Bergmann KR, et al. Myocarditis and pericarditis in the pediatric patient: validated management strategies. Pediatr Emerg Med Pract. 2015 Jul;12(7):1-22; quiz 23.

Myocarditis and pericarditis are inflammatory conditions of the heart commonly caused by viral and autoimmune etiologies, although many cases are idiopathic. Emergency clinicians must maintain a high index of suspicion for these conditions, given the rarity and often nonspecific presentation in the pediatric population. Children with myocarditis may present with a variety of symptoms, ranging from mild flu-like symptoms to overt heart failure and shock, whereas children with pericarditis typically present with chest pain and fever. The cornerstone of therapy for myocarditis includes aggressive supportive management of heart failure, as well as administration of inotropes and antidysrhythmic medications, as indicated. Children often require admission to an intensive care setting. The acute management of pericarditis includes recognition of tamponade and, if identified, the performance of pericardiocentesis. Medical therapies may include nonsteroidal anti-inflammatory drugs and colchicine, with steroids reserved for specific populations. This review focuses on the evaluation and treatment of children with myocarditis and/or pericarditis, with an emphasis on currently available medical evidence.

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Lithium toxicity

Baird-Gunning J, et al. Lithium poisoning. J Intensive Care Med. 2017 May;32(4):249-263.

Lithium is a commonly prescribed treatment for bipolar affective disorder. However, treatment is complicated by lithium’s narrow therapeutic index and the influence of kidney function, both of which increase the risk of toxicity. Therefore, careful attention to dosing, monitoring, and titration is required. The cause of lithium poisoning influences treatment and 3 patterns are described: acute, acute-on-chronic, and chronic. Chronic poisoning is the most common etiology, is usually unintentional, and results from lithium intake exceeding elimination. This is most commonly due to impaired kidney function caused by volume depletion from lithium-induced nephrogenic diabetes insipidus or intercurrent illnesses and is also drug-induced. Lithium poisoning can affect multiple organs; however, the primary site of toxicity is the central nervous system and clinical manifestations vary from asymptomatic supratherapeutic drug concentrations to clinical toxicity such as confusion, ataxia, or seizures. Lithium poisoning has a low mortality rate; however, chronic lithium poisoning can require a prolonged hospital length of stay from impaired mobility and cognition and associated nosocomial complications. Persistent neurological deficits, in particular cerebellar, are described and the incidence and risk factors for its development are poorly understood, but it appears to be uncommon in uncomplicated acute poisoning. Lithium is readily dialyzable, and rationale support extracorporeal treatments to reduce the risk or the duration of toxicity in high-risk exposures. There is disagreement in the literature regarding factors that define patients most likely to benefit from treatments that enhance lithium elimination, including specific plasma lithium concentration thresholds. In the case of extracorporeal treatments, there are observational data in its favor, without evidence from randomized controlled trials (none have been performed), which may lead to conservative practices and potentially unnecessary interventions in some circumstances. More data are required to define the risk-benefit of extracorporeal treatments and their use (modality, duration) in the management of lithium poisoning.

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Clinical management of acute hypertension

Webb TN, Shatat IF, Miyashita Y. Therapy of acute hypertension in hospitalized children and adolescents. Curr Hypertens Rep. 2014 Apr;16(4):425.

Acute hypertension (HTN) in hospitalized children and adolescents occurs relatively frequently, and in some cases, if not recognized and treated promptly, it can lead to hypertensive crisis with potentially significant morbidity and mortality. In contrast to adults, where acute HTN is most likely due to uncontrolled primary HTN, children and adolescents with acute HTN are more likely to have secondary HTN. This review will briefly cover evaluation of acute HTN and various age-specific etiologies of secondary HTN and provide more in-depth discussion on treatment targets, potential risks of acute HTN therapy, and available pediatric data on intravenous and oral antihypertensive agents, and it proposes treatment schema including unique therapy of specific secondary HTN scenarios.

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Lead poisoning

Dapul H, Laraque D. Lead poisoning in children. Adv Pediatr. 2014 Aug;61(1):313-33.

“The management of patients with lead exposure involves not only the pharmacologic management of toxicity, but also strategies for intervention and prevention of further exposure. Once an elevated lead level is found, the local health department should be notified and a home risk assessment should be performed to determine the need for abatement strategies. With the gradual lowering of the “BLL of concern” by the CDC, the threshold for action has decreased as well. The Pediatric Environmental Health Specialty Unit Network has made recommendations on further evaluation and/or intervention based on the BLL, as outlined in Table 6 [46] .”

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PCO Webinar: Early Diagnosis and Intervention of Vascular Anomalies (Infantile Hemangiomas and Malformations)

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Early Diagnosis and Intervention of Vascular Anomalies  (Infantile Hemangiomas and Malformations)

Wednesday, May 17, 2017

3:00 – 4:00 PM EDT

We invite you to join us on Wednesday, May 17, at 3:00 PM EDT when Bernard Cohen, MD, FAAP, immediate past chair of the AAP Section on Dermatology, and Linda Rozell-Shannon, PhD, discuss the early diagnosis and intervention of vascular anomalies.

During this webinar, the presenters will:

  • Distinguish between vascular malformations and tumors in infants and children, including infantile hemangiomas.
  • Discuss the need for early referral at the 4-week well baby checkup.
  • Learn the clinical presentation, diagnosis course, and management of infantile hemangiomas.
  • Recognize markers for infantile hemangiomas that are high risk for complications.
  • Understand management guidelines for uncomplicated and complicated infantile hemangiomas.
  • Review traditional and new therapies for infantile hemangiomas.
  • Explore the psychosocial issues parents face having a child with a vascular anomaly.
  • Stress the importance of insurance approval for all treatments.

To view the webinar on May 17, please click here or use the following url:

Transient hyperphosphatasemia

Chu AS, Rothschild JG. Update on benign transient hyperphosphatasemia: recognizing an underappreciated condition. Clin Pediatr (Phila). 2016 Jun;55(6):564-6.

This case illustrates the importance for the clinician to recognize the characteristics of benign transient hyperphosphatasemia in order to avoid unnecessary subspecialty referrals or extensive laboratory testing. Incorporating Kraut’s original diagnostic criteria, [4] updated with more recent relevant literature, a presumptive diagnosis of BTH can be made in children with the following:

  1. Significantly elevated alkaline phosphatase level (median: 9 times the upper limit of normal)
  2. Age <5 years (median: 18 months)
  3. History and physical examination not suggestive of bone or liver disease
  4. Normal liver tests (AST, ALT, bilirubin, GGT)
  5. Normal electrolytes, calcium, blood urea nitrogen, and creatinine
  6. AP isoenzymes show an absolute elevation of both bone and liver fractions, but the relative predominance may be of bone, liver, or mixed origin
  7. Normal PTH and Vitamin D levels
  8. Confirm BTH with a normal AP level repeated within 3 to 4 months (median: 10 weeks).

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Superior mesenteric artery syndrome (SMAS)

Lee TH, et al. Superior mesenteric artery syndrome: where do we stand today? J Gastrointest Surg. 2012 Dec;16(12):2203-11.

This is the largest case series to document the clinical features and changes in diagnostic modalities, medical and surgical managements, and their outcomes in SMAS patients. Laparoscopic duodenojejunostomy is the preferred surgical procedure when medical management of the disease fails.

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Psychogenic nonepileptic seizures (PNES)

Takasaki K, et al. Psychogenic Nonepileptic Seizures: Diagnosis, Management, and Bioethics. Pediatr Neurol. 2016 Sep;62:3-8.

Effective diagnosis and management of PNES requires the use of video EEG and an early collaborative approach between pediatricians, neurologists, psychiatrists, nursing staff, and other professional colleagues. Ethical questions that may arise should be addressed with the virtues of competence, courage, compassion, prudence, and honesty; and the principles of respect beneficence, and the avoidance of unnecessary harm.

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Prasad M, Babiker MO. Fifteen-minute consultation: when is a seizure not a seizure? Part 1, the younger child. Arch Dis Child Educ Pract Ed. 2016 Feb; 101(1):15-20.

Paroxysmal non-epileptic events (PNEs) are common, and occur in all age groups ranging from neonates to young adults. The key to diagnosis in the majority is a detailed history and careful observation. However, a few can pose diagnostic challenges for the paediatrician to differentiate them from epileptic seizures. PNEs are usually recurrent, stereotyped and some of them tend to repeatedly occur within the same context. Although the vast majority have a benign nature, they can be a source of parental anxiety, unnecessary investigations and even potentially harmful treatments. In this review, we have described the common PNEs occurring in infants and preschool children. This will be followed by a second review for older children and adolescents. We have provided a practical diagnostic approach by dividing these events into three broad categories: PNEs associated with altered consciousness, PNEs not associated with apparently altered consciousness and sleep-related PNEs.

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See also: Fifteen-minute consultation: when is a seizure not a seizure? Part 2, the older child.

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Spontaneous pneumomediastinum

Gasser CR, et al. Pediatric Spontaneous Pneumomediastinum: Narrative Literature Review. Pediatr Emerg Care. 2016 Feb 6. [Epub ahead of print]

Spontaneous pneumomediastinum is uncommon in children but must be considered in pediatric patients with acute chest and/or neck pain. History taking, physical examination, and standard chest x-ray are most often diagnostic, and there is rarely a need for other investigation.Hospitalization is not always indispensable; ambulatory management can be considered. Outcome is good, and follow-up can be clinical, therefore avoiding further x-rays.

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Abbas PI, et al. Spontaneous pneumomediastinum in the pediatric patient. Am J Surg. 2015 Dec;210(6):1031-5; discussion 1035-6.

“This is the largest series of pediatric SPM patients to date. Our study reveals potentially no added benefit from obtaining additional imaging with chest CT or esophagographies. This suggests that patients with SPM may be managed primarily with CXRs with additional imaging obtained only when clinically indicated. In addition, we noted that patients with secondary SPM were frequently admitted to treat their underlying disease, whereas those with primary SPM were often observed and discharged home without any interventions or adverse outcomes. Because of this, we suggest that patients with primary SPM may be managed conservatively in the ED and discharged with appropriate follow-up, if they do not have respiratory concerns. These management strategies for pediatric SPM may help to decrease unnecessary hospital admissions and eliminate additional costly imaging.”

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