BRUE, Brief Resolved Unexplained Events, are a common and anxiety-provoking condition that presents to the Emergency Department. In this episode we explore the definition of BRUE, contrast it with ALTE, and walk through evidence-based approaches to risk stratification. We’ll explore the original AAP framework and two subsequent prediction models to see where the recommendations stand today. This is a classic example of scary event / well child that you will see in the Emergency Department.

Learning Objectives

By the end of this episode, you will be able to:

1. Define BRUE and contrast it with the older concept of ALTE.

2. Recognize evolving risk stratification criteria

3. Apply evidence-based strategies for evaluation and counseling of infants with BRUE, including safe discharge decisions and the role of home monitoring.

References

1. Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants: Executive summary. Pediatrics. 2016;137(5):e20160591. doi:10.1542/peds.2016-0591

2. Carroll AE, Bonkowsky JL. Acute events in infancy including brief resolved unexplained event (BRUE). In: McMillan JA, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed October 2025).

3. Carroll AE, Bonkowsky JL. Use of home cardiorespiratory monitors in infants. In: McMillan JA, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed October 2025).

4. Carroll AE, Bonkowsky JL. Sudden infant death syndrome: Risk factors and risk reduction strategies. In: McMillan JA, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed October 2025).

5. Carroll AE. Patient education: Brief resolved unexplained event (BRUE) in babies (The Basics). In: UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed October 2025).

6. Nama N, Neuman MI, Finkel MA, et al. Risk prediction after a brief resolved unexplained event. JAMA Pediatr. 2023;177(12):1263–1272. doi:10.1001/jamapediatrics.2023.4197

7. Nama N, Neuman MI, Finkel MA, et al. External validation of brief resolved unexplained events prediction rules for serious underlying diagnosis. JAMA Pediatr. 2024;178(4):398–407. doi:10.1001/jamapediatrics.2024.0114

 

 

Is that penicillin or amoxicillin allergy real? Probably not. In this episode, we explore how to assess risk, talk to parents, and refer for delabeling. You’ll also learn what happens in the allergy clinic, why the label matters, and how to be a better antimicrobial steward.

Learning Objectives

1. Describe the mechanisms and clinical manifestations of immediate and delayed hypersensitivity reactions to penicillin, including diagnostic criteria and risk stratification tools such as the PEN-FAST score.
2. Differentiate between low-, moderate-, and high-risk penicillin allergy histories in pediatric patients and identify appropriate candidates for direct oral challenge or allergy referral based on current evidence and guidelines.
3. Formulate an evidence-based approach for evaluating and counseling families in the Emergency Department about reported penicillin allergies, including when to recommend outpatient referral for formal delabeling.

Connect with Brad Sobolewski

PEMBlog: PEMBlog.com

Blue Sky: @bradsobo

X (Twitter): @PEMTweets

Instagram: Brad Sobolewski

References

Khan DA, Banerji A, Blumenthal KG, et al. Drug Allergy: A 2022 Practice Parameter Update. J Allergy Clin Immunol. 2022;150(6):1333-1393. doi:10.1016/j.jaci.2022.08.028

Moral L, Toral T, Muñoz C, et al. Direct Oral Challenge for Immediate and Non-Immediate Beta-Lactam Allergy in Children. Pediatr Allergy Immunol. 2024;35(3):e14096. doi:10.1111/pai.14096

Castells M, Khan DA, Phillips EJ. Penicillin Allergy. N Engl J Med. 2019;381(24):2338-2351. doi:10.1056/NEJMra1807761

Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and Management of Penicillin Allergy: A Review.JAMA. 2019;321(2):188–199. doi:10.1001/jama.2018.19283

Transcript

Note: This transcript was partially completed with the use of the Descript AI and the Chat GPT 5 AI

 Welcome to PEM Currents, the Pediatric Emergency Medicine podcast. As always, I'm your host, Brad Sobolewski, and today we are taking on a label that's misleading, persistent. Far too common penicillin allergy, it's often based on incomplete or inaccurate information, and it may end up limiting safe and effective treatment, especially for the kids that we see in the emergency department.

I think you've all seen a patient where you're like. I don't think this kid's really allergic to amoxicillin, but what do you do about it? In this episode, we're gonna break down the evidence, walk through what actually happens during de labeling and dedicated allergy clinics. Highlight some validated tools like the pen FAST score, which I'd never heard of before.

Preparing for this episode and discuss the current and future role of ED based penicillin allergy testing. Okay, so about 10% of patients carry a penicillin allergy label, but more than 90% are not truly allergic. And this label can be really problematic in kids. It limits first line treatment choices like amoxicillin, otitis media, or penicillin for strep throat, and instead.

Kids get prescribed second line agents that are less effective, broader spectrum, maybe more toxic or poorly tolerated and associated with a higher risk of antimicrobial resistance. So it's not just an EMR checkbox, it's a label with some real clinical consequences. And it's one, we have a role in removing.

And so let's understand what allergy really means. And most patients with a reported penicillin allergy, especially kids, aren't true allergies in the immunologic sense. Common misinterpretations include a delayed rash, a maculopapular, or viral exum, or benign, delayed hypersensitivity, side effects, nausea, vomiting, and diarrhea.

And unverified childhood reactions that are undocumented and nonspecific. Most of these are not true allergies. Only a very small subset of patients actually have IgE mediated hypersensitivity, such as urticaria, angioedema, wheezing, and anaphylaxis. These are super rare, and even then they may resolve over time without treatment.

If a parent or sibling has a history of a penicillin allergy, remember that patient might actually not be allergic, and that is certainly not a reason to label a child as allergic just because one of their first degree relatives has an allergy. So right now, in 2025, as I'm recording this episode, there are clinics like the Pats Clinic or the Penicillin Allergy Testing Services at Cincinnati Children's and in a lot of our peer institutions that are at the forefront of modern de labeling.

Their approach reflects the standard of care as outlined by the. Quad ai or the American Academy of Allergy, asthma and Immunology and supported by large trials like Palace. And you know, you have a great trial if you have a great acronym. So here's what happens step by step. So first you stratify the risk.

How likely is this to be a true allergy? And that's where a tool like the pen fast comes. And so pen fast scores, a decision rule developed to help assess the likelihood of a true penicillin allergy based on the patient's history. The pen in pen fast is whether or not the patient has a self-reported history of penicillin allergy.

They get two points if the reaction occurred in the past five years. Two points if the reaction is anaphylaxis or angioedema. One point if the reaction required treatment, and one point if the reaction was not due to testing. And so you can get a total score of. Up to six points. If you have a score of less than three.

This is a low risk patient and they can be eligible for direct oral challenge. A score greater than three means they're higher risk and they may require skin testing. First validation studies show that the PEN FFA score of less than three had a negative predictive value of 96.3%. Meaning a very, very low chance of a true allergy.

And this tool has been studied more extensively in adults, but pediatric specific adaptations are emerging, and they do inform current allergy clinic protocols. But I would not use this score in the emergency department just to give a kid a dose of amoxicillin. So. For low risk patients, a pen fast score of less than three or equivalent clinical judgment clinics proceed with direct oral challenge with no skin testing required.

The protocol is they administer one dose of oral amoxicillin and they observe for 62 120 minutes monitoring for signs of reaction Urticaria. Respiratory symptoms or GI upset. This approach is safe and effective. There was a trial called Palace back in 2022, which validated this in over 300 children. In adolescents.

There were no serious events that occurred. De labeling was successful in greater than 95% of patients. And skin tested added no benefit in low risk patients. So if the child tolerates this dose, then you can remove that allergy immediately from the chart. Parents and primary care doctors will receive a summary letter noting that the challenge was successful and that there's new guidance.

Children and families are told they can safely receive all penicillins going forward. And providers are encouraged to document this clearly in the allergy section of the EMR. So you're wondering, can we actually do this in the emergency department? Technically, yes, you can do what you want, but practically we're not quite there yet.

So we'd need clearer risk stratification tools like the Pen fast, a safe place for monitoring, post challenge, clinical pathways and documentation support. You know, a clear way to update EMR allergy labels across the board and involvement or allergy or infectious disease oversight. But it's pretty enticing, right?

See a kid you diagnose otitis media. You think that their penicillin allergy is wrong, you just give 'em a dose of amox and watch 'em for an hour. That seems like a pretty cool thing that we might be able to do. So some centers, especially in Canada and Australia, do have some protocols for ED or inpatient based de labeling, but they rely on that structured implementation.

So until then, our role in the pediatric emergency department is to identify low risk patients, avoid over document. Unconfirmed reactions and refer to allergy ideally to a clinic like the pets. So who should be referred and good candidates Include a child with a rash only, especially one that's remote over a year ago.

Isolated GI symptoms. Parents unsure of the details at all. No history of anaphylaxis wheezing her hives, and no recent serious cutaneous reactions. I would avoid referring and presume that this allergy is true. If they've had recent anaphylaxis, they've had something like Stevens Johnson syndrome dress, or toxic epidermolysis necrosis.

Fortunately, those are very, very rare with penicillins and there's a need for penicillin during the ED visit without allergy backup. So even though we don't have an ED based protocol yet. De labeling amoxicillin or penicillin allergy can start with good questions in the emergency department. So here's one way to talk to patients and families.

You can say, thanks for letting me know about the amoxicillin allergy. Can I ask you a few questions to better understand what happened? This is gonna help us decide the safest and most effective treatment for your child today, and then possibly go through a process to remove a label for this allergy that might not be accurate.

You wanna ask good, open-ended questions. What exactly happened when your child took penicillin or amoxicillin? You know, look for rash, hives, swelling, trouble breathing, or anaphylaxis. Many families just say, allergic, when the reaction was just GI upset, diarrhea or vomiting, which is not an allergy. How old was your child when this happened?

Reactions that occurred before age of three are more likely to be falsely attributed. How soon after taking the medicine did the reaction start? Less than one hour is an immediate reaction, but one hour to days later is delayed. Usually mild and probably not a true allergy. Did they have a fever, cold or virus at that time?

Viral rashes are often misattributed to antibiotics, and we shouldn't be treating viruses with antibiotics anyway, so get good at looking at ears and know what you're seeing. And have they taken similar antibiotics since then? Like. Different penicillins, Augmentin, or cephalexin. So if they said that they were allergic to amoxicillin, but then somehow tolerated Augmentin.

They're not allergic. If a patient had rash only, but no hive swelling or difficulty breathing, no reaction within the first hour. It occurred more than five years ago or before the kid was three. And especially if they tolerated beta-lactam antibiotics. Since then, they're a great candidate for de labeling and I would refer that kid to the allergy clinic.

Generally, they can get them in pretty darn quick. Alright, we're gonna wrap up this episode. Most kids labeled penicillin allergic or amoxicillin allergic, or not actually allergic to the medication. There are some scores like pen fasts that are validated tools to assess risk and support de labeling.

Direct oral challenge for most patients is safe, efficient, and increasingly the standard of care. There are allergy clinics like the Pats at Cincinnati Children's that can dela children in a single visit with oral challenges alone, needing no skin testing, and emergency departments can play a key role in identifying and referring these patients and possibly de labeling ourselves in the future.

Well, that's all for this episode on Penicillin Allergy. I hope you learn something new, especially how to assess whether an allergy label is real, how to ask the right questions and when to refer to an allergy testing clinic. If you have feedback, send it my way. Email, comment on the blog, a message on social media.

I always appreciate hearing from you all, and if you like this episode, please leave a review on your favorite podcast app. Really helps more people find the show and that's great 'cause I like to teach people stuff. Thanks for listening for PEM Currents, the Pediatric Emergency Medicine podcast. This has been Brad Sobolewski.

See you next time.

In lieu of a traditional episode this holiday season I wanted to share a reading of the Pediatric Emergency Medicine version of a famous Christmas poem.

Transcript

‘Twas the night before Christmas, and I’m working a shift, The symptoms were varied, the pace was quite swift. The screens glowed with orders, the rooms filled with care, In hopes that discharge summaries soon would be there.

The nurses were moving with hustle and speed, While families recounted each child’s urgent need. And I at my computer, my coffee in hand, Prepared for the onslaught that none could have planned.

When out in the lobby there arose such a clatter, I sprang from my chair to see what was the matter. Away to the triage I flew like a flash, Dodging spilled apple juice and a child with a rash.

The ambulances were wailing, the scene quite a sight, As the complaints rolled in on this hectic night. When what to my weary eyes did appear, But a febrile infant, his parents in fear.

A nursemaid’s elbow in need of a tug, And a kid with a cough wrapped tight in a hug. A forehead lac with blood streaming red, And a teen who proclaimed, “I think I’m half-dead!”

With quick-thinking teamwork, the cases we tamed, And I whistled and shouted and called them by name: “Now flu! Now croup! Now migraines and pain! On seizures! On sepsis! That ankle is sprained!

To the trauma bay stat, through triage with speed, Move quickly, move calmly, and meet every need!” As the snow flakes that fall when wild winter winds fly, We hustled and triaged as new patients arrived.

And then, in a twinkling, I heard down the hall, The sound of retching – a vomiting call. Ondansetron ordered, the nurse prepping the dose, I saw a pale toddler, looking morose.

He was sick from his tummy to the tip of his nose, And the sounds of his misery steadily rose. His eyes were all sunken, his cheeks far too pale, But a popsicle bribe led to a triumphant exhale.

The shift rolled along with splints left and right, Broken forearms galore on this holiday night. And ketamine laughter soon filled the air, As a lac repair finished with great skill and care.

Abdominal pains brought more to the bays, With parents repeating, “He’s been sick for days.” A scan ruled out danger, the appendix intact, While the next patient arrived with an asthma attack.

The hours wore on, the crowd didn’t cease, Yet amidst all the chaos, we found moments of peace. A mom’s grateful smile, a child’s sleepy yawn, Reminded us why we keep carrying on.

So I sat at the computer and typed one last note, Cleared my inbox of tasks and the orders I wrote. And I heard myself whisper as I turned off the light, “Merry Christmas to all, and to all a calm night!”

This episode of PEM Currents features an in-depth interview with the lead author on the recent New England Journal paper on the use of probiotics in gastroenteritis. David Schnadower was kind enough to sit down with me and James Gray, a Pediatric Emergency Medicine Fellow from Cincinnati Children’s to talk about the study and its […]

I am delighted to bring you this special episode of PEM Currents, the Pediatric Emergency Medicine podcast. It’s all about intranasal ketamine and its use for acute pain management in the Pediatric Emergency Department. I had the pleasure of interviewing Theresa Frey, Assistant Professor from the Division of Emergency Medicine at Cincinnati Children’s. Theresa is […]

Pop goes the apophysis! In teenage athletes the apophyseal cartilage is the weak point along the pelvic rim. Learn about these common injuries in this edition of PEM Currents, the Pediatric Emergency Medicine podcast. Find more great educational content at PEMBlog Follow me on Twitter @PEMTweets References Kocher MS, Tucker R. Pediatric athlete hip disorders. R.Clin Sports […]

Acute Flaccid Myelitis is a rare but serious disease characterized by rapid onset of muscle weakness. Diagnosis also requires an MRI with lesions in multiple spinal levels or CSF pleocytosis. cases have been reported over the past several years and though a specific cause is unknown strains of enterovirus are suspected culprits. Check out more […]

With summer pool season in full swing allow me to freestyle a little on a common topic that many Emergency Departments and Urgent Cares seem to be swimming in every summer. This episode of PEM Currents dives right into Otitis  Externa – AKA Swimmer’s Ear and reviews diagnosis and treatment. If you were treading water […]

Kawasaki Disease, AKA Mucocutaneous Lymph Node Syndrome, is one of the most common vasculitides of childhood. The hallmark is fever ≥5 days plus 4/5 of the following; mucous membrane changes, conjunctivitis, polymorphous rash, extremity changes and lymph node enlargement. It can also lead to coronary artery aneurysms, which is why its so important to make […]

OK, so this is the least exciting topic in Pediatric Emergency Medicine… With that being said, you will all see it. And we need to be good at looking at ears, diagnosing acute otitis media, and appropriately choosing when and which antibiotic to prescribe. Follow @PEMTweets on Twitter References Karma PH, et al., Pneumatic otoscopy […]

To tell you the tooth you’ll probably see quite a few kids with dental related complaints in the Pediatric Emergency Department. This can range from cavities to invasive infections. Brush up on all things dental infections in this episode of PEM Currents. And yes, those puns were intentional. I must’ve flossed my mind! PEMBlog Briefs: […]

You don’t need a flu test to diagnose the flu! But there are situations where rapid antigen testing or PCR is valuable. Listen to this episode of PEM Currents, the Pediatric Emergency Medicine podcast, to learn more about the test characteristics of common assays and when to obtain testing when prevalence rates for the flu […]

Hyperkalemia is more than just peaked T-waves on an EKG. Learn why an elevated serum potassium level can put patients in the danger zone and how to acutely manage patients in a goal directed manner. Check out more great educational content on PEMBlog.com Follow me on Twitter @PEMTweets

In this episode of PEM Currents: The Pediatric Emergency Medicine Podcast, we explore pertussis, also known as whooping cough – a disease that remains a public health challenge despite widespread vaccination efforts. We will review the clinical presentation, diagnostic strategies, management protocols, infection control practices, and vaccination updates. This episode also covers what healthcare providers need to know about post-exposure prophylaxis, respiratory precautions, and managing occupational exposures.

Learning Objectives

1. Understand the clinical progression of pertussis through its three distinct stages and identify key symptoms, including age-specific presentations in infants and older children.
2. Implement effective management strategies for pertussis, including supportive care, appropriate antibiotic regimens, and post-exposure prophylaxis for contacts and healthcare providers.
3. Promote pertussis prevention by understanding vaccination schedules (DTaP vs. Tdap), addressing vaccine hesitancy, and adhering to infection control protocols in clinical settings.

Connect with Brad Sobolewski

PEMBlog: PEMBlog.com

Blue Sky: @bradsobo

X (Twitter): @PEMTweets

Instagram: Brad Sobolewski

Mastodon: @bradsobo

How about a fun AI song about whooping cough?

YouTube Shorts

TikTok

References

StatPearls Lauria AM, Zabbo CP. Pertussis. [Updated 2022 Oct 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519008/

AAP Pediatrics in Review Heather L. Daniels, Camille Sabella; Bordetella pertussis (Pertussis). Pediatr Rev May 2018; 39 (5): 247–257. https://doi.org/10.1542/pir.2017-0229

UpToDate

Yeh S et al. Pertussis infection in infants and children: Clinical features and diagnosis. UpToDate. Available at: https://www.uptodate.com. Accessed December 3, 2024.

MMWR

Seither R, Yusuf OB, Dramann D, et al. Coverage with Selected Vaccines and Exemption Rates Among Children in Kindergarten — United States, 2023–24 School Year. MMWR Morb Mortal Wkly Rep 2024;73:925–932. DOI: http://dx.doi.org/10.15585/mmwr.mm7341a3

Transcript

Note: This transcript was partially completed with the use of the Descript AI

Welcome to PEM Currents, the pediatric emergency medicine podcast. As always, I’m your host, Brad Sobolewski, and today we’re talking about pertussis, a disease that is challenging clinicians and public health officials alike. Despite being vaccine preventable, Pertussis is on the rise, yet again, fueled by declining vaccination rates, waning immunity, and the fact that people can’t stop coughing on each other.

In this episode, we’ll go over clinical presentation, diagnosis management, infection control, and post exposure protocols. So pertussis, or whooping cough, is caused by Bordetella pertussis, a gram negative coccobacillus. It definitely spreads via respiratory droplets, and has no environmental or animal reservoirs, making humans the sole carriers.

The incubation period averages about 7 to 10 days, and the disease progresses through some distinct clinical stages, which I will go over in a moment. Pertussis has been recognized since the 16th century. I was not practicing medicine back then. Um, with the first documented epidemic occurring in Paris in 1578.

Bordetella pertussis was isolated in 1906 by Belgian researchers, Jules Bordet and Octave Gengou, I hopefully I pronounced them right, but they’re long gone, so they won’t be mad at me,, leading to the development of a whole cell pertussis vaccine in the 1940s. Introduction of the DTP, the diphtheria tetanus pertussis vaccine, dramatically reduced disease incidence overall.

In the 1990s, we got the acellular pertussis vaccine, the DTaP, which replaced the whole cell formulation due to concerns about some side effects. So pertussis remains endemic in many regions of the world despite vaccination efforts. During the 23 24 school year, DTaP coverage among kindergartners in the United States dropped to 92.

3%, which is below the 95 percent threshold needed for herd immunity. That is is why we’re seeing an outbreak now. This is a pretty troubling trend that began during the COVID 19 pandemic and has just gotten worse since. The exemption rate for vaccines rose to 3. 3 percent. This is the highest on record.

Non medical exemptions accounted for over 93 percent of these exemptions. And 14 states in the U. S. have reported exemption rates exceeding 5 percent. Idaho is leading at 14. 3 percent. So the implications of these declining vaccination coverage rates are significant and that’s why we’re seeing more and more outbreaks, especially putting our vulnerable populations at highest risk.

Alright, let’s get back to the clinical presentation. Wait, what’s that sound? Hold on. Coughing. Yeah, so that’s the whoop and the cough of pertussis. And I’d wager that many of you have not yet heard that clinically, so that’s why I included it on this episode. So here’s the stages of disease. First is the catarrhal stage, which lasts one to two weeks.

You have rhinorrhea, mild cough, and a low grade fever, if any. You are highly contagious during this phase, but it’s often unrecognized as pertussis. Then, in the next two to eight weeks, you have the paroxysmal stage. You have these severe paroxysms of coughing, the inspiratory whoop right beforehand, post tussive emesis.

Infants, especially under six months of age, may present atypically with just apnea, cyanosis, or bradycardia. for that. Following that, you have the convalescent stage, which lasts weeks to months. You have gradual resolution of symptoms, though residual cough may persist. That’s why they call it the 100 day cough.

Aside from coughing forever, there’s some important complications you need to be aware of. And they can be severe, especially, as I noted earlier, in young infants. So respiratory complications include apnea, secondary bacterial pneumonia, and pulmonary hypertension. Children encephalopathy, often due to hypoxia.

And the mechanical complications can include rib fractures, subconjunctival hemorrhage, and even rectal prolapse due to intense coughing and valsalva. Greater than 50 percent of kids under 12 months of age with pertussis could require hospitalization. 50 percent of those kids will have apnea, 20 percent will have pneumonia, and up to 1 percent will die.

Encephalopathy occurs in about 20 percent of mortality cases, probably due to hypoxia, or maybe the toxin produced by the bacteria itself. So, making the diagnosis of pertussis starts with high index of clinical suspicion. Early diagnosis, as you’d suspect, is critical to limiting disease spread and initiating treatment.

So, PCR testing, which is widely available now, has high sensitivity in the first three to four weeks and is the preferred diagnostic test. Culture is the old gold standard, but it’s slower and less sensitive. It can take up to a week to grow. CBC might show significant lymphocytosis, um, most often in infants, but it ain’t going to make the diagnosis of pertussis for you.

And a chest x ray will just show you some non specific findings, such as peribronchial thickening in severe cases. And unless you’re worried about concomitant bacterial pneumonia, you probably don’t need a chest x ray to make the diagnosis of pertussis. You can get an isolated pertussis PCR, or Or it can come as part of a respiratory panel.

But remember those comprehensive viral respiratory panels cost 1, 600. So if you’re just worried about pertussis, don’t get the whole panel. So management starts with supportive care. Infants with apnea, cyanosis, or feeding difficulties should obviously be admitted to the hospital. They may need oxygen and or nutritional support.

And you definitely have to watch those kids very closely for the complications such as hypoxia and secondary infections. Remember, a tiny baby with pertussis can go apneic at a moment’s notice even without a persistent cough. Antibiotics reduce transmission. But do not significantly alter disease progression once the paroxysmal stage begins.

So again, you are treating with antibiotics to prevent more people from getting sick, more so than shortening the duration of illness. The main antibiotic that we use is azithromycin. For infants under 6 months of age, that’s 10mg per kg daily for 5 days. For children older than 6 months of age, 10mg per kg, max of 500mg on day 1, followed by 5mg per kg per day, max of 250mg on days 2 through 5.

That is the same dosing that you can give to a grown up. An alternative treatment, you would be trimethoprim sulfamethoxazole for patients who are allergic to macrolides. Post exposure prophylaxis is recommended for household contacts, so the people that the index patient lives with, any high risk individual, and infant, pregnant women, or immune compromised individuals that have been in any sort of contact with the person with pertussis, and and a health care worker exposed without appropriate PPE.

Again, pertussis spreads through respiratory droplets. So this necessitates strict infection control. So that starts in triage. So if you think that a patient has pertussis, then they need to be place on droplet precautions as soon as they are assessed. You wear a surgical mask and eye protection, so goggles or a face shield, and you want to maintain these precautions for five days after starting effective antibiotics or for 21 days if the patient is untreated.

As a clinician, Just ask yourself, did you wear appropriate PPE, mask and goggles? Don’t get lazy. Was the exposure prolonged or close? And rely on infection control in your institution to help decide whether or not you need post exposure prophylaxis. If you’re vaccinated and you wore PPE, you don’t need anything.

Unless you have symptoms. If you’re vaccinated and you did not wear PPE, then prophylaxis is recommended. If you’re unvaccinated and not up to date, well then what are you doing in healthcare? And immediate prophylaxis and vaccination update are required. And, okay, ’cause I just mentioned it. Let’s talk about vaccines.

So first I wanna talk about DTaP, dt, lowercase a uppercase p and t dap. Uppercase T D A P. So DTAP contain higher concentrations of diphtheria and pertussis antigens. It’s used for children under seven years of age. TDAP contains lower antigen concentrations and it’s designed for adolescents and adults to reduce reactogenicity.

There is no standalone pertussis vaccine. I’ve had patients say, well, I don’t want tetanus. Just give me the pertussis one. Well, tough Schenectes. We do not have a pertussis vaccine. alone. It’s only available in combination with diphtheria and tetanus toxoids, DTaP or Tdap. The combined vaccine boosts efficacy and ensures broader protection against all of the included infections.

Now the routine vaccination schedule, which if you are a pediatric resident, you know, like the back of your hand, the DTAP is administered at 2, 4, 6, and then between 15 and 18 months with a booster at 4 to 6 years. The Tdap is one dose at 11 to 12 years and then during every pregnancy to confer passive immunity to the newborns.

And again, depending on when you’re listening to this, you may be in the midst of a pertussis outbreak. And if you listen to this a few years later, after the original publication date in the fall of 2024, and you’re seeing another pertussis outbreak, well, dang it, we haven’t done our job. We need to strengthen school vaccination requirements.

We need to educate parents about vaccine safety and the risks of exemptions. And we need to broadly improve and ensure access to vaccinations through our community clinics. Thanks. Alright, so that’s it for this episode on Pertussis, which remains a significant public health challenge due to its severe complications in young patients and the ongoing decline in vaccination coverage.

Healthcare providers play a vital role in diagnosing and managing it, preventing its spread, and educating patients and families about the benefits of vaccination. Infection control practices and post exposure protocols are critical for protecting both clinicians and close contacts and other exposures.

Thank you so much for listening to this episode. I hope you found it educational and informative. If there’s other topics that you want to hear about, let me know. I’m on X, I’m on Blue Sky, I’m on Mastodon, I take emails, you can leave a comment on the blog, you can leave a review on your favorite podcast site, any feedback is good feedback, and encourage your colleagues to listen, and as the kids say, like and subscribe, I told my 12 year old I would say that at the end of the episode.

For PEMCurrents, the Pediatric Emergency Medicine Podcast, this has been Brad Sobolewski, see you next time.

I’m sure that you’ll probably see a case of bronchiolitis this winter. Call it a hunch. In this episode of PEM Currents you’ll learn why suctioning and ensuring hydration are still the mainstays of therapy, and why albuterol, racemic epinephrine, steroids and more don’t have a place in routine cases. And if you read any […]

This episode of PEM Currents, featuring Preston Dean – @prestonndean on Twitter, a senior Pediatric Resident at Cincinnati Children’s, is about all things Rapid Sequence Intubation. You’ll learn about equipment, techniques, drugs and more! PEMBlog.com

Fever, tachypnea and rales – it must be a community acquired pneumonia… right? Learn more about the diagnosis and management of this common problem in the Pediatric Emergency Department. Essential Reading Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, Kaplan SL, Mace SE, McCracken GH Jr, Moore MR, St Peter SD, […]

Ventricular CSF shunts are very common – many kids have them. The most common complications are malfunction and infection. This episode of PEM Currents reviews the basics and how you can assess for complications in CSF shunts in kids. PEMBlog.com Boyle, Kimia, Nigrovic. Validating a Clinical Prediction Rule for Ventricular Shunt Malfunction. Pediatric Emergency Care, 2017. […]

Vocal cord dysfunction, AKA paradoxical vocal fold motion is more common than you might think. Patients often present to the Emergency Department in respiratory distress and “wheezing.” Learn about the diagnosis itself, different phenotypes and what treatment options are out there. References Christopher KL, Wood RP 2nd, Eckert RC, Blager FB, Raney RA, Souhrada JF. Vocal-cord dysfunction […]

Get ahead of your peers and listen to this episode of PEM Currents, the Pediatric Emergency Medicine podcast where you’ll learn all about the management of acutely elevated intracranial pressure. You’ll learn about common maneuvers such as optimizing the ABCs, Keeping the head elevated and midline as well as thermoregulation. I also discuss osmotic therapies […]

Don’t hold you breath while listening to this podcast – because you’d be doing so for longer than 20 seconds – and you will have apnea. Do however, listen to learn more about cyanotic and pallid breath holding spells so that you can be prepared to diagnose and manage them in the Emergency Department. Check […]

What does the combination of erythema multiforme, fever and swollen joints equal? If you answered a visit to the Emergency Department you’re only partially correct. Serum sickness like reaction is a delayed type hypersensitivity reaction that often occurs 7-10 days after starting a course of antibiotics. Learn how you can recognize it and differentiate it […]

It’s an epidemic! OK, so not quite, but we are seeing a rise in the number of kidney stones recently and we’re not quite sure why. This episode of PEMCurrents will focus on diagnosis and treatment of stones and answer such questions as; Which pain medicine should I order first? and which is the better imaging […]

Check out the latest episode of PEM Currents the Pediatric Emergency Medicine podcast where I talk about hemorrhagic (AKA ruptured) ovarian cysts. I delve into diagnosis and management and suggest strategies for obtaining a diagnostic ultrasound. Check out more great educational content on PEMBlog.com

In this episode of PEM Currents: The Pediatric Emergency Medicine Podcast, I explore the complexities of gastroesophageal reflux (GER) and gastritis in children and adolescents. I’ll make the important distinction between gastritis – which is diagnosed only via endoscopy – and dyspepsia, the term best used to describe the symptoms many patients experience. I’ll dive […]

Ben Kerrey is a rising star in Pediatric Emergency Medicine and is the point man for an ongoing initiative at Cincinnati Children’s centered around improving safety and limiting complications during rapid sequence intubation. I recently sat down with Ben to talk about the state of RSI in pediatric patients, the difference between a checklist and a […]

This edition of PEM Currents is a bite-sized rundown on rabies, or more accurately rabies post-exposure prophylaxis since most of you will never see it clinically, but will encounter a kid who meets an unscrupulous animal.

Hematemesis in the newborn period is scary for parents but fortunately it is most often due to benign causes such as swallowed maternal blood or GERD. learn more about this surprisingly common problem on this edition of PEMCurrents, the Pediatric Emergency Medicine Podcast.

The heat is on! With warm weather comes a plethora of heat-related problems in the ED. That’s why I’m sharing this edition of PEM Currents, the Pediatric Emergency Medicine Podcast. The focus is on heat illness in its many forms. Learn about everything from the benign prickly heat, to life threatening heat stroke. Stay cool and learn […]

Kids eat stuff they’re not supposed to. Most of the time foreign bodies pass harmlessly through the GI tract. Occasionally they will get stuck. It is your job to figure out who has an impacted foreign body, and how to diagnose and manage it. Check out more Pediatric Emergency Medicine content at PEMBlog.com Follow me […]

Acquired torticollis must be differentiated from more serious symptoms and remains a common presenting complaint in the Pediatric Emergency Department. Learn more about it in this episode of PEMCurrents the Pediatric Emergency Medicine podcast.

This may be a bit hard to swallow, but not every disease process in the Emergency Department is exciting. Streptococcal pharyngitis is an incredibly common condition, especially in the Pediatric Emergency Department and I wanted to take this opportunity to answer some common questions. Who knows, perhaps after listening to this edition of PEM Currents you […]

Take a deep breath and PEEP this – PEM Currents, the Pediatric Emergency Medicine podcast proudly brings you an episode dedicated to the initial assessment and management of respiratory distress. Whether you’ve been practicing in the field for 20 years or are fresh out of medical school it is important to recognize key symptoms in […]

This edition of PEM Currents, the Pediatric Emergency Medicine Podcast™ reviews the diagnosis and management of Immune Thrombocytopenia, formerly known as Idiopathic Thrombocytopenia Purpura. You will definitely see this common acute hematologic conditions in the ED, and should be able to differentiate it from acute leukemia, meningococcemia and other concerning conditions.

This edition of PEM Currents, the Pediatric Emergency Medicine podcast briefly addresses which bruises are concerning in children under the age of 4, and what the ensuing workup should entail. You can also read more on a companion PEMBlog post.

This episode of PEM Currents discusses ECPR (Extracorporeal Cardiopulmonary Resuscitation), an advanced procedure used in cases of cardiac arrest when traditional CPR fails. ECPR involves using ECMO (Extracorporeal Membrane Oxygenation) to take over heart and lung functions, offering a last-resort option that is becoming more common in large pediatric hospitals. While ECPR shows promise in […]

This episode of PEM Currents tackles a bread and butter issue in Pediatric Emergency Medicine, the newborn with fever. I discuss management, specifically how it differs for babies under 28 days of age as well as when to get labs and how to interpret them. I also reference procalcitonin, and touch on its emerging role. […]

This episode focuses on upper GI bleeds. Serious UGI bleeds – you know, the ones with shock, massive transfusions and more – are fortunately rare in the Pediatric Emergency Department. However, there is a growing population of patients with chronic diseases that can lead to portal hypertension, varies and other causes of bleeding from the […]

I’m delighted to share the latest PEM Currents podcast! I recently sat down with Todd Florin, one of the faculty physicians at Cincinnati Children’s Hospital Medical Center and talked about bronchiolitis, delving into the controversies around the use of hypertonic saline, albuterol and more. Todd also recommended that all of my listeners check out the […]

With the recent influenza epidemic you may have also seen a rise in the number of cases of parotitis. This should not be a surprise, as acute parotitis is usually viral, self-limited and treated with supportive measures – just like the flu! Learn more by listening to this edition of PEM Currents, which is all […]

PEM Currents returns with a look at topical anesthetics used in the Emergency Department. Specifically this edition of the podcast will focus on LET, EMLA and LMX and discuss typical use.

Don’t swoon with excitement because the latest episode of PEM Currents, the Pediatric Emergency Medicine podcast is here! The focus is on convulsive syncope – essentially patients who faint and have movements that could be construed as seizures. You’ll learn how common convulsions with syncope are and what to do if you encounter them in […]

This edition of PEM Currents, the Pediatric Emergency Medicine podcast, reviews the safety and comparative efficacy of acetaminophen and ibuprofen. If you work in a Pediatric Emergency Department you’ll certainly have broken a sweat over this hot debate time and time again.

This edition of PEMCurrents echoes a recent post on the PEMBlog and reviews the use of ondansetron in acute gastroenteritis. Specifically highlighting the reduction in risk of further episodes of emesis, need for intravenous fluids and immediate admission to the hospital.

This edition of PEMCurrents takes a crack at clavicle fractures. The old dictum about broken collarbones states that if both ends of the bone are in the same room it’ll heal fine. For the most part this is true – at least in prepubescent patients. New literature in adults has suggested that outcomes are better […]

Recognizing osteomyelitis can be challenging. Treating it doesn’t have to be – especially in the Pediatric ED. This edition of PEM Currents reviews the current evidence surrounding the initial choice of antibiotic, monitoring treatment response and overall therapeutic duration. 

Syphilis has gone by many nicknames over the years including “The Great Pretender” and “The Great Imitator.” Emily Labudde, MD, a Pediatric Emergency Medicine fellow at Children’s Healthcare of Atlanta and recent pediatric residency graduate from Cincinnati Children’s discusses the various manifestations of this sexually transmitted infection, and how we can’t miss this very treatable, […]

This edition of PEM Currents focuses on the use of antiemetics to treat status migrainosus in the Pediatric ED. Prochlorperazine and Metoclopramide are safe and effective agents with a low incidence of self limited side effects that when given in combination with ketorolac result in over 90% of patient being headache free at 3 hours. […]

Ted Brenkert sticks his neck out to educate you on retropharyngeal abscesses. RPAs can be an especially worrisome diagnosis in young children who will present with fever, sore throat and limitation of neck movement. Check out pemblog.com for more educational content

This episode of PEMCurrents is narrated by Brad Sobolewski and focuses on the use of high flow in bronchiolitis. Learn about the application of high flow nasal cannulas, the mechanism behind their generation of positive airway pressure, as well as some of the literature behind its beneficial effects. Check out pemblog.com for more educational content