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Pediatric potpourri

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

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

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. GE reflux: diagnosis Clinical!!! Confirmation of more severe reflux: 24 hour pH probe Milk scan UGI barium not sens/specific

  9. GE reflux: treatment options * Consultation with peds or GI

  10. 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.”

  11. 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

  12. 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

  13. 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

  14. 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!!

  15. 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

  16. 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?

  17. 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

  18. 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

  19. 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

  20. Colic: etiology? Unknown: ? Temperament ? Ineffective parental response to crying ? Overfeeding ? Hunger

  21. 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)

  22. Hair tourniquet Treatment? • Excision • “Nair”

  23. 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

  24. 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?

  25. 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 (

  26. Omphalitis: complications • Necrotizing fasciitis • Sepsis • Portal vein thrombosis • Hepatic abscesses

  27. When should the umbilical cord separate? • Usually w/i 2 weeks • Delayed separation: think of possible leukocyte adhesion defect

  28. 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

  29. 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)

  30. Dacryocystitis Bacterial infection of nasolacrimal gland with duct obstruction Mgt: • Swab C+S • Topical + systemic antibiotics

  31. 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

  32. 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,

  33. 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

  34. 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

  35. Case 3 year old girl URTI x 5 days Now R otalgia, increased fever, irritable ++

  36. 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

  37. Otitits media – criteria? • Yellow/red • Opacity/effusion • Immobility • Bulging • Loss of landmarks

  38. 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

  39. OM Bugs • S. pneumoniae – 40% • non-typeable H. influenzae – 25% • M. catarrhalis – 10 % • others – GAS, S. aureus – rare • viral – 20-30%!

  40. 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)

  41. 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

  42. 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

  43. Decongestants? Anithistamines? Topical steroids/antibiotics? No! No! No! What about…

  44. AOM – f/u In 3 months: assess for persistent OME which may lead to hearing loss

  45. Recurrent AOM:risk factors • Smoking • Daycare • Pacifiers • Bottle-feeding • Poor antibiotic compliance

  46. Recurrent AOM:when to refer? > 3 AOM per 6 months > 4 AOM per 12 months

  47. 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

  48. otoscopic findings Facial expression

  49. Bell’s palsy in setting of AOM IV antibiotics (ceftriaxone) CT temporal bone Urgent ENT consultation need wide myringotomy

  50. 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.

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