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Pediatric Pearls from Hawaii

Pediatric Pearls from Hawaii. December 9, 2009 Francine Jolton , MD. Constipation. Different Approaches for Different Ages **Infants **Toddlers in Diapers **Children who are toilet trained. Infants. Typical story

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Pediatric Pearls from Hawaii

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  1. Pediatric Pearls from Hawaii December 9, 2009 Francine Jolton, MD

  2. Constipation • Different Approaches for Different Ages **Infants **Toddlers in Diapers **Children who are toilet trained

  3. Infants • Typical story • A 1 ½ month old comes in and mother is concerned that he is constipated. He only stools on his own 1X/week. He strains and cries but the stool is of normal consistency. Mom gives a suppository every 2 days which produces a stool

  4. Question • Is this Constipation ???? • What is the normal stooling pattern for a 1 ½ month old?

  5. Things to Consider • Could this be Hirschsprung’s, Hypothyroidism, Tethered spinal cord, etc? • Is the baby anatomically normal or is there anal stenosis or an anterior anus?

  6. Is it Infant Dyschezia? • At least 10 minutes of straining and crying before successful passage of soft stools • No other health issues • Seen in infants < 6 months old • Begins spontaneously • Resolves after a few weeks

  7. Treatment ???? • If it ain’t broke, don’t fix it • Don’t use mineral oil (risk of aspiration) • Don’t do rectal stimulation and suppositories • Don’t use low-iron formula • Could consider prune/apple juice (if old enough), lactulose, dark karo syrup

  8. The Toddler • A 2 year old only stools once/week after hours of straining, crying and parental distress. The stools are large caliber, hard, can have blood on the outside and are painful to pass. This has been going on for 6 months

  9. Things to Remember • Examine for structural anomalies, fissures • Usually starts with toilet training conflict and/or anal fissure • The “dance”, trying to stool or not???

  10. Treatment • Parental Education • Postpone Toilet Training unless child drives it • Miralax, Mineral Oil • Treat fissure (sitz baths, vaseline) • Avoid Enemas • Fiber is an adjunct

  11. Miralax • Disimpaction at 1.5 – 2 g/kg/d • ½ the dose for maintenance • Titrate to achieve a soft stool daily • Tasteless, can mix in any liquid • OTC • Don’t wean while toilet training, do wean after 2 – 3 months of normal stools

  12. Mineral Oil • 1 tablespoon (1 oz)/yr of age BID • Keep it cold and mix in thick juice • Titrate as needed • Failures caused by too small of dose, prn usage instead of qd, child refuses (keep cold), large intake of whole milk • Taper after 2 good months

  13. The Toilet Trained Child • Child sits on toilet when he feels like going (about once/week) • Soils his underwear daily • Stools are large caliber • Problem is long standing (months to years) • RX with water, juice, occassional enemas • Tries to avoid going • Can have encoporesis • Many social aspects

  14. Treatment if Mild • High fiber diet – grams/day = age + 5 • Increase fiber gradually • Can use fiber supplement (benfiber, metamucil, citrucel, etc) • Fluids • Toileting schedule

  15. Treatment for Moderate to Severe • Will likely need initial clean out • Then can use: Miralax, Mineral Oil, MOM • Dose titration for all • Can use a stimulant (Senna, Ex-Lax) • Must have a routine for toilet time • Reward System • Avoid Toilet Posture

  16. Why Treatment Fails • Family doesn’t understand the problem • Incomplete initial clean out • Inconsistent or inadequate maintenance • Stop meds too soon • No schedule • Lots of attention for the wrong behavior

  17. Special Consideration • Sexually abused child • Autism • Neurologically impaired

  18. Resources • Toilet Learning by Alison Mack • Naspghan.org • Romecriteria.org – gastroenterology issue

  19. On to Dermatology • MolluscumContagiosum • seen in 5% of children 2 – 8 years old • The only lesion that needs to be treated is the one on the eyelid causing corneal irritation • Untreated will resolve in 6 months – 3 years • Curettage most efficacious with lowest side effects but requires time and anesthesia

  20. Warts • Seen in 4 – 5% of children • Common, flat, plantar and genital • Untreated warts resolve in 6 months – 3 years • Most patients have already decided to have their warts treated • Some are painful (plantar), some are socially awkward (common) • Best evidence is topical treatments with salicylic acid for about 3 months

  21. Scabies • Treat all in the home • Permetherin 5% cream (Elimite) for > 6hours • Treat clothing and bedding • Repeat Therapy in 7 – 10 days • 30 – 60 grams/person

  22. Lice • Permethrin 1% (NIX) applies for > 6 hours • Wash or heat clothing • All contacts should be treated • -------OR----- • Cetaphil Cleanser – apply 8 – 12 oz of lotion thoroughly in hair, wait 2 minutes • Comb out excess lotion • Dry hair with hand held drier • Shampoo with usual shampoo in 8 hours

  23. A little more on Lice • Dry-on suffocation based treatment is effective without neurotoxins, nit removal of extensive house cleaning • Newly approved, Benzyl Alcohol Lotion 5% • Used in two 10 minute treatments a week a part • Still need to treat contacts, bedding, clothing, etc. • Nit removal +/- , use nit comb toward scalp

  24. Now, on to Orthopedics Developmental Dysplasia of the Hip • Spectrum of Pathology • Dysplastic • Subluxated • Dislocated • Can be present at birth (congenital) • Can occur later (developmental)

  25. Possible Outcomes of DDH • The hip can become normal • The hip begins to subluxate • The hip completely dislocates • The hip remains located but dysplastic ( leads to hip pain and arthritis in adults)

  26. Interesting Facts about the Hip • Fully formed by 11 weeks gestation • Requires normal movement for development • Normal hip anatomy with a ossific nucleus doesn’t appear on x-ray until 4 – 7 months of age • Normal hip development and growth accounts for 30% of the adult femur length (abnormalities lead to short leg length)

  27. Hip Dysplasia • Can be progressive • The Anatomy can change secondary to changes in the surrounding muscles and ligaments • Any treatment must limit damage to the medial circumflex artery to prevent AVN

  28. Diagnosis • When should the hip be examined? ***at every well child check until age 2 ***must document Who remembers the names of the tests used to examine the hip for DDH? There are 3 ……………………………………………………..

  29. Ortolani Test • CLICK OF ENTRY • Hip is flexed 90 degrees, sl. abducted • Trochanter is elevated (use middle finger) • Lift and abduct • Head slides into acetabulum

  30. Barlow Test • CLICK OF EXIT • Hip is flexed, adducted • Gentle posterior pressure

  31. Abduction • Most reliable after 3 months • Other signs disappear with muscle changes • Used for late diagnosis • Skin fold asymmetry and leg length discrepancy are unreliable.

  32. What to X-Ray • Ultrasound • Not accurate in first 6 weeks, overly sensitive • Best between 6 weeks and 6 months • Radiography • High false negative early on • Can be used after 6 months (ossific nuclei present)

  33. When and How to Treat • Want to treat early • If untreated leads to limp, short leg, back pain and arthritis in adults • Pavlik Harness Birth – 6 months • Allows for motion that fosters normal joint formation • Time in harness depends on age of diagnosis • NO DOUBLE/TRIPLE DIAPERS !!!!!! • All therapy after 6 months requires surgery, the later it occurs, less likelihood of normal joint

  34. Rotational and Angular Conditions Why Bother ? THE MOST COMMON MUSCULOSKELETAL COMPLAINTS ENCOUNTERED BY PEDIATRICIANS Need to know the difference between normal and pathology Understand torsional profiles Know when to Refer

  35. Helpful Definitions • Deformity: > 3 SD from the norm • Variation: < 3 SD from the norm • Angular Conditions: deviations from neutrality in the frontal plane • Rotational Conditions: deviation from neutrality in the axial plane • Rotation = Torsion = Version

  36. Conditions by Anatomical Area • The Feet (birth to six months) Metatarsus adductus • The Legs (6 months to 3 years) Tibial Torsion • The Knees (6 months to 3 years) Bow legs & Knock knees • The Hip (> 3 years) Femoral Anteversion

  37. Metatarsus Adductus

  38. Evaluate Three Things • Heel Bisector • Rigid vs. Supple • Ankle Range of Motion – is dorsiflexion limited? • ***Double check hip exam

  39. When to Refer • If Rigid – may need casting or surgery if a • skewfoot • Limited Dorsiflexion – could be clubfoot or other problem that could need surgery • Exasperated MD or parent

  40. Tibial Torsion • Parents and Grandparents – very concerned • Child completely unconcerned • Large standard deviations • Usually internal rotation • Can evaluate the thigh foot axis and follow

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