New Research in Pediatrics

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Q. Given that CT imaging of head-injured children has risks of radiation-induced malignancy, are there ways to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary? 

 Educational Objectives:
After evaluating this article participants will be able to:
1. Recognize and incorporate into practice the current standards in pediatric head trauma imaging
2. Understand the benefits and limitations of levalbuterol to improve patient care of asthmatic patients
3. Incorporate the latest strategies for foreign body aspiration into clinical practice
4. Implement current treatment strategies for patients with febrile seizures

Q. Given that CT imaging of head-injured children has risks of radiation-induced malignancy, are there ways to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary?


A. A new robust study for the Pediatric Emergency Care Applied Research Network validated prediction rules that identified children at very low risk of ciTBIs for whom CT can routinely be obviated.

Methodology: Patients younger than 18 years presenting within 24 hours of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments were enrolled in this study. The authors derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 hours, or hospital admission >/=2 nights). 42,412 children were enrolled (derivation and validation populations: 8,502 and 2,216 younger than 2 years, and 25,283 and 6,411 aged 2 years and older).

Findings: CT scans were obtained on 14,969 (35.3%); ciTBIs occurred in 376 (0.9%), and 60 (0.1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years:
-normal mental status
-no scalp hematoma except frontal
-no loss of consciousness or loss of consciousness < 5 seconds
-non-severe injury mechanism
-no palpable skull fracture
-acting normally according to the parents

Had a negative predictive value for ciTBI of 1176/1176 (100.0%, 95% CI 99.7-100 0) and sensitivity of 25/25 (100%, 86.3-100.0). 167 (24.1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group.


The prediction rule for children aged 2 years and older:
-normal mental status
-no loss of consciousness
-no vomiting
-non-severe injury mechanism
-no signs of basilar skull fracture
-no severe headache

Had a negative predictive value of 3798/3800 (99.95%, 99.81-99.99) and sensitivity of 61/63 (96.8%, 89.0-99.6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group.

Neither rule missed neurosurgical cases in validation populations.

Analysis: This was a well-done study with a large sample size and will become the landmark study on head injury in children. However, there are wide confidence intervals for the sensitivity and therefore it is imperative to remember that any clinical prediction rule is a guide to the care of patients but absolutely does not replace physician judgment. It is interesting that vomiting was not included in the kids under 2 years of age and ANY vomiting in children over age 2 years of age is listed as a risk factor. The authors had tried to stratify if a certain number of episodes of emesis or timing of the emesis could be linked as a predictor for TBI; however, this was difficult to accomplish.


Kuppermann N, Holmes JF, Dayan PS, et al for the Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Sep 14.

Q. How effective is it to use continuous levalbuterol in the management of children with status asthmaticus?

A. According to a recent study in the Journal of Pediatrics, Substituting high-dose continuous LEV for RAC did not reduce the time on continuous therapy and had similar adverse effects in children who had failed initial treatment with RAC.

Methodology: Children age 6 to 18 years with severe asthma exacerbation were enrolled in this randomized, double-blind trial if they failed initial emergency department (ED) therapy with RAC and systemic steroids. Subjects received equipotent doses of RAC (20 mg/hour) or LEV (10 mg/hour) within a standardized inpatient protocol. Blood samples for measurements of albuterol enantiomer, potassium, and glucose levels were obtained from the first 40 subjects. The median time until discontinuation of continuous therapy was compared using the rank-sum test, and other outcomes were compared using general linear mixed models.

Findings: A total of 81 subjects (40 in the RAC group and 41 in the LEV group) were enrolled; the 2 groups were similar at baseline. Both groups tolerated continuous therapy with similar changes in heart rate and serum potassium and glucose levels but higher serum (S)-albuterol concentrations in the subjects treated with RAC. The median time for continuous therapy was similar in the RAC and LEV groups (18.3 hours vs 16.0 hours), as were the other clinical measures.

Analysis: Yet another article that supports the fact that Xopenex is not necessarily any better than standard albuterol therapy. I do find it useful in the tiny babies who become extremely tachycardic and can go into SVT.

Andrews T, et al. High-dose continuous nebulized levalbuterol for pediatric status asthmaticus: a randomized trial. J Pediatr. 2009 Aug;155(2):205-10.e1. Epub 2009 May 21.

Q. What is the latest literature pertaining to the management of asymptomatic children with suspected, acute foreign body aspiraton? What is the criteria for bronchoscopy in this patient group?

According to a recent article in the Journal of Pediatrics, in children with a history of choking, bronchoscopy is mandatory in the presence of persistent symptoms, such as cough, dyspnea, and fever, or any abnormal physical or chest radiography findings. Bronchoscopy may not be needed in asymptomatic children with normal physical and radiographic examinations.

Methodology: Health history, physical examination, and radiologic examination were performed before bronchoscopy in all children referred for suspected FB inhalation between 2003 and 2005.

Findings: A total of 142 children, ranging in age from 3 months to 14 years (median age, 20 months), were referred with a history of suspected FB inhalation. A FB was found in 42 children with abnormal physical and radiologic findings, in 17 children with abnormal physical or radiologic findings, and in 2 children with normal physical and radiologic finding but persistent cough. Bronchoscopy revealed no FB in the children with normal physical and radiological examinations and no symptoms (n = 16).

Analysis: For now, at least discuss the case with the pediatric ENT on call to let them decide whether or not they want to perform the bronchoscopy. This is a very small study and will need further validation before putting it into routine practice.

Cohen S, et al. Suspected foreign body inhalation in children: what are the indications for bronchoscopy? J Pediatr. 2009 Aug;155(2):276-80. Epub 2009 May 15.

Q. What is the prevalence of bacterial meningitis and herpes simplex virus (HSV) encephalitis in children presenting with complex febrile seizures? How should this data impact treatment?

A. An article in Pediatric Emergency Care discusses how, given the low rate of bacterial meningitis and HSV encephalitis in children presenting with complex febrile seizures, routine lumbar puncture in these patients may be unnecessary.

Methodology: Health records from 2002 to 2006 of all children 6 months to 6 years with a discharge diagnosis from the Hospital for Sick Children (Toronto, ON) of febrile convulsion, meningitis, or encephalitis were reviewed. Rates of bacterial meningitis and HSV encephalitis in children presenting with complex febrile seizures were calculated.

Findings: There were 390 encounters of complex febrile seizures in 366 children. Of these encounters, 75 (19%) were transferred from an outlying hospital. A history of febrile convulsions was noted in 140 (36%). Lumbar puncture was performed in 146 (37%) patients. Six patients (all but one transferred) were diagnosed with bacterial meningitis (all due to Streptococcus pneumoniae). One transferred patient was diagnosed with HSV encephalitis. In patients initially presenting to our emergency department the rates of bacterial meningitis and HSV encephalitis were 0.3% (95% confidence interval, 0.0Y1.8) and 0.0% (95% confidence interval, 0.0Y1.2), respectively.

Analysis: I think it is difficult to have a blanket statement that says that we do not have to perform LP’s in patients who present with complex febrile seizures because it depends on how they present. If the child is well-appearing, and has had 2 seizures in the day, then perhaps not doing an LP is the right way to go. However, if the child is ill-appearing, 6 months old and has a prolonged seizures with a prolonged postictal phase, this is a child that we all would LP and admit. Once again, clinical judgment is the important issue. As a reminder, the definition of a simple febrile seizure is:-Age 6 months to 5 years of age
-Duration of seizure-less than 15 minutes
-Only one seizure in a 24 hour period
-Generalized seizure
-No evidence of meningitis- ie no petechia, no bulging fontanelle
-no nuchal rigidity

By definition, a complex febrile seizure lasts longer than 15 minutes, there may be more than one in a 24 hour period and the seizure may not be generalized.

Seltz LB, Cohen E, Weinstein M. Risk of Bacterial or Herpes Simplex Virus Meningitis/Encephalitis in Children With Complex Febrile Seizures Pediatr Emerg Care. 2009 Aug;25(8):494-7

Q. How effective and safe is recombinant human hyaluronidase (rHuPH20)-facilitated subcutaneous rehydration in children 2 months to 10 years of age?

A. rHuPH20-facilitated subcutaneous hydration seems to be safe and effective for young children with mild/moderate dehydration. Subcutaneous access is achieved easily, and the procedure is well accepted by clinicians and parents

Methodology: Patients with mild/moderate dehydration requiring parenteral treatment in US emergency departments were eligible for this phase IV, multicenter, single-arm study. They received subcutaneous injection of 1 mL rHuPH20 (150 U), followed by subcutaneous infusion of 20 mL/kg isotonic fluid over the first hour. Subcutaneous rehydration was continued as needed for up to 72 hours. Rehydration was deemed successful if it was attributed by the investigator primarily to subcutaneous fluid infusion and the child was discharged without requiring an alternative method of rehydration.

Findings: Efficacy was evaluated in 51 patients (mean age: 1.9 years; mean weight: 11.2 kg). Initial subcutaneous catheter placement was achieved with 1 attempt for 46/51 (90.2%) of patients. Rehydration was successful for 43/51 (84.3%) of patients. Five patients (9.8%) were hospitalized but deemed to be rehydrated primarily through subcutaneous therapy, for a total of 48/51 (94.1%) of patients. No treatment-related systemic adverse events were reported, but 1 serious adverse event occurred (cellulitis at infusion site). Investigators found the procedure easy to perform for 96% of patients (49/51 patients), and 90% of parents (43/48 parents) were satisfied or very satisfied.

Analysis: This is an interesting new way of hydrating patients without having to attempt multiple intravenous attempts. Keep in mind, that NG hydration has also been proven to be very effective for dehydrated children. A 5F feeding tube is placed and the patient can be hydrated with a starting point of 50cc/kg of pedialyte given over the first 3 hours. While conducting chart reviews of children who have decompensated and subsequently coded, the number one problem was not going to intraosseous infusion fast enough. So, while it is wonderful to try different ways to hydrate children, the IO is the way to go quickly if the child is not doing well.

Allen CH, Etzwiler LS, Miller MK etal. Recombinant Human Hyaluronidase-Enabled Subcutaneous Pediatric Rehydration. Pediatric Rehydration Study Collaborative Research Group.Pediatrics. 2009 Oct 5. [Epub ahead of print]

Ghazala Q. Sharieff, MD, is the Director of Pediatric Emergency Medicine at the Palomar-Pomerado Health System.



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