Pediatrics – Page 5 – Emergency Medicine Literature of Note

Not So Fast on Race-Related Oligoanalgesia

This recent study regarding pain control received a lot of press, covered by both Reuters and NBC News. The general gist of the breathless coverage seems to indict physicians for latent biases against treating African American children with opiates.

I’m not so certain.

This is a retrospective evaluation of a national Emergency Department database of seven years of ED visits for appendicitis, looking at pain control disparity between white children and minorities. Pain management was documented in only 57% of children, 41% of which was opiates. Children of African American descent received opiate medication only 12% of the time, leading to the authors’ observations of an apparent reluctance to treat this population with opiates.

But, I think the foundation of their analysis may be misleading. The authors state: “The following covariates were included in our analyses to adjust for potential confounding: ethnicity, age, sex, insurance status, triage acuity level, pain score, geographic region, ED type, and survey year.” However, I think these data need to be addressed at a within-hospital level, not as a pooled cohort. African Americans have been previously shown to be over-represented at low-quality, safety-net hospitals – the sort of hospitals almost assuredly do a poor job of addressing and managing pain across all their patients. Indeed, when other researchers have looked at racial disparities in care for acute myocardial infarction, performing within-hospital analyses dramatically altered their findings, with individual hospital inadequacies accounting for a greater effect than ethnicity.

The foundational issues in race-related difference in care may yet be present, but I do not believe to the magnitude these data reflect. Rather than suggesting “there may be a higher threshold of pain score for administering analgesia to black patients with appendicitis,” these data probably reflect the underlying under-resourced care available to this population. A tremendous and embarrassing problem, to be sure, but with a different approach needed for a solution.

“Racial Disparities in Pain Management of Children With Appendicitis in Emergency Departments”
http://archpedi.jamanetwork.com/article.aspx?articleid=2441797

Soothing Songs and the CT Scanner

Yes, this is a trial of music therapy. In the Emergency Department. What fun!

This is a convenience sample of 62 children up to three years of age being referred for head CT after minor trauma, randomized to either soothing music or none. Children were assessed for calmness by a visual analog scale of anxiety and a Modified Ramsay Sedation Scale before transport to CT. Then, music was either present or absent while the child was being positioned on the scanner. A second assessment of anxiety was then performed prior to CT.

The good news, as reported by the authors:

In conclusion, measured on a VAS, there was a significant decrease in agitation in children undergoing a head CT when children’s songs with integrated heart beat sounds were played before and during the procedure.

Unfortunately for their comparison, the control group was quite calm to start – with little room to improve – while the experimental group was fussier at baseline. And, even though the CT introduced some agitation into the control group, nearly identical numbers of patients in each group successfully completed their imaging. So, even though I think their intervention has value, the reliability of their conclusion is probably threatened by the chance baseline differences between groups.

But, it otherwise makes sense – and, it’s harmless, zero-cost intervention – so, why not?

“Randomized single-blinded clinical trial on effects of nursery songs for infants and young children’s anxiety before and during head computed tomography”
http://www.ncbi.nlm.nih.gov/pubmed/26314215

Clinicians or Statistics for Pediatric Abdominal Injury

PECARN is a wonderful thing. Any individual pediatric facility sees a handful of children. A handful, however, multiplied by 20, becomes potentially practice-changing.

And, this is an article further exploring the PECARN pediatric abdominal trauma prediction instrument, comparing its utility to typical clinician judgment. As part of the initial derivation study, the surveyors asked each clinician to rate the likelihood of intra-abdominal injury, stratified <1%, 1-5%, 6-10%, 11-50%, or >50%. Turns out, clinician judgement wasn’t too bad.

Of 9,252 children with <1% chance of injury requiring intervention, 35 (0.4%) had injuries identified.
Of 1,793 between 1-5% chance, 40 (2.2%).
Of 506 between 6-10% chance, 33 (6.5%).
Of 281 between 11-50% chance, 59 (21.0%).
Of 81 greater 50% chance, 36 (41.4%).

The problem with these data? 5,318 CTs were performed to identify 203 significant injuries, including 3,016 in those with <1% chance.

The prediction rule was both better and worse. It was more sensitive than clinician judgment, but also less specific. For an endeavor attempting to decrease CT utilization in children, it’s still not quite clear where this fits in – and whether using it in a fashion similar to PERC or D-dimer wouldn’t necessarily increase imaging. It may, as these authors discuss, have more value in Emergency Departments without the same level of comfort managing traumatically injured children, as it may yet in face reduce imaging in that context.

“Comparison of Clinician Suspicion Versus a Clinical Prediction Rule in Identifying Children at Risk for Intra-abdominal Injuries After Blunt Torso Trauma”

http://www.ncbi.nlm.nih.gov/pubmed/26302354

When Anaphylaxis Makes a Comeback

The frequency of biphasic anaphylaxis is a subject of some controversy, with most estimates derived from retrospective chart review. The frequency may be as high as 20%, as low as 3%, or those may yet be gross overestimations based on partial symptom recurrence.

For these folks, the answer was: 14.7%.

This is yet another evaluation of Emergency Department visits for anaphylaxis, as collected by retrospective chart review. Looking at one year’s worth of data collected at two pediatric hospitals in Canada, these authors identified 484 visits for anaphylaxis with adequate data for analysis. Of these visits, 71 met their criteria for a biphasic reaction: a period of full symptom resolution lasting at least an hour, followed by recurrence of symptoms requiring additional pharmacologic intervention. They subsequently reviewed features of the initial reaction to determine any potential predictors of biphasic manifestations.

Some of their features make sense, and some – none. Independent predictors included delayed ED presentation, wide pulse pressure, multiple doses of epinephrine to treat the initial episode, and administration of beta-agonists in the initial episode. Essentially, those patients with the most severe, multi-system involvement. However, their strongest odds ratio for predicting return of symptoms was for patients simply aged 6-9 years of age – and the authors do not address the aberration in their discussion.

So, ultimately, this study doesn’t reliably alter our management. Chances are, you’ve already been observing the mildest anaphylaxis for the shortest time, and the most severely ill for longer. Thus, as seen in this cohort, most of these severely ill patients were still undergoing observation in the ED when the biphasic reaction occurred – 3 to 6.5 hours later. All told, 18 patients were discharged from the ED and returned with biphasic symptoms – with a median time of 18.5 hours to return. So, unfortunately, there’s no reasonably useful clinical endpoint to observation that would catch all revisits – and the best course of action is simply to ensure patients have epinephrine for home use at discharge, and inform them of the small likelihood of recurrence.

“Epidemiology and clinical predictors of biphasic reactions in children with anaphylaxis”
http://www.ncbi.nlm.nih.gov/pubmed/26112147

Let’s Poison Our Kids With E-Cigarettes

The hazards of the natural world are not an issue for those of us born into “civilization”. Without lions, tigers, bears, and dingoes to endanger our babies, we’ve had to become more creative. Firearms in the home, detergent packets, and, now: highly concentrated nicotine from e-cigarettes. This short review provides a brief look at an increasingly prevalent health hazard.

The lethal dose of nicotine is approximately 1 mg/kg. Concentrations of liquid nicotine cartridges may be as high as 35 mg/mL. A typical 10 mL refill bottle, then, has easily a lethal dose for children, while a 50 mL bottle could have more than enough to bring down a horse. For comparison, a conventional cigarette contains 10 to 1 5mg of nicotine – certainly a danger, but on a different scale entirely.

The expected clinical effects are consistent with the classical nicotinic and muscarinic toxodromes – vomiting, diarrhea, salivation, bronchorrhea, seizures, rhabdomyolysis, and respiratory failure. Therapeutic management remains supportive – intravenous fluids, atropine, and mechanical ventilation as needed. Inadvertent exposures are typical, but liquid nicotine may also be used for intentional overdose in suicide attempts.

Another proud cultural innovation for the 21st century.

“Liquid Nicotine Toxicity”
http://www.ncbi.nlm.nih.gov/pubmed/26148101

The Utility of Urinalysis in Young Infants

When faced with the diagnostic evaluation of the young, febrile infant fewer than three months of age, the definitive tool for sepsis from urinary tract infection has traditionally been urine culture. This stems from uncertainty over the adequacy of urinalysis sensitivity for serious bacterial infection, i.e., those truly bacteremic from a urinary source.

This is an analysis of a multicenter database of infants with bacteremia and urinary tract infection, as measured by isolation of the same pathologic organism from both blood and urine. The key numbers:

Trace or greater leukocyte esterase: 97.6% (94.5-99.2) sensitive and 93.9% (87.9-97.5) specific.
Pyuria, >3 WBC/HPF: 96% (92.5-98.1) sensitive and 91.3% (84.6-95.6) specific.
Pyuria or any LE: 99.5% (98.5-100) sensitive and 87.8% (80.4-93.2) specific.

These are pretty impressive statistics, and differ significantly from the prior supposed sensitivity of the UA in young infants. These authors postulate the problem with prior study has been its over-reliance on urine culture, and the resulting false positives. If this seems a reasonable interpretation of the evidence, it has substantial ramifications for the diagnostic evaluation of young infants. Importantly, it has the potential for obviating invasive procedures and unnecessary over-treatment.

I would like to see independent confirmation of these authors’ findings, but, considering this study required 15 years to produce the 276 patients analyzed in this paper, this may be the best evidence we see for awhile.

“Diagnostic Accuracy of the Urinalysis for Urinary Tract Infection in Infants, 3 Months of Age”
http://www.ncbi.nlm.nih.gov/pubmed/26009628

Chillin’ Children After OHCA

Once upon a time, many adults suffering an out-of-hospital cardiac arrest received therapeutic hypothermia with a target temperature of 33°C. Then, along came the Targeted Temeperature Managment trial – in which 36°C seemed to be just as good as 33°C. Now, just to throw another confounder in the mix, we have a trial comparing 33°C to “therapeutic normothermia” – 36.8°C – and we’re doing it in children to address concerns regarding generalizability from adults.

Very detailed summaries of the numbers, methods, and enrollment can be found on other #FOAMed sites – particularly St. Emlyns and ALiEM. But, the high points:

Many – 1,355 – were screened, but ultimately only 260 were randomized and included in their primary analysis.
Adherence to temperature management protocols was good or adequate in ~90% of cases.
Hypothermia was implemented for 48 hours, followed by normothermia up to 120 hours total to match the normothermia group.
In contrast to adults, the great majority (72%) of this pediatric cohort suffered a respiratory arrest.

The outcome: no statistical difference, with 20% of the hypothermia group alive and functional at 1 year, compared with 12% of the normothermia group, a p-value of 0.14. Regarding safety, arrhythmias and culture-proven infections favored the normothermia group, 1% vs. 5%, and 39% vs. 46%, but these also did not reach statistical significance. Finally, both 28-day and 1-year mortality favored hypothermia, with an absolute difference of ~10% in each, but this was not statistically significant, either.

I will let the authors speak for me here:

“One important potential limitation of the trial is that, on the basis of the observed confidence limits for treatment differences, a potentially important clinical benefit cannot be ruled out despite the lack of a significant difference in the primary outcome measure. A larger trial might have detected or rejected a smaller intervention effect. Indeed, there was a significant difference in survival time with therapeutic hypothermia, although this was a secondary outcome measure.”

The relative likelihood of benefit for hypothermia in this trial was 1.54, with a 95% CI of 0.86 to 2.76. Now, this result crosses 1, and therefore requires interpretation in two contexts. The first is the normal distribution:

In which we visualize the frequency of potential outcomes, and the important realization the more frequent “true” outcome is most likely to occur near the center of the 95% CI range.

And, the more important context:

In which we interpret these data in the context of prior results, generalized from other settings. In this case, our prevailing opinion is one in which we suspect hypothermia – with much uncertainty regarding the details – is beneficial. As you can see, the effects of even “statistically significant” findings have only limited practical impact on the “good bet” or the “long shot”. Hence, the results of this study – which simply barely fail to reject the null hypothesis – do not hardly move the needle against the prevailing opinion.

I tend to side with the authors of this “negative” study: it is mostly likely underpowered to detect the expected benefit, and it is still reasonable to cool children following OHCA. There are many questions that remain regarding the temperature, duration, and other details – not limited only to children – but it would be erroneous to say this trial refutes the practice of hypothermia in children.

“Therapeutic Hypothermia after Out-of-Hospital Cardiac Arrest in Children”
http://www.nejm.org/doi/full/10.1056/NEJMoa1411480

The Very Young Pediatric C-Spine Rarely Needs Radiologic Clearance

It is usually reasonable to exercise an abundance of caution with trauma patients suspected of having cervical spine injuries. However, an abundance of caution sometimes means an abundance of radiation – and the costs and harms associated with such testing can be immense, regardless of technical difficulty in a young pediatric population.

This is a retrospective evaluation of 2,972 trauma patients aged less than 5 years, reviewing specifically the overall incidence of diagnosed cervical spine injury. In this 12 year cohort, a grand total of 22 had confirmed CSI. Most importantly, however, nearly all cases of CSI were associated with other serious injuries – a cohort with a median ISS of 33. Twelve of 22 arrived intubated, 13 were in extremis, and overall mortality was 50%. All evaluable patients had either neurologic deficits, severe neck pain, or were unable to range their neck.

These authors do not further describe their cohort for evaluation with regard to developing a predictive instrument for cervical spine injury, but these data do support a very reasonable conclusion regarding the rarity of pediatric injuries – and the near impossibility of isolated cervical spine injuries. I tend to agree with the authors’ stated management strategy for such patients:

“Pediatric patients with abnormal neurologic examination result, decreased mental status, neck pain, or torticollis are evaluated with cervical spine CT; however if the child is asymptomatic defined by a normal neurologic examination result, appropriate mental status, with absence of neck pain or torticollis, our first step is to remove the cervical collar. We examine the patient for cervical tenderness if they are able to communicate and observe the child for normal range of motion of the neck. In preverbal patients, we simply observe neck range of motion with the collar removed. If the child seems to move his or her neck without discomfort and full range of motion, then we do not pursue any further radiologic evaluation.”

“Absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger”
http://www.ncbi.nlm.nih.gov/pubmed/25909413

Bronchiolitis, Simplified

There are new guidelines from the American Academy of Pediatrics, just in time for the 2014-15 bronchiolitis season looming on the horizon – as if we don’t have enough to worry about with influenza and various West African hemorrhagic fevers.

But, the good news – these guidelines substantially reduce the things you have to remember to do for bronchiolitis. Specifically, the only evidence-supported intervention you have is: supportive care.

Ineffective, or of inadequate risk/benefit, treatments:

A trial of bronchodilators, such as albuterol or salbutamol.
Nebulized epinephrine.
Nebulized hypertonic saline, except possibly those requiring hospitalization.
Systemic or inhaled corticosteroids.
Chest physiotherapy.

… which basically covers everything.

And, not inconsistent with a recent trial regarding the misleading clinical weight of pulse oximetry, the guidelines state it is reasonable not to perform continuous oximetry on infants and children with bronchiolitis, and set 90% as an acceptable oxygen saturation. Finally, the authors also state routine chest radiography should be avoided, as abnormalities are common in bronchiolitis – thus leading to ineffective, and harmful, antibiotic administration.

Simply put – do no harm!

“Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis”
http://pediatrics.aappublications.org/content/early/2014/10/21/peds.2014-2742.full.pdf+html

Laundry Detergent is Delicious Candy

Children, rumor has it, are curious, persistent, and nefarious creatures. Furthermore, the entire natural environment must first be tasted. Thus, age-old cautionary guidance regarding home safety for children to prevent exposure to potentially hazardous materials.

So, naturally, laundry detergent would be kept safely out of reach of children – particularly the pre-packaged pod systems, which are candy-like and perfect for oral consumption – correct?

Nope!

According to this data from the National Poison Data System, in just a single year, there were 17,230 calls for pediatric exposure to laundry detergent pods in just two years, between January 2012 and December 2013. The majority – 79.7% of cases – were secondary to ingestion. 4.4% of patients with an ingestion were judged to necessitate hospitalization, including 102 requiring intubation. One death was reported – but the autopsy showed intracranial bleeding of uncertain/unlikely relation to the ingestion of detergent.

The authors specifically call out Procter & Gamble, maker of Tide Pods, for failure to place adequate warning labels or safety latches on their packaging – although, frankly, the ultimate responsibility lay with parents. Keep cleaning supplies safely out of reach!

“Pediatric Exposure to Laundry Detergent Pods”
http://pediatrics.aappublications.org/content/early/2014/11/05/peds.2014-0057.abstract