Category: Pediatrics

That Lego is Gone

Lego, a portmanteau of Danish words meaning “play well”, are ubiquitous toys around the world. This means the bite-sized bits are equally prevalent in the hands of infants and toddlers around the world – and in their mouths. What goes in a toddler’s mouth goes into their stomach.

This brief study evaluates six toddlers – ahem, pediatricians – who each swallowed a Lego head:

These adult children subsequently searched stools for signs of the swallowed item, as well as performed an assessment of stool consistency. Most importantly, they were able to derive infantile acronyms for their assessments – the SHAT and FART scores.

One of the six participants was never able to locate the ingested Lego part, despite two weeks of stool searching. The other five found them in their second or third bowel movement, which, on average, was 1.71 days later.  Stool consistency was unrelated to passage of the head.

Obviously, the generalizability and reliability of such a study is quite low, being adults and only six of them. Then, although these authors report “no complications”, they have not yet located one of the six heads – perhaps a future case report: “Acute appendicitis involving an unusual appendicolith”?  At the least, a potential future IgNobel prize awardee.

“Everything is awesome: Don’t forget the Lego”
https://onlinelibrary.wiley.com/doi/full/10.1111/jpc.14309

I Choose You! Observation, I Hope.

We’re back with another patient-oriented clinical decision aid from the folks who brought you Chest Pain Choice – Pediatric Head CT Choice! In this episode, our noble heroes are out to educate parents regarding the risk of intracranial injury in children who are at “intermediate risk” for clinically-important traumatic brain injury by PECARN criteria.

In this multicenter, cluster-randomized, controlled-trial, these authors tested an information graphic and educational tool against usual care, with a primary outcome of parental knowledge. Additional measures of engagement in the decision-making processes, decisional conflict, and parental trust were measured as secondary outcomes related to the cognitive aspects, along with patient-oriented outcomes such as ciTBI and imaging utilization. They included 172 clinicians at 7 sites, and enrolled 971 patients, including 516 patients who consented for recording of their discussion regarding imaging. Follow-up by telephone was obtained in 890 (92%) of patients, with the remainder of outcomes assessment limited to electronic health record and vital records follow-up.

The results are mostly good news regarding the decision aid. Parents in the intervention arm could answer 6 of 10 questions about their choice correctly, compared with 5 of 10 receiving usual care. Secondary cognitive outcomes also favored the decision instrument, and physicians surveyed were generally in favor of the decision aid, as well. Imaging at the index visit was similar between the two groups, but downstream healthcare resource use and subsequent imaging was lower in the decision aid cohort.

There are findings here to critique, of course. There was only one ciTBI in the entire cohort, and they were imaged at the index visit. The expectation – and the tool – were constructed based on a 0.9% ciTBI rate, when the actual observed incidence was 0.1%. It is reasonable to consider the practical implementation of PECARN over-classifies patients into the “intermediate risk” cohort, placing additional children at risk for unneeded imaging – which, in turn, renders their “1 in 100” information graphic misleading. Then, clinicians spent an extra 2 minutes – 38% longer – with parents when using the decision aid. How much of the improved knowledge and trust stems from the decision aid, and how much from simply spending more time in the discussion? Finally, there are uncertain manifestations of the Hawthorne effect, particularly considering over half the encounters were recorded.

Overall, however, I have few quibbles with this decision aid. At the least, it is unlikely to exert a negative effect on parental knowledge or paradoxically increase unnecessary scanning.

“Effect of the Head Computed Tomography Choice Decision Aid in Parents of Children With Minor Head Trauma”
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2703135

More Snapshots of Awful Antibiotic Use

Is there ever any good news these days? Geopolitical disasters, unwarranted pharmaceutical price increases – and physicians can’t even manage to get the evaluation for group A strep right.

This is a “successful” quality improvement paper wrapped around depressing and embarrassing data from a typical primary care pediatrics practice. These authors, primarily pediatric infectious disease specialists, were dismayed by the rate of guideline-non-compliant group A streptococcal testing and treatment in their group.

How bad?

The base rate of unnecessary GAS testing was 64% of all rapid strep tests performed. The base rate of inappropriate antibiotic prescribing – driven primarily by treating positive results in those who should never have been tested (e.g., likely non-pathogenic colonization) – was 49%.

After their multifaceted year-long intervention, they were able to achieve the amazing results of: 40% unnecessary testing … and the same, inappropriate 49% for antibiotic prescribing. When restricted to selection of antibiotic, at least, first-line antibiotics used 87% of the time.

Is this really the best we can possibly do, even after intent focus on practice improvement? And for a disease entitiy with such limited benefit for antibiotic in most modern settings?

“Improving Guideline-Based Streptococcal Pharyngitis Testing: A Quality Improvement Initiative”
http://pediatrics.aappublications.org/content/early/2018/06/18/peds.2017-2033

The Rate of Resuscitation in Pediatric DKA

A few children experience cognitive impairment and cerebral edema following the resuscitation phase of diabetic ketoacidosis. For many years, there has been suspicion the rapid volume replacement with isotonic crystalloids precipitated cerebral edema, leading to protocols requiring conservative rates of fluid administration.

Probably unnecessarily so.

This 2×2 randomized trial tested “fast” versus “slow” fluid resuscitation, as well as isotonic 0.9% saline versus 0.45% saline. “Fast” resuscitation repleted a 10% body weight fluid deficit with half of the fluid in the first 12 hours, while the “slow” resuscitation repleted a 5% fluid deficit at a steady rate over 48 hours. A little more than three hundred patients were included in each arm, with the primary outcome being a decline in mental status as measured by the Glasgow Coma Score. Persistent cognitive impairment, “clinically apparent brain injury”, and other adverse events were tracked as secondary outcomes.

Effectively, there is no discernable difference in outcomes between the four groups. Deterioration of mental status and clinically apparent brain injury were rare – occurring, essentially, around the expected 0.5-1.0% rate regardless of resuscitation speed or fluid selection. Serious adverse events were uncommon and similar across groups, without reliable signals of inferiority to any specific resuscitation strategy.

Whatever you’ve been doing these last few years, at least, hasn’t been “wrong”. Unfortunately, having failed to identify this as a preventable trigger for cerebral injury in DKA, the search for its cause must go on.

“Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis”
https://www.nejm.org/doi/full/10.1056/NEJMoa1716816

Snacking Before Bedtime

How long before a procedural sedation is fasting required? You know, of course, the American Society of Anesthesiologists guidelines specify: a mini- mum fasting period of 2 hours for clear liquids, 4 hours for breast milk, 6 hours for infant formula and light meals, and 8 hours for solids containing meat or fatty foods.

Of course, anecdotally – if anecdotally means hundreds of thousands of safe sedations – Emergency Physicians have known these restrictions are nonsense.

But, guidelines are best written off published evidence – so, we have a pre-planned analysis of the relationship between fasting time and vomiting from a Canadian cohort study of pediatric sedation. With 6,295 sedations included in their analysis, almost half of whom did not meet solids fasting guidelines, these authors found no relationship between fasting time and vomiting. There were, even, only six instances of intra-procedure vomiting, and fasting duration ranged from 1.7 hours to 17.5 hours – but they all received ketamine. None of the intra-procedure, or ~300 peri-procedural episodes of vomiting, resulted in pulmonary aspiration. No relationship was found between fasting time and any other type of adverse event, either.

So, another useful piece of literature to wave around in committee meetings – both to eliminate any fasting restrictions, and, again, to help demonstrate the safety of EP-performed procedural sedation.

“Association of Preprocedural Fasting With Outcomes of Emergency Department Sedation in Children”
https://jamanetwork.com/journals/jamapediatrics/article-abstract/2680050

The Penicillin Allergy Lie

This is a short follow-up study that touches upon a ubiquitous subject of which we’re mostly familiar – most patients with a stated allergy to penicillin do not actually have a true, IgE-mediated reaction. In the original study, these authors performed a standard 3-tier allergy testing on 100 patients with “low-risk” reported allergy symptoms, all of whom tested negative and ultimately passed a 500mg amoxicillin challenge dose.  Now, in this study, these authors re-contacted the patients and the primary care physicians to determine the downstream communication, effects of the allergy testing notification, and any adverse events related to prescribing after removal of the allergy from the patient’s chart.

Without going into much detail, there was a huge disconnect – most parents reported relaying the information, most physicians reported no information was relayed, and about half the patients had the allergy still listed in their chart. Regardless, 26 patients filled at least one prescription for a pencillin-derivative medication within the year, and one child developed a rash attributed to the amoxicillin.

The authors use this narrow experience to estimate cost savings attributed to using penicillin derivatives versus cephalosporins or clindamycin, and determine their allergy testing resulted in $1,368.13 in savings. Across the 6,700 reported penicillin allergies annually in their ED, they estimate accurate allergy information and delabeling could save nearly $200k each year.

This hardly represents all the benefits of delabeling, as the antibiotics avoided are also typically broader-spectrum, with greater contributions to antibiotic resistance. Clearly, a simpler, accepted pathway to expedite penicillin allergy delabeling would be of great value.

“Antibiotic Use After Removal of Penicillin Allergy Label”

http://pediatrics.aappublications.org/content/early/2018/04/18/peds.2017-3466

Don’t Give NEXUS II Much Thought For Kids

Into the the world of PECARN, CHALICE, and CATCH, we add NEXUS II. Why? Good question.

This is a planned secondary analysis of the NEXUS Head CT decision instrument among enrolled patients less than 18 years of age. Like most decision instruments, this rule classifies patients into “high risk” or “low risk”, with “low risk” being free of any mandated imaging. Their rule, which I will not recount, was tested in 1,018 blunt head trauma patients, and their rule picked up all 27 of those who required neurosurgical intervention. Unfortunately, it also only classified 330 patients as “low-risk” – for an abysmal 33% specificity.

The authors state it may yet have value, despite this poor specificity, as a one-way decision rule. Unfortunately, one-way decision rules are fraught with peril, as the inability to classify a patient as “low risk” is difficult to ignore.  This leads clinicians to ultimately use the one-way instrument as a two-way, despite the bleak positive predictive value. This rule also missed one of 49 patients with “significant intracranial injuries”, meaning it is reasonable to expect it may not actually be 100% sensitive.  Considering clinical judgement is vastly superior to this product, and there are enough alternative options, it is reasonable not to give this product another thought.

“Validation of the Pediatric NEXUS II Head CT Decision Instrument for Selective Imaging of Pediatric Patients with Blunt Head Trauma”
https://www.ncbi.nlm.nih.gov/pubmed/29665151

The Elephant in the PECARN/CHALICE/CATCH Room

A few months ago, I wrote about the main publication from this study group – a publication in The Lancet detailing a robust performance comparison between the major pediatric head injury decision instruments. Reading between the lines, as I mentioned then, it seemed as though the important unaddressed result was how well physician judgment performed – only 8.3% of the entire cohort underwent CT.

This, then, is the follow-up publication in Annals of Emergency Medicine focusing on the superiority of physician judgment. Just to recap, this study assessed 18,913 patients assessed to have had a mild head injury. Of these, 160 had a clinically important traumatic brain injury and 24 underwent neurosurgery. The diagnostic performance of these decision instruments is better detailed in the other article but, briefly, for ciTBI:

  • PECARN – ~99% sensitive, 52 to 59.1% specific
  • CHALICE – 92.5% sensitive, 78.6% specific
  • CATCH – 92.5% sensitive, 70.4% specific

These rules, given their specificity, would commit patients to CT scan rates of 20-30% in the case of CHALICE and CATCH, and then an observation or CT rate of ~40% for PECARN. But how did physician judgment perform?

  • Physicians – 98.8% sensitive, 92.4% specific

Which is to say, physicians missed two injuries – each detected a week later in follow-up for persistent headaches – but only performed CTs in 8.3% of the population. As I highlighted in this past month’s ACEPNow, clinical decision instruments are frequently placed on a pedestal based on their own performance characteristics in a vacuum, and rarely compared with clinician judgment – and, frequently, clinician judgment is as good or better. It’s fair to say these head injury decision instruments, depending on the prevalence of injury and the background level of advance imaging, may actually be of little value.

“Accuracy of Clinician Practice Compared With Three Head Injury Decision Rules in Children: A Prospective Cohort Study”
http://www.annemergmed.com/article/S0196-0644(18)30028-3/fulltext

When Seizures Return

This one isn’t precisely hot-off-the press, but, in having just discovered it, it’s hot to me!

This study aims to inform the guidance we provide to families after a child presents with a first-time, unprovoked seizure. Interestingly enough, the data for this analysis is dredged back up from a prospective cohort study from 2005 to 2007, in which patients with first-time seizures were being evaluated for abnormal neuroimaging. However, following discharge from the hospital or Emergency Department, patients also received short- and long-term telephone follow-up.

There were 475 patients enrolled in the original study, and differing numbers were appropriate for inclusion at their various timeframes of follow-up, depending on whether anti-epileptic therapy was started, or whether follow-up could be obtained. All told, seizure recurrence rates were:

  • 48 hours – 21/38 (5.4%)
  • 14 days – 51/359 (14.2%)
  • 4 months – 102/335 (30.4%)

These are extremely non-trivial numbers, and they surprised me. Risk facotrs associated with increased seizure incidence were recurrent seizures at initial presentation, younger age (<3 years), and presence of focal neurologic findings on initial examination. Regardless, however, even absent any of these predictors, the incidence of subsequent seizure is certainly high enough parents should be counseled they ought arrange for prompt neurology evaluation in follow-up.

“Early Recurrence of First Unprovoked Seizures in Children”

https://www.ncbi.nlm.nih.gov/pubmed/29105207

Is the Urinalysis Reliable in Young Infants?

The evaluation of the very young infant with a fever is complex, with multiple competing factors including the rarity of serious illness, the severity of serious illness, and the cost of the intensive evaluation frequently required. The most commonly identified bacterial source for fever is a urinary tract infection, and our bedside test in the Emergency Department is the urinalysis.

So, how reliable and accurate is that test?

This is an analysis of prospectively collected data from the PECARN network, looking at the evaluation of febrile infants fewer than 60 days of age. Of 4,147 patients enrolled, 289 patients had UTIs by a 50,000 CFUs/mL definition on the subsequent urine culture. Only 27 patients had bacteremia and a UTI. The news is generally mixed: using the 50,000 CFUs/mL cut-off, any abnormality on the UA was 94% sensitive for UTI and 91% specific, but was 100% sensitive for a UTI associated with bacteremia.

The authors also do analyses including different cut-offs for UTI based down to 10,000 CFUs/mL and, as you might expect, the sensitivity for any UTI diminishes. While the interpretation of the urine culture result is less applicable to the initial Emergency Department evaluation, the subsequent threshold for diagnosis is relevant to the ongoing follow-up care for the febrile infant, particularly if an initial decision involved observation without antibiotics and the infant remains symptomatic without another source.

Overall, it is reasonable to suggest – if the UA is negative, a serious bacterial illness is unlikely to be present. Some consideration should be made to the duration of illness, and natural course of delayed onset of development of cystitis or pyuria in the urine. A positive UA, however, despite the apparent high specificity, does not reliably indicate a true positive for UTI, owing to the low prevalence. This should also be taken into consideration regarding whether additional invasive evaluation is indicated.

“Accuracy of the Urinalysis for Urinary Tract Infections in Febrile Infants 60 Days and Younger”
http://pediatrics.aappublications.org/content/early/2018/01/12/peds.2017-3068