Transcript Document

Pediatric potpourri
Edward Les, MD
May 6, 2004
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
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 rate
of 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 reflux
Prevalence?
> 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
Esophagitis*
Reassurance, smaller/more
frequent feeds, thickened
feeds, positional therapy
Antacids, H2 receptor
blockers, metoclopramide
Apnea*
Nutritional rehab, NG feeds,
may need fundoplication
Monitoring, may need fundo
Recurrent aspiration*
May need fundo
FTT*
* 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:
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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:
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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:
Rarely effective:
• Counseling/
reassurance
• Respite care
• Feeding/holding/rocking
/sleeping/diaper change
• Routine burping, avoid
over/underfeeding
• Formula changes
• Simethicone to
decrease intestinal gas
• Music, car rides, swings
etc
• F/U with GP or peds to
provide support and
ensure no organic
etiology
? 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
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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?
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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
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•
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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 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
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
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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/ 10day 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.
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 burn
Conventional Parkland formula:
– 4 x 12 x 10 = 480 mL
– ½ in 1st 8 hours = 30 mL/h
Modified formula:
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–
–
–
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 2/7
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:
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
Leukemia
Distribution %
30
Survival %
75
CNS
Lymphoma
Neuroblastoma
19
13
8
60
75
10-20 (stage 3,4)
75-90 (stage 1,2)
Wilm’s
Soft tissue
Bone
6
7
5
90
65
65
Retinoblastoma
Liver
Other
4
1
8
95
45
Most common findings in
childhood ALL?
•
•
•
•
HSM
Fever
Lymphadenopathy
Bleeding
• Bone/joint pain
• Fatigue
• Anorexia
70%
40-60%
25-50%
25-50% w/
petechiae or purpura
25-40%
30%
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?