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Pediatric potpourri. Edward Les, MD May 6, 2004. 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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Pediatric potpourri

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

Agenda:Common pediatric ED problems not covered elsewhere in curriculum


Pediatric potpourri
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
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 reflux prevalence
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
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
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


  • Ge reflux diagnosis
    GE reflux: diagnosis

    Clinical!!!

    Confirmation of more severe reflux:

    24 hour pH probe

    Milk scan

    UGI barium not sens/specific


    Ge reflux treatment options
    GE reflux: treatment options

    * Consultation with peds or GI


    Pediatric potpourri
    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
    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
    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
    Signs of inadequate intake in BF infantNeifert, 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
    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 strategies1
    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


    Pediatric potpourri
    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
    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
    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
    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
    Colic: etiology?

    Unknown:

    ? Temperament

    ? Ineffective parental response to crying

    ? Overfeeding

    ? Hunger


    Colic diff dx
    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
    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

    Colic: management


    Pediatric potpourri
    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
    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
    Omphalitis: complications

    • Necrotizing fasciitis

    • Sepsis

    • Portal vein thrombosis

    • Hepatic abscesses


    When should the umbilical cord separate
    When should the umbilical cord separate?

    • Usually w/i 2 weeks

    • Delayed separation: think of possible leukocyte adhesion defect


    Pediatric potpourri
    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
    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
    Dacryocystitis

    Bacterial infection of nasolacrimal gland with duct obstruction

    Mgt:

    • Swab C+S

    • Topical + systemic antibiotics


    Gonorrheal conjunctivitis
    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
    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
    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
    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


  • Pediatric potpourri
    Case

    3 year old girl

    URTI x 5 days

    Now R otalgia, increased fever, irritable ++


    Acute otitis media
    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
    Otitits media – criteria?

    • Yellow/red

    • Opacity/effusion

    • Immobility

    • Bulging

    • Loss of landmarks


    The normal tm which ear
    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
    OM Bugs

    • S. pneumoniae – 40%

    • non-typeable H. influenzae – 25%

    • M. catarrhalis – 10 %

    • others – GAS, S. aureus – rare

    • viral – 20-30%!


    Om management
    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
    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 antibiotics1
    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!

    What about…


    Aom f u
    AOM – f/u

    In 3 months:

    assess for persistent OME which may lead to hearing loss


    Recurrent aom risk factors
    Recurrent AOM:risk factors

    • Smoking

    • Daycare

    • Pacifiers

    • Bottle-feeding

    • Poor antibiotic compliance


    Recurrent aom when to refer
    Recurrent AOM:when to refer?

    > 3 AOM per 6 months

    > 4 AOM per 12 months


    Pediatric potpourri
    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


    Pediatric potpourri

    otoscopic findings

    Facial expression


    Bell s palsy in setting of aom
    Bell’s palsy in setting of AOM

    IV antibiotics (ceftriaxone)

    CT temporal bone

    Urgent ENT consultation

    need wide myringotomy


    Pediatric potpourri
    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.


    M astoiditis
    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
    What’s this?

    Cholesteatoma

    Complications:

    • Erosion of bony labyrinth

    • Facial paralysis

    • Hearing loss

    • Meningitis/brain abscess/hydrocephalus

      Refer to ENT tout-de-suite



    Pediatric potpourri
    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
    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
    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


    Pediatric potpourri
    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:


    Pediatric potpourri
    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
    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!


    Pediatric potpourri
    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
    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


    Pediatric potpourri
    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!


    Pediatric potpourri
    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


    Pediatric potpourri
    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


    Pediatric potpourri
    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
    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
    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)


    Pediatric potpourri
    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



    Most common findings in childhood all
    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
    Most common sites of pediatric ALL extramedullary relapse?

    • CNS

    • Testicular (painless swelling, usually unilateral)


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

    • cranial n. VI palsy


    Pediatric potpourri
    Case w/ increased ICP secondary to posterior fossa tumor?

    • 18 month old girl presents with “black eyes”; developed over past week; no known trauma

    • Also has “dancing eyes” and seems off balance


    Neuroblastoma
    Neuroblastoma w/ increased ICP secondary to posterior fossa tumor?

    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


    Pediatric potpourri
    Case w/ increased ICP secondary to posterior fossa tumor?

    4 month old boy

    • “Eyes don’t look right”


    Retinoblastoma
    Retinoblastoma w/ increased ICP secondary to posterior fossa tumor?

    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


    Pediatric potpourri
    Case w/ increased ICP secondary to posterior fossa tumor?

    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
    Come to my ACH w/ increased ICP secondary to posterior fossa tumor?Grand Rounds: May 27 8 a.m.

    A Balanced Approach to the Unbalanced Child:

    Acute pediatric ataxia


    Thank you questions

    Thank you. w/ increased ICP secondary to posterior fossa tumor?

    Questions?