The MCG Pediatric Podcast

Biliary Atresia and Considerations after the Kasai Procedure

Did you know that 80% of children with biliary atresia who undergo a Kasai procedure will still require liver transplant at some point in their life? Dr. Bade, a pediatric gastroenterologist, joins medical students Tucker Oliver and Sarah Chappell to discuss evaluation and management of infants with biliary atresia. Specifically, they will:

• Discuss the presentation and diagnosis of biliary atresia
• Explain pathophysiology behind jaundice
• Discuss preoperative and postoperative recommendations for the Kasai procedure
• Review complications and outcomes of the Kasai procedure
• Share advice for navigating the diagnosis of biliary atresia with families

Special thanks to Dr. Rebecca Yang and Dr. Jennifer Tucker for peer reviewing this episode.

FREE CME Credit (requires free sign-up): https://mcg.cloud-cme.com/course/courseoverview?P=0&EID=19513 

References: 

1]          P. J. Lupo et al., “Population-based birth defects data in the United States, 2010-2014: A focus on gastrointestinal defects.,” Birth Defects Res, vol. 109, no. 18, pp. 1504–1514, Nov. 2017, doi: 10.1002/bdr2.1145.

[2]         J. L. Hartley, M. Davenport, and D. A. Kelly, “Biliary atresia,” The Lancet, vol. 374, no. 9702, pp. 1704–1713, Nov. 2009, doi: 10.1016/S0140-6736(09)60946-6.

[3]         S. S. Sundaram, C. L. Mack, A. G. Feldman, and R. J. Sokol, “Biliary atresia: Indications and timing of liver transplantation and optimization of pretransplant care.,” Liver Transpl, vol. 23, no. 1, pp. 96–109, Jan. 2017, doi: 10.1002/lt.24640.

[4]         D. Volpert, F. White, M. J. Finegold, J. Molleston, M. DeBaun, and D. H. Perlmutter, “Outcome of Early Hepatic Portoenterostomy for Biliary Atresia,” J Pediatr Gastroenterol Nutr, vol. 32, no. 3, pp. 265–269, Mar. 2001, doi: 10.1097/00005176-200103000-00006.

[5]         R. Fawaz et al., “Guideline for the Evaluation of Cholestatic Jaundice in Infants: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition.,” J Pediatr Gastroenterol Nutr, vol. 64, no. 1, pp. 154–168, Jan. 2017, doi: 10.1097/MPG.0000000000001334.

[6]         P. H. Y. Chung et al., “Life long follow up and management strategies of patients living with native livers after Kasai portoenterostomy.,” Sci Rep, vol. 11, no. 1, p. 11207, May 2021, doi: 10.1038/s41598-021-90860-w.

[7]         E. H. Gad, Y. Kamel, T. A.-H. Salem, M. A.-H. Ali, and A. N. Sallam, “Short- and long-term outcomes after Kasai operation for type III biliary atresia: Twenty years of experience in a single tertiary Egyptian center-A retrospective cohort study.,” Ann Med Surg (Lond), vol. 62, pp. 302–314, Feb. 2021, doi: 10.1016/j.amsu.2021.01.052.

[8]         A. M. Calinescu et al., “Cholangitis Definition and Treatment after Kasai Hepatoportoenterostomy for Biliary Atresia: A Delphi Process and International Expert Panel.,” J Clin Med, vol. 11, no. 3, Jan. 2022, doi: 10.3390/jcm11030494.

[9]         S. Kiriyama et al., “Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos),” J Hepatobiliary Pancreat Sci, vol. 25, no. 1, pp. 17–30, Jan. 2018, doi: 10.1002/jhbp.512.

[10]      K. Decharun, C. M. Leys, K. W. West, and S. M. E. Finnell, “Prophylactic Antibiotics for Prevention of Cholangitis in Patients With Biliary Atresia Status Post-Kasai Portoenterostomy,” Clin Pediatr (Phila), vol. 55, no. 1, pp. 66–72, Jan. 2016, doi: 10.1177/0009922815594760.

[11]      E. Jung, W.-H. Park, and S.-O. Choi, “Late complications and current status of long-term survivals over 10 years after Kasai portoenterostomy.,” J Korean Surg Soc, vol. 81, no. 4, pp. 271–5, Oct. 2011, doi: 10.4174/jkss.2011.81.4.271.

[12]      S. S. Sundaram et al., “Health related quality of life in patients with biliary atresia surviving with their native liver.,” J Pediatr, vol. 163, no. 4, pp. 1052–7.e2, Oct. 2013, doi: 10.1016/j.jpeds.2013.04.037.

[13]      B. L. Shneider et al., “Efficacy of fat-soluble vitamin supplementation in infants with biliary atresia.,” Pediatrics, vol. 130, no. 3, pp. e607-14, Sep. 2012, doi: 10.1542/peds.2011-1423.

[14]      J. P. Molleston and B. L. Shneider, “Preventing variceal bleeding in infants and children: is less more?,” Gastroenterology, vol. 145, no. 4, pp. 719–22, Oct. 2013, doi: 10.1053/j.gastro.2013.08.026.

[15]      G. Grisotti and R. A. Cowles, “Complications in pediatric hepatobiliary surgery,” Semin Pediatr Surg, vol. 25, no. 6, pp. 388–394, Dec. 2016, doi: 10.1053/j.sempedsurg.2016.10.004.

[16]      F. R. Sinatra, “Consultation with the Specialist: Liver Transplantation for Biliary Atresia,” Pediatr Rev, vol. 22, no. 5, pp. 166–168, May 2001, doi: 10.1542/pir.22-5-166.

[17]      I. Sriram and D. Nicklas, “Biliary Atresia,” Pediatr Rev, vol. 43, no. 11, pp. 659–661, Nov. 2022, doi: 10.1542/pir.2021-005287.

[18]      L. H. Rodijk et al., “Parental wellbeing after diagnosing a child with biliary atresia: A prospective cohort study.,” J Pediatr Surg, vol. 57, no. 4, pp. 649–654, Apr. 2022, doi: 10.1016/j.jpedsurg.2021.05.026.

[19]      A. Sanchez-Valle, N. Kassira, V. C. Varela, S. C. Radu, C. Paidas, and R. S. Kirby, “Biliary Atresia: Epidemiology, Genetics, Clinical Update, and Public Health Perspective.,” Adv Pediatr, vol. 64, no. 1, pp. 285–305, Aug. 2017, doi: 10.1016/j.yapd.2017.03.012.

Salicylate Toxicity Management in Children

Did you know that salicylate containing substances alone were responsible for over 6,000 cases of pediatric poison exposures in 2020? Dr. Arden Conway, a Pediatric Critical Care Physician, joins Medical Students Morgan Franklin and Ifrah Waris to discuss the evaluation and management for salicylate overdose in a pediatric patient. Specifically, they will: 

• Review the pathophysiology of salicylate toxicity
• Review the basic assessment skills for acutely ill pediatric patients
• Discuss the diagnostic options and evaluation for a child presenting with a potential salicylate overdose
• Discuss the management and monitoring of salicylate overdose
• Medications and treatments reviewed: activated charcoal, elimination enhancement, hemodialysis 
• Discuss the potential complications of salicylate overdose

Special thanks to Dr. Rebecca Yang and Dr. Jennifer Tucker for peer reviewing this episode.

FREE CME Credit (requires free sign-up): https://mcg.cloud-cme.com/course/courseoverview?P=0&EID=19512 

References: 

Anderson, M. (2021). Initial management of suspected poisoning in children and young people. Paediatrics and Child Health, 31(10), 382-387.

Chyka PA, Erdman AR, Christianson G, Wax PM, Booze LL, Manoguerra AS, Caravati EM, Nelson LS, Olson KR, Cobaugh DJ, Scharman EJ, Woolf AD, Troutman WG; Americal Association of Poison Control Centers; Healthcare Systems Bureau, Health Resources and Sevices Administration, Department of Health and Human Services. Salicylate poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(2):95-131. doi: 10.1080/15563650600907140.

Darracq, M. A., & Cantrell, F. L. (20136). Hemodialysis and extracorporeal removal after pediatric and adolescent poisoning reported to a state poison center. The Journal of Emergency Medicine., 44(6), 1101–1107. https://doi.org/10.1016/j.jemermed.2012.12.018

Espírito Santo, R., Vaz, S., Jalles, F., Boto, L., & Abecasis, F. (2017). Salicylate Intoxication in an Infant: A Case Report. Drug safety - case reports, 4(1), 23. https://doi.org/10.1007/s40800-017-0065-9

Gummin DD, Mowry JB, Beuhler MC, Spyker DA, Bronstein AC, Rivers LJ, Pham NPT, Weber J. 2020 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 38th Annual Report. Clin Toxicol (Phila). 2021 Dec;59(12):1282-1501. doi: 10.1080/15563650.2021.1989785.

Mukerji V, Alpert MA, Flaker GC, Beach CL, Weber RD. Cardiac conduction abnormalities and atrial arrhythmias associated with salicylate toxicity. Pharmacotherapy. 1986 Jan-Feb;6(1):41-3. doi: 10.1002/j.1875-9114.1986.tb03449.x.

Palmer, B. F., & Clegg, D. J. (2020). Salicylate toxicity. New England Journal of Medicine, 382(26), 2544-2555.

Runde TJ, Nappe TM. Salicylates Toxicity. [Updated 2021 Jul 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499879/

Catch Up Immunizations for Children

Immunizations are a critical component of the well child management in pediatric patients, as they are responsible for the prevention of numerous serious diseases with devastating consequences even if adequately treated. While many providers are well versed in the standard immunization schedule for children, the care and management of under-immunized children may present itself a challenge. Join Dr. Shreeti Kapoor, a general pediatrician for over 25 years, and recent Pediatric Resident graduate, Dr. Monique Bailey as they discuss caring for under-immunized children. Specifically, they will:

• Review the recommended vaccination schedule for all children, with a focus on those aged 0-4 years.
• Discuss the CDC catch-up immunization schedule with examples from three different age groups.
• Consider the special case of catch-up vaccination for international adoptees as well as interpreting records containing other immunizations (e.g. BCG vaccine) from a few examples of international endemic areas.
• Review common causes of febrile illnesses in young, vaccinated and under-immunized children.
• Examine the treatment algorithm and recommended prophylactic antibiotic options for unvaccinated or under-immunized children.
• Special thanks to Dr. Leila Stallworth, Dr. Erica Sapp and Dr. Rebecca Yang for peer reviewing this episode.

FREE CME Credit (requires free sign-up):  https://mcg.cloud-cme.com/course/courseoverview?P=0&EID=19511

References:  

Centers for Disease Control and Prevention. (2022, February 17). Birth-18 years immunization schedule. Centers for Disease Control and Prevention. Retrieved April 5, 2022, from https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html

Centers for Disease Control and Prevention. (2022, February 17). Catch-up immunization schedule. Centers for Disease Control and Prevention. Retrieved April 5, 2022, from https://www.cdc.gov/vaccines/schedules/hcp/imz/catchup.html

Finkel, L. , Ospina-Jimenez, C. , Byers, M. & Eilbert, W. (2021). Fever Without Source in Unvaccinated Children Aged 3 to 24 Months. Pediatric Emergency Care, 37 (12), e882-e885. doi: 10.1097/PEC.0000000000002249.

Starr M. (2013). Paediatric travel medicine: vaccines and medications. British journal of clinical pharmacology, 75(6), 1422–1432. https://doi.org/10.1111/bcp.12035

NHS. (2019, April 26). BCG vaccine for tuberculosis (TB) overview. NHS choices. Retrieved April 6, 2022, from https://www.nhs.uk/conditions/vaccinations/bcg-tuberculosis-tb-vaccine/

Centers for Disease Control and Prevention. (2019, October 30). Typhoid vaccine information statement. Centers for Disease Control and Prevention. Retrieved April 6, 2022, from https://www.cdc.gov/vaccines/hcp/vis/vis-statements/typhoid.html#:~:text=There%20are%20two%20vaccines%20to,as%20an%20injection%20(shot)

Lopez, A. L., Gonzales, M. L., Aldaba, J. G., & Nair, G. B. (2014). Killed oral cholera vaccines: history, development and implementation challenges. Therapeutic advances in vaccines, 2(5), 123–136. https://doi.org/10.1177/2051013614537819

Lee DID, Vanderhout S, Aglipay M, Birken CS, Morris SK, Piché-Renaud PP, Keown-Stoneman CDG, Maguire JL. Delay in childhood vaccinations during the COVID-19 pandemic. Can J Public Health. 2022 Feb;113(1):126-134. doi: 10.17269/s41997-021-00601-9

Kroger A, Bahta L, Hunter P. General best practice guidelines for immunization. Best practices guidance of the Advisory Committee on Immunization Practices (ACIP). Special situations. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/special-situations.html

Pollen-Food Allergy Syndrome (PFAS)

Have you ever eaten something and began feeling itchiness and tingling of your lips or throat? This could be due to PFAS, which stands for Pollen-Food Allergy Syndrome. PFAS is a hypersensitivity reaction that can occur in individuals who have seasonal allergic rhinitis. The symptoms are caused by a cross-reactivity between plant pollens and food proteins following the ingestion of certain fresh fruits, vegetables, and nuts. Join medical student Ryan Boykin and Pediatric Allergist Dr. Sarah Spriet as they discuss the evaluation, diagnosis, and management of PFAS.  

After listening to this episode, leaners should be able to:

• Describe the pathophysiology of PFAS
• Understand the differences between PFAS and an IgE-mediated food allergy and identify the diagnostic studies that may aid in distinguishing between the two
• Recall common foods associated with PFAS and identify their cross-reactivity patterns
• Identify which patients are at greater risk of systemic reactions and when to prescribe an epinephrine auto-injector
• Identify when to refer patients to an Allergy & Immunology subspecialist

 Special thanks to Dr. Richard Bickel and Dr. Rebecca Yang for peer review of content of this episode.

FREE CME Credit (requires free sign-up): https://mcg.cloud-cme.com/course/courseoverview?P=0&EID=19510

References:

• Bolhaar ST, et. al. Efficacy of birch-pollen immunotherapy on cross-reactive food allergy confirmed by skin tests and double-blind food challenges. Clin Exp Allergy. 2004 May;34(5):761-9. doi: 10.1111/j.1365-2222.2004.1939.x. PMID: 15144469.
• Carlson, G., & Coop, C. (2019). Pollen food allergy syndrome (PFAS): a review of current available literature. Annals of Allergy, Asthma & Immunology, 123(4), 359-365.
• Osterballe M, Hansen TK, Mortz CG, Bindslev-Jensen C. The clinical relevance of sensitization to pollen-related fruits and vegetables in unselected pollen-sensitized adults. Allergy. 2005 Feb;60(2):218-25. doi: 10.1111/j.1398-9995.2005.00674.x. PMID: 15647044.
• Poncet, P., Sénéchal, H., & Charpin, D. (2020). Update on pollen-food allergy syndrome. Expert Review of Clinical Immunology, 16(6), 561-578.
• Priyamvada Tatachar, Smita Kumar; Food-induced Anaphylaxis and Oral Allergy Syndrome. Pediatr RevApril 2008; 29 (4): e23–e27. https://doi.org/10.1542/pir.29-4-e23
• Sicherer SH. Clinical implications of cross-reactive food allergens. J Allergy Clin Immunol. 2001 Dec;108(6):881-90. doi: 10.1067/mai.2001.118515. PMID: 11742262.
• Sicherer, S. H., Warren, C. M., Dant, C., Gupta, R. S., & Nadeau, K. C. (2020). Food allergy from infancy through adulthood. The Journal of Allergy and Clinical Immunology: In Practice, 8(6), 1854-1864.

Nocturnal Enuresis

Nocturnal enuresis is a common problem for pediatric patients that can be quite distressing for children as well as their parents. In this episode join Madeline Snipes, a medical student at the Medical College of Georgia as she discusses nocturnal enuresis with Chief of Pediatric Urology at the Children's Hospital of Georgia, Dr. Bradley Morganstern, and Associate Professor of Pediatrics, Dr. Susan Goldberg, on an overview of nocturnal enuresis. Specifically, they will review: 

• The definition of nocturnal enuresis and its basic epidemiology.  
• The potential causes of nocturnal enuresis.  
• The appropriate workup for a pediatric patient with nocturnal enuresis.  
• When referral to a pediatric urologist is indicated.  
• The various treatment options for a pediatric patient with nocturnal enuresis.  
• And finally the potential sequelae that may result from untreated nocturnal enuresis. 

Special thanks to Dr. Jordan Gitlin, pediatric urologist at NYU’s Winthrop Hospital, and Dr. Shreeti Kapoor, general pediatrician and associate professor of pediatric medicine at the Medical College of Georgia at Augusta University. 

FREE CME Credit (requires free sign-up):  https://mcg.cloud-cme.com/course/courseoverview?P=0&EID=19509 

References:

1. Nevéus T, Fonseca E, Franco I, et al. Management and treatment of nocturnal enuresis—an updated standardization document from the International Children’s Continence Society. Journal of Pediatric Urology. 2020;16(1):10-19. doi:10.1016/j.jpurol.2019.12.020 
2. Järvelin MR, Vikeväinen-Tervonen L, Moilanen I, Huttunen NP. Enuresis in seven-year-old children. Acta paediatrica Scandinavica. 1988;77(1):148-153. doi:10.1111/j.1651-2227.1988.tb10614. 
3. de Sena Oliveira AC, Athanasio B da S, Mrad FC de C, et al. Attention deficit and hyperactivity disorder and nocturnal enuresis co-occurrence in the pediatric population: a systematic review and meta-analysis. Pediatric Nephrology. 2021;36(11):3547-3559. doi:10.1007/s00467-021-05083-y 
4. Forsythe WI, Redmond A. Enuresis and spontaneous cure rate. Study of 1129 enuretis. Arch Dis Child. 1974;49(4):259-263. doi:10.1136/adc.49.4.259 
5. von Gontard A, Mauer-Mucke K, Plück J, Berner W, Lehmkuhl G. Clinical behavioral problems in day- and night-wetting children. Pediatr Nephrol. 1999;13(8):662-667. doi:10.1007/s004670050677 
6. Robson WL. Clinical practice. Evaluation and management of enuresis. N Engl J Med. 2009;360(14):1429-1436. doi:10.1056/NEJMcp0808009 
7. Yeung CK, Sreedhar B, Sihoe JD, Sit FK, Lau J. Differences in characteristics of nocturnal enuresis between children and adolescents: a critical appraisal from a large epidemiological study. BJU Int. 2006;97(5):1069-1073. doi:10.1111/j.1464-410X.2006.06074.x 
8. Sá CA, Martins de Souza SA, Villela MCBVA, et al. Psychological Intervention with Parents Improves Treatment Results and Reduces Punishment in Children with Enuresis: A Randomized Clinical Trial. J Urol. 2021;205(2):570-576. doi:10.1097/JU.0000000000001351 
9. Jackson EC. Nocturnal enuresis: giving the child a "lift". J Pediatr. 2009;154(5):636-637. doi:10.1016/j.jpeds.2009.01.041 
10. Plaire JC, Pope JC 4th, Kropp BP, et al. Management of ectopic ureters: experience with the upper tract approach. J Urol. 1997;158(3 Pt 2):1245-1247. 
11. Alnatour IM, Alnashrati T. Nocturnal Enuresis. Middle East Journal of Family Medicine. 2022;20(7):127-131. doi:10.5742/MEWFM.2022.9525106 
12. van Summeren JJGT, Holtman GA, van Ommeren SC, Kollen BJ, Dekker JH, Berger MY. Bladder Symptoms in Children With Functional Constipation: A Systematic Review. J Pediatr Gastroenterol Nutr. 2018;67(5):552-560. doi:10.1097/MPG.0000000000002138 
13. Brownrigg N, Braga LH, Rickard M, et al. The impact of a bladder training video versus standard urotherapy on quality of life of children with bladder and bowel dysfunction: A randomized controlled trial. J Pediatr Urol. 2017;13(4):374.e1-374.e8. doi:10.1016/j.jpurol.2017.06.005 

The Early Days of the Newborn Infant

Bringing home and caring for a newborn can be overwhelming for a new caregiver, but proper guidance and education in the newborn nursery can alleviate many worries… and be lifesaving! Dr. Nirupma Sharma, a Pediatric Hospitalist, is joined by fourth year medical student, and future pediatrician, Grace Porter to discuss key educational areas of newborn care essential for pediatricians and caregivers to know upon discharge from the hospital. Specifically, they will:

• Review key environmental safety factors for the newborn including safe sleep practices, smoke avoidance, caregiver awareness, infectious exposures, and car safety.
• Discuss normal feeding, voiding, stooling, and spitting up patterns for newborns with anticipatory guidelines for caregivers if infants deviate from those patterns.
• Special thanks to Dr. Alice Little Caldwell and Dr. Rebecca Yang for peer reviewing this episode.

FREE CME Credit (requires free sign-up): https://mcg.cloud-cme.com/course/courseoverview?P=0&EID=19508

References: 

1. Rachel Y. Moon, Rebecca F. Carlin, Ivan Hand, THE TASK FORCE ON SUDDEN INFANT DEATH SYNDROME AND THE COMMITTEE ON FETUS AND NEWBORN; Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment. Pediatrics July 2022; 150 (1): e2022057990. 10.1542/peds.2022-057990
2. Johanna B. Warren, Carrie A. Phillipi; Care of the Well Newborn. Pediatr Rev January 2012; 33 (1): 4–18. https://doi.org/10.1542/pir.33-1-4
3. American Academy of Pediatrics. (2022, March 16). Shaken baby syndrome: Protect your infant from abusive head trauma. HealthyChildren.org. Retrieved March 7, 2023, from https://www.healthychildren.org/English/safety-prevention/at-home/Pages/Abusive-Head-Trauma-Shaken-Baby-Syndrome.aspx
4. Centers for Disease Control and Prevention. (2022, June 21). Data and statistics for SIDS and SUID. Centers for Disease Control and Prevention. Retrieved March 7, 2023, from https://www.cdc.gov/sids/data.htm
5. Dangers of Secondhand Smoke . Pediatric Patient Education 2021; 10.1542/peo_document025
6. American Academy of Pediatrics. (2021, August 5). Baby's first days: Bowel movements & urination. HealthyChildren.org. Retrieved March 7, 2023, from https://www.healthychildren.org/English/ages-stages/baby/Pages/Babys-First-Days-Bowel-Movements-and-Urination.aspx
7. Jennifer, K. (2022, May 9). How often, how much, what color: Your newborn poop and pee questions answered. Lurie Children's. Retrieved March 7, 2023, from https://www.luriechildrens.org/en/blog/what-to-know-about-newborn-poop-and-pee/
8. Pediatric Care Advice; Spitting Up (Normal Reflux). Pediatric Patient Education 2022; 10.1542/ppe_schmitt_225
9. Robert H. Pantell, Kenneth B. Roberts, William G. Adams, Benard P. Dreyer, Nathan Kuppermann, Sean T. O’Leary, Kymika Okechukwu, Charles R. Woods, SUBCOMMITTEE ON FEBRILE INFANTS; Clinical Practice Guideline: Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old. Pediatrics August 2021; 148 (2): e2021052228. 10.1542/peds.2021-052228
10. Natasha, S. K. (2022, June 30). Depression during & after pregnancy: You are not alone. HealthyChildren.org. Retrieved March 7, 2023, from https://healthychildren.org/English/ages-stages/prenatal/delivery-beyond/Pages/understanding-motherhood-and-mood-baby-blues-and-beyond.aspx
11. Dennis R. Durbin, Benjamin D. Hoffman, COUNCIL ON INJURY, VIOLENCE, AND POISON PREVENTION, Phyllis F. Agran, Sarah A. Denny, Michael Hirsh, Brian Johnston, Lois K. Lee, Kathy Monroe, Judy Schaechter, Milton Tenenbein, Mark R. Zonfrillo, Kyran Quinlan; Child Passenger Safety. Pediatrics November 2018; 142 (5): e20182460. 10.1542/peds.2018-2460

Noninvasive Respiratory Support

Noninvasive respiratory support is an important modality utilized in the pediatric critical care setting to treat respiratory failure without the use of an artificial airway. On today's discussion, pediatric critical care fellow, Dr. John-David Bruce joins pediatric hospitalist, Dr. Brynn Ehlers and Dr. Gene Fisher who is a pediatric intensivist that serves as the division chief of Pediatric Critical Care unit at the Children's Hospital of Georgia.

After listening to this podcast, learners should be able to: 

1. Recognize different types of noninvasive respiratory support
2. Have an understanding of basic settings involved in the different modes of noninvasive respiratory support
3. Discuss conditions that are most ideal for noninvasive respiratory support 
4. Recognize when it is necessary to escalate to a higher mode of respiratory support
5. Common complications of noninvasive respiratory support and how do you treat them.

FREE CME Credit (requires free sign-up):  https://mcg.cloud-cme.com/course/courseoverview?P=0&EID=19507 

References:

• Amin, R, & Arca, MJ. Feasibility of non-invasive neurally adjusted ventilator assist after congenital diaphragmatic hernia repair. Journal of Pediatric Surgery, 2019;54(3):434-438.
• Coletti, KD, Bagdure, DN, Walker, LK, Remy, KE, & Custer, JW. High-flow nasal cannula utilization in pediatric critical care. Respiratory Care, 2017;62(8):1023-1029.
• Desai, JP, & Moustarah, F. Pulmonary Compliance. StatPearls Publishing. 2021.  https://www.ncbi.nlm.nih.gov/books/NBK538324/
• Fedor, KL. Noninvasive respiratory support in infants and children. Respiratory Care, 2017;62(6):699-717.
  Franklin, D, Babl, FE, & Schlapbach, LJ, et al. A randomized trial of high-flow oxygen therapy in infants with bronchiolitis. The New England Journal of Medicine, 2018;378:1121-1131.
• Intagliata, S, Rizzo, A, & Gossman, WG. Physiology, Lung Dead Space. StatPearls Publishing. 2020. https://www.ncbi.nlm.nih.gov/books/NBK482501/
  Morrison, WE, Nelson McMillan, KL, & Shaffner, DH. (Eds.). Roger's Handbook of Pediatric Intensive Care (5th ed.). 2017. Wolters Kluwer.
• Najaf-Zadeh A, & Leclerc F. Noninvasive positive pressure ventilation for acute respiratory failure in children: a concise review. Ann Intensive Care. 2011;1(1):15. doi:10.1186/2110-5820-1-15
• Oymar, K, & Bardsen, K. Continuous positive airway pressure for bronchiolitis in a general paediatric ward; a feasibility study. BMC Pediatrics. 2014;14:122.
• Pope, JF, & Birnkrant, DJ. Noninvasive ventilation to facilitate extubation in a pediatric intensive care unit. Journal of Intensive Care Medicine. 2000;15(2):99-103. 
• Storre, JH, Bohm, P, Dreher, M, & Windisch, W. Clinical impact of leak compensation during non-invasive ventilation. Respiratory Medicine. 2009;103(10):1477-1483. 
• Silver AH, Nazif JM. Bronchiolitis. Pediatr Rev. 2019;40(11):568-576. doi:10.1542/pir.2018-0260

Acetaminophen Toxicity

Did you know that household Tylenol is one of the most common causes of both intentional and unintentional toxicity in the pediatric population? Dr. George Hsu, a Pediatric Emergency Physician, joins Dr. Rebecca Yang and Medical Students Morgan Franklin and Ifrah Waris to discuss the evaluation and management for acetaminophen overdose in a pediatric patient.  Specifically, they will: 

• Review the basic assessment skills and evaluation for a child presenting with a potential acetaminophen overdose
• Discuss the diagnostic options and monitoring of acetaminophen overdose
• Discuss how to use the Rumack-Matthew nomogram in the treatment of acetaminophen overdose
• Medications and treatments reviewed: N-acetylcysteine, activated charcoal, and gastric lavage
• Discuss the potential complications of acetaminophen overdose
• Special thanks to Dr. Rebecca Yang and Dr. Arden Conway for peer reviewing this episode.

Special thanks to Dr. Rebecca Yang and Dr. Arden Conway for peer reviewing the discussion today. 

FREE CME Credit (requires free sign-up):  https://mcg.cloud-cme.com/course/courseoverview?P=0&EID=19506

References: 

• Agrawal S, Khazaeni B. Acetaminophen Toxicity. [Updated 2021 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441917/
• Heard K. J. (2008). Acetylcysteine for acetaminophen poisoning. The New England journal of medicine, 359(3), 285–292. https://doi.org/10.1056/NEJMct0708278
• Hinson JA. Mechanism of acetaminophen-induced liver toxicity. In: Kaplowitz N, DeLeve LD, eds. Drug-Induced Liver Disease. 3rd ed. London, England: Academic Press; 2013:305-330.
• Hon KL, Hui WF, Leung AKC. Antidotes for childhood toxidromes. Drugs in Context 2021; 10: 2020-11-4. DOI: 10.7573/dic.2020-11-4
• Greene SL, Dargan PI, Jones AL. Acute poisoning: understanding 90% of cases in a nutshell. Postgrad Med J. 2005 Apr;81(954):204-16. doi: 10.1136/pgmj.2004.024794. PMID: 15811881; PMCID: PMC1743253.
• Lee J, Fan NC, Yao TC, Hsia SH, Lee EP, Huang JL, Wu HP. Clinical spectrum of acute poisoning in children admitted to the pediatric emergency department. Pediatr Neonatol. 2019 Feb;60(1):59-67. doi: 10.1016/j.pedneo.2018.04.001. Epub 2018 Apr 19. PMID: 29748113.
• Manov I, Motanis H, Frumin I, Iancu TC. Hepatotoxicity of anti-inflammatory and analgesic drugs: ultrastructural aspects. Acta Pharmacol Sin. 2006 Mar;27(3):259-72. doi: 10.1111/j.1745-7254.2006.00278.x. PMID: 16490160.
• Myers WC, Otto TA, Harris E, Diaco D, Moreno A. Acetaminophen overdose as a suicidal gesture: a survey of adolescents' knowledge of its potential for toxicity. J Am Acad Child Adolesc Psychiatry. 1992 Jul;31(4):686-90. doi: 10.1097/00004583-199207000-00016. PMID: 1644732.
• Park, B. K., Dear, J. W., & Antoine, D. J. (2015). Paracetamol (acetaminophen) poisoning. BMJ clinical evidence, 2015, 2101.
• Riordan M, Rylance G, Berry K. Poisoning in children 2: painkillers. Arch Dis Child. 2002 Nov;87(5):397-9. doi: 10.1136/adc.87.5.397. PMID: 12390909; PMCID: PMC1763068.
• Silberman J, Galuska MA, Taylor A. Activated Charcoal. [Updated 2022 Jul 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482294/
• Shekunov, J., Lewis, C. P., Vande Voort, J. L., Bostwick, J. M., & Romanowicz, M. (2021). Clinical Characteristics, Outcomes, Disposition, and Acute Care of Children and Adolescents Treated for Acetaminophen Toxicity. Psychiatric Services, appi-ps.
• Sheridan DC, Hendrickson RG, Lin AL, Fu R, Horowitz BZ. Adolescent Suicidal Ingestion: National Trends Over a Decade. J Adolesc Health. 2017 Feb;60(2):191-195. doi: 10.1016/j.jadohealth.2016.09.012. Epub 2016 Nov 23. PMID: 27889404.
• Silberman J, Galuska MA, Taylor A. Activated Charcoal. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482294/
• Runde TJ, Nappe TM. Salicylates Toxicity. [Updated 2021 Jul 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499879/
• Yarema M, Chopra P, Sivilotti MLA, Johnson D, Nettel-Aguirre A, Bailey B, Victorino C, Gosselin S, Purssell R, Thompson M, Spyker D, Rumack B. Anaphylactoid Reactions to Intravenous N-Acetylcysteine during Treatment for Acetaminophen Poisoning. J Med Toxicol. 2018 Jun;14(2):120-127. doi: 10.1007/s13181-018-0653-9. Epub 2018 Feb 8. Erratum in: J Med Toxicol. 2018 Mar 12;: PMID: 29423816; PMCID: PMC5962465.

 

Preventing Obesity Through Early Nutrition & Physical Activity

Over the past two decades the number of children with obesity has continued to rise. Obesity in childhood predisposes children to both immediate and future health risk. Dr. Rebecca Yang, a general pediatrician, joins community pediatrician Dr. Ashley Miller to discuss nutrition and physical activity recommendations throughout childhood. Specifically, they will:

• Discuss the role nutrition and physical activity plays in pediatric obesity
• Educate on nutritional requirements for healthy growth and development
• Determine on how food insecurity plays a role in obesity
• Inform about recommendations for physical activity and age-appropriate guidelines
• Understand the barriers to physical activity

Special thanks to Dr. Shreeti Kapoor who peer reviewed today’s episode.

FREE CME Credit (requires free sign-up): https://mcg.cloud-cme.com/course/courseoverview?P=0&EID=12494

References:

• American Academy of Pediatrics. (2022, May 13). Recommended Drinks for Children Age 5 & Younger. Retrieved from Healthy Children: https://www.healthychildren.org/English/healthy-living/nutrition/Pages/Recommended-Drinks-for-Young-Children-Ages-0-5.aspx
• COUNCIL ON COMMUNITY PEDIATRICS, C. O. (2015). Promoting Food Security for All Children. Pediatrics , 136(5), e1431-e1438. doi:10.1542/peds.2015-3301
• Felipe Lobelo, Natalie D. Muth, Sara Hanson, Blaise A. Nemeth, COUNCIL ON SPORTS MEDICINE AND FITNESS, SECTION ON OBESITY, Cynthia R. LaBella, M. Alison Brooks, Greg Canty, Alex B. Diamond, William Hennrikus, Kelsey Logan, Kody Moffatt, K. Brooke Pengel, Andrew R. Peterson, Paul R. Stricker, Christopher F. Bolling, Sarah Armstrong, Matthew Allen Haemer, John Rausch, Victoria Rogers, Stephanie Moore Walsh; Physical Activity Assessment and Counseling in Pediatric Clinical Settings. Pediatrics March 2020; 145 (3): e20193992. 10.1542/peds.2019-3992
• Hemmingsson E. Early Childhood Obesity Risk Factors: Socioeconomic Adversity, Family Dysfunction, Offspring Distress, and Junk Food Self-Medication. Curr Obes Rep. 2018 Jun;7(2):204-209. doi: 10.1007/s13679-018-0310-2. PMID: 29704182; PMCID: PMC5958160.
• Lee JW, Lee M, Lee J, Kim YJ, Ha E, Kim HS. The Protective Effect of Exclusive Breastfeeding on Overweight/Obesity in Children with High Birth Weight. J Korean Med Sci. 2019 Mar 8;34(10):e85. doi: 10.3346/jkms.2019.34.e85. PMID: 30886551; PMCID: PMC6417996.
• Maternal Diet. (2022, May 17). Retrieved from Center for Disease Control and Prevention: https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/diet-and-micronutrients/maternal-diet.html
• Lobelo F, Muth ND, Hanson S, Nemeth BA; COUNCIL ON SPORTS MEDICINE AND FITNESS; SECTION ON OBESITY. Physical Activity Assessment and Counseling in Pediatric Clinical Settings. Pediatrics. 2020 Mar;145(3):e20193992. doi: 10.1542/peds.2019-3992. Epub 2020 Feb 24. PMID: 32094289.
• USDA . (2022, April 22). Definitions of Food Security. Retrieved from USDA Econimic Reserach Service: https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-u-s/definitions-of-food-security/

Status Epilepticus

Status Epilepticus is one of the most common pediatric neurologic emergencies and requires prompt, targeted treatment to reduce patient morbidity and mortality. On this podcast, Pediatric Critical Care Physician, Dr. Renuka Mehta, Pediatric Resident Physician, Dr. Yvonne Ibe, and medical student, Emily Austin will discuss management for status epilepticus and rapid interventions that can be potentially lifesaving—because in seizure management, time is brain. 

FREE CME Credit (requires sign-in):  https://mcg.cloud-cme.com/course/courseoverview?P=0&EID=19530

Thank you for listening to this episode from the Department of Pediatrics at the Medical College of Georgia. An additional thanks to Dr. Lorna Bell, Dr. George Hsu, and Dr. Rebecca Yang who provided editing and peer review of today’s discussion.

If you have any comments, suggestions, or feedback- you can email us at mcgpediatricpodcast@augusta.edu

Remember that all content during this episode is intended for educational purposes only. It should not be used as medical advice to diagnose or treat any particular patient. Clinical vignette cases presented are based on hypothetical patient scenarios. Thank you for your support!

References:

Alldredge, B. K., Gelb, A. M., Isaacs, S. M., Corry, M. D., Allen, F., Ulrich, S., Gottwald, M. D., O’Neil, N., Neuhaus, J. M., Segal, M. R., & Lowenstein, D. H. (2001). A Comparison of Lorazepam, Diazepam, and Placebo for the Treatment of Out-of-Hospital Status Epilepticus. New England Journal of Medicine, 345(9), 631–637. https://doi.org/10.1056/NEJMoa002141 

Chamberlain, J. M., Kapur, J., Shinnar, S., Elm, J., Holsti, M., Babcock, L., Rogers, A., Barsan, W., Cloyd, J., Lowenstein, D., Bleck, T. P., Conwit, R., Meinzer, C., Cock, H., Fountain, N. B., Underwood, E., Connor, J. T., Silbergleit, R., Neurological Emergencies Treatment Trials, & Pediatric Emergency Care Applied Research Network investigators. (2020). Efficacy of levetiracetam, fosphenytoin, and valproate for established status epilepticus by age group (ESETT): a double-blind, responsive-adaptive, randomised controlled trial. Lancet (London, England), 395(10231), 1217–1224. https://doi.org/10.1016/S0140-6736(20)30611-5 

Chamberlain, J. M., Okada, P., Holsti, M., Mahajan, P., Brown, K. M., Vance, C., Gonzalez, V., Lichenstein, R., Stanley, R., Brousseau, D. C., Grubenhoff, J., Zemek, R., Johnson, D. W., Clemons, T. E., & Baren, J. (2014). Lorazepam vs Diazepam for Pediatric Status Epilepticus: A Randomized Clinical Trial. JAMA, 311(16), 1652. https://doi.org/10.1001/jama.2014.2625 

Chen, J., Xie, L., Hu, Y., Lan, X., & Jiang, L. (2018). Nonconvulsive status epilepticus after cessation of convulsive status epilepticus in pediatric intensive care unit patients. Epilepsy & Behavior: E&B, 82, 68–73. https://doi.org/10.1016/j.yebeh.2018.02.008 

Fine, A., & Wirrell, E. C. (2020). Seizures in Children. Pediatrics in Review, 41(7), 321–347. https://doi.org/10.1542/pir.2019-0134 

Glauser, T., Shinnar, S., Gloss, D., Alldredge, B., Arya, R., Bainbridge, J., Bare, M., Bleck, T., Dodson, W. E., Garrity, L., Jagoda, A., Lowenstein, D., Pellock, J., Riviello, J., Sloan, E., & Treiman, D. M. (2016). Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Currents, 16(1), 48–61. https://doi.org/10.5698/1535-7597-16.1.48 

Hanhan, U. A., Fiallos, M. R., & Orlowski, J. P. (2001). Status epilepticus. Pediatric Clinics of North America, 48(3), 683–694. https://doi.org/10.1016/s0031-3955(05)70334-5 

Kapur, J., Elm, J., Chamberlain, J. M., Barsan, W., Cloyd, J., Lowenstein, D., Shinnar, S., Conwit, R., Meinzer, C., Cock, H., Fountain, N., Connor, J. T., Silbergleit, R., & NETT and PECARN Investigators. (2019). Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. The New England Journal of Medicine, 381(22), 2103–2113. https://doi.org/10.1056/NEJMoa1905795 

Lyttle, M. D., Rainford, N. E. A., Gamble, C., Messahel, S., Humphreys, A., Hickey, H., Woolfall, K., Roper, L., Noblet, J., Lee, E. D., Potter, S., Tate, P., Iyer, A., Evans, V., Appleton, R. E., Pereira, M., Hardwick, S., Messahel, S., Noblet, J., … Hobden, G. (2019). Levetiracetam versus phenytoin for second-line treatment of paediatric convulsive status epilepticus (EcLiPSE): a multicentre, open-label, randomised trial. The Lancet, 393(10186), 2125–2134. https://doi.org/10.1016/S0140-6736(19)30724-X 

Raspall‐Chaure, M., Chin, R. F. M., Neville, B. G., Bedford, H., & Scott, R. C. (2007). The Epidemiology of Convulsive Status Epilepticus in Children: A Critical Review. Epilepsia, 48(9), 1652–1663. https://doi.org/https://doi.org/10.1111/j.1528-1167.2007.01175.x 

Riviello, J. J., Ashwal, S., Hirtz, D., Glauser, T., Ballaban-Gil, K., Kelley, K., Morton, L. D., Phillips, S., Sloan, E., Shinnar, S., American Academy of Neurology Subcommittee, & Practice Committee of the Child Neurology Society. (2006). Practice parameter: diagnostic assessment of the child with status epilepticus (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology, 67(9), 1542–1550. https://doi.org/10.1212/01.wnl.0000243197.05519.3d 

Sánchez Fernández, I., Abend, N. S., Agadi, S., An, S., Arya, R., Brenton, J. N., Carpenter, J. L., Chapman, K. E., Gaillard, W. D., Glauser, T. A., Goodkin, H. P., Kapur, K., Mikati, M. A., Peariso, K., Ream, M., Riviello, J., Tasker, R. C., & Loddenkemper, T. (2015). Time from convulsive status epilepticus onset to anticonvulsant administration in children. Neurology, 84(23), 2304–2311. https://doi.org/10.1212/WNL.0000000000001673 

Trinka, E., Cock, H., Hesdorffer, D., Rossetti, A. O., Scheffer, I. E., Shinnar, S., Shorvon, S., & Lowenstein, D. H. (2015). A definition and classification of status epilepticus--Report of the ILAE Task Force on Classification of Status Epilepticus. Epilepsia, 56(10), 1515–1523. https://doi.org/10.1111/epi.13121 

Welch, R. D., Nicholas, K., Durkalski-Mauldin, V. L., Lowenstein, D. H., Conwit, R., Mahajan, P. V., Lewandowski, C., Silbergleit, R., & Neurological Emergencies Treatment Trials (NETT) Network Investigators. (2015). Intramuscular midazolam versus intravenous lorazepam for the prehospital treatment of status epilepticus in the pediatric population. Epilepsia, 56(2), 254–262. https://doi.org/10.1111/epi.12905