Petechiae/purpura in well-appearing infants.

BACKGROUND: Well infants with petechiae and/or purpura can present to emergency departments, and their management can be difficult. Many will have extensive investigations and treatment that may not be necessary. METHODS: This was a retrospective and descriptive audit investigating well infants (<8 months of age) presenting with petechiae or purpura in the absence of fever to a pediatric emergency department over a 9½-year period. All presenting problems of petechiae or purpura were reviewed. Patients were excluded if they appeared unwell, were febrile or have a history of fever, or had eccyhmoses on presentation. RESULTS: Thirty-six babies were identified. The average age was 3.8 months (range, 1-7 months). The majority of the infants had localized purpura/petechiae to the lower limbs (92%) with two thirds of these patients having bilateral signs. None had generalized signs. Most infants had a full blood count (94%), coagulation profile (59%) and C-reactive protein (59%), and blood cultures (59%), with all being normal (except for mild elevation in platelets). Nine patients were admitted for observation, with only 1 patient having progression of signs. This patient had a diagnosis of acute hemorrhagic edema of infancy. The rest of the patients were thought to have either a mechanical reason for their petechiae/purpura (tourniquet phenomena) or a formal diagnosis was not specified. CONCLUSIONS: Well infants with localized purpura and/or petechiae with an absence of fever are more likely to have a benign etiology. Further study is required to determine if a full blood count and coagulation profile is necessary, or a period of observation (4 hours) is all that is required. If there is no progression of signs, it is likely that they can be safely discharged. The likely cause may be due to a tourniquet phenomenon (eg, diaper).

Post-traumatic stress symptoms and cognition in children exposed to motor vehicle accident trauma.

Research investigating the cognition of children exposed to non-familial trauma is scarce and the effects of post-traumatic stress symptoms in this population remain unclear. Thus, this research aimed to investigate the cognition of children exposed to motor vehicle accidents given the high incidence of this trauma globally. It was hypothesized that children with post-traumatic stress symptoms (PTSS; i.e., children with subthreshold or a full diagnosis of PTSD; n = 6) would perform significantly worse on cognitive measures compared to children exposed to trauma only (TO; i.e., children with very minimal or no PTSS; n = 10) and a healthy control group (n = 19). Analyses showed children with PTSS demonstrated significantly poorer perceptual reasoning F(2,32) = 7.21, p = .01, partial η2 = .31; verbal learning F(2,32) = 3.87, p = .05, partial η2 = .20; and delayed verbal memory F(2,32) = 4.40, p = .05, partial η2 = .22, compared to HCs. The magnitude of the differences between the groups was large. Differences in immediate verbal recall, executive functioning, and verbal intellectual abilities were moderate to large in magnitude, with the PTSS group performing worse than both groups, but these findings did not reach significance. Overall findings from this study provide further support for the notion that children exposed to non-familial trauma with significant PTSS display cognitive difficulties compared to healthy children.

A randomized controlled trial of 2 methods of immobilizing torus fractures of the distal forearm.

OBJECTIVES: Immobilization of torus fractures of the distal forearm, for 1 to 4 weeks in a slab, cast, or splint, produces good radiological and functional outcomes. This study assesses the pain associated with 2 forms of immobilization used for these injuries. METHODS: A randomized controlled trial comparing fiberglass volar slab and encircling plaster-of-paris cast was conducted at a children's hospital emergency department. Patients presenting with torus fractures of the distal forearm were enrolled and reviewed after 2 weeks of immobilization. A daily questionnaire was used during immobilization to assess pain, satisfaction, and activity state of the child. RESULTS: Adequate data were available for 42 participants in each group. Immobilization in a volar slab was associated with the following: increased duration of pain, with a median of 6.0 days (interquartile range [IQR] 2.0-11.0) versus 3.0 days (2.0-5.0) P = 0.009, and an increased time to resumption of normal activity at 2 weeks 67% versus 95%, P = 0.001. Average daily pain severity was similar in the 2 groups (35 mm on visual analogue scale [VAS] for the cast group vs. 39 mm for the slab group), P = 0.48. Stratified analysis showed pain on enrollment of greater than 50 mm on VAS, which was a strong association for longer duration of pain in both groups, P < 0.001. CONCLUSIONS: Use of a slab may increase the duration of pain, especially in patients who had more severe pain at presentation.

11. Fractures and minor head injuries: minor injuries in children II.

Fractures in children are common, but the plasticity of children's bones means that they may be incomplete. If a child has deformity, swelling or bony point tenderness in a limb after a fall, it is likely to be fractured. A fractured limb that appears deformed will most probably need to be reduced. Effective splinting, using whatever means is readily available, and early, adequate analgesia, can ameliorate the severe pain associated with a fracture. In young children with open growth plates, Salter-Harris type I injuries of the distal fibula are more common than ligament injuries of the ankle. After an ankle ligament injury, functional treatment--brace or tapes, with active physiotherapy--results in a better outcome than immobilisation. A child with a head injury, who does not lose consciousness, has only one or no episodes of vomiting, and is stable, alert and interactive, and neurologically normal, is extremely unlikely to have sustained an intracranial injury.

10. Bruising, abrasions and lacerations: minor injuries in children I.

Minor injuries in children (those that could reasonably be expected to heal with minimal medical intervention) are extremely common. The possibility of more serious injuries should be considered and excluded early. Successful examination requires gaining the child's trust, relieving pain early, and using a flexible and creative examination technique. Bruising may suggest a more serious underlying injury, or the bruising pattern may indicate non-accidental injury or a bleeding disorder. Superficial abrasions and lacerations can be safely cleaned with good quality water, and all foreign material should be removed. Deeper wounds with suspected damage to nerves, tendons or circulation need formal exploration under a general anaesthetic. Good local anaesthesia can be produced by topical preparations, and many wounds can be closed with tissue adhesives with an excellent cosmetic result. Antibiotics should be prescribed for specific circumstances, such as wounds with extensive contamination or tissue damage, and all children with injuries should be checked for adequate tetanus cover for prophylaxis.