GSACEP Lecture Series: Pediatric Updates by Dr. Nadia Pearson

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Episode Transcript

Nadia Pearson (00:14):
All right. So good afternoon. Thank you to Dr.
Tilly and team for inviting meback to lecture. It's been
probably several years now thatI have been back to lecture. I
think 2019 was the last time. Soa little bit about me. So I'm
Dr. Nadia Pearson, I amcurrently the command surgeon at

(00:35):
the a med Medical Center ofExcellence. And I will be taking
over as the chief of theDepartment of Operational
Medicine come May. So I have afellowship training in pediatric
emergency medicine. And also Iam board eligible for EMS. So
wealth of experience, I like tolecture on lots of topics that
are relevant, lots of thingsthat I get questions on

(00:58):
personally, phone calls, etc.
There's so much information outthere. And I feel like in
general, the emergency medicinephysician does a really great
job of resuscitating and knowinglots about pediatric things.
It's just the very small chunkof Pediatrics like the
congenital lesions, the thingsthat you don't see very often
the parents dealing with thosekind of interactions that really

(01:21):
trip us up sometimes. Okay, sojust a couple of things. And
this intro slide here. So thecalls that I've been getting
recently are through thereferral center, and it's more
from people from folks that aredownrange in certain areas,
who's deployed here and has notseen a kid downrange. Okay, look
around, there's not anybody thathas raised their hand. Right. So

(01:49):
I just want to point that out.
Because when we when I first gotinto the military, I really
didn't think about pediatricswhen I was going to be deployed,
preparing for deployments. And Ithink the majority of patients
that I saw, specifically on myfirst deployment, this was back
in Iraq was pediatric cases. Andfor sure, I was not ready for

(02:13):
it. We had no pediatric traumacases, no equipment that was
small enough. We didn't haveprotocols, obviously, you know,
we had some emergency physiciansthat were there, but the
experiences from that I've kindof taken to heart and to take
taken with me. So lately, whohave we had to deal with as far

(02:35):
as pediatrics, it's been therefugees. So the Afghan mission,
kids down at the border, andwe're getting more and more
phone calls about those kinds ofthings. And who are these kids?
These kids are the ones thatdon't have really good medical
care, like you would expectbeing in the United States in an
emergency department. So lack ofvaccines, lack of access to

(02:57):
care, lots of precipitousdeliveries that we've gotten
phone calls on precipitatedprecipitous deliveries, not only
just they didn't know, they werepregnant, or they knew they were
pregnant, and had no idea whatgestational age they were so
very difficult to deal with,especially when we're talking to
them over the phone.

Unknown (03:22):
Okay, so what are we going to talk about
specifically? So this slide, inparticular, has given me a lot
of angst, because most of all ofus are all add type
personalities, right? So we liketo have things that are very
much chunked, and you noticethat there's 11 things on here
and not 10. So my kids areactually here with me today, and

(03:46):
they can vouch for this, like,for example, at the gas station,
you have to stop pumping yourgas at a zero or a five. So
that's just kind of my role. So11, I chose things that were
that I felt that were veryimportant. So we're gonna go
through these pretty quickly.
Okay. All right. This isprobably, if I could tell you
anything in this lecture. Theseupdates were done in 2021. So

(04:08):
probably the most important toyou. So you probably want to get
your camera's out if you haven'tseen this CPGs, the clinical
guidelines for pediatric feversthat were just published in
August of last year. So you'llnotice it says eight to 60 days
old. Why does it say eight to 60days old? Well, in that first
week, majority of them are inthe hospital and if you get

(04:30):
somebody with a fever or alittle infant with a fever,
you're gonna do the full workupanyway, there's no real the
baby's feeding. Well, the baby'syou know, doing all the normal
things cooing doing, you knowwhat it's supposed to do. So
first seven days, that's anautomatic eight days. This is
where you get the parents comingin to say, well, they're eating
well, they're feeding, they'repeeing, They're pooping. They're

(04:53):
doing all the things thatthey're supposed to do, but they
felt really warm. And they had afever, or they had a subjective
fever. All right. So, over thedata for the last 40 years,
we've had so many differentguidelines and so many different
criterias that that we have todo, there's no issue again, with

(05:15):
a kid that doesn't look, well,you're gonna do everything along
with that, the issues or thecontroversies come when a kid
looks well, these threeguidelines that I'm gonna give
you are for kids that have atemperature greater than 100.3.
So 100.4 or greater, that's38.0 38.5. If you're 101.3 or

(05:37):
higher, that's considered a highrisk criteria. And I'm going to
point that out into theguidelines for you. So back in
the 1970s, we really didn't havea good plan for screening Group
B strep, and a lot of hospitaladmissions, increased costs. And
we were keeping kids in thehospital for a week, sometimes

(06:01):
two weeks at a time waiting oncultures waiting on different
results. And we did a fullsepsis workup back then for any
kid who had any sort ofelevation and temperature under
90 days old. So that's threemonths old. So 80s to 90s. This
was a new effort that decreasethe amount of hospitalizations

(06:22):
and we looked at differentparameters in the research. So
white blood cell count, absoluteneutrophil, count bands, your
analysis, all those kinds ofthings. And then the CSF Of
course, LP, the question isalways do I need to LP or not
LP, so all of those things,really great 80 to 95%
sensitivity. In addition, we hadnew criteria to look at. So this

(06:46):
is when your Rochester criteriawere developed. And this shift
was towards not admitting all ofthose kids up to 90 days of age,
it was more so the 30 and under,okay, so 30 and under. And this
is where it gets tricky, whereit changes with the new
guideline and a new criteria,the ones that were 30 to 90
days, there, we're starting todo some more outpatient

(07:09):
treatment with them. So they'llsend the cultures, these are the
parents that say, Oh, my kid isfeeding well. But I didn't know
what to do about the fever. Idon't know if I should bring him
to the doctor. And the doctorsalways say go to the emergency
department. Those are the onesin generally in the past that we
could send home with someroasts, often and outpatient
cultures.

(07:31):
Unfortunately, there's a lot ofpractice differentials out in
the community, and most peoplereally weren't following the
criteria. So we went on. Andthere was a this was part of the
review article from 20, Augustof 2021. And the AAP there was
five criteria really, that theywere looking at, and what really

(07:52):
influenced all of these changes.
So number one, changingbacteriology, lots of different
bugs that are now in the system.
And also we have a really goodgroup B strep screening
criteria. So most of the time inwell developed countries, when
you have a female that brings achild in or a male that brings a
child in that has a fever, theyhave a really good maternal

(08:14):
history of being screened forGroup B strep. Okay, so less,
less cases of Group B strep thatwe're seeing as a result of
that. Also strep pneumovaccinations. So that's going
up, and then increase safety offood screening, and very, very
rare where we see a case oflisteria. So that's one of those

(08:36):
board buzz questions, but wereally don't see it anymore. In
this age group. The other thing,cost of care has accelerated
tremendously. And there's beenlots of delays in care because
of all these cool whiz bangthings that we can do. And
there's been issues with kidsnot getting the right
antibiotics, not getting theright care not getting fluids on

(08:56):
board sooner. You know, usingeither ultrasound or the
translucent probes to try andput lines and all this delays,
the actual care sometimes ofinfants, also practice
variability and all the thingsthat we can do. There's Miss
treatments that happen. Numberthree is advanced testing. So we

(09:18):
have all sorts of panels that wecan order. We have gi panels, we
have encephalitis panels, PCR,you name it, we can do it. The
thing that we don't do as oftenright now is our inflammatory
markers. And this is really,really Keystone for the new
guidelines for to 2021. Soprocalcitonin is made by the

(09:39):
thyroid, and it increasessignificantly with bacterial
infection. So in kidsspecifically procalcitonin is
one of those things inflammatorymarkers that you absolutely if
you have it available at yourhospital, you do want to order
procalcitonin The other thing isCRP. It's made by the liver and
it's also highly selective andwill increase at a higher rate,

(10:01):
and to a higher level withserious bacterial infections, so
good to know about those things,improve hospital care, rapid
discharges, and integration ofthe parents into caring for the
infants and kids in thehospitals, that has been a
significant improvement intrying to get the kids home
sooner. And then, of course,rapidly evolving research. So we

(10:25):
have a lot of data over theselast 40 years. So collaborative
multicenter trials, we'retalking hundreds of 1000s of
data points that lead to theseclinical practice guideline
changes. Alright, so here theyare, this is for the eight to 21
days old. And you'll notice inhave a pointer, but right in the

(10:51):
middle, it says increased HSVrisk. So increased HSV risk,
what is that going to be? That'sgoing to be pretty much anything
if there's other kids around,and they have cold sores, runny
nose congestion, in addition toa maternal history of HSV, or

(11:12):
vaginal delivery. So these arethe ones, especially if they
have a fever in the first threeweeks of life, I usually just
add on the Acyclovir,empirically, since we do have
PCR testing for HSV. So addedon, there's really no harm in
adding it on, especially if it'sjust a one time dose, and then
you'll get your PCR back forthat. So this is the guideline.

(11:35):
And interestingly, it hasnothing, everybody in this
guideline is going to get theLP, and is well, we'll get a
urine a blood culture, and thenyou perform the inflammatory
markers to plus or minus theinflammatory markers are going
to be very, very important forthe the three weeks out from 21

(11:57):
to 28 days or around 29 days todo those inflammatory markers.
So you can do the inflammatorymarkers when you do this workup.
But it won't necessarily changethe course of what you do.
22 to 28 days is the next chunkcategory. And this is a big
change. Because before we hadzero to 30 days, 30 to 60 days

(12:19):
and 60 to 90 days. So there'sone little week window in here
that we're doing things a littlebit differently in this adds the
inflammatory markers, okay. Andthere's a lot of studies that
are showing invasive, seriousbacterial illness greater than
25 days is decreased down toabout point 4%. So we're really

(12:42):
trying to get these kids out ofthe hospital or at least not
admitted and not necessarilyhave the full workup with us. So
big takeaways with this, iftheir inflammatory markers are
low, that's your procalcitonin.
If you have it, the CRPS youdon't need to LP these kiddos if
they have a significant fever.
In addition, if you look at theguidelines, specifically,

(13:05):
inflammatory markers, puts fevergreater than one Oh 1.3 And a
significant level risks. So ifyou have a fever, that's
100.3 100.5. That's notnecessarily a significant fever,
according to this guideline with1000s of patients enrolled with
multicenter stuff, a multicentertrial procalcitonin, CRP, and I

(13:29):
put the information up in theupper left hand corner for those
triggers, you'll find it all inthe figure. And it's right out
of the clinical practiceguidelines paper. So it's
important to know this one. Soif you see if you're at the top
fever to 100.3 or less, and theylook well. So this is a kid that

(13:51):
you know is feeding is notvomiting, peeing pooping, you
can do blood cultures, urinecultures, and not have to LP
them. If that if theirinflammatory markers are low. If
their inflammatory markers are alittle bit elevated, however you
go down the LP route, it doesn'tnecessarily mean that you need

(14:13):
to keep them in the hospital,but you can send them home with
some medication. The two weekrisk of invasive bacterial
illness. So if they're two weeksold, is at about 5.3. About when
it goes to three weeks, it getsdown to 3.3. And then this is
where it comes to 1.6% ofserious bacterial illness. So

(14:36):
this is why we can send kidsthat are 2020 Something days
old, with a fever home for care.
29 to 60 days so this is thisnext chunk of time. So again,
these guys do not need an LP iftheir markers are low. Okay, And
if they're they have low andthey have a positive urine, you

(15:02):
can still send them home withsome antibiotics. All right,
these are the ones, you'reprobably going to want to do
some rocephin, or some followon, just make sure you have all
of your cultures pending withthis. So again, the same
inflammatory markers, the samecut off associated with this. So
with these new guidelines,bottom line, you can send kids
home that are actually prettyyoung, as long as you have the

(15:25):
right information, and they'rewell appearing and you document
it very, very well in yourrecord. Unfortunately, I've been
on several cases where theemergency physician did not
document all of the criteria forbeing well appearing. So you
know, when we got to court, wedid the whole, you know, we ran

(15:46):
through everything. And ofcourse, the parent was like, No,
my kid would need would refuseto suckle wouldn't take any
feeds or anything. And ofcourse, if you paint a picture
of an infant that's not doingall the infant things that
equals, you know, somethingthat's bad. And unfortunately,
you can send somebody home. Andthen they develop something, you
know, within the next 12 hours,it doesn't necessarily mean that

(16:07):
the emergency physician didsomething, especially, you know,
in reviewing those cases, theselabs weren't concerning at all.
So just be careful with yourdocumentation, especially when
you have the 29 days old or lesskids, and then make sure they
also have close follow up. Sothis day and age, especially for
those folks who are usingGenesis Now, it's really easy to

(16:28):
go from first net in Genesis andif you haven't, you'll get the
pleasure of doing this turnoversoon. But you'll get to send
messages to the primary careteam very easily. It's like a
cut and paste kind of thing.
Just open your message centerand said, Hey, I need a close
follow up for this kid tomorrow.
All right, next topic offeverish concerns that we get a

(16:50):
lot of questions on is onpolitesse versus granulomas and
what they are both occur aroundthe time when the umbilical cord
is healing or it's drying up,both will look bright red.
Both will look bright red, butthe granuloma wood will look

(17:13):
more like a cherry red and Ihave some pictures coming up
with that there should neverthere should never with a
granuloma if you're going tosilver nitrate it be any
streaking redness around it'sjust the granuloma tissue itself
that should be read any rednessaround the court at all dry it
up should be very concerning tous as emergency physicians for

(17:35):
anaphylaxis and I would go aheadand treat for sepsis. And this
is going back to the physiologyof how infants and where the
portal where in the near theliver in the portal vein, the
circulation is coming from inthe fetal circulation. So this
bacteria spreads very, veryquickly. So this is going to be

(17:55):
your infant within six to 12hours that is going to crash if
you don't get them someantibiotics on board. So be very
careful with armful itis, theone on the right hand side is
going to be your granuloma, seehow bright red it is. That's
when you can just take a silvernitrate stick and you can you
can burn it a little bit andit'll decrease the amount of

(18:16):
bleeding and oozing that willhave granulomas tend to not get
infected. It's just like an overexacerbation of the tissue in
that area from where the cordwas. This one is really bad. The
one on the left hand side that'sa sepsis until proven otherwise.
Okay, so this is my rundown. Thetwo minute rundown of congenital

(18:38):
heart disease. So in general,emergency physicians don't have
to know everything aboutcongenital heart disease to
adequately treat an infant withcongenital heart or or a
consideration of congenitalheart. So I'm going to dumb this
down to like three, three orfour slides here. Okay, and this

(18:59):
is how I think about it. If youhave an infant that is around
two ish weeks old, and there'sanother spike and congenital
heart around for four to fiveweeks, and that's usually for
your sciatic lesions, you onlyhave three different
presentations that you need toworry about as an emergency
physician, you have shock, andthat looks like your typical

(19:21):
shock. So you're gonna getcardiovascular collapse
associated with that. You'regonna get the blueberry baby,
that's the sciatic baby and theylook blue, or you're gonna get a
kid that looks that's in heartfailure. Okay, so three
different presentations. Andwhat is heart failure? We all
this bread and butter emergencymedicine for adults, what does
it look like? It's a kid that'shaving difficulty breathing. The

(19:44):
only thing in kids that's goingto be different is you're not
going to see your lowerextremity edema, like you would
in an old person with heartfailure because it usually comes
on pretty rapidly. Okay, threepresentations. When you read
about congenital heart murmursare something that you read
about a lot. I would caution youalways listen. But don't always

(20:08):
say if they don't have a murmur,they don't have a congenital
heart lesion. Because if thatheart is not pumping
effectively, and it's not movingthe blood through wherever it
needs to go through, you'renot going to hear a murmur.
Okay, though, the loud ones,like the machine, gun murmurs,
and all of those a wholesystolic murmurs, you're gonna
hear them, and you're gonna say,oh, my gosh, I don't know what
that is, but you're gonna hearit everywhere on the chest, and

(20:29):
you can almost feel those. Thoseare not the ones I'm talking
about. I'm talking about, like,the other murmurs that you
listen, you're like, Oh, I hearnext just you can s3 Or when
asked for I can't even rememberback in medical school. If it's
an s3 or an S four, it doesn'tmatter murmurs, the more murmur
it's not going to guide youryour treatment and your, your
diagnosis. Okay, so murmurs,they're great. If it's not, I'm

(20:54):
not going to rule out congenitalheart, you always want to get a
chest X ray, what is the chest Xray going to tell you? Big
Heart, little heart, heart onstring, something's not right
with the heart. That's what it'sgoing to tell you. The other
thing when you have a kid thathas difficulty breathing or is
blue, sometimes they do getother things like spontaneous
new modes and stuff. So you'regonna look for all the typical

(21:15):
stuff in an infant. And thenyou're gonna get signs, you're
gonna look for signs ofpulmonary over circulation. So
this is going to be your volumeoverloaded kid infant, who is in
heart failure. So it's going tolook like a fluffy chest X ray.
All over. So chest X ray ispretty important with an infant.

(21:36):
If you have a very big heart,Big Heart, heart failure, or
another congenital lesion. Bevery careful with kids, you're
gonna have you know, to dealwith the 160s to 180 heart rate,
but they get a lot ofarrhythmias. One trick with the
EKG with little kids is do adouble time, EKG, so double time

(22:00):
it out. So it increases thelength in between. And then you
can actually see if there's areadme as are weird waves in
there, and then you probablywon't be able to interpret it.
It's okay, the cardiologistswill want a snapshot of it so
they can look take a peek atthat. So very important to get
that and you'll look like a Youlook like a pen pro if you get
the EKG double timed, pre andpost ductal saturations. So the

(22:23):
ductus arteriosus is fetalcirculation, because the
placenta does all thecirculation and then everything
gets shunted through the ductusthrough the rest, because you
don't go to the lungs basicphysiology, the ductus. So pre
is going to be on the patient'sright side post is going to be

(22:46):
on the patient's left side. Somake sure in your charts and all
my infant charts, I alwaysdocument femoral pulses, and pre
and post doctoral saturations.
What does that mean, you justput the pole socks on the right
side, you put the pole socks onthe left side. So sometimes I
use the feet, sometimes they usethe arm and the leg, it just

(23:08):
kind of depends where the nursesare working, you got to work
around them. The other thing isfor extremity blood pressures,
pediatric cardiologists willalways want you to get for
extremity blood pressures. Thenurses freaked out about this,
because it's very difficult,sometimes putting on the little
teeny, teeny tiny cough on aneonate. But you gotta get them
and they're pretty accurate too.
And usually you can feel whenyou feel the femoral pulses, you

(23:31):
can feel that they're weak,they're bounding, or they're not
at all, then not at all oneswill freak you out, because
you'll be like, I don't feelanything. But then you go up
here or you go into the brachialand like oh, it's they have to
have a really great bloodpressure. Why can't I feel the
femoral pulses? Well, congenitallesions will do that. Okay, so
you had your threepresentations, right. So that

(23:55):
was the first side, threedifferent presentations. Okay,
so left side versus right side.
Again, you don't need to knowspecifically all the lesions but
you need to know leftventricular outflow tract
obstruction versus rightventricle, right ventricular
outflow obstruction, okay. Ingeneral, infant hearts do not

(24:20):
like poor cardiac output. Okay,they just, they just don't like
new muscle, they like goodcardiac output. If you have a
child who has a left sidedlesion, whatever it might be ko
art, critical aortic stenosis,interrupted art hypoplastic,
left, left heart syndrome,they're going to present with

(24:43):
acidosis and metabolicderangements. Okay? If it is not
diagnosed prenatally, most ofyour big lesions are going to be
diagnosed prenatally, but again,precipitous refugee care any of
those and also if they didn't,you know get good care, they
might not know. Okay, do a bloodgas and be very suspicious. Your

(25:07):
differential for left sidedlesions is going to be your
typical stuff that causesmetabolic acidosis in infants.
So what's that goingto be? sepsis, so we're all
worried about sepsis. Don'tforget the left heart or left
heart in infants. So shock, whatdo you want to do to treat it,
you're going to do same thing asalways fluid boluses, trying to

(25:29):
get that blood pressure upantibiotics, consider sepsis.
And if no response, you're gonnago to doing your prostaglandins
to open the ductus to try andget extra oxygenated blood over
onto that left side. Right, soleft ventricular side is not
working outflow tractobstruction, you need to push

(25:51):
the blood onto that side, okay,or open the ductus to get
additional flow. Right side,okay, that was left side, right
side of lesions, these are goingto be your blueberry babies,
these are your sciatic babies,these are the ones that are
going to be not really toKipnuk, they're going to look

(26:12):
pretty well, but they're goingto be blue, they're not going to
be feeding very well. Butthey're just going to kind of be
looking at you, they'll sleepthey wake up and kind of do
their thing. But the parentsknow something is not right. And
usually, if they're born in atertiary center, you're not
going to see these very muchbecause they're they have now

(26:33):
instituted doing right and leftsided blood pressures, or a
pulse ox at least one timebefore they're discharged from
the hospital. There's a lot ofbabies that are born at birthing
centers that are not athospitals that don't have all
the access to a lot of thecongenital things that you would

(26:53):
expect. So be very careful. Andespecially if if they're born
outside of a hospital situation,or haven't been followed by a
doc provider that's been lookingat all these things haven't had
a an ultrasound, and they're,you know, throughout their
pregnancy, be wary of that. Socentral diagnosis in a baby is
always pathologic, there'salways something going on if you

(27:17):
have central cyanosis. So in themiddle of the chest, and
basically what happens, most ofthese will have a right to left
shunt. So somehow they have toget some oxygenated blood for
something over to that leftside. Okay? If it is, and it's
like, basically not going to thelungs. So to diagnose this, you

(27:39):
want to do a hyperoxia test tosee and all it is is you put the
baby on 100% oxygen, and you seewhat happens and you draw a gas
after that. So pre and post, preand post pre and post oxygen.
Alright, it's pretty intuitive.

(28:01):
If you give lots of oxygen, andthe lungs are working well. What
would you expect your oxygenlevels to do? You would expect
them to go up. Right? So this ishow you differentiate? Is it the
lungs? There, though? Are thelungs doing what they need to do
to oxygenate the blood? Or isthe heart not doing what it

(28:22):
needs to do to move the bloodover. So about 150 is what you
would expect your oxygen levelsto go up if you put a baby on
100% Oxygen, okay, it's prettyeasy. So make sure you get your
chest X ray. All right. So nowyou guys are all experts really,
at those three presentations ofinfants with congenital heart,

(28:46):
you know about left sidedfailure, you know about right
sided failure. You want to doall the labs just like normal
CVC EKG. And make sure you havesupportive care. So fluids and
make sure you have theprostaglandins. Of course, that
board question withprostaglandins. Make sure you
anticipate intubation, rightbecause every time you give

(29:08):
prostaglandins, they just forgetto breathe. This is what heart
failure looks like in a kid.
This is what you're going to seeon the X ray. So pretty similar,
although it's obviously apediatric film, but pretty
similar to the adult in terms ofwhat it will look like fluffy
all over, not necessarily in afocal area, not on the right

(29:29):
side just kind of everywhere.
And this is probably a kidthat's going to end up getting
intubated. And a read me is onthis one too. The other thing
that I did not mention as far asdoing the heart exam, in kids,

(29:49):
the liver is very telling. Soeven when you're giving boluses
for sepsis, you want to makesure that you're feeling the
liver edge, sometimes even threebolus says when we do that 20
per kilo times three thing.
You'll see the liver edge justcoming down during like after
the second bullet, you're like,oh, no, this kid is already
fluid overloaded, that shouldclue you in that there's

(30:10):
something else going on cardiac,other than just plain sepsis. So
anytime I'm resuscitating aninfant, always have your hand on
the liver. All right. Hopefully,there's no questions about
cardiac stuff, but we're gonnakeep moving because I got those
11 things. Another thing that weget lots of questions on whether
they have fevers, or don't havefevers is rashes. For me, it's

(30:33):
either a good rash, or it's abad rash, and a kid and usually
you can tell the difference,because kids are pretty tolerant
of most things. He talks. Sothese are common buzzwords in
pediatrics, but we don't hear itvery much in the emergency
department. Acne is prettycommon. How do you know with
acne? How do you know what's atox seborrhea dermatitis, we get

(30:55):
calls for impetigo all the time.
And I'm like, No, it's justSumeria. Just put them on some,
you know, shampoos and stuff.
And then the other thing, we sawa lot of this, and we got a lot
of phone calls for candidalvaginal type rashes, and a lot
of the providers pre notnecessarily emergency medicine

(31:15):
providers. But they theypreempted what they were telling
us like about sexual abuse, itjust it automatically went to
that. And this is, this is apretty pretty common thing in
pediatrics have Canada and toalso have back bacteria down
there. These are not secondaryinfections. These are not

(31:36):
sepsis, SJS, 10, any of thosebad things. So you just need to
tell parents that this is notanything to worry about. So the
one on the top right, isneonatal acne. And the etiology
etiology of it is a lot of theandrogens from the mom. And it
comes in waves. Based on what ifthe mom is breastfeeding, that's

(31:59):
usually the kids that we'regoing to see this in most often.
And sometimes because you justit looks bad in pictures.
Sometimes, you know, we do goahead and treat with what we'd
normally treat acne with. It'slike a Benza wheel or something
like that. I particularly don'tlike doing that because less is
more with kids, they shouldn'tbe putting lotions, they
shouldn't be putting anything onthese rashes. This one is common

(32:21):
on the right hand side here,your left, that is Millea. So
they look like little teeny tinywhite dots. It's very hard not
to go in the parents want tosquish them and do all sorts of
things. Tell them not to do it.
This will go away on its own,nothing to do about this. E
talks. This is the one that theparents will come in and say I

(32:45):
think there's fleas in the inthe crib. They just look all
kind of eaten up. usuallyhappens one or two days after
birth. And again, nothing to dowith this one. Interesting. You
have to make sure when you'relooking at these rashes, it
spares the palms and soles ofthe feet. So you'll see this all

(33:05):
over. But it should never be onthe palms in the soles. That's
that could be sepsis orsomething else. So this one, e
tox is also very common, butdon't confuse it with something
else. It is rarely ever seen inpreemies exactly know why it has
to do with the newborn immunesystem and eosinophils reacting

(33:30):
to the new environment. Ibelieve the path of is for
premieres is that they're justtheir immune system is not as
well developed as a full termbaby. So I think that's why this
looks bad. But it is not. Thisis seborrhea it's on the hair in

(33:51):
the scalp. This is your cradlecap. Unfortunately, some
parents will take those littlecradle cap combs, and they think
they can just scrape this wholething out. And I've seen some
scalps that are bleeding so youcan get a secondary infection if
they're doing all that stuff. Soyou want to tell them don't
don't do all that. Just someketo Connells all of that. This

(34:13):
it looks very empathy Janus butit's not. It's just seborrhea
and eczema, the one on thebottom on the right. That is
eczema that has herpes in it.
Okay, all eczema doesn't haveherpes and I don't want you to
take that away but very commonlybecause kids put their fingers
in their mouth and you know,they they touch stuff. It's

(34:35):
stuff Eczema is very itchy.
Don't miss eczema her Peda calmokay, if you have any concern at
all, send a PCR do somethingsend a culture put them on it
preemptively. Usually witheczema her Peda calm, if it's
not scratched to death by thekid will have some sort of

(34:56):
vesicles or something in therash that you'll be able to see
with that Moving on. This isyour candidal rash. This almost
looked exactly like a couple ofpictures that I got texted from
downrange, like, Hey, what isthis? What do I do? I'm
concerned. There's vesicles. AndI'm like, Yeah, that's just

(35:18):
diaper DERM. It's candidal it'svery painful for the kid. They
don't want to pee, they can getUTIs from it. I haven't had
really good luck with all theDESA tins and zinc based stuff.
So usually just some petroleumbased protectant from the urine
so the urine doesn't irritateit, and then steroids, steroids,

(35:40):
steroids, and antifungal somesome Clotrimazole will clean
this right up. So the barrierthing because most people want
to dry out rashes. This is notone that you want to dry out
because of the issue with theurine issue, the urine
contacting that. Her bandana, sothis is super common. And

(36:04):
parents get very, veryfrustrated when it doesn't go
away. Their strep rash doesn'tgo away with antibiotics. All of
these are variants of herbyantenna, they can look terrible.
They can have vesicles, they canhave ptti they can have giant
ulcers, steroids help if you geta lot of edematous changes in

(36:26):
the mouth. And the other thingis magic mouthwash I usually
give them you have to be carefulwith the Lidocaine if you mix
lidocaine with Benadryl andMaalox and do like a pink magic
that way, so I usually tailor tothe child if they can swish and
spit. The pathology or thephysiology to help is usually
like a coating so Maalox to coatthose lesions, so they're able

(36:51):
to drink and really that's thebottom line. You just want them
to drink fluids to not getdehydrated. This is going to be
about your two year old. So herAngina is a variant of hand Foot
and Mouth caused bycoxsackievirus or a type of
crocs virus, and it's prettyclassic. You'll also see
vesicles with this stuff in themouth, but don't forget, you'll

(37:15):
also get stuff all over thehands all over the feet. And
it's very common, verytransmissible, not really much
to do about it, other than makesure you know Tylenol, Motrin,
if they have a fever and makesure they're drinking blood in
the diaper. This is a prettycommon one. And you would think
it's mostly just frombreastfeeding from maternal

(37:39):
bleeding that they ingest andthen, but there's there are
other issues. In infants, femaleinfants, withdrawal bleeding
from moms, estrogen is a commonones you'll see vaginal bleeding
in female infants. meckel'sintussusception, I think I've
seen it maybe a handful of timeswhere they actually get the

(38:02):
current jelly stools, mostlymostly not fishless. I have seen
blood and diaper with that aswell. You do want to get a
workup with some labs.
Basically, for the coax for thatusually that's what I get just
to make sure that there's notsomething else going on down
there. And then ultrasound ifyou think they have an

(38:23):
interception, just generalworkup, there's really not much
to do as far as the actual bloodin the stool. fissures is
another thing when they havevery hard stools. Not much to do
about that either. And kids, wewould not necessarily do any
kind of stool treatment.
Abdominal Pain mimics. There.
I've been on a couple of caseswhere we've had some misses for

(38:48):
abdominal pain. So abdominalpain was one of those things
that kids present with prettycommonly and if you don't really
think about it, you can misssomething. Most recently, we've
seen issues with COVID kids thathave presented with abdominal
pain with COVID. And norespiratory symptoms really,

(39:12):
it's just the My stomach hurtsand diarrhea. But they had when
they came back the second or thethird time, pretty significant
mesenteric adenitis, causinginflammatory changes around the
appendix and then appendicitisassociated with that. So
basically the COVID kasiappendicitis, but something not
to miss, especially if you'reroutinely getting the COVID

(39:35):
swabs and you see that don'tforget, even with the abdominal
pain, you have to go in andexamine and don't miss the
appendicitis. torsion is anotherthing kids won't necessarily
tell you like hey, it hurts downthere or localize the pain
really well I always alwaysalways every every abdominal
pain chart will always mentioneither the testes or the ovaries

(40:00):
like why I do or do not thinkit's that and if you don't have
a backup study to and I'm notsaying you have to get that on
everyone, just make sure you'rethinking it through and
documenting in your chart. Itjust this option is another one
and then less Least Common hasprobably kidney stones, but kids
infants do get kidney stonesinterception. So, interestingly,

(40:23):
I had a kid, it was actually a19 year old who had a car
accident, and it was found andhe said he was just so sleepy
and didn't know what was wrong.
And of course, we did all thetrauma scans, the only thing we
found was an interception. Thatwas fairly recently so that was
a new one for me. But there aretwo presentations of innocence

(40:49):
option, you're either going tohave the screamers and then the
ones that you know go silent andthe screamers go silent. I don't
see that quite as often as theones that are just like Space
Cadets. Like they're justlooking around like the parents
like there's something wrongwith my kid. And yeah, you do
everything nothing reallyconcerning on exam. And then

(41:10):
it's just kind of spidey sense.
You ultrasound me like oh, man,that's a giant assumption in
there that they gotta go getreduced. So two presentations.
Don't forget the second one, theSpace Cadet the parent that
saying something is off. I don'tknow what it is with my kid.
With a basically benign exam,you just you know. So the only
things to know about it isdeception is when not to send to

(41:31):
your friendly radiologists. SoFrank peritonitis, fluid, or
HSP. They have concerns withthat they always need to see a
pediatric surgeon strep vaginalitis This is another one that we
get my head I think two or threeof them calls from people

(41:51):
downrange. This causes UTI anditching for whatever pathology
don't forget the pinworms. Thisis a common common thing in kids
to get pinworms from the vaginalarea. So we do the tape test. It
sounds kind of gross, but youjust do the parents to do them
and learn. And then they youknow call back and you give them

(42:13):
the the treatment for thatsometimes you'll even see it
like if you put the tape thereon the back area, put their
diaper back on and wait a littlebit and then go back and check
while you're you know, typing uptheir chart, you'll see them
then tostrep vaginitis is very, very
common. From again, kids fingersitching lots of bacteria in

(42:34):
areas the on estrogen is tissueis very, very thin. So bacteria
can get in there, and then youjust treat this with some
antibiotics. It gets betterCOVID Miss D. So this was a
really interesting phenomenonthat we started to see probably
I would say, late 2020. Or atleast we noted it was something

(42:57):
different than Kawasaki, ingeneral COVID will increase the
respect to bacterial illnessesin infants. So there is a
correlation because if forexample, there's COVID in the
house, there's less likelihoodthat they're gonna bring in
those kids, those infants withrunny nose cough could cause
congestion, because they just iIt's probably just the COVID

(43:20):
Right, so increased risk. That'svery well noted in the
literature from the last coupleof years. Miss C is multi system
inflammatory syndrome inchildren. And the diagnostic
criteria is correlated withSARS, cov. Two, but it has a
really high frequency of GIsymptoms, and only GI symptoms.

(43:40):
So 71% of them will haveabdominal pain. I'm sorry, just
GI symptoms in general 34% ofthem will have abdominal pain,
27% of them will have a lot ofcopious diarrhea, cough and
respiratory distress, 4.5 and9.6%. So with a respiratory
virus, it's a little contraryand Contra. contradictory to say

(44:05):
that, well, they have stomachpain, they and COVID that they
don't have this, so you got tolook for it. So these are a lot
of bounceback kids that comeback with Miss C. So 41% will
have changes on their x raywhether that's enlarged cardiac
silhouette from a pericardialeffusion myocarditis. These kids

(44:27):
also have extremely highinflammatory markers. So your
procalcitonin is your CRPS and63%. So more than half of these
kids will require either one ortwo Iona tropes to maintain
their blood pressure. So theseare kind of sick kids. 28% of
those require ventilatorysupport of the ones who are

(44:50):
diagnosed with MS. See, is sortof resembles Kawasaki with all
of the severe cytokine storm. Ithink when And when COVID first
came out, we were talking aboutthe inflammatory cascade and all
the things that are going onphysiologically associated with
that this really looks likethat. This looks like a toxic
shock, it looks like an extremecytokine increase, it's usually

(45:13):
your older kids. So this isgoing to be at least your five
year old and older, so not somuch the younger kids. So
Kawasaki is going to be more solike an average around like a
one to two year old. This isgoing to be like a 10 710 year
old that comes in and prettysignificant abdominal distress.

(45:34):
Most of them will havemyocardial involvement of some
sort, whether that's a depressedEF, a arrhythmias, pericardial
effusions pretty significantlywhere they need draining and
then myocarditis. What are wetreat them with treatments are
mainly supportive, we reallydon't know yet exactly what to

(45:55):
do about this other than thestuff that we normally do. So
IVIG will be a treatment,steroids will be a treatment to
try and help with thatinflammatory cascade. And then
cardio respiratory support. Solike I said, a good chunk of
them are going to needmechanical ventilation. For

(46:15):
this. For the cardio portion,not so much the pulmonary issue.
overall outcomes are generallyfavorable. So the motor
mortality of somebody who'sdiagnosed with MS. D a child, so
only about 2%. So whether thatis the you know, cause of you

(46:37):
know, the inflammatory cascaderesolving or is, you know, some
self limiting issues or ouramazing treatment, I'm not
really sure. But that's prettylow for something that's that's
significant. And we don't seethat very often. So Missy versus
Kawasaki. So the age criteria isa giveaway for that. And the
other thing is the predilectionfor Kawasaki for Asian infants

(47:01):
versus with Missy, we're seeinga very large portion of African
American or black babies,infants that not babies, older
children that have Misty, so andthere's a lot of statistics that
are looking at differentcommunities different rates
Access to Care also so that thatliterature is evolving with that

(47:25):
the cardiac issues are much muchmore prominent with Miss D, then
with Kawasaki, so careful withthat as well. And then we talked
about those inflammatorymarkers, and the more we learn
about it, as far as theprocalcitonin, the CRP, and
we're able to use those, I thinkwe're gonna get out a diagnosis

(47:46):
and get our treatments sooner.
So we're gonna see kids gettingbetter faster with that. So this
is the last one. So bronchitis,so we don't have any new
guidelines. So 2014 was actuallythe last time the guidelines
were updated. But the thing thatmost people have trouble kind of
wrapping their brain around iswhat not to do. When we see a

(48:09):
kid that comes in wheezing, andjust retracting and having lots
of difficulty breathing, it'shard not to throw on some
albuterol it's hard not to trysome receive MC EPI, it's hard
not to give them steroids andall the stuff that we were
trained to do. In general,that's not indicated with
bronchial itis, the bronchial iskids, you want to give them a

(48:30):
little bit of oxygen, if theyhave a family history of you
know, reactive airwaysignificant asthma. Since we
can't diagnose asthma, you wantto try to do that, to give them
some albuterol. But in general,I don't even I just call for
high flow call for CPAP and justget their work of breathing
fixed. Once you fix that theyusually do better. So again,

(48:53):
bronchitis, don't give themsteroids don't do all of the
other things. hypertonic saline,we used to dump that in a lot.
racemic EPI, that was like athing of the day, too. We were
doing that don't do thatanymore. And you'll see a huge
difference just with high flow,it turns them around really,
really quickly. All right. Am Idoing on time, I think I talked

(49:18):
really fast. So that was 11things that we went over. So
hopefully you took out somethingof one of those things. So the
new new fever guidelines. Soinflammatory markers was the big
thing with that. Right? So makesure you're incorporating that

(49:39):
also the time chunks. So zero toseven days. Everybody gets the
treatment for fevers, wellappearing. Seven to 20 are eight
to 22 days 22 to 29 days andthen the older ones from there.
So there's three differentcriteria and you can look those
up. I usually have them hand Onmy phone to go down the

(50:00):
algorithm, colitis, badgranulomas, not bad silver
nitrate them congenital heartdisease, three presentations.
Then you got your left outflowtract, your right outflow tract,
heart failure and you knoweverything about congenital
heart disease Herpin Ginna, andrashes. Those are very common
don't let them fool you. Bloodin the diaper. Also pretty

(50:23):
common abdominal pain and theabdominal pain COVID stuff.
Don't miss appendicitis withCOVID and especially in those
Missy kids, get them treatedearly and make sure if you're
thinking at all Miss D, put anultrasound on their heart and
make sure you get that chest Xray and EKG pretty quickly
because they downward spiralvery rapidly. Strap. That's

(50:45):
pretty common and then finallythe bronchial itis question.
That was a ton of stuff. Allright. Thank you