Grand Rounds: Controversies in Peds

On March 31 Matt White provided a nuanced and evidence-based review of three common controversies in pediatrics. The awesome summary created by Kristen Weersink below doesn’t quite do it justice. However, if you missed the presentation live, this summary is a great start to get you thinking about these common presentations. Next time you are working a shift with Matt pick his brain. Believe me, he’s got an insane amount of knowledge to drop.

Side note: It’s possible you’ll hear Matt referred to as Donald Trump in the coming months…you had to be there! There was lots of laughter and fun at this edition of grand rounds including an animated analysis of antibiotic consumption in Newfoundland – I’m sure you can guess who had the room belly laughing. The presenter and audience were in fine form, as usual.

Hope to see you all out for the next one! In the meantime, feel free to ask any questions or discuss pediatric controversies below.

march-31-grand-rounds

To download a PDF copy of this infographic click here.

References

Fever:
1. Vallancourt et al. Repeated emergency department visits among children admitted with meningitis or septicemia: a population-based study. 2015. Annals of EM. 65;6. 625.
2. Huppler et al. Performance of low-risk criteria in the evaluation of young infants with fever: review of the literature. Pediatrics, 2010. 125;2. 228.
3. Baraff, L. Management of infants and young children with fever without a source. Pediatric Annals. 2008. 37;10. 673.
4. Green et al. Sick Kids Look Sick. Pediatrics. 2015. 65;6. 655.
5. ACEP Clinical Policy. Clinical Policy for children younger than 3 years presenting to the ED with Fever. Annals of Emergency Medicine. 2003. 42;4. 530.
6. Green, S. Evaluation styles for well-appearing febrile children: Are you a “risk minimizer” or a “test-minimizer.” Annals of Emergency Medicine, 1999. 33;2. 211.
7. Baraff et al. Practice Guideline for the Management of Infants and Children 0 to 36 months of age with fever without a source. Annals of Emergency Medicine. 1993. 22;7. 1198.
8. Watson et al. Scope and epidemiology of pediatric sepsis. Ped. Critical Care. 2005. 6;3. 3.
9. Wilkinson et al. Prevalence of occult bacteria in children aged 3 to 36 months presenting to the ED with fever in the post pneumococcal conjugate vaccine era. Academic EM. 2009. 16;3. 220

AOM:
1. Spiro, D., Tay, KY., Arnold, D. Dziura, J. Baker, M., Shapiro, E. Wait-and-See Prescription for the Treatment of Acute Otitis Media. JAMA, 2006, 296; 10. 1235-1241
2. Tahtinen et al. A Placebo-Controlled Trial of Antimicrobial Treatment for Acute Otitis Media. NEJM. 2011. 364;2. 116-126.
3. Venekamp RP. Antibiotics for Acute Otitis Media in Children. Cochrane Review, 2015.
4. Thompson et al. Effect of antibiotics for otitis media on mastoiditis in children: a retrospective cohort study using the UK general practice research database. Pediatrics, 2009. 123;424.
5. Le Saux et al. A randomized, double-blind, placebo-controlled non inferiority trial of amoxicillin for clinically diagnosed acute otitis media in children 6 months to 5 years of age. CMAJ. 2005; 173;3. 335.
6. Garrison et al. High-dose versus standard-dose amoxicillin for acute otitis media. Annals of Pharmacotherpay. 2004. 28;15.
7. Liberathal et al. CPG: The Diagnosis and Management of Acute Otitis Media from the AAP. Pediatrics. 131;3;964.
8. Hoberman et al. Treatment of acute otitis media in children under 2 years of age. NEJM. 2011;365.2. 105.
9. Le Saux et al. CPS: Management of acute otitis media in children six months of age and older. Pediatric Child Health 2016;21;1. 39-44.

UTI:
1. Shaw, K. Call for a rational approach for testing for urinary tract infection as a source of fever in infants. Annals of EM. 2013. 61;5. 566.
2. Newman et al. Pediatric Urinary Tract Infection: does the evidence support aggressively pursuing the diagnosis? Annals of EM. 2013. 61;5. 559.
3.3Robinson et al. CPS Urinary tract infection in infants and children: diagnosis and management. Ped Children Health, 2014. 19;6. 315.
4. AAP Guideline. Urinary Tract Infection: CPG for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics, 2011, 128;3. 595.
5. Davies, D. Bag urine specimens still not appropriate in diagnosing urinary tract infections in infants. Ped Children Health.  2004. 9;6. 377
6. Schroeder et al. Diagnostic accuracy of the urinalysis for UTI in infants < 3 months of age. Pediatrics. 2015, 135;6, 968.
7. Ralston et al. Occult Serious Bacterial Infection in Infants Younger than 60-90 days with bronchiolitis: a systemic review. Arch Pediatric Adolesc Med. 2011. 165;10. 951.
8. Elkhunovich et al. Assessing the utility of urine testing in febrile infants aged 2 to 12 months with bronchiolitis. Pediatric Emergency Care. 2015. 31;9. 616.
9. Henadaus et al. Risk of urinary tract infection in infants and children with acute bronchiolitis. Pediatric Child Health. 2015. 20;5.25.

The Concept

I look forward to Thursdays. I love walking into Richardson and seeing familiar faces, ready to discuss topics related to the specialty that I adore. The ritual of Grand Rounds will never get old but this site might help it evolve!

The Issue

Senior residents put an extraordinary amount into preparing for Grand Rounds and Journal Club. Their reviews are thought-provoking, discussion-inciting and sometimes practice-changing for those who attend. Unfortunately, busy schedules, off-service rotations and clinical duties make it impossible for all members of the department to be there in real-time. Furthermore, we are usually discussing issues that would benefit from collaboration with our specialist counterparts but again, scheduling makes their physical presence challenging to coordinate. We’ve been wondering:

Can we extend the discussion beyond the walls of Richardson Theatre? Can we offer a place for asynchronous engagement in Grand Rounds and Journal Club? Can we find a way for junior residents to be more involved?

Offering a Solution

We believe that the answer to all of the above questions is “Yes!”. Posts in the Journal Club and Grand Rounds sections will highlight content and the Our People posts will highlight the awesome folks that make up the QEmerg crew. These posts are not meant to replace attendance because nothing beats a good face-to-face discussion. Nothing beats the ritual of Rounds. We do hope, however, that these summary posts will:

  •  highlight a few key points from each session to bring those not in attendance into the loop
  • create space for ongoing discussion for those who wish they had added something to the conversation
  •  act as a space where we could request input from those outside of the department

This website will be junior resident led meaning that summaries from sessions will come be written by junior residents and approved by the seniors presenting. This process will provide active learning opportunities for juniors and a great way to start our involvement in these important departmental events.

Feedback

This website is a work in progress and designed with QEmerg residents, physicians and staff in mind. We want to know what you like and what you don’t. Any and all feedback welcome – help the ritual evolve!