Category: Pediatrics

Stepping Up to Choosing Wisely

ACEP recently published their own “Choosing Wisely” campaign contribution – a list of five changes to Emergency Medicine practice that ought be encouraged in the interests of increasing cost-effective care.  While most would agree the ACEP version is reasonable, I think many clinicians hoped for something a little more earth-shattering.

Something like the Pediatric Hospital Medicine list for Choosing Wisely.

These authors specifically looked at the top 10 inpatient diagnoses in terms of volume and aggregate costs, and specifically evaluated components of treatment as candidates for recommendations.  And, even speaking as someone who makes an effort to minimize testing – I find these recommendations take an impressive step in terms of aggressive reduction in resource utilization.

The highlights:
Do not order chest radiographs in children with asthma or bronchiolitis.
Do not use bronchodilators in children with bronchiolitis.
Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection.

How often do you get radiographs in patients with respiratory disease – that get discharged?  How about admitted?  The authors estimate 60% of admitted patients receive radiographs, with fewer than 2% affecting clinical management.

Or, routine bronchodilator therapy – which, frankly, is ordered for a lot of children simply due to a sense we ought to do something.  Both beta-agonist and racemic epinephrine fall under this recommendation, as they’ve not been shown to confer any reliable, clinically meaningful, patient-oriented outcome in bronchiolitis.

Finally – corticosteroids.  Young children, even with albuterol-responsive wheezing, showed no benefit when corticosteroids were added.  These are not harmless interventions, particularly for growing infants, and seems to pre-dispose some folks to subsequent readmission.

With pediatric respiratory season on the horizon, I challenge all of you to use this document as a tool share with colleagues and consultants to decrease unnecessary testing and therapy.

“Choosing Wisely in Pediatric Hospital Medicine: Five Opportunities for Improved Healthcare Value”
http://www.ncbi.nlm.nih.gov/pubmed/23955837

It’s Silly Season on Flu

We still don’t know whether neuraminidase inhibitors (e.g., oseltamivir [Tamiflu]) are helpful.  Roche has prevented access to trial data until just this year, and the results of independent review are still pending.  However, that has not stopped plenty of smart, well-meaning folks from taking their claims at face-value and using NAIs to treat influenza.

This is a retrospective registry review of 3 years of children admitted to California ICUs with a laboratory-confirmed diagnosis of influenza.  850 children were identified in the registry, and 784 children had clinical information available for analysis.  Of these, 653 received NAIs and 38 (6%) died.  Of the remaining 131 untreated patients, 11 (8%) died.  Using a multivariate model adjusting for univariate predictors of death, NAI therapy was associated with decreased mortality (OR = 0.36, 95% CI 0.16-0.84).

But, while registry reporting was mandatory for deaths due to influenza, it was only optional for ICU hospitalization – leading to an unknown selection bias in their study cohort.  There were also 23 deaths reported prior to hospitalization for whom no data is available.  Most patients in the study treated with NAIs were H1N1, while the small remainder comes from the post-pandemic period with a mix of H1N1, other influenza As, and influenza B – and therefore may not be generalizable to a non-pandemic influenza season.  A standardized abstraction form was used, but the complete baseline demographics collected are not included in the article; most patients included had significant respiratory comorbidities, and these chronically ill children were far more likely to die regardless of treatment.  In summary, with a small sample size, likely missing data from abstraction, and selection bias underlying their cohort, the multivariate analysis upon which they based their final conclusion is junk.

In contrast to the editor’s summary “What this study adds”, which concludes special emphasis on treatment with NAIs may improve survival, I would revise it to say: “No additional practice-changing evidence”.

Now, I can’t say I’m opposed to treatment of hospitalized influenza patients with NAIs – least of all, those in the ICU.  While outpatient therapy with NAIs for influenza is almost certainly a waste of money, in severe disease, the cost relative to the entire expenditure shrinks rapidly – the threshold for cost-effectiveness is met even if one patient out of a hundred has a one day reduction in ICU length-of-stay.  But, it’s inappropriate to over-sell the meaning in this data to suggest any certainty NAIs are helpful.

“Neuraminidase Inhibitors for Critically Ill Children With Influenza”
http://www.ncbi.nlm.nih.gov/pubmed/24276847

Another Taste of the Future

Putting my Emergency Informatics hat back on for a day, I’d like to highlight another piece of work that brings us, yet again, another step closer to being replaced by computers.

Or, at the minimum, being highly augmented by computers.

There are multitudinous clinical decision instruments available to supplement physician decision-making.  However, the general unifying element of most instruments is the necessary requirement of physician input.  This interruption of clinical flow reduces acceptability of use, and impedes knowledge translation through the use of these tools.

However, since most clinicians are utilizing Electronic Health Records, we’re already entering the information required for most decision instruments into the patient record.  Usually, this is a combination of structured (click click click) and unstructured (type type type) data.  Structured data is easy for clinical calculators to work with, but has none of the richness communicated by freely typed narrative.  Therefore, clinicians much prefer to utilize typed narrative, at the expense of EHR data quality.

This small experiment out of Cincinnati implemented a natural-language processing and machine-learning automated method to collect information from the EHR.  Structured and unstructured data from 2,100 pediatric patients with abdominal pain were analyzed to extract the elements to calculate the Pediatric Appendicitis Score.  Appropriateness of the Pediatric Appendicitis Score aside, their method performed reasonably well.  It picked up about 87% of the elements of the Score from the record, and was correct when doing so about 86%, as well.  However, this was performed retrospectively – and the authors state this processing would still be substantially delayed by hours following the initial encounter.

So, we’re not quite yet at the point where a parallel process monitors system input and provides real-time diagnostic guidance – but, clearly, this is a window into the future.  The theory:  if an automated process could extract the data required to calculate the score, physicians might be more likely to integrate the score into their practice – and thusly lead to higher quality care through more accurate risk-stratification.

I, for one, welcome our new computer overlords.

“Developing and evaluating an automated appendicitis risk stratification algorithm for pediatric patients in the emergency department”

Language Barriers as Overdose Risk

This is a simple study, but demonstrates an incredibly important risk – the effect on language barriers on subsequent prescription dosing errors.

These authors followed up English-speaking and Spanish-speaking parental dyads being prescribed acetaminophen at discharge from the Emergency Department.  The discharge instructions were observed, and, following discharge, the parents were asked to repeat back their understanding of the correct weight-based dose of acetaminophen for their child.

English-speaking parents:  25% dosing errors
Spanish-speaking parents:  54% dosing errors

Firstly, these are both too high – despite a standardized chart given to parents.  Observation of discharged indicated providers only explicitly identified the dose of acetaminophen for parents 37% of the time.

Secondly, it’s clear an extra level of care needs to be taken when language barriers present themselves.  The dosing error risk remained significant whether adjusted for health literacy, income, or preferred language of discharge instructions.

We can, and need, to do better.

“Parental Language and Dosing Errors After Discharge From the Pediatric Emergency Department”
http://www.ncbi.nlm.nih.gov/pubmed/23974717

Observation of Minor TBI Prevents Harms

This study regarding the observation of children following minor traumatic brain injury is a little bit oddly spun by its authors and the medical news.

As we all know, most children presenting to the Emergency Department for minor head trauma do not have a clinically significant injury.  Regardless, a significant portion of these children receive non-therapeutic cranial radiation to further assure parents and clinicians alike.  The PECARN group, a few years back, published a rough decision instrument to help classify ~50% of these patients as “very low risk” (<0.05% risk of TBI) to give clinicians a tool to obviate CT scanning.

This group at Boston Children’s prospectively evaluated clinicians’ use of immediate CT scanning versus delayed CT scanning (observation).  They find, of course, that observing children in the ED for a short period, rather than making an immediate decision regarding CT use, resulted in decreased use of CT.  Thusly, the press releases state “Waiting and Watching Can Reduce Use of Brain Scans for Kids in the Emergency Department“.

But, watching and waiting doesn’t benefit the children in this cohort – other than preventing avoidable harms.  The eight children who had CT scans showing clinically important injuries were easily identified by clinicians as requiring immediate CT.  The period of observation doesn’t change the short-term clinical outcome of any of the patients – it only “treats” the risk-aversion of clinicians and parents.  “Watching and waiting” may reduce scans – but discharging the entire observation cohort immediately would have reduced scans even further, without missed cTBI (although the study is underpowered to truly detect all events down to an appropriate “zero-miss” threshold).

While I agree this is an important clinical problem to address, I simply find an odd discordance between the patient-oriented features and the resource utilization-oriented outcome measured.

“Effect of the Duration of Emergency Department Observation on Computed Tomography Use in Children With Minor Blunt Head Trauma”
www.ncbi.nlm.nih.gov/pubmed/23910481

Dermabond … The Tongue?

In an addition to the pages of possibly brilliant innovations, this is a case report of an attempt to use 2-octyl cyanoacrylate (Dermabond) on the tongue.  The authors document a gaping laceration to the tongue on a pediatric patient – and a family that refused consent for sedation and suture repair.  So, even though Dermabond is not recommended for use on mucosal surfaces – onward!

After extensive drying, the authors document secure and successful closure.  However, at the 24 hour wound check, the glue had begun to detach, requiring removal of the first application and a second treatment.  No further complications were encountered, and a 14-day revisit showed complete resolution of the injury.

I agree with these authors – the tongue is not a trivial repair, particularly in the unruly youth.  The risk is probably minimal – although, the tissue adhesive could be problematic if it comes detached.  The laceration itself is documented in images – and, while it’s possible the still images don’t tell the story, I’m not sure it necessitated any repair at all.

I appreciate the novel use, but it’s unclear if this is a technique worth much enthusiasm in revisiting.

“Pediatric Tongue Laceration Repair Using 2-Octyl Cyanoacrylate (Dermabond)”
www.ncbi.nlm.nih.gov/pubmed/23827167

Bacterial Meningitis in Complex Febrile Seizure

The AAP has guidelines for simple febrile seizure – “There, there, the frightening demonic possession your child just experienced is nothing to worry about.”  Complex febrile seizures, however, are offered far less conclusive guidance.

This little retrospective review from UC San Diego evaluates 193 patients presenting with complex febrile seizure.  Lumbar puncture was performed in 136, and 1 patient ultimately received a diagnosis of bacterial meningitis.  The authors suggest, cognizant of the limitations, that complex febrile seizures need not routinely undergo LP.

This is entirely reasonable and consistent with the prior literature.  The largest retrospective review, from Boston Children’s, identified 3 cases with bacterial meningitis out of 526 children.  A systematic review and meta-analysis identified 41 cases of bacterial meningitis out of 1996 children.  There are additional cases of viral meningitis and encephalitis in these cohorts as well – of uncertain clinical significance – but the general implication is that otherwise well-appearing children ought not need LP absent other signs of CNS infection.

It would, of course, be fabulous if a consensus guidelines would further reinforce this evidence.

“Necessity of Lumbar Puncture in Patients Presenting with New Onset Complex Febrile Seizures”
www.ncbi.nlm.nih.gov/pubmed/23687537

“Yield of lumbar puncture among children who present with their first complex febrile seizure.”
www.ncbi.nlm.nih.gov/pubmed/20566610‎

“Risk of bacterial meningitis in young children with a first seizure in the context of fever: a systematic review and meta-analysis.”
www.ncbi.nlm.nih.gov/pubmed/23383133‎

Negative CTs and Pediatric Abdominal Trauma

I am biased – I helped set the Pediatric Emergency Care Applied Research Network up back as a research assistant peon before medical school – so it always pleases me to report on PECARN’s newest outputs.

This is a preplanned sub-analysis of their massive observational pediatric blunt trauma study.  Their pediatric blunt trauma decision instrument, unfortunately, turned out to not be terribly useful.  This data on the outcomes of patients with negative abdominal CT scans, at least, ought to help us.

Of the 3,819 patients enrolled with normal abdominal CTs following blunt trauma, 6 went on to have clinically significant abdominal injuries requiring intervention.  They provide a lot of detail about the patient population, but their conclusion is pretty simple: don’t routinely admit these trauma patients for observation to try and catch that 0.02%.  If there’s no other indication for admission, they may be discharged with appropriate symptom return precautions.

“A Multicenter Study of the Risk of Intra-Abdominal Injury in Children After Normal Abdominal Computed Tomography Scan Results in the Emergency Department”
www.ncbi.nlm.nih.gov/pubmed/23622949

Simple SBI Prediction – Hopeless

It remains a noble endeavour to attempt to identify the risk of serious bacteria infections in children.  That said, many have tried, and many have failed.

These authors from the Netherlands and the United Kingdom try, yet again.  They note the best performing decision instrument incorporates 26 variables – which they feel is unworkably unwieldy in a clinical setting – and attempt to derive their own, tighter instrument.  Unfortunately, the clinical variables that shake out of their prediction methodology all have odds ratios less than 6 – leading to a prediction model that can be calibrated only either for horrible sensitivity or horrible specificity.  The sensitive model will lead to over-testing of an otherwise well population, and the specific model will essentially pick up only the cases that were clinically obvious.

It’s becoming pretty clear over the years that attempting to reduce the number of discrete clinical variables in the febrile SBI decision-instrument is a dead-end strategy.  Complex clinical problems simply defy dimension reduction.  Furthermore, the true test of a decision instrument also ought not just be statistical evaluation in a vacuum, but comparison with clinical judgement.

“Clinical prediction model to aid emergency doctors managing febrile children at risk of serious bacterial infections: diagnostic study”
www.bmj.com/content/346/bmj.f1706

Fewer CTs, More Ultrasounds in Children

It’s pretty clear that children shouldn’t be receiving CT scans, whenever possible.  Despite this, the rate of CT for the diagnosis of pediatric appendicitis continues to rise.


This is a retrospective review from the Medical University of South Carolina that describes their implementation of an imaging protocol designed to encourage ultrasound use.  They report before-and-after statistics for their protocol – and, unsurprisingly, they’re pro-ultrasound.


Their protocol is generally simple – if it’s clinical appendicitis, consult surgery.  If it’s uncertain, do ultrasound first – if ultrasound equivocal, do CT.  If the patient appears unwell, skip ultrasound and do CT to evaluate for perforation.  Their institution started out with 82% of patients undergoing appendectomy having received CT, with this percentage dropping to 20% following implementation of the protocol.  Their negative appendectomy rate was stable at 5% after implementation, as well.  They also note the cost of a pediatric CT is $6500 compared with ultrasound at $1100.


The main disadvantage of their protocol was the low sensitivity exhibited by ultrasound – 61% – and the length of stay resulting from patients who required both ultrasound and CT – nearly 8 hours.  Considering ultrasound sensitivity depends on the experience of the operator, efforts to implement this strategy might benefit from upgrading local ultrasound capabilities.


“Clinical Practice Guidelines for Pediatric Appendicitis Evaluation Can Decrease Computed Tomography Utilization While Maintaining Diagnostic Accuracy”
www.ncbi.nlm.nih.gov/pubmed/23611916‎