Explore every episode of the podcast Pediatric Emergency Playbook

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Myth: “No olive, no problem”   

Reality: Rare finding, since we diagnose earlier

Pyloric stenosis occurs in young infants because the pyloric sphincter hypertrophies, causing near-complete obstruction of the gastric outlet.

More common in boys, preterm babies, first-born. Less common in older mothers. Association with macrolide use.

Presentation

Young infant arrives with forceful vomiting, but can’t quite get enough to eat “the hungry, hungry, not-so-hippo”.

Early presentation from 3 to 5 weeks of age: projectile vomiting

Later presentation up to 12 weeks: dehydration, failure to thrive, possibly the elusive olive

Labs may show hypOchloremic, hypOkalemic metabOlic acidosis: “all the Os”

Watch out for hyperbilirubinemia, the “icteropyloric syndrome”: unconjugated hyperbilirubinemia from dehydration.

Ultrasound shows a pylorus of greater than 3 mm wide and 14 mm long.  Memory aid: 3.14 is “pi”.  In pyloric stenosis, π-lorus > 3 x 14

Treatment

Various options, may be deferred depending on age, availability, severity of illness, including:

Pyloromyotomy — definitive.  The Ramstedt pyloromyotomy is an open procedure and involves a involves a longitudinal incision along the pylorus, and blunt dissection just to level of the submucosa.  The laparoscopic approach (umbilicus) is less invasive but may convey an increased risk of incomplete relief of the obstruction or perforation through the mucosa.  Also, this approach involves longer OR and anesthesia time.   

Endoscopic balloon dilation – not as effective as pyloromyotomy; reserved for poor surgical candidates.

Conservative management — an NG tube is passed by IR, and the infant slowly feeds and “grows out of it”.  Atropine is sometimes used to relax the pyloric sphincter.  Also usually reserved for poor surgical candidates.

Selected references

Aboagye J, Goldstein SD, Salazar JH, Papandria D, Okoye MT, Al-Omar K, Stewart D, Lukish J, Abdullah F. Age at presentation of common pediatric surgical conditions: Reexamining dogma. J Pediatr Surg. 2014 Jun;49(6):995-9.

Bakal U, Sarac M, Aydin M, Tartar T, Kazez A. Recent changes in the features of hypertrophic pyloric stenosis. Pediatr Int. 2016 May;58(5):369-71.

Sharp WW, Chan W. Images in emergency medicine. Infant with projectile vomiting. Peristaltic abdominal waves associated with infantile hypertrophic pyloric stenosis. Ann Emerg Med. 2014 Mar;63(3):289,308.

Staerkle RF, Lunger F, Fink L, Sasse T, Lacher M, von Elm E, Marwan AI, Holland-Cunz S, Vuille-Dit-Bille RN. Open versus laparoscopic pyloromyotomy for pyloric stenosis. Cochrane Database Syst Rev. 2021 Mar 9;3(3):CD012827.

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Hernia

Myth: “If it’s not strangulated, it’s elective”

Reality: Unlike in adults, all hernias in children are repaired at the time of diagnosis because:

• The risk of incarceration and strangulation is high
• There is a 30% risk of testicular infarction due to pressure on the gonadal vessels
• It is not worth messing around and “trying to navigate the system”

Most groin hernias in children are indirect inguinal hernias (incomplete closure of processus vaginalis).

Most indirect hernias are in boys (10-fold risk), and on the right (60%). Premature babies are at higher risk as well.  15% are bilateral.

Hernias often bulge further with crying. For infants, in supine position, gently restrain their feet on the gurney.  They hate it and will cry.  For older children, have them laugh, cough, or blow through a syringe.

The “silk glove sign” is not reliable, but if found is highly suggestive of an inguinal hernia.  Roll the cord structures across the pubic tubercle.  If you feel catching, like two sheets of silk rubbed together, this suggests edema from the patent processus vaginalis.

Most (80%) incarcerated hernias can be reduced initially and admitted for surgery 24-48 hours after edema has improved.  Use age- and patient-appropriate sedation and reduce if no peritonitis or concern for strangulation.

Hydroceles usually are: non-communicating (with the abdomen); worse with crying or during the day; improve by morning; and self-resolve by age 2 without intervention.  Communicating hydroceles are: usually present at birth; are associated with a patent processus vaginalis; and are often repaired later, if not resolved by 1 or 2 years of age.

Girls may have an ovary incarcerated in hernial sac.

Open repair or laparoscopic techniques are used.  The laparoscope offers visualization of the contralateral side without significant risk of injury to vas deferens.

A metachronous hernia develops later on the other side.  Some surgeons opt to explore both sides at the time of diagnosis, others take conservative approach (small risk of fertility issues if both are open-explored)

My take: regardless of presentation, needs admission

Selected References

Abdulhai S, Glenn IC, Ponsky TA. Inguinal Hernia. Clin Perinatol. 2017 Dec;44(4):865-877

Brandt ML. Pediatric hernias. Surg Clin North Am. 2008 Feb;88(1):27-43, vii-viii. doi: 10.1016/j.suc.2007.11.006.

Esposito C, Escolino M, Cortese G, Aprea G, Turrà F, Farina A, Roberti A, Cerulo M, Settimi A. Twenty-year experience with laparoscopic inguinal hernia repair in infants and children: considerations and results on 1833 hernia repairs. Surg Endosc. 2017 Mar;31(3):1461-1468.

Olesen CS, Mortensen LQ, Öberg S, Rosenberg J. Risk of incarceration in children with inguinal hernia: a systematic review. Hernia. 2019 Apr;23(2):245-254

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Chances are, you’d be right to chalk up the pain to functional constipation — 90% of pediatric constipation is functional, multifactorial, and mostly benign — as long as it is addressed.

We’re not here for “chances are“; we’re here for “why isn’t it?“

Ask yourself, could it be:

Anatomic malformations: anal stenosis, anterior displaced anus, sacral hematoma

Metabolic: hypothyroidism, hypercalcemia, hypokalemia, cystic fibrosis, diabetes mellitus, gluten enteropathy

Neuropathic: spinal cord abnormalities, trauma, tethered cord

Neuromuscular: Hirschprung disease, intestinal neuronal dysplasia, myopathies, Down syndrome, prune belly syndrome

Connective tissue disorders: scleroderma, SLE, Ehlers-Danlos syndrome

Drugs: opioids, antacids, antihypertensives, anticholinergics, antidepressants, sympathomimetics

Ingestions: heavy metals, vitamin D overload, botulism, cow’s milk protein intolerance

Failure to thrive

Abdominal distention

Lack of lumbosacral curve

Midline pigmentation abnormalities of the lower spine

Tight, empty rectum in presence of a palpable fecal mass

Gush of fluid or air from rectum on withdrawal of finger

Absent anal wink

You gotta push the boat out of the mud before you pray for rain.

Polyethylene Glycol (PEG) 3350 (Miralax): 1 to 1.5 g/kg PO daily for 3 to 6 consecutive days.  Maximum daily dose: 100 g/day PO.  Follow-up with maintenance dose (below) for at least 2 months (usually 6 months)

Lactulose: 1.33 g/kg/dose (2 mL/kg) PO twice daily for 7 days

Mineral Oil (school-aged children): 3 mL/kg PO twice daily for 7 days

Polyethylene Glycol (PEG) 3350 (Miralax): 0.2 to 0.8 g/kg/day PO.  Maximum daily dose: 17 g/day. Maintenance dosing for Miralax may need to be tailored; up to 1 g/day maintenance.  

Lactulose: 1 to 2 g/kg/day (1.5 to 3 mL/kg/day)PO divided once or twice daily.  Maximum daily dose: 60 mL/day in adults.

Mineral Oil: 1 to 3 mL/kg/day PO divided in 1 to 2 doses; maximum daily dose: 90 mL/day

Docusate (Colace): 5 mg/kg/day PO divided QD, BID, or TID (typical adult dose 100 mg BID)

Senna, Bisocodyl — complicated regimens; use your local reference

1. Are you sure?  Have you tried oral disimpaction over days?
2. No phosphate enemas for children less than 2.
3. Saline enemas are generally safe for all ages
4. Be careful with the specific dose — please use your local reference

Selected References

Freedman SB et al. Pediatric Constipation in the Emergency Department: Evaluation, Treatment, and Outcomes. JPGN 2014;59: 327–333.

North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Clinical Practice Guideline: Evaluation and Treatment of Constipation in Infants and Children. JPGN 2006; 43:e1-e13.

Tabbers MM et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. JPGN 2014;58: 258–274.

1. Set the stage – exude confidence and be prepared
2. Choose the right cannula size – a smaller working IV is infinitely better than none
3. Feeling is better than looking – trust yourself
4. Mark the site – things get wonky when you take your hands off to disinfect
5. Tourniquets can mess you up – try to use a holder’s hand to occlude the vein
6. The holder rules – get as many hands on deck as you need.
7. Tension is good –  a little counter traction on the skin with your non-dominant hand helps to decrease the friction as the needle goes through the fascial layers.
8. Stay in line – your needle is an extension of your arm
9. Gravity is your friend – the kinder, gentler tourniquet
10. The 3 Fs – flash, flatten, and forward. Get the flash at a 30 degree angle, flatten that angle, (advance another 1mm), and advance the plastic catheter over the needle into success

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Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009.

Nellans et al. Pediatric Hand Injuires. Hand Clin. 2013 November ; 29(4): 569–578

Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009.

Adolescent with mallet finger and Kirschner wire fixation. Nellans et al. Pediatric Hand Injuires. Hand Clin. 2013 November ; 29(4): 569–578

Mallet finger in splint. Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009.

Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009.

Lee SA et al. Ultrasonography of the finger. Ultrasonography 2016; 35(2): 110-123.

Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009.

A, B: Relatively normal appearance; C: in flexion, rotational abnormality evident. Liao CY et al. Pediatric Hand and Wrist Fractures. Clin Plastic Surg 46 (2019) 425–436

Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009.

Mims L et al. Extra-Octave Fracture in a 14-Year-Old Basketball Player. Journal of Pediatrics. 2017; 186: P206-206

Same boy, after reduction and ulnar splint

Same boy, on follow-up at 17 days

Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009.

radiopaedia.org

wikipedia.org

Kiely AL et al. The optimal management of Seymour fractures in children and adolescents: a systematic review protocol. Systematic Reviews. 2020; 9 (150).

Liao CY et al. Pediatric Hand and Wrist Fractures. Clin Plastic Surg 46 (2019) 425–436

Lin JS et al. Treatment of Acute Seymour Fractures. J Pediatr Orthop. 2009; 39(1):e23-e27.

Mims L et al. Extra-Octave Fracture in a 14-Year-Old Basketball Player. Journal of Pediatrics. 2017; 186: P206-206

Mohseni M et al. Ulnar Collateral Ligament Injury. Stat Pearls. 2020

Nellans et al. Pediatric Hand Injuires. Hand Clin. 2013 November ; 29(4): 569–578

Pattni A et al. Volar Plate Avulsion Injury. Eplasty. 2016; 16: ic22.

Stevenson J et al. The use of prophylactic flucloxacillin in treatment of open fractures of the distal phalanx within an accident and emergency department: a double-blind randomized placebo-controlled trial. The Journal of Hand Surgery: British & European. 2003; 28(5): 388-394

Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009

Selected References

Bergeron MF, Devore C, et al. Council on Sports Medicine and Fitness and Council on School Health, Policy statement—Climatic heat stress and exercising children and adolescents. Pediatrics 2011; 128:e741.

Casa DJ et al. The Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs: Best-Practices Recommendations. J Athl Train. 2013 Jul-Aug; 48(4): 546–553.

DeFranco MJ et al. Environmental issues for team physicians. Am J Sports Med. 2008 Nov;36(11):2226-37.

Ishimine P. Hyperthermia. In: Pediatric Emergency Medicine, Baren JM, Rothrock SG, Brennan JA, Brown L (Eds), Saunders Elsevier, Philadelphia 2008. p.992.

Jardine DS. Heat illness and heat stroke. Pediatr Rev 2007; 28:249.

Ask yourself -- again -- why is this not... appendicitis-torsion-intussusception-etc.

Admit sick children, but most go home, so...

Selected References

Khan WA et al. Central Nervous System Manifestations of Childhood Shigellosis: Prevalence, Risk Factors, and Outcome. Pediatrics. 1999 Feb;103(2):E18

Lee JY et al. Diagnostic yield of stool culture and predictive factors for positive culture in patients with diarrheal illness. Medicine (Baltimore). 2017 Jul; 96(30): e7641.

Nelson JD et al. Treatment of Salmonella gastroenteritis with ampicillin, amoxicillin, or placebo. Pediatrics 1980; 65:1125.

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Amount needed in addition to maintenance fluids:

Add 1/2 of X to maintenance over the 1st 8 hours

Add the other 1/2 of X to maintenance over the next 16 hours

Yin et al. Bedside Escharotomies for Burns

Selected References

Mahar PD et al. Clinical differences between major burns patients deemed survivable and non-survivable on admisssion. Injury. 2015; 46:870-873.

Mathis E et al. Pediatric Thermal Burns and Treatment: A Review of Progress and Future Prospects. Medicines. 2017; 4:91.

Osuka A et al. Glycocalyx shedding is anhanced by age and correlates with increased fluid requirement in patients with major burns. Shock. 2017; 50(1):60-65.

Sebastian R et al. Percutaneous pigtail catheter in the treatment of pneumothorax in major burns: The best alternative? Burns. 2015; e24-227

Sherren PB et al. Lethal triad in severe burns. Burns. 2014; 1492-1496.

Strobel AM et al. Emergency Care of Pediatric Burns. Emerg Med Clin N AM. 2018; 441-458.

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