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?