Pediatric Emergencies & Child Abuse
Fever by age, the dehydrated toddler, and injuries that don't add up
The febrile infant: age drives the workup
Why age matters. Fever is a temperature of 38.0 °C (100.4 °F) or higher, measured rectally in young infants. Neonatal immune immaturity makes serious bacterial infection unpredictable—a neonate can look well with bacteremia or meningitis—so age, not appearance, sets the workup. Key neonatal pathogens are group B streptococcus, E. coli, and Listeria (hence ampicillin). Urinary tract infection is the most common serious bacterial infection.
| Age | Evaluation | Disposition |
|---|---|---|
| 0–28 days | 0 to 21 days: full sepsis evaluation even if well-appearing (blood, urine, and CSF cultures). 22 to 28 days: urinalysis, blood culture, and inflammatory markers; LP if markers are abnormal, optional if normal | 0 to 21 days: admit; empiric ampicillin + gentamicin. 22 to 28 days: admit if markers are abnormal; selected low-risk infants may be observed at home |
| 29–60 days | Urine and blood cultures plus inflammatory markers (procalcitonin, CRP, absolute neutrophil count) | Risk-stratify; low-risk infants may avoid LP |
| Over 3 months | Well-appearing, immunized child usually has a viral illness | Look for a source; check urine when UTI is plausible |
In a febrile neonate, add acyclovir when HSV is possible: vesicles, seizures, ill appearance, CSF pleocytosis, elevated transaminases, or maternal genital herpes.
Dehydration and fluids
Estimating the deficit. Acute weight loss is the most accurate measure. At the bedside, prolonged capillary refill, dry mucous membranes, and absent tears are among the most useful single signs; poor skin turgor and a sunken fontanelle add support. Tachycardia comes early, while hypotension is a late sign in children.
- Mild (about 3–5%): near-normal exam, slightly dry mucosa.
- Moderate (6–9%): dry mucous membranes, few tears, tachycardia, reduced urine output.
- Severe (≥10%): lethargy, delayed capillary refill, cool mottled skin, eventually hypotension.
Oral rehydration first. Oral rehydration solution is first-line for mild-to-moderate dehydration, given in small, frequent amounts; a dose of ondansetron helps a vomiting child keep it down. Severe dehydration or shock gets a 20 mL/kg bolus of isotonic fluid (normal saline or lactated Ringer's), reassessed and repeated as needed—never hypotonic saline or D5W as a bolus.
Maintenance: the 4-2-1 rule. 4 mL/kg/hr for the first 10 kg, 2 mL/kg/hr for the next 10 kg, and 1 mL/kg/hr for each kilogram beyond 20. A 25-kg child needs 40 + 20 + 5 = 65 mL/hr.
In hypernatremic dehydration, lower sodium slowly (about 10–12 mEq/L per day); rapid correction causes cerebral edema.
Febrile seizures
| Feature | Simple | Complex |
|---|---|---|
| Type | Generalized | Focal |
| Duration | Under 15 minutes | Over 15 minutes |
| Frequency | Once in 24 hours | Recurs within 24 hours |
| Evaluation | Find and treat the fever source; no EEG, imaging, or routine LP | May warrant further evaluation; LP if meningitis is suspected |
Simple febrile seizures are benign. Reassure the family: recurrence is about 30% (more likely when the first seizure occurs before 18 months or with a family history), and later epilepsy risk is only slightly increased. Antipyretics do not prevent recurrence, and daily antiepileptic prophylaxis is not indicated.
Complex febrile seizures may warrant further evaluation. Perform an LP when meningitis is suspected, especially in an ill-appearing child or an infant whose exam is unreliable; incomplete Hib or pneumococcal immunization or pretreatment with antibiotics lowers the threshold. Any seizure lasting over 5 minutes is treated with a benzodiazepine.
Poisonings and ingestions
| Toxin | Clues | Treatment |
|---|---|---|
| Acetaminophen | Often asymptomatic early; hepatotoxicity after 24 hours | N-acetylcysteine, guided by a 4-hour level on the Rumack-Matthew nomogram (most effective within 8 hours) |
| Iron (prenatal vitamins) | Vomiting, GI bleeding, radiopaque pills on X-ray, metabolic acidosis | Deferoxamine; charcoal does not bind iron |
| Opioids | Pinpoint pupils, respiratory depression, coma | Naloxone |
| Tricyclic antidepressants | Wide QRS, arrhythmias, seizures, anticholinergic signs | Sodium bicarbonate |
| Organophosphates | Cholinergic excess: salivation, bronchorrhea, bradycardia, miosis | Atropine + pralidoxime |
| Salicylates | Tinnitus, respiratory alkalosis then anion-gap metabolic acidosis | Urine alkalinization with bicarbonate; hemodialysis if severe |
A button battery lodged in the esophagus is a surgical emergency: it causes liquefactive necrosis within hours, so it is removed urgently. On X-ray a double-ring (halo) outline distinguishes it from a coin.
Nonaccidental trauma
When the story doesn't fit. Suspect abuse when the injury is inconsistent with the stated mechanism or the child's developmental stage, care is delayed, the history changes, or injuries are in various stages of healing. Bruising in a non-mobile infant is a red flag—those who don't cruise rarely bruise—as is bruising of the torso, ears, or neck in a young child.
- Posterior rib fractures: anteroposterior squeezing of the chest; highly specific.
- Metaphyseal corner (bucket-handle) fractures: shaking or pulling of a limb.
- Spiral long-bone fractures in a non-ambulatory infant.
- Immersion burns: stocking-glove distribution with sharp margins and no splash marks.
- Abusive head trauma (shaken baby): retinal hemorrhages with subdural hematoma from torn bridging veins.
Usually accidental or benign. A toddler's (spiral distal tibial) fracture in a newly walking child, a clavicle fracture in a newborn (birth trauma), and a distal radius buckle fracture in a school-age child. Consider mimics such as osteogenesis imperfecta, bleeding disorders, and congenital dermal melanocytosis.
- Protectensure the child's immediate safety, admitting if home is unsafe
- Skeletal surveyall children under 2 with suspected abuse
- Head CT and dilated retinal examlook for subdural hematoma and retinal hemorrhages
- Coagulation studiesexclude a bleeding disorder
- Report and documentnotify Child Protective Services; record findings objectively
Physicians are mandatory reporters: notify CPS on reasonable suspicion. Proof is not required, parental consent is not needed, and failure to report is illegal.
Safe sleep, SIDS, and BRUE
Sudden infant death syndrome peaks at 2–4 months. Reduce risk with supine sleep on a firm mattress, no soft bedding or bumpers, room-sharing without bed-sharing, a pacifier at sleep, and no smoke exposure; breastfeeding is also protective.
Brief resolved unexplained event (BRUE). A sudden episode in an infant under 1 year—color change (cyanosis or pallor), absent or irregular breathing, marked change in tone, or altered responsiveness—that resolves and remains unexplained after history and exam. It is low-risk if the infant is over 60 days old, born at ≥32 weeks' gestation with a postconceptional age ≥45 weeks, it is the first event, it lasted under 1 minute, and no CPR was needed. Low-risk infants need reassurance and caregiver education, not an extensive workup.