Category: Pediatrics

Death By Horticulture

This case report, by the surgeons across the street at Baylor, describes a novel cause for bowel obstruction in children.  Apparently, in the course of plant cultivation, it is useful to have water-retaining gel spheres.  Advertised to retain water and grow to 400 times their original size, a child swallowed a “Water Balz” and developed a small bowel obstruction requiring laparoscopy and enterotomy.


More interestingly, the surgeons obtained five of these balls and evaluated their growth pattern.  The balls began life at ~0.95cm in diameter and, after 96 hours, reached a diameter of ~5.5cm, most of the growth in the first 12 hours.  Based on this, the surgeons estimate any swallowed balls would likely easily pass through the pylorus before resulting in complete bowel obstruction.


The claim of growth to 400 times size, however, is unfounded.  The balls they studied only grew to 200 times original size.


“Water-Absorbing Balls: A “Growing” Problem”

www.ncbi.nlm.nih.gov/pubmed/22987870

Pediatric Intubation – Not Always Successful

This is an observational study of pediatric medical resuscitation, published in Annals of Emergency Medicine, using video to evaluate the frequency of various adverse events during pediatric intubation.

As expected in a teaching institution, there is a fair bit of variability in initial success rates – ranging from 35% first-pass success for pediatrics residents up to 89% for PEM or anesthesia attendings.  Overall 52% had success on the first attempt.  Unfortunately, 61% experienced at least one adverse event during intubation.  These were typically not clinically important with regard to patient-oriented outcomes.

However,  what is more entertainingly concerning is how few of the complications make it into the medical record.  The written documentation overestimates first-attempt success, underestimates desaturation during the procedure, and even completely omits any mention of one of the two episodes of CPR required during resuscitation.

My guess is that Cincinnati Children’s may have had a documentation quality review after this data were collected.


“Rapid Sequence Intubation for Pediatric Emergency Patients: Higher Frequency of Failed Attempts and Adverse Effects Found by Video Review”
www.ncbi.nlm.nih.gov/pubmed/22424653

Acetaminophen and Asthma

If this article strikes your fancy – then you’ll never look at acetaminophen the same way again.


Published in Pediatrics, this is a bit of a commentary summarizing epidemiological data in both children and adults related to the association between acetaminophen (paracetamol) use and asthma.  Specifically, that there is one, based on the studies he reviews, including:
• A prospective childhood asthma study of 520,000 subjects suggesting a dose-response effect between acetaminophen and asthma in children, up to an increased OR for wheezing of 3.25 for children taking acetaminophen at least once a month.
• A meta-analysis of six pediatric studies with a pooled increased OR for wheezing of 1.95 related to acetaminophen use.
• A meta-analysis of six adult studies with up to an increased OR for asthma of 2.87 for adults taking acetaminophen weekly.


…and several others.  The author does not suggest any specific mechanism through which acetaminophen increases airway reactivity, but he has changed his practice to reduce acetaminophen usage to the minimum.  I can’t say I disagree with his hypothesis, and there does appear to be a preponderance of mounting evidence, although I wouldn’t say this is an area where I am intimately familiar with the literature.


“The Association of Acetaminophen and Asthma Prevalence and Severity”
www.ncbi.nlm.nih.gov/pubmed/22065272

Honey For Pediatric Cough

Sponsored by the Honey Board of Israel, this small study supposes to demonstrate that honey is superior to control in the treatment of pediatric nighttime cough.  Specifically, honey is superior to silan date extract, which apparently resembles and tastes like honey.


This is a prospective, double-blind study of three different honey arms and one control arm.  Each group had approximately the same pre-intervention symptomatology severity – cough severity, bothersome nature of the cough, and sleeplessness for bother parent and child – and all interventions improved symptoms.  The scores, supposing clinical relevance to a 0.75 difference in score on a 4-point scale, were significantly improved by all interventions.  Then, the various types of honey all either strongly trended towards or reached statistical superiority over the silan date extract.


So, if your child has a cough – honey seems to be a reasonable intervention.  If you don’t have honey, give them silan date extract!  If you have neither – well, just don’t use dextromethorphan.  And, 20% of infant botulism cases are traced to contaminated honey, so the current recommendation is not to give honey to patients aged less than 1 year.


Incidental note is also made by the authors that some children likely disliked the more aromatic eucalyptus and citrus honeys.


“Effect of Honey on Noctural Cough and Sleep Quality:  A Double-blind, Randomized, Placebo-Controlled Study”
http://www.ncbi.nlm.nih.gov/pubmed/22869830

Mistakes Were Made

This is a fascinating series in Pediatric Emergency Care in which interesting cases from published medical malpractice verdicts are featured.  Each case – typically ending poorly – is followed by a short editorial on the underlying disease processes, with pearls regarding treatment, diagnosis, and the case outcome.  Reading these cases, hopefully, will not contribute to recency bias, and ideally serve simply as brief reminders of clinical features of the rare sick children lurking in the haystack of walking well.


Medicine – as much as or greater than any other profession – is a delicate mix of confidence, humility, and the recognition of the underlying biases in our cognition and practice.  Most of this blog focuses on practicing based on evidence, applying the rules and probabilities of populations as guides towards the diagnosis and treatment of individual patients.  Therefore, when reading these Legal Briefs, I simply want to reinforce the dangers of anecdote-based medicine.

“Pediatric Emergency Medicine:  Legal Briefs”

Keeping Children Happy

When I started in medicine – hardly long ago – Child Life, if it existed at all in the Emergency Department, might have consisted of a few plastic toys and perhaps a Nintendo Entertainment System.  Now, the staple of every department is an iPad, filled with apps and distractions for children.

This is a short article from the Pediatric literature reviewing a few cases in which tablet computers proved useful, along with a review of several apps worth loading on for distraction during potentially troubling procedures.  Most of the apps reviewed are for iPad, but equivalent exist for Android devices and iPhone.



I’ve definitely gotten mileage out of the movie “Toy Story 3” on my iPhone – perfect for the 3 AM laceration repair when Child Life has gone home for the night.

“Using a Tablet Computer During Pediatric Procedures – A Case Series and Review of the ‘Apps'”

Massive Overtesting for Febrile Seizures

Frightening, yet benign, febrile seizures are seen frequently in the Emergency Department.  The American Academy of Pediatrics recommends minimal evaluation for uncomplicated febrile seizures, and invasive testing only in complex cases or those with other indications for testing.

Despite this, the real-world experience documented by these authors at a community hospital in New York is slightly different.  Rather than minimal testing, 100% of patients – mostly aged greater than 12 months – received a CBC and Chem7.  94% received a blood culture, 94% received a urine culture, and 85% had a chest x-ray.  24% had CSF cultures and 21% had CT scans – mostly the complex febrile seizures.

The yield of all this testing – they diagnosed a few UTIs, and one blood culture grew out salmonella.  The authors appropriately feel this testing strategy is excessively wasteful – and confirms the AAP recommendations.

“Current Role of the Laboratory Investigation and Source of the Fever in the Diagnostic Approach”
http://www.ncbi.nlm.nih.gov/pubmed/22653461

A Little Proof of Harms from CTs

It is popular to worry about the harms of CT scans in small children.  A retrospective Swedish study suggests decreased intelligence.  And, our models based on nuclear weapon exposure data combined with dummy CT exposure suggest these scans are likely to result in an increased risk of malignancy.

This is another retrospective study in the National Health Service of Britain comparing malignancy outcomes with their exposure to CT in childhood.  The scary headline: CT scan radiation triples the risk of leukemia and primary brain malignancy.  Of course, triple the risk is essentially 1 additional case of leukemia and 1 additional case of primary brain malignancy in the first 10 years after exposure.  So, this is potentially another study you can use to discuss the Number Needed to Harm with families when discussing the need for CT radiation in pediatric cases.

Now, whether articles like this trigger a wave of legal trolling for malignancies preceded by CT remains to be seen….

“Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours:  a retrospective cohort study”
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60815-0/abstract

Plain C-Spine Radiography in Children

In adults, the use of plain radiography has largely been replaced in the U.S. by computed tomography over concerns regarding missed injuries – and some literature even argues that, given the right clinical circumstances, even a normal CT scan is inadequate.  But, in children, the harms of radiation exposure are greater, so pediatrics has been more hesitant to move to CT as the first imaging study of the cervical spine in blunt trauma.

Unfortunately, this retrospective PECARN study of children with cervical spine injuries isn’t as helpful as one would hope.  The authors identified 204 children, 58 of whom were aged less than 7 years, who sustained a CSI and had plain radiographs of the cervical spine performed.  Of these patients, 127 patients had a definite injury on plain radiography.  41 additional patients had “possible” abnormalities.  Then, 20 films were judged to be inadequate by technique.  And, finally, there were 18 adequate radiographs with normal findings who subsequently had a CSI identified.  The overall sensitivity, then, was 90% (CI 85-94%) – which compares very similarly to the sensitivity in adults from the 34,000 patients in the NEXUS study.
The authors note that most missed injuries fell into two general categories: they were either subtle and non-morbid, or the patients were altered/intubated/focal neurologic findings.  It is probably still reasonable to start with screening plain-film radiography and use clinical judgment to determine when CT may be necessary, but if you’re looking for airtight evidence to guide your decision-making, CSI in children is too rare to generate that sort of data.
“Utility of Plain Radiographs in Detecting Traumatic Injuries of the Cervical Spine in Children”

Codeine, Potentially Unpredictably Lethal

Frequently used in the pediatric population, codeine is a narcotic analgesic in prodrug form.  In the body, codeine is metabolized to morphine through the CYP2D6 pathway.  In the general population, it is estimated that approximate 10% of codeine undergoes conversion to morphine.

We’re generally familiar with the concept that a certain percentage of the population is ineffective at metabolizing codeine, and therefore receives no additional analgesic effect.  However, the flip side, as these authors report, is a CYP2D6 genotype of over-metabolizers.  In this case series, the over-metabolism of codeine in three post-surgical children likely resulted in supra-therapeutic conversion to morphine, leading to respiratory arrest.

The short summary – when possible, avoid medications that are unpredictably metabolized – such as codeine.

“More Codeine Fatalities After Tonsillectomy in North American Children”
www.ncbi.nlm.nih.gov/pubmed/22492761