Davis, T. PICU Q+A: stridor, Don't Forget the Bubbles, 2013. Available at:
PICU Q+A: This Q+A is about stridor in a previously well child.
Sam, a 9-day old boy, is rushed into the paediatric emergency room by his distraught parents. Bright red blood is soaking through the front of his cloth nappy.
A brit milah, or bris, is the traditional Jewish circumcision ceremony that usually takes place on the 8th day of life. It is carried out by a mohel. The mohel may not be a medical practitioner. Followers of Islam are also circumcised (Khitan) though there is no prescribed time after birth in which must take place as long as it is before the age of 10.
Whilst a number of religions including Islam and Judaism require newborn boys to be circumcised the proportion of boys that undergo the procedure is declining. Currently, about 10-20% of boys born in Australia and less than 10% in New Zealand are circumcised.
The Royal Australasian College of Physicians’ policy statement on male circumcision states that “there is no evidence that the benefits outweigh the risk of the procedure”. The American Academy of Pediatrics holds the opposite view.
A 2009 Cochrane meta-analysis found that male circumcision in sub-Saharan Africa reduced male-to-female rates of HIV transmission by 36-66%. Males who have been circumcised are unlikely to pass on HPV to their partners in life and will not get skin cancer of the penis.
It is generally contraindicated if there is any genital developmental abnormality such as hypo- or epispadias or if the patient has ambiguous genitalia. It is also not recommended in the children of parents with haemophilia until the child has been tested. It goes without saying that it should not be performed on the sick or jaundiced infant either.
Complications occur following approximately 1 in 500 procedures. The tip of the penis is often crusted and inflamed. Sucrose should be used prior to the removal of the dressing in the neonate.
If there is profuse bleeding this may be a marker of an underlying coagulopathy and so should be tested for. Bleeding may be due to a snipped vessel or localized inflammation/infection. Direct pressure with a surgical dressing such as Kaltostat should halt the bleeding. Very rarely a single suture is needed to tie off a bleeding vessel.
Should there be any cellulitis to the penis in the neonate then they should be admitted for IV antibiotics.
Once the nappy was removed it was obvious that there was active bleeding to the area where the foreskin had been removed. After giving some sucrose the vaseline gauze dressing was removed and a bleeding point identified. When the application of a surgical dressing failed to stop the bleeding a penile block was placed and a single stitch tied off the guilty blood vessel. The clotting profile was normal and Sam was discharged to follow up with his primary care provider.
Royal Australasian College of Physicians, Paediatrics & Child Health Division. Circumcision of infant males. [cited 2013 Jul 22]
American Academy of Pediatrics Task Force on Circumcision. Male circumcision. Pediatrics. 2012 Sep;130(3):e756-85.
Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database Syst Rev. 2009 Apr 15;(2).
Medication errors are a particular area of interest for me, so this paper caught my eye….here’s my summary of it.
It’s a paper by Benkelfat et al and is published in the September 2013 issue of the Journal of Emergency Medicine.
Benkelfat R, Gouin S, Larose G, Bailey B. Medication errors in the management of anaphylaxis in a pediatric emergency department. J Emerg Med. 2013 Sep;45(3):419-25.
It looked at using standard order forms to reduce medication errors when managing anaphylaxis in paediatric emergency.
It may seem surprising, but most doctors do not know the correct dose of adrenaline (epinephrine) to give in the management of anaphylaxis.
Tain and Rubython (2007) showed, in a New Zealand study, that only 20% of doctors actually knew the right dose and route of administration of adrenaline for anaphylaxis. And Drost and Narayan (2010) found that only 15% of UK doctors would give adrenaline as recommended by the UK resuscitation guidelines. These studies were all in adults, and one would expect that in children there would be even more error due to weight variation and low frequency of presentation.
We need to be able to treat anaphylaxis quickly, safely and optimally, as patients can deteriorate rapidly and die from this. And an overdose of adrenaline comes with its own set of side effects.
The authors introduced a standard order form (SOF) which was given to doctors when prescribing medications for anaphylaxis (in their Paediatric Emergency Department in Canada).
They then looked at the frequency of medication errors before introducing the SOF and after introducing the SOF.
This was done retrospectively through searching for patients coded with anaphylaxis or anaphylactic shock in their ED database. The notes were then cross-checked with the National Institute of Allergy and Infectious Disease diagnostic criteria for anaphylaxis to make sure the patients did actually have anaphylaxis.
Incorrect medication dosages (10% and 25% margin of error for doses); wrong drug administration; and a delay in administration (15 min delay for adrenaline, 30 min delay for other drugs).
96 patients were included – 31 in the Pre-SOF group and 65 in the Post-SOF group. In the Post-SOF group 30 patients were SOF negative – this means that even though SOF had been introduced in the department, the SOF was not used for that patient.
A whopping 60% of medication charts contained at least one medication error (59% post-SOF).
The number of dosage errors did reduce significantly when the SOF was used (this was the same using either the 10% error margin or the 25% one).
Perhaps most importantly for our learning, the correct adrenaline doses for managing anaphylaxis in paediatric emergency are…
Give IM doses of 1 in 1000 adrenaline into the lateral thigh (can repeat after 5 mins if not improving). Avoid subcutaneous administration and do not use IV bolus adrenaline unless cardiac arrest is likely. Nebulized adrenaline can be used as adjunctive therapy (to IM) but not as 1st line.
Dosing can be 0.01ml/kg of 1 in 1000, or if it is easier to remember:
Thain S, Rubython J. Treatment of anaphylaxis in adults: results of a survey of doctors at Dunedin Hospital, New Zealand. N Z Med J, 2007;120:1252.
Droste J, Narayan N. Hospital doctor’s knowledge of adrenaline (epinephrine) administration in anaphylaxis in adults is deﬁcient. Resuscitation 2010;81:1057–8.
A 5-year-old boy, Kayden, is brought in by his mother as she is concerned that there is something wrong with his penis – every time he tries to pass urine it balloons in his foreskin and goes all over the floor.
A non-retractile foreskin is the norm in neonates and may be present in 60% of boys under one year of age. By 4 years of age, 90% of boys are able to retract their foreskin. The majority of cases that present to either primary care or the emergency department are physiological phimosis. True phimosis is caused by forcible retraction of the foreskin leading to a tight circular band of scar tissue. Some studies suggest an increased incidence of balanitis xerotica obliterans (BXO).
Application of 0.05% betamethasone ointment bd applied to the tip of the foreskin for 4-6 weeks reduces localized inflammation and helps loosen any inner preputial adhesions from the underlying tissue thus making it easier to retract. The majority of children with phimosis will not need any surgical intervention. Children with BXO may be referred early for circumcision though it may recur.
When the foreskin is left in the pulled back position it can impair venous return from the glans leading to oedema. This may lead to ischaemia and necrosis if left untreated. It is commonly related to previous phimosis where a ring of tough fibrous scar tissue forms around the foreskin. Whilst its presentation is usually obvious do not forget to consider the diagnosis of a hair tourniquet.
The foreskin should be returned to its normal position as quickly as possible. The pain should be relieved with parenteral/intranasal analgesia. Often lignocaine jelly (similar to that used for catheterisation) is enough to numb the pain whilst an ice pack is applied to help reduce oedema. Once these have had ten minutes to work use the thumb of your dominant hand to push down on the glans whilst sliding the foreskin back in place. If this does not work a flexible, self-adhering bandage may be used to compress oedema.
In the majority of occasions, the simple measures described above should be effective for returning the foreskin to its natural position. For completeness sake, it is worth being aware of some of the surgical options available but these should only be carried out by experienced practitioners. For the older child, it may be necessary to perform a penile block (under sedation) in order to aid reduction. More brutal surgical techniques have been described, including multiple punctures of the glans to reduce oedema or performing a dorsal slit (cutting the fibrous ring of tissue). The child should then be referred to a paediatric surgeon for consideration for circumcision as a later date.
PARAchutes come down and so does the foreskin in PARAphimosis.
Balanitis is inflammation of the glans of the penis that is often accompanied by inflammation of the overlying foreskin. It is more common in boys that have not been circumcised.
Balanitis may be either
A penile skin swab is not needed as the majority of cases clear up with empiric treatment.
Most cases of balanitis are irritant in origin and respond well to simple measures. It can be tough to distinguish between irritant and infective forms and so treatment may need to be escalated if simple hygiene methods fail. If the symptoms are not improving after 7 days then a penile skin swab should be taken
Children with recurrent or chronic balanitis should be referred to a paediatrician or a dermatologist.
Kayden is diagnosed with phimosis and is prescribed four weeks of topic steroid cream. When he is seen for another matter a month later you enquire as to his problem and find that he no longer misses his target.
You’re working as the paeds reg overnight at a regional centre when ED phones you about an incoming patient – Josef, 8 – who’s in a delayed intensification cycle of his treatment for ALL and has a fever of 38.6oC. Josef’s last chemotherapy was last week, and an FBC done 2 days ago showed WCC 4.0×109/L with an absolute neutrophil count 0.9×109/L.
Febrile neutropaenia may be the only feature of a life-threatening infection, a major cause of morbidity and mortality in paediatric oncology patients. A 2005 study of over 12000 children established a mortality rate as high as 3%. Around 1 in 5 children will have microbiologic evidence of infection during induction chemotherapy, and this number jumps to ~40% if the fever returns upon ceasing antibiotic therapy.
You move Josef to a resus bay with isolation (and cytotoxic) procedures in place. He is febrile to 38.6oC, mildly tachycardic but normotensive. You do not identify an immediate threat to life after considering shock, overwhelming sepsis, respiratory compromise. You take a thorough history and examine Josef.
Neutropenia is an absolute neutrophil count <0.5×109/L, or <1×109/L with a predicted decline to less than 0.5×109/L within 48 hours.
What is the child’s oncology diagnosis and where in the treatment course are they? Different chemotherapeutic agents have relatively stronger myeloablative effects, leading to more fulminant and predictable neutropenia. As chemo agents vary with diagnosis and cycle, it’s important to clarify which medications have been given and the number of many days since last chemotherapy.
Compliant with antifungal & pneumocystis prophylaxis? Think about PCP pneumonia in any oncology child presenting with work of breathing.
What kind of central venous access +/- last accessed? Central venous access is a double-edged sword – an essential access for chemo that allows a reduction in the number of peripheral venipuncture, but also the most common source of bacterial infection in chemo kids.
Sick contacts? Remember, just because your patient has an oncology diagnosis doesn’t mean they don’t catch other age-appropriate illnesses, like gastroenteritis, upper respiratory infections and the like. Of course, they’re often more severe, but it’s important to look!
Examine for signs of dehydration, sepsis and anaemia.
Examine the central line site. A good time to look is when the line is being accessed for cultures. Check the age of the dressing and note any erythema or cracks in the line.
Look at the skin all over.
Examine as for a fever without source.
Have a good look in the mouth – mucositis is common and a possible entry site.
Likewise, the perianal area is susceptible to skin breakdown, with or without perianal abscesses.
Take particular note of any areas of erythema.
It’s worth considering the pathophysiology of erythema; local inflammatory mediators (IL-1, IL-6, TNFa) signal neutrophils to marginate, roll and undergo diapedesis to the area of action. But in the absence of a full neutrophil response, any localized erythema will likely be reduced, and pus not formed in the usual volume.
Thus, the smallest area of erythema should be considered as a possible source for infection, especially around central access sites or surgical wounds.
FBC (are they actually neutropaenic?)
Blood culture (central lines/PICC)
Urea & electrolytes, consider calcium, magnesium, phosphate (dehydration, renal dysfunction, tumor lysis syndrome)
Liver function tests (liver dysfunction secondary to chemotherapy agents)
CXR if increased work of breathing, poor SpO2
Nasopharyngeal aspirate if rhinorrhoea (make sure the PLT >50×109/L beforehand)
Consider coagulation profile
Focused investigations as per history and examination
Stool sample if diarrhoea, with C. difficile toxin if on recent antibiotics
IV access is gained, via Josef’s tunneled central line, by an experienced staff member. Bloods are sent for FBC, culture and UEG, LFT, Ca/Mg/PO4, coags.
Most hospitals have well-established protocols for the treatment of febrile neutropenia. Be aware of where to find yours and the choice of anti-infective agents.
Start antibiotic treatment promptly; it may be life-saving. This is not a time to faff about waiting for the results of investigations as antibiotics are the treatment irrespective of any preliminary results.
Some protocols advise anti-fungal treatment in addition to antibiotics. These protocols will vary between centres and over time with changing resistance patterns.
Remember to discuss your patient with the oncologist on call; these kids will usually need admission and, on occasion, transfer to the tertiary oncology centre.
Antibiotics are the mainstay of treatment in febrile neutropaenia. Miadema and her Dutch colleagues are presently undertaking a Cochrane Review of intravenous vs oral empiric treatment of febrile neutropaenia.
The Therapeutic Guidelines currently recommends:
Piperacillin+tazobactam 100+12.5mg/kg (Max 4+0.5g) IV q8h
or cefipime 50mg/kg (Max 2g) IV q8h
or ceftazidime 50mg/kg (Max 2g) IV q8h
If you have a suspicion of MRSA, central line infection or haemodynamically unstable, add vancomycin. Gentamicin or amikacin may be indicated.
Management of Fever in the Paediatric Oncology Patient v3.0 17102012 Febrile Neutropenia Protocol QPHON QCCC
Miadema et al. [Protocol] Empirical antibiotic therapy for febrile neutropenia in pediatric cancer patients. Cochrane Library.
Afzal, S. et al. Risk Factors for Infection-Related Outcomes During Induction Therapy for Childhood Acute Lymphoblastic Leukemia, The Pediatric Infectious Disease Journal • Volume 28, Number 12, December 2009 pp 1064-68
Therapeutic Guidelines : Antibiotic. Severe Sepsis: empirical therapy (no obvious source of infection): febrile neutropenic patients. Therapeutic Guidelines Group. Revised June 2010. (etg40 July 2013)
A 4-year-old girl presents with bruising over her legs, trunk and face. Mum has noticed them appear over the last week. She has been completely well with no other symptoms. There is no history of trauma. After an anxious 1 hour wait, the bloods are back-Hb 113, WCC 7.3, Plt 8 x 109/L.
Idiopathic thrombocytopenic purpura (ITP) is a reduction in platelet count in the absence of any other cause (<100 × 109/L). Whilst normal platelets last eight to ten days, in ITP there are autoantibodies that destroy them in the first few hours. It has a peak incidence of two to five years of age (chronic ITP peaks in adolescence). There is often a recent history (one to six weeks) of a viral illness or immunisation.
The most common sign is petechiae (1-5 mm red or purple non-blanching spots) on the skin or mucosa – these indicate capillary haemorrhages. Some mucocutaneous bleeding is often seen, but it is rare for this to be severe (<5%).
Other symptoms of autoimmune disorders should NOT be present in ITP – e.g. no weight loss, rashes, alopecia, joint swelling. The examination should be normal with no hepatosplenomegaly or lymphadenopathy.
It is diagnosed by having a low platelet count with a normal haemoglobin (unlike in leukaemia, TTP, HUS and DIC). If there is a history of previous bleeding then consider other diagnoses. Bone marrow aspirate is only recommended if there is persistent bleeding in spite of a platelet count >20 × 109/L.
The answer is simple: treat the patient not the platelet count. Assess if the patient has haematuria, melaena, menorrhagia, epistaxis, mucosal bleeding or tonsillar purpura/petechiae.
Although there is variation between specialists, they will all be more concerned with the signs of wet purpura or haematuria rather than just the petechiae on the skin.
Prednisolone 1-2mg/kg OD for at least three weeks then taper
Methylprednisolone 30mg/kg/day for three days, then 20mg/kg /day for four days
Consider where there is significant bleeding (0.8-1g/kg) – can rapidly raise the platelet count Effects takes place in one to five days and lasts for two to four weeks
Only give platelets if there is an intracranial hameorrhage (ICG) or significant bleeding. Can be effective after IVIG administration and this can prolong platelet survival (otherwise transfused platelets are quickly destroyed)
Admit if there is significant bleeding: epistaxis>1 hour; haematemesis; haemoptysis, intracranial haemorrhage, melaena. Or if there is an unclear diagnosis or problematic social circumstances.
Most ITP self resolves. 80% will have resolved by six months (with or without treatment). 5% of ITP patients will have a recurrence. Although it seems counterintuitive, the lower the platelet count at the beginning, the better. Uncomplicated ITP normally has a platelet count of <20 × 109/L. Chronic ITP does not resolve within six months and accounts for 10% of ITP.
Confirmation is based on excluding other differentials such as acute leukaemia, aplastic anaemia, HUS. A full blood count and film us usually adequate to make the diagnosis.
While the platelets are low, the patient is at risk of bleeding. ICH is a serious but rare (1%) side effect. Parents should watch out for any signs of ICH, urinary bleeding, GI bleeding, excessive mucosal bleeding and menorrhagia (in older patients).
They should avoid NSAIDs while the platelet count is low.
Older children should avoid contact sports. This is completely impractical for young children so is not helpful advice – will only stress out the parents!
Patients should be reviewed within two weeks of initial presentation and have a repeat FBC. Aim for weekly GP follow up initially and then PRN until resolution.
Paediatric outpatient review at six weeks three months and six months. Refer to haematology if unclear diagnosis, unresolved after six months or a haematological malignancy is suggested by the blood count.
Pediatric EM Morsels – Wet purpura and ITP
UMEM Educational Pearls – ITP
Royal Children’s Hospital, Melbourne – Guidelines for ITP
Princess Margaret Hospital for Children – ITP Guideline
BMJ BestPractice – ITP
Grainger JD, Rees, JL, Reeves M, Bolton-Maggs PHB. Changing trends in the UK management of childhood ITP. Arch. Dis. Child. 2012;97:8-11.[/toggle]
Jaxxon, a 13-year-old boy, forgot to wear his box whilst at cricket training and was hit in the groin by a high-speed ball. He thought nothing of it as the pain disappeared after an hour or so but presented to your emergency department a day later as the pain returned and was more intense.
Torsion occurs in 1 in 4000 men less than 25 years old. It has a bimodal distribution. 65% of cases occur during puberty due to hormone-induced changes in size.
10% of cases occur in boys under one year of age. Some of these torsions may have occurred before delivery!
An undescended testis is at increased risk of torsion as is a testicle subjected to trauma.
The tunica vaginalis extends over the epididymis and spermatic cord forming a cavity in which the testicle can hang and swing freely – like the clapper of a bell.
They have an increased risk of torsion.
12% of men have this deformity at post mortem.
Nothing in the history can reliably let you rule out a torsion. The pain is often acute in onset and unremitting. It may wake the patient in the middle of the night and be associated with nausea and vomiting.
Pain due to trauma should settle within an hour or so.
They may also give a history of previous similar incidents when the testis has torted and detorted spontaneously.
The classical exam finding is of an exquisitely tender, high riding testicle with a horizontal lie though secondary hydrocele may mask this.
This is the absence of the cremasteric reflex on the side of the affected testicle. It was once thought that if the cremasteric reflex was present then it could not be torsion. Unfortunately, a number of case reports have since refuted this. Relying on the presence of the reflex to rule out torsion will lead to trouble.
Ischemia and infarction of the testis may occur within 4 hours of torsion though one study has suggested a 90% salvage rate if operated on within 6 hours of onset.
Rates of success drop to 50% by 12 hours.
Time is testicle and if you have a high degree of clinical suspicion then the patient should go to the operating room (regardless of fasting state) for surgical exploration.
If the history is greater than 12 hours and there is some diagnostic doubt then two methods of imaging modalities may be considered.
Colour-flow doppler ultrasound has a quoted sensitivity of 88% and a specificity of 90% and may also be useful in making alternative diagnoses such as epididymo-orchitis, rupture, or bleeding. However, if the testicle has spontaneously detorted the resultant hyperaemia on ultrasound can be confused for epididymo-orchitis. Tc-99 scintigraphy is 100% sensitive but is not widely available.
You could try to externally detort the testis. This does not negate the need for scrotal exploration but may buy you some time.
The key is good procedural sedation and the rotating the affected testicle as if you were opening the pages of a book.
The hydatid of Morgagni (one of five possible testicular appendages) is an embryological remnant of the Mullerian system found in the upper pole of the testis. As puberty hits raging hormones make this, and other appendages swell. This makes them more likely to twist on their precarious blood supply.
The pain of a torted hydatid is supposed to be more insidious in onset and less intense. As it becomes more ischaemic it can be visible as a small blue dot on the testicle though this may be masked by a reactive hydrocele.
Treatment is conservative with supportive underwear and NSAID’s but the diagnosis can be hard to make and so exploration is often needed.
Given the greater than 24 hour history and the possibility of testicular rupture, a colour-flow Doppler was performed. This confirmed the presence of a large haematocoele and a non-viable testis. It was removed in the operating room later the same day.
Ringdahl E, Teague L. Testicular torsion. Am Fam Physician. 2006 Nov 15;74(10):1739-43. Review. Free full text
Cuckow PM, Frank JD. Torsion of the testis. BJU Int. 2000 Aug;86(3):349-53.
Mellick LB. Torsion of the testicle: it is time to stop tossing the dice.Pediatr Emerg Care. 2012 Jan;28(1):80-6. Free full text