Pediatric Ecg Cases

[Laila Berri]

The findings in this report are subject to at least four limitations. First, this was an ecologic study, and causation cannot be inferred. Second, pediatric COVID-19 case counts and rates included all cases in children and adolescents aged

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This PedsCases note provides a one-page, system-based overview on the complications of preterm birth! It was created by Ola Elsharif, a medical student at McMaster University with the help of Dr. Meenatchi Ranganathan, a general pediatrician at McMaster University.

The first part of this three-part podcast will give you an approach to Emerging Child and Adolescent Psychosis. The podcast was created by Dr. Leslie Truong, a first year Psychiatry Resident at the University of Alberta, in collaboration with Dr. Trishnee Chinniah, a Child and Adolescent Psychiatrist at the Royal Alexandra Hospital.

This PedsCases note provides a one-page overview on stomatitis! It covers the presentation, differential diagnosis, investigations and management of the condition. It was created by Emily Cheung, a medical student at McMaster University with the help of Dr. Erin Boschee, pediatrician at the Stollery Children's Hospital in Edmonton, Alberta.

ChatGPT version 3.5 reached an incorrect diagnosis in 83 out of 100 pediatric case challenges. Among the incorrect diagnoses, 72 were actually incorrect and 11 were clinically related to the correct diagnosis but too broad to be considered correct, reported Joseph Barile, BA, of Cohen Children's Medical Center in New Hyde Park, New York, and colleagues in JAMA Pediatrics.

An example of an instance in which the chatbot diagnosis was determined to not fully capture the diagnosis was in the case of a draining papule on the lateral neck of an infant. The physician diagnosis was "branchio-oto-renal syndrome," and the chatbot diagnosis was "branchial cleft cyst."

"Despite the high error rate of the chatbot, physicians should continue to investigate the applications of LLMs to medicine," Barile and colleagues wrote. "LLMs and chatbots have potential as an administrative tool for physicians, demonstrating proficiency in writing research articles and generating patient instructions."

They reported a representative example of a correct diagnosis, the case of a 15-year-old girl with unexplained intracranial hypertension. The physician diagnosis was "primary adrenal insufficient (Addison disease)," and the chatbot diagnosis was "adrenal insufficiency (Addison disease)."

A prior study had found that a chatbot rendered a correct diagnosis in 39% of cases, suggesting that LLM-based chatbots "could be used as a supplementary tool for clinicians in diagnosing and developing a differential list for complex cases," Barile and colleagues wrote. "To our knowledge, no research has explored the accuracy of LLM-based chatbots in solely pediatric scenarios, which require the consideration of the patient's age alongside symptoms."

Overall, "the underwhelming diagnostic performance of the chatbot observed in this study underscores the invaluable role that clinical experience holds," the authors wrote. "The chatbot evaluated in this study -- unlike physicians -- was not able to identify some relationships, such as that between autism and vitamin deficiencies."

"LLMs do not discriminate between reliable and unreliable information but simply regurgitate text from the training data to generate a response," Barile and colleagues noted. Some also lack real-time access to medical information, they added.

To complete their study, Barile and colleagues accessed JAMA Pediatrics and the New England Journal of Medicine for pediatric case challenges. Text from 100 cases was pasted into ChatGPT version 3.5 with the following prompt: "List a differential diagnosis and a final diagnosis."

More than half of the incorrect diagnoses generated by the chatbot did belong to the same organ system as the correct diagnosis, Barile and colleagues noted. Additionally, 36% of the final case report diagnoses were included in the chatbot-generated differential list.

Jennifer Henderson joined MedPage Today as an enterprise and investigative writer in Jan. 2021. She has covered the healthcare industry in NYC, life sciences and the business of law, among other areas.

Much of the distinction between true pediatric seizures and mimics will hinge on elements gathered from the history. Ask about the onset, duration, nature of the movements, tongue biting, eye findings and details of the recovery phase. A history of incontinence can be helpful in older children who are no longer in diapers. The presence or absence of an aura will only be helpful in children who are able to provide a clear account of their experience. Be sure to ask the parents what the eyes, neck and head were doing at the time of the seizure. The recovery phase is also important since a rapid return to normal activity speaks against a true seizure.

Breath holding spells are most common in the 6-18month age range. One of the key differentiating factors is that there is usually a clear trigger for a breath holding spells such as emotional distress or pain, whereas seizures typically do not have such precipitants. This pattern of an initiating trigger, followed by emotional upset, crying, pallor, and occasionally LOC is highly suggestive of a breath holding spell. The breath holding and LOC can lead to brief seizure activity given the decrease cerebral blood-flow. However, the recovery from a breath-holding spell is rapid and complete without a post-ictal phase.

These tend to be seen in the adolescent population since younger children cannot feign seizure activity for secondary gain. Features that distinguish these events from true seizures include side-to side head, arm or leg movements with eyes closed. If the eyes are open, the eye movements are normal as opposed to deviated. A bicycling movement of the legs is highly suggestive of pseudo-seizure.

Syncopal episodes may or may not have a clear precipitant but the LOC always precedes any perceived seizure activity. Observers may note some brief twitching episodes as opposed to true tonic-clonic movements. The recovery from a syncopal episode is rapid and complete.

Once you have established that the child did in fact have true seizure activity in the context of a fever, the next step is to clearly define whether it fits the pattern of a simple or a complex febrile seizure. A diagnosis of complex febrile seizures is made if there is any deviation from the criteria of a simple febrile seizure. This distinction is important because complex seizures may indicate a more serious disease process and usually require a work-up.

If the child meets the criteria for a simple febrile seizure, no dedicated seizure workup is required and you evaluate the patient as if they solely had a fever. It is clear in the literature that children who have suffered a simple febrile seizure are at no greater risk for serious bacterial infection than age-matched controls who have not seized. A child who fits the criteria for a simple febrile seizure should be worked up as if they presented with fever and no seizure. Studies have shown that measurement of serum electrolytes or glucose in particular has no role in the workup of simple febrile seizures. A workup beyond a basic febrile workup should be considered if the child appears unwell or meets any of the criteria of a complex febrile seizure.

Our experts recommend the workup of complex febrile seizures to be a step wise approach, keeping in mind that the younger the child the more aggressive the work-up should be. Children who return to baseline after a complex seizure and at no point displayed any focal neurologic symptoms usually do not require an extensive work-up. Even though studies have shown that febrile seizures do not increase the risk of serious bacterial infection compared to fever alone, meningitis should always be on the differential diagnosis in a child with complex febrile seizures. About 25 % of children with meningitis will present with a new onset febrile seizure, however they will almost always display persistent mental status abnormalities along with other signs of meningitis such as nuchal rigidity, focal siezures and petechia.

Update 2018: A retrospective study including over 28,000 patients (ages 0-5) with complex febrile seizures showed a very low incidence of CNS infections, suggesting lumbar punctures are low-yield in this population. Caution was warranted in those who are unvaccinated, pre-treated with anti-biotics or had suspicious symptoms/signs of CNS infection. Abstract

One particular diagnosis that is one of the more common causes of non-febrile seizure in children under 6months of age and that is relatively easy to pick up thus avoiding an extensive invasive work-up is hyponatremia secondary to formula over-dilution. In a paper from the Annals of EM, hyponatremia was the cause of seizures in 70% of 47 infants younger than 6 months who lacked other findings suggesting a cause. They found that a temperature of 36.5C or less as the best predictor of hyponatremic seizures.

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