Pearls for the office from the Paediatric ER Dr. Rodrick Lim MD

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1 Pearls for the office from the Paediatric ER Dr. Rodrick Lim MD Division of Emergency Medicine, Department of Medicine Division of Paediatric Emergency Medicine, Department of Paediatrics

2 DISCLOSURES No potential conflicts of interest to declare

3 OUTLINE To educate front-line clinicians about current changes in management for common pediatric conditions To educate front-line clinicians on things to consider prior to sending children to the ER

4 TOPIC OUTLINE:» Common: asthma vs bronchiolitis, simple fractures, gastroenteritis» Problematic: fever, sepsis, UTI» New issues/advances on the horizon: high flow oxygen, head imaging,sedation in the very young,

5 BRONCHIOLITIS VS ASTHMA» Bronchiolitis often defined as first episode of wheezing in the right season, under the age of 2 years.» Treatment:???

7 CANADIAN LUNG ASSOCIATION Objective: To develop a position paper on the diagnosis and management of asthma in preschoolers. Design: Expert Consensus Joint Statement by CPS and CLA

8 CANADIAN LUNG ASSOCIATION Bottom Line:» Terms such as bronchospasm, reactive airway disease, wheezy bronchitis and happy wheezer should be abandoned.» Recurrent preschool wheezing can be associated with substantial morbidity and may impact long-term health.

9 CANADIAN LUNG ASSOCIATION Bottom Line:» Wheezing in early life has been associated with reduced lung function at six years of age that generally persists until adulthood» The magnitude of the reduction is approximately a 10% lower predicted FEV1, compared with healthy peers» Airway remodelling (ie, irreversible damage to the airways) has been documented in toddlers and may explain the altered lung function trajectory» Early diagnosis is, therefore, important to avoid treatment delay, reduce morbidity and, potentially, maximize lung growth and function.

10 CANADIAN LUNG ASSOCIATION:

11 CANADIAN LUNG ASSOCIATION Bottom Line:» Asthma can be diagnosed in children one to five years of age.» The diagnosis of asthma requires documentation of signs or symptoms of airflow obstruction, reversibility of obstruction (improvement in these signs or symptoms with asthma therapy) and no clinical suspicion of an alternative diagnosis.» Bronchiolitis usually presents as the first episode of wheezing in a child <1 year of age.» The diagnosis of asthma should be considered in children one to five years of age with recurrent asthma-like symptoms or exacerbations, even if triggered by viral infections.

12 FRACTURE MANAGEMENT:» Trends away from cast all:» Buckle Fractures» Clavicle Fractures» Toddlers Fractures

13 HIGHER RISK CLAVICLE FRACTURES:

14 GASTROENTERITIS:

15 » Results Among 647 randomized children (mean age, 28.3 months; 331 boys [51.1%]; 441 (68.2%) without evidence of dehydration), 644 (99.5%) completed follow-up. Children who were administered dilute apple juice experienced treatment failure less often than those given electrolyte maintenance solution (16.7% vs 25.0%; difference, 8.3%; 97.5% CI, to 2.0%; P <.001 for inferiority and P =.006 for superiority). Fewer children administered apple juice/preferred fluids received intravenous rehydration (2.5% vs 9.0%; difference, 6.5%; 99% CI, 11.6% to 1.8%). Hospitalization rates and diarrhea and vomiting frequency were not significantly different between groups.

16 » Conclusions and Relevance Among children with mild gastroenteritis and minimal dehydration, initial oral hydration with dilute apple juice followed by their preferred fluids, compared with electrolyte maintenance solution, resulted in fewer treatment failures. In many high-income countries, the use of dilute apple juice and preferred fluids as desired may be an appropriate alternative to electrolyte maintenance fluids in children with mild gastroenteritis and minimal dehydration.

17 TOPIC OUTLINE:» Common: asthma vs bronchiolitis, simple fractures, gastroenteritis» Problematic: fever, sepsis, UTI» New issues/advances on the horizon: high flow oxygen, head imaging,sedation in the very young,

18 FEVER/SEPSIS TRENDS:» Search for magic test ongoing» Thresholds decreasing» Inotrope choices changing in Pediatric sepsis» Goal directed therapy: Pediatric ongoing

19 UTI:

20 UTI STATEMENT HIGHLIGHTS:» UTI should be ruled out in preverbal children with unexplained fever and in older children with symptoms suggestive of UTI (dysuria, urinary frequency, hematuria, abdominal pain, back pain or new daytime incontinence).» A midstream urine sample should be collected for urinalysis and culture in toilet-trained children; others should have urine collected by catheter or by suprapubic aspirate.» UTI is unlikely if the urinalysis is completely normal. A bagged urine sample may be used for urinalysis but should not be used for urine culture.

21 UTI STATEMENT HIGHLIGHTS:»» Antibiotic treatment for seven to 10 days is recommended for febrile UTI. Oral antibiotics may be offered as initial treatment when the child is not seriously ill and is likely to receive and tolerate every dose.» Children <2 years of age should be investigated after their first febrile UTI with a renal/bladder ultrasound to identify any significant renal abnormalities. A voiding cystourethrogram is not required for children with a first UTI unless the renal/bladder ultrasound reveals findings suggestive of vesicoureteral reflux, selected renal anomalies or obstructive uropathy.

22 TOPIC OUTLINE:» Common: asthma vs bronchiolitis, simple fractures, gastroenteritis» Problematic: fever, sepsis, UTI» New issues/advances on the horizon: high flow oxygen, head imaging,sedation in the very young,

23 » HIGH FLOW OXYGEN:» Revolutionizing respiratory management in children» Decreasing need for intubation» Used for a variety of conditions» Transitioning to use on floors ongoing

24 HEAD IMAGING:» Continues to be major challenge» General anesthetic» Radiation exposure» 1 Bang MRI s availability

26 ANESTHETIC EXPOSURE Objective: To establish whether general anaesthesia in infancy has any effect on neurodevelopmental outcome. Design: International assessor-masked randomised controlled equivalence trial, infants younger than 60 weeks postmenstrual age, born at greater than 26 weeks' gestation, and who had inguinal herniorrhaphy, from 28 hospitals in Australia, Italy, the USA, the UK, Canada, the Netherlands, and New Zealand. Infants were randomly assigned (1:1) to receive either awake-regional anaesthesia or sevoflurane-based general anaesthesia.

27 ANESTHETIC EXPOSURE Design: The primary outcome of the trial will be the Wechsler Preschool and Primary Scale of Intelligence Third Edition (WPPSI-III) Full Scale Intelligence Quotient score at age 5 years. The secondary outcome, reported here, is the composite cognitive score of the Bayley Scales of Infant and Toddler Development III, assessed at 2 years.

28 ANESTHETIC EXPOSURE Findings: - The reported secondary outcome of neurodevelopmental outcome at 2 years of age in the General Anaesthesia compared to Spinal anaesthesia (GAS) trial infants were randomly assigned to receive awakeregional anaesthesia and 359 to general anaesthesia - Outcome data were available for 238 children in the awakeregional group and 294 in the general anaesthesia group.

29 ANESTHETIC EXPOSURE Bottom Line: - For this secondary outcome, we found no evidence that just less than 1h of sevoflurane anaesthesia in infancy increases the risk of adverse neurodevelopmental outcome at 2 years of age compared with awake-regional anaesthesia.

30 TOPIC OUTLINE:» Common: asthma vs bronchiolitis, simple fractures, gastroenteritis» Problematic: fever, sepsis, UTI» New issues/advances on the horizon: high flow oxygen, head imaging,sedation in the very young

31 » Questions?

The McMaster at night Pediatric Curriculum

The McMaster at night Pediatric Curriculum Robinson, J, et al. and the Canadian Pediatric Society. Urinary tract infection in infants and children: Diagnosis and management. Pediatr Child Health 2014;