it to last up to 30 minutes, which is usually enough time for shorter, non-painful procedures.

Dosing and When to Use ItFor anxiolysis and minimal sedation, a dose of 1-2 mcg/kg intranasally works well. This level of sedation is comparable to what you’d achieve with midazolam, and it requires the same level of monitoring. If you need deeper sedation, you can go up to 4 mcg/kg, but that will require closer monitoring. A default dose of 2mcg/kg is reasonable if you are building an order set.

Dexmedetomidine is particularly effective for situations where you want the patient to be in a sleep-like state, such as during imaging studies, straightforward laceration repairs, or digital blocks. It’s great because it keeps patients calm without completely knocking them out, which is perfect for these kinds of procedures.

Intranasal dexmedetomidine is definitely an intriguing option when it comes to minimal sedation. It’s safe, effective, and user-friendly, especially in non-painful procedures. Whether you’re dealing with imaging studies or laceration repairs, this medication offers a reliable way to keep patients calm and comfortable. It’s definitely worth considering as part of your sedation toolkit.

ReferencesArain SR, Ebert TJ. The efficacy, side effects, and recovery characteristics of dexmedetomidine versus propofol when used for intraoperative sedation. Anesth Analg. 2002 Aug;95(2):461-6, table of contents. doi: 10.1097/00000539-200208000-00042. PMID: 12145072.

Carollo DS, Nossaman BD, Ramadhyani U. Dexmedetomidine: a review of clinical applications. Curr Opin Anaesthesiol. 2008 Aug;21(4):457-61. doi: 10.1097/ACO.0b013e328305e3ef. PMID: 18660652.

Tobias JD. Dexmedetomidine: applications in pediatric critical care and pediatric anesthesiology. Pediatr Crit Care Med. 2007 Mar;8(2):115-31. doi: 10.1097/01.PCC.0000257100.31779.41. PMID: 17273114.

Reel B, Maani CV. Dexmedetomidine. [Updated 2023 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513303/

Note: I edited the following sentence “A default dose of 2mg/kg is reasonable if you are building an order set.” to reflect a typo in the original post. Doses of IN Dexmedetomidine are in mcg/kg

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If the Wu Tang clan produced a track about strep throat in children it might sought like this. Also ODB could be “Oropharyngeal Disease Bacteria.”

LyricsI’m at your throat like strep
erythema, fever and exudate
pain when I swallow
It hurts and so can relate
swollen lymph nodes in the neck
belly pain headache and more stuff
can you treat it?
he is whining I’ve had enough
rapid test is so accurate
a cure is so easy
amoxicillin for most kids
the treatment will ease thee

[chorus]strep throat!
rheumatic fever is no joke
swab the tonsils, check the test
antibiotics you know the rest

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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Recently, I had the opportunity to present a morning report to the residents and medical students at Cincinnati Children’s, focusing on the topic of febrile seizures. The session was highly engaging, with a lot of interest from the audience, as febrile seizures are a common but often frightening experience for families.

During the presentation, we covered a range of topics, including the definition and incidence of febrile seizures, their causes, and how to manage and counsel families when their child experiences a febrile seizure. The session was interactive, and we addressed many important questions that healthcare providers often encounter when dealing with febrile seizures in the emergency department.

Morning Report – Febrile SeizuresDownloadI have attached the PDF version of my presentation slides for your review. Below, I’ve listed some of the key questions we answered during the session:

These are the questions that we answered about febrile seizures:

• Slide 4: What are febrile seizures and how common are they?
• Slide 6: Why do they happen?
• Slide 13: What is the risk of epilepsy following febrile seizures?
• Slide 18: What is the evaluation and management for simple febrile seizures?
• Slide 21: What is the evaluation and management for complex febrile seizures?
• Slide 25: What is the role of lumbar puncture in the evaluation?
• Slide 33: What is the role of imaging in febrile seizures?
• Slide 41: What are the recurrence risks and factors?
• Slide 43: Are febrile seizures associated with an increased risk of mortality?
• Slide 45: Is there a role for preventative therapy or rescue drugs?
• Slide 50: How do we talk to families about febrile seizures?

Feel free to review and share these slides with your colleagues. Your feedback and any further questions you might have are always welcome!

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Time is testicle! Acute scrotal pain must be evaluated promptly in the ED. You’ll see swelling, extreme pain, sidling testis, and absent cremaster reflex. You’ve got 4 to 6 hours at most to get the patient to surgery. Time is testicle! Also yacht rock.

Lyrics[Verse]Pain started suddenly
Testicle twists freely
Side lying swollen now
Cremaster gone, holy cow!
Now pain accelerates
Emergency! cannot wait
Ultrasound to diagnose
4 to 6 hours don’t cut it close

[Chorus]Time is testicle!
Dee-torsion is surgical
Orchiopexy
Will hopefully fix me

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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Dog bites are unfortunately common in the Emergency Department. Remembering which ones to suture for cosmetic concerns while assuring we reduce the risk of infections is important. Also, most should get antibiotics. Which one? Dogmentin! (It’s a portmanteau of Dog and Augmentin)…

LyricsWhat you’re hearin’ is true, dog bites on the rise
Take a big chunk outta hands face or thighs
Animal safety prevention 101
cuddly puppies can still bring us fun
But if kids are bitten we gotta step up our game
Make sure we manage all of the pain
Cleanin’ the wound with copious volume
Primarily close cosmetic places
That goes most for the parts of those faces
Otherwise stitch loose, and please never glue
And prescribe Dogmentin whatever you do

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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Bogus man! Kids can get kidney stones too. This alt-rock homage discusses imaging, pain control, and more.

LyricsEveryone knows that kidney stones cause so much pain
colicky anguish radiation to the flank and symptoms all the same
toradol is the first choice along with fluids if you’re a nice doc
an ultrasound can show hydronephrosis if a stone’s blocked

[chorus]kidney stones can happen in children
think about the pain, the pee, the ultrasound if you feel me
don’t forget to check for U-T-I
Urology doesn’t want you to be that guy

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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The CaseAn intrepid child presents to the Emergency Department after falling from the monkey bars. He has significant pain and swelling about the elbow, along with very limited voluntary range of motion, but his neurovascular status is intact. The X-Rays show the following:

Image courtesy Ortho Bullets https://www.orthobullets.com/pediatrics/4007/supracondylar-fracture–pediatricImage courtesy Ortho Bullets https://www.orthobullets.com/pediatrics/4007/supracondylar-fracture–pediatricThe DiagnosisThis is a Type II Supracondylar Fracture of the Humerus. These injuries are generally seen after a fall onto an outstretched extremity. The monkey bars are the “classic” playground apparatus in which they occur – just far enough to fall to allow one time to stick their arm out towards the ground. The most important X-Ray view is the 90-degree true lateral, but you will also need an AP view. That will allow you to assess for characteristic X-Ray findings such as:

• Posterior fat pad sign: Lucency on the lateral view along the posterior distal humerus and olecranon fossa. This is highly suggestive of occult fracture around the elbow even if there is not an obvious fracture.
• Displacement of the anterior humeral line: The anterior humeral line should intersect the middle third of the capitellum in children > 5 years old, and touch the capitellum in children in children <5.

Here is the annotated version of our patient’s X-Ray demonstrating the findings:

ManagementIf you see a Type II and above splint for comfort (posterior long arm angled at a position tolerable to the child 30-90 degrees) and give pain medicine! There are four types of Supracondylar Fractures of the Humerus. Their management differs by type of course.

Nonoperative treatment for supracondylar fractures of the humerus involves long arm casting with less than 90° of elbow flexion. Indications for this method include a warm perfused hand without neuro deficits and Type I (non-displaced) fractures, as well as Type II fractures that meet specific criteria such as the anterior humeral line intersecting the capitellum, minimal swelling, and no medial comminution. Casting lasts for three weeks with repeat radiographs at one week to check for displacement.

Operative treatment options include closed reduction and percutaneous pinning (CRPP) and open reduction. Indications for CRPP include Type II and III supracondylar fractures. Timing of CRPP is dictated by neurovascular status. Non-urgent cases, which can wait overnight, include a warm perfused hand without neuro deficits.

Urgent cases, requiring same-day treatment, include open fractures, a pulseless limb, non-perfused hand, sensory nerve deficits, excessive swelling, and signs like the “brachialis sign” which indicates a more serious injury with a higher likelihood of arterial injury. “Floating elbow” injuries also require timely pinning to reduce the risk of compartment syndrome.

Podcast EpisodeReferencesVaquero-Picado A, González-Morán G, Moraleda L. Management of supracondylar fractures of the humerus in children. EFORT Open Rev. 2018 Oct 1;3(10):526-540. doi: 10.1302/2058-5241.3.170049. PMID: 30662761; PMCID: PMC6335593.

Saeed W, Waseem M. Elbow Fractures Overview. 2023 Aug 7. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 28723005.

Woon, C. Supracondylar Fracture – Pediatric: Ortho Bullets. Accessed 7/17/2024. https://www.orthobullets.com/pediatrics/4007/supracondylar-fracture–pediatric

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Ovarian Torsion causes lots of pain and vomiting. If you want to get a transabdominal ultrasound you need a full bladder. Also Motown is cool.

LyricsIt’s a fallopian twist of fate
Pain and vomiting won’t abate
You thought it was gas
And that it would pass
But now you hope it’s not too late

Ultrasound of the belly
Transabdominal needs jelly
A full bladder as well
Ovary’s deep in the well
Blood flow I hope we will see

[Chorus]Torsed again!
It’s a cruel twist of fate
Consult Gynecology
Before it’s too late

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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Syphilis has gone by many nicknames over the years including “The Great Pretender” and “The Great Imitator.” Emily Labudde, MD, a Pediatric Emergency Medicine fellow at Children’s Healthcare of Atlanta and recent pediatric residency graduate from Cincinnati Children’s discusses the various manifestations of this sexually transmitted infection, and how we can’t miss this very treatable, but sneaky malady.

ListenEmily Labudde & Brad Sobolewski “Syphilis” PEM Currents: The Pediatric Emergency Medicine Podcast, July 10, 2024http://Www.pemcincinnati.com/podcastsSubscribe* Apple Podcasts * Spotify * YouTube

ReferencesEmily J. Labudde, Jane Lee; A Review of Syphilis Infection in Pediatric Patients. Pediatr Rev. July 2024; 45 (7): 373–380. https://doi.org/10.1542/pir.2023-006309

Centers for Disease Control and Prevention. “Sexually Transmitted Disease Surveillance 2021.” Centers for Disease Control and Prevention, 2021. Available from: https://www.cdc.gov/std/statistics/2021/default.htm.

Centers for Disease Control and Prevention. “Sexually Transmitted Infections Treatment Guidelines 2021.” Centers for Disease Control and Prevention, 2021. Available from: https://www.cdc.gov/std/treatment-guidelines/syphilis.htm.

Centers for Disease Control and Prevention. “Youth Risk Behavior Surveillance System.” Centers for Disease Control and Prevention, 2021. Available from: https://www.cdc.gov/healthyyouth/data/yrbs/index.htm.

TranscriptNote: This transcript was partially completed with the use of the Descript AI

Welcome to PEMCurrents, the Pediatric Emergency Medicine Podcast, as always, I’m your host Brad Sobolewski. Today’s episode is all about the great pretender, syphilis. And let’s face it, it’s not just a disease for Medieval royalty. It’s on the rise in the United States and abroad. So let’s talk about the manifestations and management.

And I’ve got a special guest host. This is Emily Labudde, originally from Detroit, at the time of recording this episode, a third year categorical pediatric resident at Cincinnati Children’s and a soon to be pediatric emergency medicine fellow in Atlanta. I’m going to pass the mic to you, Emily. My name is Emily Labudde, and I’m a third year pediatric resident at Cincinnati Children’s Hospital, and I’ll be starting fellowship in pediatric emergency medicine this summer at Emory University Children’s Healthcare of Atlanta.

Today’s podcast is going to cover acquired syphilis infection. Now, I know what you’re thinking. We don’t see a lot of syphilis in the pediatric ED. That’s what I thought, too, until I saw it, and with syphilis on the rise, it’s likely we’ll start to see more. I recently published a review article on syphilis in Pediatrics in Review, which you should check out.

It is far more detailed and also covers congenital syphilis, which is beyond the scope of this episode. At the end of this podcast, you should be able to appreciate the rising incidence of syphilis in the United States, especially amongst young people, recognize various signs and symptoms associated with different stages of syphilis infection, and identify the appropriate workup for possible syphilis infection, including co infections.

Syphilis is fondly referred to as the great imitator because of its various presentations. Headache? Could be syphilis. Rash? Could be syphilis. Weight loss? Could be syphilis. Epitrochlear lymphadenopathy? That’ll be on your boards. Definitely syphilis. I bet I could argue to have syphilis on every differential in some way, shape, or form.

But there are certain clues that can help guide you toward a more reasonable consideration of syphilis infection. Thank you, Jen. The U. S. is seeing a lot more cases of syphilis over the last decade or so. And, since we know from the CDC’s Youth Risk Behavior Survey that many American teens are having sex with less than optimal condom use and infrequent STI testing, pediatricians everywhere should be thinking more about acquired syphilis infection, not just congenital syphilis.

There are three stages of syphilis infection. Primary syphilis is often missed as it presents as a painless genital ulcer. Secondary syphilis causes systemic symptoms such as fever, anorexia, headache, malaise, lymphadenopathy, arthralgias, and rash, that classic rash on the palms and soles. It’s worth looking at a variety of pictures of this rash, some examples of which we have included in the show notes, as its appearance can vary, especially between different skin colors.

Tertiary syphilis is rare, and you’re almost guaranteed not to see it in a pediatric ED as it develops decades after initial infection. It’s characterized by gummas, which are granulomatous soft tissue tumors seen most often in the liver, but also in the bone, brain, heart, skin, testis, and eyes, and end organ damage, particularly of the central nervous system.

At any stage, patients can develop neurosyphilis, that can present with vision changes, neuropathies, seizures, or altered mental status. You may have heard this once or twice before, but your history and physical exam are so important, especially when looking for an infection like syphilis that can present in many different ways.

A thorough review of systems can help guide your differential and can point towards co infections with other STIs. Brush up on your sexual history taking skills because they’re critical here. This includes all the details like who has what parts and where they put them. Teens are awkward and they get super nervous when you kick out mom and dad and ask them what they’ve been doing on the weekends, but you won’t fully understand your patient’s risks without asking these questions.

It’s good preparation prior to the physical exam, which, you guessed it, should be thorough. We’re talking full body skin exam, neuro exam, genital exam, and all of the lymph nodes. Now, it would be really nice if our patients came in saying, Hey, my partner has syphilis, please test me for syphilis. And, like we talked about, syphilis can look like a lot of different things, so it’s important to keep your differential broad.

Syphilis testing can be divided into two types, treponemal and non treponemal. You’ll want to start with a non treponemal test, such as an RPR or VDRL. The RPR or Rapid Plasma Reagent, which has now largely replaced the earlier VDRL or Venereal Disease Research. Laboratory Test is a non-specific serological test for syphilis that uses CARDIOLIPIN as antigen.

These are highly sensitive tests. But watch out for false positives. The RPR is also useful for post treatment monitoring. Trepanemal tests, such as the FTA ABS, are used as confirmation in the setting of a positive non trepanemal test. Patients with neurologic complaints should undergo CSF testing as well.

And, of course, where there’s one, there’s probably more. Use the information from your very thorough sexual history to test your patient for any other STIs they are at risk for. Patients with primary or secondary syphilis can be treated with a single dose of benzathine penicillin G or a 14 day course of doxycycline if your patient has a penicillin allergy.

For any patient with tertiary or neurosyphilis or a pregnant patient with any stage of infection, 10 to 14 days of penicillin G is the only option, even in penicillin allergic patients. So, if a patient has a severe penicillin allergy, have rescue medications available. Watch out for that Gerrish Herxheimer reaction, I know you haven’t heard those words since medical school, which can cause fever, headache, myalgias, or nausea and vomiting in the first 24 hours after treatment.

Last, but not least, remember that in some cases you’re telling your patient about their disease and possibly some dishonesty from their partner. Be sure to counsel them on sharing their results with all of their sexual partners, as well as your responsibility to inform the local health department for disease tracking purposes and the option for third party partner notification.

A few brief points on congenital syphilis, which is covered more in depth in the review article. We most often see this in infants born to mothers with poor prenatal care, as our OB colleagues do a great job screening for syphilis multiple times during pregnancy. Most infants with congenital syphilis are asymptomatic at birth, with appearance of hepatomegaly, jaundice, copious rhinorrhea, lymphadenopathy, and a similar maculopapular rash on their hands and feet that develop later in infancy.

Think about congenital syphilis in your little ones presenting like biliary atresia, who have a normal gallbladder treon ultrasound. Late congenital syphilis in children older than two can present with more severe features that are frequently tested on boards. Things like gummas, facial dysmorphias like saddle nose deformity and frontal bossing, sabershins, Hutchinson teeth, developmental delay, and hearing and vision concerns.

You’ll want to check a non trepanemal test in these kids, as maternal trepanemal antibodies can persist for over 15 months. Patients with congenital syphilis also receive treatment with penicillin G, 50, 000 units per kilo, frequency determined by their age. Thanks so much for listening, now get out there and practice your sexual histories.

Emily, thank you very much. Hopefully you all found this information helpful and we’ll be able to pick syphilis out of the lineup the next time you encounter it in the emergency department. If you want to learn how to produce a podcast episode, reach out to me, just like Emily did, and we will go through the entire process.

If you’ve got ideas for topics, send them my way. Any feedback that you have is greatly appreciated. Send me an email, leave a comment on the blog, a review on your favorite podcast site, or even a message through social media. And as my 12 year old would remind me to say, subscribe and share. For Pam Currens, the Pediatric Emergency Medicine Podcast, this has been Brad Sobolewski.

See you next time.

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Dude! If you could remember the rockin’ drug sequence to for anti epileptics in the Emergency Department that would be totally awesome! Wait, there’s a hair metal song with lyrics to that effect? Rad!

Lyrics[Chorus]Benzo, Benzo, second line
Seizures stop in record time!

[Verse]Seizures longer than five minutes straight
Need medication to help them abate
Lorazepam’s great if you have an I V
I M drugs are fine too you’ll see

[Chorus]Benzo, Benzo, second line
Seizures stop in record time!

[Verse]Keppra, Depakote, Fospheny too
All second line drugs are out there for you
Wait 5 minutes then re-dose
Seizures stopping you are close

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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Heat Stroke is a serious medical diagnosis that can be differentiated from other forms of heat illness. If only there were a calypso song to teach you the main findings…

Lyrics[Chorus]Hot, So Hot, It’s Heat Stroke
Got to cool them down
Hot, Hot with heat stroke
You must cool them down

[verse]Core Temp greater than 40 or 104
Dry hot skin and sweating no more
Pinpoint pupils, Trouble breathing
Bizarre behavior, confusion or seizing

[Chorus]Hot, So Hot, It’s Heat! Stroke!
Got to cool them down

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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It’s a new wave of information! RSV causes bronchiolitis. OK, so it’s not new. We can make a clinical diagnosis, and X-Rays are not necessary for most children with Bronchiolitis.

LyricsWheezing and coughing subcostal retractions

Nasal secretions suctioning action

RSV causes the typical cases

Worried looks on parental faces

Usual course with typical findings

Normal oxygen sats is a silver lining

It’s bronchiolitis, diagnosis so easy

There’s no need for X-Rays in a baby this wheezy

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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It used to be ALTE but now it’s BRUE. Brief Resolved Unexplained Event. It is a better name after all. And it makes for better puns.

LyricsSudden brief resolved single episode
baby’s under a year old
Cyanosis pallor or breathing and tone change
altered responsiveness and no way to explain[chorus]something’s brewing here
Brief resolved unexplained event
observation’s warranted for high risk infants

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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Supraventricular tachycardia is really fun to convert. You go do all kinds of vagal maneuvers which are basically heart games. Then there’s the REVERT maneuver – it works great! Search for it and learn it. Or watch this video.

LyricsS V T!

A heart rate so fast
as fast as can be

S V T!

EKG super fast rate with no p waves
Q R S is narrow, that’s what you will see

S V T!

Stable kids get maneuvers so vagal
Ice to the face, bear down, Revert maneuver if you say so

S V T!

Adenosine, ramp up the dose, next thing on the table
Cardioversion is to be used if they are unstable

S V T!

S V T!

Button battery!

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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Cervical Spine Injuries are fortunately rare in children. this episode is all about learning when to suspect them, how to immobilize the C-spine properly, and which imaging test to choose. It was inspired by a hot-off-the-presses publication from the Pediatric Emergency Care Applied Research Network (PECARN) focused on clinical decision rules for cervical spine imaging in children.

Here is the aforementioned PECARN paper:

Leonard, J. C., Harding, M., Cook, L. J., Leonard, J. R., Adelgais, K. M., Ahmad, F. A., Browne, L. R., Burger, R. K., Chaudhari, P., Corwin, D. J., Glomb, N. W., Lee, L. K., Owusu-Ansah, S., Riney, L. C., Rogers, A. J., Rubalcava, D. M., Sapien, R. E., Szadkowski, M. A., Tzimenatos, L., Ward, C. E., Yen, K., Kuppermann, N. (2024). PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study. Lancet Child & Adolescent Health. https://doi.org/10.1016/S2352-4642(24)00104-4.

@PECARNTeam on X

ListenCervical Spine Injuries – Brad Sobolewski, MD, MEd – PEM Currents: The Pediatric Emergency Medicine Podcast – 2024http://www.pemcincinnati.com/podcastsAlso maybe watch this music video that details how to clear the C-spine

…also maybe watch this music video that details how to clear the C-spine

Subscribe* Apple Podcasts * Spotify * YouTube

ReferencesLeonard, J. C., Harding, M., Cook, L. J., Leonard, J. R., Adelgais, K. M., Ahmad, F. A., Browne, L. R., Burger, R. K., Chaudhari, P., Corwin, D. J., Glomb, N. W., Lee, L. K., Owusu-Ansah, S., Riney, L. C., Rogers, A. J., Rubalcava, D. M., Sapien, R. E., Szadkowski, M. A., Tzimenatos, L., Ward, C. E., Yen, K., Kuppermann, N. (2024). PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study. Lancet Child & Adolescent Health. https://doi.org/10.1016/S2352-4642(24)00104-4.

Sasser SM, Hunt RC, Faul M, Sugerman D, Pearson WS, Dulski T, Wald MM, Jurkovich GJ, Newgard CD, Lerner EB; Centers for Disease Control and Prevention (CDC). Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage, 2011. MMWR Recomm Rep. 2012 Jan 13;61(RR-1):1-20. PMID: 22237112.

Leonard JR, Jaffe DM, Kuppermann N, Olsen CS, Leonard JC; Pediatric Emergency Care Applied Research Network (PECARN) Cervical Spine Study Group. Cervical spine injury patterns in children. Pediatrics. 2014 May;133(5):e1179-88. doi: 10.1542/peds.2013-3505. PMID: 24777222; PMCID: PMC9923608.

Baker C, Kadish H, Schunk JE. Evaluation of pediatric cervical spine injuries. Am J Emerg Med. 1999 May;17(3):230-4. doi: 10.1016/s0735-6757(99)90111-0. PMID: 10337876.

Leonard JC, Browne LR, Ahmad FA, Schwartz H, Wallendorf M, Leonard JR, Lerner EB, Kuppermann N. Cervical Spine Injury Risk Factors in Children With Blunt Trauma. Pediatrics. 2019 Jul;144(1):e20183221. doi: 10.1542/peds.2018-3221. PMID: 31221898; PMCID: PMC6615532.

Leonard JC, Jaffe DM, Olsen CS, Kuppermann N. Age-related differences in factors associated with cervical spine injuries in children. Acad Emerg Med. 2015 Apr;22(4):441-6. doi: 10.1111/acem.12637. Epub 2015 Mar 16. PMID: 25779934.

Leonard JC, Kuppermann N, Olsen C, Babcock-Cimpello L, Brown K, Mahajan P, Adelgais KM, Anders J, Borgialli D, Donoghue A, Hoyle JD Jr, Kim E, Leonard JR, Lillis KA, Nigrovic LE, Powell EC, Rebella G, Reeves SD, Rogers AJ, Stankovic C, Teshome G, Jaffe DM; Pediatric Emergency Care Applied Research Network. Factors associated with cervical spine injury in children after blunt trauma. Ann Emerg Med. 2011 Aug;58(2):145-55. doi: 10.1016/j.annemergmed.2010.08.038. Epub 2010 Oct 29. PMID: 21035905.

TranscriptNote: This transcript was partially completed with the use of the Descript AI

Welcome to PEM Currents, the Pediatric Emergency Medicine Podcast. As always, I’m your host Brad Sobolewski, and this episode is all about cervical spine injuries in children. Now, fortunately, cervical spine injuries in kids are rare. They only happen in about 1- 2 percent of pediatric blunt trauma injuries.

But, In children with cervical spine injuries, at least one in five have permanent neurologic deficits, and serious cervical spine injuries, there’s a 7 percent mortality rate. So severe mechanisms are the scenarios where you are most likely to see a C spine injury in kids. So these are motor vehicle collisions with a patient ejected from the car, motor vehicle collision with death of another occupant, and Intrusion into the patient’s passenger compartment of greater than 12 inches at the roof and or greater than 18 inches at any site. So you got to ask the prehospital personnel about the injury and the crash scene fall of a distance greater than 10 feet or two to three times the child’s height diving into a body of water and an axial load. So force applied to the top of the head and acceleration deceleration Injury of the head.

So you hit your head on a dashboard during a head on collision. A clotheslining force. So that’s caused by a rope, a cable, or another object exerting traction on or striking the neck while the body is in forward motion. And certain sports do have a higher association with cervical spine injuries like football, hockey, wrestling, bicycling, trampoline use or riding ATVs. Infants can get a cervical spine injury during breech delivery or, unfortunately, during non accidental trauma as well. Axial injuries, occiput to C2, are much more commonly seen in children under the age of eight – it’s three quarters of all cervical spine injuries. These are most often due to motor vehicle collisions and falls.

Kids this age are more susceptible because of their big lollipop heads. You know, they have a giant head size related to their body size and they have loose joints and ligaments overall. Their C spine fulcrum is higher at birth, it’s at C2 to C3, as opposed to C5 to C6, which is the usual position in older children and adolescents just through the process of normal growth.

The most common injuries seen in these younger patients are growth plate fractures and ligamentous injuries. It’s particularly difficult to diagnose cervical spine injuries in kids under three because they can’t give you an accurate history and cooperate with the exam. Older children, so older than eight, so middle schoolers and up, have a higher likelihood of injuries in the C3 to C7 range.

This makes up about half of the injuries. And these happen during motor vehicle collisions and sports. You more often will see vertebral body and arch fractures as opposed to the growth plate fractures and ligamentous injuries in the younger children. And overall, C spine injury can occur through a lot of different mechanisms including flexion, extension, vertical compression, rotation, or combination of all of the above.

And though we’re talking about injuries to the vertebra, the cervical spine, spinal cord injuries themselves happen either due to direct compression, or disruption of the cord itself by a fracture, fragment, or a sublux vertebra. Let’s go ahead and pivot to initial management. And we need to suspect cervical spine injuries in any patient with multisystem blunt force trauma.

You want to limit spine motion during your primary survey, the ABCs, or the rapid cardiopulmonary assessment. Someone can hold c spine, and we’ll talk about more about maintaining and clearing the c spine in a little bit. You’ll do jaw thrust alone as an airway maneuver. No head tilt. Orotracheal intubation with video laryngoscopy is ideal.

C spine injuries themselves can impact airway maintenance and or patency. So if you have an unstable injury above C3, you can actually have respiratory paralysis. A lower cervical injury could impact the phrenic nerve. The cervical spinal column injury itself may be associated with airway obstruction from retropharyngeal hemorrhage, edema, or maxillofacial trauma.

You should also consider the possibility of quote unquote spinal shock. This is due to the loss of sympathetic output and vasodilatation. So you could worry about this in a bradycardic and hypotensive patient, but in multisystem trauma hypotension is more likely hemorrhage. than it is spinal shock.

Resuscitate with volume and blood. When evaluating the cervical spine in particular, if you can get details on the mechanism, that’s fantastic. You’ve got some specific injury patterns that you should be on the lookout for. So a patient that has hyperflexion can have a vertebral body wedge fracture and disruption of the posterior elements.

A hyperextension Extension injury will compress the posterior elements and disrupt the anterior longitudinal ligament. This is the hangman’s fracture, the posterior neural arch of C1 or the pedicles of C2. Axial load can cause burst fracture, so someone that dives into a pool. A rotational injury will disrupt the facets.

This is more common in combination with an extension or flexion injury, not just rotation alone. And then there’s the specific Atlanto Axial Rotary Subluxation Pattern. It’s often minor trauma in younger children, where C1 and C2 essentially get stuck on each other in a rotary position, and the kid can’t turn their neck.

Children will have some localized cervical pain, muscle spasm, decreased neck range of motion. They may or may not have neurological symptoms, even if they’ve resolved. These can include paresthesias, numbness, or weakness. The distribution of these neurologic symptoms is really variable, and it can range from involvement of single dermatomes to dramatic neurologic deficits including quadriplegia.

The ability to walk does not completely exclude a C spine injury. And interestingly, even children with no symptoms can have a cervical spine injury. There is a retrospective review of children just before the turn of the millennium that found that even 10 percent of that population with cervical spine injury were initially asymptomatic.

Finally, there are some children that you need to be aware are more predisposed to cervical spine injury than others. And this includes children with Down syndrome, clipple feel, osteogenesis imperfecta, marfans, Ehlers Danlos, chronic steroid use, rickets, and more. When it comes to physical examination of a child with a suspected cervical spine injury, remember, immobilize the c spine, either by hand, so another team member holding inline c spine, or by placing a collar, like an Aspen or Miami.

The ABCs are, as always, incredibly important. An axial injury, occiput to C2, causes abrupt cessation of respiration, so that patient will be apneic. A patient who is hypoventilating may have injuries of the spinal cord at the level of diaphragmatic control, so C3, C4, C5. And hypotension, bradycardia, or temperature instability can result from hemorrhagic and or spinal shock.

When examining the neck, you want to maintain in line stabilization. You have to palpate, but don’t press too hard on the spinous processes for local tenderness, muscle spasm, or obvious deformity. Either start at C7 and work your way up, or find C1 and work your way down. Be deliberate about touching each cervical vertebrae.

Tell younger children to use their words. Yes if it hurts, no if it doesn’t. Don’t shake their head. They always do this. A child with midline cervical tenderness. is more likely to have a cervical spine injury than a child with paraspinous muscular tenderness or spasm. Infants and toddlers who can’t cooperate can actually be cleared without imaging after minor trauma if they have a normal neurologic examination that includes mental status and GCS 15 and no other life threatening injuries.

It’s really hard to know if an 18 month old has C spine pain or not. In my experience, doing a neurologic exam is really difficult in the resuscitation area, especially when a patient is supine and has an immobilized c spine. The overall Glasgow Coma Scale and evaluation of tone, strength, sensation, and reflexes constitutes a complete neurologic exam.

50 percent of all children with cervical spine injuries will have some sort of neurological deficit. And yes, doing a neuro exam is hard, and it takes practice. Part of that is learning ways to get patients to participate when they are uncomfortable or scared. And subtle findings are fortunately most common, but harder to elicit.

An isolated sensory deficit is the most common neurological finding in cervical spine injury. Ipsilateral posterior spinal column and contralateral anterior column are tested via light touch. The anterolateral spinal column is tested with pinprick or pain. The ipsilateral posterior spinal column is tested with position sense, so moving that toe, and dysesthesia will localize to the central cord.

And this is a podcast, so I can’t make you conjure up a table in your head, but I think it is important to remember where some deficits will come from if you have injuries at particular levels. And so if you have an injury at C2 to C3, you may just see apnea. C3 and C4 control the diaphragm, so you want to make sure the patient is spontaneously breathing.

C5 is flexion of the biceps. with the palm up, or supinated. C6 is extension of the wrist. C7 is extension of the elbow. L2 through L4 are extension of the knee. L5 is dorsiflexion of the great toe. And S3 and 4 is rectal tone. So absence of rectal tone is a poor prognostic sign, but it’s also not sensitive for cervical spine injury.

In a child with a GCS of 15 with no active neurological complaints, I would argue that a digital rectal exam is pretty invasive, and just squeezing the buttocks together is probably a good proxy. A child with altered mental status, or decreased responsiveness, or high index of suspicion for cervical spine injury should get a digital rectal examination.

And yes, on board exams! You have these spinal cord injury syndromes. They show up again and again and again. I’ve actually rarely seen them in pediatric practice, fortunately. But for completeness, here they are. Anterior cord syndromes are from hyperflexion, and you’ll see paralysis and loss of pain sensation without loss of light touch or proprioception.

Central cord syndromes are from hyperextension, and you’ll see weakness that is greater in the upper as opposed to the lower extremities, and transient burning sensation of the hands and fingers. Brown Sequard syndrome, which is cord hemisection, will lead to ipsilateral paralysis, loss of proprioception, and loss of light touch, and a contralateral loss of pain and temperature sensation.

And then Horner syndrome is disruption of the sympathetic chain. So you’ll see ipsilateral ptosis, meiosis, and anhydrosis. Okay, so let’s say the ABCs are normal, GCS is 15, and there are no focal neurologic findings. How do we attempt to clear the C spine? So for this, you’re gonna need another team member.

So have the patient lie supine. Have your assistant hold inline C-spine mobilization. They’re gonna be standing above the patient’s head, and then you’ll remove the anterior front portion of the collar. Reach behind their neck, inside the back portion of the collar, and feel very intentionally. See one all the way down to C seven.

Or the reverse, C7 all the way up to C1, asking the patient at each one if there is pain. And again, tell them to use their words, yes or no, and not nod or shake their head. And they’ll still mess this up. At each cervical vertebrae, feel for any swelling or step off. So one that feels kind of more in than the rest.

If there is pain at any cervical vertebrae, replace the collar. And then you’ll move on to imaging, which we’re going to talk about in just a moment. If there is absolutely no pain in C1 through C7, You can have your teammate release inline c spinal mobilization and then ask the patient to actively flex, extend, and rotate to the left and right, all at 45 degrees.

If they have no pain in the midline with any of these movements, then the cervical spine is clinically cleared. But if they have pain or decreased range of motion in any direction, replace the collar and move on to imaging. No matter where you work, you should apply clinical decision rules with an imaging algorithm for anybody with suspected cervical spine injuries.

Now in grown ups, you’re probably familiar with the Canadian C spine rule. It’s a highly sensitive rule that is designed to prevent missing cervical spine injuries while limiting the amount of unnecessary radiologic examinations. This Canadian C spine rule does not apply to children under 16 years of age.

In many settings in adults, plain radiographs have actually been abandoned in favor of CT scans. And a negative CT scan, if you rule in via the Canadian C spine rule, is generally sufficient to clear the majority of C spine injuries and allows for collar removal. In children, though, we prioritize limiting radiation risk.

And so it’s recommended, based on recent evidence from the Pediatric Emergency Care Applied Research Network, PCARD, that we have a three tiered decision rule. So the highest risk patients, these patients have a risk of cervical spine injury of about 12%, are going to recommend immediate medical attention.

CAT scan. These patients will have altered mental status, A GCS of three to eight or unresponsive on the AVPU alert, voice pain, unresponsive, mnemonic. Highest risk patients also include those with any abnormality of the airway, breathing, or circulation. and somebody with a focal neurological deficit. And then there’s an intermediate risk group that has a just under 4%, specifically a 3.

6 percent chance of a cervical spine injury. And these are patients that it is recommended to get a plain x ray. These are patients with posterior neck pain, altered mental status, but a GCS of greater than eight. Or patients with a substantial head or torso injury and substantial means that they’re going to require an intervention or observation in the hospital.

And then there’s a low risk group with a risk of cervical spine injuries of 0. 2 percent or less. And these patients generally don’t need any imaging. And so this is, uh, Assuring through meticulous investigation that none of the following risk factors are present. So neck pain or midline posterior neck tenderness, decreased range of motion or pain with range of motion on flexion, extension, or rotation to the left and right, torticollis, altered mental status so a GCS of 14 or less, any focal neurologic finding and remember sensory deficits are the most common in cervical spine injuries, Any substantial coexisting injuries, so especially torso injuries or child abuse injuries.

Any relevant predisposing condition like Down syndrome. And high risk mechanisms. Diving, hanging, an axial load force, a clothes lining force, or a motor vehicle collision with significant intrusion, ejection from the vehicle, or a death in the vehicle. So again, if the child is negative for all of those, you don’t have to place a collar.

And you don’t need any imaging, and that includes an x ray or a CT scan. The goal of using this high intermediate, low tiered approach is to cut the rate of CAT scans in children by greater than 50%. And so the Pediatric Emergency Care Applied Research Network is actively working on that, initially in an ED setting, with future work in the pre hospital setting.

And so hopefully that helps you understand when to get imaging. But what about the actual imaging choices themselves? Plain x rays are the initial choice in children with normal mental status, but cervical spine tenderness. They’ve got adequate sensitivity to exclude unstable c spine injuries. There are two view x ray series of the neck, that’s an AP and a lateral, or a three view series, cross table lateral, AP, and when obtainable, then open mouthed odontoid.

Multiple views, as you’d expect, are more sensitive, like 90%, as opposed to a single view, which is only 79%. Some children are chunky, and it’s hard to see all seven cervical vertebrae, but you do need to see that for a complete set of film. Some of you might work at a place where they get the swimmer’s view, where they grab both patients hands or wrists, and then pull down to try to get the shoulders out of the way to show C7.

If you have a high suspicion for cervical spine injury, don’t do this. Flexion extension views have fallen out of favor in my practice environment because CT is readily available. The FlexX views are still used in some situations, and they could show some ligamentous disruption. This is where the patient actively flexes and extends with X rays taken.

Never do passive flexion of a suspected C spine injury. CT or CAT scans, by default, get axial images. computed axial tomography. Then the computer is going to do fancy sagittal, coronal, and 3D reconstruction, which is totally cool. CT scans are indicated in any child with altered mental status, a GCS of 3 to 8, or unresponsive on the AFPU.

Also, in children with an abnormal airway breathing and or circulation. and orifocal neurologic deficit. The risk of radiation is the primary concern here, and radiology departments should follow the ALERA, or as low as reasonably acceptable, principle. A C spine CT delivers substantially more radiation to the skin, thyroid, and spinal cord, up to 10 50 percent more.

Children younger than 5 years of age are more prone to radiation induced malignancies due to the increased radio sensitivity of certain organs and a longer latency or life period to develop a cancer. Calculating the lifetime risk of getting cancer from CT scans is hard to do, which is great because we’re not just like scanning people for no reason and seeing if they get cancer later.

The best current estimate is that the estimated lifetime cancer mortality risk attributable to the radiation exposure from a CT for a one year old is approximately 0. 07 to 0. 18%. So not zero, but pretty low. The risk of radiation exposure exceeds the benefit of CT imaging in the majority of children evaluated for C spine injury.

So most of them don’t have a very low GCS, or abnormal ABCs, or focal neurologic deficits. That’s why PCARN is doing this work. Many adult centers will readily get CT scans in adults with suspected c spine injuries. These are just not necessary in the majority of children. Either nothing or plain x rays are sufficient.

And what about MRI? It’s becoming increasingly available. In anybody with an abnormal neurologic examination, or when imaging of the spinal cord or other soft tissues is paramount, MRI can be very helpful. For It is superior to CT for visualizing soft tissues and identifying intervertebral disc herniation, ligamentous injuries, and spinal cord edema, as well as hemorrhage, compression, and transection type injuries.

MRI is actually less sensitive than CT for detection of fractures of the posterior elements of the c spine and injuries to the cranial cervical junction. So it’s not perfect. Even fast protocols for MRIs are tough to get in children under the age of 6 years, they require sedation. And spinal cord injury without radiographic abnormality, C.

Wura, was defined way back in 1982, and I was 4 or 5 years old when this happened. And this was objective signs of myelopathy as a result of trauma in the absence of findings on plane radiographs, flexion extension radiographs, and cervical CT. CWRA is kind of a moot point when you have an imaging modality that uses fancy magnets to jiggle water molecules and take a cool picture.

You can demonstrate injury to the spinal cord and spinal ligaments. And so in anybody with a localizable neurologic sign or symptom, I’m not saying you have to get it in the ED because that’s just not practical, but these patients will, upon admission or shortly after their initial assessment, need an MRI at some point.

And though this episode is focused on cervical spine injuries, it goes without saying that if somebody has thoracic or lumbar spine pain, they should get plain imaging of that, or if they have substantial multisystem trauma and you’re getting a CT scan of the chest or abdomen, that is obviously going to include those bones as well.

Now moving on to disposition. Any patient with a cervical spine injury or a neurologic deficit They’re getting admitted to the hospital. And this obviously includes patients who need surgery, like unstable fractures and those sort of things. That’s a spine or neurosurgery operation. Patients with stable fractures, so an isolated spinous process, or transverse process fractured, identified by CT, will have a rigid cervical collar applied, so an aspen or vista, With trauma and spine follow up within a week.

Kids wear this collar 24 7. So again, you’ve got an isolated, stable fracture, no displacement, no neurologic symptoms, no other injuries, that kid could go home and they’re going to wear that collar 24 7. You have to teach them how to take care of it. If you have a negative x ray, but persistent midline c spine pain, we also recommend keeping the kid in the cervical collar and follow up at a trauma or spine center within a week.

Could you get a CT scan in those situations? Yes, but still most pediatric trauma centers will void the ionizing radiation of the CT scan and keep the patient in the collar until trauma follow up. Okay, so let’s wrap up this episode. Fortunately, cervical spine injuries in children are rare. You should learn how to clinically clear a C spine and know that it takes two people to do it correctly.

Practice your neurologic examination in children who are being evaluated for traumatic injuries. Know which mechanisms are more likely to cause C spine injuries. And make sure that you’re using a clinical decision rule with an imaging algorithm for kids with suspected C spine injuries. Highest risk patients should get CT scans.

They have a 1 in 8 chance of a c spine injury, altered mental status, GCS 3 to 8, unresponsive, abnormal ABCs or focal neurologic deficit. Patients that are intermediate risk have a less than 1 in 25 chance of a c spine injury and that’s when we would get a plain x ray. So they have Posterior midline neck pain, altered mental status, but a GCS of greater than 8, or some substantial comorbid head or thoracic injury that requires management or admission to the hospital.

Patients with no findings will have a less than 0. 2 to 0. 3 percent chance of a cervical spine injury and don’t need any imaging at all. So this is a patient with no midline neck pain, no pain on neck range of motion, Normal mental status, normal neurologic exam, no comorbidities, and no high risk mechanisms.

I encourage you all to take a look at the new publication from the PCAR Network in Lancet Child and Adolescent Health. I’ve provided a link in the show notes. This is the state of the art paper on the use of decision rules for cervical spine imaging in children. To learn more about the Pediatric Emergency Care Applied Research Network, or PCARN, check out PCARN.

org. You can also follow them on x at pkarn team. If you’ve got feedback on this episode, send it my way. Email, direct message on x, a comment on the blog, I’d love to hear it. Hopefully you found this information useful and you can take it back to your next shift. Overall, that’s the goal of this podcast.

Encourage your colleagues to listen and subscribe. Hopefully they will find it helpful as well. And please let me know if there are any topics specifically related to trauma and injuries in children that you think that I should cover. For PEMCurrents, the Pediatric Emergency Medicine Podcast, this has been Brad Sobolewski.

See you next time.

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Swallowing button batteries is a dumb idea. It can melt your esophagus and stuff. Endoscopy is the way to remove them. But if you have a long delay there are sucralfate protocols. But just don’t swallow them in the first place.

LyricsIf a button battery is swallowed
please do not delay
The electric charge can melt
the mucosal wall all away
If it’s stuck in the esophagus
and you’ve got a real long wait
You can give some temporizing
enteral sucralfate
But ultimately that kid
needs to get a scope
To remove that caustic battery
you gotta hold on to that hope

[Chorus]Endoscopy!
Button battery!

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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What if a boy band from the year 2000 wrote a song about he management of status asthmaticus and then someone made a video and then posted that video to a Pediatric Emergency Medicine blog. You’d think that would be pretty silly right?

LyricsDifficulty breathing, asthma’s bad tonight
albuterol and atrovent
Dexamethasone
All right!
Magnesium infusion
Terb and ketamine
If you need that bipap
It’s the worst you’ve seen

[Chorus]Status! Asthamticus!
Follow the treatment plan
Reassess and watch that PRAM score
And you will be the man!

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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Lyme disease has 3 stages. I have a hard time remembering them. Perhaps some pop punk will help? Learn about Early, Early disseminated, and Late Lyme. And remember, It’s Doxycycline Time!

Lyrics[Chorus] Tick, Tick, Tick, Tick, BOOM!
It’s Lyme! Doxycycline Time!
Tick, Tick, Tick, Tick, BOOM!

[Verse]Early disease is just one E M lesion
Maybe one tick bite in the warm season
Early disseminated is worse, I’ll confide this
More rash, neuro stuff, and carditis
Late disease joints really ache
Lyme arthritis is real, chronic Lyme? That’s fake!

[Chorus] Tick, Tick, Tick, Tick, BOOM!

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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Racepinephrine (Racemic epinephrine) is used for croup patients who have stridor at rest and post extubation stridor. It is currently on national shortage and many facilities have a very limited supply of the nebules on hand. In times of shortage, intravenous EPINEPHRINE 1 mg/mL can be utilized as a nebulized solution in place of racepinephrine using the dosing of 0.5 mg/kg to a max of 5 mg. Doses that result in a volume of less than 3 mL should have normal saline added to the nebulizer to make a minimum volume of 3 mL.

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Hyperpronation is better than supination-flexion for Nursemaid’s Elbow reduction. Also they call it pulled elbow in Australia. Which is a better name. Swiftly listen to this brief educational song.

Lyricssubluxation of the annular ligament about the radial head

it’s called a nursemaids elbow, I know you’re well read

there’s a couple maneuvers that will make it all better

hyperpronation is best, there’s no need to fret sir

[Chorus]

hello nursemaid’s my old friend

you’ve come to triage yet again

use the maneuver that will do the best

hyperpronation better than the rest

How these videos were producedThis song and video were created using Artificial Intelligence programs:I began by writing custom lyrics inspired by notable genres and music artists. All of the lyrics are my original creations and inspired by the original work

The music was then created on the Udio AI music platform

I utilized Adobe Photoshop and Image_Creators AI images on the Poe Platform to create the album art and background images

I then edited the final video on Final Cut Pro

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Febrile Seizures are among the most common neurological problema in young children, occurring in 1 out of 50 children between the ages of 6 months and 5 years of age. This episode of PEM Currents: The Pediatric Emergency Medicine Podcast is a Question and Answer style exploration of some of the most common learning points in this incredibly important topic.

Listen“Febrile Seizures” Brad Sobolewski, MD, MEd – PEM Currents: The Pediatric Emergency Medicine Podcasthttp://www.pemcincinnati.com/podcasts

SubscribeReferencesXixis KL, Samanta D, Smith T, et al. Febrile Seizure. [Updated 2024 Jan 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448123/

Feenstra B, Pasternak B, Geller F, et al. Common variants associated with general and MMR vaccine-related febrile seizures. Nat Genet 2014; 46:1274.

Mullan PC, Levasseur KA, Bajaj L, Nypaver M, Chamberlain JM, Thull-Freedman J, Ostrow O, Jain S. Recommendations for Choosing Wisely in Pediatric Emergency Medicine: Five Opportunities to Improve Value. Ann Emerg Med. 2024 Feb 11:S0196-0644(24)00017-9. doi: 10.1016/j.annemergmed.2024.01.007. Epub ahead of print. PMID: 38349290.

Guedj R, Chappuy H, Titomanlio L, De Pontual L, Biscardi S, Nissack-Obiketeki G, Pellegrino B, Charara O, Angoulvant F, Denis J, Levy C, Cohen R, Loschi S, Leger PL, Carbajal R. Do All Children Who Present With a Complex Febrile Seizure Need a Lumbar Puncture? Ann Emerg Med. 2017 Jul;70(1):52-62.e6. doi: 10.1016/j.annemergmed.2016.11.024. Epub 2017 Mar 2. PMID: 28259480.

Shinnar S, Hesdorffer DC, Nordli DR Jr, Pellock JM, O’Dell C, Lewis DV, Frank LM, Moshé SL, Epstein LG, Marmarou A, Bagiella E; FEBSTAT Study Team. Phenomenology of prolonged febrile seizures: results of the FEBSTAT study. Neurology. 2008 Jul 15;71(3):170-6. doi: 10.1212/01.wnl.0000310774.01185.97. Epub 2008 Jun 4. PMID: 18525033.

Murata S, Okasora K, Tanabe T, Ogino M, Yamazaki S, Oba C, Syabana K, Nomura S, Shirasu A, Inoue K, Kashiwagi M, Tamai H. Acetaminophen and Febrile Seizure Recurrences During the Same Fever Episode. Pediatrics. 2018 Nov;142(5):e20181009. doi: 10.1542/peds.2018-1009. Epub 2018 Oct 8. PMID: 30297499.

TranscriptNote: This transcript was partially completed with the use of the Descript AI

Welcome to PEMCurrents, the Pediatric Emergency Medicine Podcast. As always, I’m your host, Brad Sobolewski. This episode is all about febrile seizures, one of the most common neurological problems that you will see in the emergency department in children. And you know what? I’m going to structure this episode like a bit of a question and answer session.

I’ll ask a question, and then I’ll answer it. So the first and perhaps most important question is, What are febrile seizures and how common are they? Well, they are the most common neurologic disorder of infants and young children, and they happen in about 2 to 4 percent of children between the ages of 6 months and 5 years of age.

I’ll tell parents that they happen in about 1 out of 50 kids. It’s associated with fever, but in a child without evidence of intracranial infection. They are not considered a form of epilepsy. They peak between 12 and 18 months of age, the male to female ratio is 1. 6 to 1, and there is a higher prevalence reported in certain regions like Japan’s Mariana Islands.

A febrile seizure, very simply, is a convulsion associated with a temperature greater than 38 degrees Celsius. The child does not have any acute systemic metabolic problems like hypoglycemia or hyponatremia, and you don’t have to test for those. We’ll talk about that later. And they have no history of previous afebrile seizures.

So why do they happen? Well, they’re likely related to a vulnerability of the developing nervous system to the effects of fever. The neurons that generate these seizures aren’t completely myelinated until age 6. And these neurons that are undermyelinated are more hyper excitable by cytokines during fever in these younger children who get sick more often.

And of course, underlying genetic susceptibility plays a role. And so other risk factors include a high fever, A viral infection, certainly particular viruses. A recent immunization. Hmm. Family history of febrile seizures. Prenatal exposure to nicotine. Atopic diseases. And maybe iron deficiency anemia. And so check this out.

Febrile seizures are due to the degree of fever, not the rate of temperature rise, even though we see them as the temperature is increasing rapidly in the early parts of the illness. And this has been known since the 1950s. The majority of children have febrile seizures on the first day of illness. In some cases, it’s actually their first manifestation of illness.

Like, they’re just a little bit congested, and then they’re convulsing. And then they find out that they’re febrile. The degree of fever associated with febrile seizures is variable, and it depends on the kid’s threshold convulsive temperature. So everybody has a little bit of a different set point. But most often, the fever is greater than 39 degrees Celsius, but 25 percent of febrile seizures do occur between the temperatures of 38 and 39.

In a study of just over 100 children, the temperature of febrile seizures was significantly higher than the mean temperature of fevers in children that did not have seizures, so 104 versus 103. 3. The seizure threshold is lower in infants. who have more febrile illnesses. So viral infections are often associated with high fever in kids, you know that.

One of the most classic viruses associated with febrile seizures is HHV 6. So human herpes virus 6. Another common one is influenza, specifically influenza A. So HHV 6 is the cause in one third of all first time febrile seizures in U. S. children under 2 years of age. The mean maximum fever in infants with a primary HHV 6 infection is generally 39. 5 Celsius, so 103 Fahrenheit or higher. So the incidence of febrile seizures associated with primary HHV 6 infection is estimated as high as 36 percent in 12 to 15 month olds. Other common causes include adenovirus RSV, HSV, CMV, HHV 7, and in Asia, influenza A is number one. The type of viral infection is not important in predicting the future recurrence of febrile seizures or whether or not the child will have a complex febrile seizure.

In kids up to two and a half years of age, breastfeeding may be a preventative factor for febrile seizures. Vaccines don’t cause autism, but they might cause febrile seizures. So the risk of febrile seizures is increased after administration of diphtheria, tetanus, toxoid, and whole cell pertussis, along with measles, mumps, rubella, and MMR with varicella vaccines.

The absolute risk is small, and genetic susceptibility likely plays a role in seizures after vaccines. The risk of a future febrile seizure with a subsequent vaccine is generally lower than the risk of the disease that you are vaccinating against. In drug company sponsored studies, the absolute risk of a febrile seizure after an MMRV vaccine is about 3 to 4 febrile seizures for every 100, 000 children receiving the vaccine.

So again, pretty darn low. So how do we categorize febrile seizures? We all know that there’s simple, That may not be the best terms, but that’s what we’ve got. So the focality, in a simple febrile seizure, they are generalized. A complex febrile seizure is focal, so the shaking is limited to one limb or one side of the body.

The duration, the duration for simple febrile seizures is less than 15 minutes, though 10 minutes has been proposed. Complex febrile seizures, on the other hand, are longer than 15 minutes. A simple febrile seizure is limited to a single episode in a 24 hour period, whereas complex febrile seizures, there is a recurrence of more than once in that 24 hour period.

Overall, 80 percent or more febrile seizures are simple, and 20 percent are complex. Ultimately, though, the history that you get may not be reliable. Both the motor movements and characteristics of the seizure, as well as the duration, are really hard to assess in a patient’s home. Obviously, you should ask about immunization status and whether or not the child has any underlying medical or neurologic problems or developmental delay.

And let’s be honest, the term simple sort of undersells how scary this is for families. There’s nothing simple about watching their child have convulsions and looking like they were gonna die. And why does the complex heterogeneity? Think about it this way. Two one minute seizures occurring an hour apart in a well appearing febrile child seem different than focal one sided convulsions or febrile status epilepticus.

More research is needed. So what’s the recurrence risk after febrile seizures? This is an important thing that we talk to families about. So the overall recurrence rate is approximately 30 to 35%. I will tell parents it’s a one in three chance. If you have two or more febrile seizures, you have a 50% chance of subsequent events.

The subsequent seizure is almost always similar to the first. So 95% of initial simple febrile seizures have recurrent, simple febrile seizures. And interestingly, they’re usually about the same length as well. The risk of recurrence is much higher in children under 12 months of age. So, though it’s one third overall, it’s about 50- 65 percent in children under 12 months of age when they have their first febrile suture.

In older children, like preschool and above, the risk is less than 20 percent. In a study published by Berg in Archives of Pediatrics and Adolescent Medicine in 1997, when I was a freshman in college, they looked prospectively at 428 children with a first febrile seizure. They noted that 17 percent had one recurrence, 9 percent had two recurrences, and 6 percent had three or more.

Three quarters of these recurrences were within one year of the initial seizure, and almost all were within two years. They found four factors for increased recurrence risk. Young age, history of febrile seizures in a first degree relative, lower degree of fever while in the emergency department, and brief duration between the onset of fever and the initial seizure.

Kids with all four of those had a 70 percent risk of recurrence, none of them only 20%. Complex features on the initial seizure were not associated with the risk of recurrence. Other factors that have been reported regarding recurrence in the literature include abnormal development before the first febrile seizure, recurrence of seizures within the same illness, children with one recurrence, and of course children who have had an unprovoked seizure after a febrile seizure are more likely to have future febrile seizures.

So what’s the risk of epilepsy following a febrile seizure? Well, 1% One out of a hundred human beings have epilepsy. If you have one simple febrile seizure, your risk of epilepsy is somewhere between 1 and 1. 5 percent. So it really doesn’t go up significantly. In a normal child with a simple febrile seizure, that risk is only slightly above that of the general population.

So they don’t really need a neurologic workup. Complex febrile seizures or a child with abnormal developmental history, or a child with a family history of epilepsy, have a risk of epilepsy development of about 5 to 10 percent after a febrile seizure. Some other factors related to the risk of epilepsy, if that first seizure is complex, the risk of epilepsy is about 18 times that of simple febrile seizures.

If the child has focal seizures, prolonged seizures, and repeated episodes within 24 hours during the same illness, the risk of epilepsy is 2%, 7%, 20 percent and 50 percent was 3, or all of those risk factors. One cohort study of almost 200 children with febrile seizures found the risk of epilepsy was highest in the first five years and appeared to decrease over time.

And other risk factors for epilepsy that have been identified in independent studies include Todd’s paralysis, short fever duration before the seizure, late onset of febrile seizures over three years of age, and multiple febrile seizure recurrences. There’s a tenfold increase. So what’s the evaluation and management for simple febrile seizures?

I joke that it’s discharge home, but really, Choosing Wisely recommends that we do not order laboratory studies or CT scans for a patient with a simple febrile seizure who has returned to baseline mental status. Labs just aren’t necessary. This postictal period is usually brief, so 20 to 30 minutes or up to 2 hours.

I think 2 hours is too long. And if the kid returns to a neurologic baseline, they’re unlikely to have a metabolic or structural abnormality that you’re going to need to identify. So in that child who has recovered with a normal neurological examination, You don’t need labs. They’re painful, they can give you erroneous or unexpected or irrelevant results, and they’re expensive.

So really focus on targeted testing. If you think they’re at risk for a UTI, well, yeah, get a urine. Go after COVID and flu if you think the swabs are beneficial or strep, but otherwise, you can avoid labs. In general, I think parents are most worried that their child’s gonna have a brain tumor or something wrong inside their head, and naturally, their minds will gravitate towards getting a CT scan.

These are expensive studies with a large amount of radiation, and in the absence of concerning signs on history in the exam, the rate of scarring abnormalities, mass, stroke, or other problems is really, really low, so like less than 1%. So in general, you don’t need a CT scan to show that the brain looks normal.

Children with recurrent febrile seizures or epilepsy following febrile seizures benefit more from MRI and EEG. What about complex febrile seizures? How do we evaluate and manage them? So again, focal onset greater than 15 minutes and or recurrent within 24 hours. The majority of children who develop complex febrile seizures will do so with their first seizure.

Todd’s paresis, so transient hemiparesis following a febrile seizure, usually of a complex or focal type, is rare and happens in about 1. 5 to 2 percent of cases. Prolonged or focal febrile seizures have a higher likelihood of meningitis or structural abnormalities, but still that risk is low. And so even in complex febrile seizures, if the child recovers, EEG or MRI may be the only test, if any, that they need.

You should develop a specific plan for each patient with each patient. A pediatric neurologist. So in terms of lumbar puncture, yes, you can get an LP and CSF studies to exclude meningitis or encephalitis in a child with a complex febrile seizure. The literature has long told us that in children older than 6 months of age who are completely vaccinated, you do not need to get an LP and CSF.

to rule out meningitis in a child with a simple febrile seizure. Admittedly, 25 percent of children with meningitis will have seizures at or before the initial presentation, but almost all of these kids will also have other signs and symptoms of meningitis, like altered consciousness, nuclear rigidity, a petechial rash.

So if you have a child with a complex febrile seizure, but they don’t have any other signs of meningitis, you don’t necessarily need to tap them. If febrile seizures occur after the second day of illness, if you have febrile status epilepticus, these should be other considerations as to whether or not an LP is needed.

But overall, the yield of LP is very low. Now note that pleocytosis can be seen in epileptic seizures, but it’s actually rare in febrile seizures without meningitis. So what does the AAP say? Well, they say that LP should be performed when there are meningeal signs or symptoms or other clinical features that suggest possible meningitis or intracranial infection.

Yeah, you should consider it in infants between 6 and 12 months of age if the immunization status for Hib or strep pneumonia is deficient or undetermined. So, 3, Strep pneumos, and two or three HIBs. And you should also consider an LP when the patient is on antibiotics, because antibiotic treatment could mask the signs and symptoms of meningitis.

This is perhaps the most nuanced scenario. If a child has a complex febrile seizure, and fortunately it’s a rare one that you’ll see, but you should consider, maybe they’re on otitis media, and then they have a febrile seizure, and it’s complex, probably tap that kid. In a study from Kim published in Pediatrics in 2010, they looked at 526 children with complex febrile seizures.

Almost two thirds of this population got lumbar punctures and only three had meningitis, all with a reason to suspect it. So one was clinically non responsive, one had a bulging fontanel and apnea, that’s a bad combo, and one was well appearing but had a positive blood culture for strep pneumonia and they didn’t do an LP, so they just presumed that they have meningitis?

I’m squinting. You can’t see that on the podcast, but that kid probably didn’t have meningitis. Another relatively large cohort of children with complex febrile seizures, published in 2017, showed that the incidence of bacterial meningitis in 839 patients with complex febrile seizures was 0. 7%, and none of them had HSV.

All five of those patients with meningitis had a concerning exam, and four out of five were less than 12 months of age. So, if somebody with a complex febrile seizure is going to have meningitis, there’s going to be other stuff going on. Simple febrile seizures do not require neurology consults or admissions.

They can be discharged home. Previously healthy and developmentally and neurologically normal children with two brief self resolved seizures within a 24 hour period, so technically a complex febrile seizure, can be discharged home with as needed neurology referral if the family and you are comfortable with that plan.

For Febrile status epilepticus, you should stop the seizure with medicines and admit to neurology in the PICU. And complex febrile seizures with focal features, strongly consider admission and always discuss with child neurology. And so briefly, let’s talk about that neurology referral and follow up.

Neurology will often see children in the near term with complex febrile seizures who you felt are safe for discharge but need evaluation. EEG itself is not useful in determining the risk of recurrent febrile seizures. If you’re looking for epilepsy, abnormalities are more likely to be seen on EEG when it’s performed shortly after the seizure, so less than 10 days, and when convulsions are of a longer duration and have focal features.

In children with focal complex febrile seizures, neurology is almost always going to get an MRI as well, and in children under 6, they’re probably going to need general anesthesia to do that. Alright, so what about the management of febrile status epilepticus? So originally this was defined as greater than 30 minutes.

It’s back down to 15 minutes, but there’s a current movement to define status epilepticus as greater than 5 minutes. And 5 minutes is a really long time to watch a kid seize, so I get it. In 1 third of febrile status epilepticus, the actual seizure duration is underestimated in the emergency department.

And the clinical clues that a seizure has ended are often subtle. So a child that is no longer seizing will have closed eyes and deep breathing. If the eyes are persistently open and deviated, even if there’s no limb convulsions or stiffening, they may have ongoing focal seizures. It’s really hard to figure this out.

I’ve also seen kids that are febrile having rigers, or just from a sympathetic surge after a seizure. So, response to painful stimuli, closed eyes, regular breathing. These are all subtle findings along with your vitals like capnography that can help you figure out if that kid is still seizing. In a wonderfully named study called Febstat, which was initially published back in 2008 as a multi center perspective cohort of 119 children one month of five years with febrile status, they noted that the median duration of seizures was 68 minutes.

They were convulsive in all but one child. They were continuous in half and intermittent in the other half. Two thirds of these status. Patients were partial. It was the first febrile seizure for 3 out of 4 children in the study. And HHV 6 was the most common identified infectious etiology. There was also a higher than expected family history of epilepsy in this population.

So if the seizure is going on longer than 5 minutes, start with an IV benzodiazepine if you can. So diazepam or lorazepam. Buckle midazolam or rectal formulations like diastat are alternatives if you don’t have an IV. If that first benzodiazepine doesn’t work, give it again at five minutes. If that doesn’t work five minutes later, give a second line drug.

Generally, levotiracetam or Keppra is the first choice for second line, but you could use fosfenitoin or valproate if you’ve got them. So are febrile seizures associated with an increased risk of mortality? This is very pertinent to familial concerns. Early reports actually suggest that febrile seizures were associated with an increased risk of sudden death later on.

We found that that’s probably not true and that small excess in mortality is really restricted to complex febrile seizures. These patients have pre existing neurologic abnormalities. Those are the ones that are really most at risk. Alright, well what about prescribing preventative medicines or rescue drugs?

I don’t think that children that have a single simple febrile seizure need to be prescribed rectal diastats. But if they’ve had a prolonged febrile seizure, including febrile status epilepticus, or have had multiple febrile seizures, prescribing diazepam rectal gel or midazolam nasal spray in an older child who is an appropriate size could be a good idea.

One dose administered rectally or nasally will not lead to respiratory depression. And so in general, if you’ve got a child that’s at risk for a prolonged future febrile seizure, are good candidates for rescue meds. through a process of shared decision making. Now, you could prevent the risk of subsequent febrile seizures by putting a kid on prophylactic anti epileptic medications.

Most febrile seizures are benign and the side effects of the AEDs generally outweigh the benefits. So you don’t need to put somebody on phenobarbital to stop them from having another febrile seizure. So the use of antipyretics, so acetaminophen, ibuprofen, at the first sign of fever does not prevent a recurrence of febrile seizures in a child that’s had one before.

Morata and colleagues did a single center perspective randomized control trial back in 2018 that noted that regular antipyretics may reduce the recurrence of febrile seizures during the same fever episode, so during that illness. But other studies, including one from Rosenblum back in 2013, which was a meta analysis of three RCTs of acetaminophen, ibuprofen, and diclofenac, starting antipyretics, at the onset of illness could not reduce the rate of recurrent febrile seizures compared with placebo.

Why don’t antipyretics work? Well, they facilitate heat loss, but they don’t inhibit heat production, or lower the threshold convulsive temperature during the initial stage of fever that triggers a seizure. Now, interestingly, phenobarbital can actually treat fever and seizures, but, you know, there’s side effects, so it’s not recommended.

Okay. So is there anything else on the differential? If you’re sure it’s a febrile seizure and you know what you’re doing, generally, you’re right. But, kids can have shaking chills, which are involuntary movements in febrile children that are fine, rhythmic, and oscillatory movements about a joint. They rarely involve the facial or respiratory muscles.

They usually involve both sides of the body simultaneously, and they are not associated with the loss of consciousness, and they are suppressible by touch. So shaking chills can easily be differentiated from fevers. Children with breath holding spells, the cyanotic or pallid types, will sometimes have stiffening or convulsing when they lose consciousness.

And yes, I’ve seen kids with colds and fever who have breath holding spells. And then there’s genetic epilepsy plus febrile seizures, which you are not going to diagnose in the ED. These are autosomal dominant seizures. mutations of sodium and calcium channels that lead to seizures with fever in early childhood that continue beyond six years of age.

And then there’s Dravet syndrome. So, Dravet syndrome is also known as severe myoclonic epilepsy of infancy. It will often resemble complex febrile seizures under one year of age. It’s a de novo mutation, so not inherited, of a voltage gated sodium channel in more than 80 percent of the patients with it.

So that’s why phosphenytoin doesn’t work in Dravet syndrome. And if you’ve heard of Dravet, probably the only thing you remember is that phosphenytoin doesn’t work. And I’ve been told by a wise pediatric neurologist where I work that Any female patient under 12 months of age with complex febrile seizures has Dravet syndrome until proven otherwise.

So that’s one special population with a complex febrile seizure, even two in a 24 hour period that deserves special workup. So let’s end with the last and perhaps most important question. How do we talk to families about febrile seizures? Well remember, they are scared, right? I would acknowledge that this was perhaps the most frightening thing they’ve ever seen their child do.

They are worried that it’s not going to stop and that their child would die. They may have felt helpless, but reinforce what they did right. Maybe they moved their child to the floor in the rescue position, or quickly called 911, or got help. All of these are active decisions that the family made to help their child, even if they could not have prevented the febrile seizure.

Define what a seizure is in ways they’ll understand, including how common febrile seizures are. Again, simple febrile seizures, 1 out of 50 children. Explain how the body protects itself during seizures. So there’s a sympathetic surge leading to increased heart rate. The skin will look pale due to peripheral vasoconstriction and shunting of blood to the core organs.

And when you’re seizing, you will close your glottis, your vocal cords, to prevent from aspiration, which leads to perioral cyanosis. So parents often will recall their child stiff, convulsing, and blue in the face. All of these are physiologic things that we expect during seizures, and I think it’s important to address how those were things that the body did You are certainly going to want to say whether or not the child had a simple or complex febrile seizure, because that will dictate what you do next.

Discuss the recurrence risk and what to do if it happens again, i. e., one third after you’ve had one, 50 50 chance after two or more, and you should always be evaluated by default. Talk about the use of antipyretics and their limited impact on recurrence. So they could reduce the risk during this illness, but they don’t necessarily reduce the risk in a future febrile illness.

And use lab tests, and especially CT scans of the brain judiciously. In a child who has recovered, is back to their baseline, has a normal neurologic exam, and no underlying neurologic problems, they’re unlikely to recover. to have any central nervous system abnormalities seen on imaging, nor any significant metabolic or infectious abnormalities seen on targeted lab testing.

So it’s A OK to not get any studies, but remember, you’re not doing nothing. You’re providing education and reassurance to a worried family. You can do this. If the child has recovered and you think it’s a simple febrile seizure, even if you’ve never seen one before, you’re gonna be right. You They’re that common.

I definitely recommend that you practice your speech or approach to febrile seizures before you go into the room if you haven’t done this before. So find an experienced senior resident, fellow, or attending and review it with them. You want to make sure that you can both give the family useful information.

but also not overwhelm them and anticipate what questions they might have. Well that’s it for this episode focused on febrile cedars. I hope you found it useful and will take the information back with you to your next shift in the emergency department. If you have suggestions for other topics that you’d like me to address in the future, send them my way.

I’ll take an email, a comment on the blog, a message on a social media platform of your choosing. My 12 year old told me that I should remind you to subscribe, and and review. Bottom line is I’m just happy if more people listen because that means more people learn and any feedback you can send in my direction, even if it’s in the form of a review, is very welcome.

For PEM Currents, the Pediatric Emergency Medicine Podcast, this has been Brad Sobolewski. See you next time.

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Simple febrile seizures are scary for parents – but all that is really needed is reassurance and education.

LyricsFebrile seizures, you’re warm and you’re shaking
Not like a teen who’s convulsing and faking
The fever spikes, unconscious and stiff
tonic and clonic it’s over in a jiff
Simple febrile seizures they may seem scary,
Parents are trembling worried and wary
they’re self limited and stop on their own
all you need is reassurance and discharge home

This song and video were created using AI – but I wrote the lyrics. The music was created on the Udio AI music platform with Adobe Photoshop and Image_Creators AI images on the Poe Platform. I edited the final video on Final Cut Pro.

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The only annual “non-medical” post to PEMBlog is here. My annual anniversary video that I produce for my wife.

Ok, so it has become clear by now that I’m having difficulty making it to Hallmark to buy an appropriate anniversary card. Are there any stores still open in the Greater Cincinnati area? I’m not sure anymore. I need to own up to my failures. I really wanted to find an ideal card this year. Seriously, I mean it. The use of AI to write really nice poems for anniversary cards has revolutionized things. There’s got to be a perfect card out there. And I still couldn’t get out there and buy the perfect card. So, you get yet another video. At least it’s, like, seriously, my absolute favorite song of all time. And that’s cool, right? Happy Anniversary Kerri. Enjoy this video.

Previous Anniversary Videos can be found here

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Did you scan the QR code?

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Do I really have to include the link?

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Here are some more ellipses…

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Fine, here’s the link…

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Pediatric strokes are rare and challenging to diagnose. There is a validated Pediatric Stroke Scale from the NIH that can be used in conjunction with a stroke protocol that involves Neurology, Radiology, and a local/regional Stroke Team.

Review the tool at MD Calc, the direct link is – https://www.mdcalc.com/calc/10270/pediatric-nih-stroke-scale-nihss –

MD Calc Pediatric NIH Stroke ScaleImportant notes* The overall true predictive value of the Pediatric NIH stroke scale continues to be studied. Retrospective use has been shown to be valid and reliable in one cross-sectional study (Beslow 2012).This score has not been validated in hemorrhagic stroke; and thus availability of Neurosurgery is paramount * Pediatric strokes are rare, and tPA is still being investigated; the true benefit of tPA is not well defined * Children with sickle cell disease presenting with acute ischemic stroke will likely benefit from emergent blood transfusion to reduce hyperviscosity. Early consultation with a pediatric hematologist and neurologist is mandatory.

References / Key ArticlesIchord RN, Bastian R, Abraham L, et al. Interrater reliability of the Pediatric National Institutes of Health Stroke Scale (PedNIHSS) in a multicenter study. Stroke. 2011;42(3):613-7. The original primary reference

Beslow LA, Kasner SE, Smith SE, et al. Concurrent validity and reliability of retrospective scoring of the Pediatric National Institutes of Health Stroke Scale. Stroke. 2012;43(2):341-5. Validation study

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Be sure to check out our previous posts on: BRONCHIOLITIS, EPIGLOTTITIS, PNEUMONIA, and CROUPThe Problem:Free open access medical education (aka FOAM) is great in that it allows for asynchronous, focused learning. But there are some challenges when it comes to the utilization of FOAM:

– Decentralization of FOAM resources

– Concerns about the quality of information being presented

The Solution:The Systematic Online Academic Resource, or SOAR, review was created in an effort to address some of these limitations. The SOAR review format, adapted from the traditional systematic review methodology, aims to “systematically identify online resources by topic…[and] assess the quality of these resources with a validated tool, and collate links.” The first several SOAR reviews were done on topics related to general emergency medicine: Renal and Genitourinary; Endocrine, Metabolic, and Nutritional Disorders; and Sickle Cell Disorders.

We want to help you learn!We published the first pediatric SOAR review in AEM Education and Training on the topic of respiratory infectious disease. After searching 177 keywords using FOAMSearch, the top 50 FOAM websites on the (now defunct) Social Media Index, and seven additional PEM-focused blogs, we reviewed and quality assessed 441 blog posts on relevant topics. For each blog, we extracted information such as author names and date of publication. Most importantly, we scored each post using a seven question scoring tool called the rMETRIQ tool. The rMETRIQ tool is a quality evaluation tool for online educational resources. Prior SOAR reviews have established an rMETRIQ high-quality cutoff score of greater than or equal to 16. In this new pediatric SOAR review, we found that only 36 of the 441 blog posts reached this high-quality threshold score.

How can I use these findings?Our SOAR review provides readers with a curated list of high-quality blog posts on topics of respiratory infectious disease. The table below contains information for high-quality blog posts on assorted respiratory topics – all of the topics that haven’t been covered in our previous posts, including author names, dates of publication, and links for easy access. The posts are organized by rMETRIQ score. Happy learning!

High-Quality Blog Posts on: ASSORTED RESPIRATORY TOPICS

| Topic | First Author | Name of Blog Post | Date of Publication | Link | rMETRIQ Score | | --- | --- | --- | --- | --- | --- | | Strep pharyngitis | Long, Brit | emDOCs Podcast – Episode 27: An Understated Myth? Strep Throat & Rheumatic Fever | 4/27/21 | Click to Open | 19 | | Hand-foot-and-mouth disease | Rasuli, Bahman | Enterovirus 71 | 1/24/14 | Click to Open | 19 | | Peritonsillar abscess | Sumpter, Ryan | EM@3AM: Peritonsillar Abscess | 3/7/20 | Click to Open | 18 | | Influenza | Barr, Laurel | Influenza Mimics: Pearls & Pitfalls | 2/9/16 | Click to Open | 18 | | Tracheitis | Fox, Sean | Tracheitis in Children: a 2018 Update | 11/30/18 | Click to Open | 18 | | Tuberculosis | Gaillard, Frank | Ghon lesion | 2/19/10 | Click to Open | 18 | | COVID-19 | Reyes, Miguel | Data from Israel on the BNT162b2 (Pfizer) mRNA COVID-19 Vaccine | 3/30/21 | Click to Open | 18 | | Uvulitis | Fox, Sean | Uvulitis—Pediatric EM Morsels | 4/12/19 | Click to Open | 17 | | Legionella infection | Fox, Sean | Legionellosis in Children | 4/6/18 | Click to Open | 17 | | Multisystem Inflammatory Syndrome in Children | Gaines, C. Blair | Multisystem Inflammatory Syndrome in Children (MIS-C) versus Kawasaki Disease | 8/31/20 | Click to Open | 17 | | Lemierre’s syndrome | Irankunda, Edmond | More than a Sore Throat: Lemierre’s Syndrome | 6/5/19 | Click to Open | 16 | | Antibiotics | Hao, Rosy | Antibiotics for Pediatrics Infections and Amoxicillin Dosing | 9/29/20 | Click to Open | 16 | | Pertussis | Long, Brit | Pertussis: Not Your Typical URI | 3/15/17 | Click to Open | 16 | | Sinusitis | Gaillard, Frank | Fungal sinusitis | 4/9/10 | Click to Open | 16 | | Hand-foot-and-mouth disease | Lewis, Claire | Coxsackie virus | 5/31/22 | Click to Open | 16 | | Shortness of breath | Stime, Katrina | PEM Pearls: Chest Radiographs for Shortness of Breath | 3/27/20 | Click to Open | 16 | | Peritonsillar abscess | Bridwell, Rachel | emDOCs Podcast: Episode 34 – Peritonsillar Abscess | 8/3/21 | Click to Open | 16 | | Enterovirus | Brown, Jason | The Wheeze That Wasn’t – An Observation on Enterovirus D-68 | 11/6/14 | Click to Open | 16 | | Otitis media | Milne, Ken | SGEM#132: ONE BALLOON FOR OTITIS MEDIA WITH EFFUSION | 10/15/15 | Click to Open | 16 | | Sore throat | Parker, Casey | On Sick Kids, Sore Throats, Swabs and Such | 9/16/14 | Click to Open | 16 | | COVID-19 | Nanjayya, Vinodh | Report of the WHO-CHINA Joint Mission onCoronavirus Disease 2019 (COVID-19) | INTENSIVE Review | 4/7/20 | Click to Open | 16 |

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This episode will help you better prepare for and manage children with inborn errors of metabolism in the Emergency Department. Consider it a supplement to what you remember from Biochemistry and the instructions on the family’s laminated care plan sheet. My special guest podcaster, Emily Groopman, is an actual Pediatric Geneticist in training and we hope that you will find this episode useful.

ListenMetabolic Disorders – PEM Currents: The Pediatric Emergency Medicine Podcast – by Emily Groopman and Brad Sobolewskihttp://www.pemcincinnati.com/podcasts

SubscribeAbout the guest podcaster for this episode…Emily Groopman, MD, PhD is a first-year resident in the Combined Pediatrics-Medical Genetics Residency Program at Children’s National Hospital/NIH. She did her MD/PhD at Columbia University, where she investigated the diagnostic utility of exome sequencing for kidney disease. She is a member of the Clinical Genome Resource Inborn Errors of Metabolism (IEM) Clinical Domain Working Group, where as a biocurator she assesses the pathogenicity of variants in IEM-associated genes to facilitate expedited genetic diagnosis for IEMs. She aims to become a physician-scientist in pediatrics and medical genetics, engaging in bench-to-bedside research that utilizes multi-omics-based approaches to provide a molecular diagnosis and support personalized care for individuals with suspected rare genetic diseases and their families. You can contact her via email at egroopman@childrensnational.org.

ReferencesJeanmonod R, Asuka E, Jeanmonod D. Inborn Errors of Metabolism. [Updated 2023 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459183/#

Rice GM, Steiner RD. Inborn Errors of Metabolism (Metabolic Disorders). Pediatr Rev. 2016 Jan;37(1):3-15; quiz 16-7, 47. doi: 10.1542/pir.2014-0122. PMID: 26729777.

Burton BK. Inborn errors of metabolism in infancy: a guide to diagnosis. Pediatrics. 1998 Dec;102(6):E69. doi: 10.1542/peds.102.6.e69. PMID: 9832597.

TranscriptNote: This transcript was partially completed with the use of the Descript AI

Welcome to PEM Currents, the Pediatric Emergency Medicine Podcast. As always, I’m your host, Brad Sobolewski, and this episode focuses on the management of children with metabolic disorders who present to the emergency department. I know that this is a subject that makes us all a little bit nervous, and you’re just hoping that the parents have a good laminated sheet to tell you everything that you need to do.

Unfortunately, that’s not always the case. And, let’s face it, there are some great principles that you can apply across metabolic diseases to make sure that you are safely taking care of these children. And you’re thinking, hey! Brad’s not a pediatric medical geneticist. No, I’m not. So I called in a ringer.

Or, well, the ringer called me. So my special guest host on this episode is a trainee in pediatrics and medical genetics. Her name is Emily Groopman, and she’s a current resident at Children’s National Hospital. After doing her MD PhD at Columbia University, where she investigated the genetic diagnosis of kidney disease, she started her residency training with the long term goal of being a physician scientist caring for patients with rare genetic disorders.

She came to me with the idea for this episode based on a recognized need to reinforce key principles in the management of children with inborn errors of metabolism who present to the emergency department. I put a lot more information about Dr. Groopman and how to contact her in the show notes. But now I’m going to pass the mic.

Take it away, Emily.

Inborn errors of metabolism, or IEMs, refer to a diverse group of disorders that result from mutations in genes that are involved in pathways responsible for breaking down nutrients and generating energy. In other words, metabolism. While each of these conditions is individually rare, when considered as a group, they are IEMs occur in approximately 1 in 2, 500 births and can have severe health consequences, including ketoacidosis, cardiac arrhythmias, and encephalopathy.

Therefore understanding these diseases, their presentations and their evaluation is critical for emergency medicine providers. So first, a little bit about their etiology and epidemiology. IEMs are primarily caused, as I mentioned, by mutations in genes involved in metabolism. In other words, genes that include enzymes and other proteins that are involved in breaking down nutrients like carbs, proteins, and fats, and generating energy.

IEMs vary in their inheritance. Most IEMs are inherited in an autosomal recessive manner. Meaning that an individual must inherit two copies of the mutation, so one from each of his or her parents, to be affected. Since an individual must have two copies of the mutation to be affected, the parents and other family members who have one copy, which are known as carriers, will be unaffected.

So, importantly, you may not have a positive family history. Other factors, such as environmental influences, epigenetic changes, the microbiome, and additional genes, may also impact the penetrance of IEMs. In other words, whether or not individuals with a disease causing mutation manifest the associated genetic disease, and also the expressivity.

In other words, which features of the disease individuals with the mutation show for these conditions. Now, newborn screening, or NBS, includes testing newly born infants for certain IEMs.

Since which IEMs are tested for vary state by state, the tests used do not, and the tests do not have perfect sensitivity. And not all IEMs are included on NBS, NBS can miss individuals with IEMs. Therefore, and I want to stress this again, negative results on NBS do not rule out the possibility of IEM.

And it’s always worth considering IEM among children, including among older children and teens, who present with suggestive symptoms. So what’s the pathophysiology of IEMs? Now, IEMs result from disruption of major metabolic processes in our body. And these major metabolic processes include carbohydrate metabolism, protein metabolism, fatty acid oxidation, and glycogen storage.

And together, these processes help store us store nutrients from the food we eat and use it to generate energy. Now, carbs are our body’s preferred source of energy. When we eat, our bodies break down carbohydrates into glucose, which can be used by our cells to generate energy, aka ATP, via cellular respiration.

The glucose that is not immediately used to generate energy is stored in the liver and muscle cells as glycogen. When we’re between meals, in other words, we’re not eating, we’re not fasting, our bodies break down glycogen into glucose so that we can continue to generate the energy our cells need to function.

And altogether, we have enough stored glycogen to last for approximately 24 hours without food. Now, let’s say you fasted for that 24 hours, and at this point your glycogen stores will be depleted. At this point, our bodies have to shift to alternate pathways, first going down the hierarchy of gluconeogenesis, where you can make glucose from amino acids and other non sugar compounds, and then fatty oxidation.

In other words, breaking down fatty acids into the compound acetyl CoA, which can be used to generate energy. Now importantly, fatty oxidation yields ketone bodies. And when the body is in a state that it’s relying primarily on fatty oxidation to generate glucose. You’ll need to get, you’ll accumulate high amounts of ketones leading to ketoacidosis, which is a metabolic emergency.

Now IEMs can disrupt any of these pathways and importantly can have severe health consequences. So what are you going to see? On clinical presentation. Now, first off, realize that most IEMs present with very nonspecific clinical features. You won’t be able to diagnose them on history and physical alone.

And biochemical testing is really needed in most cases to independently diagnose a specific IEM. Therefore, in the ED, the goal is really to recognize the science and symptoms on history and physical exam that are suggestive of metabolic disease. identifying which specific IEM the patient has is part of the later long term evaluation, typically with the help of your friendly geneticist.

It is not the job or the expectation of the EM provider. So what are some of these suggestive clinical features? They include neurologic dysfunction, which is one of the most common that includes things like developmental delay, regression, AKA loss of developmental milestones, hypotonia, encephalopathy, or seizures.

GI symptoms are the second most common, and they include vomiting, food intolerance, food aversion, GERD, refractory to normal antireflux measures, diarrhea, and dehydration. You should also think about IEM in cases where you have failure to thrive, exercise intolerance, or autonomic instability. Now, as I mentioned earlier, since these are autosomal recessive disorders, where you need to have two copies of the mutate, of a mutation to manifest disease, oftentimes family history is negative.

However, sometimes you might hear of siblings or other relatives who had early onset neurologic or GI dysfunction or died early in life, and this can often be attributed to sepsis or sudden infant death syndrome because the symptoms of these overlap with IEMs. You also might see a family history of multiple miscarriages and or constant infinity.

Now typically, IEMs involved in glucose, protein, or fat breakdown, which are, the formal term for them is called intermediary metabolism, will have a short asymptomatic interval. They would kind of like there’s a honeymoon period of days to weeks depending on the IEM after birth. And then they’ll present with acute metabolic decompensation in the neonatal period.

And these neonates typically present looking really, really unwell. So they’re lethargic, they might vomit, they’re hypotonic, hypothermic, they might have fever or seizures. And this is due to buildup of the toxic intermediates of the stalled metabolic pathway. Now the important thing for EM providers to know is that this can mimic the presentation of sepsis.

So you should consider IEM on your differential, especially when the ID workup is negative. And the neonate’s symptoms are refractory to standard measures. In these children, in children, IEMs can present with acute metabolic or neurologic decompensation, like vomiting, coma, or seizures, oftentimes precipitated by episode, things that are metabolically stressful.

So think infection, exercise, or change in diet. Now IEMs involving excretion pathways will generally present with symptoms related to the buildup of the toxic metabolites that cannot be excreted. Now, this, because this gets a lot of buzz, hyperammonemia is a very common feature of a number of different IEMs.

And so it’s important to know its presentation. Hyperammonemia presents with difficulty feeding, lethargy, altered mental status, seizures, vomiting, and vital symptoms of anomalies, most commonly loss of regulation or low core temperature. Now, in contrast, individuals with IEMs that involve pathways for accessing stored energy Can be asymptomatic or well appeared for long periods of time as long as they have a steady supply of energy.

So for instance, in infants who often follow a regular feeding schedule, they can slip under their radar as they’re getting enough energy and in a period in routine forms, and they don’t need to then have any kind of tapping into their stored energy. But again, metabolic GI illness, interrupt other interruptions in feeding schedule, intense exercise.

will result in symptoms. And depending on the specific IEM, these can range from severe metabolic decompensation like hypoglycemia or ketoacidosis, to more subtle features like muscle cramps. So to summarize, consider IEM for neonates with severe unexplained progressive or refractory illness shortly after birth, children who have severe neurologic or GI dysfunction, neglects associated with vomiting.

For metabolic stressors like fever or fasting, and children who are presenting with acidosis or hypoglycemia. Now, what should we do for evaluation and next steps in management? So, again, to reinforce, since IEMs have very specific non specific presentations, the goal in the ER is not to specifically diagnose the IEM.

Rather, it’s recognizing the child in front of you may have an IEM and do what you need to do to acute, for acute stabilization for their associated symptoms. So first, like pretty much many presentations, do ABC, get your PALS as indicated, and get IV access. Next, you want to stop the intake of potentially toxic compounds like protein, fat, glucose, and fructose, and this includes NG or G tube feeds if the child does have them.

Make them NPO and give IV, and give IV fluids with 10 percent dextrose, normal saline, or half normal saline. So D10NS or D10 half NS at one and a half times their maintenance rate. And the goal here is to give glucose, which is that, you know, number one, pure substrate for energy iteration metabolic pathways at a sufficient volume or rate so that this patient does not need to use the other metabolic pathways that might be causing their presentation.

Next, get stat labs, look at metabolic anomalies for blood labs. You want to get some lights, you can get a BMP or CMP glucose, LFT, CRP. CK, urea, and also assess their acid base status, so venous, capillary, or arterial blood gas, and also get COAGs. you want to look at their ammonia and lactate and importantly, if you can, , you want to get a plasma sample for some more sophisticated metabolic tests that can be done later.

So those would be a plasma sample for plasma amino acids, organic acids, acyl carnitine, other compounds, which your friendly geneticist, when you consult them will be incredibly happy you got. Now you also want to get some urine samples. You want to check the color and odor with a urine analysis. Look at the pH, whether there’s glucose, protein, ketones in there.

And you can also store some urine sample for downstream testing. As certain metabolic disorders, you want to look at organic acids in the urine. Now, if you end up needing to get an LP, you can also freeze some extra CSF for downstream testing. Aim for around two to five mils. And then, aside from these tests, There are some additional studies that might be indicated by clinical symptomatology.

So for instance, if they’re having cardiac issues, think about getting an EKG or an echocardiogram. If they’re encephalopathic, you want to consider neural imaging, CT or MRI. And importantly, call a stat genetics consult for further guidance or management. These patients typically do need to be admitted, even if it’s just for monitoring, and if they’re very much deranged in their ABCs, their mental status, they may need to be admitted to the ICU.

So you’ve done your initial workup, nothing’s really conclusive yet, and this patient’s still in the ED. your genetics consult hasn’t responded yet. What should you do? First, continue the glucose infusion. Then, once you get the go ahead from your genetics consult, send samples for specialized metabolic evaluation, including plasma amino acids and acyl carnitines, urine amino acids and organic acids, and whatever else your consult recommends.

Keep an eye on their labs. Again, your consult can give you some helpful tips on the frequency of monitoring, including their lights, glucose, lactate, acid base status, and ammonia. And importantly, if you’re at a referring facility, the most important things are really the basics. So get the ABCs, start D10.

If the patient has a metabolic plan, whether it’s in their electronic medical record and or in their carrier gibbous fans. Follow it. This was made by people who know them very well. If labs are very difficult to get, let’s say the kid’s a difficult stick, at least get a finger stick glucose, get IV access, and start those fluids, D10, either NS or half NS, at one and a half times maintenance.

An obtundate or somnolent child can still tolerate intraosseous access, especially if you put the lidocaine in, 0. 5 mg per kg, max 20 mg. You can use 1 or 2 percent Lido. this video. And really get that access in so you can start those fluids and stabilize the child. Make plans to safely transport the child to a tertiary care after stabilization.

and connect and contact genetics and the accepting ED as soon as you can. Emily, thank you so much. I really appreciate you sharing your knowledge and information and hopefully this was a helpful refresher and primer for the next time that you see a child with a metabolic disorder in the emergency department.

If there’s other topics that you want to hear on the podcast, reach out and let me know. I will take an email. I will take a direct message on X. I will take a comment on Facebook or the blog. If you have the time, leave a review. It helps more people find the show, and therefore more people learn about the care of ill and injured children in the emergency department.

And if you’re like Dr. Groopman, And you’re wondering, Hey, can I record a podcast? The answer is yes, you can. If there’s a topic that you’re interested in learning and teaching about, and it relates to the care of children in the emergency department, send it my way. For PEM Currents, the pediatric emergency medicine podcast.

This has been Brad Sobolewski. See you next time.

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Be sure to check out our previous posts on: BRONCHIOLITIS, EPIGLOTTITIS, and PNEUMONIAThe Problem:Free open access medical education (aka FOAM) is great in that it allows for asynchronous, focused learning. But there are some challenges when it comes to the utilization of FOAM:

– Decentralization of FOAM resources

– Concerns about the quality of information being presented

The Solution:The Systematic Online Academic Resource, or SOAR, review was created in an effort to address some of these limitations. The SOAR review format, adapted from the traditional systematic review methodology, aims to “systematically identify online resources by topic…[and] assess the quality of these resources with a validated tool, and collate links.” The first several SOAR reviews were done on topics related to general emergency medicine: Renal and Genitourinary; Endocrine, Metabolic, and Nutritional Disorders; and Sickle Cell Disorders.

We want to help you learn!We published the first pediatric SOAR review in AEM Education and Training on the topic of respiratory infectious disease. After searching 177 keywords using FOAMSearch, the top 50 FOAM websites on the (now defunct) Social Media Index, and seven additional PEM-focused blogs, we reviewed and quality assessed 441 blog posts on relevant topics. For each blog, we extracted information such as author names and date of publication. Most importantly, we scored each post using a seven question scoring tool called the rMETRIQ tool. The rMETRIQ tool is a quality evaluation tool for online educational resources. Prior SOAR reviews have established an rMETRIQ high-quality cutoff score of greater than or equal to 16. In this new pediatric SOAR review, we found that only 36 of the 441 blog posts reached this high-quality threshold score.

How can I use these findings?Our SOAR review provides readers with a curated list of high-quality blog posts on topics of respiratory infectious disease. The table below contains information for high-quality blog posts on the topic of CROUP, including author names, dates of publication, and links for easy access. Happy learning!

High-Quality Blog Posts on: CROUP

| First Author | Name of Blog Post | Date of Publication | Link | rMETRIQ Score | | --- | --- | --- | --- | --- | | Pankow, Alexis | Croup (Laryngotracheobronchitis) | 2/7/18 | Click To Open | 18 | | Gaillard, Frank | Croup | 2/1/19 | Click to Open | 16 |

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Be sure to check out our previous posts on: BRONCHIOLITIS and EPIGLOTTITISThe Problem:

Free open access medical education (aka FOAM) is great in that it allows for asynchronous, focused learning. But there are some challenges when it comes to the utilization of FOAM:

– Decentralization of FOAM resources

– Concerns about the quality of information being presented

The Solution:The Systematic Online Academic Resource, or SOAR, review was created in an effort to address some of these limitations. The SOAR review format, adapted from the traditional systematic review methodology, aims to “systematically identify online resources by topic…[and] assess the quality of these resources with a validated tool, and collate links.” The first several SOAR reviews were done on topics related to general emergency medicine: Renal and Genitourinary; Endocrine, Metabolic, and Nutritional Disorders; and Sickle Cell Disorders.

We want to help you learn!We published the first pediatric SOAR review in AEM Education and Training on the topic of respiratory infectious disease. After searching 177 keywords using FOAMSearch, the top 50 FOAM websites on the (now defunct) Social Media Index, and seven additional PEM-focused blogs, we reviewed and quality assessed 441 blog posts on relevant topics. For each blog, we extracted information such as author names and date of publication. Most importantly, we scored each post using a seven question scoring tool called the rMETRIQ tool. The rMETRIQ tool is a quality evaluation tool for online educational resources. Prior SOAR reviews have established an rMETRIQ high-quality cutoff score of greater than or equal to 16. In this new pediatric SOAR review, we found that only 36 of the 441 blog posts reached this high-quality threshold score.

How can I use these findings?Our SOAR review provides readers with a curated list of high-quality blog posts on topics of respiratory infectious disease. The table below contains information for high-quality blog posts on the topic of PNEUMONIA, including author names, dates of publication, and links for easy access. Happy learning!

High-Quality Blog Posts on: PNEUMONIA

| First Author | Name of Blog Post | Date of Publication | Link | rMETRIQ Score | | --- | --- | --- | --- | --- | | Fox, Sean | Pediatric Pneumonia | 2/24/17 | Click To Open | 16 | | Sobolewski, Brad | Community acquired pneumonia: Clinical presentation | 6/1/17 | Click to Open | 16 |

Coming March 21…How to Find a Quality Blog Post on CROUP

View Details

Be sure to check out our previous post on: BRONCHIOLITISThe Problem:Free open access medical education (aka FOAM) is great in that it allows for asynchronous, focused learning. But there are some challenges when it comes to the utilization of FOAM:

– Decentralization of FOAM resources

– Concerns about the quality of information being presented

The Solution:The Systematic Online Academic Resource, or SOAR, review was created in an effort to address some of these limitations. The SOAR review format, adapted from the traditional systematic review methodology, aims to “systematically identify online resources by topic…[and] assess the quality of these resources with a validated tool, and collate links.” The first several SOAR reviews were done on topics related to general emergency medicine: Renal and Genitourinary; Endocrine, Metabolic, and Nutritional Disorders; and Sickle Cell Disorders.

We want to help you learn!We published the first pediatric SOAR review in AEM Education and Training on the topic of respiratory infectious disease. After searching 177 keywords using FOAMSearch, the top 50 FOAM websites on the (now defunct) Social Media Index, and seven additional PEM-focused blogs, we reviewed and quality assessed 441 blog posts on relevant topics. For each blog, we extracted information such as author names and date of publication. Most importantly, we scored each post using a seven question scoring tool called the rMETRIQ tool. The rMETRIQ tool is a quality evaluation tool for online educational resources. Prior SOAR reviews have established an rMETRIQ high-quality cutoff score of greater than or equal to 16. In this new pediatric SOAR review, we found that only 36 of the 441 blog posts reached this high-quality threshold score.

How can I use these findings?Our SOAR review provides readers with a curated list of high-quality blog posts on topics of respiratory infectious disease. The table below contains information for high-quality blog posts on the topic of EPIGLOTTITIS, including author names, dates of publication, and links for easy access. Happy learning!

High-Quality Blog Posts on: EPIGLOTTITIS

| First Author | Name of Blog Post | Date of Publication | Link | rMETRIQ Score | | --- | --- | --- | --- | --- | | Singh, Gagandeep | Epiglottitis | 1/29/10 | Click To Open | 20 | | Helman, Anton | EM Quick Hits 32 Checkpoint Inhibitors, AdultEpiglotitits, HSP, Heat Stroke, Bell’s Palsy andLeukemia | 9/21/21 | Click to Open | 17 | | Rogers, Matt | Epiglottitis | 8/26/15 | Click to Open | 16 |

Coming March 20…How to Find a Quality Blog Post on PNEUMONIA

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The Problem:Free open access medical education (aka FOAM) is great in that it allows for asynchronous, focused learning. But there are some challenges when it comes to the utilization of FOAM:

– Decentralization of FOAM resources

– Concerns about the quality of information being presented

The Solution:The Systematic Online Academic Resource, or SOAR, review was created in an effort to address some of these limitations. The SOAR review format, adapted from the traditional systematic review methodology, aims to “systematically identify online resources by topic…[and] assess the quality of these resources with a validated tool, and collate links.” The first several SOAR reviews were done on topics related to general emergency medicine: Renal and Genitourinary; Endocrine, Metabolic, and Nutritional Disorders; and Sickle Cell Disorders.

We want to help you learn!We published the first pediatric SOAR review in AEM Education and Training on the topic of respiratory infectious disease. After searching 177 keywords using FOAMSearch, the top 50 FOAM websites on the (now defunct) Social Media Index, and seven additional PEM-focused blogs, we reviewed and quality assessed 441 blog posts on relevant topics. For each blog, we extracted information such as author names and date of publication. Most importantly, we scored each post using a seven question scoring tool called the rMETRIQ tool. The rMETRIQ tool is a quality evaluation tool for online educational resources. Prior SOAR reviews have established an rMETRIQ high-quality cutoff score of greater than or equal to 16. In this new pediatric SOAR review, we found that only 36 of the 441 blog posts reached this high-quality threshold score.

How can I use these findings?Our SOAR review provides readers with a curated list of high-quality blog posts on topics of respiratory infectious disease. The table below contains information for high-quality blog posts on the topic of BRONCHIOLITIS, including author names, dates of publication, and links for easy access. Happy learning!

High-Quality Blog Posts on: BRONCHIOLITIS

| First Author | Name of Blog Post | Date of Publication | Link | rMETRIQ Score | | --- | --- | --- | --- | --- | | Misch, Michael | Episode 59 – Bronchiolitis | 2/9/15 | Click To Open | 18 | | Milne, Ken | SGEM #167: The management of bronchiolitis in community hospitals | 12/18/16 | Click to Open | 18 | | Ostermayer, Daniel | Bronchiolitis (peds) | 11/17/22 | Click to Open | 17 | | Casas, Tamara | Pediatric Small Talk – Battling Bronchiolitis: Supportive Care and A Tincture of Time | 10/6/21 | Click to Open | 17 | | Milne, Ken | SGEM#228: WINDS OF CHANGE – HIGH FLOW NASAL OXYGEN FOR ACUTE BRONCHIOLITIS? | 9/8/18 | Click to Open | 17 | | Levine, Amy | Do the AAP’s New Bronchiolitis Guidelines Throw the Baby Out With the Bathwater? | 1/30/15 | Click to Open | 16 | | Lubberdink, Ashley | TREKK Series | Bronchiolitis Guidelines | 7/19/16 | Click to Open | 16 | | Milne, Ken | SGEM#157: NEBULIZED HYPERTONIC SALINE FOR ACUTE BRONCHIOLITIS | 6/12/22 | Click to Open | 16 |

Coming March 19…How to Find a Quality Blog Post on EPIGLOTTITIS

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New this year at the AAP NCE we will be hosting a brand new session that will highlight the talents of some of the very best educators in PEM. Faculty in the first ten years following training will be eligible to submit their very best presentation in any format on any topic Four finalists will present live at the NCE and compete for the title belt. More details on how to submit your presentation will be coming VERY SOON until then check out the teaser trailer.

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Newborn infants need intramuscular injections of Vitamin K in order to produce critical clotting factors. If they don’t get it they can have potentially life threatening bleeding. This is a podcast episode that reviews Vitamin K Deficient Bleeding AKA Hemorrhagic disease of the newborn.

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Listenhttp://www.pemcincinnati.com/podcasts

SubscribeReferencesAmerican Academy of Pediatrics, Committee on Fetus and Newborn. Controversies Concerning Vitamin K and the Newborn. Pediatrics 2003 July; 112(1):191-2.

Ross, JA, Davies SM. Vitamin K prophylaxis and childhood cancer. Med Pediatr Oncol. 2000 Jun;34(6):434-7.

Cornelissen, M., et al. Prevention of vitamin K deficiency bleeding: efficacy of different multiple oral dose schedules of vitamin K. Eur J Pediatr. 1997 Feb; 156(2):126-30.

Greer, FR, et al. Improving the vitamin K status of breastfeeding infants with maternal vitamin K supplements. Pediatr. 1997 Jan;99(1).

Kher P, Verma RP. Hemorrhagic Disease of Newborn. [Updated 2023 Jun 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558994/#

TranscriptNote: This transcript was partially completed with the use of the Descript AI

Welcome to PEM Currents, the pediatric emergency medicine podcast. As always, I’m your host, Brad Sobolewski. Today, we’re gonna talk about vitamin k deficient bleeding, also known as hemorrhagic disease of the newborn. This is a bleeding disorder that manifests in the first few days to weeks of life after delivery. Under the umbrella are a whole range of hemorrhagic diseases, but the most important is vitamin k deficient bleeding.

I’ll get into why in a moment. Vitamin k itself is a fat soluble vitamin mainly synthesized by gut bacteria. Newborns have minimal vitamin k reserves in a sterile gut. And there’s insufficient placental transfer and breast milk is deficient in vitamin K, so that’s why infants need vitamin K at birth. Without it, they can’t produce clotting factors 2, 7, 9, and 10.

You need all those. In brand newborns, the levels are about 20 percent or less of adult values, but within a month after birth, they arise to within normal limits. Other causes of hemorrhagic disease of the newborn include hereditary clotting factor deficiencies such as hemophilia A or B. And the most common item on the differential, especially for late onset, which we’ll talk about in a moment, is trauma, non accidental or accidental trauma. So why am I covering this topic?

Well, a lot of people out there are actually refusing vitamin k for their newborns. Why? Well, families state that they have concerns about the preservative in the injection, maybe that it could cause autism. It doesn’t. The pain from the injection could be harmful to the infant.

They perceive that the intramuscular vitamin k is a vaccine. It’s not. The dose of intramuscular vitamin K is too high. It isn’t. A potential for adverse reactions to an injection like anaphylaxis.

Anaphylaxis can happen after IV infusion and it’s been rarely reported after I’m injection, like winning the Powerball odds. The injection is perhaps a potential entry for germs, that the intramuscular vitamin K causes cancer. So there was 1 study published in the British Medical Journal in 1990. It raised that concern, suggesting that the risk of cancer was doubled in babies that receive vitamin K after birth. Many studies since then in Europe and the United States have refuted this claim and there is absolutely no association between vitamin k and cancer.

Other concerns about vitamin K include that vitamin K may overwhelm the newborn’s immune system. There’s just a general desire to be natural and perhaps a belief that oral vitamin k prenatally to the mother is more effective, but it isn’t. Furthermore, parents who refuse IM vitamin k tend to refuse other preventative measures, including the Hep B vaccine at birth, prophylaxis against gonococcal ophthalmia, which is really bad, and subsequent routine vaccination. Approximately 1 half of the severe cases of vitamin k deficient bleeding are associated with parental refusal vitamin k during the birth and hospitalization. So hemorrhagic disease of the newborn vitamin k deficient bleeding can be categorized into 3 groups based on the age of onset.

Early occurs within the first 24 hours after birth and it’s generally due to maternal medicines that block vitamin k action. Uh, most commonly, these are anti epileptics like phenytoin, phenobarbital, carbamazepine or primidone. They could also be anticoagulants, coumadin, aspirin or even some antibiotics like cephalosporins. The incidence in infants who have not received vitamin k prophylaxis in parents that are on these medicines could be 6 to 12 percent. Classical vitamin k deficient bleeding happens within 1 week of neonatal life, the second through the seventh day.

With vitamin k, the risk is 0.01 percent. If babies are exclusively breastfed and they don’t get vitamin k at birth, that increases the risks. Late onset is from 8 days up to 6 to 12 months. And this is generally exclusively breastfed babies and babies with diarrhea, cholestasis or malabsorption because vitamin k absorption is dependent on bile. The risk is about 1 in 15000 to 1 in 20000 births.

Most common symptom of late onset is intracranial bleeding with a mortality of 20 to 50 percent and all the associated morbidity of an intracranial hemorrhage. The reason for the increased risk in exclusively breastfed infants, I. E. Even those who don’t get any solids or anything else, is because there’s only marginal levels of vitamin K in breast milk. Other causes of late onset, cystic fibrosis, celiac, chronic diarrhea, alpha 1 antitrypsin deficiency, and forms of hepatitis.

So if you suspect vitamin k deficient bleeding, take a good history. These are some of the points in the history that could lead to you making the diagnosis. So take a history of the drugs that mom was on during pregnancy, especially anticonvulsants. Preterm babies are at a higher risk. Breastfed or bottle fed?

Again, bottle- or formula fed infants are at a lower risk because fortified feedings have higher levels of vitamin K. Where was the delivery? Home delivered infants don’t have access to immediate vitamin k prophylaxis at the same rates that hospitalized infants do. So physical findings that you might see in a patient with vitamin K deficient bleeding include cephalohematoma, intracranial bleeding, intrathoracic bleeding, like hemoptysis or associated respiratory distress, intra abdominal bleeding, so you can see melena, hematemesis, you know, isolated GI bleed. You know, you could also think intussusception and mccals.

Skin, you’ll see petechiae on the mucous membranes. You’ll see hemorrhage or petechiae inside the mouth, on the gums, in the nose, excessive bleeding after circumcision, bleeding from the umbilical cord stump after it’s cut and if the umbilical cord falls off, bleeding from vaccine sites. And I mentioned it before and I’ll say it again, but intracranial bleeding is the worst possible outcome. It’s associated with late onset vitamin k deficient bleeding, and it presents with a floppy baby, lethargy, feeding difficulties, bulging fontanels, poor respiratory effort, altered consciousness, convulsions or pallor. These are sick looking babies.

So in evaluation, you wanna get a CBC. Uh, vitamin k deficient bleeding will have normal platelet levels. Thrombocytopenia actually suggests a maternal immune thrombocytopenia in a newborn. They can make antibodies to platelets which can cross the placenta. Clotting profile, the INR will be greater than 4, because again those factors are needed for proper blood clotting.

The PT will be more than 4 times normal. That’s increased due to decreased activity of factor 7. The PTT will also be increased due to decreased activity of factors 2, 9, and 10. The clotting time will be increased due to clotting factor deficiencies, but fibrinogen levels will remain normal. Protein induced by vitamin k antagonists, PIVCA, I guess.

There’s an estimation you can get a lab on that. Any amount of PIVCA is abnormal and indicates vitamin k deficiency. This disappears around day 5 after the administration of vitamin k, but this lab is not part of the routine ED evaluation. Imaging is targeted at the differential diagnosis in the site of bleeding. So get a chest x-ray or an ultrasound, determine if there’s bleeding in the body cavities, you know, the chest or the abdomen.

Um, CT and MRI are most useful to evaluate for intracranial hemorrhage. So treatment. Uh, vitamin k at birth. I think I mentioned that before. So for an infant that’s greater than 1500 grams, so most of the babies that you’ll be taking care of, 1 milligram I’m Less than 1500 grams, 0.3 mgs per kg up to 0.5 mg per kilogram I’m Intravenous vitamin K is not recommended for prophylaxis in preterm infants.

The form that we now give is vitamin K1, It’s a naturally occurring fat soluble form of vitamin k. So before the introduction of vitamin k 1, long before any of us trained, they used vitamin k 3. K3 was a synthetic water soluble derivative. And in higher doses, it was associated with kernicterus hemolytic anemia and hyperbiliruminemia. So vitamin K1, current version, very safe.

Again, in the US, intramuscular vitamin K at birth is recommended. There are no known toxicity or side effects associated with vitamin K1. Now in some parts of Europe, they’ll do oral regimens at birth, at 2 to 4 weeks, and at 6 to 8 weeks. Uh, they can be weekly or even daily. There’s no licensed oral form for newborns in the US.

Some have given infants the injectable liquid by mouth, but it’s not observed and that’s an unstudied intervention. There’s no safety or efficacy data available on that route of administration. In countries that have gone to oral prophylaxis, failures, even with good compliance, have been reported. Failures have not been reported with routine I’m prophylaxis. So based on the available observational evidence, a single I’m dose of vitamin k appears to be more effective in preventing late onset vitamin k deficient bleeding versus oral regimens.

So maternal dietary changes have little effect overall on vitamin K status of the newborn. There was 1 smaller study that showed that 5 milligrams a day or 800 percent of the recommended daily allowance may raise infant serum levels to near formula fed infants in moms that are breastfeeding. But there’s no FDA approved multivitamin that contains that amount of vitamin K. So if you have a baby with hemorrhagic disease of the newborn, in early and classic forms, the treatment is oral vitamin K, 2 milligrams dose, repeated at 2 to 4 weeks and 6 to 8 weeks. And so again, these are milder forms of bleeding.

All breastfed babies with diarrhea and malabsorption situations require an additional postnatal dose of vitamin K to prevent late onset vitamin K deficient bleeding. For the late form of the disease, oral vitamin K is not as efficacious as parenteral. Hence, the 0.5 to 1 milligram single I’m dose should be administered. A presumptive diagnosis of vitamin k deficient bleeding should be made in an infant presenting with bleeding or neurologic symptoms, and either a prolonged PT and or INR, a history of not receiving vitamin k prophylaxis at birth. You should immediately give them 1 to 2 milligrams IV or sub q.

The vitamin k dose should normalize the coagulation profile within 2 to 3 hours. Infants may need resuscitation with blood products if they’ve lost more than 20 percent of their blood volume. And remember, a newborn can become hypotensive by bleeding enough inside their brain. And also, babies may need 10 to 20 ml per kilo of fresh frozen plasma. I’m going to leave you with a quote from Stanford University and Lucille Packard Children’s Hospital.

So the success of vitamin K prophylaxis has been so dramatic that many practitioners have actually never seen an infant afflicted with hemorrhagic disease of the newborn or vitamin k deficient bleeding. Now, it’s a popular trend in some areas to refuse prophylaxis in an effort to keep things natural for the infant. However, it’s important to keep in mind that the infants most at risk for the classic form of the disease are healthy babies who are exclusively breastfed. So we need to work closely with the parents who refuse vitamin k to help them understand the need for prophylaxis and the severity of the disease. The benefit of using I’m vitamin k injection should be explained to parents.

For those that refuse injection, counseling about the adverse effects of vitamin k deficient bleeding should be explained. The alternate oral dose of 2 milligrams should be recommended in the parents that strictly refuse I’m along with a repetition of that dose at 2 to 4 and then 6 to 8 weeks of age. Alright. So that’s all that I’ve got for this episode on vitamin k deficient bleeding AKA hemorrhagic disease of the newborn. Hopefully, you will feel armed to discuss vitamin k refusal with parents, as well as understand the different forms of the disease, including early, which is related to maternal medicines, classical, which is exclusively breastfed infants who don’t get vitamin k at birth, and the late form, which is the most dire and presents often with intracranial hemorrhage. If you have ideas for other episodes or topics you’d like to suggest, send them my way. I will take your feedback via email, a comment on PEMBLOG, a direct message on a social media platform, a snail mail.

However you wanna get feedback in my direction, let me know. Encourage your colleagues to listen to the podcast as well. More listeners means more learning. And, hey, I know that this can be a tough tough topic to discuss with some parents. I think we’re all better armed to have those conversations if we practice them beforehand.

So hopefully, this episode will prepare you for the next time you meet a newborn whose parents are using vitamin k. For PEM currents, the pediatric emergency medicine podcast, this has been Brad Sobolewski. See you next time

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Just look at the rash – then scroll down to reveal the diagnosis. That’s it. This child was placed on Amoxicillin for acute otitis media and this rash developed after 9 days of treatment. The child has fever and swollen feet as well.

It’s Serum Sickness Like Reaction!This is a delayed allergic reaction to an antibiotic. Another name would be Urticaria Multiforme with systemic symptoms and joint involvement. The main treatment is discontinuing the antibiotic. You can also add cetirizine (even twice daily), and H2 blockers like Cimetidine if the symptoms become more significant. Tell families that this rash will always look worse on days 2,3, and 4 an to not be alarmed. Your hospital might even have a specific clinic to follow this up – like the PATS – Penciling Allergy Testing Service at Cincinnati Children’s.

ReferencesRixe N, Tavarez MM. Serum Sickness. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538312/

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Labs or CT scans are not necessary to provide additional diagnostic information or reassurance for most children who recover completely following simple febrile seizures or unprovoked first time generalized seizures. The rate of abnormalities on these studies is very low, and the cost and downsides are too high to justify ordering them on a regular basis.

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Did you know that screening laboratory tests in the medical clearance process of pediatric patients who require inpatient psychiatric admission are not recommended unless clinically indicated?

This video discusses why we don’t need labs for most children and adolescents who are being admitted to an inpatient mental health facility via an admittedly silly (but representative) conversation. The incidence of mental health problems in children has increased in the last two decades, with suicide surpassing homicide as the second leading cause of death in teenagers. Most children with acute mental health issues do not have underlying medical etiologies for these symptoms. A large body of evidence, in both adults and children, has shown that routine laboratory testing without clinical indication is unnecessary and adds to health care costs. Any diagnostic testing should be based on a thorough history and physical examination. Universal requirements for routine testing should be abandoned.

You can learn more about the Choosing Wisely Pediatric Emergency Medicine recommendations here:

The Choosing Wisely Pediatric Emergency Medicine Recommendations

The Choosing Wisely Campaign Toolkit

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This is a blog post designed to disseminate the important work of Choosing Wisely, an initiative of the the American Board of Internal Medicine Foundation, the goal of which is the spark conversations between clinicians and patients about what tests, treatments, and procedures are needed – and which ones are not.

The Choosing Wisely Pediatric Emergency Medicine Recommendations

The Choosing Wisely Campaign Toolkit

Expert ContributorsShabnam Jain, MD, MPHEmory University/Children’s Healthcare of Atlanta
Atlanta, GA, USA
sjain@emory.edu

Shilpa Patel, MD, MPH
Children’s National Hospital
Washington, DC, USA
SPatel@childrensnational.org

Acute-onset psychosis can occur due to an underlying medical cause or psychiatric disease and the two can be challenging to differentiate. However, the vast majority of pediatric patients with psychiatric complaints do not present with undifferentiated acute psychosis; rather, they are seen for behavioral concerns or suicidal ideation. When should the emergency physician obtain lab tests to medically clear such patients?

Decades ago, psychiatric complaints in the pediatric ED were infrequent. It was therefore common practice to obtain some or all of the following studies:

• Complete blood counts
• Chemistries (electrolytes, liver panel)
• Drug screens (urine drugs of abuse, acetaminophen, salicylate, ethanol)
• Urinalysis
• Thyroid studies
• EKGs
• Head CT

These were all obtained in an effort to make sure that medical interventions were not needed before admitting the patient to an inpatient psychiatric facility. These labs were not truly indicated, but it was common practice and viewed as “not a big deal.” Also, while evidence for lab evaluation based on history and exam findings was established for adults, children were considered to have a medical etiology (organic psychosis) until proven otherwise.

Now, on any given day, a busy pediatric ED is expected to care for a multitude of patients with a variety of psychiatric complaints every day. In fact, some Emergency Departments note that as many as one tenth of their patient volume is mental health. These presentations include behavior concerns, depression, anxiety, and harm to self or others. The vast majority of these patients have obvious psychosocial stressors and emotional dysregulation that are clearly not due to medical pathology. They carry existing diagnoses and are followed by outpatient mental health providers. Acute onset psychosis is relatively rare. There is abundant evidence showing that routine lab tests in such patients have a very low yield and are not indicated, in adults as well as in children.

What remains as relevant today as always is the importance of a thorough assessment in all such patients to exclude medical (quickly reversible) etiologies for their symptoms. Life threatening non-psychiatric causes of acute psychosis include hypoglycemia, cerebral hypoxia, drug toxicity, CNS abnormalities (such as brain tumor, meningoencephalitis, injury, seizures, or stroke), metabolic conditions, electrolyte disturbances, hepatic failure, uremia, or thyrotoxicosis. Patients with psychosis caused by medical illness usually have abnormal vital signs, altered mental status, and impaired orientation with compromised intellectual function. Visual and tactile hallucinations (as opposed to auditory) are frequently prominent. Attention to any toxidromes, any abnormal vital signs or mental status, eye findings, and neurologic examination provide the greatest help in narrowing the differential diagnosis.

On the other hand, a patient with psychiatric etiologies typically has normal vital signs; normal orientation to person, place, and time; and intact memory with good cognitive functioning. Hallucinations, if present, are usually auditory in nature and neurologic exam is normal.

The key differentiating points in who needs lab tests and who does not are: ‘acute-onset psychosis’ and ‘any abnormal findings on history or exam’. If there are concerns after a thorough history and exam, appropriate lab tests are indicated. In those without psychosis, those with likely psychosocial issues, especially those with a prior history of psychiatric diagnoses, and with reassuring history and exam, lab tests are not necessary to exclude a medical condition.

Why then do we inflict more pain on an already suffering child when they need comfort and reassurance? And we do this even when we know from years of growing evidence that the yield of these routinely ordered screening tests is very poor? The answer lies in old habits and, in many US states, inpatient psychiatric facilities that ‘require’ these tests for medical clearance before accepting the patient. In addition to the aforementioned tests, the COVID-19 pandemic has led many to request or require viral testing prior to inpatient admission, even in asymptomatic patients.

The Choosing Wisely recommendation hopes to encourage change on both these fronts.

Do not obtain screening laboratory tests in the medical clearance process of pediatric patients who require inpatient psychiatric admission unless clinically indicated

A pragmatic approach to this will take:

1. An individual commitment to (a) consider lab tests only for presentations where a medical etiology is in the differential, such as acute onset psychosis, and (b) order diagnostic tests directed by the patient’s history and physical examination. Routine laboratory testing does not need to be performed.
2. Systematic change so that routine laboratory testing is not required by facilities accepting patients for inpatient psychiatric treatment. Laboratory evaluation should be based on individual patient history and exam.

Pediatric behavior and mental health is an epidemic, and one that is likely to get even worse. We need to choose wisely and act prudently for our patients, as individual practitioners and as accepting inpatient psychiatric facilities.

This episode of PEM Currents: The Pediatric Emergency Medicine Podcast approaches the topic from another angle and also discusses how we can avoid sending lab studies to “medically clear” patients requiring psychiatric admissions featuring an in depth interview with Dr. Shabnam Jain and Dr. Shilpa Patel.

ReferencesThrasher TW, Rolli M, Redwood RS, et al. ‘Medical clearance’ of patients with acute mental health needs in the emergency department: a literature review and practice recommendations. WMJ. 2019;118(4):156-163

Donofrio JJ, Horeczko T, Kaji A, Santillanes G, Claudius I. Most routine laboratory testing of pediatric psychiatric patients in the emergency department is not medically necessary. Health Aff (Millwood). 2015;34(5):812-818

Chun TH. Medical clearance: time for this dinosaur to go extinct. Ann Emerg Med. 2014;63(6):676-677

Donofrio JJ, Santillanes G, McCammack BD, et al. Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance. Ann Emerg Med. 2014;63(6):666-675.e663.

Santillanes G, Donofrio JJ, Lam CN, et al. Is medical clearance necessary for pediatric psychiatric patients? J Emerg Med. 2014;46(6):800-807

Santiago LI, Tunik MG, Foltin GL, Mojica MA. Children requiring psychiatric consultation in the pediatric emergency

Berg JS, Payne AS, Wayra T, Morrison S, Patel SJ. Implementation of a Medical Clearance Algorithm for Psychiatric Emergency Patients. Hosp Pediatr (2023) 13 (1): 66–71

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Repetitive Read Syndrome is affecting Radiologists across the globe. Symptoms include dictations including the same phrasing and suggesting clinical correlation repeatedly. We can help our Radiology colleagues by avoiding unnecessary chest X-ray orders for most children with respiratory problems such as bronchiolitis, asthma exacerbations, croup, or first-time wheezing. Choosing Wisely recommends that doctors and all medical providers have detailed conversations with patients and their families about why X-Rays are unlikely to give new information or provide any additional reassurance. They also expose young children to unnecessary radiation.

The Choosing Wisely Pediatric Emergency Medicine Recommendations

The Choosing Wisely Campaign Toolkit

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Did you know that chest X-Rays are not recommended for most children with respiratory problems such as bronchiolitis, asthma exacerbations, croup, or first-time wheezing. Choosing Wisely recommends that doctors and all medical providers have detailed conversations with patients and their families about why X-Rays are unlikely to give new information or provide any additional reassurance. They also expose young children to unnecessary radiation. This video features Dr. Vincent Alexander who conducts a simulated discussion with a parent of a child with a respiratory illness.

You can learn more about the Choosing Wisely Pediatric Emergency Medicine recommendations in the links below

The Choosing Wisely Pediatric Emergency Medicine Recommendations

The Choosing Wisely Campaign Toolkit

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This is a blog post and a podcast episode designed to disseminate the important work of Choosing Wisely, an initiative of the the American Board of Internal Medicine Foundation, the goal of which is the spark conversations between clinicians and patients about what tests, treatments, and procedures are needed – and which ones are not. [...]

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Staring this week, and continuing for the next five, we will be releasing new content supporting the key Pediatric Emergency Medicine recommendations of Choosing Wisely.

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Henoch–Schönlein Purpura (HSP) is a common vasculitis seen in younger children. The classic skin finding is palpable purpura in gravity dependent areas of the body (buttocks and legs). Children can also have arthralgias, abdominal pain and intussusception, and even nephritis. Learn about the diagnosis and management of Henoch–Schönlein Purpura (HSP) in this brief podcast episode.

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Sleep apnea in children is associated with adverse neurodevelopmental and cardiovascular outcomes. This brief post reviews treatments in children.

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If you are a pediatric resident in a large hospital you may end of replacing more dislodged G-tubes than performing lumbar punctures. Seriously. Learn about the procedure in this post.

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The Jones fracture is a fracture of the 5th metatarsal. It has a high rate of non-union and you should involve Orthopedics in the near term after managing the injury in the ED.

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It is summertime, so the bees and bugs are out! In this episode, Dr. Ben Grebber, a pediatric resident at Boston Children's Hospital/Tufts Children's Hospital, discusses Bee Stings and Spider Bites. A very common pediatric summer complaint in emergency departments, urgent cares, and primary care offices, this episode covers common signs and symptoms, some pathophysiology, and recommended treatments.

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We are in the midst of a staggering mental health crisis. Thousands of children and adolescents spend days at time in Emergency Departments waiting for definitive mental health disposition. This podcast episode hosted by Brad Sobolewski (@PEMTweets) and co-authored by Dennis Ren (@DennisRenMD) is all about what we should consider when boarding children in the [...]

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There are protocols in place that assist highly trained Emergency Medical Service providers in assuring that agitated children are safely transported to their destination. This podcast episode is all about what prehospital providers should do to get these agitated children safely to the ED.

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When we think of managing agitated patients we think of medicines – but that shouldn’t be our first option. However, medications can be adjuncts to non-pharmacologic means to help keep agitated children safe from harm. This podcast episode is all about age-appropriate pharmacologic management strategies for agitated children.

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I recorded this episode of the Cincinnati Children’s podcast Young & Healthy with Hannah Carron, one of the Pediatric Emergency Medicine at our institution. It provides succinct recommendations on when to call 911, seek care in the Emergency Department or Urgent Care, when to ask the advice of your primary care provider, and even when virtual urgent care visits are appropriate. Hannah did a tremendous job highlighting some of the most important take home points for patients and families!

You can stream the episode here:

Episode Show Notes

It is scary and stressful when your child is sick or injured. Deciding where to go for emergency or urgent medical care is not always easy. On today’s episode of Young & Healthy, we provide the information you need so you are ready to make that decision if the time comes.

Emergency doctors Brad Sobolewski and Hannah Carron join us and share insight on what injuries need an immediate trip to the emergency department and what injuries are okay to have seen in urgent care. They also discuss the option of virtual urgent care, where to go for mental health crises and common misunderstandings about the emergency department. Listen today so you’re ready for anything that may happen tomorrow!

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Patient that are agitated should always be treated with dignity and respect. This entails utilizing the least invasive non-pharmacologic means of assisting them, before moving to physical or chemical restraints. This podcast episode hosted by Brad Sobolewski (@PEMTweets) and co-authored by Dennis Ren (@DennisRenMD) is all about age-appropriate non pharmacologic management strategies for agitated children. It is also episode 2 in a 5 episode series focused on agitation in children and adolescents.

After listening to this episode you will be able to:

• Discuss specific age-appropriate non pharmacologic management strategies for agitated children
• Discuss how we can safely use holds and restraints, and how these are temporary measures

This episode is a co-production of the Emergency Medical Services for Children Innovation and Improvement Center whose mission is to minimize morbidity and mortality of acutely ill and injured children across the emergency continuum. We have developed a series of pain focused episodes.

Other Episodes in the Agitation SeriesEpisode 1: Differentiating organic versus psychiatric causes of agitation and altered mental status | Supplementary EMDocs article

Episode 3: Pharmacologic management of agitated children (Coming May 31, 2023)

Episode 4: Safe pre-hospital transport of the agitated child (Coming June 7, 2023)

Episode 5: Management of the child with mental health problems who is boarded in the Emergency Department (Coming June 14, 2023)

ListenAgitation Episode 2: Non-pharmacologic management of the agitated child – Brad Sobolewski, MD, MEd & Dennis Ren, MD – PEM Currents: The Pediatric Emergency Medicine Podcasthttp://www.pemcincinnati.com/podcasts

SubscribeEMDocs CollaborationEMDocs.net – the excellent Emergency Medicine site will also be contributing a supplementary article for each episode that will be posted each Friday following the release of the podcast episode. These articles will take another look at the content included in this episode.

Special thanks to Manpreet Singh, MD (@MprizzleER) for helping to put this collaboration together.

EMSC IICTo learn more about the Emergency Medical Services for Children Innovation and Improvement Center visit https://emscimprovement.center

Email km@emscimprovement.center

Follow on Twitter @EMSCImprovement

EMSC IIC: Pediatric Education and Advocacy Kit (PEAK): Agitation

PEAK Agitation resources* EIIC/TREKK: Care of the Agitated Patient Algorithm * EIIC/TREKK: Agitation Medication Dosing Recommendation Table * EIIC: De-escalation Tips for Pediatric Agitation Infographic * EIIC: Emergency Department Management of the Agitated Pediatric Patient Interactive Learning Module * EIIC: Agitation in Neurodivergent Patients with Drs. Alice Kuo and Ilene Claudius Podcast * EIIC: Safe Control of the Agitated Patient Webinar Series with Dr. Marianne Gausche-Hill * New England EMSC: New England Regional Behavioral Health Toolkit

DisclaimerThe Emergency Medical Services for Children Innovation and Improvement Center is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award (U07MC37471) totaling $3M with 0 percent financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov

To learn more about the Emergency Medical Services for Children Innovation and Improvement Center visit https://emscimprovement.center

Email km@emscimprovement.center

Follow on Twitter @EMSCImprovement

ReferencesBerzlanovich AM, Schöpfer J, Keil W. Deaths due to physical restraint. Dtsch Arztebl Int. 2012 Jan;109(3):27-32. PMC3272587.

Coburn VA, Mycyk MB. Physical and chemical restraints. Emerg Med Clin North Am. 2009 Nov;27(4):655-67, ix. doi: 10.1016/j.emc.2009.07.003. PMID: 19932399.

Downes MA, Healy P, Page CB, Bryant JL, Isbister GK. Structured team approach to the agitated patient in the emergency department. Emerg Med Australas. 2009 Jun;21(3):196-202. PMID: 19527279.

Knox DK, Holloman GH Jr. Use and avoidance of seclusion and restraint: consensus statement of the american association for emergency psychiatry project Beta seclusion and restraint workgroup. West J Emerg Med. 2012 Feb;13(1):35-40. PMC3298214.

Melamed E, Oron Y, Ben-Avraham R, Blumenfeld A, Lin G. The combative multitrauma patient: a protocol for prehospital management. Eur J Emerg Med. 2007 Oct;14(5):265-8. PMID: 17823561.

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Most children who present to Pediatric Emergency Departments these days with mental health concerns – including agitation – have a known psychiatric problem or diagnosis. Furthermore, the connection between physical and functional symptoms is inextricably linked in many patients. Why then do we persist with the “is it medical/organic or psych” question? Ultimately, this episode hosted by Brad Sobolewski (@PEMTweets) and co-authored by Dennis Ren (@DennisRenMD) is less about “is it psych or not” and more about not missing something because you assumed the patient had a mental or behavioral problem. It is also episode 1 in a 5 episode series focused on agitation in children and adolescents.

After listening to this episode you will be able to:

• Describe the findings on history and physical examination that differentiate organic vs psychiatric causes of agitation and altered mental status.
• Develop a strategy to differentiate organic from psychiatric causes of altered mental status, including using ancillary studies

This episode is a co-production of the Emergency Medical Services for Children Innovation and Improvement Center whose mission is to minimize morbidity and mortality of acutely ill and injured children across the emergency continuum. We have developed a series of pain focused episodes.

Other Episodes in the Agitation SeriesEpisode 2: Non-pharmacologic management of agitated children (Coming May 24, 2023)

Episode 3: Pharmacologic management of agitated children (Coming May 31, 2023)

Episode 4: Safe pre-hospital transport of the agitated child (Coming June 7, 2023)

Episode 5: Management of the child with mental health problems who is boarded in the Emergency Department (Coming June 14, 2023)

ListenAgitation Episode 1: Differentiating organic versus psychiatric – Brad Sobolewski, MD, MEd & Dennis Ren, MD – PEM Currents: The Pediatric Emergency Medicine Podcasthttp://www.pemcincinnati.com/podcastsSubscribeEMDocs CollaborationEMDocs.net – the excellent Emergency Medicine site will also be contributing a supplementary article for each episode that will be posted each Friday following the release of the podcast episode. These articles will take another look at the content included in this episode.

Special thanks to Manpreet Singh, MD (@MprizzleER) for helping to put this collaboration together.

EMSC IICTo learn more about the Emergency Medical Services for Children Innovation and Improvement Center visit https://emscimprovement.center

Email km@emscimprovement.center

Follow on Twitter @EMSCImprovement

EMSC IIC: Pediatric Education and Advocacy Kit (PEAK): Agitation

DisclaimerThe Emergency Medical Services for Children Innovation and Improvement Center is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award (U07MC37471) totaling $3M with 0 percent financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov

To learn more about the Emergency Medical Services for Children Innovation and Improvement Center visit https://emscimprovement.center

Email km@emscimprovement.center

Follow on Twitter @EMSCImprovement

ReferencesHua LL, COMMITTEE ON ADOLESCENCE. Collaborative Care in the Identification and Management of Psychosis in Adolescents and Young Adults. Pediatrics 2021; 147.

Sedel F, Baumann N, Turpin JC, et al. Psychiatric manifestations revealing inborn errors of metabolism in adolescents and adults. J Inherit Metab Dis 2007; 30:631.

Chun TH, Sargent J, Hodas GR. Psychiatric emergencies. In: Textbook of Pediatric Emergency Medicine, 5th, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. P.1820.

Cunqueiro A, Durango A, Fein DM, et al. Diagnostic yield of head CT in pediatric emergency department patients with acute psychosis or hallucinations. Pediatr Radiol 2019; 49:240.

Gerson R, Malas N, Feuer V, Silver GH, Prasad R, Mroczkowski MM. Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry. West J Emerg Med. 2019 Mar;20(2):409-418. doi: 10.5811/westjem.2019.1.41344. Epub 2019 Feb 19. Erratum in: West J Emerg Med. 2019 May;20(3):537. Erratum in: West J Emerg Med. 2019 Jul;20(4):688-689. PMID: 30881565; PMCID: PMC6404720.

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Syncope is described as a brief loss of consciousness and postural tone caused by transient global cerebral hypoperfusion. It is followed by a complete recovery. An estimated 80% of pediatric syncope is due to autonomic (vasovagal or neurocardiogenic) syncope. Our role as providers is to identify the patients who have a life-threatening etiology to their syncope. The majority of these are cardiac and so today we will review what to look for in your screening ECG.

History and physical examination are critical components to any emergency department evaluation but are especially helpful in syncope patients.

A review of red-flag symptoms can be found in the linked PEMBlog post.Cardiac SyncopeMost life-threatening etiologies are related to cardiac syncope and are estimated to be 1.5%-6% of pediatric syncope. This is why ECG is recommended for all initial episodes of syncope with a reported sensitivity as high as 96%. Therefore, what are we looking for with our ECG?

Concerning ECG findings* Long QT syndrome: QTc longer than 480 msec. * Brugada syndrome: ST elevation in V1-V3 with a negative T wave (slide or saddleback morphology). * Wolf-Parkinson-White syndrome: Short PR interval of <120 ms with associated slurred. upstroke and wide QRS complex (delta wave). * Hypertrophic Obstructive Cardiomyopathy: Precordial high voltages with deep Q waves.

Long QT syndromeLong QT (LQT) syndrome has three subtypes classified as LQT1, 2 and 3. The upper limit of a normal corrected QT (QTc) is widely agreed to be < 450 msec. In a syncope patient, a QTc >480 msec may be suggestive of LQT as the etiology of the syncopal episode. Your history and medication reconciliation will assist in determining acquired vs congenital variants. In LQT, syncope is related to torsades de pointes and death occurs due to ventricular fibrillation.

Congenital Long QT Syndrome with arrow showing QT interval (courtesy of life in the fast lane https://litfl.com/wp-content/uploads/2018/08/Congenital-Long-QT-Syndrome-ECG-LQTS-2.jpg)LQT1 is most common, triggered by emotional or physical stress (diving, swimming). One form of LQT1, AR Jervell and Lange-Nielsen syndrome is associated with congenital deafness. LQT2 is associated with stress or at rest and can be triggered by loud noises which are pathognomonic. LQT3 is associated with bradycardia. Most are AD Romano-Ward syndrome with variable penetrance. Acquired long QT can be caused by electrolyte disorders, eating disorders and/or medications.

Brugada SyndromeBrugada syndrome is an inherited cardiac sodium channel disorder. There are three types of changes seen on ECG. Type 1 ECG changes of V1, V2 ST segment elevation with associated T wave inversion is diagnostic but not always present. Type 2 and 3 seen below are supportive but not always diagnostic of Brugada and should prompt Cardiology evaluation. Type 2 is described as a saddleback shape. Type 3 can appear like type 1 or type 2 but with <2 mm of ST elevation. The sodium channel abnormality predisposes to polymorphic ventricular tachycardia which can lead to sudden death.

Brugada Syndrome with circled diagnostic abnormalities of ST elevation in V1-V2 with a negative T wave (courtesy of life in the fast lane https://litfl.com/wp-content/uploads/2018/08/ECG-Brugada-Syndrome-Type-1-2.jpg)
Two additional types of ECG changes seen in Brugada Syndrome (courtesy of life in the fast lane https://litfl.com/wp-content/uploads/2018/08/Brugada-syndrome-type-1-2-3.jpg)Wolf-Parkinson-White SyndromeWolf-Parkinson-White syndrome has a classic triad of delta wave, shortened PR interval and widened QRS complex. It is also known as pre-excitation.

Wolf-Parkinson-White Syndrome with circled short PR interval, broad QRS with arrow pointing to classic delta wave (courtesy of life in the fast lane https://litfl.com/wp-content/uploads/2018/08/Type-A-WPW-ECG-3.jpg)Structural Heart DiseaseThere are several structural heart disease etiologies of syncope. Hypertrophic obstructive cardiomyopathy (HOCM) is caused by abnormalities in the cardiac sarcomere proteins leading to blockage of the outflow tract from hypertrophied interventricular septum. The hallmarks of a syncope presentation from this include a history of dyspnea, exercise intolerance, syncope and angina. The risk of sudden death is high. Assess for large amplitude QRS complexes with ST-segment changes and deep narrow Q waves. Left atrial enlargement can also be seen. Other structural disorders who may present similarly are aortic valve stenosis and coronary abnormalities.

HOCM ECG with red arrow showing high voltage in the precordial leads and blue arrows showing deep Q waves (courtesy of life in the fast lane https://litfl.com/wp-content/uploads/2021/04/HCM-ECG.png)OthersSVT and Bradycardia can be additional causes of syncope identified through telemetry and ECG. Addressing these may require medical intervention or pacing depending on the etiology (medication related vs structural).

Discussing obtaining an ECG with patients and familiesPresentations to the emergency department for syncope can be stressful for families. I recommend framing the ECG discussion as screening the electrical connections of the heart to ensure that the heart is not the reason for the scary syncopal episode that they experienced. This must be grounded in a discussion of the most common etiologies of syncope and what makes their particular presentation concerning vs reassuring (see above).

ReferencesBurns, Ed, et al. “QT Interval.” Life in the Fast Lane • LITFL, 14 May 2022, litfl.com/qt-interval-ecg-library/.

Buttner, Robert, et al. “Pre-Excitation Syndromes.” Life in the Fast Lane • LITFL, 2 Feb. 2022, litfl.com/pre-excitation-syndromes-ecg-library/.

Buttner, Robert, et al. “Hypertrophic Cardiomyopathy (HCM).” Life in the Fast Lane • LITFL, 22 May 2022, litfl.com/hypertrophic-cardiomyopathy-hcm-ecg-library/.

Fleisher, Gary R., et al. Textbook of Pediatric Emergency Medicine. Wolters Kluwer/Lippincott Williams & Wilkins Health, 2015.

Larkin, John, et al. “Brugada Syndrome.” Life in the Fast Lane • LITFL, 20 Sept. 2022, litfl.com/brugada-syndrome-ecg-library/.

Ritter, Saskia, et al. “What is the yield of screening echocardiography in pediatric syncope?.” Pediatrics 105.5 (2000): e58-e58.

Sanatani, Shubhayan, et al. “Canadian Cardiovascular Society and Canadian Pediatric Cardiology Association position statement on the approach to syncope in the pediatric patient.” Canadian Journal of Cardiology 33.2 (2017): 189-198.

Sobolewski, Brad. “It’s Not the Heart? Red Flags in Children with Syncope.” PEMBlog, 8 Feb. 2020, pemcincinnati.com/blog/redflags-syncope/.

Pre-Publication Peer ReviewThis post underwent pre-publication peer review on Thursday May 11, 2023. A group of Pediatric Emergency Medicine fellows and attending reviewed this post, offered feedback, and appraised the content using the structure of the revised METRIQ score.

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Lumbar punctures are painful! This is due to the needle puncturing the skin and deeper tissues and the pressure changes in the spinal canal. Some general recommendations to reduce pain during LP include:

Comfortable Positioning: The patient should be instructed to lie on their side with their knees drawn up to their chest and their chin tucked in, or sit upright with their head and upper back forward (often on a bedside table with a pillow). This helps to open up the spaces between the vertebrae and makes it easier for the needle to enter.

Distraction techniques: Deep breathing, focusing on a pleasant image or listening to music, child life specialists, and more can help the patient to relax and reduce the perception of pain.

Sedation: Midazolam, ketamine, fentanyl, or other agents may be used to for anxiolytics and sedation.

Local anesthesia: Lidocaine injected into the skin and deeper tissues at the site of the puncture can numb the tract and reduce pain. It has also been shown to increase the likelihood of success.

What about topical anesthetics? Can a topical cream or gel containing lidocaine or prilocaine be applied to the skin at the site of the puncture before the procedure to numb the area and reduce pain? And what about the J-Tip, a device that uses pressurized gas to send medication into the subcutaneous portion of the skin – deeper than topical anesthetics? The topical creams take up to 40-45 minutes to absorb completely and generally penetrate the outer two to three millimeters of skin most reliably. Injectable lidocaine, when done well, is reliable – but it can take years to master the ideal technique that doesn’t create a giant mound of subcutaneous lidocaine that can impact needle entry and landmarks. Is there evidence for the J-Tip? Should we be using it for LPs instead of injecting? There is inconclusive evidence that it’s better than placebo for IVs too – it may help… (see Auerbach, 2009). Let’s take a look at a couple of studies.

Needle-free jet injection of lidocaine for local anesthesia during lumbar puncture: a randomized controlled trial
Ferayorni et al.
Pediatr Emerg Care

This randomized, double-blinded, placebo-controlled trial in infants 0-3 months old getting an LP, younger than 3 months, presenting to the ED meeting clinical criteria for LP. All patients were administered the J-Tip and were then randomized to either treatment with 1% buffered lidocaine or an equivalent amount of sterile normal saline before LP. Vital signs, facial expressions, and crying times were recorded. These were used by two independent reviewers to determine Neonatal Facial Coding System with pain scores. The study included 55 patients and the authors noted that mean pain scores at the time of needle insertion were 4.1 (1.3) for the lidocaine group and 4.8 (0.5) for the saline group (P = 0.01). Length of cry was also shorter for those in the lidocaine group (38.5 versus 48.8 seconds (P = 0.04)). Agreement – κ – was 0.76 between 2 independent reviewers.

The authors conclude that J-Tip reduced crying time and facial pain scores with a decent kappa (agreement). The sample size was all in this single site, and J-Tip was not used in direct comparison to injectable.

A Randomized Double Blind Trial of Needle-free Injected Lidocaine Versus Topical Anesthesia for Infant Lumbar Puncture
Caltagirone et al.
Acad Emerg Med, 2017

This was a single-center (one academic Pediatric Emergency Department) randomized double-blind trial of J-Tip versus EMLA – topical anesthetic (TA) cream for pain relief in 66 infant LPs. Patients got randomized to J-Tip syringe containing 1% lidocaine and a placebo TA cream or J-Tip syringe containing saline and TA. The primary outcome was the difference between the Neonatal Faces Coding Scale (NFCS) before the procedure and during LP needle insertion. Secondary outcomes included changes in heart rate (HR) and NFCS throughout the procedure, difficulty with LP, number of LP attempts, provider impression of pain control, additional use of lidocaine, skin changes at LP site, and LP success.

Ultimately after excluding some for age, the study enrolled 32 to J-Tip, 34 to EMLA. They saw no difference detected in NFCS between the two treatment groups before the procedure and during needle insertion for the LP (p = 0.58, p = 0.37). Neither HR nor NCFS differed, and perception of pain by provider, and need for additional lidocaine were similar. Interestingly the J-Tip group were twice as likely to have a successful LP regardless of level of provider experience (level of training, prior LP experience) versus those in the TA group (relative risk = 2.0; 95% confidence interval = 1.01-3.93; p = 0.04).

Overall there was some pain relief, but there was no comparison to injectable – the long taught gold standard. Also, I don’t feel you can actually conclude that J-Tip makes you more likely to be successful if you are less experienced. They concluded that the depth of anesthesia from J-Tip was responsible for this. Their convenience sample size was small, and the J-Tip group had 3 APPs vs none and 4 attending vs 1 in the J-Tip vs TA group. We know that trainees don’t get many LPs these days and there’s too much variability in their population.

ConclusionsOK, so that’s not a lot of evidence. I therefore cannot conclude that J-Tip is anything other than an adjunct to the proper injection lidocaine before an LP. There is no direct comparison of J-Tip versus injecting lidocaine into the lumbar space. Furthermore, I have seen so many LPs performed without local anesthesia over the past several years in infants. Why? Without adequate anesthesia we are causing pain. Take the time to learn how to inject lidocaine correctly. It will not “ruin your landmarks.” If you are in a position to impact training for fellows, residents, and students advocate that injectable lidocaine be taught in line with the LP technique. And if you are in a position to try J-Tip before injecting lidocaine go ahead – it might help.

Bottom Line: The evidence does not show that J-Tip can replace injected lidocaine for local anesthesia during infant lumbar punctures

ReferencesCaltagirone R, Raghavan VR, Adelgais K, Roosevelt GE. A Randomized Double Blind Trial of Needle-free Injected Lidocaine Versus Topical Anesthesia for Infant Lumbar Puncture. Acad Emerg Med. 2018 Mar;25(3):310-316. doi: 10.1111/acem.13351. Epub 2017 Dec 26. PMID: 29160002.

Ferayorni A, Yniguez R, Bryson M, Bulloch B. Needle-free jet injection of lidocaine for local anesthesia during lumbar puncture: a randomized controlled trial. Pediatr Emerg Care. 2012 Jul;28(7):687-90. doi: 10.1097/PEC.0b013e31825d210b. PMID: 22743744.

Auerbach M, Tunik M, Mojica M. A randomized, double-blind controlled study of jet lidocaine compared to jet placebo for pain relief in children undergoing needle insertion in the emergency department. Acad Emerg Med. 2009 May;16(5):388-93. doi: 10.1111/j.1553-2712.2009.00401.x. Epub 2009 Apr 15. PMID: 19388923.

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This is my one annual non-medical post – every year since our third anniversary I’ve been making a music video. Here is the one for anniversary number 16. Enjoy!

Something tells me that I will eventually have to buy an anniversary card from Hallmark for my wife Kerri. Hallmark stores are still open right? Maybe that’s my excuse. Maybe I’ll wait until they all close down because nobody wants to buy a card anymore and then I’m in the clear. Yes, that’s the plan. Until the demise of the Hallmark empire I will continue to make these anniversary videos which I know are a mere substitute for the majesty of some lovely rhyming couplets, a few flowers, and maybe a fancy bird on some nice card stock. I’d even pick an envelope from another card because the one that was “suggested” was green, and Kerri likes pink. That’s a good plan. Someday my dear. Someday… Until then, Happy 16th Anniversary, I guess.

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Dr. Kit Carney and Dr. Kristen Humphrey discuss gun violence, its impact on our patients and their families, as well as practical tips on advocating for safe storage of firearms, and how we can support victims of violence.

ListenGun Violence and Safety (2023) – Brad Sobolewski, MD, MEd – featuring Kit Carney, MD & Kristen Humphrey, MD – PEM Currents: The Pediatric Emergency Medicine Podcasthttp://www.pemcincinnati.com/podcasts

SubscribeAdvocacy and education resources* Be SMART Campaign
Be SMART emphasizes the importance of responsible gun ownership and secure gun storage. Ultimately, secure gun storage prevents kids from accessing guns. When we protect our kids from the dangers of gun violence, the whole community stands to benefit. * Brady: Asking Saves Kids (ASK)
ASK (Asking Saves Kids) is a simple way to help keep kids safe and a fundamental part of our End Family Fire campaign. Parents and guardians ask all sorts of questions before they allow their children to visit other homes; they ask about pets in the house, discuss allergies and Internet access, and ask questions about supervision. As part of our End Family Fire campaign, ASK encourages parents and guardians to add one more question to this conversation: “Is there an unlocked gun in your house?” * AAP Gun Safety Toolbox

Resources for gun violence survivors* Everytown * Sandy Hook Promise * Moms Demand Action * Giffords: Courage to Fight Gun Violence

Talking to children about gun violence* Cincinnati Children’s Blog: Tips for Talking to Kids About Violence in the News * National Association of School Psychologists: Talking to Children About Violence: Tips for Parents and Teachers * HealthyChildren.org: How to Talk With Kids About Tragedies & Other Traumatic News Events

Ohio specific resources* Ohio coalition against gun violence * Ohio coalition against gun violence resource list

ReferencesCouncil on injury, violence, and poison prevention executive committee, M. Denise Dowd, Robert D. Sege, H. Garry Gardner, Kyran P. Quinlan, Michele Burns Ewald, Beth E. Ebel, Richard Lichenstein, Marlene D. Melzer-Lange, Joseph O’Neil, Wendy J. Pomerantz, Elizabeth C. Powell, Seth J. Scholer, Gary A. Smith; Firearm-Related Injuries Affecting the Pediatric Population. Pediatrics November 2012; 130 (5): e1416–e1423. 10.1542/peds.2012-2481

Haasz, M., Boggs, J. M., Beidas, R. S., & Betz, M. E. (2022). Firearms, physicians, families, and kids: Finding words that work. The Journal of Pediatrics, 247, 133–137. https://doi.org/10.1016/j.jpeds.2022.05.029

Gifford. (2022, August 10). Child Access & Safe Storage. Giffords. Retrieved October 7, 2022, from https://giffords.org/lawcenter/gun-laws/policy-areas/child-consumer-safety/child-

Goldstick, J. E., Cunningham, R. M., & Carter, P. M. (2022). Current causes of death in children and adolescents in the United States. New England Journal of Medicine, 386(20), 1955–1956. https://doi.org/10.1056/nejmc2201761

Gun violence prevention. Children’s Defense Fund. (2022, March 18). Retrieved October 7, 2022, from https://www.childrensdefense.org/policy/policy-priorities/gun-violence-prevention/access-prevention-and-safe-storage/

Episode Transcript[Kit] Hello! I’m Dr. Carney and I am a pediatric resident at Cincinnati Children’s Hospital Medical Center. I’m here with my co-resident, Dr. Humphrey. Today, we are going to discuss firearm safety and ways to screen for it in both the ED and clinic settings. Thank you for hosting us, Brad!

The goals of this episode are to:

1. Report updated statistics about pediatric firearm-related injuries and deaths in the US
2. Discuss and review the updated American Academy of Pediatrics’ recommendations on firearm safety
3. Discuss updated strategies for counseling your patients and families on firearm safety, and
4. Talk about how we can support patients and families who are victims of gun violence

[ Kit ] To best understand how prevalent firearm-related injuries are, let’s discuss some statistics:

• Firearms are now the leading cause of death among children 0-19 years old in the United States. While gun violence is a global issue, the United States houses a disproportionate amount of these gun violence instances.
• While the United States accounts for just 4% of the world’s population, it accounts for 35% of firearm suicides and 9% of firearm homicides.
• Each year, 3200 children die from firearm-related injuries. This means that a child dies from a firearm every 2 hours and 45 minutes. Unfortunately, this number has continued to rise as gun sales have soared.
• From 2019 to 2020, the rate of firearm related deaths among children increased by 30%. When we look more closely at these numbers, we note that prominent racial disparities exist regarding firearm injury, as well.
• Black children and teens are 4 times more likely than their white peers to die by firearms.

[ Kristen ] These fire-arm related fatalities among children are due not only to homicide or accident, but also suicide.

• Firearms account for the greatest number of suicide deaths. Guns are by far the greatest risk for completed suicide, because they are so lethal. Guns have a 90% mortality rate when used for suicide.
• Unfortunately, of the weapons used in these suicides, as well as in school shootings and unintentional homicides, 70-90% of them came from unsecured weapons at the child’s home.
• Research demonstrates that fewer than half of all gun owners store their firearms safely, and that many children have access to these guns.
• Of the estimated 4.6 million children in the US who live with at least one unsecured firearm in their home, 75% of those know where guns are stored in their home and 22% have handled guns without their caregivers’ knowledge.

[ Kit ] To help address these harrowing statistics, the American Academy of Pediatrics has released updated recommendations concerning safe firearm storage practices.

• The most effective measure caregivers can take to prevent fire-arm related injuries is to remove them from the home.
• For those families who do have guns in the home, these firearms should be unloaded and locked, with ammunition stored and locked separately.
• Cable locks, trigger locks, and lockboxes are all safe ways to store firearms.
• A Cable lock is a looped wire that works similarly to a bike lock. This mechanism allows you to loop one end of the wire through the handgun to prevent the gun from being fired or loaded, and then connect that end of the wire to the lock at the end of the loop. You can purchase these for about $10 at local retailers.
• A trigger lock is a two-piece mechanism. The two pieces fit over the trigger guard so that the gun’s trigger cannot be released and allow the gun to fire. These trigger locks come with either a key and lock; a keypad, or a combination lock. One can purchase these for about $10 at local retailers.
• Finally, a Gun lock box is a combination-protected box that is similar to a safe but is small enough to house just a gun. You can purchase these for about $25-100.
• Studies demonstrate that utilizing one of these storage methods can reduce the suicide and unintentional gun deaths in children by up to 54%.

[ Kristen ] Great question.

• In our current environment, it can feel overwhelming as a healthcare provider to discuss firearms. The encouraging news is that the majority of parents report that they would feel comfortable discussing firearm safety with their pediatrician. Nonjudgmental communication is key to this conversation. Healthcare providers need to be aware of and manage their biases concerning this topic, and that starts by ensuring that we ask all families about it.
• Firearm safety can be discussed in any setting, but ideally it is a preventative, rather than a reactionary, conversation.
• It helps to first frame this conversation as one about safety, perhaps in the context of discussing car seats, water safety, or bike helmets because optimizing a patient’s safety is often a common goal of both caregivers and healthcare providers.
• For example, you might say “I like to talk about firearm safety with all of my patients because we know firearms can pose a safety risk to children. Research has shown that the safest way to store firearms is to store them locked, unloaded, and separately from ammunition.”
• While the AAP continues to emphasize that the most effective measure to prevent firearm-related injuries is their absence in the home.

New studies demonstrate that families respond best to a normative statement. This means that the clinician normalizes that many people have firearms in the home. An example of this normative statement would be “for any firearms in the home, or other homes your child may visit, are they stored locked and unloaded?” Asking about both their home and other homes they visit allows families to talk about this subject without having to disclose a gun in their own house.

• After asking this question, you can also ask if families would like to hear more information about safe storage practices, such as cable locks and lockboxes.
• When discussing firearms, it is important to keep in mind the age of the patient.
  • In younger children (ages 1-9), firearm injuries are typically related to unintentional injury, as children as young as 2-3 are capable of pulling a trigger.
  • However, In adolescents, (ages 10-19), nearly 97% of firearm injuries are related to intentional homicide or suicide. In this patient population, especially if there are significant mental health concerns, discussion about removing firearms from the home temporarily and voluntarily may help promote the patient’s safety.

[ Kit ]

• It is important that both the adolescent and the parent be engaged in these discussions, as adolescents are prone to more impulsivity and need to understand the dangers for themselves, as they are able to get access even without a caregiver’s knowledge.
• To help caregivers keep their adolescents and younger children safe, I often refer families to the ASK (or asking saves kids) campaign to provide them with the tools to ask their children about the presence of firearms in both new and familiar circumstances. These new circumstances can include a new babysitting job, a new roommate, or a new playmate.
• The Be SMART campaign is another excellent resource for both parents and healthcare providers for modeling firearm safety conversations. S stands for secure all guns in the home and vehicles; M stands for model responsible behavior around guns; A stands for ask about presence of unsecured firearms in other locations; R stands for recognize the role of guns in suicide T stands for tell peers to be SMART. Check out the references section of this PEM currents episode for links to the ASK and Be SMART websites, as well as for other links for learning how to talk to children about gun violence.

[ Kristen]

• Because those impacted by gun violence often experience trauma and are at higher risk for suicide, we as healthcare providers need to ensure that families get early access to mental health support. National support groups for families and patients who have experienced gun violence include: Trauma Survivors Network, Survivors Empowered, and the Gun Violence Survivors Foundation. There are also local survivors groups through Cincinnati’s chapter of Mom’s Demand Action and Every Town.

[Kit] Let’s review what we talked about today:

• [Kit] Gun sales and violence have increased since 2020, and firearms are now the leading cause of death for those aged 0-19
• [Kit] While younger children are more likely to become injured 2/2 unintentional use, adolescents are more likely to become injured due to intentional homicide or suicide attempts
• [Kit] Many caregivers are open to discussing firearm safety with their healthcare provider in the context of other anticipatory guidance
• [Kristen] The American Academy of Pediatrics states that discussing with ALL families that firearms should be unloaded and locked, with locked ammunition stored separately, would significantly decrease the rate of firearm-related injury among children
• [Kristen] Victims of firearm related injury and their families are at higher risk for mental health crises; providing them with support is essential to ensuring their ongoing well-being

[Kristen] If you are interested in becoming involved at a legislative level, Moms Demand Action is a national organization that provides information for local, state, and national advocacy around gun safety.

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A special thanks to Dr. Cristina Tarango, director of the Hemophilia Treatment Center at Cincinnati Children’s and Lisa Littner, Project Manager at Cincinnati Children’s who helped me research and write this post.

…and it’s called Hemlibra (Emicizumab)

Why this med is important and why kids are on it?Emicizumab (Hemlibra) was approved in 2018 for routine bleeding prophylaxis in hemophilia A with or without inhibitors. Emicizumab is not a factor concentrate like we use to treat kids with acute bleeds. It is a humanized, monoclonal bispecific antibody that binds activated factor IX and factor X. By simultaneously binding enzyme and substrate, emicizumab mimics one of the functions of FVIII. Emicizumab, though, does not fully normalize hemostasis. Rather, it can change the bleeding phenotype from severe hemophilia to mild hemophilia – thus potentially reducing the risk of complications. An increasing number of children and adolescents with hemophilia A are on Hemlibra, and therefor the purpose of this post is to educate and raise awareness. It is therefore no hyperbole to say that Emicizumab has been a life-changing therapy for individuals with hemophilia A who have factor VIII inhibitors (alloantibodies against factor VIII). Emicizumab allows these individuals to have good bleed control, improvement in their joint health and their quality of life.

However, FVIII and the bispecific antibody are fundamentally different proteins and subject to different modes of regulation.

How to know if a patient is on it?Patients on emicizumab will have it listed on their medication list. Patients/caregivers should also be able to tell you if they are on emicizumab (Hemlibra).

How is it different than factor concentrate?Emicizumab cannot be used to treat an acute bleeding episode like factor can. Emciziumab, unlike factor, does not normalize hemostasis. This means that when someone on emizumab gets injured or has bleeding, they still need to receive factor concentrate.

Emicizumab requires 4 weekly loading doses to get to steady state.

The concomitant use of FEIBA in individuals with hemophilia A and inhibitors on emiziumab can cause thrombosis or thrombotic microangiopathy. This is a black box warning. Fortuntately, recombinant activated factor VIIa (NovoSeven) can be still used in individuals on emicizumab if they have bleeding episodes.

Despite these cautions, emicizumab has several advantages over factor concentrate prophylaxis. Emiciziumab is given subcutaneously rather than intravenously, and it has a much longer half-life. Individuals on emicizumab can be dosed once a week, every 2 weeks or every 4 weeks. That has decreased the burden of treatment for many individuals with severe hemophilia A (factor VIII levels <1%) or those with moderate hemophilia A (factor VIII levels 1-5%) with a severe bleeding phenotype.

How are the labs we (might) need to obtain different?It is important to know that emicizumab interfers with common coagulation testing. Emicizumab affects the aPTT by shortening it, even though circulating factor VIII levels are very low. Because most standard factor activity assays for factor VIII are aPTT-based, factor VIII levels on emicizumab are inaccurately elevated (as are factor IX, XI, XII levels). These effects on coagulation testing can be seen up to 6 months after a dose of emicizumab. Many ED providers may get a factor VIII level to decide if a patient needs factor treatment if a patient is already on “prophylaxis.” Life-threatening bleeding due to unreliable standard coagulation tests in the setting of emicizumab is classified as an important potential risk of taking this medication. And finally…

Any individual with hemophilia who either comes in with bleeding or a significant injury should receive factor concentrate, regardless of what drug they use for prophylaxis. Factor first!

For more information on global efforts to care for patients with hemophilia and the recent World Hemophilia Day check out the World Hemophilia Day – WFH – World Federation of Hemophilia

ReferencesOldenburg J, Mahlangu JN, Kim B, Schmitt C, Callaghan MU, Young G, Santagostino E, Kruse-Jarres R, Negrier C, Kessler C, Valente N, Asikanius E, Levy GG, Windyga J, Shima M. Emicizumab Prophylaxis in Hemophilia A with Inhibitors. N Engl J Med. 2017 Aug 31;377(9):809-818. doi: 10.1056/NEJMoa1703068. Epub 2017 Jul 10. PMID: 28691557.

Jiménez-Yuste V, Peyvandi F, Klamroth R, Castaman G, Shanmukhaiah C, Rangarajan S, García Chavez J, Martinez R, Kenet G, Alzahrani H, Robson S, Schmitt C, Kiialainen A, Meier O, Ozelo M. Safety and efficacy of long-term emicizumab prophylaxis in hemophilia A with factor VIII inhibitors: A phase 3b, multicenter, single-arm study (STASEY). Res Pract Thromb Haemost. 2022 Nov 14;6(8):e12837. doi: 10.1002/rth2.12837. PMID: 36397934; PMCID: PMC9663319.

Mahlangu J, Iorio A, Kenet G. Emicizumab state-of-the-art update. Haemophilia. 2022 May;28 Suppl 4(Suppl 4):103-110. doi: 10.1111/hae.14524. PMID: 35521723; PMCID: PMC9321850.

Hassan E, Jonathan L, Jayashree M. Real-world experience on the tolerability and safety of emicizumab prophylaxis in paediatric patients with severe haemophilia A with and without FVIII inhibitors. Haemophilia. 2021 Nov;27(6):e698-e703. doi: 10.1111/hae.14432. Epub 2021 Oct 10. PMID: 34628693.

Nardi MA. Hemophilia A: Emicizumab monitoring and impact on coagulation testing. Adv Clin Chem. 2023;113:273-315. doi: 10.1016/bs.acc.2022.12.001. Epub 2023 Jan 16. PMID: 36858648.

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There are several decision rules for ankle injury X-Rays in children. Ankle fractures occur most commonly in 10-15 year olds, and usually result from an inversion injury mechanism. Sprains are far more common and usually involve the anterior talofibular ligament. Let’s briefly review some of the existing rules that we use to (hopefully) help us order fewer ankle X-Rays.

Ottawa Ankle Rules (in children)//Key Reference//
Plint AC, Bulloch B, Osmond MH, Stiell I, Dunlap H, Reed M, Tenenbein M, Klassen TP. Validation of the Ottawa Ankle Rules in children with ankle injuries. Acad Emerg Med. 1999 Oct;6(10):1005-9. PMID: 10530658.

The original ankle rules do apply to skeletally immature children under 16. The rules consist of the following criteria:

1. Pain/tenderness in the malleolar zone AND
2. Tenderness along the the distal 6 cm of the posterior edge of the medial malleolus OR
3. Tenderness along the the distal 6 cm of the posterior edge of the lateral malleolus OR
4. Inability to bear weight both immediately and in the emergency department (for four steps)

If a child meets these criteria, X-Ray is recommended to rule out a significant fracture. If the child does not meet either of these criteria, imaging is generally not necessary. The sensitivity of this rule is in the high 90%s but the specificity is much lower (low 20%s).

The low-risk ankle rules//Key Reference//
Boutis K, Grootendorst P, Willan A, Plint AC, Babyn P, Brison RJ, Sayal A, Parker M, Mamen N, Schuh S, Grimshaw J, Johnson D, Narayanan U. Effect of the Low Risk Ankle Rule on the frequency of radiography in children with ankle injuries. CMAJ. 2013 Oct 15;185(15):E731-8. PMID: 23939215.

Developed in a pediatric population and specify the following criteria

• The injury is acute (<3 days old)
• The child is not at risk for pathological fractures (eg, osteogenesis imperfecta or known focal bone lesion such as an osteoid osteoma)
• The child has no congenital anomaly of the feet or ankles
• The child can reliably express pain or tenderness
• Physical examination demonstrates tenderness or swelling confined to the distal fibula and/or adjacent lateral ligaments distal to the anterior tibial joint line
• No gross deformity, neurovascular compromise, or other serious and potentially distracting injury are present
• Tenderness and/or swelling isolated to the distal fibula
• Tenderness adjacent to lateral ligaments distal to the tibial joint line

This rule allows low-risk fractures including avulsion, buckle, and nondisplaced Salter-Harris I and II fractures of the distal fibula to forgo imaging. These low-risk fractures have excellent outcomes with nonoperative management and splinting alone – so not getting the X-Ray is (actually) okay, but admittedly this is a tough sell to parents. The sensitivity of the initial study was nigh on 100%.

Malleolar zone algorithm//Key Reference//
Dayan PS, Vitale M, Langsam DJ, Ruzal-Shapiro C, Novick MK, Kuppermann N, Miller SZ. Derivation of clinical prediction rules to identify children with fractures after twisting injuries of the ankle. Acad Emerg Med. 2004 Jul;11(7):736-43. doi: 10.1197/j.aem.2004.02.517. PMID: 15231460.

This one’s goal is to maximize the sensitivity for identifying children with significant fractures and came from a prospective study of children with ankle and mid foot injuries in a single tertiary center. There is low risk of an ankle fracture if:

• There is no bone tenderness at either malleolus or just proximal to the fibular malleolus OR
• They are able to walk 4 steps in the ED and have no swelling at either malleolus, even if there is bone tenderness

The initial study’s sensitivity is 100% and specificity 19.1%. This has not been validated yet.

How do they stack up?Interestingly, the Low Risk Ankle Rules ask you to forgo X-Rays even if there might be a fracture because the risk of just splinting is so low that the kid will do well whether you know there is a fracture or not. One could see this being applied differently in an outpatient office without easy access to X-rays versus an ED or Urgent care where X-Rays are easy to get. However, the cumulative cost (for individuals and for us all) is important to consider. In general the Ottawa Ankle Rules are the most sensitive (rule out) for clinically important fractures, whereas the Low Risk Ankle Rules are the most specific (rule in) for clinically important fractures. Deploying the Low Risk Ankle Rules also allow you to reduce the ordering of X-Rays the most. A comparison of the test characteristics from a 2009 validation study by Gravel et al is as follows:

Radiography was performed for 245 of the 272 participants. All patients with no radiograph were reached by telephone. Forty-seven participants had a clinically important fracture. The sensitivity and specificity of the rules were 1.00 (95% confidence interval [CI] 0.93 to 1.00) and 0.27 (95% CI 0.21 to 0.33) for the Ottawa Ankle Rules, 0.87 (95% CI 0.75 to 0.94) and 0.54 (95% CI 0.47 to 0.60) for the Low-Risk Exam, and 0.94 (95% CI 0.83 to 0.98) and 0.24 (95% CI 0.19 to 0.31) for the Malleolar Zone Algorithm.

How to I talk to parents if you decide not to order X-Rays?Regardless of which rule you use it’s a good idea to have a good discussion with families. Here is an example of how I might do this:

Your child has an ankle injury that typically heals very well with the immobilization that we are providing, limits on weight-bearing until the pain improves, and treatment of the pain and swelling by using ice, compression, elevation and ibuprofen as needed. At this time, X-Ray would not truly help us in deciding the best way to treat your child’s ankle injury. It is highly likely that they have a sprain or, in the worst case, a very tiny fracture to the fibula, a bone on the outside of the ankle. Even if there’s a small fracture, this heals very well with the treatment we are recommending and children don’t need further X-Rays, or follow-up from an orthopedic specialist. However, if you find that your child’s injury is not feeling better within a week, please follow up with your doctor. X-Rays may be necessary at that time.

Brad Sobolewski, MD, MEd – talking to parents about not getting an X-Ray for ankle injuries

ReferencesBoutis K, Grootendorst P, Willan A, Plint AC, Babyn P, Brison RJ, Sayal A, Parker M, Mamen N, Schuh S, Grimshaw J, Johnson D, Narayanan U. Effect of the Low Risk Ankle Rule on the frequency of radiography in children with ankle injuries. CMAJ. 2013 Oct 15;185(15):E731-8. PMID: 23939215.

Johnson, S. T., & Lynch, M. (2018). Acute Ankle Injuries. Pediatrics in Review, 39(9), 453-465. doi: 10.1542/pir.2017-0116

Stiell, I. G., Wells, G. A., Hoag, R. H., Sivilotti, M. L., Cacciotti, T., & Verbeek, P. R. (1995). Implementation of the Ottawa ankle rules. Journal of the American Medical Association, 273(16), 1281-1284. doi: 10.1001/jama.1995.03520400025030

Hess, E. P., Homme, J. H., Kharbanda, A. B., & Mayo-Smith, W. W. (2013). Low risk of ankle fractures in children with isolated ankle bruises. Archives of Pediatrics and Adolescent Medicine, 167(6), 539-543. doi: 10.1001/archpediatrics.2013.236

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The epiglottis is the toilet seat of the airway. That’s a useful function. But what if becomes so swollen and inflamed that it leads to airway obstruction and respiratory failure. That’s bad. That’s also what epiglottitis is. You can also call it supraglottitis. Either way you need to recognize this potentially life threatening malady and secure a definitive airway in the sickest patients ASAP.

ListenEpiglottitis – PEM Currents: The Pediatric Emergency Medicine Podcast – Brad Sobolewski, MD, MEd – April 12. 2023http://www.pemcincinnati.com/podcastsSubscribeReferencesRafei K, Lichenstein R. Airway infectious disease emergencies. Pediatr Clin North Am 2006; 53:215.

Sobol SE, Zapata S. Epiglottitis and croup. Otolaryngol Clin North Am 2008; 41:551.

Richards AM. Pediatric Respiratory Emergencies. Emerg Med Clin North Am. 2016 Feb;34(1):77-96. PMID: 26614243.

Faden H. The dramatic change in the epidemiology of pediatric epiglottitis. Pediatr Emerg Care. 2006 Jun;22(6):443-4. PMID: 16801849

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The CaseA five year old was jumping ever so vigorously in a bounce house and was knocked out of the bounce house by, as she noted, a “very big kid.” She landed awkwardly on her right shoulder and arm and cried out in immediate pain. She has no numbness and tingling in her hand, but “a whole lot” of pain in her upper arm. There are no lacerations or breaks in the skin. She was transported to the ED and the after some intranasal pain meds the following X-Ray was obtained (images courtesy Radiopedia):

Image courtesy Radiopedia – https://radiopaedia.org/cases/23972 – Accessed 3/24/23The DiagnosisThis is a transverse fracture of the proximal humerus – the so-called “surgical neck” of the humerus.

ManagementGiven that she has no neuromuscular deficits the management is conservative and includes placing her initially into a bulky splint + sling and swathe for comfort. You’ve got a few options- none is better than any other and your choice depends on patient comfort, size, and ability to manage it at home. From Academic Life in Emergency Medicine, below are some pictures of a couple of options. In addition to the two below I’ve also used a posterior long arm, and an upper arm sugartong nested together. Ultimately, the management is non-surgical in the vast majority of cases, and patients should be seen in Orthopedics with 3-5 days.

Either sling + swathe + splint or a shoulder immobilizer are recommended for minimally displaced fractures (≤ ⅓ the width of the shaft and ≤20 degrees angulated). Patients can start pendulum exercises in 2 to 4 weeks, then active range of motion movements including raising the arm overhead in 4 to 6 weeks. Return to usual activities is possible at 8 weeks. This patient was angulated, and therefore the splints seen below are recommended. Nevertheless almost all cases in this age range will remodel – without surgery – which is remarkable! Sometimes Ortho will place a hanging arm cast to add weight and can improve the deformity. Ibuprofen is the mainstay of pain management. Kids may want to sleep in a recliner for the first 1 to 2 weeks.

Kids ≥12 years with significant displacement generally get surgery. Anyone with an intra-articular fracture, dislocation + fracture, open fracture, or neuromuscular compromise needs immediate Orthopedic consultation. These are all rare in small children fortunately.

Courtesy ALiEM – https://www.aliem.com/splinter-series-104/Courtesy ALiEM – https://www.aliem.com/splinter-series-104/ReferencesShrader MW. Proximal humerus and humeral shaft fractures in children. Hand Clin 2007; 23:431.

Hohloch L, Eberbach H, Wagner FC, et al. Age- and severity-adjusted treatment of proximal humerus fractures in children and adolescents – A systematical review and meta-analysis. PLoS One 2017; 12:e0183157.

Benoudina S, Humeral surgical neck fracture. Case study, Radiopaedia.org (Accessed on 24 Mar 2023) https://doi.org/10.53347/rID-23972

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The CaseThe following pruritic rash is the reason for a visit to the ED. You are aiming to be efficient and nail the diagnosis and present a treatment plan while also presenting three patients with right lower abdominal pain to your attending.

Courtesy NHS.UK Accessed 3/15/23The DiagnosisOf course it’s ringworm! Also known as dermatophytosis or tinea corporis, ringworm is a common fungal infection that affects the skin, hair, and nails. It is caused by dermatophytic fungi that loooove warm and humid environments. It is highly contagious and can be spread through direct contact with an infected person or animal, as well as through contact with contaminated objects such as combs, brushes, and clothing. People who are at higher risk of developing ringworm include those who live in crowded or humid environments, those who have weakened immune systems, and those who have a history of skin conditions such as eczema. The most common species include;

• Trichophyton rubrum
• Trichophyton tonsurans
• Microsporum canis
• Epidermophyton floccosum

It is most common in children and young adults. Symptoms vary depending on the location of the infection.

• Tinea corporis: Infection of the skin. It usually appears as a red, scaly rash that is circular or ring-shaped, hence the name ringworm. The rash may be itchy and may have raised edges
• Onychomycosis: When the infection affects the nails, it can cause the nails to become thick, discolored, and brittle.
• Tinea capitis: Infection of the scalp, it can cause patchy hair loss and scaly, red areas on the scalp.
• Tinea cruris: Jock itch, perineal infection
• Tinea manuum: hand
• Tinea pedis: Feet

The diagnosis is usually made based on the appearance of the rash or affected area. Occasionally a fungal culture (or even biopsy) may be necessary to confirm the diagnosis. Ringworm can look a lot like eczema as well (nummular eczema, nummular means coin!).

ManagementFor mild cases of tinea corporis, over-the-counter antifungal creams, lotions, or powders are often effective. they should be applied as directed for two weeks, even if symptoms get better sooner. These include;

• clotrimazole
• miconazole
• terbinafine
• tolnaftate

For more severe cases of tinea corporis or for infections that do not respond to topical treatments, oral antifungal medications may be necessary. These include terbinafine, itraconazole, and fluconazole – which are typically taken for two to four weeks, depending on the severity of the infection. Tinea capitis requires oral therapy, generally griseofulvin. Oral antifungals can impact meds for patients with chronic liver or kidney disease.

Counsel patients on prevention which includes maintaining good personal hygiene, avoiding contact with infected people or animals, and avoiding sharing personal items such as combs, brushes, and clothing. It is also important to keep the skin clean and dry, as moist environments can promote the growth of fungi. Wash those horses shoes!

ReferencesYee G, Al Aboud AM. Tinea Corporis. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544360/

Ringworm. NHS. https://www.nhs.uk/conditions/ringworm/ – Accessed 3/15/2023

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Norovirus is the leading cause of viral gastroenteritis worldwide and is also a major cause of food borne illness. It spreads rapidly and causes vomiting and diarrhea that lead to many ED visits. Hopefully this brief episode will enrich the discussions that you have with patients and their families when making the diagnosis of viral gastroenteritis.

@PEMTweets on Twitter

My Mastodon account @bradsobo

ListenNorovirus – PEM Currents: The Pediatric Emergency Medicine Podcast – Brad Sobolewski, MD, MEd – February 28, 2023http://www.pemcincinnati.com/podcasts

SubscribeReferencesO’Ryan ML, Peña A, Vergara R, Díaz J, Mamani N, Cortés H, Lucero Y, Vidal R, Osorio G, Santolaya ME, Hermosilla G, Prado VJ. Prospective characterization of norovirus compared with rotavirus acute diarrhea episodes in chilean children. Pediatr Infect Dis J. 2010 Sep;29(9):855-9. doi: 10.1097/INF.0b013e3181e8b346. PMID: 20581736.

King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep 2003; 52:1.

Wilhelmi I, Roman E, Sánchez-Fauquier A. Viruses causing gastroenteritis. Clin Microbiol Infect 2003; 9:247.

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Staphylococcal scalded skin syndrome (SSSS) is a rare but serious bacterial skin infection caused by Staphylococcus aureus. It is most commonly seen in young children and infants, although cases have been reported in adults as well. SSSS is characterized by widespread blistering, peeling and flaking of the skin, giving it a “burned” appearance. SSSS is caused by specific strains of Staphylococcus aureus that produces exfoliative toxins which lead to the breakdown of the protein that holds the skin cells together, leading to the formation of blisters and the subsequent detachment of the skin.

Risk FactorsThe following factors increase the risk of SSSS:

• Age: Young children and infants are most commonly affected by SSSS.
• Immunosuppressed patients have a higher risk
• Patients with cuts, abrasions, or other skin damage, as well as those with chronic skin conditions like eczema are at increased risk of developing SSSS.
• Patients with a history of staph infections

SymptomsThe symptoms of SSSS typically appear 2-3 days after the initial infection and may include:

• Blisters: Red, painful blisters that burst easily and leave raw, exposed skin.
• Peeling: The skin may start to peel and flake, giving it a “burned” appearance.
• Rash: A red, scaly rash may develop over large areas of the body.
• Fever: A low-grade fever is common in SSSS cases.
• Mucosal involvement: In severe cases, the mouth, eyes, and genital area may be affected.

Many patients with SSSS are ill appearing and irritable.

A child with SSSS – courtesy Brad Sobolewski, MD, MEdDiagnosisThe diagnosis of SSSS is made based on the patient’s symptoms and a physical examination. A sample of fluid from a blister may be cultured to confirm the presence of Staphylococcus aureus.

TreatmentTreatment for SSSS typically involves antibiotics to clear the infection and supportive care to manage symptoms. Hospitalization is often necessary to provide intravenous antibiotics and fluid replacement. The antibiotic of choice for staphylococcal scalded skin syndrome (SSSS) is typically a penicillin – methicillin, nafcillin, or oxacillin. The Staph aureus that causes SSSS is not generally MRSA. In “true” penicillin allergy clindamycin or vancomycin may be used. Supportive care includes IV fluids, pain management and wound care. In severe cases, skin grafting may be necessary to repair damaged skin.

PreventionYou can recommend the following measures can help patients prevent the spread of staph infections:

• Good hygiene: Wash your hands frequently and clean cuts and abrasions promptly.
• Avoid sharing personal items: Avoid sharing towels, razors, or other personal items that may be contaminated with Staphylococcus aureus.
• Cover wounds: Cover cuts and abrasions with a clean, dry bandage.
• Seek prompt treatment: If you develop symptoms of a staph infection, seek prompt medical attention.

ReferencesBraunstein I, Wanat KA, Abuabara K, McGowan KL, Yan AC, Treat JR. Antibiotic sensitivity and resistance patterns in pediatric staphylococcal scalded skin syndrome. Pediatr Dermatol. 2014 May-Jun;31(3):305-8.

Ross A, Shoff HW. Staphylococcal Scalded Skin Syndrome. [Updated 2022 Jul 26]. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448135/

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Cindy Chang (one of our amazing Pediatric Emergency Medicine fellows) and I recently recorded an episode of the Cincinnati Children’s podcast Young & Healthy where we discussed the concept and practice of first aid, CPR, AEDs, bleeding control as well as our work with one of our local school districts to teach grade schoolers and middle schoolers first aid techniques including how to apply a tourniquet. The episode can be found on your favorite podcast device, or via the embedded player right here.

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High ankle sprains are injuries to the distal tibiofibular syndesmosis. They are far less common that the usual lateral ankles sprains that we see in the Pediatric Emergency Department. American football and ice hockey are the most common sports in which injuries occur, with the mechanism being an external rotation force applied to a dorsiflexed ankle. Generally this is when a foot is firmly planted and the leg is forcefully rotated during a tackle. Patients have pain in the anterolateral ankle – but in higher grade injuries the pain may be a lot more diffuse. Severe injuries limit weight bearing significantly.

On exam you can see lateral and possibly anterior ankle edema, and tenderness over the anterior inferior tibiofibular ligament and more proximally across the interosseous membrane. Patients won’t be able to hop on one foot and will experience pain upon dorsiflexion & external rotation. Sensitive signs for syndesmotic injury include tenderness over the AITFL, inability to perform a single-leg hop, and a painful dorsiflexion-external rotation test. You can also perform a squeeze test by placing the heel of each hand just above the mid calf and then compress the tibia and fibula by squeezing in the anteromedial to posterolateral directions. A “positive” squeeze test will result in the patient feeling pain in the distal syndesmosis, just above the ankle joint.

X-Rays should be obtained if you suspect a high ankle sprain. Diastasis (further apart than normal) of the distal fibula and tibia means that the syndesmosis is torn (grade 2 or 3) and this patient should be referred to Orthopedics because surgery is generally required in these cases. Any fracture also means that surgery should be considered. This can happen in a few days as long as there is no neurovascular compromise. MRI can lead to definitive diagnosis, but this is not necessary to obtain in the Emergency Department. Grade 1 injuries are fortunately the most common type.

Initial management includes non-weightbearing (crutches) with an ace-wrap or ankle lacer. Any fracture can be placed into a boot, or a below the knee splint. Ibuprofen, elevation, and ice can help. Grade 1 (no fracture and partial tears) get physical therapy whereas grade 2 and 3 (tears, disastasis, or any fracture) need surgery.

ReferencesVosseller JT, Karl JW, Greisberg JK. Incidence of syndesmotic injury. Orthopedics 2014; 37:e226.

Mauntel TC, Wikstrom EA, Roos KG, et al. The Epidemiology of High Ankle Sprains in National Collegiate Athletic Association Sports. Am J Sports Med 2017; 45:2156.

Prakash AA. Epidemiology of High Ankle Sprains: A Systematic Review. Foot Ankle Spec 2020; 13:420.

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“Neurodivergent” is a term used to describe brain functionality and how it differs in some people. These individuals perceive, interpret and interact with the world in ways that are different than what we typically encounter. The Emergency Department is a potentially challenging and stressful place for Neurodivergent children, and this episode discusses strategies to help make their experience just a little bit better.

This episode features the talents of Ilene Claudius, MD, the Director of Quality and Process Improvement for the Emergency Department at and Alice Kuo, MD, Professor and Chief of Medicine-Pediatrics and Preventive Medicine – both at UCLA.

It is also a co-production of the Emergency Medical Services for Children Innovation and Improvement Center whose mission is to minimize morbidity and mortality of acutely ill and injured children across the EMS for children continuum.

To learn more about the Emergency Medical Services for Children Innovation and Improvement Center visit:

EMSCImprovement.center

email: km@emscimprovement.center

Follow @EMSCImprovement on Twitter

Contact Ilene Claudius, MD

Contact Alice Kuo, MD

ListenAgitation in Neurodivergent Children – PEM Currents: The Pediatric Emergency Medicine Podcast – Brad Sobolewski, MD, MEdhttp://www.pemcincinnati.com/podcastsSubscribeReferencesEMSC IIC Pediatric Education and Advocacy Kit (PEAK): Agitation

De-escalation tips for pediatric agitation: EMSC Innovation & Improvement Center

DisclaimerThe Emergency Medical Services for Children Innovation and Improvement Center is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award (U07MC37471) totaling $3 million with zero percent financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

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It is possible for an adolescent to have a myocardial infarction. Maybe they had a previous history of Kawasaki Disease – or they have myocarditis, or a lipid metabolism disorder. It is also true that you are much more likely to see “benign early repolarization” on an EKG in a teenager (or young-ish adult up to age 50). Early Repolarization is widespread ST segment elevation that is also known as “J-point elevation” that looks like MI or myocarditis. Per Life in the Fast Lane, the features of benign early repolarization are:

• Widespread concave ST elevation, most prominent in the mid-to-left precordial leads (V2-5)
• Notching or slurring at the J point (best seen in V4)
• Prominent, slightly asymmetrical T waves that are concordant with the QRS complex
• ST elevation : T wave height ratio in V6 < 0.25 (see below)
• No reciprocal ST depression to suggest Occlusion MI

Benign Early Repolarization – from Life in the Fastlane – Accessed 1/19/2023The above EKG shows Benign Early Repolarization. See if you can pick out the following characteristics:

• Generalised concave ST elevation in precordial (V2-6) and limb leads (I, II, III, aVF)
• J-point notching is evident in the inferior leads (II, III and aVF)
• ST elevation : T wave ratio < 0.25 in V6

Here are some examples of the J-point notching (the “fish hook”) of benign early repolarization in precordial leads – note that the notching is best seen in V4:

Benign Early Repolarization – from Life in the Fastlane – Accessed 1/19/2023OK – so I know what you’re feeling right now if you’re reading this and you are Pediatric Emergency Medicine or General Pediatrics. Shoot! I kinda need to look at some STEMI EKGs to remember what they look like because I feel bad that I don’t know enough about what they actually look like… Go ahead, here’s a great link.

Welcome back!

How can we differentiate STEMI from Benign Early Repolarization?Other that just eyeballing it – which I suggest you don’t do. There is a validated calculator that has been developed to help make the differentiation, and it is on MDCalc.

Subtle Anterior STEMI Calculator from MDCalcYou need to first sure the EKG shows ≥1 mm ST elevation in ≥1 of the precordial leads V2-V4. If it shows any one of the following, then it is NOT normal variant, and is very likely to be LAD occlusion and an MI:

• 5 mm ST elevation

• Non-concave ST elevation
• Inferior reciprocal changes
• Anterior ST depression
• Terminal QRS distortion in V2 or V3
• Q waves in any of V2 to V4
• Any T wave inversion from V2 to V6

The score asks you to then calculate the following:

• Bazett-corrected QT interval in msec
• QRS amplitude in lead V2 in mm
• R wave amplitude in lead V4 in mm
• ST segment elevation 60 ms after the J point in lead V3

A score ≥18.2 is likely to be anterior STEMI (83.3% sensitivity, 87.7% specificity, and 85.9% diagnostic accuracy per the original study from Driver et al.), whereas a score <18.2 is likely to be benign early repolarization.

Now test yourself using this tool on the following case from Dr. Smith’s ECG Blog:

A teenager with chest painKey Resource

Benign Early Repolarisation

ReferencesDriver BE, Khalil A, Henry T, Kazmi F, Adil A, Smith SW. A new 4-variable formula to differentiate normal variant ST segment elevation in V2-V4 (early repolarization) from subtle left anterior descending coronary occlusion – Adding QRS amplitude of V2 improves the model. J Electrocardiol. 2017;50(5):561-569.

Bozbeyoğlu E, Aslanger E, Yıldırımtürk Ö, et al. A tale of two formulas: Differentiation of subtle anterior MI from benign ST segment elevation. Ann Noninvasive Electrocardiol. 2018;:e12568.

Smith SW, Khalil A, Henry TD, et al. Electrocardiographic differentiation of early repolarization from subtle anterior ST-segment elevation myocardial infarction. Ann Emerg Med. 2012;60(1):45-56.e2.

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Commotio cordis is caused by the blunt impact of a hard object directly over the heart occurring during a specific window of ventricular repolarization leading to immediate collapse, ventricular fibrillation, and cardiac arrest. This episode focuses on risk factors and management of this rare but catastrophic injury.

American Heart Association CPR and AED Training

ListenCommotio cordis – PEM Currents: The Pediatric Emergency Medicine Podcast by Brad Sobolewski, MD, Medhttp://www.pemcincinnati.com/podcastsSubscribeReferencesLink MS. Commotio cordis: ventricular fibrillation triggered by chest impact-induced abnormalities in repolarization. Circ Arrhythm Electrophysiol. 2012 Apr;5(2):425-32. doi: 10.1161/CIRCEP.111.962712. PMID: 22511659.

Madias C, Maron BJ, Weinstock J, et al. Commotio cordis–sudden cardiac death with chest wall impact. J Cardiovasc Electrophysiol 2007; 18:115.

Maron BJ, Gohman TE, Kyle SB, et al. Clinical profile and spectrum of commotio cordis. JAMA 2002; 287:1142.

Maron BJ, Estes NA 3rd. Commotio cordis. N Engl J Med 2010; 362:917.

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The “infected stone” is a urologic emergency. Patients with nephrolithiasis causing obstruction and fever / concern for concomitant urinary tract infection you should obtain urine and blood cultures, and initiate antibiotic therapy. Other useful labs include CBC with differential and a renal profile (chem-7). Empiric antibiotic therapy is based on local resistance patterns and whether or not the patient has had a previous UTI. Proteus, Providencia, Klebsiella, Pseudomonas, and enterococci are commonly seen bacteria. Ceftriaxone is a good first choice for many patients, but you may need broader agents like Piperacllin/Tazobactam. Boys are more likely to have obstructive uropathy; 80% of stones + UTI are male.

Urosepsis is a rare, but life treating complication of obstructing kidney stones. Urology will perform emergent drainage of the affected kidney by placing either a ureteral stent of percutaneous nephrostomy tube – this lowers the intrarenal pelvic pressure due to stone-induced obstruction. Staged removal of the calculi follows.

Non-obstructing stones can also be associated with UTIs that are difficult to clear. Start antibiotics empirically and consider calling Urology in the ED or arranging follow up in the next day or two. The threshold to remove the stone in the face of a UTI is very low.

ReferencesBarreto L, Jung JH, Abdelrahim A, et al. Medical and surgical interventions for the treatment of urinary stones in children. Cochrane Database Syst Rev 2018; 6:CD010784.

Yoshimura K, Utsunomiya N, Ichioka K, Ueda N, Matsui Y, Terai A. Emergency drainage for urosepsis associated with upper urinary tract calculi. J Urol. 2005 Feb;173(2):458-62. doi: 10.1097/01.ju.0000150512.40102.bb. PMID: 15643207.

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Happy Holidays everyone! I won’t be posting new content until after the new year. Why? Because I am working several shifts during the holiday week and you all should be spending time with friends and family instead of reading my silly little blog. See you in 2023!

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Let me start off by stating that yes – abdominal migraines are a thing. They fit under the umbrella of migraine variants – which are episodic syndromes related to migraines but presenting with symptoms other than headache. Other examples include periodic vomiting, hemiplegic migraine, and retinal/ophthalmic migraine. I won’t cover those three here.

Abdominal migraines are characterized by recurrent bouts of abdominal pain that last from 2 to 72 hours in a child who is asymptomatic in between the episodes. This pain is dull, constant, periumbilical and hard to localize. Children also have at least two of the following; pallor, anorexia, nausea, and/or vomiting. Children are afebrile and do not have peritoneal signs or urinary symptoms. There is no headache, and photophobia and phonophobia ate rarely seen. Some experts think that you should have five discrete episodes before you make a diagnosis.

Up to 1 in 25 children may experience them – with as many as 15% of kids with chronic periodic abdominal pain having abdominal migraines. They present between 2 and 10 years and end by early adolescence – where most transition into experiencing more classic migraine headaches. There is often a very strong family history of migraines as well. Other causes such as constipation or GERD need to be ruled out but a careful history. As you might imagine these children are often worked up for abdominal pain on multiple occasions and the differential is broad including, but not limited to gastritis, GERD, irritable bowel, pancreatitis, cholelithiasis, kidney stones and more. Most of these patients are too young to habitually use marijuana and in my experience cannabis hyperemesis syndrome is not a consideration. If labs have been sent they’ll all be normal – these include the “belly labs,” CBC, Renal/CMP, liver panel, urinalysis, lipase etc,. Imaging is also non-revelatory. formal diagnostic criteria require five episodes. Because symptoms overlap with other conditions that can cause abdominal pain, it is not unusual for children to require some degree of evaluation.

Treatment is symptomatic, and includes ibuprofen, acetaminophen, and ondansetron as first line. Children refractory to these can get the “migraine cocktail” – prochlorperazine + ketorolac OR metoclopramide + ketorolac. In my personal experience this has worked well in the past and parents are receptive too this lines of diagnostic thinking and treatment. many of them have suffered form migraine headaches themselves and are understanding.

ReferencesAngus-Leppan H, Saatci D, Sutcliffe A, Guiloff RJ. Abdominal migraine. BMJ. 2018 Feb 19;360:k179. doi: 10.1136/bmj.k179. Review. PubMed PMID: 29459383.

Klein J, Koch T. Headache in Children. Pediatr Rev. 2020 Apr;41(4):159-171. doi: 10.1542/pir.2017-0012. Review. PubMed PMID: 32238545.

Napthali K, Koloski N, Talley NJ. Abdominal migraine. Cephalalgia. 2016 Sep;36(10):980-6. doi: 10.1177/0333102415617748. Epub 2015 Nov 17. PMID: 26582952.

Winner P. Abdominal Migraine. Semin Pediatr Neurol. 2016 Feb;23(1):11-3. doi: 10.1016/j.spen.2015.09.001. Epub 2015 Oct 21. PMID: 27017015.

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Peritonsillar Abscesses are the most common deep neck infection in adolescents and young adults. You will see them in grade schoolers as well. Learn about the diagnosis and management, including making the choice between needle aspiration versus wielding a scalpel for incision and drainage.

ListenPeritonsillar Abscesses – PEM Currents: The Pediatric Emergency Medicine Podcast – Brad Sobolewski, MD, Med – December 8, 2022http://pemcincinnati.com/podcastsSubscribeMore…My Mastodon account @bradsobo

ReferencesUngkanont K, Yellon RF, Weissman JL, et al. Head and neck space infections in infants and children. Otolaryngol Head Neck Surg 1995; 112:375.

Schraff S, McGinn JD, Derkay CS. Peritonsillar abscess in children: a 10-year review of diagnosis and management. Int J Pediatr Otorhinolaryngol 2001; 57:213.

Sumpter, R, Bridwell, R. emDOCs: Emergency Medicine @3AM: Peritonsillar Abscess. http://www.emdocs.net/em3am-peritonsillar-abscess/. March 7, 2020. Accessed December 8, 2022.

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Tongue lacerations are surprisingly common in the Emergency Department. Fortunately most of them don't require any specific interventions. You just let them go and they heal on their own. Really. But if you do have to repair I offer advice in this brief podcast episode.

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This post details ways to deal with a situation where the patient / family "Wants to talk to your supervisor"

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There are many demands in the emergency department. Perhaps the most important ones come from patients and their families. This post looks at those situations in which patients/parents are requesting – nay demanding specific tests.

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Here is a podcast episode that I recorded for Cincinnati Children's show "Young & Healthy" entitled "Parents, We Need Your Attention: Babies and Kids are Sick, Children’s Hospitals are Full, Wait Times are Long." It addresses why our EDs, Urgent Cares, and Hospitals are so busy, and offers caregiver focused advice on Bronchiolitis management.

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There's an amoxicillin shortage right now... seriously. This post includes guideline resources and alternative option recommendations like tablets and capsules.

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Perioribital cellulitis (AKA Preseptal cellulitis)is a soft tissue infection of the eyelids and skin anterior to the orbit. It must be differentiated from the more invasive and dangerous orbital cellulitis. Treatment varies depending on the original source (sinusitis, local trauma, stye etc,.). Learn all about periorbital cellulitis in this brief episode of PEM Currents: The Pediatric Emergency Medicine Podcast.

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Perioribital / Preseptal cellulitis is a common complaint in children and must be differentiated from more dangerous orbital infections. Learn all about it in this post.

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PEMPix is the American Academy of Pediatrics Section on Emergency Medicine’s annual visual diagnosis competition. This year, in addition to the 10 finalists I will be presenting at the National Conference and Exhibition I will be sharing four cases online in advance of the conference. This is the last of the four cases. See if you can conquer all four "mountains" and guess the correct diagnosis.

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PEMPix is the American Academy of Pediatrics Section on Emergency Medicine’s annual visual diagnosis competition. This year, in addition to the 10 finalists I will be presenting at the National Conference and Exhibition I will be sharing four cases online in advance of the conference. This is the third of the four cases. See if you can conquer all four "mountains" and guess the correct diagnosis.

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PEMPix is the American Academy of Pediatrics Section on Emergency Medicine’s annual visual diagnosis competition. This year, in addition to the 10 finalists I will be presenting at the National Conference and Exhibition I will be sharing four cases online in advance of the conference. This is the second of the four cases. See if you can conquer all four "mountains" and guess the correct diagnosis.

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PEMPix is the American Academy of Pediatrics Section on Emergency Medicine’s annual visual diagnosis competition. This year, in addition to the 10 finalists I will be presenting at the National Conference and Exhibition I will be sharing four cases online in advance of the conference. This is the first of the four cases. See if you can conquer all four "mountains" and guess the correct diagnosis.

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Each day from October 3 through 6, 2022 I will be releasing one of the four online PEMPix cases. The theme in advance of the AAP National Conference and Exhibition in Anaheim, CA should be obvious to any theme park aficionado. This year I received 88 submissions for PEMPix, and these 4 online cases will be accompanied by ten cases presented in person at the Section on Emergency Medicine session on Saturday October 8th.

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Bad things happen when you don't have enough neutrophils. After getting cytotoxic chemotherapy you tend to have even fewer neutrophils. This can put you at risk for neutropenic enterocolitis which should be suspected in an immunocompromised child with fever and abdominal symptoms. Treatment is broad spectrum antibiotics and the imaging test of choice is CT with contrast. Learn all about this potentially catastrophic condition in this brief podcast episode.

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Enterovirus D68 is currently causing upper and lower respiratory tract symptoms in a vast number of children in North America. It can also cause acute flaccid myelitis - learn a bit more about it in this blog post.

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We are running critically low on the bottles of albuterol that are used to compound continuous treatments. There is not a shortage of metered dose inhalers and nebules. Here's how you should adjust your treatment plans in lieu of this information.

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The Pediatric Education and Advocacy Kit (PEAK) Pain podcast series consists of 5 episodes that all focus on different aspects of assessing, managing, and supporting the pediatric patient in pain. This series was coproduced by the Emergency Medical Services for Children Innovation and Improvement Center (EIIC) and features episodes from 5 of the leading podcasters in Pediatric Emergency Medicine.

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Patients with severe asthma exacerbations will get the proverbial "kitchen sink" thrown at them when it comes to treatment. First of all, that old idiomatic statement posits asthma treatment as a battle, which it shouldn't be. But you should be armed with a solid understanding of the evidence behind the treatments that we use when treating patients with this potentially fatal disease.

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PEMBlog is ten years old! What started as an extension of a Twitter Trivia Contest for residents at Cincinnati Children's has turned into one of the defining accomplishments of my career. Thank you for reading, and helping me on my journey to become a better teacher.

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Dewdrops on a rose petal. You've all heard the description, right? But how many of you have actually seen chicken pox in the wild. And what about monkey pox - does it look the same? How can I tell them apart? I wish there was a brief podcast episode focused on varicella that would help answer some of these questions...

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Neonatal mastitis is a rare, but potentially dangerous infection in newborns. Learn more about the workup and treatment in this PEMBlog Brief.

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Hand, Foot, and Mouth (and Butt) disease is incredibly popular in the summer/warm weather months in the Northern Hemisphere (August through October). It is so popular that I guarantee you will see it many times. This brief episode will teach you how to make the diagnosis and review strategies for management - which are largely supportive.

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High fever, no other symptoms followed by a rash? What could it be?

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Laceration repair is one of the quintessential procedures that children undergo in Emergency Departments. Minimizing pain and anxiety for children is a much better idea than just holding them down and getting it done. This episode will teach you all about local anesthetics, when to use anxiolytics and procedural sedations s well as the considerable value of nonpharmacologic intervention - including Child Life Specialists.

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Lyme disease prevalence continues to rise - especially in places where we didn't see it before (like Ohio!). this podcast episode focuses on making the diagnosis, the different stages of disease, as well as when to prophylaxis, treat, and how testing works - all in under 15 minutes.

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This post reviews the diagnosis and management of nonspecific vulvovaginitis in prepubertal girls.

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post is to provide some background and then to offer a summary of the sort of problems that can happen when babies don't get formula or breast milk.