PHM 2025 Session Recap
Presenters (Jen Fuchs, MD, Emilee Lewis, MD, Steve Weinberg, MD, Kevin Weinberger, DO, and Eric Zwemer, MD, MEHP) from this year’s “Umm Dr. Dancel…” escorted us through a playlist of topics, highlighting key studies that have led us away from common practices of yesteryear:
Category 1: Med wrecks, Wrecking Ball – Miley Cyrus
Myth #1: Cefdinir is the oral version of ceftriaxone, No – Meghan Trainor
- Inferior in vivo activity: 59% susceptibility to pneumoniae, 81% to M. catarrhalis versus cefpodoxime’s 84% and 100%, respectively.
- Suboptimal pharmacokinetics: 16-25% bioavailability; <3-13% urinary concentration in pediatrics versus >90% for cephalexin; 31-35% lung penetration versus 200% for amoxicillin.
- Antibiotic stewardship: third-generation cephalosporins are associated with increased colonization or infection with VRE and ESBL, and increased risk of difficile infection.
Myth #2: Docusate treats constipation, Push It – Salt n Pepa
- Claim that docusate increases stools is based on one adult randomized controlled trial (RCT) from 1968 that excluded 19 patients who received the placebo but had increased stools. Nine other RCTs have demonstrated no significant benefit in adults. No data to suggest benefit in pediatrics.
- Miralax and lactulose are the only stool softeners that have been proven to work in pediatric patients.
Category 2: New in Newborn, Baby – Justin Bieber
Myth #3: HIV is a contraindication to breastfeeding, Late To The Party – Kasey Musgraves
- Use of maternal suppressive anti-retroviral therapy and/or infant prophylaxis has decreased the risk of infant HIV transmission to <1%.
- Contraindication to breastfeeding is based upon maternal viral load:
- Undetectable: no absolute contraindication
- If detected: pause breastfeeding and recheck
- If ≧ 200 copies/mL: stop breastfeeding.
Myth #4: Hypothermia in term newborns is infection until proven otherwise, Ice Ice Baby – Vanilla Ice
- Hypothermia (rectal temp ≦35 °C) occurs in nearly 22% of neonates. Most commonly seen in high-risk, preterm, and very low birth weight infants.
- Well appearing infants with a single nonrecurrent episode of mild hypothermia (36.0-36.4 °C) are less likely to have a serious bacterial infection than those with moderate hypothermia (<36.0°C or recurrent episodes).
Myth #5: Red reflex in newborns is helpful for detecting retinoblastoma, Red Red Wine – UB40
- Proper newborn eye exam = dimmed room, ~18inches away, examining both eyes
- Leukocoria is classically associated with retinoblastoma (most common intraocular tumor of childhood), but can also be seen with cataracts or vitreous humor abnormalities, except retinal hemorrhage.
- Many infant eye abnormalities that require medical or surgical intervention may not be identified with an abnormal red reflex. A normal infant eye exam does not exclude an abnormality, but an abnormal exam always warrants referral to an ophthalmologist.
- Family history is key! Always refer patients whose family members have a history of eye abnormalities such as retinoblastoma, juvenile or congenital cataracts, or glaucoma.
Category 3: Nuanced Pneumonia, Take My Breath Away – Berlin
Myth #6: Mycoplasma pneumonia is usually a benign, self-limited infection, and macrolides are definitive therapy, Who’s Afraid of Little Old Me? – Taylor Swift
- Mycoplasma pneumonia accounts for 40% of community-acquired pneumonia in children and is associated with endemic outbreaks every three to seven years.
- Its lack of a cell wall carries inherent resistance to certain antibiotics.
- Macrolides are first-line, however, with 12% resistance in North America, up to 30% in Europe, and almost 90% in East Asia. Consider a second-line antibiotic such as fluoroquinolone or tetracycline if not improving or has had relevant recent travel/exposures.
- Consider steroids ± IVIG in refractory disease.
Myth #7: Anaerobic bacteria are the main cause of aspiration pneumonia, Every Breath You Take – The Police
- Aspiration pneumonia and pneumonitis look clinically similar. However, pneumonitis is more likely to be from aspiration of sterile gastric contents and result in symptoms within a few hours of a macroaspiration event, compared to pneumonia, which can be micro- or macroaspiration of oral/enteric bacteria with a gradual onset of symptoms.
- Data exists in the adult world to support recommendations against empiric anaerobic coverage (from the Infectious Diseases Society of America and American Thoracic Society). Notable exceptions to these recommendations include patients with necrotizing pneumonia, empyema, severe periodontal disease, or a longer duration of illness. Similar data in pediatrics is limited!
- Treatment with anaerobic coverage alone resulted in a shorter length of stay compared to gram-negative coverage alone, despite Pseudomonas being the most common pathogen isolated in one study of pediatric patients with aspiration pneumonia. There is no significant difference in outcomes or treatment failure rates for patients treated with seven days or fewer of antibiotics compared to those treated for more than seven days.
Myth #8: Risk of pneumonia in children with neurologic impairment can be lowered through secretion management and/or g-tube placement, Head Above Water – Avril Lavigne
- Children with severe neurologic impairment (SNI) represent 5% of admissions but 40% of readmissions. And pneumonia is the cause of death in 39% of children with cerebral palsy.
- Children with g-tubes who were admitted with pneumonia had a lower risk of death but a higher risk of severe pneumonia.
- Most beneficial prevention strategy was shown to be routine dental care.
Category 4: Decompensation Dogmas, Help – The Beatles
Myth #9: PEWS can predict pediatric decompensation, All Along the Watchtower – Bob Dylan
- PEWS = pediatric early warning score, incorporating behavior, vital signs, and physical exam findings to identify patients at risk for clinical deterioration
- Where it’s beneficial: pediatric oncology patients in resource-limited settings
- Where it’s questionable: no impact on mortality in high-resource settings
- Difficult to assess due to institutional variability, subjectivity of some assessments, and the rapidity with which pediatric patients typically decompensate.
Myth #10: Positive blood cultures should always be repeated, Bad Blood – Taylor Swift ft. Kenrick Lamar
- Repeating positive cultures has not been proven to significantly improve outcomes.
- Consider repeating if: history of prior positive blood cultures, the culture was drawn from a central venous catheter, or cultures grow yeast, aureus, or p.aeruginosa. Consider, though less strongly, if cultures are growing non-fermenting gram-negative rods (other than p.aeruginosa) or if there’s concern for hospital-acquired bloodstream infection.
- Factors that do not favor repeating: growth of strep species or anaerobic organisms.
Key Takeaways:
- Cefdinir = Cefdinope. For UTIs, choose cephalexin. And for community-acquired pneumonia, choose amoxicillin.
- … unless you are worried about Mycoplasmia pneumonia. But if your patient has traveled somewhere in Europe or East Asia and isn’t getting better with that Z-pack, consider second-line treatment for resistant Mycoplasma.
- … unless you are also worried about aspiration in your patient with severe neurologic impairment. In that case, make sure you are covering for anaerobes since it has been shown to decrease their odds of going to the ICU and shortening their overall length of stay. At least until more data comes out!
Dr. Nelson
Dr. Nelson is a med-peds-trained PHM Fellow at the University of Pittsburgh Medical Center – Children’s Hospital of Pittsburgh.
