pediatric potpourri edward les, md may 6, 2004. agenda: common pediatric ed problems not covered...
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Pediatric potpourri
Edward Les, MD
May 6, 2004
Agenda: Common pediatric ED problems not covered elsewhere in curriculum
Infantile colicNeonatal conjunctivitisGastroesophageal refluxBreast-feeding issuesOmphalitis
Basic rules of fluid managementBreath-holding eventsConstipation Pediatric oncology briefsOtitis media
Case
3-week-old boy brought to ED with c/o emesis since first week of life
Formula changed twice with no improvement
Effortless spitting up after each feed
Birthweight 7 lbs 2 oz, now 8 lbs
What’s appropriate rateof weight gain for babes?Regain BW by 10 days
then 20-30 g per day 1st 3 months
Double BW by 5 months of age
15-20 g /day 3-6 months
10-15 g/day 6-9 months
10 g/day 9-12 months
Gastroesophageal refluxPrevalence? > 40% of infants regurgitate >once/day
– 50% resolve by 6 months, 75% by 12 months, 95% by 18 months
Nelson et al, Arch Pediatr Adolesc Med, 2000
Orenstein, Pediatr Rev, 1999
Gastroesophageal reflux
Not a disease in most cases…
simply reflects immature LES tone
only ~ 1 in 300 infants has “significant” reflux with associated complications
Nelson’s Pediatrics 2000
Name 5 complications of infant GE reflux:1. Parental anxiety
– the biggie
2. Esophagitis(arching, irritability, Sandifer)
3. Failure to thrive
4. Apnea/choking (ALTE)
5. Recurrent aspiration
GE reflux: diagnosis
Clinical!!!
Confirmation of more severe reflux:
24 hour pH probe
Milk scan
UGI barium not sens/specific
GE reflux: treatment options
Simple GER Reassurance, smaller/more frequent feeds, thickened feeds, positional therapy
Esophagitis* Antacids, H2 receptor blockers, metoclopramide
FTT* Nutritional rehab, NG feeds, may need fundoplication
Apnea* Monitoring, may need fundo
Recurrent aspiration* May need fundo
* Consultation with peds or GI
Case
Teary, very stressed 23-year-old first time mom with 3-day-old breast-fed little girl
• ++ worried that baby “not getting enough”• seems hungry, spends 40 minutes nursing but is “on
and off repeatedly, cries a lot• “my breasts are REALLY SORE, and I’m not sure I
even have enough milk for her….”• “I called HealthLink to see if I could give her formula
and the nurse gave me a 10 minute lecture about the importance of breast-feeding.”
Baby’s exam:
No dysmorphism; moderate jaundice
Alert, rouses easily, strong cry
AF normal, roots, v. strong suck, oropharynx/palate normal
Normal RR bilat
Chest clear, CVS normal, good pulses; sl. mottled extremities
Abdomen/umbilicus normal
Normal female genitalia and anus
Spine/hips normal
Normal Moro, grasp, tone, reflexes
Ed’s rules of infant nutrition
1. “Breast is best”…..…but ultimately the kid
simply needs enough to eat!!!
2. Lactation consultants are your friends
Signs of inadequate intake in BF infant
Neifert, Clin Perinatol 1999
• Irregular or non-sustained sucking at breast• < 1 wet diaper per feed• Nursing < 10 minutes/breast each feed; also,
shouldn’t be > 25 minutes/breast• Failure to demand to nurse at least 8 times daily• Taking only 1 breast at each feeding• Crying, fussing, and appearing hungry after most
feedings• Too much weight loss in first week, suboptimal gain
thereafter
BF strategies• Nipple care
– Exposure to air, keep dry b/w feeds, apply lanolin, manual milk expression, more freq shorter feeds, nipple shields
• Proper technique– Feed when hungry– Ensure proper latch – watch babe feed in ED– Most babies are not “avid suckers” in the first three days; by day
4 they “wake up” and start packing on the weight they’ve lost
• Supplemental bottle feeds with manually expressed milk or formula if necessary– “nipple confusion” is overblown!!
BF strategies
• Before assuming mom has insufficient milk, exclude 3 possibilites:
1. Errors in feeding technique
2. Remediable maternal factors: diet, lack of rest, or emotional distress
3. Physical disturbances in the baby that interfere with eating or weight gain
Case
• 4-week-old babe presents with very anxious parents – he’s been crying incessantly for several hours, completely inconsolable; several other episodes over past few days, seems to be getting worse. Otherwise feeding well, 6 wet diapers/day, stooling well, no fever. Previously well.
• Approach?
How much crying is normal?
At 2 weeks: 2 hours per day
Increases to 3 hours at 6 weeks, then declines to ~ 1 hour at 12 weeks
Infantile colic
• Excessive crying or fussiness• Occurs in 10-20% of infants
Defined as paroxysms of crying in an otherwise healthy infant for > 3 hours/day on > 3 days/week, usually begins ~ 3 weeks of age and resolves at around 3 months of age
If things haven’t settled by 4 months, consider alternate dx
Colic
• Intense crying for several hours, usually in late afternoon or evening
• Often infant appears to be in pain, may have legs drawn up, may have slight abdominal distension
• May have temporary relief with passage of gas
Repercussions: • early discontinuation of BF• Multiple formula changes• Parental anxiety and distress• Increased incidence of child abuse
Colic: etiology?Unknown:
? Temperament
? Ineffective parental response to crying
? Overfeeding
? Hunger
Colic: diff dx?
Rule out:
• Hair tourniquet• Corneal abrasion• Incarcerated hernia• Consider abuse (shaken baby)• Other (ie reflux esophagitis, UTI, inguinal
hernia, testicular torsion, intussusception, etc)
Hair tourniquet
Treatment?
• Excision• “Nair”
Colic: management
Reasonably effective:• Counseling/ reassurance• Respite care• Feeding/holding/rocking/
sleeping/diaper change• Routine burping, avoid
over/underfeeding
• F/U with GP or peds to provide support and ensure no organic etiology
Rarely effective:• Formula changes• Simethicone to decrease
intestinal gas• Music, car rides, swings
etc
? Phenobarb or benadryl for occasional relief
Case
• 10 day old female with foul-smelling discharge from umbilicus
• Afebrile, feeding/voiding/pooping well, no red flags on history
Just a smelly belly button or something more?
Omphalitis
• Purulent, foul-smelling discharge with erythema of surrounding skin
• Secondary to poor cord hygiene
• S. aureus/Group A Strep/Gm –’s
• Tx; topical care and systemic antibiotics (
Omphalitis: complications
• Necrotizing fasciitis• Sepsis• Portal vein
thrombosis• Hepatic abscesses
When should the umbilical cord separate?
• Usually w/i 2 weeks
• Delayed separation: think of possible leukocyte adhesion defect
Case 3 day old babe:
– Red eye with discharge
– Differential diagnosis?
• Chemical irritation (esp AgNO3)• Nasolacrimal duct obstruction w/ dacryocystitis • Gonorrhea• Chlamydia• Herpes simplex• Infantile glaucoma
Diagnosis: gram stain, culture, flourescein, antigen detection
Congenital nasolacrimal duct obstruction
5% of all newborns
*absence of conjunctival injection!
Warm compresses, gentle massage, watchful waiting
95% resolve by 6 months; if not, refer for probing (earlier if multiple episodes of dacryocystitis)
Dacryocystitis
Bacterial infection of nasolacrimal gland with duct obstruction
Mgt:
– Swab C+S
– Topical + systemic antibiotics
Gonorrheal conjunctivitis
Hyperpurulent discharge at day 2-4
• Potentially a disaster!!• Mgt?
– Need FSW– Admit for antibiotics, eye irrigation, mgt of
complications: corneal ulceration, scarring, synechiae formation
– Rx concomitantly for Chlamydia– Rx mom and her partner
Chlamydial conjunctivitis
C. trachomatis : presents on day 3-10 (but may be up to 6 weeks)
Mom with active untreated chlamydia: babe has 40% chance of infection
What’s the real worry here?
• 10-20% have associated pneumonia – untreated can lead to chronic cough and pulmonary impairment
• “well” with pneumonia and staccato cough• Creps/wheezes; patchy infiltrates w/ hyperinflation• CBC: eosinophilia• Rx: systemic erythro x 14 days• Treat mom and her partner,
Herpetic conjunctivitis
• Day 2-16• Flourescein stain: dendritic ulcer
• Do FSW
Rx:• IV acyclovir, topical vidarabine• 30-50% of cases recur w/i 2 years
Infantile glaucoma
Classic triad (seen in 30%):– Epiphora– Photophobia– Blepharospasm
• Injected red watery eye• Cloudy, enlarged cornea• Cupped optic disk• Buphthalmos if dx delayed
Emergent referral to opthalmologist
Case
3 year old girl
URTI x 5 days
Now R otalgia, increased fever, irritable ++
Acute otitis media
• accounts for 30% of all pediatric outpatient antimicrobial prescripitions
• Diagnostic accuracy?– We suck– Pediatricians only ~ 50%
correct• Pichichero et al 2001:
study of 514 pediatricians
Otitits media – criteria?
• Yellow/red
• Opacity/effusion
• Immobility
• Bulging
• Loss of landmarks
The normal TM: which ear?
An annulus fibrosus
Lpi long process of incus - sometimes visible through a healthy translucent drum
Um umbo - the end of the malleus handle and the centre of the drum
Lr light reflex - antero-inferioirly
Lp Lateral process of the malleus
At Attic also known as pars flaccida
Hm handle of the malleus
OM Bugs
• S. pneumoniae – 40%
• non-typeable H. influenzae – 25%
• M. catarrhalis – 10 %
• others – GAS, S. aureus – rare
• viral – 20-30%!
OM – management?
General:– Analgesics/antipyretics
< 2 years: antibiotics x 10 days> 2 years: watchful waiting
• recheck in 48-72 hours• 80% spont. resolution• If no improvement: treat w/ abx (x 5 days)
OM - antibiotics
1st line (x 5 days)
• Amoxicillin 40 mg/kg/d
• Hi-dose amoxicillin 90 mg/kd/day– If recent (< 3 months) antibiotics exposure or daycare or recurrent AOM
• Pen-allergic: erythromycin-sulfisoxasole (40 mg/kg/d erythromycin) or TMP/S (6-10 mg/kg/d TMP)
Consider 10 days if recurrent AOM or perforated TM
Maximum dose not to exceed adult dose
OM - antibiotics
Non-responders
• [Amoxicillin-clavulanate (40 mg/kg/d amox) x 10 days+/- amoxicillin] (40 mg/kg/d) x 10 daysor
• Cefuroxime (40 mg/kg/d) x 10 daysor
• Cefprozil (30 mg/kg/d) x 10 days
B-lactam – allergic• Erythromycin-sulfisoxazole (40 mg/kg/d) x 10 days
or• Azithromycin (10 mg/kg 1st day, 5 mg/kg/d 4 more days)
or • Clarithromycin (15 mg/kg/d) x 10 days
Maximum dose not to exceed adult dose
What about…
• Decongestants?
• Anithistamines?
• Topical steroids/antibiotics?
No!
No!
No!
AOM – f/u
In 3 months:
assess for persistent OME which may lead to hearing loss
Recurrent AOM:risk factors
• Smoking
• Daycare
• Pacifiers
• Bottle-feeding
• Poor antibiotic compliance
Recurrent AOM:when to refer?
> 3 AOM per 6 months
> 4 AOM per 12 months
Case
3 year old girl
Treated for AOM x 3/7 with cephalexin; abx changed to azithro day 4 because of L facial swelling GP attributed to “drug allergy”
Now day 6, presents to ED with ongoing L “facial swelling”
Alert, afebrile, playful
otoscopic findings
Facial expression
Bell’s palsy in setting of AOM
IV antibiotics (ceftriaxone)
CT temporal bone
Urgent ENT consultation
need wide myringotomy
Case
11-year-old boy – History of chronic OM with
effusion; presents w/ 10-day history of fever, R otalgia and right, dull occipital headache
– Alert, temperature of 38.4 C. – Otoscopy: thickened, but
intact TM; middle ear effusion
– Postauricular edema, erythema, tenderness, and fluctuance
– Neuro exam normal
WBC 18.7 w/ left shiftCT scan of the temporal bones: soft tissue changes within the middle ear and mastoid and an overlying subperiosteal abscess and possible lateral sinus thrombosis.
Mastoiditis
• Bulging erythematous tympanic membrane• Erythema, tenderness, and edema over the
mastoid area• Postauricular fluctuance• Protrusion of the auricle
ED Tx: IV abx (ceftriaxone), CT, ENT consult
What’s this?
Cholesteatoma
Complications:
• Erosion of bony labyrinth• Facial paralysis• Hearing loss• Meningitis/brain
abscess/hydrocephalus
Refer to ENT tout-de-suite
Management?
Case
8 year old boy melting candles on stove
• Pot on fire: grabs pot, flames his face and hair, pulls hot burning wax over his hands, legs; standing in pool of hot wax before running from room
• Exam: Alert, GCS 15, not hoarse; has circumoral 1st and 2nd degree burn; 15% BSA 2nd degree burns to rest of body
Mgt?
Fluid management
• Note that the Parkland formula is modified for kids < 20 kg: accounts for proportionately higher maintenance fluid req in smaller children = 3 mL/kg/% burn (1/2 in 1st 8 hours) PLUS maint fluids
• Know the rule of thumb for maint fluids in kids: 4-2-1– 4 ml/kg 1st 10 kg– 2 ml/kg 2nd 10 kg– 1 ml/kg >20 kg
Example: 12 kg kid with 10% BSA burnConventional Parkland formula:
– 4 x 12 x 10 = 480 mL– ½ in 1st 8 hours = 30 mL/h
Modified formula:– 3 x 12 x 10 = 360 mL– ½ in 1st 8 hours = 23 mL/h– Add maint fluid: 44 mL/h– TOTAL fluids = 67 mL/h
Case 3 year old boy c/o abdominal pain x 2/7No BM x 10 days; having problems for 4 months
• No prev hx constipation• Coincided with start of toilet training
• Exam normal except palpable mass LLQ;• Rectal reveals large amount of stool in vault; no fissure
– Some soiling noted on underwear
AXR:
Case 3 year old boy No BM x 10 days; having problems for 4 months
• No prev hx constipation• Coincided with start of toilet training
• Exam normal except palpable mass LLQ;• Rectal reveals large amount of stool in vault; no fissure
– Some soiling noted on underwear
Management?
Functional constipation:“Re-train the bowel”
Often not aggressive enough
• Enemas – adult fleets OK after age 2– May need multiple over 2 or 3 days– In severe cases, Go-Lytely ‘til clear
• Toilet training strategies• Diet: fiber/fluids• Lactulose
– 0.5 ml/kg bid, adjust prn
• Mineral oil– 1 ml/kg hs
• Infants: Karo syrup 1 tsp/8 oz formula
GP or peds f/u important Always consider and r/o organic causes!
Case
7 day old breast-fed boy• c/o “constipation”• Mom concerned because no BM for past 3
days
Passed mec day 1, stooled day 2 and 4
What’s normal stool frequency?
When is the first stool normally passed?
99% of infants pass 1st stool w/i 1st 24 hours• Failure = possible
obstruction/anatomic/physiologic abnormality
• 95% of Hirschprung’s disease and 25% of CF do not pass 1st stool 1st day
• Prems: common to have delayed passage of 1st stool
Case Constipated 6 month old boy• Has always stooled infreq ~ 1/week• Also v. slow feeder
O/E:• T 35.9, P 60, R 20, BP 90/60• Abdomen soft, non-distended, rectal vault contains soft
stool; back exam unremarkable• Appears generally hypotonic
Dx?
Hypothyroid!
Case 10 month old girl
• Very constipated for several months, suppository dependent
• Has always fed poorly
O/E: alert, small for age• Abdo mildly distended, palpable mass LLQ• Rectal: no stool in ampulla
Dx test?
Rectal suction biopsy: Hirschprung’s
Case
6 month old infant with lethargy, constipation, poor feeds x 2 days
O/E: afebrile, VSS, but poor suck, gen hypotonia, absent reflexes
Diagnosis?
• Infant botulism: ingestion of spores in honey/corn syrup; source often unknown
• Hospitalize; may need intubation– Treat with BIG
Case
15 month boy brought to ED by paramedics after episode of cyanosis and apnea accompanied by some shaking of the extremities
• Prev well• Event occurred just after mom denied him a
cookie before dinner
Diagnosis?
Breath-holding spells
Common b/w 6 months and 4 years (peak 1½ - 3 yrs.)
Benign!Some association w/ iron deficiency
Mocan et al. Arch Dis Child 1999.
• Blue/cyanotic type– Vigorous crying provoked by physical/emotional upset leads
to end-expiratory apnea– Followed by cyanosis, opisthotonus, rigidity, loss of tone, +/-
brief jerking
• Pallid type– Precipitated by unexpected event that frightens the child
When is a BHE not a BHE?
• Precipitating event is minor or non-existent
• Hx of no or minimal crying or breath-holding
• Episode last > 1 minute
• Period of post-episode sleepiness lasts > 10 minutes
• Convulsive component of episode is prominent and occurs before cyanosis
• Child is < 6 months or > 4 years old
Consider seizure disorder or cardiac etiology (esp long QT syndrome)
Case
3 year old boy with Down’s syndrome
• 1 week of fatigue, irritability, pallor; petechial rash today
• No hx of fever, URTI sx, vomiting or diarrhea
O/E: pale, lethargic; diffuse lymphadenopathy and HSM
Pediatric oncology
Cancer Distribution % Survival %
Leukemia 30 75
CNS 19 60
Lymphoma 13 75
Neuroblastoma 8 10-20 (stage 3,4)
75-90 (stage 1,2)
Wilm’s 6 90
Soft tissue 7 65
Bone 5 65
Retinoblastoma 4 95
Liver 1 45
Other 8
Most common findings in childhood ALL?• HSM 70%• Fever 40-60%• Lymphadenopathy 25-50%• Bleeding 25-50% w/
petechiae or purpura• Bone/joint pain 25-40%• Fatigue 30%• Anorexia 20-35%
Most common sites of pediatric ALL extramedullary relapse?
1. CNS
2. Testicular (painless swelling, usually unilateral)
Most common cranial nerve abnormality in children presenting w/ increased ICP secondary to posterior fossa tumor?
• cranial n. VI palsy
Case
• 18 month old girl presents with “black eyes”; developed over past week; no known trauma
• Also has “dancing eyes” and seems off balance
Neuroblastoma
Most common malignancy of infancy
• Mean age 20 months• Arises from neural crest tissure (adrenal medulla,
sympathetic ganglia)• Most common presentation is painless abdo/flank mass;
may see calcifications on AXR• Multiple metastases possible• Infants may have “blueberry muffin” rash• Perioribital ecchymoses and opsoclonus/mycolonus should
prompt consideration of neuroblastoma• Dx: imaging, urine VMA/HVA
Case
4 month old boy
• “Eyes don’t look right”
Retinoblastoma
Usually confined to the eye
• 60% nonhereditary and unilateral• 15% hereditary (AD) and unilateral• 25% hereditary (AD) and bilateral
Hereditary types at increased risk of other neoplasms: brain, osteosarcoma, soft tissue sarcoma, melanomas
Case
3 year-old boy with unsteady gait– Progressively worse x 12 hours, now refusing to walk– Had varicella 2 weeks ago
On exam: – Afebrile, looks well– Mild truncal unsteadiness, ataxic gait– Normal strength and reflexes
Diagnosis?
Come to my ACH Grand Rounds: May 27 8 a.m.
A Balanced Approach to the Unbalanced Child:
Acute pediatric ataxia
Thank you.
Questions?