PEDIATRIC CONCERNS
Educational Objectives
| The goal of this program is to improve the management of common pediatric and adolescent health concerns. After
hearing and assimilating this program, the clinician will be better able to:
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 | 1. Identify causes of vomiting, gastroesophageal reflux, and diarrhea in infants.
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| 2. Select effective therapy for common pediatric rashes.
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| 3. Assess cognitive development, risks, and resiliency factors in children and adolescents.
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| 4. Counsel patients and parents about reducing risky behavior, such as tobacco smoking and alcohol use.
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| 5. Describe current trends in toxic drug exposures in adolescents.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee 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
Drs. Roberts and Key spoke in Kiawah Island, SC, on June 18, 2007, at An Intensive Review of Family Medicine, presented
by the Medical University of South Carolina. Dr. Lamb was recorded in Napa, CA, at Clinical Pharmacology
2007: Drug Therapy Management, presented April 27-29, 2007, by the University of California, Davis, Health System.
The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
| ISSUES DURING FIRST YEAR OF LIFE —James R. Roberts, MD, MPH, Associate Professor of Pediatrics, Medical
University of South Carolina, Charleston
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| Vomiting: common in infants; most often due to gastroesophageal reflux; results in formula changes; case presentation—
infant, 5 wk of age, vomiting since birth; infant vomits ≤20 min after taking formula; after 3 visits to primary care physician
and several formula changes, infant on Nutramigen; vomiting nonprojectile but bilious for last week; mother brings
infant to emergency department; infant at birth weight and appears cachectic and dehydrated; abdomen distended and
tender; abdominal x-ray shows bowel obstruction (“double bubble” sign); infant had midgut volvulus with no ischemia to
valve; important to identify obstructions; history and physical examination—determine whether infant appears ill or dehydrated;
fever; lethargy; age at onset; bilious or nonbilious; character of emesis; in first 3 to 4 mo of life, consider sepsis,
gastroesophageal reflux, malrotation or malformation, and bowel obstruction; at 6 wk of age, consider pyloric stenosis
(onset of vomiting sudden; perform ultrasonography [US]); bilious vomiting critical (may be due to duodenal atresia or
stenosis or malrotation with or without volvulus); nonbilious vomiting not always urgent, but absence does not rule out
serious illness
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| Duration and course of emesis: 1 to 2 wk of emesis with failure to thrive can indicate chronic disease; chronic emesis
without failure to thrive or other problems may indicate long duration of reflux; evaluate immediately for bilious or nonprojectile
emesis; abdominal x-ray; perform abdominal US and check electrolytes to rule out pyloric stenosis; consider
surgery; consider formula intolerance and reflux in infants who appear well
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| Gastroesophageal reflux: genetic association with hiatal hernia, erosive esophagitis, and adenocarcinoma; infantile
esophagitis may be associated with eosinophilic esophagitis; presentation—irritability; apparent life-threatening event
(ALTE); asthma; wheezing; dysphagia; feeding refusal; course of illness—usually starts shortly after birth; infant spits up
immediately or 20 to 30 min after feeding; nonprojectile; reflux eventually outgrown; management—upright positioning;
frequent burping (eg, after every fluid ounce); antireflux formulas may be helpful; thicken formula with rice cereal (eg, 1-
4 tsp of rice cereal for 4 fl oz of formula); ranitidine, 7 to 8 mg/kg per day; lansoprazole approved by Food and Drug Administration
(FDA) for children ≥1 yr of age (in children <1 yr of age consider 1 mg/kg per day [off-label use]); watch for
failure to thrive, apnea, wheezing, Sandifer’s syndrome (esophageal irritation; baby turns neck to side)
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| Other causes of vomiting: sepsis; dietary protein intolerance; hydrocephalus; shaken baby syndrome; respiratory infection;
metabolic disorders
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| Diarrhea: common; determine whether bloody or nonbloody, acute or chronic; look for evidence of systemic disease; differential
diagnosis—sepsis (Salmonella, Shigella); anal fissure; intussusception (“currant jelly stool”) indicates obstruction
and infant likely to be lethargic; necrotizing enterocolitis; inflammatory bowel disease; Meckel’s diverticulum;
juvenile polyp; history—ask about other gastrointestinal (GI) complaints, rashes, foods that mimic hematochezia (eg,
iron supplements, red beets, gelatin), and water supply; physical examination—ill appearance; dehydration; anal fissure;
bleeding tendency (ask about circumcision); laboratory testing—obtain stool cultures and check white blood cells; complete
blood cell count and differential; erythrocyte sedimentation rate; abdominal x-ray to rule out obstruction; consider
starting infant on hydrolysate formula (especially for cases of milk protein intolerance); if no resolution after 2 wk of formula,
consider endoscopy; Salmonella—in infants <3 mo of age, treat with antibiotics (eg, intravenous [IV] ampicillin);
risk for invasive disease higher; often due to viral gastroenteritis; may be due to transient lactose intolerance (use soy-
based formula for short time) or excess apple juice (American Academy of Pediatrics recommends ≤4 fl oz/day)
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| Rotavirus: rotavirus vaccine, live (RotaTeq)—oral solution; pentavalent; start by or before 12 wk of age and give third
dose no later than 32 wk of age; no increased risk for intussusception; well tolerated; intussusception reported shortly after
licensing (evaluation found number of cases not excessive); recent changes in immunization schedule—add rotavirus;
diphtheria and tetanus toxoids and acellular pertussis vaccine, adsorbed (DTaP); DTaP, hepatitis B (recombinant), and inactivated
poliovirus vaccine combined (Pediarix; provides 4 doses of hepatitis B vaccine); at 12 mo of age, start hepatitis
A vaccine, inactivated (give booster injection 6 mo later); measles, mumps, rubella, and varicella virus vaccine, live (ProQuad;
at 4 yr of age, give second dose of varicella vaccine)
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| Lead poisoning: screening recommended at 9 to 12 mo of age and again at 2 yr of age; fingerstick acceptable for initial
screening; use venipuncture for patients with fingerstick reading >10 µg/dL; number of cases declining; candidates for
screening—patients on Medicaid; children from families of low socioeconomic status; children who live in pre-1950
housing or near industrial sources that release lead; children whose parents work with lead hazards (eg, lead-based paints
used on ships and bridges); risk for exposure—motor milestones (eg, crawling, pulling self up); spending time on floor;
putting things in mouth; dust and soil from lead-based paint; imported miniblinds; toys; jewelry; water (eg, from lead soldering
and copper pipes in homes built in 1930s and 1940s); management—identify and remove source, or remove child
from source; education; chelating agent can be used if blood lead level ≥40 µg/dL; child may have iron deficiency
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| Iron deficiency: can cause abnormal mental development; low prevalence in United States; higher incidence in blacks;
check hemoglobin at 9 or 12 mo of age (10.5 g/dL considered abnormal); if hemoglobin 11 g/dL, remember that iron
stores decrease before child becomes anemic (start iron therapy [1-2 kg/day]; use ferrous sulfate or 3-6 mg/kg per day of
elemental iron)
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| Sun exposure: up to 5 blistering sunburns by age 15 yr associated with relative risk for melanoma of 2.2; keep infants <6
mo of age out of direct sunlight (hats, sunglasses, and loose coverings recommended); sunscreen recommended for children
>6 mo of age
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| Common pediatric rashes: erythema toxicum—pustules with surrounding erythema; resolves in few weeks; keratosis
pilaris—usually hereditary; often precursor to atopic dermatitis; frequently seen with positive family history of allergy;
flesh-colored papular rash on face, trunk, neck, and arms; can present at any age; in white patients, papules red or pink,
fine, and sandpapery; in black patients, papules appear white; many or few papules may be present; atopic dermatitis—
dry scaly rash on cheeks; primary treatment lubrication; instruct parents to apply steroid cream after lotion; control itching
to prevent infection; inflammatory lesions seen on cheeks (common; treat with hydrocortisone cream); shininess and
slight scaling may not need steroid cream; topical steroids—hydrocortisone and hydrocortisone valerate (0.2%; ointment
has higher potency); triamcinolone; mometasone (eg, Elocon) used as second- or third-line therapy (ointments higher
strength than creams because of greater absorption); id (dermatophytid) reaction—often in child treated for tinea capitis
for 2 days; papular rash; not allergic reaction; hypersensitivity to dermatophyte; papulovesicular eruption on arms and
legs common; seborrhea—rash on scalp; usually starts on hair line (sometimes face, neck, or behind ears); selenium sulfide
shampoo recommended; steroid cream occasionally recommended; greasy scaling may resolve spontaneously;
scabies—classic presentation in between fingers and toes; intensely pruritic; can be seen on wrists, between folds of skin,
on belt line, and on head, palms, and soles; look at caregiver’s fingers; apply 5% permethrin cream from hair line to toes;
lindane no longer recommended, due to toxicity and seizures; Kawasaki disease—less common; can present in first 1 to 2
yr of life; morbilliform appearance similar to measles; swollen hands and feet; conjunctivitis; red cracked lips; marked irritability
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| THE TROUBLING TEENS —Janice D. Key, MD, Professor of Pediatrics, Medical University of South Carolina, Charleston
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| Stages of development: development of abstract thinking; sexual development; social development; independence;
physical development not directly coordinated with cognitive development
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| Cognitive development: concrete thinking—latency age; child cannot learn from experience, unable to understand abstract
ideas, and unable to develop hypotheses (ie, unable to complete “if-then” statements, eg, “if you don’t do your
homework, then you will fail”); abstract learner—able to learn from own experience, experience of others, and hypothetical
experience (eg, “if I do this, then I will get grounded”); able to understand abstract ideas and generate multiple hypotheses
to solve problems; function of frontal lobe; impaired decision-making and planning alters regulation of affect
and emotion
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| Neural development: continues through life; brain must be used “like a muscle” to continue developing; pre-teenagers
with inactive frontal lobe stimulus-bound (ie, child inflexible with changes in environment; myopic for future; cannot plan
for consequences of current actions; responsive to emotion; has blunted response to task punishment)
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| Risk and resiliency: affected by socioeconomic status, family structure, parenting style, earlier sexual debut, obesity,
involvement with law, drug and alcohol abuse, eating disorders, and depression; divorce associated with school failure,
drug use, early sex, and later marriage
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| Types of parenting: protective or not protective; permissive—chaotic and inconsistent; lacks leadership; associated with
risk; authoritarian—rigid; extremely strict; not age-adjusted; associated with risk; authoritative—most protective; benevolent
dictatorship; interest of children at heart, but parents in control; children listened to, but “they don’t have a vote”
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| Protective factors: nearly 50% of risk for alcohol use attributed to parent who drinks, difficulty in school, lack of organized
activities, and friends who drink; protective factors include eating dinner together, positive parenting, providing input
into parent’s decisions, and having other interests; external developmental assets (“something we can do something
about”) should contribute to internal developmental assets
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| Assessing risk-taking behavior and resiliency factors: history—starting at age 11 yr, speaking to child with
some assurance of confidentiality recommended; ask about home, school, and activities; screen for depression, suicidality,
sexual activity, and substance use
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| Determining cognitive state: not evidence-based; ask child to create hypothesis; fairy tale completion test—concrete
thinker cannot provide another hypothesis or ending to story; early abstract thinker can provide one alternative ending;
mature abstract reasoner can complete story effortlessly and provide multiple endings; eg, ask, “in the Little Red Riding
Hood tale, if the wolf gets sick with the flu, then what would happen?”; man on bridge test—ask, “what happens when an
evil man is walking across the middle of a tall bridge over a river, and the bridge breaks?”; if child responds with “it depends
(eg, whether man can swim)” then neurons in frontal lobe starting to connect; moral development evident if child
mentions man is evil
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| Case presentations: 1) boy 11 yr of age; parents recently separated; does well in school; activities include playing video
games; recently became irritable; admits to tobacco smoking; fairy tale completion response—“if wolf sick with flu, then
wolf gets up and eats grandmother; it’s his job”; boy concrete thinker; risks—change in family; depression; risk for decline
in school performance; frequent irritability (sign of depression) may indicate adjustment disorder to parents’ separation;
no constructive activities; resiliency factors—does well in school; both parents involved; management—encourage
sports and activities and parental involvement; address tobacco smoking with concrete statement (eg, “your breath smells
terrible and your teeth are yellow”); 2) girl 16 yr of age on oral contraceptives (OCs); lives with both parents; activities
include “hanging out” and tobacco smoking; sexually active (uses condoms and OCs); fairy tale completion response—“I
guess the grandmother lives, or Little Red Riding Hood takes the basket to the wolf and takes care of him”;
management—assess stage of change (not needed in concrete thinkers) and risks and resiliency factors; encourage organized
school or church activities; address tobacco smoking by, eg, discussing amount of money spent on cigarettes (set
goal to discuss quitting); provide community resources; 3) girl 18 yr of age; single mother; honor roll student; plays on
sports teams; no depression or substance use; fairy tale completion response—“the wolf’s brother might come and do the
job, grandma might live, or grandma gets up and beats him up”; management—assess stage of change (ie, preparation
and unprotected sex); resiliency factors include adult abstract thinking and preparation for change; discuss hypothetical
situations and avoidance of risks in future; discuss contraception and emergency contraception
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| TOXIC DRUG EXPOSURES AMONG ADOLESCENTS —John P. Lamb, PharmD, Clinical Professor of Medicine, University
of California, Davis, School of Medicine, Sacramento, CA
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| Poisonings: nearly 2.5 million poisonings per year in United States; 22.8% treated in health care facility; most unintentional;
intentional—≈305,000 cases; 65% suicide gesture, 15% misuse of product, 15% abuse (“trying to get high”);
unintentional—241,000 cases due to therapeutic errors; 102,000 cases due to misuse of product
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| Children and teenagers: nearly 50% of poisonings of teenagers 13 to 19 yr of age managed in health care facility; children
<12 yr of age—exposures due to general accidents; teenagers—49% of poisonings unintentional, 46% intentional
(in adults, 25% intentional); intentional exposures due to abuse of prescription and over-the-counter (OTC) medications;
2005 study—found 19% of teenagers tried prescription drugs to get high; 10% abused cough medicine (eg, dextromethorphan);
55% do not think abusing cough medicine risky; 29% feel prescription pain relievers not addictive
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| Classes of abused drugs: stimulants; street drugs; sedatives and psychiatric drugs; analgesics and opiates; account for
29% of drug calls in adults, 20.6% of calls in teenagers
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| Fatal exposures: 0.0024% in children <6 yr of age, 0.008% in children 6 to 12 yr of age (6 times as high in teenagers, 3
times as high in adults); in all age groups, 15% due to abuse, 50% suicide; in teenagers, 40% suicide, 36% abuse;
analgesics—OTC (eg, acetaminophen [eg, Tylenol], aspirin); 30% of fatalities in teenagers due to methadone, 13% morphine,
17% oxycodone and oxycodone and acetaminophen; fentanyl; hydrocodone and acetaminophen; propoxyphene
and acetaminophen (Darvocet A500)
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| Narcotic analgesic toxicity: due to, eg, codeine, methadone, fentanyl, hydrocodone and acetaminophen (eg, Lortab),
oxycodone (eg, OxyContin), morphine; mild overdose—drowsiness; pinpoint pupils; hypotension; bradycardia; significant
overdose—respiratory depression; coma; possibility of pulmonary edema; respiratory death; seizures associated
with codeine, dextromethorphan, meperidine, propoxyphene, and tramadol; treatment—charcoal; whole bowel irrigation
for long-acting products; naloxone (Narcan; infusion for long-acting products); watch patient for several hours after last
Narcan dose
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Suggested Reading
Binder JR et al: Distinct brain systems for processing concrete and abstract concepts. J Cogn Neurosci 17:905, 2005;
Buckley NA et al: An analysis of age and gender influences on the relative risk for suicide and psychotropic drug self-
poisoning. Acta Psychiatr Scand 93:168, 1996; Cohen AL et al: National surveillance of emergency department visits
for outpatient adverse drug events in children and adolescents. J Pediatr 152:416, 2008; Cox WM et al: Motives for
drinking, alcohol consumption, and alcohol-related problems among British secondary-school and university students. Addict
Behav 31:2147, 2006; Heitzeg MM et al: Affective circuitry and risk for alcoholism in late adolescence: differences
in frontostriatal responses between vulnerable and resilient children of alcoholic parents. Alcohol Clin Exp Res 32:414,
2008; Heyse JF et al: Evaluating the safety of a rotavirus vaccine: the REST of the story. Clin Trials5:131, 2008; Hyman
PE et al: Childhood functional gastrointestinal disorders: neonate/toddler. Gastroenterology 130:1519, 2006; Lessenger
JE et al: Abuse of prescription and over-the-counter medications. J Am Board Fam Med 21:45, 2008; Newman
K et al: Relationships between parenting styles and risk behaviors in adolescent health: an integrative literature review.
Rev Lat Am Enfermagem 16:142, 2008; Orchard D: Rashes in infants. Pitfalls and masquerades. Aust Fam Physician
30:1047, 2001; Roberts JR et al: Childhood lead poisoning. J S C Med Assoc 103:76, 2007; Szkolnicka B: Prescription
and over-the-counter medication in deliberate self-poisoning and accidental overdosing--preliminary study. Przegl Lek
62:568, 2005.
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