POTD. Pediatric Grand Round. Pediatric Fevers

Today’s Pediatric grand rounds was given by Dr. Prashant Mahajan, MH, MPH, MBA. 

• Professor and Vice-chair of the department of Emergency Medicine; Professor of Pediatric Medicine, Division Chief of Pediatric Emergency Medicine, Professor of Pediatrics at the University of Michigan

• For those that don’t know him- He’s really smart and has done a ton of research on febrile infants

• and he's proposing a new model to rule out serious bacterial infections in infants <60 days old. 

TL:DR

• Serious Bacterial Infection (SBI) can be ruled out febrile infants from 29-60 days old with a-

  • Negative UA

  • Absolute Neutrophil Count (ANC) < 4090/μg

  • Procalcitonin < 1.72 ng/m

• This prediction rule has a

  • Sensitivity of 97.7% (95% CI, 91.3-99.6)

  • Negative predictive value of 99.6% (95% CI, 98.4-99.9)

  • Negative likelihood ratio of 0.04 (95% CI, 0.01-0.15)

  • Specificity of 60.0% (95% CI, 56.6-63.3)

• This rule requires further validation, but has promise to substantially decrease the use of lumbar punctures, broad-spectrum antibiotics, and hospitalization for many febrile infants 60 days and younger.

The longer and more detailed approach:

- 8-13% of infants <60 days with  fever have a SBI

• ~5-8% have a UTI

• ~1-2% have bacteremia

• ~0.5% have meningitis

- ~500,000 febrile infants are evaluated by healthcare professionals annually

• Missed SBIs may lead to serious complications

• Febrile infants frequently receive invasive management including lumbar punctures, broad spectrum antibiotics, and hospitalization

• Variation exists in the management of febrile infants <60 days

• 90% of those 28 days or less receive lumbar puncture and admission

• The incidence of SBIs has decreased over time

• We need to balance hospital related complications, costs, and increases in antimicrobial resistance with the consequences of missed SBIs

- Our screening tests to assess for SBIs have holes in them

• Physical Exam

  • Yale Observation Scores (YOS) in infants with SBI’s have similar median scores to those without SBI’s

  • I didn't know the YOS was a thing either. It's a clinical score developed on 6 behavioral domains to predict SBI’s, 

• CBC’s are not sensitive in ruling out bacteremia or meningitis

  • WBC< 5,000 has a sensitivity of 10%, specificity of 91%

  • WBC> 15,000 has a sensitivity of 18%, specificity of 87%

• Several of the commonly used rules for febrile infants (Philadelphia, Rochester, Boston, and Pittsburgh) were not statistically derived and therefore lacked optimal balance between test sensitivity (avoiding missed SBIs) and specificity (preventing overtesting and overtreating patients without SBIs). Additionally, several included data from LP’s an invasive procedure not required in the newly proposed rule (Boston, Phladelphia, Pittsburgh, Milwaukee.

- In this study

• Negative UA alone ruled out an SBI in 97.6% of cases

  • Anyone hear of diapedesis? Consult Hector Vazquez for more info

• Negative UA + ANC <4090 ruled out SBI in 99.2% of cases

• Negative UA + ANC <4090 + PCT <1.71 ruled out SBI in 99.8% of cases

- Further validation in a cohort with more SBI’s is needed before implementation of this new rule.

The conclusion

• Dr. Mahajan recommends using this rule in infants 29-60 days old. He currently recommends pursing your institutions’s standard of care (Full Sepsis Workup) in infants 28 days old or less  

The Article:

https://jamanetwork.com/journals/jamapediatrics/fullarticle/2725042

POTD: Foreign Body of the Nose

Foreign body of the Nose

•        Most common age range: 2-5 yo

•        Most common FB: beads, beans, peanuts, toy parts

•        Beware of: button batteries and two magnets, as always.

•        Can lead to septal perforation/necrosis of tissue.

•        Be suspicious of nasal FB when you see unilateral discharge, often malodorous

•        Complications: infection, aspiration, epistaxis

To remove:

•        Topical lidocaine or afrin?

• Pro: improve tolerance of/cooperation with the procedure

• Con: risks displacement of the FB

How to remove

1) Mechanical extraction: You need a cooperative child and good visualization.

2) Suction: must exercise extreme caution not to push further back and aspirated into the trachea

3) Positive Pressure: Parent’s kiss, bag mask, continuous pressure

• Start by asking the child to blow their nose, occluding the unaffected nostril as they do this. Sometimes, this alone may expel the foreign body.

• Parent’s Kiss: One of my preferred methods. Has a 50 % success rate.

Kissing parent: The technique is performed by a parent by placing their mouth over the child’s (giving a ‘big kiss’), while they occlude the unaffected nostril. The parent then exhales into the child’s mouth, generating positive pressure, similar to that of nose blowing. See picture below for demonstration.

Nothing working? You may need an ENT consult because the FB is so posterior that above methods are futile.

Now that it’s removed:

·       Don’t forget to inspect for trauma or retained FB

References:

•        PEM playbook foreign bodies: excellent peds podcast by Dr. T Horeczko - ‎2015

•        Wiki EM: Nose foreign body

Look at this retro parent’s kiss!

POTD: Foreign bodies, Ears!

This is a two part series for POTD. Foreign bodies: Ears and Nose! Today, Ears!

Quick Anatomy review to help locate that FB:

•        Anatomy

–       medial 2/3 is fixed in temporal bone –where many FBs are lodged and/or where trauma

•        Ask yourself: is it graspable or non-graspable?

–       Graspable: 64% success rate, 14% complication rate

–       Non-graspable: 45% success rate, 70% complication rate

•        What instrument/method should I use for what?

–       Alligator forceps: think something graspable like paper, foam

–       Suction tip: think something non graspable like a round object such as a bead

–       Irrigation: think something non graspable like a bead (note: do not irrigate organic material as will swell or break apart)

–       Glue: something non graspable like a bead or organic material that might swell or break if irrigated

Pearls on insect FB:

·       Kill it first. They will fight.

-        What to use? Lidocaine jelly, viscous lidocaine (2%), lidocaine solution, isopropyl alcohol, or mineral oil.

-        After they are dead, you can remove or can send to ENT for removal (most patients will want it out, can you blame them?)

o    An ENT friend of mine says to keep the insect in the ear and let them remove because we tend to cause trauma. Something to keep in mind.

What if I caused or the FB (like that insect fighting for their life) caused local trauma?

•        TM rupture?

–       Keep dry

•        When to use otic abx drops

–       Any trauma or dirty FB injury (think: that insect crawling around) or canal lacerations/abrasions.

–       What to give? Ofloxacin drops or the very expensive ciprodex.

•        ENT f/u

Pitfalls

•        Inspect after removal

–       Something else in there? Abrasions/trauma and need prophylactic antibiotic ear drops

•        If at first you don’t succeed, try again. But consider changing the technique of removal. Remember the law of diminishing returns.

References:

Pem playbook: excellent peds podcast by Dr.  T Horeczko - ‎2015

Wiki EM: Ear foreign body