Welcome to the first edition of the HipPEMcrates Mailbag – where we answer common questions from the Pediatric ER. These are the questions you jot down during a shift to look up later, the clinical pearls you hear your colleagues share during signout, maybe even that one thing that your resident asked you that makes you go “hmm, how can I dance around this one in a way that still makes me sound smart?”
Why a mailbag? Well, in the spirit of your favorite blogger or podcaster (Bill Simmons, anyone?), a mailbag lets us cover a lot of topics at once in a way that’s easily digestible before, during, or after a shift. I’ve done my best to link the evidence in the answers so that you can see the primary literature. If it goes well? Maybe we will do more. Not ready to make any rash decisions quite yet. On that note…
Why do serum sickness-like reactions always seem to find their way from Urgent Care to the ER, and what kind of workup should I do?
Ok, sorry for the cynicism, maybe a little recency bias and a 7-shifts-in-8-days stretch, but serum sickness-like reaction (SSLR) seems to be one of those diagnoses that scares people, maybe more than it should. Sure, the urticarial-like rash and fever can be suggestive of something more scary (SJS, Kawasaki, Meningococcemia), but typically there’s a pretty good history for SSLR. If you’ve been on a new medication in the last two weeks (think Amoxicillin or Cephalosporins) and now you have rash, fever, and joint pain? Congrats, your amoxicillin cured that ear infection – but you’ve just earned yourself a classic serum sickness-like reaction as a parting gift.
So you’ve made the diagnosis, now what? Well, treatment tends to be easy – withdraw the offending agent, start antihistamines and/or NSAIDs for symptom control. Consider steroids if symptoms are severe enough (in fact, they might recover quicker with steroids). As for workup? For a well appearing child with SSLR, probably nothing! Labs don’t tend to help in what is primarily a clinical diagnosis. Want to do something (I mean, they are in the ER…)? If anything, send urine. While proteinuria or hematuria may not change your management (it should clear once the patient recovers), it might help guide how soon the patient should follow up with their pediatrician.
You’re forgetting the most important question – can the child have the antibiotic ever again?
Short answer: We are not quite sure.
Long answer: A recent article just took a look at this question. SSLR is not a classic IgE- or immune complex–mediated allergy; this may suggest that we don’t have to treat it the same as a true antibiotic allergy (to be fair, what pediatric chart is complete without “rash to amoxicillin” at 9 months old?). On the flip side, one study showed that SSLR can recur in children who even passed an allergy challenge. So do we list it as an allergy, likely limiting which antibiotics the child can get for the rest of his or her life, or do we leave it off, knowing that there’s a chance they may have SSLR in the future. Not sure we have enough data to definitively answer that! Next question…
How cold is too cold – what is a hypothermic infant?
One of the age-old questions of the pediatric emergency room. And spoiler alert: There’s no one right answer. You can think about the well appearing, hypothermic infant in two ways: Either it is an incidental finding likely related to a developing thermoregulatory system (Evidence: Well-appearing neonates with incidentally noted hypothermia at a routine visit are at low risk for serious infection). Orrrrr, it’s a harbinger of something really bad (Evidence: Up to 8% of infants with hypothermia presenting to the ED have an SBI). The most common threshold for hypothermia you’ll hear is ≤36.0°C. Even my good (and very smart) friend Johnny Lo couldn’t statistically determine a temperature threshold to reliably identify bacterial infection. So, where does that leave us? I guess it’s dealer’s choice for what temperature you use. One positive though: if you do choose to use ≤36.0°C as your cutoff, the AAP Clinical Practice Guideline does not misclassify any SBI or IBI as low risk, although it will lead to some overtesting (aka high sensitivity, low specificity).
What else can I give for pain from a sore throat?
You’re familiar with these cases: a teenager who was diagnosed with pharyngitis by the pediatrician, either is on antibiotics (if strep positive) or not, and is coming to you because their throat just hurts so badly. No judgment from me – I had this before Step 1 (or should I say Strep 1? Thank you, I’ll be here all week). That needle-in-your-throat pain is the real deal. These kids are usually using Tylenol and Motrin at home, so can steroids be an option for symptom management when they come to the ED?
The IDSA Clinical Practice Guidelines does not recommend adjunctive therapy with corticosteroids (Sidenote: There was a great discussion about this on the PEM listserv recently – clearly, we’re all still figuring out the role of steroids in sore throat pain). But does it work? One of my mentors, and author of one of the best PEM blogs out there, Dr. Brad Sobolewski, covered this topic in a great post that cites several relevant studies, so I’ll direct you to read his article and share his conclusion here: “The cumulative evidence suggests that a single dose of oral or IM corticosteroid (dexamethasone) can meaningfully reduce the quantity and length of pain in children and adolescents with sore throat diagnoses that do and do not require antibiotics…I would give a dose of dex to this patient in question, because I think it may keep them from needing to return to the ED and can help them achieve better pain relief sooner – as long as they are still using ibuprofen or acetaminophen.”
That’ll be it for our first mailbag! How did it go? Share your thoughts in the comment section below or send us an email at HipPEMcrates@gmail.com! Do you have a question you’d like answered, share that too! Until next time…
Dr. Joshua Belfer, MD, is a Pediatric Emergency Medicine physician at the Children’s Hospital of Philadelphia, and is the Founder and Editor-in-Chief of HipPEMcrates. He can be reached at HipPEMcrates@gmail.com.
Thank you for this post. As an adult EM physician who sees a fair share of kids, it’s nice to have some of these points to look back at and forward to. Excited for the next one