PEDIATRIC CONCERNS
From the 34th Annual Family Practice Refresher Course, sponsored by the David Geffen School of Medicine at
the University of California, Los Angeles
| EYE PROBLEMS IN CHILDREN—Claudia Wang, MD, Clinical Professor of Pediatrics, David Geffen School of Medicine
at the University of California, Los Angeles
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| Red reflex in newborn infants: look for reddish-orange reflex (reddish-brown in babies with darker pigment)
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| Causes of white reflex (leukocoria): cataracts—may be genetic; may be due to infections (eg, varicella-zoster),
metabolic disorder (eg, galactosemia), or systemic disorder (eg, diabetes); retinopathy of prematurity; retinoblastoma
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| Nasolacrimal duct stenosis: usually presents at 3 to 5 wk of age with excessive tearing; treatment—time; may resolve
spontaneously within few months in first year of life; massage (challenging; press nasolacrimal sac with shortened
fingernail); antibiotics (if thick crusting of eyes); if unresolved at 9 mo to 1 yr of age, refer to ophthalmologist
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| Dacryocystocele: blockage of Hasner membrane and blockage of superior and inferior cuniculi; lump or mass with bluish
discoloration; eye pushed upward; refer to ophthalmologist
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| Congenital glaucoma: can be present at birth; usually presents during first weeks to months of life; incidence 1 in 12500;
developmental anomaly (inhibition of drainage of eye); features—excessive tearing; photophobia; blepharospasm; squinting
or blinking; cloudy cornea; corneal enlargement; urgent referral to ophthalmologist required; associated with Sturge-
Weber syndrome; neurologic and ophthalmologic consultations important
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| Strabismus: transient strabismus normal during first 4 mo of life (after 4 mo of age, refer to ophthalmologist); look for
fixed deviations (tropias) by checking corneal light reflex (ask child to fixate eye, then shine light on eye from ≈1 ft
away); cover-uncover test—in older children to elicit phoria (transient eye deviation; eyes usually straight-on); with
exophoria (eye turns outward) and esophoria (eye turns inward), eyes realign when cover removed; amblyopia—
decreased vision in one or both eyes; critical period from birth to 3 mo of age (failure of visual image to reach retina during
critical period; irreversible); may be due to congenital cataract, complete ptosis, growth (eg, hemangioma on eyelid)
that inhibits image from reaching retina, or extreme near- or far-sightedness; treatment includes patching of good eye and
surgery
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| Chemical burns: lavage—perform immediately for 10 to 15 min; place child in bathtub and open eyelids with fingers,
allowing lukewarm water to trail down arm; bring child to hospital; emergency department—quick assessment of visual
acuity; if child symptomatic or has loss of visual acuity, lavage again for 15 min; topical anesthetics; check pH of eye
with pH strips; flush with normal saline for 15 min and reexamine; do not lavage eye when ruptured globe suspected (refer
to ophthalmologist); after lavaging, perform more visual acuity testing (with corrective lenses if child wears glasses
[remove contact lenses]); use fluorescein to make sure no disruption of epithelial layer; urgent ophthalmologic consultation
; complications—ulceration; perforation; glaucoma; cataracts; retinal detachment; loss of vision; treatment—
antibiotics; cycloplegics (decrease formation of adhesions); patching
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| Trauma: assess mechanism of injury; look for foreign bodies; omit physical examination if ruptured globe or corneal laceration
suspected (refer immediately to ophthalmologist); assess visual acuity and pupil size; palpate orbital rim; check
for crepitus or step-off in case of fracture into sinus area (check whether eye “socked in”); internal examination (direct
ophthalmoscopy; check upper and lower fornices); ruptured globe—true eye emergency; usually caused by sharp projectile
object; do not manipulate, patch, or apply pressure to eye; provide protective shield (eg, cut out cup and tape over
eye) and send to ophthalmologist; if patient vomiting, avoid Valsalva’s maneuver and consider giving antiemetics; studies
(eg, x-rays) not necessary; send directly to ophthalmologist
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| Hyphema: urgent ophthalmology referral; blood in anterior chamber of eye; initially may appear hazy; rebleeding can
cause late complications (eg, secondary glaucoma) and usually occurs after 3 to 5 days in 20% of patients; treatment—
prevent rebleeding; rest; cycloplegics to maintain clot; antifibrinolytic agents; eye shield; steroids (controversial)
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| Foreign bodies in eye: use saline or cotton-tipped applicator to locate foreign body; perform single eyelid eversion with
cotton swab (double eyelid eversion requires eyelid retractor)
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| Iris prolapse: occurs with corneal lacerations; iris tissue plugs laceration; results in teardrop-shaped pupil
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| Corneal abrasions: painful tearful eye; photophobia; determine whether epithelial layer disrupted (use wet fluorescein
strip or fluorescein drops and cobalt blue or Wood’s light); if vertical linear lines visible, look for retained foreign body;
treatment—patching controversial because 1) cornea requires oxygenation to avoid anaerobic metabolism and to promote
healing; 2) produces moist environment conducive to bacterial infection; Pseudomonas risk factor for patients who wear
contact lenses; 3) prevents blinking and tear production; tears contain IgA, IgG, lysozyme, and complement that protect
against infection; patching generally not recommended except for child who rubs or pokes eye; instead, treat with cycloplegics
and/or antibiotics; refer to ophthalmologist
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| Fractures: orbital floor fracture—limited upward gaze; bruising of lower eyelid; nosebleed; orbital crepitus; fracture
into sinus area; decreased sensation of ipsilateral cheek and upper lip; medial wall fracture—orbital crepitus; nosebleed;
depressed nasal bridge; enophthalmos; superior wall fracture—rare; fracture into sinuses near anterior cranial
fossa; entry of air (pneumocephalus) or bacteria; meningitis; brain abscess; drainage of cerebrospinal fluid
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| Lens trauma: dislocation—iridodonesis (tremulous iris); subluxation—can also be associated with Marfan syndrome
and homocystinuria
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| Cherry red spot: seen with central retinal artery occlusion and lipid storage diseases
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| Retinoblastoma: average age at presentation 18 mo; 90% present at <3 yr of age; leukocoria most common presenting
sign, followed by strabismus; positive family history in ≈5% of cases; bilateral or unilateral; treatment—focus on retaining
vision; enucleation (if child has retinal detachment and no vision ability); cryotherapy; chemotherapy; radiation; consider
side effects
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| Eye infections: consider age; duration of symptoms; presence of discharge; ill contacts at home; vision changes; infections
(eg, gram-negative organisms, Gonorrhea, Chlamydia); consider age of presentation; if mother had prolonged rupture of
membranes and potentially ascending infection, could present at 5 days of age; herpes conjunctivitis can present in first 2 wk
of life; allergic conjunctivitis—seasonal; excessive tearing and itching; treat with antihistamine; viral conjunctivitis—
common during fall and winter; caused by adenovirus; consider in children with pharyngitis and conjunctivitis; no treatment
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| Periorbital and orbital cellulitis: causative agents include Staphylococcus and Streptococcus with onset of vaccines
and Haemophilus influenzae; orbital cellulitis more significant; lost or extraocular movement; decreased vision;
photophobia; proptosis; emergency care needed; computed tomography (CT) to check for severity and abscess in orbit;
obtain cultures; treat with intravenous (IV) antibiotics; close monitoring by ophthalmologist
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| Hordeolum (stye): painful red swelling; treatment—warm compress; cleansing with baby shampoo; consider topical
antibiotics; chalazion—chronic granulomatous inflammation; initially painful; may leave firm mass; cosmetic problem
(may require surgery for removal)
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| DENTAL AND UROLOGIC DISORDERS—Dr. Wang
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Dental Disorders
| Concerns: neonatal teeth—aspiration; extraction; dental caries—many bottled waters not supplemented with fluoride;
incidence of dental caries increasing in children and adults; delayed tooth eruption—refer to dentist if no eruption by 15
mo of age; rule out hypothyroidism or ectodermal dysplasia
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| Ellis classification for fractures: class I—involves enamel only; does not cause temperature sensitivity or pain; no
immediate dental consultation required; class II—disruption of dentin; pain; sensitivity to cold and hot; applying coating
over area helpful (dental consultation important); class III—pulp exposed; severe tooth pain; temperature sensitivity;
emergent dental consultation to treat and prevent infection and possible need for root canal
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| Root fractures: identified by x-ray; emergent dental consultation required; better prognosis for fractures closest to root
tip than for those closest to crown area
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| Tooth injuries: concussion—no tooth instability; no urgent need for dental consultation; subluxation—instability (<2
mm); refer to dentist for splinting; prognosis good; intrusion—tooth impacted; possible injury to permanent tooth bud;
urgent dental consultation required to determine whether tooth should be allowed to erupt naturally or be extracted;
extrusion—disruption of stabilization of periodontal ligament; refer to dentist for splinting and protection; avulsion of
permanent tooth— clean tooth by holding by crown and rinsing gently; replace tooth into socket, or transport in solution
(eg, saline, milk) and go to dentist quickly to save tooth
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Urologic Emergencies
| Penile anomalies: micropenis (phallus <2.5 cm; requires referral to endocrinologist); ventral and dorsal cleft disruption;
chordee (ventral bend at shaft of penis); hypospadias (more common distally than at base); phimosis—narrow or tight
foreskin; if child uncircumcised do not pull back foreskin until child 2 to 3 yr of age; by age 6 to 7 yr, foreskin should be
fully retractile; avoid paraphimosis (constricts shaft of penis; emergency care required)
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| Testicular and scrotal anomalies: bilateral undescended testicles require urgent endocrinologic consultation; unilateral
undescended testicles—more common in premature infants (testes descend during seventh to ninth month of gestation);
occurs in 30% of premature infants, 3% of term infants, and 1% in babies ≤1 yr of age; observe and refer after 1
yr; higher risk for cancer and fertility issues
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| Cryptorchidism: associated with prune-belly syndrome; bilateral; abnormal abdominal musculature; renal tract anomalies
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| Urethral anomalies: posterior urethral valves common; weak urinary stream
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| URINARY TRACT INFECTIONS—Robert Ettenger, MD, Professor of Pediatrics, David Geffen School of Medicine at
the University of California, Los Angeles
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| General principles: renal parenchymal infection (but not cystitis) can have important sequelae (eg, scarring) in children;
high fever (>102ºF) strongly suggests pyelonephritis; often difficult to distinguish cystitis from pyelonephritis in young children
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| Concepts that may influence practice: 1) primate studies from 1990s show antibiotic treatment given within 72 hr
effective in decreasing subsequent renal damage; 2) in children <24 mo of age, rates of symptomatic infection, reinfection,
and renal scarring did not differ between those treated orally (ie, outpatients) and those treated IV (ie, inpatients); 3)
admit children who cannot tolerate oral antibiotics, or who do not respond to therapy and cannot be adequately followed;
4) mean time to defervescence with treatment usually 24 hr
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| Bag urine culture: false-positive rate high (85%); sensitivity ≈100%; false-negative results unlikely and good for ruling
out urinary tract infection (UTI); positive culture must be corroborated by other form of urine culture
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| Urinary testing: if positive for nitrites or leukocyte esterase, sensitivity for UTI 88% (specificity 93%); if positive for nitrites
alone, specificity 98% (sensitivity 50% due to time [4 hr] required for nitrite to be generated by bacteria in bladder);
in uncentrifuged urine with pyuria and bacteruria, sensitivity 85% (specificity nearly 100%; specificity 99% in centrifuged
urine); dipsticks can miss ≤12% of UTIs (obtaining cultures necessary in almost all cases); child without pyuria or bacteruria
17 times less likely to have UTI than child with either finding; child with pyuria and bacteruria 85 times more likely to
have UTI
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| Management options for recurrent UTIs: 1) obtain routine urine cultures at 1-mo intervals and treat when cultures
positive; 2) instruct parents to immediately seek care for any febrile illness or urinary symptoms; perform urinalysis and
urine culture followed by prompt treatment; 3) give 6 to 12 mo of prophylactic nitrofurantoin (Furadantin); 4) give 6 to
12 mo of prophylactic trimethoprim-sulfamethoxazole (eg, Bactrim); 5) perform dimercaptosuccinic acid (DMSA) scanning
at 6 mo to look for scarring
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| Recurrent UTIs: 8% to 30% of patients with UTI have experienced ≥1 symptomatic UTI; prompt treatment important for
preventing renal scarring; history of fever >24 hr before diagnosis associated with renal scarring, and pyelonephritis likely;
8% of children who present to pediatrician at first sign of fever of unknown origin or urinary symptoms have pyelonephritis
but no renal scarring; if child with history of UTI presents with fever, reasonable to obtain culture and treat immediately
with antibiotics, depending on urinalysis and culture; previous strategy of routine surveillance with monthly urine studies
and prompt treatment when cultures become positive does not provide better outcomes (eg, onset of scarring) than other
management strategies; meta-analyses concluded that quality and sizes of studies precluded any conclusions about efficacy
of long-term antimicrobials for UTI prevention; some advocate 6 to 12 mo of trimethoprim-sulfamethoxazole or nitrofurantoin
in select children with recurrent febrile UTIs and scarring (may be appropriate when other options failed)
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| Case presentation: girl 3 yr of age, with first UTI and fever (101ºF); treated with oral cephalexin (eg, Keflex) and defervesced
in 36 hr; options for imaging studies—ultrasonography (US) alone; voiding cystourethrography (VCUG) alone;
US and VCUG; CT urography, with or without US and/or VCUG; DMSA scanning; evaluation—lower urinary tract and
vesicoureteral reflux (VUR); check for structural abnormalities in upper urinary tract, especially hydronephrosis; detect renal
scarring; primary goal of imaging studies to detect reflux; American Academy of Pediatrics (AAP) guidelines—
children <24 mo of age with UTI and no expected clinical response within 2 days of antibiotics should undergo prompt US
followed by VCUG at earliest convenient time; if patient responds with defervescence before 24 hr, perform US and VCUG
at earliest convenient time
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| Grades of VUR: grade I—reflux in ureter only; “no big problem”; grade II—reflux into pelvocaliceal system; not
significant; grade III—pelvocaliceal dilatation; grade IV—pelvocaliceal ballooning; caliceal blunting; ureteral dilatation;
grade V—massive dilatation with intrarenal reflux; severe reflux (grades III-V) leads to increased risk for acute inflammatory
damage and scarring; reflux present in 1% of all children, and in 40% of children with febrile UTI; 96% with
first UTI have grades I to III; spontaneous resolution occurs in 70% of all cases, 85% in grades I to III, and 25% to 41%
in grades IV and V; incidence of renal scarring after febrile UTI, 5% to 38%; reflux neither necessary nor sufficient to result
in renal scarring
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| Factors associated with renal scarring: high-grade reflux; number of febrile UTIs; delay (>3 days) in treatment of
acute UTI; young age (<7 yr of age); obstruction; voiding dysfunction; some studies suggest scarring may be associated
with reflux in utero and with renal dysplasia
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| Management of VUR: supportive and suppressive antibiotics; continue monitoring until VCUG shows no reflux; 30%
incidence of breakthrough UTIs; less frequent monitoring (eg, every 2 yr with mild VUR, every 3 yr with moderate to severe
VUR) with VCUG; stop antibiotics when VCUG negative; long-term antibiotics do not fully prevent UTI and
scarring; medical vs surgical treatment—single studies suggest similar outcomes (eg, reduction of glomerular filtration
rate and risk for UTI and renal damage) with medical and surgical treatment; combined treatment resulted in 60% reduction
in febrile UTIs by 5 yr, but no concomitant significant reduction in risk for new or progressive renal damage in 5
yr; surgery decreased number of UTIs, but not total number of children who developed UTIs or number of children who
developed kidney damage; uncertain whether identification and treatment of children with VUR confers important benefit;
indications for surgery—older children or children with progressive VUR (grades IV or V); lesser degrees of reflux
with progressive scarring; nonadherence to medical regimen over time
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Suggested Reading
Andersson L: Dental injuries in small children. Dent Traumato 23:195, 2007; Cariello AJ et al: Epidemiological
findings of ocular trauma in childhood. Arq Bras Oftalmol 70:271, 2007; Do LG et al: Risk-Benefit Balance in the Use
of Fluoride among Young Children. J Dent Res 86:723, 2007; Hodson E et al: Interventions for primary vesicoureteric
reflux. Cochrane Database Syst Rev:CD001532, 2007; Lin CH et al: Evaluation of imaging studies for vesicoureteral
reflux in infants with first urinary tract infection. Acta Paediatr Taiwan 48:68, 2007; Marques TC et al: Treatment of
phimosis with topical steroids and foreskin anatomy. Int Braz J Urol 31:370, 2005; McLaughlin C et al: The red reflex.
Pediatr Emerg Care 22:137, 2006; Melamud A et al: Retinoblastoma. Am Fam Physician 73:1039, 2006; Rahman
I et al: Open globe injuries: factors predictive of poor outcome. Eye 20:1336, 2006; Spence J et al: Diagnosing urinary
tract infections in febrile infants and children: when evidence-based medicine and clinical practice collide. CJEM 2:197,
2000; Tuygun C et al: Usefulness of a New Dysfunctional Voiding and Incontinence Scoring System in Predicting Treatment
Effect in Children with Voiding Dysfunction. Urol Int 79:76, 2007; Wilson S et al: Epidemiology of dental trauma
treated in an urban pediatric emergency department. Pediatr Emerg Care 13:12, 1997.
Educational Objectives
| The goal of this program is to improve the management of pediatric eye, dental, and urologic problems. After hearing and
assimilating this program, the participant will be better able to:
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 | Recognize and treat nasolacrimal duct stenosis, strabismus, and hyphema in infants and children.
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| Determine severity of dental fractures and injuries, and refer for emergency consultation as indicated.
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| Perform effective diagnostic screening for urinary tract infections (UTIs).
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| Prevent recurrent UTIs with appropriate screening and prophylaxis.
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| List risk factors for renal scarring.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified
conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business
or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Drs. Wang and Ettenger spoke in Los Angeles, CA, at the 34th Annual Family Practice Refresher Course, presented
May 29 through June 2, 2007, by the David Geffen School of Medicine at the University of California, Los Angeles. The
Audio-Digest Foundation thanks the speakers and the David Geffen School of Medicine for their cooperation in the production
of this program.
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