Post on 08-Feb-2022
Key Diagnoses in Pediatrics
October 10, 2019
Objectives
At the completion of this educational activity, the learner will be able to:
• Explain how pediatric disease progression differs from adult progression
• Describe pediatric presentations of BPD, Dysphagia, Malnutrition, Septic
Shock and Heart Failure
• Begin to expand your CDI team’s scope of practice to pediatrics
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The patient is a 6 month old ex 28-week male with a history of a prolonged
NICU stay and ventilator use. He is now at home on 1/8 L/min O2 by nasal
cannula and takes a diuretic medication. He is followed by the Pulmonology
service as an outpatient.
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Bronchopulmonary Dysplasia (BPD)
What terms might you see?
• Ex-…weeker
• Former preemie
• Chronic lung disease
Why do providers use these terms?
• Unsure of exact criteria
• Assume the terms are interchangeable
• Patients are not babies anymore
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Bronchopulmonary Dysplasia (BPD)
Bronchopulmonary Dysplasia (BPD)
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Severity-Based Definition of BPD
A premature infant (< 32 weeks’ gestational age) with BPD has persistent parenchymal lung disease,
radiographic confirmation of parenchymal lung disease and at 36 weeks post menstrual age (PMA)
requires 1 of the following FiO2 ranges/oxygen levels/O2 concentrations for ≥ 3 consecutive days to
maintain arterial oxygen concentration in the 90%-95% range:
Higgins RD, Jobe AH, Koso-Thomas M, Bancalari E, Viscardi RM, Hartert TV, et al. Bronchopulmonary Dysplasia:
Executive Summary of a Workshop. J Pediatr. 2018;197:300-308
Grade Invasive IPPV* CPAP, NIPPV, or
nasal cannula
≥3 L/min
Nasal cannula
flow of
1 - < 3 L/min
Hood
Oxygen
Nasal cannula
< 1 L/min
I --- 21% 22-29% 22-29% 22-70%
II 21% 22-29% ≥30% ≥30% >70%
III >21% ≥30%
Note: BPD Grade III (A) signifies early death (between 14 days of postnatal days and 36 weeks) owing to persistent
parenchymal lung disease and respiratory failure that cannot be attributable to other neonatal morbidities.
*Excluding infants ventilated for primary airway disease or central respiratory control conditions
Abbreviations: IPPV, intermittent positive pressure ventilation; NIPPV, noninvasive positive pressure ventilation
Consider the diagnosis of “BPD” when …
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Comorbidities Therapies Other clues
Extreme prematurity h/o mechanical ventilation Documentation of O2
toxicity
Low birth weight Home O2 Receives
Synagis/Palivizumab
Long NICU stay Chronic diuretics Increased risk of ICU care
& respiratory support with
colds
Other preemie dx: ROP,
NEC
Chronic inhaled steroid Acute on chronic resp
failure
Chronic visits to
pulmonology
New need for mechanical
ventilation
Chronic respiratory
“insufficiency”
documented
Dysphagia
The patient is a 9 mo female who was admitted with RSV bronchiolitis. She has
a history of recurrent respiratory infections, wheeze and coughing with
feedings. The patient was evaluated by the Feeding Team and was noted to
have mild to moderate laryngeal penetration with aspiration of thin liquids.
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Dysphagia
What terms might you see?
• Aspiration
• Oromotor dysfunction
• Feeding difficulties
• G-tube dependent
• Swallowing dysfunction
Why do providers use these terms?
• The consequence may seem more important clinically than the
underlying cause
• Don’t think about the resource utilization
• May not know why patient has a G-tube
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Consider the diagnosis “dysphagia” when …
Comorbidities Symptoms Diagnosis Other clues
Spastic
quadriplegia
Coughing with
feeds
Feeding team
evaluation
Thickened feeds
Esophageal
atresia/TEF
Baby doesn’t suck
well
Videofluoroscopic
swallow study
(modified barium
swallow)
Recurrent
aspiration
pneumonia
Brain injury
Milk coming out
nose
Fiberoptic
endoscopic
evaluation of
swallow
NPO – gastrostomy
only
Craniofacial
malformations
Lips turn blue with
feeds
Robinul/
glycopyrrolate
Neuromuscular d/o Increased
secretions after
feeds
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Dysphagia: Adult and pediatric differences
Adult
Esophageal stricture 2°to GERD
or esophageal cancer
Achalasia
Scleroderma
Pill esophagitis
Stroke
Parkinson’s
ALS
Pediatric
Esophageal stricture 2°to caustic
ingestion or s/p EA repair
Vascular anomalies
Craniofacial malformations
Foreign body
Retropharyngeal abscess
SMA
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Malnutrition
The patient is a 17 year old male with CF and chronic sinusitis. He was recently
admitted for a CF pulmonary exacerbation. He was evaluated by the Nutrition
team and the consult note states the patient has a BMI z score of -3.2
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Malnutrition
What terms might you see?
• Failure to thrive (FTT)
• Poor weight gain
• Inappropriate weight loss
• Insufficient weight gain
• Poor growth
Why do providers use these terms?
• FTT viewed as a broad term for the eval & treatment of poor weight gain
• Multiple definitions (i.e., WHO, ASPEN)
• Malnutrition may be viewed as a component of FTT, not other way
around
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Consider the diagnosis “malnutrition” when …Clinical
manifestations
Orders Etiology Caloric
supplementation
Decreased weight
gain velocity
TPN panel Failure to ingest
sufficient calories
Increased calorie
feeds
Decreased height
velocity
Re-feeding labs Increased metabolic
demands
NG feeds or G-tube
placement
Inadequate weight
for corrected age
Nutritionist consult Altered nutrient
absorption or
utilization
TPN
Inadequate weight
for height
Tube or central line
placement for
nutrition
Increased nutrient
losses Calorie counts
Inadequate BMI Speech consult Feeding team
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Malnutrition: Adult and pediatric differences
Adult
CHF – coronary artery disease
Depression
Malignancy
Social isolation
Dementia
COPD
Alcohol dependence
Hand tremors
Pediatric
CHF – congenital heart defect
Cystic fibrosis
Craniofacial malformations
Adenoidal hypertrophy
Child neglect
Genetic syndromes
Milk allergy
Intestinal tract obstruction
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Septic shock
The patient is a 4 year old female with acute lymphoblastic leukemia. She
recently completed a round of chemotherapy and has pancytopenia. The
patient presents to the ED with a fever and decreased urine output x 1 day. On
exam, she looks ill, is tachycardic and has a normal blood pressure. Skin is
cool and mottled with a cap refill of 3 seconds. Lactic acid is 3.7 mmol/L. Her
condition remains unchanged despite 60ml/kg IV fluid so an Epinephrine
infusion is started.
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Septic shock
What terms might you see?
• SIRS/sepsis physiology
• Sepsis with pressor requirement
• Poor perfusion
• Bacteremia
Why do providers use these terms?
• Institutional culture
• Multiple definitions exist
• Don’t appreciate imprecise nature of language
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Septic shock resources
Adult
• Society of Critical Care Medicine/European Society of Intensive Care
Medicine 2016 guidelines
• Infectious Diseases Society of America does not endorse the
SCCM/ESICM 2016 guidelines
Pediatric
• Randolph, et al. International pediatric sepsis consensus conference:
definitions for sepsis and organ dysfunction in pediatrics. 2005
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Septic shock: Adult and pediatric differences
Adult
Hypotension is required
Pediatric
Hypotension is NOT required
Inadequate perfusion despite
adequate fluid resuscitation (≥40
mL/kg IV fluid)
Inadequate perfusion:
• Hypotension
• Vasoactive drugs to maintain
normal BP
OR
• 2 of the following: prolonged
capillary refill, oliguria,
metabolic acidosis/ elevated
arterial lactate
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Heart failure
The patient is a 3 month old male who was born with a complete AV canal,
large ASD, large VSD and severe common AVV regurgitation. Echocardiogram
with severe systolic biventricular dysfunction. The patient was treated with
Epinephrine and Milrinone. His lesions were not amenable to surgical repair
and he was ultimately listed for heart transplant given symptoms of
progressive heart failure.
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Heart failure
What terms might you see?
• Ventricular dysfunction
• Low cardiac output syndrome
• Cardiac insufficiency
• Excessive lung water
• Pulmonary over-circulation
Why do providers use these terms?
• Don’t appreciate imprecise nature of language
• May not know the exact definitions
• Institutional culture
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Heart failure
Clinical
manifestations
Evaluation Etiology Therapies
Poor feeding PE - tachycardia, poor
perfusion, gallop,
tachypnea, wheezing,
hepatomegaly
Congenital defects Diuretics
Dyspnea and sweating
with feeds
CXR – cardiomegaly,
pulmonary edema
Cardiomyopathy Inotropes – Milrinone,
Epinephrine
Sleeping more than
normal
Echo – structural
defects, decreased
systolic function,
chamber enlargement
Myocarditis ACE inhibitors
Chronic
cough/wheeze
Labs – elevated BNP,
elevated lactate,
elevated troponin
Myocardial ischemia
(Kawasaki disease,
ALCAPA)
Other meds: β-
blockers anti-
arrythmics, digoxin
Abdominal pain, N/V Other - cardiac cath,
cardiac MRI, EKG,
exercise testing
Arrhythmias Mechanical circulatory
support - ECMO,
LVAD
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Heart failure: Adult and pediatric differences
Adult
Many cases due to ischemic
heart disease and hypertension
May present as exercise
intolerance, lightheadedness
Concomitant COPD
PediatricMany cases due to structural defect
May present as poor feeding/
malnutrition
Many cases of heart failure are
amenable to surgical repair - corrective
or palliative
Some CHF is not due to either systolic
or diastolic dysfunction
Echocardiogram can be difficult in non-
sedated babies
JVD not typically seen in infants/young
children
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Kids are not just little adults!
• Pediatric anatomy, physiology and pathology may differ from adults in
many ways
Kids are resilient and may not show signs of falling off the cliff until they
are already falling
Disease process and clinical presentation may be very different between
the two groups
• They may share the same diagnostic nomenclature
• There are less standard criteria and diagnostic definitions in pediatrics
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Pediatric Summary
Thank you to:
Daxa Clarke, MD
Lucinda Lo, MD
Sheilah Snyder, MD
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Questions?
Corinna.Foley@childrens.harvard.edu
Amy.Sanderson@childrens.harvard.edu
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