Joining Forces-the NEW ALL CHOA Emergency Department Newsletter

Welcome to the new newsletter including ALL Emergency Departments of Children’s Healthcare of Atlanta. This newsletter now includes collaboration from the Emergency Department of Scottish Rite. The information included in this newsletter combines the efforts of the two largest groups of pediatric emergency medicine physicians in the Atlanta Metro area.  The Division of Pediatric Emergency Medicine at Emory University and Pediatric Emergency Medicine Associates (PEMA). Emory Physicians staff the Hughes Spalding and Egleston EDs while PEMA physicians staff Scottish Rite and 7 other pediatric emergency departments throughout the metro area including one hospital in Chattanooga, Tennessee.  We are continuing to expand our outreach and collaborative efforts to all metro Atlanta area physicians who care for children including Emergency Medicine, Pediatric and Family Medicine Physicians.  Please feel free to forward this newsletter link to your colleagues. Don’t hold onto this valuable information pass it on. Sometimes with growing and merging  we can experience some delays thus we recognize this newsletter is delayed in publication.  Stay tuned in the next few months as our website will move to a new location and we will be offering continuing medical education.  Also check out this article on Medbytes-Partnering to Improve Pediatric Emergency Medicine Care here is the link that is accessible to those with md portal access-https://md.choa.org/articles/2017/07/20/ed-partnership-fraser-doh.

 

Please enjoy this quarter’s newsletter articles on summer safety tips and new  information on the effects of acetaminophen. Finally, see below the history of PEM (Pediatric Emergency Medicine) in Atlanta including the history of Emory Pediatric Emergency Medicine and Pediatric Emergency Medicine Associates.

 

The Story of Pediatric Emergency Medicine in Atlanta

By Thuy Bui thuy.bui@pemaweb.com

By Wendy Little
wendalyn.little@emory.edu

 

 

 

 

 

 

 

 

Children’s Healthcare of Atlanta is one of the largest and busiest pediatric healthcare systems in the United States. The three CHOA emergency departments collectively encounter over 220,000 visits per year and the hospitals, with their full complement of pediatric subspecialty providers, care for some of the sickest and most medically complex patients in the state and the region.

While specialized pediatric healthcare in Atlanta dates back to the early 1900s, there were no pediatric emergency departments and no pediatric emergency specialists in Atlanta until the mid-1980’s.  The growth of emergency medical care for children in Atlanta over the past 30 years has been phenomenal!

The first children’s hospital in Atlanta, Scottish Rite Convalescent Home for Crippled Children, opened its doors in 1915. Key movers behind this included orthopedic surgeon Dr. Michael Hoke (the hospital’s first medical director), philanthropist Mrs. “Bertie” Wardlaw, real estate developer Mr. Forrest Adair and the Scottish Rite Masons.  The hospital started out as two rented cottages in Decatur with 20 beds and became a full medical building housing 50 beds in 1919.  The medical facility stayed in Decatur until 1976 when it moved to its current seven-acre site in North Atlanta and became Scottish Rite Children’s Hospital.

The Henrietta Egleston Hospital for Children was founded in 1928.  Thomas R. Egleston Jr, a wealthy Atlantan, left money in his will for the founding of a children’s hospital to be named after his mother, Henrietta Egleston. The first Egleston hospital was located in Atlanta on what is now Ralph Magill Avenue.  In 1956 , Emory University donated land for an expanded facility on the Emory campus, thus beginning the long-standing relationship between Emory University and Egleston. The “new” Egleston Children’s Hospital on Clifton Road opened in 1959.

Pediatric Emergency Medicine (PEM) is a relatively new specialty with the first fellowship established in 1980.  The first board subspecialty exam, a collaboration of the American Board of Pediatrics and American Board of Emergency Medicine, was administered in 1992.  In 1998, Pediatric Emergency Medicine Fellowship became an accredited specialty.  There are just over 1700 Pediatric Emergency Medicine board certified physicians in the country and 68 in the State of Georgia.

Pediatric emergency medicine became available to the children of Atlanta in 1984. Pediatric emergency medicine pioneer, Dr. Joseph Simon, opened Atlanta’s first freestanding pediatric emergency department at Scottish Rite. It was comprised of eight exam rooms with one trauma bay and staffed by a group of four pediatric trained physicians doing 24 hour shifts.  During its first full year of operation, the department saw 5,000 patients. That same year, Egleston opened its Acute Treatment Area. It had two exam rooms and a four bed holding area. It was initially open for 9 hours overnight on weekdays and 24 hours per day on weekends, and saw approximately 8800 patients per year.  Patients could not walkin to the facility, but had to be referred by a physician. A formal emergency department opened in 1988 with 24-hour physician coverage. In 1986, Egleston was designated as a pediatric trauma center with Scottish Rite receiving its designation the following year.

The Hughes Spalding Pavilion opened in 1952 as a private hospital on the campus of Grady Memorial Hospital. Until 1992, pediatric patients were first seen in a 24-hour walk-in clinic on the second floor of Grady, staffed mainly by Emory pediatric residents. Seeing over 60,000 patients per year, wait times were notoriously long, with patients routinely waiting over 12 hours to be seen.  In 1992 , Hughes Spalding was re-opened as a dedicated pediatric facility, including an emergency department consisting of a six-bed observation room, an asthma room with chairs to accommodate approximately 10 patients, three private emergency department rooms, an urgent care/clinic area and a single resuscitation room. In 2006, Children’s Healthcare of Atlanta assumed clinical operations at Hughes Spalding.

In 1998, to help preserve and improve pediatric health care in the region, Scottish Rite Children’s Hospital and Egleston Children’s Healthcare System officially merged to become Children’s Healthcare of Atlanta.  With its assumption of responsibility at Hughes Spalding Children’s Hospital in 2006, Children’s Healthcare of Atlanta became one of the largest pediatric healthcare systems in the country.  Currently, the system’s three emergency departments (Egleston, Hughes Spalding, and Scottish Rite) manage more than 220,000 patient visits per year.

Each of the emergency departments has undergone major changes over the years. Today CHOA Egleston has 36 private patient rooms (including dedicated beds  for orthopedic and gynecologic care, as well as mental health rooms with video-monitoring capability) and four trauma bays, caring for more than 70,000 patients a year. In 2009,  CHOA Egleston became the first and only Level 1 Pediatric Trauma Center in the state of Georgia. Similarly CHOA Scottish Rite has 50 private patient rooms (including rooms dedicated for orthopedic and gynecologic care, and mental health rooms with video-monitoring capability) and four trauma bays. Designated as a Level 2 Pediatric Trauma Center, it now provides care for over 100,000 patients annually. CHOA Hughes Spalding underwent a major renovation in 2010. The updated facility includes a new emergency department with 32 private rooms (including rooms designated for orthopedic and gynecologic care, as well as mental health rooms with video-monitoring capability) and one resuscitation room, and provides care for more than 52,000 patients annually.

The variety of options and easy accessibility of pediatric emergency medicine care make Atlanta unique. This validates the need for all 3 Children’s Healthcare of Atlanta hospitals to collaborate and reach out to referring partners in the community and work together to improve children’s health in our community. The universal theme that joins us in our diversity of roles and practice is that we are dedicated to making all children better today and healthier tomorrow.

 

Childhood Injury

by Sarah Gard Lazarus sarah.lazarus@pemaweb.com

 

Childhood injury remains the number one cause of death for children ages 1 to 19 in the US. To address this problem, a multidisciplinary group of Children’s Healthcare of Atlanta physicians and staff from the departments of trauma, emergency medicine, advocacy, and primary care came together to form Children’s Injury Prevention Program (CHIPP) in January 2016. CHIPP’s mission is to provide a multidisciplinary approach to reduce childhood injury, both unintentional and intentional in the greater Atlanta area through evidence-based injury prevention programs, research, education, and community outreach.  CHIPP is a CHOA-based organization that has grown rapidly as a pediatric injury prevention coalition since it’s inception and includes representatives from multiple specialties at all three of CHOA’s campuses.  In addition, CHIPP partners with Safe Kids, Georgia Department of Public Health, Center for Disease Control, Injury Prevention Research Center at Emory, and the Injury Free Coalition for Kids.

The coalition is doing active work in motor vehicle safety, safe sleep, non-accidental trauma, and recently received a grant to establish a Safety Store at the Scottish Rite campus. This store will provide low-cost safety equipment, including car seats, bike helmets, and smoke detectors to families of patients. An injury prevention specialist will staff the store, and also work as a car seat technician, able to inspect car seats that were purchased on site.

As summer continues, CHIPP thanks you for reminding families of the following safety information and tips:

– Drowning is the leading cause of injury death in children ages 1 through 4

-Nothing is as effective as one-on-one supervision in drowning prevention: stay within arms reach

-If you have a pool, make sure that there is a four-sided fence surrounding it. The fence should be at least four feet tall and should have a lock on it.

-Consider taking a CPR and first-aid class

-At parties, appoint a parent as the designated “watcher”. This person should abstain form drinking, not have their phone in hand, and keep their focus on the children in the pool. They should wear a sign that establishes them as the “Water Watcher”

-Empty collapsible baby pools after each use. Children can drown in as little as an inch of water

-Anytime you go to a beach or the lake, place your child in a life jacket

Thank you for keeping children safe in our community!

Acetaminophen, Asthma, ADHD and Autism: At what point do we change our practice?

By Claudia Morris
claudia.r.morris @emory.edu

Acetaminophen (APAP, Tylenol) is the most commonly dispensed medication in the United States, representing 5% of all treatments, and is generally used to alleviate pain and/or fever. Most agree that treating pain is important, however, treatment to reduce fever is not “medically necessary”. Fever is an evolutionarily conserved natural protective mechanism to fight infection, yet unfounded fever phobia is common among parents and practitioners. This creates an ideal market for antipyretics like acetaminophen, the drug of choice for fever in young children. Originally marketed internationally in the 1950s, its use increased significantly in the 1980s due to concerns of aspirin use and Reye’s syndrome. However nearly 20 years ago, new concerns were raised about the safety of acetaminophen and its potential link to asthma1, including a case-control study that suggested that frequent acetaminophen use in adults was associated with asthma, and among those who already had asthma, with more severe disease2. The mechanism for this association was thought to be the depletion of glutathione in the lung, leading to greater oxidative stress3,4. With asthma prevalence increasing world-wide, this concern leads to more than a decade of observational research on acetaminophen use and asthma in adults, children and pregnant women, with over 2500 publications now in the literature on this topic5-19. A 2009 meta-analysis that considered all clinical and observational studies at the time, ultimately including 425,140 subjects, found a pooled odds ratio for asthma in patients using acetaminophen to be 1.6 [1.46-1.77], increased risk of asthma with prenatal acetaminophen use, and an increased risk of asthma and wheezes in both children and adults exposed to acetaminophen, with a dose-dependent response noted in many studies12. Some experts in the field have begun to take a stand: Dr. Holgate wrote “There is now overwhelming evidence establishing a link between APAP and asthma20, while Dr. McBride stated in Pediatrics “In my opinion, the balance between the likely risks and benefits of acetaminophen has shifted for children with a history or family history of asthma. I can understand how those responsible for regulation or policy statements of professional organizations might be more comfortable waiting for incontrovertible evidence. There remains a possibility that confounding variables might explain some or all of the association between APAP and asthma. For this reason, we need further studies. At present, however, I need further studies not to prove that APAP is dangerous but, rather, to prove that it is safe. Until such evidence is forthcoming I will recommend avoidance of APAP by all children with asthma or those at risk for asthma and will work to make patient’s, parents, and primary care providers aware of the possibility that APAP is detrimental to children with asthma”21. Fortunately, some reassurance was recently provided by Sheehan and colleagues, in the Acetaminophen versus Ibuprofen in Children with Asthma (AVICA) trial, a 48-week prospective, blinded, randomized controlled trial that compared the as–needed use of acetaminophen with that of ibuprofen for fever or pain in 300 children 12-59 months of age with mild-persistent asthma receiving treatment with asthma controller therapies. The investigators did not find any significant difference in the primary outcome of asthma exacerbations leading to treatment with systemic glucocorticoids or in any of the secondary outcomes between the two groups, suggesting no greater risk of asthma exacerbation with acetaminophen use compared to ibuprofen22,23. However, the AVICA trial does not address whether acetaminophen use can lead to the development of asthma in otherwise healthy children, nor whether it is associated with worsening of symptoms in children with moderate to severe asthma. Questions and clinical equipoise remain. Several large epidemiologic studies linking acetaminophen use in pregnancy and ADHD 24-26 warrant further investigation. Recent studies identifying an association of ADHD with asthma and allergies 27-30 may foreshadow a potentially unrecognized mechanistic overlap between these conditions. Epidemiologic studies linking maternal use of acetaminophen during pregnancy to increased risk of autism gives further pause 31-34. A small study linking acetaminophen but not ibuprofen use with MMR, and autism, may warrant the discouragement of acetaminophen use during vaccination until more information is available35,36.

According to a 2007 CDC report, acetaminophen is responsible for approximately 56,000 emergency department visits, 26,000 hospitalizations, and over 450 deaths per year. Now, large epidemiologic studies have found an association with acetaminophen use and asthma as well as ADHD and autism. Although a causal relationship cannot be assumed based on the current literature, more studies of safety are needed. In the meantime, just like cold medicines and antibiotic overuse, the risks of acetaminophen need to be reassessed. I personally echo the sentiments of Dr. McBride, and have changed my practice in pediatric emergency medicine. Fever is your friend. It is a physiologic mechanism with benefits. Worried caregivers need reassurance to combat fever phobia and education on appropriate use of antipyretics. Treat misery and discomfort rather than a cut-off temperature. Alternatives to acetaminophen may also be considered, however all medications have risks that need to be weighed against their true benefits.      

References

  1. Varner AE, Busse WW, Lemanske RF, Jr. Hypothesis: decreased use of pediatric aspirin has contributed to the increasing prevalence of childhood asthma. Ann Allergy Asthma Immunol. 1998;81(4):347-351.
  2. Shaheen SO, Sterne JA, Songhurst CE, Burney PG. Frequent paracetamol use and asthma in adults. Thorax. 2000;55(4):266-270.
  3. Fitzpatrick AM, Teague WG, Holguin F, Yeh M, Brown LA. Airway glutathione homeostasis is altered in children with severe asthma: evidence for oxidant stress. J Allergy Clin Immunol. 2009;123(1):146-152 e148.
  4. Stephenson ST, Hadley G, Brown LA, Fitzpatrick AM. Decreased expression of acetaminophen-metabolizing enzymes and glutathione in asthmatic children after acetaminophen exposure. J Allergy Clin Immunol. 2012;129(3):867-869.
  5. Lesko SM, Louik C, Vezina RM, Mitchell AA. Asthma morbidity after the short-term use of ibuprofen in children. Pediatrics. 2002;109(2):E20.
  6. Barr RG, Wentowski CC, Curhan GC, et al. Prospective study of acetaminophen use and newly diagnosed asthma among women. American journal of respiratory and critical care medicine. 2004;169(7):836-841.
  7. Eneli I, Sadri K, Camargo C, Jr., Barr RG. Acetaminophen and the risk of asthma: the epidemiologic and pathophysiologic evidence. Chest. 2005;127(2):604-612.
  8. Koniman R, Chan YH, Tan TN, Van Bever HP. A matched patient-sibling study on the usage of paracetamol and the subsequent development of allergy and asthma. Pediatr Allergy Immunol. 2007;18(2):128-134.
  9. Persky V, Piorkowski J, Hernandez E, et al. Prenatal exposure to acetaminophen and respiratory symptoms in the first year of life. Ann Allergy Asthma Immunol. 2008;101(3):271-278.
  10. Beasley R, Clayton T, Crane J, et al. Association between paracetamol use in infancy and childhood, and risk of asthma, rhinoconjunctivitis, and eczema in children aged 6-7 years: analysis from Phase Three of the ISAAC programme. Lancet. 2008;372(9643):1039-1048.
  11. Rebordosa C, Kogevinas M, Sorensen HT, Olsen J. Pre-natal exposure to paracetamol and risk of wheezing and asthma in children: a birth cohort study. Int J Epidemiol. 2008;37(3):583-590.
  12. Etminan M, Sadatsafavi M, Jafari S, Doyle-Waters M, Aminzadeh K, Fitzgerald JM. Acetaminophen use and the risk of asthma in children and adults: a systematic review and metaanalysis. Chest. 2009;136(5):1316-1323.
  13. Bakkeheim E, Mowinckel P, Carlsen KH, Haland G, Carlsen KC. Paracetamol in early infancy: the risk of childhood allergy and asthma. Acta Paediatr. 2011;100(1):90-96.
  14. Farquhar H, Stewart A, Mitchell E, et al. The role of paracetamol in the pathogenesis of asthma. Clin Exp Allergy. 2009;40(1):32-41.
  15. Shaheen SO, Newson RB, Sherriff A, et al. Paracetamol use in pregnancy and wheezing in early childhood. Thorax. 2002;57(11):958-963.
  16. Perzanowski MS, Miller RL, Tang D, et al. Prenatal acetaminophen exposure and risk of wheeze at age 5 years in an urban low-income cohort. Thorax. 2010;65(2):118-123.
  17. Lowe A, Abramson M, Dharmage S, Allen K. Paracetamol as a risk factor for allergic disorders. Lancet. 2009;373(9658):120; author reply 120-121.
  18. Thomsen SF, Kyvik KO, Skadhauge L, Steffensen I, Backer V. Intake of paracetamol and risk of asthma in adults. J Asthma. 2008;45(8):675-676.
  19. Beasley RW, Clayton TO, Crane J, et al. Acetaminophen use and risk of asthma, rhinoconjunctivitis, and eczema in adolescents: International Study of Asthma and Allergies in Childhood Phase Three. American journal of respiratory and critical care medicine. 2011;183(2):171-178.
  20. Holgate ST. The acetaminophen enigma in asthma. American journal of respiratory and critical care medicine. 2011;183(2):147-148.
  21. McBride JT. The association of acetaminophen and asthma prevalence and severity. Pediatrics. 2011;128(6):1181-1185.
  22. Sheehan WJ, Mauger DT, Paul IM, et al. Acetaminophen versus Ibuprofen in Young Children with Mild Persistent Asthma. N Engl J Med. 2016;375(7):619-630.
  23. Litonjua AA. Acetaminophen and Asthma–A Small Sigh of Relief? N Engl J Med. 2016;375(7):684-685.
  24. Thompson JM, Waldie KE, Wall CR, Murphy R, Mitchell EA, group ABCs. Associations between acetaminophen use during pregnancy and ADHD symptoms measured at ages 7 and 11 years. PloS one. 2014;9(9):e108210.
  25. Liew Z, Ritz B, Rebordosa C, Lee PC, Olsen J. Acetaminophen use during pregnancy, behavioral problems, and hyperkinetic disorders. JAMA Pediatr. 2014;168(4):313-320.
  26. Brandlistuen RE, Ystrom E, Nulman I, Koren G, Nordeng H. Prenatal paracetamol exposure and child neurodevelopment: a sibling-controlled cohort study. Int J Epidemiol. 2013;42(6):1702-1713.
  27. Chen MH, Su TP, Chen YS, et al. Asthma and attention-deficit/hyperactivity disorder: a nationwide population-based prospective cohort study. J Child Psychol Psychiatry. 2013;54(11):1208-1214.
  28. Tsai CJ, Chou PH, Cheng C, Lin CH, Lan TH, Lin CC. Asthma in patients with attention-deficit/hyperactivity disorder: a nationwide population-based study. Ann Clin Psychiatry. 2014;26(4):254-260.
  29. Borschuk AP, Rodweller C, Salorio CF. The influence of comorbid asthma on the severity of symptoms in children with attention-deficit hyperactivity disorder. J Asthma. 2017:1-7.
  30. Miyazaki C, Koyama M, Ota E, et al. Allergic diseases in children with attention deficit hyperactivity disorder: a systematic review and meta-analysis. BMC Psychiatry. 2017;17(1):120.
  31. Olsen J, Liew Z. Commentary: Acetaminophen use in pregnancy and neurodevelopment: attention function and autism spectrum symptoms. Int J Epidemiol. 2016;45(6):1996-1997.
  32. Avella-Garcia CB, Julvez J, Fortuny J, et al. Acetaminophen use in pregnancy and neurodevelopment: attention function and autism spectrum symptoms. Int J Epidemiol. 2016;45(6):1987-1996.
  33. Andrade C. Use of acetaminophen (paracetamol) during pregnancy and the risk of autism spectrum disorder in the offspring. J Clin Psychiatry. 2016;77(2):e152-154.
  34. Liew Z, Ritz B, Virk J, Olsen J. Maternal use of acetaminophen during pregnancy and risk of autism spectrum disorders in childhood: A Danish national birth cohort study. Autism Res. 2016;9(9):951-958.
  35. Schultz ST, Klonoff-Cohen HS, Wingard DL, Akshoomoff NA, Macera CA, Ji M. Acetaminophen (paracetamol) use, measles-mumps-rubella vaccination, and autistic disorder: the results of a parent survey. Autism. 2008;12(3):293-307.
  36. Schultz ST, Gould GG. Acetaminophen Use for Fever in Children Associated with Autism Spectrum Disorder. Autism Open Access. 2016;6(2).

 

ED Usage Tips

(ways to make things easier for your patients when referring them)

 

* Utilize CHOA App for ED/urgent care wait times

* Encourage patients to utilize MyChart to see labs

* If sending patient for a procedure, for ex: abscess drainage, fracture reduction keep them NPO

* ALWAYS call transfer center before referring a patient

* Hughes Spalding is different: no access to surgeons, no ICU, no 24 hour ultrasound, no MRI, minimal subspecialists-Hematology and the O’s (Opthalmology, Non-surgical Orthopedics, Oral Surgery)

* When referring a patient leave a cell phone number to contact you and update your colleagues on patients being referred to the ED

* Labs and X-rays can be done at the hospital as outpatients with an order from you – the patient doesn’t have to come via the ED unless you also want them seen by an ED physician.

* Respiratory viral panel testing is generally not indicated for previously healthy children in whom treatment for influenza is not necessary (or can be done on clinical grounds)

To Tamiflu or Not to Tamiflu?

 

shpic

Sherita Holmes, MD sherita.holmes@emory.edu

Every year we expect a flu epidemic which usually starts in the fall and lasts until spring (as early as October and last until late May).  According to the most recent CDC Weekly U.S. Influenza Surveillance Report (week 8 – February 25th), flu activity remains elevated in the United States; although it appears to be downtrending.1
We know that in a majority of patients; the flu manifests as a nuisance that causes our patients to have high fevers with self-limited respiratory symptoms, fatigue, and myalgias. However, we also know that in the very young (age < 2 years) or very old (age > 65 years) as well as those with underlying medical conditions (i.e. asthma, immunosuppression, diabetes, heart disease) [see Table 1]; the flu can be fatal. This flu season there have been 40 pediatric deaths reported thus far [Figure 1].1 This underscores the importance of prevention and why it is critical that we encourage flu vaccination, especially in these high risk groups.

 

While vaccination is important in preventing influenza, we can use antiviral medications to shorten the length of illness (by 1-2 days), reduce complications such as pneumonia, and lessen severity.2 Antiviral medications should be started as soon as possible – ideally within the first 48 hours of illness – for any patient with suspected or confirmed influenza who: has severe, complicated, or progressive illness; is in a high risk group; or is hospitalized.3 Consider chemoprophylaxis in patients in high risk groups with known exposure to influenza.

 

There are two classes of antivirals for influenza: neuraminidase inhibitors (oseltamivir, zanamivir) and adamantanes (amantadine, rimantadine). The adamantanes are not effective against influenza B and there are high levels of resistance against the current influenza A viruses. For 2016-2017 flu season, the CDC only recommends using the neuraminidase class of antivirals. Oseltamivir (Tamiflu) is available in pill or liquid form, while zanamivir (Relenza) only available in inhaled form. Please refer to Tables 2 and 3 for further information regarding antiviral medication age designations, contraindications, adverse effects, and dosages.3,4

 

In the battle against influenza, we must do our best to not only identify the appropriate patients that would benefit from antiviral medications, but most importantly to encourage all patients and their loved ones to get vaccinated.

 

 

 

 

CDC https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm

Table 3 Harper et al. https://doi.org/10.1086/598513

 

 

 

 

 

References:

 

  1. CDC Weekly U.S. Influenza Surveillance Report

https://gis.cdc.gov/grasp/fluview/flu_by_age_virus.html

 

  1. Campbell, Angela. CDC Expert Commentary 2016-2017 Influenza Antiviral Recommendations

http://www.medscape.com/partners/cdc/public/cdc-commentary

 

  1. Centers for Disease Control (CDC) and Prevention 2016-2017 Flu Season

https://www.cdc.gov/flu/about/season/current.htm

 

  1. Harper, S.A., Bradley, J.S., Englund, J.A., et al. Seasonal Influenza in Adults and Children—Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management: Clinical Practice Guidelines of the Infectious Diseases Society of America

https://doi.org/10.1086/598513

Pediatric Appendicitis Practice Guidelines

Reena Blanco, MD
rnarwan@emory.edu

Alesia Fleming, MD, MPH
aflemi2@emory.edu

 

Acute appendicitis is the most common, non-traumatic surgical emergency encountered in children. Early identification can lead to timely removal preventing perforation and its complications.  Abdominal pain is a common symptom in the emergency department.  To help differentiate the surgical from medical emergencies, CHOA emergency medicine, surgery and radiology teams collaborated to develop the suspected appendicitis clinical guideline.

The broad goals of the team were to:

  • Identify children with the highest risk of appendicitis
  • decrease utilization of abdominal CT to diagnose appendicitis
  • Increase utilization of the Pediatric Appendicitis Score (PAS).
  • Streamline and standardize clinical evaluation
  • Decrease time to diagnosis and definitive care

 

The guideline was implemented in 2013 using the PAS as a common language tool to better communicate across services.  Patients 5 years and older with abdominal pain for less than 72 hours** suspected of having appendicitis are evaluated according to the pathway with screening labs, given an initial IV fluid bolus and pain medication.  After this, the PAS score is calculated and used to further guide care and communicate across services for next steps.

Patients with a PAS of 0-4 have a low suspicion for appendicitis. The physician should consider other diagnoses. There is always a risk that the patient may develop further symptoms as disease progresses therefore if discharged home, these patients need to be seen by their PCP within 24 hours for re-evaluation.

A PAS of 5-7 is equivocal for appendicitis and diagnostic imaging or surgical consult is warranted.  The guideline promotes US as the exam of choice for initial evaluation.  Ultrasound has a sensitivity is 98% and specificity is 92% in identifying appendicitis in those where the appendix was clearly seen. In addition to eliminating exposure to ionizing radiation ultrasound can evaluate female patients for ovarian torsion which is part of the differential of appendicitis.  The exact correlations between radiation exposure and cancer in children is not known, and utilizing alternative imaging modalities such as ultrasound limit exposure to ionizing radiation.

If the patient has a PAS >8 there is a high suspicion for appendicitis, imaging is not required, and surgery should be immediately consulted.

The guideline does not represent a professional care standard and physicians will need to be prudent in determining most appropriate care, but it does offer an approach to abdominal pain that should help with efficiency of care and ultimate outcome of our patients.

 

**exclusions outlined in clinical practice guidelines on md.choa.org under

clinical excellence->clinical practice guidelines

 

 

Streptococcus Pharyngitis Q and A-Ask the Expert?

By Chris Van Beneden, MD MPH. GetSmart@cdc.gov

By Chris Van Beneden, MD MPH. GetSmart@cdc.gov

By Katherine Fleming-Dutra, MD GetSmart@cdc.gov

By Katherine Fleming-Dutra, MD GetSmart@cdc.gov

By Craig Shapiro, MD cshapi2@emory.edu

By Craig Shapiro, MD cshapi2@emory.edu

 

1. What are the different types of diseases that Group A strep causes?

Streptococcus pyogenes are gram-positive cocci that grow in chains. They are β -hemolytic, meaning that they exhibit a clear zone of hemolysis when grown on blood agar plates. They belong to group A in the Lancefield classification system for β-hemolytic Streptococcus, and thus are also called group A Streptococcus. Group A Streptococcus can cause a variety of infections, the most common of which is streptococcal pharyngitis or strep throat. Group A Streptococcus can also cause scarlet fever, skin infections like impetigo and cellulitis, non-suppurative complications of streptococcal infections such as acute rheumatic fever and post-streptococcal glomerulonephritis, and invasive diseases such as pneumonia, septic arthritis, septicemia, meningitis, necrotizing fasciitis, streptococcal toxic shock syndrome, and musculoskeletal and surgical wound infections.

2. What causes the rash of scarlet fever?

Scarlet fever, or scarlatina, is a strep infection that occurs with a characteristic scarlatiniform rash. The characteristic rash is red with fine papules (“sandpaper”), appearing initially on the trunk and spreading peripherally over hours to days to cover almost the entire body. Most often scarlet fever occurs with streptococcal pharyngitis but it can occur with streptococcal wound infections or impetigo. It is caused by a particular strain of group A Streptococcus that produces a pyrogenic exotoxin, which leads to the rash.

3. Should we treat patients just based on the scarlatiniform rash?

Because the differential diagnosis of scarlet fever includes viral pharyngitis with a viral exanthema and other mucocutaneous syndromes such as Kawasaki Disease and Stevens-Johnson syndrome (SJS), the diagnosis of scarlet fever should be confirmed with a rapid antigen detection test (i.e. rapid strep test) performed on a throat swab or throat culture prior to antibiotic treatment.

4. If a patient has a positive strep test, do we have to treat?

CDC encourages clinicians to follow the Infectious Diseases Society of America (IDSA) 2012 Clinical Practice Guidelines for the Diagnosis and Management of Group A Streptococcal Pharyngitis. These are national, evidence-based recommendations regarding how to diagnose and treat streptococcal pharyngitis.

Streptococcal pharyngitis is usually self-limited, even if not treated with antibiotics. However, IDSA recommends treatment with antibiotics for patients with streptococcal pharyngitis because it speeds recovery, limits transmission of group A Streptococcus to others, and most importantly, decreases the risk of acute rheumatic fever and suppurative complications (e.g., peritonsillar abscess, mastoiditis).

It is important to emphasize that IDSA recommends treatment for patients with symptomatic streptococcal pharyngitis that has been confirmed to be due to group A Streptococcus using a positive rapid antigen detection test (also called a rapid strep test) or throat culture. This is because asymptomatic colonization with group A Streptococcus is very common. In the winter, as many as 20% (1 in 5) of children can be asymptomatically colonized in the oropharynx with group A Streptococcus and will test positive by rapid strep test or throat culture. However, children with asymptomatic colonization typically do not need antibiotic treatment; these children do not have symptoms, are much less likely to transmit group A Streptococcus to others, and are very unlikely to develop suppurative or nonsuppurative complications, such as acute rheumatic fever.

A rapid strep test or throat culture should only be performed in children who have signs and symptoms of streptococcal pharyngitis. Because colonization is common, testing children who do not have signs and symptoms of strep throat leads to many false positives and unnecessary antibiotic use. IDSA states that patients with clear viral symptoms—including cough, runny nose, hoarseness, oral ulcers, conjunctivitis—do not need to be tested for group A Streptococcus because these are symptoms of viral pharyngitis.

Antibiotics have risks too—including allergies, side effects, and promotion of antibiotic resistance. Correctly selecting the patients who need a strep test can help us protect our patients from avoidable adverse drug events and antibiotic resistance.

5. Some children keep getting recurrent streptococcal pharyngitis. Why is that?

It is not uncommon to see a child several times a year with sore throat and positive test results for group A Streptococcus. Many children who appear to have recurrent streptococcal pharyngitis actually have recurrent episodes of viral pharyngitis and are asymptomatically colonized with group A Streptococcus. They test positive for group A Streptococcus because they are colonized. Repeated antibiotic treatment in these children is unnecessary because they are less likely to transmit group A Streptococcus to others and are very unlikely to develop complications. However, identifying carriers can be difficult. How to determine whether someone is a carrier is addressed in the Infectious Diseases Society of America guidelines and the Red Book.

6. What are the signs/symptoms of group A Streptococcus infection?

The main signs and symptoms of streptococcal pharyngitis are sore throat with a sudden onset, pain with swallowing, and fever. Streptococcal pharyngitis also commonly presents with patchy exudates on the tonsils and anterior cervical lymphadenopathy. Streptococcal pharyngitis may include headache, abdominal pain and vomiting, but these symptoms occur in the presence of sore throat symptoms.

Streptococcal pharyngitis does not cause cough, runny nose, hoarseness, oral ulcers or conjunctivitis. These are symptoms that more commonly occur with viral pharyngitis, and therefore neither strep testing nor antibiotics are needed for patients with these symptoms.

7. What ages commonly get strep pharyngitis?

Streptococcal pharyngitis is most common among children 5 to 15 years of age, but it can occur in adults. It is very rare in children younger than 3 years of age, as streptococcal disease in children less than 3 years of age rarely manifests as pharyngitis. Instead, young children with group A Streptococcus infection may get a mucopurulent rhinitis associated with fever, irritability, and poor appetite.

8. Which ages groups should be tested for strep pharyngitis?

Streptococcal pharyngitis is most common among children 5 through 15 years of age. Because children less than 3 years of age rarely get streptococcal pharyngitis and acute rheumatic fever is very rare in children less than 3 years, IDSA guidelines recommend against routinely testing children less than 3 years of age for streptococcal pharyngitis, as this may lead to false-positive tests and unnecessary antibiotic use. In select symptomatic children less than 3 years of age who have other risk factors for GAS pharyngitis, such as children who have an older sibling with confirmed streptococcal pharyngitis, IDSA guidelines state that testing can be considered.

9. What is the risk of scarlet fever in adults?

Scarlet fever can occur in adults if infected with the strain of group A Streptococcus that produces a pyrogenic exotoxin. However, scarlet fever is most common in children 5 to 15 years of age.

10. Is there any benefit to treating patients <2 years old?

The vast majority of children less than 3 years of age should not be tested for streptococcal pharyngitis, as this can lead to false-positive tests and unnecessary antibiotic use. In select children less than 3 years of age, such as symptomatic children who have an older sibling with confirmed streptococcal pharyngitis, IDSA guidelines state that testing can be considered.

11. When do you treat asymptomatic siblings of a child with a positive strep test? Is there a lower age limit for that? (I.e. would you treat a 6 month-old who’s 4 yea- old sibling has strep?)

IDSA guidelines specifically recommend against streptococcal testing or treating asymptomatic household contacts of patients with streptococcal pharyngitis. One-third of household contacts of children with streptococcal pharyngitis will become symptomatic, in which case testing and treatment is indicated. However, studies have shown that treating asymptomatic household contacts with penicillin is not effective at preventing them from later developing symptomatic streptococcal pharyngitis. Treating asymptomatic household contacts needlessly exposes them to the risks of antibiotics without benefiting them.

12. Is there a website/poster that is available from the CDC that we can share with our colleagues or patient families?

For more information about group A Streptococcus, please visit: http://www.cdc.gov/groupastrep/diseases-public/index.html

For more information about appropriate antibiotic use and the Get Smart: Know When Antibiotics Work Program, please visit: http://www.cdc.gov/getsmart/ Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):e86–102.

Committee on Infectious Diseases. Group A streptococcal infections. In Kimberlin DW, Brady MT, Jackson MA, Long SS, editors. 30th ed. Red Book: 2015 Report of the Committee on Infectious Diseases. Elk Grove Village (IL): American Academy of Pediatrics; 2015:732–44.

Questions answered by: Katherine Fleming-Dutra, MD, Craig Shapiro, MD, and Chris Van Beneden, MD MPH.

Dr. Fleming-Dutra is a pediatric emergency physician with the Get Smart: Know When Antibiotics Program in the Office of Antibiotic Stewardship at the Centers for Disease Control and Prevention (CDC). Dr. Shapiro is pediatric infectious diseases physician and director of the Antibiotic Stewardship Program at Children’s Healthcare of Atlanta. Dr. Van Beneden is a medical epidemiologist and expert on group A Streptococcus in the Respiratory Diseases Branch in the Division of Bacterial Diseases at CDC.