PEDIATRIC DILEMMAS
| CLINICAL PROBLEMS IN CHILDREN AND ADOLESCENTS —Shannon M. Thyne, MD, Assistant Clinical Professor
of Pediatrics, University of California, San Francisco, School of Medicine; Director, Children’s Health Center, and Medical
Director, Pediatric Asthma Clinic, San Francisco General Hospital
|
| Weight: weight loss normal in first few days after birth; birth weight should be regained by tenth day after birth, doubled
by 4 to 5 mo of age, tripled by 1 yr of age, and quadrupled by 2 yr of age; newborns should gain 10 to 30 g/day for first 3
mo, 15 to 20 g/day for rest of first year
|
| Puberty: girls—age of menarche decreasing in United States; average age of menarche in black girls, 12.1 yr (12.9 yr in
white girls); according to some endocrinologists, reasonable to see development of secondary sexual characteristics in
children as young as 8 yr of age; begins with breast development, followed by pubic hair, growth spurt, and menarche;
boys—not dependent on ethnicity; sexual development before 9 yr of age considered precocious; begins with increased
testicular volume, followed by pubic hair, penile enlargement, and growth spurt
|
| Causes of childhood deaths: number one cause accidents (eg, motor vehicle accidents, falls, poisoning, drowning,
fires and burns); 0 to 1 yr of age—developmental and genetic conditions present at birth; sudden infant death syndrome
(SIDS); conditions associated with low birth weight or prematurity; 1 to 4 yr of age—accidents; developmental and genetic
conditions; cancer; 5 to 14 yr of age—accidents; cancer; homicide; 15 to 24 yr of age—accidents; homicide; suicide;
in black boys and men, incidence of homicide greater than that of accidents
|
| Sudden infant death syndrome: risk factors—prone sleeping position; tobacco smoke exposure (before or after
birth); soft bedding; prematurity; perinatal drug exposure; education important; side sleeping unacceptable
|
| Colic: healthy well-fed infants with paroxysms of crying lasting >3 hr per day and occurring >3 times per week; occurs
when child begins to become aware of environment but does not yet understand it; should not occur in first few days after
birth; symptoms present by 2 wk of age; most episodes occur in early evening; usually resolves by 3 mo of age; peaks at
5 to 10 wk (same time frame as shaken baby syndrome); treatment—emotionally consoling behaviors, eg, rhythmic
rocking; encourage sucking (pacifiers shown to decrease SIDS); swaddling, bundling, and cuddling; medications not recommended
(simethicone safe but not recommended); realize colic will resolve; children still irritable after 3 mo of age or
children not progressively improving should be worked up, eg, for reflux or hair tourniquet syndrome
|
| Iron deficiency anemia: iron better absorbed from human milk than from formula; every infant taking formula should
be given iron-fortified formula; remind mothers who are breast-feeding to take iron supplements; starting at 4 to 6 mo of
age, source of iron (eg, iron-fortified cereal) recommended; most common between 9 to 24 mo of age; cow’s milk—
contains small amount of bioavailable iron; replaces food with higher iron content; inhibits iron absorption; can cause
gastrointestinal (GI) bleeding; clinical manifestations—pallor; most children present asymptomatically; screen children
between 9 and 12 mo of age, followed by every year until age 5 yr; laboratory testing—complete blood cell count
(CBC); if treatment fails, proceed with ferritin testing and other iron studies; responses to oral iron therapy—
reticulocytosis in 2 to 3 days; hemoglobin increases 1 g/dL within 1 mo; in children with hemoglobin 10 to 11 g/dL (or
lower), start iron therapy empirically (2-4 mg/kg per day) and recheck in 3 mo
|
| Lead poisoning: contributes to iron deficiency anemia; no safe level of lead (≥5 µg/dL concerning); decrease in intelligence
associated with every 1-µg/dL increase in lead; common lead sources in California include paint, toys, clay pots
heated on stove, and tamarind candy
|
| Breath-holding spells: common; usually occur in children 6 to 18 mo of age; often associated with positive family history;
onset before age 5 yr (consult neurologist if onset after age 5 yr); usually precipitated by upsetting event; breath held
on exhalation; child undergoes color change and becomes hypotonic; some cases associated with seizure activity; child
becomes limp and returns to consciousness; diagnosed by thorough history; cyanotic and pallid spells occur occasionally
to several times daily; peak at age 2 yr; differential diagnosis—seizure; rule out prolonged QT interval with electrocardiography
(ECG); developmental process
|
| Enuresis: developmental process; age and incidence—5 yr of age, 15% to 20%; 10 yr of age, 5%; 15 yr of age, 1% to
2%; spontaneous cure rate high; nocturnal enuresis more common in boys; diurnal enuresis uncommon, but more likely
in girls; etiology—positive family history; bladder capacity; sleep level; uncomplicated—nocturnal symptoms; physical
examination and urinalysis (UA) normal; complicated—positive history of voiding dysfunction; abnormal neurologic
examination; positive history of urinary tract infection; positive UA; interventions—rule out complicating factors, eg, infection;
after age 3 yr, focus on self-awakening, bedtime habits, getting up in middle of night, and praise for dry mornings;
as children become older, use motivation or enuresis alarm (>8 yr of age); do not make child “feel bad”;
desmopressin (eg, DDAVP)—consider in children ≥12 yr of age; 2 sprays per nostril at bedtime for 1 mo; taper to 1 nostril,
then taper to every other day; use depends on clinician’s comfort level; discuss risks of holding urine
|
| Acute scrotum: history and physical examination—fever; sexual activity; cremasteric reflex; appearance of scrotum;
palpation; differential diagnosis—testicular torsion; trauma; epididymitis; tumor; evaluation—UA; conventional or
color Doppler ultrasonography; testicular torsion—onset acute; can be associated with trauma or physical activity (eg,
soccer); physical findings—edema; erythema; scrotum riding high; tenderness; torsion of appendix testis (“blue dot”
finding); absence of cremasteric reflex; decreased blood flow on nuclear imaging; surgical emergency (orchiopexy on
other testicle standard of care)
|
| Intussusception: invagination or telescoping of proximal intestine into bowel; often occurs after viral illness, leading to
inflammation of nodes; most common in children 3 mo to 6 yr of age; etiology usually unknown; classic presentation—
severe colicky pain; bringing knees to chest while crying; limpness followed by awakening feeling fine; worsens over
time; currant jelly stool; dilated bowel loops; use barium enema to observe telescoping; management includes fluid resuscitation,
reduction with air or barium enema, and surgery; untreated intussusception severe; during first 24 hr after reduction,
patients at risk for recurrence (admit children to hospital overnight); recovery rate excellent; rotavirus vaccine—in
1998, associated with increased incidence of intussusception; removed from market in 2003; new vaccine available
(given before age of susceptibility for intussusception; must be started at 2-mo series, and by age 10 wk; start series at
recommended age)
|
| Idiopathic thrombocytopenic purpura (ITP): most common acquired bleeding disorder in children <10 yr of age;
platelet count ≤150,000/µL; presentation—purpuric rash (large welts classic); patients look well; absence of other
causes of thrombocytopenia; petechiae; purpura; nosebleed; hematuria; recent history of viral illness; absence of
hepatosplenomegaly; laboratory studies—thrombocytopenia; can have anemia from bleeding; bone marrow normal; peripheral
blood smear normal; natural history—most cases acute; in children, usually not recurrent; remits spontaneously;
mortality related to central nervous system bleeding; management—steroids (affect ability to stage cancer in children
with leukemia; consider bone marrow test before treatment); intravenous (IV) immunoglobulin
|
| Henoch-Schönlein purpura (HSP): IgA-mediated small-vessel vasculitis; in children 2 to 12 yr of age; children often
have preceding upper respiratory infection (URI); 1.5 times more common in boys than in girls; presentation—mild
lesions or significant disease; children appear sick; rash not always present; bowel wall thickening; scrotal swelling in
boys; arthritis; hematuria; nephritis; treatment—supportive; steroids if abdominal pain severe
|
| Febrile seizures: determine cause of fever; typical—tonic-clonic seizure lasting <15 min; most occur in child 6 mo of
age to 5 yr of age (peaks at 15-18 mo of age); 1 seizure in 24 hr; atypical—seizure lasting >15 min; >1 seizure in 24 hr;
seizure that remains focal; Todd’s paralysis after seizure; facts and statistics—occur in 3% to 4% of children; do not
cause mental retardation, cerebral palsy, learning disorders, epilepsy, or afebrile seizures, but risk for epilepsy increases
slightly in children with positive family history and febrile seizures; work-up—if child returns to baseline, no seizure
work-up needed; blood studies, electroencephalography (EEG), and lumbar puncture (LP) not recommended routinely;
American Academy of Pediatrics recommends considering LP in children <12 mo of age with first febrile seizure; patients
with evidence of meningeal signs or abnormal neurologic examination should have full work-up; treatment—treat
cause of fever; “stacking” of ibuprofen or acetaminophen controversial (depends whether family able to chart appropriately);
no data support preventing fever prevents febrile seizure (often, fever starts before parents recognize child ill or fever
rises very quickly; not inappropriate to treat child with febrile illness with antipyretic, but does not change chance for
febrile seizure); work-up of atypical febrile seizures—determine source of fever; consider neurologic evaluation; in children
with multiple febrile seizures, not unreasonable to train families in use of rectal diazepam at home; refer to neurologist
|
| Acute life-threatening event (ALTE): child stops breathing for ≥30 sec; median age 2 mo; “not a diagnosis, it’s a
complaint”; described as cyanosis, limpness, choking, gagging, change in muscle tone; slightly increases risk for
SIDS; 5% to 6% of children who died of SIDS had reported ALTE; respiratory pauses lasting ≤15 sec normal
|
 | Differential diagnosis: acute conditions—sepsis; meningitis; respiratory syncytial virus (RSV) in first year of life associated
with apnea; pertussis associated with apnea until 2 to 3 yr of age; toxins; metabolic processes; chronic conditions—
seizures; reflux; prolonged QT interval; child abuse; Munchausen syndrome by proxy; anatomic abnormalities
|
| Management: hospitalization and monitoring for 24 to 48 hr; work-up as indicated; treatment based on etiology; home
apnea monitors—controversial; useful in children at increased risk for SIDS; generally not recommended; may be
useful in child with severe ALTE, symptomatic preterm child with apnea and bradycardia, or child with sibling who
had similar history and died of SIDS; may not be helpful due to sensitization to false alarms; alarm parameters difficult;
use until child free of significant event for ≥2 mo
|
| Asthma: consider foreign bodies in children who present with wheezing; affects ≈15% of children; symptoms often appear
before age 5 yr; decrease in symptoms with home environmental controls comparable to that of initiation of low-
dose inhaled corticosteroids; steroids safe and effective; persistent asthma—daytime symptoms >2 times per week;
nighttime symptoms >2 times per month; exacerbations requiring multiple inhaled therapy >2 times per year; patients
should be on controller medication; whenever controller medication increased, reassess patient in 1 mo; after patient controlled,
decrease medication and reassess in 1 to 3 mo
|
| ADDITIONAL THOUGHTS ON CHILDHOOD ASTHMA —James R. Roberts, MD, MPH, Associate Professor of Pediatrics,
Medical University of South Carolina
|
| Introduction: children from low-income families less likely to receive preventive care and more likely to have complications;
black children less likely to visit physician for asthma and less likely to use inhaled corticosteroids for asthma;
compared to white children, black children 3 times more likely to be hospitalized and 4 times more likely to die from
asthma; barriers to treatment—lack of health insurance, primary care provider, or coordinated care; high cost of medications;
lack of recognition of severity of asthma; suboptimal compliance with guidelines; confusion about symptoms
|
| Allergic rhinitis: consider in children with symptoms of common cold and sinusitis persisting for >2 wk; children with
allergic rhinitis and ectopic dermatitis have asthma; treatment—inhaled bronchodilator (eg, albuterol, 2.5-5.0 mg every
30-60 min); metered dose inhaler (MDI) or continuous nebulizer; albuterol inhaler with MDI associated with fewer side
effects; consider patient compliance; give sufficient dose (eg, 4-6 puffs); oral or IV steroids, 1 to 2 mg/kg; magnesium
sulfate in emergency department (ED)
|
| When to admit to hospital: child treated in office 3 times; need for O2 ; if child presents to office in late afternoon,
start treatment and send to hospital or ED; child appears sick and has poor history of returning for follow-up visits
|
| Treatment: steroids, 1 to 2 mg/kg per day (onset within 4 hr); fluticasone; fluticasone and salmeterol (Advair Diskus);
use “the one you’re comfortable with”; compliance low with cromolyn 2 to 4 times daily, especially for older patients;
classify asthma; use written asthma care plan; continue peak flow monitoring while patient standing straight; control environmental
triggers
|
| Exercise-induced asthma: bronchospasm caused by loss of heat and/or water; patients hyperventilate in cool drier air
during exercise; characterized by coughing and shortness of breath during or after exercise; must be distinguished from
poor fitness level; look at peak flow and forced expiratory volume in 1 sec (FEV1 ; 15% decrease over 20-30 min after exercise
likely sign of exercise-induced bronchospasm); treatment—albuterol before exercise; salmeterol effective for 10
to 12 hr (onset faster with albuterol); cromolyn before exercise; lengthy warm-up helpful
|
| Environmental triggers: determine exposure sites; sufficient evidence showing association with dogs, molds, viruses,
and nitrous oxide; limited evidence about irritants, RSV, and environmental tobacco smoke; many false-positive results
with in vitro testing; use allergy testing to determine exposures and interventions; dust mites—compared to placebo,
polyurethane casings for mattresses found to decrease allergens, reduce airway reactivity, and significantly decrease need
for inhaled steroids; bedding should be washed in hot water weekly; improvement should be seen in ≈1 mo; air cleaners
produce ozone and can worsen asthma; remove or wash and dry stuffed animals; use high efficiency particulate air
(HEPA) vacuum cleaner; avoid using humidifiers; cats—exposure at school shown to exacerbate asthma in children sensitive
to cats; use of HEPA air cleaner, replacement of mattress and pillow covers, and removal of cat from bedroom
shown to reduce allergen levels, but did not affect disease activity; nasal steroids shown to improve asthma in children allergic
to cats; effective interventions include finding new home for cat and keeping cat outdoors (may take up to 30 wk
for cat allergens to decline); washing cat reduces allergens for <1 wk; mice—integrated pest management (eg, filling
holes, vacuuming and cleaning, low-toxicity pesticides) decreases allergen levels; cockroaches—insecticide bait found
to reduce allergens significantly (lasts >1 yr); integrated pest management and boric acid in bait stations recommended;
do not spray concentrated liquids inside home; mold and mildew—control humidity inside home with, eg, central air conditioner;
avoid using humidifiers; vent clothes dryers and bathrooms to outdoors; use exhaust fan; check for leaky faucets;
large mold area (eg, >9 ft2 ) should be managed by professional cleaner; smaller areas may be cleaned with chlorine
solution or ammonia compounds (do not mix)
|
Suggested Reading
Almqvist C et al: Worsening of asthma in children allergic to cats, after indirect exposure to cat at school. Am J Respir
Crit Care Med 163:694, 2001; Dewolfe CC: Apparent life-threatening event: a review. Pediatr Clin North Am 52:1127,
2005; Domellöf M: Iron requirements, absorption and metabolism in infancy and childhood. Curr Opin Clin Nutr Metab
Care 10:329, 2007; Edner A et al: Why do ALTE infants not die in SIDS? Acta Paediatr 96:191, 2007; Ehnert B et
al: Reducing domestic exposure to dust mite allergen reduces bronchial hyperreactivity in sensitive children with asthma. J
Allergy Clin Immunol 90:135, 1992; Glazener CM et al: Desmopressin for nocturnal enuresis in children. Cochrane
Database Syst Rev:CD002112, 2000; Hüdaoglu O et al: Parental attitude of mothers, iron deficiency anemia, and
breath-holding spells. Pediatr Neurol 35:18, 2006; Ikeda T et al: Intussusception in children of school age. Pediatr Int
49:58, 2007; Lee WL: Long-term outcome of children with febrile seizures. Ann Acad Med Singapore 18:32, 1989;
Morgan WJ et al: Results of a home-based environmental intervention among urban children with asthma. N Engl J
Med 351:1068, 2004; Pearlman DS et al: An evaluation of levalbuterol HFA in the prevention of exercise-induced
bronchospasm. J Asthma 44:729, 2007; Singer JI et al: Acute testicular pain: Henoch-Schönlein purpura versus testicular
torsion. Pediatr Emerg Care 8:51, 1992.
Educational Objectives
| The goal of this program is to improve the management of common clinical problems in children. After
hearing and assimilating this program, the clinician will be better able to:
|
| 1. Recognize atypical findings in children with colic, breath-holding spells, and acute scrotum.
|
| 2. Counsel parents about febrile seizures.
|
| 3. List the differential diagnosis of acute life-threatening events.
|
| 4. Select appropriate therapy for exercise-induced asthma.
|
| 5. Help reduce environmental triggers that cause allergy and asthma.
|
Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and planning committee 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 and planning committee reported nothing to disclose.
Acknowledgements
Dr. Thyne spoke in San Francisco, CA, on July 9, 2007, at the Family Medicine Board Review Course, presented by the University
of California, San Francisco, School of Medicine. Dr. Roberts was recorded in Kiawah Island, SC, at An Intensive Review
of Family Medicine, presented June 18-23, 2007, by the Medical University of South Carolina. The Audio-Digest
Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
|
