Lactate is commonly used in the adult ED when evaluating septic patients, but there is a lack of literature validating its use in the pediatric ED.  Pediatric studies have suggested that in the ICU population, elevated lactate is a predictor of mortality and may be the earliest marker of death.
 
A retrospective chart review over a 1 year period showed that one elevated serum lactate correlated with increased pulse, respiratory rate, white blood cell count and platelets.  Serum lactate had a negative correlation with BUN, serum bicarbinate and age.  Elevated lactate levels were higher for admitted patients. However, the mean serum lacate level was not statistically different between those diagnosed with sepsis and those that were not.
 
The study included 289 patients less then 18 years who had both blood cultures and lactate drawn.  This community hospital had a sepsis protocol in place that automatically ordered a lactate with blood cultures.  Only previously healthy children were included.
 
The study is limited by its small sample size and overall low lactate levels.  Despite having a protocol in place, only 39% of patients who had blood cultures drawn had lactate levels available for analysis.  The mean serum lacate in this study was 2.04 mM indicating that the study population may not have been sick enough to determine mortality implications.  There were no serial measurements.

 
Bottom line:  Consider measuring serum lacate in your pediatric patient with suspected sepsis.  Pediatric ICU literature does suggest that an serum lactate as low as 3mM is associated with an increased mortality in the ICU.

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Risk stratisfication score introducted by Maden Samuel in 2002.

The Pediatric Appendicitis Score had a sensitivity of 1, speciificity of 0.92, positive predictive value of 0.96, and negative predictive value of 0.99

Signs:

• Right lower quadrant tenderness = 2 points
• Cough/Percussion/Hop RLQ tenderness = 1 point
• Pyrexia = 1 point

Symptoms:

• RLQ migration of pain = 1 point
• Anorexia = 1 point
• Nausea/Vomiting = 1 point

Laboratory Values:

• Leukocytosis = 2 points
• Polymorphonuclear neutrophiia = 1 point

Scores of 4 or less are least likely to have acute appendicitis, while scores of 8 or more are most likely.

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• enterovirus which lives in digestive tract, and is highly contagious
• outbreaks worse in summer and fall, but is a self-limited illness
• causes mild flu-like symptoms such as fever, headache, muscle aches, sore throat. with fever usually lasting less than 3 days
• hand, foot, and mouth disease: syndrome of painful blisters in oropharynx and plams of hands and soles of feet
• herpangina: painful blisters in oropharynx, usually posterior in location
• hemorrhagic conjunctivitis: eye pain with injected conjunctivia
• serious complications include: viral meningitis and encephalitis, myocarditis, and secondary bacterial infections

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Infant lumbar puncture is often difficut and may require repeated attempts.  The traditional body positioning is lateral decubitus.  Previous studies have examined the saftey of having the patient in a sitting position, and neonatal studies have suggested that the subarachnoid space increases in size as the patient is moved to the seated position.  A study by Lo et al published last month looked to see if the same held true in infants.
 
50 healthy infants less then 4 months old had the subarachnoid space measured by ultrasound between L3-L4 in 3 positions: lateral decubitus, 45 degree tilt and sitting upright.
 
This study found that the size of the subarachnoid space did not differ significantly between the 3 positions.  Authors postulated that a reason for increase sitting LP success rate that had been reported in anestesia literature with tilt position could be due to other factors such as increased CSF pressure, intraspinous space widening or improved landmark identification.

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Ultrasound findings of appendicitis

• noncompressible appendix with an outer diameter in any portion > 6mm
• appendicolith
• hyperechoic periappendiceal fat
• loss of echogenic submucosal layer
• increased blood flow of the appendix on color Doppler ultrasound scanning
• periappendiceal collections seen in the absence of a visualized abnormal appendix

Ultrasound images:
http://www.youtube.com/watch?v=d9jKM6x52nk
http://sonocloud.org/watch_video.php?v=MWHM3D7KD25H
http://sonocloud.org/watch_video.php?v=54862AYWGHGA

• diarrhea lasting less than 14 days
• in children, almost all diarrhea is due to an infectious agent
• most etiologies are self-limited and do not need further evaluation except in the following conditions:

1. infants < 2 months of age
2. gross blood in stool
3. WBC's on microscopic exam of stool
4. toxic-appearance
5. immunocompromised child
6. diarrhea developing while an inpatient

• therapy is aimed at oral rehydration and providing nutrional needs
• ORT is best with commerical formulations specific for this as most other clear liquids (juice, sodas) are hypertonic and have excess glucose resulting in ongoing diarrhea-like stools
• after rehydration, resume the child's normal diet. 

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Acute ischemic stroke occurs in 3.3/100,000 children per year.  Up to 30% of these are caused by varicella.  This can be diagnosed if the patient has had varicella infection within the past 12 months, has a unilateral stenosis of a great vessel, and has a positive PCR or IgG from the CSF.

Treatment includes anticoagulation, acyclovir for at least 7 days and steroids for 3-5 days.

Outcome is normally good and spontaneous improvement can be seen.

Inflammation of other arteries, including other areas of the brain, can also be seen.  Treatment options for this can include high dose glucocorticoids and possibly immunosuppresive agents.

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

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

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

2013 AAP AOM Guidelines UPDATE

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

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

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

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

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

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

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

Max doses of common anesthetics

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

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

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

Pearls:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Question

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

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

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

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

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

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

Most cases occur in late winter and early spring.

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

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

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

Treatment is largely supportive with efforts to maintain hydration.

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

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

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