Top Ten Pediatric Emergency Medicine Articles from 2021

Written by Denrick Cooper

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This review article highlighted some of the pivotal pediatric emergency medicine literature in 2021. It is a great update on commonly seen pathology in the pediatric population.

Why does this matter?
The authors did a great job of summarizing 10 pediatric research articles from 2021. It can be difficult to filter through the most important articles in EM literature. If only there was a blog who did such a thing :). Luckily, JF is here to give you a summary…of the summary. Buckle up – it’s a long but important one.

Keeping up with the pediatric Joneses

Abx in CAP
We recently covered CAP-IT here. In lower and middle income countries, treatment of mild to moderate CAP with shorter durations of antibiotics has proven successful. Bielicki et al randomized 824 children over a 6 month period who were diagnosed with CAP in the ED or in hospital to 4 separate treatment courses of amoxicillin: 1) 35-50 mg/kg/d 3 days 2) 35-50 mg/kg/d for 7 days  3) 70 – 90 mg/kg/d for 3 days 4) 70 – 90 kg/kd/d for 7 days. The primary outcome was the need for subsequent systemic antibiotics.  This study found lower doses were noninferior to higher doses (12.6% vs 12.4%) and 3-day duration was noninferior to 7 days (12.5% vs 12.5%).  In severe disease, lower dose and shorter duration was inferior (17.3% vs 13.5%; 15.2% vs 11.3%).  Results support physician treatment of uncomplicated, non-severe pediatric CAP with shorter duration, lower-dose antibiotic regimens.

High risk BRUEs
The BRUE tool does a good job of identifying low risk patients we can send home; however, there is limited literature on the outcomes of patient that are considered high risk and are admitted to the hospital. Bochner et al. performed a multicenter, retrospective, cohort study with 2,036 infants who presented to the ED with a BRUE. Of the total BRUE cases, 37% were admitted and 1.5% of the admitted patients had a serious life-threatening diagnosis. This is much lower than previous studies, but may hint at a need for further stratification of high risk patients. At the same time, it may give us resolve to discharge lower risk patients.

Severe Covid-19 Risk Factors
Few studies exist on predictors of severe COVID-19 disease in the pediatric population. Graff et al performed a retrospective cohort study of 454 children under the age of 21 found to have severe COVID disease, defined as requiring inpatient admission or needing ventilatory support. Multivariable logistic regression models revealed severe disease was associated with SOB on presentation (OR =16; 95% CI 6.4 – 39), young age < 4 months (OR= 7.9; CI 3 – 20), cardiac disease (OR 6.6; 95%CI, 1.1-40), and immunocompromised state (OR = 3.5;CI 1.5 – 8) among other factors.

Antifibrinolytics for hemorrhage
Although children do not experience life threatening bleeds as often as adults, the mortality is still very high for severe bleeds. Spinella et al sought to expand on the impact of antifibrinolytic effect on mortality using a secondary prospective cohort analysis of 449 patients with life threatening bleeds under the age of 18. Cox proportional hazard regression model showed 0.29 and 0.45 decreased odds of mortality at 6 h and 24 h, respectively; no benefit was shown at 28 days. No difference between TXA and aminocaproic acid was seen either.  Antifibrinolytics may be beneficial in life threatening bleeds in the pediatric population.

Steroids for retropharyngeal abscess
We covered this article here. Steroids have been used as an adjuvant therapy to antibiotics for medical management of retropharyngeal abscesses, but there is concern about the utility of these drugs in avoiding overall progression and worsening severity of infections.  Of the 2,259 pediatric patients diagnosed with retropharyngeal or parapharyngeal abscesses in this study, 26% received steroids, with most getting dexamethasone (98%). There was less need for surgical drainage in the corticosteroid group vs non corticosteroid group (22% vs 52%, p < .001). Secondary outcomes revealed patients treated with corticosteroids had more CT scans, less opioid analgesia, and lower hospital costs, suggesting adjunctive therapy with steroids may be the way to go.

Evaluation of fever in infants
We covered this article here. The American Academy of Pediatrics updated guidelines in 2021 on the appropriate way to workup febrile infants 8 – 60 days old with a prior documented fever in the prior 24 hours.

  • Infants 8 – 21 days are to obtain a sepsis workup including basic labs, blood and urine cultures, LP, and antibiotics with hospital admission.
  • Infants 22-28 days, one of the main changes in the guidelines, are to receive basic labs including blood and urine cultures as well as procalcitonin and CRP. Children who are well appearing with normal labs can forgo LP with hospital admission for further observation +/- antibiotics depending on management with the inpatient team. If any abnormalities in lab testing, patients are admitted with LP and antibiotics.
  • Infants 29 – 60 days old are worked up as the previous group, with basic labs, blood and urine cultures, and inflammatory markers. If the patient is well appearing and labs are normal they can be discharged without antibiotics with close follow up with PCP.

Serum Sodium in Diabetic Ketoacidosis
We covered this article here. A recent PECARN study showed no association between infusion rate or type of fluid with cerebral edema. In the original study, a group of children suffering from DKA were randomized into 4 groups: 0.45% or 0.9% Normal saline either at a starting rate of 10 mL/kg or 20 mL/kg. In this secondary analysis, no association was seen between decrease in serum sodium and mental status or cerebral edema. Sodium levels depended on initial electrolyte balance, degree of dehydration, and osmolality of IV fluids. This may help us fine tune how we approach DKA IV fluid replacement in future.

Risk of concurrent serious bacterial infection in mastitis
Few large studies have been published on the prevalence of concomitant serious bacterial infections (defined as bacteremia, bacterial meningitis or UTI) with neonatal mastitis.  This multicenter, retrospective cross-sectional study over a 10 year period of 657 infants with mastitis found only 6 infants with SBI. All of these patients, however, were described as well appearing. With this in mind, the authors recommend to admit patients with neonatal mastitis to the hospital.

Follow up in buckle fractures of the radius
Radial buckle fractures are the most common fractures seen in children, and removable splint seems to be adequate. Research on PCP follow up vs orthopedic surgery follow up show return to normal function rates. A randomized controlled single blinded study of 133 patients with buckle fractures were placed in two groups, one with removable wrist splint with scheduled 1-2 week PCP follow up compared to home removal of splint with follow up only if patient deemed needed. The study found home management was non inferior to strict PCP follow up based on return to function and compliance. No significant differences were seen in the two groups based on patient and parent satisfaction and complications. The “at home” group had cost saving benefits.

Risk factors for invasive herpes virus infection
We covered this article here. Invasive neonatal herpes can be difficult to diagnose, as neonates have nonspecific symptoms. A retrospective nested case-control study was performed with 149 cases of HSV. 1,340 controls were matched with cases. The highest odds ratios of invasive HSV disease were associated with vesicular rash (55 OR, 17-181 95%CI) , age < 14 days (9 OR, 3.4 – 25 95% CI), age between 14 – 28 days (6.4 OR, 2.3 – 18 95% CI), and seizures (6.1 OR, 2.3-16 95% CI).

Source
Updates in pediatric emergency medicine for 2021. Am J Emerg Med. 2022 Feb 19;56:244-253. doi: 10.1016/j.ajem.2022.02.019. Epub ahead of print.

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