Pediatric potpourri

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Pediatric potpourri

• Edward Les, MD
• May 6, 2004

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Agenda Common pediatric ED problems not
covered elsewhere in curriculum

• Infantile colic
• Neonatal conjunctivitis
• Gastroesophageal reflux
• Breast-feeding issues
• Omphalitis

• Basic rules of fluid management
• Breath-holding events
• Constipation
• Pediatric oncology briefs
• Otitis media

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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

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Whats 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

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Gastroesophageal refluxPrevalence?

• gt 40 of infants regurgitate gtonce/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

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Gastroesophageal reflux

• Not a disease in most cases
• simply reflects immature LES tone
• only 1 in 300 infants has significant reflux
  with associated complications
• Nelsons Pediatrics 2000

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Name 5 complications of infant GE reflux

• 1. Parental anxiety
• the biggie
• 2. Esophagitis
• (arching, irritability, Sandifer)
• Failure to thrive
• Apnea/choking (ALTE)
• 5. Recurrent aspiration

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GE reflux diagnosis

• Clinical!!!
• Confirmation of more severe reflux
• 24 hour pH probe
• Milk scan
• UGI barium not sens/specific

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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
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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 Im 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.

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Babys 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

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Eds rules of infant nutrition

• 1. Breast is best..
• but ultimately the kid simply needs enough to
  eat!!!
• 2. Lactation consultants are your friends

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Signs of inadequate intake in BF
infant Neifert, Clin Perinatol 1999

• Irregular or non-sustained sucking at breast
• lt 1 wet diaper per feed
• Nursing lt 10 minutes/breast each feed also,
  shouldnt be gt 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

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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 theyve lost
• Supplemental bottle feeds with manually expressed
  milk or formula if necessary
• nipple confusion is overblown!!

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BF strategies

• Before assuming mom has insufficient milk,
  exclude 3 possibilites
• Errors in feeding technique
• Remediable maternal factors diet, lack of rest,
  or emotional distress
• Physical disturbances in the baby that interfere
  with eating or weight gain

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Case

• 4-week-old babe presents with very anxious
  parents hes 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?

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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

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Infantile colic

• Excessive crying or fussiness
• Occurs in 10-20 of infants
• Defined as paroxysms of crying in an otherwise
  healthy infant for gt 3 hours/day on gt 3
  days/week, usually begins 3 weeks of age and
  resolves at around 3 months of age

If things havent settled by 4 months, consider
alternate dx
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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

20
Colic etiology?

• Unknown
• ? Temperament
• ? Ineffective parental response to crying
• ? Overfeeding
• ? Hunger

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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)

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Hair tourniquet

• Treatment?
• Excision
• Nair

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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

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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?

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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 (

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Omphalitis complications

• Necrotizing fasciitis
• Sepsis
• Portal vein thrombosis
• Hepatic abscesses

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When should the umbilical cord separate?

• Usually w/i 2 weeks
• Delayed separation think of possible leukocyte
  adhesion defect

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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

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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)

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Dacryocystitis

• Bacterial infection of nasolacrimal gland with
  duct obstruction
• Mgt
• Swab CS
• Topical systemic antibiotics

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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

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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
• Whats 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,

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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

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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

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Case

• 3 year old girl
• URTI x 5 days
• Now R otalgia, increased fever, irritable

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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

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Otitits media criteria?

• Yellow/red
• Opacity/effusion
• Immobility
• Bulging
• Loss of landmarks

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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
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OM Bugs

• S. pneumoniae 40
• non-typeable H. influenzae 25
• M. catarrhalis 10
• others GAS, S. aureus rare
• viral 20-30!

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OM management?

• General
• Analgesics/antipyretics
• lt 2 years antibiotics x 10 days
• gt 2 years watchful waiting
• recheck in 48-72 hours
• 80 spont. resolution
• If no improvement treat w/ abx (x 5 days)

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OM - antibiotics

• 1st line (x 5 days)
• Amoxicillin 40 mg/kg/d
• Hi-dose amoxicillin 90 mg/kd/day
• If recent (lt 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
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OM - antibiotics

• Non-responders
• Amoxicillin-clavulanate (40 mg/kg/d amox) x 10
  days
• /- amoxicillin (40 mg/kg/d) x
  10 days
• or
• Cefuroxime (40 mg/kg/d) x 10 days
• or
• 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
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What about

• Decongestants?
• Anithistamines?
• Topical steroids/antibiotics?

• No!
• No!
• No!

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AOM f/u

• In 3 months
• assess for persistent OME which may lead to
  hearing loss

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Recurrent AOMrisk factors

• Smoking
• Daycare
• Pacifiers
• Bottle-feeding
• Poor antibiotic compliance

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Recurrent AOMwhen to refer?

• gt 3 AOM per 6 months
• gt 4 AOM per 12 months

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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

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• otoscopic findings
• Facial expression

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Bells palsy in setting of AOM

• IV antibiotics (ceftriaxone)
• CT temporal bone
• Urgent ENT consultation
• need wide myringotomy

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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 shift CT scan of the temporal
bones soft tissue changes within the middle ear
and mastoid and an overlying subperiosteal
abscess and possible lateral sinus thrombosis.
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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

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Whats this?

• Cholesteatoma
• Complications
• Erosion of bony labyrinth
• Facial paralysis
• Hearing loss
• Meningitis/brain abscess/hydrocephalus
• Refer to ENT tout-de-suite

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Management?
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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?

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Fluid management

• Note that the Parkland formula is modified for
  kids lt 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 gt20 kg

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Example 12 kg kid with 10 BSA burn

• Conventional 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

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Case

• 3 year old boy
• c/o abdominal pain x 2/7
• 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
• AXR

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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?

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Functional constipationRe-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!
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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
• Whats normal stool frequency?

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When is the first stool normally passed?

• 99 of infants pass 1st stool w/i 1st 24 hours
• Failure possible obstruction/anatomic/physiologi
  c abnormality
• 95 of Hirschprungs disease and 25 of CF do not
  pass 1st stool 1st day
• Prems common to have delayed passage of 1st
  stool

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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!
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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 Hirschprungs
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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

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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?

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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

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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 gt 1 minute
• Period of post-episode sleepiness lasts gt 10
  minutes
• Convulsive component of episode is prominent and
  occurs before cyanosis
• Child is lt 6 months or gt 4 years old
• Consider seizure disorder or cardiac etiology
  (esp long QT syndrome)

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Case

• 3 year old boy with Downs 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

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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)
Wilms 6 90
Soft tissue 7 65
Bone 5 65
Retinoblastoma 4 95
Liver 1 45
Other 8
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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

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Most common sites of pediatric ALL extramedullary
relapse?

1. CNS
2. Testicular (painless swelling, usually unilateral)

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Most common cranial nerve abnormality in children
presenting w/ increased ICP secondary to
posterior fossa tumor?

• cranial n. VI palsy

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Case

• 18 month old girl presents with black eyes
  developed over past week no known trauma
• Also has dancing eyes and seems off balance

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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

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Case

• 4 month old boy
• Eyes dont look right

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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

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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?

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Come to my ACH Grand Rounds May 27 8 a.m.

• A Balanced Approach to the Unbalanced Child
• Acute pediatric ataxia

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• Thank you.
• Questions?