Debriefing

When should we give epinephrine, and how long do children need to be observed afterward?Dr. Bob Belfer speaks with pediatric emergency physician and researcher Dr. Tim Dribin (Cincinnati Children’s Hospital Medical Center) about pediatric anaphylaxis. Drawing on multicenter research and bedside experience, they explore how to improve recognition, reduce hesitation around epinephrine, and tailor observation and discharge decisions to the individual patient.They discuss early peanut introduction, the lessons of the LEAP trial, and AnaTool, a clinical support tool designed to help healthcare professionals recognize and manage anaphylaxis. They also examine Dr. Dribin’s 2025 study in The Lancet Child & Adolescent Health on the timing of repeat epinephrine, what it suggests about shorter observation periods for selected patients, and which children warrant greater caution. The conversation addresses reaction severity, access to epinephrine, local care pathways, and shared decision-making with families.Finally, a lightning round covers intranasal epinephrine, diagnostic pitfalls involving gastrointestinal symptoms, and the roles of steroids and antihistamines. They tackle another challenging question: does every child who receives epinephrine in the community need an ED visit? Dr. Dribin discusses emerging evidence, the practical challenges of these decisions, and the research needed to guide future care.Studies and resources discussedDu Toit G, Katz Y, Sasieni P, et al. Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy. J Allergy Clin Immunol. 2008;122(5):984-991.Du Toit G, Roberts G, Sayre PH, et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med. 2015;372(9):803-813. The LEAP trial.Dribin TE, Muraro A, Camargo CA Jr, et al. Anaphylaxis definition, overview, and clinical support tool: 2024 consensus report—a GA²LEN project. J Allergy Clin Immunol. 2025;156(2):406-417.e6.AnaTool: FARE’s interactive anaphylaxis clinical support tool for healthcare professionals, with assessment of anaphylaxis likelihood and epinephrine dosing guidance.Dribin TE, Sampson HA, Zhang Y, et al. Timing of repeat epinephrine to inform paediatric anaphylaxis observation periods: a retrospective cohort study. Lancet Child Adolesc Health. 2025;9(7):484-496.Dribin TE, Schnadower D, Sampson HA, et al. Prediction model for children with anaphylaxis who may not require emergency department care: a multicenter retrospective cohort study. J Allergy Clin Immunol Pract. 2026;14(9):2038-2050.e5.About the guestDr. Tim Dribin is a pediatric emergency physician at Cincinnati Children’s Hospital Medical Center. His research focuses on improving the recognition and management of anaphylaxis, personalizing observation and discharge decisions, and developing tools to support clinicians, patients, and caregivers in the ED and community.About the podcastThe PEM Podcast features thoughtful conversations, practical teaching, and the people and ideas shaping pediatric emergency medicine. It is hosted by Dr. Bob Belfer and is part of HipPEMcrates, an independent pediatric emergency medicine education platform.Visit HipPEMcrates.com for pediatric emergency medicine articles, literature reviews, clinical pearls, and educational resources.

How can we make a high-risk, low-frequency procedure safer for the critically ill child?Dr. Bob Belfer speaks with pediatric emergency physician and airway educator Dr. Josh Nagler (Boston Children's Hospital) about pediatric tracheal intubation. Drawing on multicenter airway registry data and bedside experience, they explore what improves first-attempt success, what contributes to adverse events, and where the pediatric evidence remains limited.They discuss preoxygenation, the physiology and practical tradeoffs of apneic oxygenation, and video versus direct laryngoscopy - including how a shared screen can support real-time coaching. Dr. Nagler offers practical guidance on stylets, patient positioning, and adapting the setup for infants versus adolescents. They also examine the NEAR4PEM pre-intubation checklist, preparation for peri-intubation hypotension, and the emerging potential of artificial intelligence to identify difficult airways and recognize anatomic landmarks.Finally, they tackle a challenging question: who should make the first intubation attempt? The conversation explores how to balance patient safety with the need to train clinicians who may one day manage a pediatric airway without immediate specialist support.Learn more and register for the CHOP/Boston Children's Pediatric Emergency Medicine Conference here.Studies and resources discussedMiller KA, Dechnik A, Miller AF, et al. Video-assisted laryngoscopy for pediatric tracheal intubation in the emergency department: a multicenter study of clinical outcomes. Ann Emerg Med. 2023;81(2):113-122.Miller KA, Prieto MM, Wing R, et al. Development of a paediatric airway management checklist for the emergency department: a modified Delphi approach. Emerg Med J. 2023;40(4):287-292.National Emergency Airway Registry for Pediatric Emergency Medicine (NEAR4PEM): multicenter airway research, quality improvement, and the pre-intubation checklist.National Emergency Airway Registry for Children (NEAR4KIDS): pediatric airway safety research and intubation safety resources.Gawande A. The Checklist Manifesto: How to Get Things Right.About the guestDr. Josh Nagler is a pediatric emergency physician at Boston Children’s Hospital and an Associate Professor of Pediatrics and Emergency Medicine at Harvard Medical School. His research and teaching focus on pediatric airway management, video-assisted laryngoscopy, procedural coaching, and medical education.About the podcastThe PEM Podcast features thoughtful conversations, practical teaching, and the people and ideas shaping pediatric emergency medicine. It is hosted by Dr. Bob Belfer and is part of HipPEMcrates, an independent pediatric emergency medicine education platform.Visit HipPEMcrates.com for pediatric emergency medicine articles, literature reviews, clinical pearls, and educational resources.

What does declining confidence in childhood vaccines mean for the child with fever in the pediatric ED?Dr. Bob Belfer speaks with pediatric infectious disease physician and vaccine expert Dr. Paul Offit about vaccine hesitancy in 2026. Using the framework of confidence, complacency, and convenience, they explore how the COVID era changed public trust and why the consequences of vaccine decisions can fade from memory when vaccines succeed.They revisit Andrew Wakefield’s retracted MMR paper and discuss a recent study of more than 2.5 million U.S. children that found no association between MMR vaccination and autism. Dr. Offit explains the purpose of the National Vaccine Injury Compensation Program, why a report to VAERS does not establish causation, and how the Vaccine Safety Datalink can investigate a potential safety signal. The conversation also covers COVID-19 and influenza vaccination, measles outbreaks, the hepatitis B birth dose, and changes in how vaccine recommendations are presented.Finally, they turn to the pediatric ED: how should an unimmunized toddler with fever and no clear source change a clinician’s concern for invasive bacterial infection?Studies and resources discussedWorld Health Organization Strategic Advisory Group of Experts on Immunization. Report of the SAGE Working Group on Vaccine Hesitancy. 2014.Burstain TL, Jacques D, Burstain JM. Association between first MMR vaccination before age 2 years and childhood autism in a U.S. EHR cohort of 2.5 million children. Pediatr Infect Dis J. Published online July 28, 2026. doi:10.1097/INF.0000000000005349.Wakefield AJ, Murch SH, Anthony A, et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet. 1998;351(9103):637-641. Retracted in 2010.Offit PA. Flawed research and its enduring repercussions. Science. 2020;370(6512):43. A review of Brian Deer’s The Doctor Who Fooled the World.Centers for Disease Control and Prevention. About VAERS and About the Vaccine Safety Datalink.Health Resources and Services Administration. About the National Vaccine Injury Compensation Program.About the guestDr. Paul Offit is Director of the Vaccine Education Center and an attending physician in the Division of Infectious Diseases at Children’s Hospital of Philadelphia. He is a professor of pediatrics and the Maurice R. Hilleman Professor of Vaccinology at the Perelman School of Medicine at the University of Pennsylvania. He co-invented the rotavirus vaccine RotaTeq.About the podcastThe PEM Podcast features thoughtful conversations, practical teaching, and the people and ideas shaping pediatric emergency medicine. It is hosted by Dr. Bob Belfer and is part of HipPEMcrates, an independent pediatric emergency medicine education platform.Visit HipPEMcrates.com for pediatric emergency medicine articles, literature reviews, clinical pearls, and educational resources.

Does the type of crystalloid we choose change outcomes for children with septic shock?Dr. Bob Belfer speaks with pediatric intensivist and sepsis researcher Dr. Scott Weiss about the landmark PRoMPT BOLUS trial, which compared balanced crystalloids with 0.9% saline in more than 9,000 children.They discuss why fluid boluses help - and why their effects may be temporary - the meaning of the MAKE30 outcome, how the trial’s findings should influence fluid choice in the ED and ICU, and why lower rates of hyperchloremia did not translate into better patient-centered outcomes. They also review the 2026 pediatric Surviving Sepsis guidelines, including sepsis screening, the timing and selection of vasoactive medications, lactate and procalcitonin, point-of-care ultrasound, and the emerging role of AI and precision medicine in pediatric sepsis.Studies discussedBalamuth F, Weiss SL, Long E, et al. Balanced fluid or 0.9% saline in children treated for septic shock. N Engl J Med. Published online April 24, 2026.Weiss SL, Balamuth F, Long E, et al. PRagMatic Pediatric Trial of Balanced vs nOrmaL Saline FlUid in Sepsis: study protocol for the PRoMPT BOLUS randomized interventional trial. Trials. 2021;22(1):776.Weiss SL, Keele L, Balamuth F, et al. Crystalloid fluid choice and clinical outcomes in pediatric sepsis: a matched retrospective cohort study. J Pediatr. 2017;182:304-310.e10.Lehr AR, Rached-d’Astous S, Barrowman N, et al. Balanced versus unbalanced fluid in critically ill children: systematic review and meta-analysis. Pediatr Crit Care Med. 2022;23(3):181-191.Self WH, Semler MW, Wanderer JP, et al. Balanced crystalloids versus saline in noncritically ill adults. N Engl J Med. 2018;378(9):819-828.Semler MW, Self WH, Wanderer JP, et al. Balanced crystalloids versus saline in critically ill adults. N Engl J Med. 2018;378(9):829-839.Zampieri FG, Machado FR, Biondi RS, et al. Effect of intravenous fluid treatment with a balanced solution vs 0.9% saline solution on mortality in critically ill patients: the BaSICS randomized clinical trial. JAMA. 2021;326(9):818-829.Finfer S, Micallef S, Hammond N, et al. Balanced multielectrolyte solution versus saline in critically ill adults. N Engl J Med. 2022;386(9):815-826.Delgado Moya FP, Antequera A, Muriel A, et al. Buffered solutions versus 0.9% saline for resuscitation in critically ill adults and children. Cochrane Database Syst Rev. 2026;4(4).Weiss SL, Peters MJ, Alhazzani W, et al. Surviving Sepsis Campaign international guidelines for the management of sepsis and septic shock in children 2026. Intensive Care Med. 2026;52(5):937-983.Weiss SL, Peters MJ, Alhazzani W, et al. Executive summary: Surviving Sepsis Campaign international guidelines for the management of sepsis and septic shock in children 2026. Pediatr Crit Care Med. 2026;27(4):494-513.Scott HF, Sevick CJ, Colborn KL, et al. Clinical Decision Support for Septic Shock in the Emergency Department: A Cluster Randomized Trial. Pediatrics. 2025;156(1):e2024069478.Ventura AMC, Shieh HH, Bousso A, et al. Double-blind prospective randomized controlled trial of dopamine versus epinephrine as first-line vasoactive drugs in pediatric septic shock. Crit Care Med. 2015;43(11):2292-2302.Ramaswamy KN, Singhi S, Jayashree M, Bansal A, Nallasamy K. Double-blind randomized clinical trial comparing dopamine and epinephrine in pediatric fluid-refractory hypotensive septic shock. Pediatr Crit Care Med. 2016;17(11).Eisenberg MA, Carlson L, Graham DA, et al. Epinephrine vs norepinephrine as initial treatment in children with septic shock. JAMA Netw Open. 2025;8(4).About the guestDr. Scott Weiss is the Division Chief of Critical Care Medicine at Nemours Children’s Hospital. His clinical and translational research focuses on pediatric sepsis, including mitochondrial dysfunction, fluid resuscitation, biomarkers, and precision medicine.About the podcastThe PEM Podcast features thoughtful conversations, practical teaching, and the people and ideas shaping pediatric emergency medicine. It is hosted by Dr. Bob Belfer and is part of HipPEMcrates, an independent pediatric emergency medicine education platform.Visit HipPEMcrates.com for pediatric emergency medicine articles, literature reviews, clinical pearls, and educational resources.

The podcast is back - with a new name and a new season of conversations.Dr. Bob Belfer introduces The PEM Podcast, formerly the CHOP PEM Podcast, and shares what listeners can expect from its return: thoughtful conversations, practical teaching, and insights from the people shaping pediatric emergency medicine. Upcoming episodes will feature national and international experts discussing pediatric sepsis, fluid management, and much more.The PEM Podcast is now part of the HipPEMcrates network, an independent pediatric emergency medicine education platform. If you’re already subscribed, there’s nothing you need to do - new episodes will appear right here in your feed.We’re glad to be back. Stay tuned.

Mental Health Emergencies featuring Dr. Jeremy Esposito

Take Care of Maya

Monday Morning Quarterback: COVID with Dr. Paul Offit

Abusive Head Trauma: From the ER to the courtroom with Dr. Cindy Christian

Debriefing with Dr. Lauren Zinns