Pediatric Pearls

Newborns have increased rates of bilirubin production due to RBC's with shorter life spans, and a decreased rate of bilirubin elimination due to decreased ability of the neonatal liver to conjugate bilirubin

About 60% of newborns will become clinically jaundiced

Bilirubin levels peak at 4 days of life, and may not decline before day 7

• Admission and treatment should be considered urgently when serum total bilirubin >25mg/dL, with exchange transfusion if it is >30mg/dL or the infant has signs of kernicterus.
• There are nomograms which plot the bilirubin level according to the infant's age in hours to determine if an infant is at risk for being at toxic levels.

Increased bilirubin production: blood-group incompatibilities, RBC-enzyme deficiency, and RBC structural defects

Sepsis, UTI, congenital infection (syphilis, CMV, etc)

A common debate on the topic of pediatric burns is whether or not blisters should be debrided. ALL PEDIATRIC BURN BLISTERS SHOULD BE DEBRIDED.

• There are two reasons for this:
• 1. Without debridement of burn blisters, the depth of a burn cannot be assessed, and such an assessment will certainly affect treatment and disposition.
• 2. There is conflicting (poor) evidence that blister fluid provides both protective and damaging properties, however, there is excellent evidence that ruptured blisters, or large blisters which are likely to rupture, carry a higher risk of infection if not debrided.

Therefore, all blisters should be debrided.

Sargent, RL. Management of blisters in the partial-thickness burn: an integrative research review. J Burn Care Res 2006; 27:66.

Alsbjorn, B, Gilbert, P, Hartmann, B, et al. Guidelines for the management of partial-thickness burns in a general hospital or community setting--recommendations of a European working party. Burns 2007; 33:155.

Infants and young children who have ingested enough ethanol to cause a peak serum level ≥50 mg/dL (11 mmol/L) are at risk for profound hypoglycemia, in addition to the other effects of alcohol seen in adults

The key is that the dangerous serum level is MUCH lower in children than in adults, and children require FAR smaller volume than what may be considered dangerous by adults.

Supportive care is the key to good outcomes, with particular focus on treating hypoglycemia - check your D-sticks early and often.

Consider child protective services involvement in every case of pediatric intoxication, and consider measurement of serum acetaminophen levels as well as other possible toxic ingestion candidates.

Activated charcoal cannot adsorb ethanol and should only be used if other substances are being considered.

Children who are asymptomatic for six hours, and have a safe home environment, may be discharged.

Idiopathic Thrombocytopenic Purpura (ITP)

Immune-mediated destruction of circulating platelets

2-5 years of age

Adolescence

TRUE

FALSE; there is NO hepatosplenogmegaly in ITP.

Low platelets with megathrombocytes on smear

Normal hemoglobin (which differentiates from TTP, HUS, and DIC)

TRUE

Treatment reserved for platelet counts <20,000 OR significant bleeding

• -IVIG (best response rate of 95%)
• -Corticosteroids (79% resposne rate)
• -Anti-rH (D) immunoglobulin (82% reesponse reate)

If the child displays 2 or more of the following symptoms there is enough evidence from case series that there will be a clinically signficant lesion found on EGD:

• -Vomiting
• -Drooling
• -Stridor
• -Presence of Oropharyngeal Burns

That being said, many clinicians would elect for EGD and assessment of airway with stridor alone. Do not be fooled into thinking if you see no oral lesions that there is no way the child ingested the caustic. Each case series showed a lack of correlation of physical exam findings to EGD findings.

The main side effect of ondansetron in this setting appears to be an increased frequency of diarrhea after administration (Emerg Med J, 11/09, pg 785).

Diagnosis is clinical - labs and XRays will not help you, unless you want to rule out a specific alternate diagnosis. It's all about the H&P.

Supportive care, including bulb suction of secretions, placing the child in a position of comfort, and possibly providing humidified air, is the mainstay of treatment.

Ribavirin, corticosteroids, and antibiotics are not indicated. Don't use them.

Bronchodilators have no benefit in bronchiolitis alone, and non-response to bronchodilators supports the diagnosis of bronchiolitis. If a trial does work, know what you are treating - some children with bronchiolitis may have an underlying component of reactive airway disease, and should be treated accordingly.

Before disposition be sure that the child can tolerate PO.

A fussy, tachypneic child may require admission for IV hydration if they are unable to tolerate feeds - recall that infants are obligate nose breathers.

Beware the RSV bronchiolitis bounceback - the peak incidence of respiratory failure in RSV bronchiolitis is after 3-4 days of illness, when most children should be improving.

• Jaundice appearing during the second to third day of life is most likely physiologic and will dissipate by the fifth or sixth day
• (EM Clin NA;25:1117) .

In general, when a foreign body lodges in the esophagus, it occurs in the upper esophagus in pediatric patients and the lower esophagus in adults.

In particular, in children, they most commonly lodge at the cricopharyngeal narrowing at the level of C6.

Less common areas for entrapment in the pediatric esophagus include: the thoracic inlet (T1); the aortic arch (T4); the tracheal bifurcation (T6); and the hiatal narrowing (T10-11).

1. Girls > Boys, but boys may be older at presentation - don't forget 15 year old boys and SCFE.

2. An early radiographic finding may only be physis widening, so consider comparison films - the ice cream may only be levatating, but not falling off.

3. 23% of these children present with knee pain - think before diagnosing an obese 15 yearold boy with a knee sprain from football. *bonus* Recall that this injury is non weight-bearing.

• 1) Excessive, unexplained paroxysms of crying in an otherwise well-nourished normal infant
• 2) Lasts >3 hours/day, and occurs >3 days/week...ughh!
• 3) Usually occurs at the same time of the day or evening
• 4) Usually resistant to most attempts to quell itinfant may have excess flatus and draw legs up during episodes (but don't change formulas)
• 5) Begins in first week of life and ends by 4 months of age

• 1. NEC is an inflammatory lesion of bowel which can progress to intestinal gangrene, with perforation, and /or peritonitis
• 2. Characterized by abdominal distension, feeding difficulties, and GI bleeding
• 3. Mainly affects pre-term infants, and most commonly affects distal ileum and proximal colon
• 4. Usually presents during the first 2 weeks of life, but may occur up to 3 months of age in infants who who born weighing <1000grams
• 5. Classic finding on abdominal XR is pneumatosis intestinalis or air in the bowel wall (pathognomonic) and is present 50-75% of the time
• 6. Treat emergently with nasogastric decompression, IVF recussitation, NPO, and IV antibiotics

The increase in circulating prostaglandins - one of the metabolic derangements associated with DKA - is felt to be the cause of the nausea, vomiting, and abdominal pain

(JEM, Vol. 39, pg. 449).