Tis the season, to be jolly. Right? Well, it’s not quite the holiday season but the cold and flu season is upon us. According to the Center for Disease Control and Prevention, “Influenza causes more hospitalizations among young children than any other vaccine-preventable disease.” The flu vaccine is the best protection and is recommended for all children ages 6 months and older. Last year, 110 children died of the flu. In 2009 358 children died from influenza. The CDC stated that “every year, influenza kills between 12,000 and 49,000 people and can send more than 700,000 people to the hospital.” The CDC website has a tremendous amount of good information on influenza, such as prevention, symptoms, and educational materials.

In addition to the vaccinations, we should all remember to stay home when we are sick and avoid others who may be sick, avoid touching our face in particular the eyes, nose and mouth which is how the germs spread, and finally wash our hands frequently, and keep surfaces and objects clean.

Though we are familiar with the flu, there appears to be a new ailment that the disease community is not as familiar. You may have heard something about this emerging concern on the news. It is called AFM, or Acute Flaccid Myelitis. Apparently, there has been a surge in the number of cases reported. Through October 16, 2018, there have been 62 confirmed cases in 22 states. Utah is one of those states. There were only 33 cases in 16 states reported last year. The numbers have doubled with 90 percent of the cases occurring in children with an average of four years old.

What is AFM and how does it present itself? It is a rare and serious condition that causes inflammation in the spinal cord which causes weakness in the arms and/or legs. It generally occurs through August to December. They have not been able to isolate a common cause or pathogen. Exposure may occur when in close contact to infected people, especially if they are coughing and sneezing, with contaminated surfaces and mosquito bites.

Symptoms include:

• Sudden onset of arm or leg weakness
  
• Loss of reflexes and muscle tone
  
• Trouble urinating
  
• Difficulty swallowing
  
• Slurred speech
  
• Eyelid or facial droop
  
• May have pain in the limbs
  
• May have inability to breath
  

What should EMS Do?

Be aware of this disease and discuss with your medical director how to manage these patients. If EMS sees signs of lib, weakness in a child, they should seek immediate evaluation by an appropriate health care provider. Above all, use standard precautions such as PPE, hand hygiene and disinfecting vehicle and equipment.

For additional information on AFM:

https://www.cdc.gov/acute-flaccid-myelitis/ https://www.cdc.gov/acute-flaccid;myelitis/amf-surveillance.html

https://www.cdc.gov/acute-flaccid-myelitis/about-amf.html

https://www.cdc.gov/acute-flaccid-myelitis/references.html

As always, we would like to thank you for your continued service to the children of Utah and support of the EMS for Children program. We wish you good health and good cheer as you continue your community service through this holiday season. We truly appreciate your dedication and commitment.

Jolene Whitney

jrwhitney@utah.gov

A decade ago respiratory season meant double bunking beds, long wait times, and a weekly emergency intubation or two for infants sick with a viral respiratory illness (usually RSV). With advancements in airway management we have seen less and less intubation and more use of highflow, CPAP and BiPAP. Studies have shown that early recognition and intervention during respiratory distress can help avoid the invasive procedures.

Respiratory complaints are still the number one reason EMS is called on pediatric patients. They are also the number one reason for pediatric ED visits by body system according to a statistical brief put out in August. Upper and lower respiratory diseases, asthma, influenza, bronchiolitis, and pneumonia should keep us all busy this winter.

RESPIRATORY SEASON

“The art of medicine consists of amusing the patient while nature cures the disease”- Voltaire

Background:

As pediatric viral respiratory season approaches once again, just around the corner, it is good to remember a few bottoms lines about kids and respiratory season. In the US, bronchiolitis is the most common cause of hospitalization among infants <1yr of age and occurs more in the winter months (generally December to March). Bronchiolitis is inflammation and congestion in the bronchioles, or smallest parts of the airways (see the picture above), from a viral infection.

These viruses include, but are not limited to, RSV (respiratory syncytial virus), Coronavirus, Adenovirus, Rhinovirus, Influenza, Human metapneumovirus, and parainfluenza viruses. We can use GermWatch through the Intermountain website (https://intermountainhealthcare.org/health-information/germwatch/) to identify trends each month.

The disease process in each individual child can vary from length of illness and severity: some children may only experience a few days with mild cough, congestion and low-grade fevers while others may require intubation for respiratory failure. Some of the risk factors for severe disease include history of premature birth, age less than 12weeks, chronic lung disease, congenital heart disease (VSD, ASD, hypoplastic left heart, etc), neurologic disease (cerebral palsy, etc), or immunodeficiency (children receiving chemotherapy for leukemia, etc), and children who live in a smoking environment.

Patient assessment:

Most important is to provide the support needed for the child at the initial assessment. If the child is <88% on room air, provide supplemental oxygen in the form of nasal canula and escalate as needed. The next step is to determine respiratory rate and whether there is evidence of work of breathing. Work of breathing can be described and assessed by observing retractions (subcostal, intercostal, suprasternal), grunting or head-bobbing. When assessing the respiratory status of these young children, make sure that they are as comfortable as possible. We have all seen crying children- they are tachypnic and retracting! Next, consider an anti-pyretic because children with fevers can have a higher respiratory rate and heart rate.

Treatment:

For non-severe bronchiolitis, the treatment is supportive and includes suctioning with nasal bulb or NoseFrida, hydration and monitoring for progression of disease. Supportive care also includes the use of Tylenol (over 3months as fever in infants <90days requires hospital evaluation) and Ibuprofen (over 6months) for pain and fever. Depending on age and underlying disease, some patient will receive TamiFlu if they are positive for influenza.

In the hospital, the respiratory support can include nasal canula, high flow nasal canula, CPAP, BiPAP or intubation. Some patients are given a trail of albuterol, a bronchodialator, but the data does not suggest that this lessens hospitalization or need for oxygen support. Many children require IV fluids for hydration and frequency nasal-pharyngeal (NP) suctioning.

Complications to consider:

One of the most common complications of bronchiolitis is dehydration due increased fluid loss (fever, rapid breathing) and decreased intake (breathing too quickly or fatigue). When assessing hydration status, consider their urine output, heart rate, fontanelle (normal vs. sunken), and mucosa/lips. Bronchiolitis may also be complicated by a secondary bacterial lung infection or febrile seizures. One of the most significant complications that can be seen is apnea, which can be subtle and does require referral to the emergency department. A low respiratory rate may be an ominous finding in pediatric patients. Another concerning complication is respiratory failure which can be due to inability to ventilated causing hypercapnia, or elevated pCO2, fatigue, or hypoxia.

Prevention:

We encourage good hand-hygiene to prevent the transmission of the infectious agent through family members. We also encourage decreased exposure to cigarette smoke for children. We encourage annual influenza vaccines for children and their families.

References:

https://intermountainhealthcare.org/health-information/germwatch/

https://www.mayoclinic.org/diseases-conditions/bronchiolitis/symptoms-causes/syc-20351565

https://www-uptodate-com.ezproxy.lib.utah.edu/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis?search=bronchiolitis%20children&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H70679837

Along with flu and bronchiolitis respiratory season brings it's share of croup. The primary symptoms of croup are inspiratory stridor, barking cough and hoarseness. When treating croup albuterol is ineffective. The mainstays of treatment are steroids-to reduce edema (usually dexamethasone) and nebulized epinephrine-to open the upper airways.

Dexamethasone dosing is 0.6 mg/kg by mouth once, max 16mg. At Primary Children's Hospital we use the tablets, crushed and mixed with some snow cone syrup. The two most popular flavors are Tigers Potion (Blood) and blue raspberry.

Nebulized epinephrine is very effective and can be acquired as an ampule for nebulization or epinephrine for injection. Both are equally as effective, but the dosing is very different. Racemic epinephrine is a mix of both left handed(L) and right handed(D) molecules of epinephrine (isomers). The left handed version was thought to cause fewer side effects but later studies have not proven this to be true.

Racemic epinephrine is available as a 2.25% neb (0.5ml). Dose=0.05 mL/kg (Max 0.5mL), diluted to 3ml with NS -nebulized once and may be repeated every 15-20 minutes.

Epinephrine for injection (1mg/mL) Dose= 0.5mL/kg (Max= 5 mL) nebulized once, may repeat every 15-20 minutes.

10/3/2018 by: Colleen Kraft, MD, MBA, FAAP, President, American Academy of Pediatrics

​"Today, Congress made great strides toward keeping children safe during air travel. The Federal Aviation Administration (FAA) reauthorization, on its way to the president for signature into law, includes the bipartisan Airplane Kids in Transit Safety (KiTS) Act, a long-time priority of the AAP."

Currently, the emergency medical kits on airplanes are not designed with children's needs in mind–they lack the right medications in an appropriate dose and formulation and the equipment is too large to fit a child. The Airplane KiTS Act addresses that problem by requiring the FAA to review and update the contents of the emergency medical kits on planes, which is something that hasn’t been done in almost 20 years. Families will soon be able to rest a little easier knowing that if their child experiences an in-flight emergency, like a seizure, asthma attack, or allergic reaction, the right drugs and equipment will be on board.

The American Academy of Pediatrics thanks Representatives Sean Patrick Maloney (D-N.Y.) and John Faso (R-N.Y.) and Senators Brian Schatz (D-Hawaii) and Jerry Moran (R-Kan.) who championed the Airplane KiTS Act from beginning to end. Pediatricians stand ready to assist with the swift implementation of this critical legislation so that all families can have the peace of mind they deserve while traveling."

EMSC Pediatric Education for Prehospital Providers

Register online at peppsite.org. Look up classes in Utah and find the one that will work for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($18.95). Return to peppsite.org to register for the class and follow the prompts.

If you have any questions, please email Erik Andersen at eandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.

The Emergency Medical Services for Children (EMSC) Program aims to ensure that emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure that the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, no matter where they live, attend school or travel.

Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: 801-707-3763
Facebook: facebook.com/Chirp-UtahDepartmentofHealth