TOPICS. Wheezing/Asthma THE BEST PEDIATRIC LITERATURE THAT STILL AFFECT YOUR PRACTICE

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Agnes McLaughlin
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1 THE BEST PEDIATRIC LITERATURE THAT STILL AFFECT YOUR PRACTICE Ghazala Q. Sharieff MD, MBA Wheezing/asthma Croup Immunizations and fever Appendicitis Complex febrile seizures Procedures Head Injury Zofran TOPICS Wheezing/Asthma

2 DECADRON VS PREDNISONE? Qureshi F et al. J Peds pts between 2 and 18 years of age prospectively enrolled, off-even day randomized trial of patients who required a second dose of albuterol Pts either received prednisone 2mg/kg with 4 additional daily doses or Decadron 0.6mg/kg (max 16 mg) in ED and one additional dose to take the next day Primary outcome measure was relapse at 10 days DECADRON VS PREDNISONE? Qureshi F et al. J Peds % of 272 patients who received Decadron and 6.9% of 261 patients in the prednisone group relapsed Pts who received prednisone had more vomiting, more pts missed > 2 days of school, and more parents missed work Authors conclude that dexamethasone has similar efficacy to oral prednisone with greater compliance and less sideeffects Asthma and Steroids Chang Med J Australia Sept kids, mean age 5 yrs Randomized to 5days prednisolone (1mg/kg) vs 3days prednisolone + 2 days placebo 82% followed up No diff in % kids symptom-free by day #7 Additional prednisolone: 3day 8% vs 5day 5% Similar results for mild, moderate, severe asthma

3 CROUP Dose of Dex? Dobrovoljac M. Emerg Med Australasia 2009 Previous study: 0.15mg/kg effective 1995: mandatory 0.15mg/kg dex implemented Croup visits to the ED stayed the same Overall and ICU admission rates declined LOS declined No sig diff in re-admission rate CONCLUSION: 0.15mg/kg is effective in pts with mild to moderate croup Inpatient RX after RE Rudinsky S, Sharieff G etal JEM subjects admitted after 2 ED RE doses, 36% received clinically important inpatient interventions: RE (n = 68 ), heliox (n = 9 and supplemental oxygen (n = 4) Of patients who received inpatient RE, 53% received only 1 dose. No patients underwent intubation or transfer to higher level of care.

4 CONCLUSIONS Rudinsky S, Sharieff G etal JEM 2015 Inpatient interventions after 2 ED doses of RE for croup were infrequent, most commonly RE administration. Most patients asymptomatic upon admission require 0 1 inpatient RE doses and may be candidates for outpatient management. PEDIATRIC FEVER Immunizations and Fever Wolff Academic Emerg Med Dec 2009 Infants, 6-12 weeks, fever 38C, 7yr study? Immunized <72hrs prior to visit 1,978 infants with minimum workups ( UA and Blood) 213 infants had recent immunizations (11%) 75% presented within 24 hours SBI s: Immunized prior to ED visit 2.8% vs Not 7% Immunized less than 24 hrs prior: 0.6% Immunized more than 24 hrs: 8.9% SBI s, Immunized - all UTI s

5 Duration of fever and UTIs Salleeh H. J Peds 2010 Prospective, cohort study of 818 children age 3-36 months with documented fever without source Primary outcome: yield of positive bag dipsticks defined as positive for nitrates or more than trace leukocyte esterase Secondary outcome = positive catheter cultures on each day of fever Duration of fever and UTIs Salleeh H. J Peds 2010 Positive bag urinalyses increased with duration of fever: 14.8% (35/237) on day % (43/163) on day 3 Positive catheter cultures increased in the same fashion: 4.8% (11/229) on day % (20/159) on day 3 Duration of fever and UTIs Salleeh H. J Peds 2010 Conclusion: The yield of positive bag urinalyses and catheter cultures increased significantly in children with fever of 3 days or longer duration

Conclusion: patients who meet CFS criteria based on number of seizures and who are well appearing, may not require LP PETECHIAE How likely is meningococcal disease? Wells LC et al.

6 Value Of LP for First CFS Fletcher EM. Sharieff G.West J Emerg Med patients 6mths- 5 years, had 2 brief febrile seizures within 24 hrs 17 had LPs- no CSF findings LP on 136 ( 70%) 14 had pleocytosis, 1 had ABM. Conclusion: patients who meet CFS criteria based on number of seizures and who are well appearing, may not require LP PETECHIAE How likely is meningococcal disease? Wells LC et al. Arch Dis Child, children with petechial rash, infants to 15 years of age. The ability of clinical features and lab studies to predict meningococcal disease was studied 24 (11%) had proven meningococcemia 5 kids had temperatures less than 37.5C Median age was less than 2 years of age, with 55% of pts with petechiae being less than 3 years

with a CRP less than 6 mg/dl had meningococcal disease OTITIS MEDIA/PHARYNGITIS Acute Otitis Media Spiro.

7 PETECHIAE How likely is meningococcal disease? Wells LC et al. Arch Dis Child, 2001 Patients with meningococcemia more likely to have temps >38.5C, have purpuric lesions, be ill-appearing, have delayed capillary refill times, prolonged INR, and abnormal neutrophil counts No patients with petechiae above SVC had meningococcemia and no child with a CRP less than 6 mg/dl had meningococcal disease OTITIS MEDIA/PHARYNGITIS Acute Otitis Media Spiro. JAMA kids non-toxic kids 6mo-12yo with AOM All received ibuprofen and otic analgesic drops Randomized to WASP (48 hrs) or standard treatment Called 5 days, 12 days & 5 weeks later Prescription not filled: WASP 62% vs 13% Why was Rx filled? Fever, otalgia, fussiness Length of otalgia: 2.4 d vs 2.0 d No difference in otorrhea, unscheduled visits, future AOM More diarrhea in standard group

8 GI EMERGENCIES Acute Appendicitis-Other Tests? Gavela T. Peds EM Care consecutive pts admitted with acute appendicitis Age, sex, time since diagnosis, laboratory data, complications (abscess, intestinal obstruction), presence of hemodynamic instability, mortality, length of stay, and need for admission to the pediatric intensive care unit. Acute Appendicitis- Other tests? CRP and PCT predict the outcome of pediatric patients with appendicitis. Children with CRP >3 mg/dl and/or PCT> 0.18 ng/ml have a greater risk of complications

Imaging and Appendicitis Bachur R etal.ann Emerg Med 2012 1810 children, 3-18 years, mean 10.9 yrs 49% males 1216 had CT, 832 had US, 238 had both Sensitivity of CT- 0.94-0.

9 Imaging and Appendicitis Bachur R etal.ann Emerg Med children, 3-18 years, mean 10.9 yrs 49% males 1216 had CT, 832 had US, 238 had both Sensitivity of CT <12-71 hours Sensitivity of US increased with duration of pain 0.79 for <12 hours; 0.85 for hours,0.96 for >48 hours A Practical Approach To Appendicitis RLQ pain and good history, WBC and CRP + => OR +/- history and equivocal labs=> Ultrasound US positive=> OR US negative, but worrisome exam/history or labs=> CT or MRI CT or MRI neg but pt still with pain=> admission for observation!

10 Zofran and Return Visits Sturm, J. Ann Emerg Med ,117 kids with dx of vomiting or gastroenteritis 19,857 kids received ondansetron Zofran group had less initial admissions Zofran group more likely to return to within 72 hrs Zofran group more likely to be admitted on return Zofran, cont d Proportions of alternative diagnoses on hospital discharge were not significantly different between both groups Zofran does not appear to mask serious diagnoses Did not account for whether pts were given additional zofran to take at home or if they actually took it if given an Rx Rx for concussion?

4%) 616 ( 9.7%) got Rx for ondansetron Am J Emerg Med 2013 Zofran use 3.

11 Ondansetron after head injury Sturm etal. Am J Emerg Med children who underwent head CT for head injury and discharged home got ondansetron in ED ( 19.4%) 616 ( 9.7%) got Rx for ondansetron Ondansetron after head injury Sturm etal. Am J Emerg Med 2013 Zofran use 3.7% in 2003 vs 22% in 2010 Lower likelihood of 72 hr return 1.1% vs 2.7% ( p<0.001) Conclusion: No masking of symptoms and a decrease in return ED visits in children who undergo CT, receive ondansetron and are discharged TRAUMA & RESUSCITATION

12 Pediatric Head Trauma Kupperman Lancet October 2009 Prospective study, 25 hospitals 42,000 kids <18yo, <24 hrs head trauma, GCS Derived and validated decision rules CT s done on 35% Clinically important brain inj 0.9%, surgery 0.1% Pediatric Head Trauma Kupperman (cont) Less than 2yrs: normal mental status, no scalp hematoma except frontal, no LOC, or LOC <5 seconds, non-severe injury, no palpable scalp fracture, acting normally Sensitivity 100% (86-100%) More than 2yrs: normal mental status, no LOC, no vomiting, non-severe injury, no basilar skull fracture, no severe headache Sensitivity 96.8% ( %) No surgical cases missed Dangers of Radiation Hall etal. BMJ 2004 Statistical odds suggested that high school attendance decreased progressively as the radiation dose increased, Similar significant dose-response relationship in cognitive function. Low dose radiation used for CT scanning of the brain at a young age may have adverse effects on subsequent cognitive ability.

Positioning for Lumbar Puncture Pediatrics 2010; 125: e1149 e1153 Objective/Method To determine a position that maximizes interspinous space as measured by bedside ultrasound A

13 Positioning for Lumbar Puncture Pediatrics 2010; 125: e1149 e1153 Objective/Method To determine a position that maximizes interspinous space as measured by bedside ultrasound A prospective convenience sample of children under age 12 was performed Using a portable ultrasound device, the L3-L4 or L4-L5 interspinous space was measured with the subject in 5 different positions

14 Positioning Results There were 28 subjects enrolled (13 girls and 15 boys) at a median age of 5 years The sitting-flexed position provided a significantly increased interspinous space Flexion of the hips increased the interspinous space in both the sitting and lateral recumbent positions Flexion of the neck did not significantly change the interspinous space A new technique for fast and safe collection of urine in newborns Herreros Fernandez M etal. Arch Dis Child 2013; 98: 27-29

Procedure 80 infants less than 30 days of age were fed, and 25 minutes later, genitals cleaned with warm water and soap and dried with sterile gauze.

15 Procedure 80 infants less than 30 days of age were fed, and 25 minutes later, genitals cleaned with warm water and soap and dried with sterile gauze. Before stimulation technique, infants received pacifier or 2% sucrose syrup Stimulation of bladder by gently tapping the suprapubic area at a frequency of 100 taps per minute for 30 seconds Stimulation of lumbar paravertebral zone in the lower back with light circular massage for 30 seconds. Repeated until micturition began and midstream urine caught in a sterile container. Results 86.3% success rate Median time to sample collection was 45 s No complications other than controlled crying were observed

16 TAKE HOME POINTS Dexamethasone for asthma Lower dose dex for croup Fever evaluation for infants 24 hours after immunizations. WASP for otitis media Head CT guidelines for minor head injury Zofran for emesis and concussion MAN OF THE YEAR CONTEST Runner Up

17 Man of the year 2nd Place Man of the year 3 rd Place Man of the year 1st Place

Pediatric Tricks of the Trade

For This Lecture Pediatric Tricks of the Trade For pdf copy, go to: Lectures.umem.org/FEP (will be posted for 1 month) Questions? mlu@umem.org Mimi Lu, MD Clinical Assistant Professor Assistant Residency