GSACEP Lecture Series: Pediatric Update by Dr. Nadia Pearson

Hear the latest for the littles from pediatric EM physician Dr. Nadia Pearson.

Transcript

Nadia Pearson: 1:15

All right. So good afternoon. Thank you to Dr. Tilly and team for inviting me back to lecture. It's been probably several years now that I have been back to lecture. I think 2019 was the last time. So a little bit about me. So I'm Dr. Nadia Pearson, I am currently the command surgeon at the a med Medical Center of Excellence. And I will be taking over as the chief of the Department of Operational Medicine come May. So I have a fellowship training in pediatric emergency medicine. And also I am board eligible for EMS. So wealth of experience, I like to lecture on lots of topics that are relevant, lots of things that I get questions on personally, phone calls, etc. There's so much information out there. And I feel like in general, the emergency medicine physician does a really great job of resuscitating and knowing lots about pediatric things. It's just the very small chunk of Pediatrics like the congenital lesions, the things that you don't see very often the parents dealing with those kind of interactions that really trip us up sometimes. Okay, so just a couple of things. And this intro slide here. So the calls that I've been getting recently are through the referral center, and it's more from people from folks that are downrange in certain areas, who's deployed here and has not seen a kid downrange. Okay, look around, there's not anybody that has raised their hand. Right. So I just want to point that out. Because when we when I first got into the military, I really didn't think about pediatrics when I was going to be deployed, preparing for deployments. And I think the majority of patients that I saw, specifically on my first deployment, this was back in Iraq was pediatric cases. And for sure, I was not ready for it. We had no pediatric trauma cases, no equipment that was small enough. We didn't have protocols, obviously, you know, we had some emergency physicians that were there, but the experiences from that I've kind of taken to heart and to take taken with me. So lately, who have we had to deal with as far as pediatrics, it's been the refugees. So the Afghan mission, kids down at the border, and we're getting more and more phone calls about those kinds of things. And who are these kids? These kids are the ones that don't have really good medical care, like you would expect being in the United States in an emergency department. So lack of vaccines, lack of access to care, lots of precipitous deliveries that we've gotten phone calls on precipitated precipitous deliveries, not only just they didn't know, they were pregnant, or they knew they were pregnant, and had no idea what gestational age they were so very difficult to deal with, especially when we're talking to them over the phone. Okay, so what are we going to talk about specifically? So this slide, in particular, has given me a lot of angst, because most of all of us are all add type personalities, right? So we like to have things that are very much chunked, and you notice that there's 11 things on here and not 10. So my kids are actually here with me today, and they can vouch for this, like, for example, at the gas station, you have to stop pumping your gas at a zero or a five. So that's just kind of my role. So 11, I chose things that were that I felt that were very important. So we're gonna go through these pretty quickly. Okay. All right. This is probably, if I could tell you anything in this lecture. These updates were done in 2021. So probably the most important to you. So you probably want to get your camera's out if you haven't seen this CPGs, the clinical guidelines for pediatric fevers that were just published in August of last year. So you'll notice it says eight to 60 days old. Why does it say eight to 60 days old? Well, in that first week, majority of them are in the hospital and if you get somebody with a fever or a little infant with a fever, you're gonna do the full workup anyway, there's no real the baby's feeding. Well, the baby's you know, doing all the normal things cooing doing, you know what it's supposed to do. So first seven days, that's an automatic eight days. This is where you get the parents coming in to say, well, they're eating well, they're feeding, they're peeing, They're pooping. They're doing all the things that they're supposed to do, but they felt really warm. And they had a fever, or they had a subjective fever. All right. So, over the data for the last 40 years, we've had so many different guidelines and so many different criterias that that we have to do, there's no issue again, with a kid that doesn't look, well, you're gonna do everything along with that, the issues or the controversies come when a kid looks well, these three guidelines that I'm gonna give you are for kids that have a temperature greater than 100.3. So 100.4 or greater, that's 38.0 38.5. If you're 101.3 or higher, that's considered a high risk criteria. And I'm going to point that out into the guidelines for you. So back in the 1970s, we really didn't have a good plan for screening Group B strep, and a lot of hospital admissions, increased costs. And we were keeping kids in the hospital for a week, sometimes two weeks at a time waiting on cultures waiting on different results. And we did a full sepsis workup back then for any kid who had any sort of elevation and temperature under 90 days old. So that's three months old. So 80s to 90s. This was a new effort that decrease the amount of hospitalizations and we looked at different parameters in the research. So white blood cell count, absolute neutrophil, count bands, your analysis, all those kinds of things. And then the CSF Of course, LP, the question is always do I need to LP or not LP, so all of those things, really great 80 to 95% sensitivity. In addition, we had new criteria to look at. So this is when your Rochester criteria were developed. And this shift was towards not admitting all of those 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, where it changes with the new guideline and a new criteria, the ones that were 30 to 90 days, there, we're starting to do some more outpatient treatment with them. So they'll send the cultures, these are the parents that say, Oh, my kid is feeding well. But I didn't know what to do about the fever. I don't know if I should bring him to the doctor. And the doctors always say go to the emergency department. Those are the ones in generally in the past that we could send home with some roasts, often and outpatient cultures. Unfortunately, there's a lot of practice differentials out in the community, and most people really weren't following the criteria. So we went on. And there was a this was part of the review article from 20, August of 2021. And the AAP there was five criteria really, that they were looking at, and what really influenced all of these changes. So number one, changing bacteriology, lots of different bugs that are now in the system. And also we have a really good group B strep screening criteria. So most of the time in well developed countries, when you have a female that brings a child in or a male that brings a child in that has a fever, they have a really good maternal history of being screened for Group B strep. Okay, so less, less cases of Group B strep that we're seeing as a result of that. Also strep pneumo vaccinations. So that's going up, and then increase safety of food screening, and very, very rare where we see a case of listeria. So that's one of those board buzz questions, but we really don't see it anymore. In this age group. The other thing, cost of care has accelerated tremendously. And there's been lots of delays in care because of all these cool whiz bang things that we can do. And there's been issues with kids not getting the right antibiotics, not getting the right care not getting fluids on board sooner. You know, using either ultrasound or the translucent probes to try and put lines and all this delays, the actual care sometimes of infants, also practice variability and all the things that we can do. There's Miss treatments that happen. Number three is advanced testing. So we have all sorts of panels that we can 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 often right now is our inflammatory markers. And this is really, really Keystone for the new guidelines for to 2021. So procalcitonin is made by the thyroid, and it increases significantly with bacterial infection. So in kids specifically procalcitonin is one of those things inflammatory markers that you absolutely if you have it available at your hospital, you do want to order procalcitonin The other thing is CRP. It's made by the liver and it's also highly selective and will increase at a higher rate, and to a higher level with serious bacterial infections, so good to know about those things, improve hospital care, rapid discharges, and integration of the parents into caring for the infants and kids in the hospitals, that has been a significant improvement in trying to get the kids home sooner. And then, of course, rapidly evolving research. So we have a lot of data over these last 40 years. So collaborative multicenter trials, we're talking hundreds of 1000s of data points that lead to these clinical practice guideline changes. Alright, so here they are, this is for the eight to 21 days old. And you'll notice in have a pointer, but right in the middle, it says increased HSV risk. So increased HSV risk, what is that going to be? That's going to be pretty much anything if there's other kids around, and they have cold sores, runny nose congestion, in addition to a maternal history of HSV, or vaginal delivery. So these are the ones, especially if they have a fever in the first three weeks of life, I usually just add on the Acyclovir, empirically, since we do have PCR testing for HSV. So added on, there's really no harm in adding it on, especially if it's just a one time dose, and then you'll get your PCR back for that. So this is the guideline. And interestingly, it has nothing, everybody in this guideline is going to get the LP, and is well, we'll get a urine a blood culture, and then you perform the inflammatory markers to plus or minus the inflammatory markers are going to be very, very important for the the three weeks out from 21 to 28 days or around 29 days to do those inflammatory markers. So you can do the inflammatory markers when you do this workup. But it won't necessarily change the course of what you do. 22 to 28 days is the next chunk category. And this is a big change. Because before we had zero to 30 days, 30 to 60 days and 60 to 90 days. So there's one little week window in here that we're doing things a little bit differently in this adds the inflammatory markers, okay. And there's a lot of studies that are showing invasive, serious bacterial illness greater than 25 days is decreased down to about point 4%. So we're really trying to get these kids out of the hospital or at least not admitted and not necessarily have the full workup with us. So big takeaways with this, if their inflammatory markers are low, that's your procalcitonin. If you have it, the CRPS you don't need to LP these kiddos if they have a significant fever. In addition, if you look at the guidelines, specifically, inflammatory markers, puts fever greater than one Oh 1.3 And a significant level risks. So if you have a fever, that's 100.3 100.5. That's not necessarily a significant fever, according to this guideline with 1000s of patients enrolled with multicenter stuff, a multicenter trial procalcitonin, CRP, and I put the information up in the upper left hand corner for those triggers, you'll find it all in the figure. And it's right out of the clinical practice guidelines paper. So it's important to know this one. So if you see if you're at the top fever to 100.3 or less, and they look well. So this is a kid that you know is feeding is not vomiting, peeing pooping, you can do blood cultures, urine cultures, and not have to LP them. If that if their inflammatory markers are low. If their inflammatory markers are a little bit elevated, however you go down the LP route, it doesn't necessarily mean that you need to keep them in the hospital, but you can send them home with some medication. The two week risk of invasive bacterial illness. So if they're two weeks old, is at about 5.3. About when it goes to three weeks, it gets down to 3.3. And then this is where it comes to 1.6% of serious bacterial illness. So this is why we can send kids that are 2020 Something days old, with a fever home for care. 29 to 60 days so this is this next chunk of time. So again, these guys do not need an LP if their markers are low. Okay, And if they're they have low and they have a positive urine, you can still send them home with some antibiotics. All right, these are the ones, you're probably going to want to do some rocephin, or some follow on, just make sure you have all of your cultures pending with this. So again, the same inflammatory markers, the same cut off associated with this. So with these new guidelines, bottom line, you can send kids home that are actually pretty young, as long as you have the right information, and they're well appearing and you document it very, very well in your record. Unfortunately, I've been on several cases where the emergency physician did not document all of the criteria for being well appearing. So you know, when we got to court, we did the whole, you know, we ran through everything. And of course, the parent was like, No, my kid would need would refuse to suckle wouldn't take any feeds or anything. And of course, if you paint a picture of an infant that's not doing all the infant things that equals, you know, something that's bad. And unfortunately, you can send somebody home. And then they develop something, you know, within the next 12 hours, it doesn't necessarily mean that the emergency physician did something, especially, you know, in reviewing those cases, these labs weren't concerning at all. So just be careful with your documentation, especially when you have the 29 days old or less kids, and then make sure they also have close follow up. So this day and age, especially for those folks who are using Genesis Now, it's really easy to go from first net in Genesis and if you haven't, you'll get the pleasure of doing this turnover soon. But you'll get to send messages to the primary care team very easily. It's like a cut and paste kind of thing. Just open your message center and said, Hey, I need a close follow up for this kid tomorrow. All right, next topic of feverish concerns that we get a lot of questions on is on politesse versus granulomas and what they are both occur around the time when the umbilical cord is healing or it's drying up, both will look bright red. Both will look bright red, but the granuloma wood will look more like a cherry red and I have some pictures coming up with that there should never there should never with a granuloma if you're going to silver nitrate it be any streaking redness around it's just the granuloma tissue itself that should be read any redness around the court at all dry it up should be very concerning to us as emergency physicians for anaphylaxis and I would go ahead and treat for sepsis. And this is going back to the physiology of how infants and where the portal where in the near the liver in the portal vein, the circulation is coming from in the fetal circulation. So this bacteria spreads very, very quickly. So this is going to be your infant within six to 12 hours that is going to crash if you don't get them some antibiotics on board. So be very careful with armful itis, the one on the right hand side is going to be your granuloma, see how bright red it is. That's when you can just take a silver nitrate stick and you can you can burn it a little bit and it'll decrease the amount of bleeding and oozing that will have granulomas tend to not get infected. It's just like an over exacerbation of the tissue in that area from where the cord was. This one is really bad. The one on the left hand side that's a sepsis until proven otherwise. Okay, so this is my rundown. The two minute rundown of congenital heart disease. So in general, emergency physicians don't have to know everything about congenital heart disease to adequately treat an infant with congenital heart or or a consideration of congenital heart. So I'm going to dumb this down to like three, three or four slides here. Okay, and this is how I think about it. If you have an infant that is around two ish weeks old, and there's another spike and congenital heart around for four to five weeks, and that's usually for your sciatic lesions, you only have three different presentations that you need to worry about as an emergency physician, you have shock, and that looks like your typical shock. So you're gonna get cardiovascular collapse associated with that. You're gonna get the blueberry baby, that's the sciatic baby and they look blue, or you're gonna get a kid that looks that's in heart failure. Okay, so three different presentations. And what is heart failure? We all this bread and butter emergency medicine for adults, what does it look like? It's a kid that's having difficulty breathing. The only thing in kids that's going to be different is you're not going to see your lower extremity edema, like you would in an old person with heart failure because it usually comes on pretty rapidly. Okay, three presentations. When you read about congenital heart murmurs are something that you read about a lot. I would caution you always listen. But don't always say if they don't have a murmur, they don't have a congenital heart lesion. Because if that heart is not pumping effectively, and it's not moving the blood through wherever it needs to go through, you're not going to hear a murmur. Okay, though, the loud ones, like the machine, gun murmurs, and all of those a whole systolic 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 hear it everywhere on the chest, and you can almost feel those. Those are not the ones I'm talking about. I'm talking about, like, the other murmurs that you listen, you're like, Oh, I hear next just you can s3 Or when asked for I can't even remember back in medical school. If it's an s3 or an S four, it doesn't matter murmurs, the more murmur it's not going to guide your your treatment and your, your diagnosis. Okay, so murmurs, they're great. If it's not, I'm not going to rule out congenital heart, you always want to get a chest X ray, what is the chest X ray going to tell you? Big Heart, little heart, heart on string, something's not right with the heart. That's what it's going to tell you. The other thing when you have a kid that has difficulty breathing or is blue, sometimes they do get other things like spontaneous new modes and stuff. So you're gonna look for all the typical stuff in an infant. And then you're gonna get signs, you're gonna look for signs of pulmonary over circulation. So this is going to be your volume overloaded kid infant, who is in heart failure. So it's going to look like a fluffy chest X ray. All over. So chest X ray is pretty important with an infant. If you have a very big heart, Big Heart, heart failure, or another congenital lesion. Be very careful with kids, you're gonna have you know, to deal with the 160s to 180 heart rate, but they get a lot of arrhythmias. One trick with the EKG with little kids is do a double time, EKG, so double time it out. So it increases the length in between. And then you can actually see if there's a readme as are weird waves in there, and then you probably won't be able to interpret it. It's okay, the cardiologists will want a snapshot of it so they can look take a peek at that. So very important to get that and you'll look like a You look like a pen pro if you get the EKG double timed, pre and post ductal saturations. So the ductus arteriosus is fetal circulation, because the placenta does all the circulation and then everything gets shunted through the ductus through the rest, because you don't go to the lungs basic physiology, the ductus. So pre is going to be on the patient's right side post is going to be on the patient's left side. So make sure in your charts and all my infant charts, I always document femoral pulses, and pre and post doctoral saturations. What does that mean, you just put the pole socks on the right side, you put the pole socks on the left side. So sometimes I use the feet, sometimes they use the arm and the leg, it just kind of depends where the nurses are working, you got to work around them. The other thing is for extremity blood pressures, pediatric cardiologists will always want you to get for extremity blood pressures. The nurses freaked out about this, because it's very difficult, sometimes putting on the little teeny, teeny tiny cough on a neonate. But you gotta get them and they're pretty accurate too. And usually you can feel when you feel the femoral pulses, you can feel that they're weak, they're bounding, or they're not at all, then not at all ones will freak you out, because you'll be like, I don't feel anything. But then you go up here or you go into the brachial and like oh, it's they have to have a really great blood pressure. Why can't I feel the femoral pulses? Well, congenital lesions will do that. Okay, so you had your three presentations, right. So that was the first side, three different presentations. Okay, so left side versus right side. Again, you don't need to know specifically all the lesions but you need to know left ventricular outflow tract obstruction versus right ventricle, right ventricular outflow obstruction, okay. In general, infant hearts do not like poor cardiac output. Okay, they just, they just don't like new muscle, they like good cardiac output. If you have a child who has a left sided lesion, whatever it might be ko art, critical aortic stenosis, interrupted art hypoplastic, left, left heart syndrome, they're going to present with acidosis and metabolic derangements. Okay? If it is not diagnosed prenatally, most of your 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 blood gas and be very suspicious. Your differential for left sided lesions is going to be your typical stuff that causes metabolic acidosis in infants. So what's that going to be? sepsis, so we're all worried about sepsis. Don't forget the left heart or left heart in infants. So shock, what do you want to do to treat it, you're going to do same thing as always fluid boluses, trying to get that blood pressure up antibiotics, consider sepsis. And if no response, you're gonna go to doing your prostaglandins to open the ductus to try and get extra oxygenated blood over onto that left side. Right, so left ventricular side is not working outflow tract obstruction, you need to push 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 going to be your blueberry babies, these are your sciatic babies, these are the ones that are going to be not really to Kipnuk, they're going to look pretty well, but they're going to be blue, they're not going to be feeding very well. But they're just going to kind of be looking at you, they'll sleep they wake up and kind of do their thing. But the parents know something is not right. And usually, if they're born in a tertiary center, you're not going to see these very much because they're they have now instituted doing right and left sided blood pressures, or a pulse ox at least one time before they're discharged from the hospital. There's a lot of babies that are born at birthing centers that are not at hospitals that don't have all the access to a lot of the congenital things that you would expect. So be very careful. And especially if if they're born outside of a hospital situation, or haven't been followed by a doc provider that's been looking at all these things haven't had a an ultrasound, and they're, you know, throughout their pregnancy, be wary of that. So central diagnosis in a baby is always pathologic, there's always something going on if you have central cyanosis. So in the middle of the chest, and basically what happens, most of these will have a right to left shunt. So somehow they have to get some oxygenated blood for something over to that left side. Okay? If it is, and it's like, basically not going to the lungs. So to diagnose this, you want to do a hyperoxia test to see and all it is is you put the baby on 100% oxygen, and you see what happens and you draw a gas after that. So pre and post, pre and post pre and post oxygen. Alright, it's pretty intuitive. If you give lots of oxygen, and the lungs are working well. What would you expect your oxygen levels to do? You would expect them to go up. Right? So this is how you differentiate? Is it the lungs? There, though? Are the lungs doing what they need to do to oxygenate the blood? Or is the heart not doing what it needs to do to move the blood over. So about 150 is what you would expect your oxygen levels to go up if you put a baby on 100% Oxygen, okay, it's pretty easy. So make sure you get your chest X ray. All right. So now you guys are all experts really, at those three presentations of infants with congenital heart, you know about left sided failure, you know about right sided failure. You want to do all the labs just like normal CVC EKG. And make sure you have supportive care. So fluids and make sure you have the prostaglandins. Of course, that board question with prostaglandins. Make sure you anticipate intubation, right because every time you give prostaglandins, they just forget to breathe. This is what heart failure looks like in a kid. This is what you're going to see on the X ray. So pretty similar, although it's obviously a pediatric film, but pretty similar to the adult in terms of what it will look like fluffy all over, not necessarily in a focal area, not on the right side just kind of everywhere. And this is probably a kid that's going to end up getting intubated. And a read me is on this one too. The other thing that I did not mention as far as doing the heart exam, in kids, the liver is very telling. So even when you're giving boluses for sepsis, you want to make sure that you're feeling the liver edge, sometimes even three bolus says when we do that 20 per kilo times three thing. You'll see the liver edge just coming down during like after the second bullet, you're like, oh, no, this kid is already fluid overloaded, that should clue you in that there's something else going on cardiac, other than just plain sepsis. So anytime I'm resuscitating an infant, always have your hand on the liver. All right. Hopefully, there's no questions about cardiac stuff, but we're gonna keep moving because I got those 11 things. Another thing that we get lots of questions on whether they have fevers, or don't have fevers is rashes. For me, it's either a good rash, or it's a bad rash, and a kid and usually you can tell the difference, because kids are pretty tolerant of most things. He talks. So these are common buzzwords in pediatrics, but we don't hear it very much in the emergency department. Acne is pretty common. How do you know with acne? How do you know what's a tox seborrhea dermatitis, we get calls for impetigo all the time. And I'm like, No, it's just Sumeria. Just put them on some, you know, shampoos and stuff. And then the other thing, we saw a lot of this, and we got a lot of phone calls for candidal vaginal type rashes, and a lot of the providers pre not necessarily emergency medicine providers. But they they preempted what they were telling us like about sexual abuse, it just it automatically went to that. And this is, this is a pretty pretty common thing in pediatrics have Canada and to also have back bacteria down there. These are not secondary infections. These are not sepsis, SJS, 10, any of those bad things. So you just need to tell parents that this is not anything to worry about. So the one on the top right, is neonatal acne. And the etiology etiology of it is a lot of the androgens from the mom. And it comes in waves. Based on what if the mom is breastfeeding, that's usually the kids that we're going to see this in most often. And sometimes because you just it looks bad in pictures. Sometimes, you know, we do go ahead and treat with what we'd normally treat acne with. It's like a Benza wheel or something like that. I particularly don't like doing that because less is more with kids, they shouldn't be putting lotions, they shouldn't be putting anything on these rashes. This one is common on the right hand side here, your left, that is Millea. So they look like little teeny tiny white dots. It's very hard not to go in the parents want to squish 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 the parents will come in and say I think there's fleas in the in the crib. They just look all kind of eaten up. usually happens one or two days after birth. And again, nothing to do with this one. Interesting. You have to make sure when you're looking at these rashes, it spares the palms and soles of the feet. So you'll see this all over. But it should never be on the palms in the soles. That's that could be sepsis or something else. So this one, e tox is also very common, but don't confuse it with something else. It is rarely ever seen in preemies exactly know why it has to do with the newborn immune system and eosinophils reacting to the new environment. I believe the path of is for premieres is that they're just their immune system is not as well developed as a full term baby. So I think that's why this looks bad. But it is not. This is seborrhea it's on the hair in the scalp. This is your cradle cap. Unfortunately, some parents will take those little cradle cap combs, and they think they can just scrape this whole thing out. And I've seen some scalps that are bleeding so you can get a secondary infection if they're doing all that stuff. So you want to tell them don't don't do all that. Just some keto Connells all of that. This it looks very empathy Janus but it's not. It's just seborrhea and eczema, the one on the bottom on the right. That is eczema that has herpes in it. Okay, all eczema doesn't have herpes and I don't want you to take that away but very commonly because kids put their fingers in their mouth and you know, they they touch stuff. It's stuff Eczema is very itchy. Don't miss eczema her Peda calm okay, if you have any concern at all, send a PCR do something send a culture put them on it preemptively. Usually with eczema her Peda calm, if it's not scratched to death by the kid will have some sort of vesicles or something in the rash that you'll be able to see with that Moving on. This is your candidal rash. This almost looked exactly like a couple of pictures that I got texted from downrange, like, Hey, what is this? What do I do? I'm concerned. There's vesicles. And I'm like, Yeah, that's just diaper DERM. It's candidal it's very painful for the kid. They don't want to pee, they can get UTIs from it. I haven't had really good luck with all the DESA tins and zinc based stuff. So usually just some petroleum based protectant from the urine so the urine doesn't irritate it, and then steroids, steroids, steroids, and antifungal some some Clotrimazole will clean this right up. So the barrier thing because most people want to dry out rashes. This is not one that you want to dry out because of the issue with the urine issue, the urine contacting that. Her bandana, so this is super common. And parents get very, very frustrated when it doesn't go away. Their strep rash doesn't go away with antibiotics. All of these are variants of herby antenna, they can look terrible. They can have vesicles, they can have ptti they can have giant ulcers, steroids help if you get a lot of edematous changes in the mouth. And the other thing is magic mouthwash I usually give them you have to be careful with the Lidocaine if you mix lidocaine with Benadryl and Maalox and do like a pink magic that way, so I usually tailor to the child if they can swish and spit. The pathology or the physiology to help is usually like a coating so Maalox to coat those lesions, so they're able to drink and really that's the bottom line. You just want them to drink fluids to not get dehydrated. This is going to be about your two year old. So her Angina is a variant of hand Foot and Mouth caused by coxsackievirus or a type of crocs virus, and it's pretty classic. You'll also see vesicles with this stuff in the mouth, but don't forget, you'll also get stuff all over the hands all over the feet. And it's very common, very transmissible, not really much to do about it, other than make sure you know Tylenol, Motrin, if they have a fever and make sure they're drinking blood in the diaper. This is a pretty common one. And you would think it's mostly just from breastfeeding from maternal bleeding that they ingest and then, but there's there are other issues. In infants, female infants, withdrawal bleeding from moms, estrogen is a common ones you'll see vaginal bleeding in female infants. meckel's intussusception, I think I've seen it maybe a handful of times where they actually get the current jelly stools, mostly mostly not fishless. I have seen blood and diaper with that as well. You do want to get a workup with some labs. Basically, for the coax for that usually that's what I get just to make sure that there's not something else going on down there. And then ultrasound if you think they have an interception, just general workup, there's really not much to do as far as the actual blood in the stool. fissures is another thing when they have very hard stools. Not much to do about that either. And kids, we would not necessarily do any kind of stool treatment. Abdominal Pain mimics. There. I've been on a couple of cases where we've had some misses for abdominal pain. So abdominal pain was one of those things that kids present with pretty commonly and if you don't really think about it, you can miss something. Most recently, we've seen issues with COVID kids that have presented with abdominal pain with COVID. And no respiratory symptoms really, it's just the My stomach hurts and diarrhea. But they had when they came back the second or the third time, pretty significant mesenteric adenitis, causing inflammatory changes around the appendix and then appendicitis associated with that. So basically the COVID kasi appendicitis, but something not to miss, especially if you're routinely getting the COVID swabs and you see that don't forget, even with the abdominal pain, you have to go in and examine and don't miss the appendicitis. torsion is another thing kids won't necessarily tell you like hey, it hurts down there or localize the pain really well I always always always every every abdominal pain chart will always mention either the testes or the ovaries like why I do or do not think it's that and if you don't have a backup study to and I'm not saying you have to get that on everyone, just make sure you're thinking it through and documenting in your chart. It just this option is another one and then less Least Common has probably kidney stones, but kids infants do get kidney stones interception. So, interestingly, I had a kid, it was actually a 19 year old who had a car accident, and it was found and he said he was just so sleepy and didn't know what was wrong. And of course, we did all the trauma scans, the only thing we found was an interception. That was fairly recently so that was a new one for me. But there are two presentations of innocence option, you're either going to have the screamers and then the ones that you know go silent and the screamers go silent. I don't see that quite as often as the ones that are just like Space Cadets. Like they're just looking around like the parents like there's something wrong with my kid. And yeah, you do everything nothing really concerning on exam. And then it's just kind of spidey sense. You ultrasound me like oh, man, that's a giant assumption in there that they gotta go get reduced. So two presentations. Don't forget the second one, the Space Cadet the parent that saying something is off. I don't know what it is with my kid. With a basically benign exam, you just you know. So the only things to know about it is deception is when not to send to your friendly radiologists. So Frank peritonitis, fluid, or HSP. They have concerns with that they always need to see a pediatric surgeon strep vaginal itis This is another one that we get my head I think two or three of them calls from people downrange. This causes UTI and itching for whatever pathology don't forget the pinworms. This is a common common thing in kids to get pinworms from the vaginal area. So we do the tape test. It sounds kind of gross, but you just do the parents to do them and learn. And then they you know call back and you give them the the treatment for that sometimes you'll even see it like if you put the tape there on the back area, put their diaper back on and wait a little bit and then go back and check while you're you know, typing up their chart, you'll see them then to strep vaginitis is very, very common. From again, kids fingers itching lots of bacteria in areas the on estrogen is tissue is very, very thin. So bacteria can get in there, and then you just treat this with some antibiotics. It gets better COVID Miss D. So this was a really interesting phenomenon that we started to see probably I would say, late 2020. Or at least we noted it was something different than Kawasaki, in general COVID will increase the respect to bacterial illnesses in infants. So there is a correlation because if for example, there's COVID in the house, there's less likelihood that they're gonna bring in those kids, those infants with runny nose cough could cause congestion, because they just i It's probably just the COVID Right, so increased risk. That's very well noted in the literature from the last couple of years. Miss C is multi system inflammatory syndrome in children. And the diagnostic criteria is correlated with SARS, cov. Two, but it has a really high frequency of GI symptoms, and only GI symptoms. So 71% of them will have abdominal pain. I'm sorry, just GI symptoms in general 34% of them will have abdominal pain, 27% of them will have a lot of copious diarrhea, cough and respiratory distress, 4.5 and 9.6%. So with a respiratory virus, it's a little contrary and Contra. contradictory to say that, well, they have stomach pain, they and COVID that they don't have this, so you got to look for it. So these are a lot of bounceback kids that come back with Miss C. So 41% will have changes on their x ray whether that's enlarged cardiac silhouette from a pericardial effusion myocarditis. These kids also have extremely high inflammatory markers. So your procalcitonin is your CRPS and 63%. So more than half of these kids will require either one or two Iona tropes to maintain their blood pressure. So these are kind of sick kids. 28% of those require ventilatory support of the ones who are diagnosed with MS. See, is sort of resembles Kawasaki with all of the severe cytokine storm. I think when And when COVID first came out, we were talking about the inflammatory cascade and all the things that are going on physiologically associated with that this really looks like that. This looks like a toxic shock, it looks like an extreme cytokine increase, it's usually your older kids. So this is going to be at least your five year old and older, so not so much the younger kids. So Kawasaki is going to be more so like an average around like a one to two year old. This is going to be like a 10 710 year old that comes in and pretty significant abdominal distress. Most of them will have myocardial involvement of some sort, whether that's a depressed EF, a arrhythmias, pericardial effusions pretty significantly where they need draining and then myocarditis. What are we treat them with treatments are mainly supportive, we really don't know yet exactly what to do about this other than the stuff that we normally do. So IVIG will be a treatment, steroids will be a treatment to try and help with that inflammatory cascade. And then cardio respiratory support. So like I said, a good chunk of them are going to need mechanical ventilation. For this. For the cardio portion, not so much the pulmonary issue. overall outcomes are generally favorable. So the motor mortality of somebody who's diagnosed with MS. D a child, so only about 2%. So whether that is the you know, cause of you know, the inflammatory cascade resolving or is, you know, some self limiting issues or our amazing treatment, I'm not really sure. But that's pretty low for something that's that's significant. And we don't see that very often. So Missy versus Kawasaki. So the age criteria is a giveaway for that. And the other thing is the predilection for Kawasaki for Asian infants versus with Missy, we're seeing a very large portion of African American or black babies, infants that not babies, older children that have Misty, so and there's a lot of statistics that are looking at different communities different rates Access to Care also so that that literature is evolving with that the cardiac issues are much much more prominent with Miss D, then with Kawasaki, so careful with that as well. And then we talked about those inflammatory markers, and the more we learn about it, as far as the procalcitonin, the CRP, and we're able to use those, I think we're gonna get out a diagnosis and get our treatments sooner. So we're gonna see kids getting better faster with that. So this is the last one. So bronchitis, so we don't have any new guidelines. So 2014 was actually the last time the guidelines were updated. But the thing that most people have trouble kind of wrapping their brain around is what not to do. When we see a kid that comes in wheezing, and just retracting and having lots of difficulty breathing, it's hard not to throw on some albuterol it's hard not to try some receive MC EPI, it's hard not to give them steroids and all the stuff that we were trained to do. In general, that's not indicated with bronchial itis, the bronchial is kids, you want to give them a little bit of oxygen, if they have a family history of you know, reactive airway significant asthma. Since we can't diagnose asthma, you want to 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 just get their work of breathing fixed. Once you fix that they usually do better. So again, bronchitis, don't give them steroids don't do all of the other things. hypertonic saline, we used to dump that in a lot. racemic EPI, that was like a thing of the day, too. We were doing that don't do that anymore. And you'll see a huge difference just with high flow, it turns them around really, really quickly. All right. Am I doing on time, I think I talked really fast. So that was 11 things that we went over. So hopefully you took out something of one of those things. So the new new fever guidelines. So inflammatory markers was the big thing with that. Right? So make sure you're incorporating that also the time chunks. So zero to seven days. Everybody gets the treatment for fevers, well appearing. Seven to 20 are eight to 22 days 22 to 29 days and then the older ones from there. So there's three different criteria and you can look those up. I usually have them hand On my phone to go down the algorithm, colitis, bad granulomas, not bad silver nitrate them congenital heart disease, three presentations. Then you got your left outflow tract, your right outflow tract, heart failure and you know everything about congenital heart disease Herpin Ginna, and rashes. Those are very common don't let them fool you. Blood in the diaper. Also pretty common abdominal pain and the abdominal pain COVID stuff. Don't miss appendicitis with COVID and especially in those Missy kids, get them treated early and make sure if you're thinking at all Miss D, put an ultrasound on their heart and make sure you get that chest X ray and EKG pretty quickly because they downward spiral very rapidly. Strap. That's pretty common and then finally the bronchial itis question. That was a ton of stuff. All right. Thank you