COMMON PEDIATRIC PROBLEMS
Caren Mangarelli, M.D.
Special Thanks to Dr. Joel Schwab, Residency Director, Dept. of Pediatrics, University of Chicago Children’s Hospital.
CONTENTS
1. Acute Gastroenteritis
2. Acute Otitis Media
3. Otitis Media with Effusion
4. Anemia
5. Bronchiolitis
6. Constipation/Encopresis
7. Croup
8. Dentistry
9. Nocturnal Enuresis
10. Sleep Problems
11. Strep Pharyngitis
12. The Pink or Red Eye
13. Toilet Training
ACUTE GASTROENTERITIS
Characterized by rapid onset of diarrhea with or without vomiting, fever and abdominal pain. Diarrhea is defined as frequent, loose, unformed liquid stools. Most cases caused by viral or self-limited bacterial disease.
Important History
1. Recent travel.
2. Known sick exposures.
3. Recent use of antibiotics.
4. Daycare attendance.
5. Previous state of health (ie. Immunocompromised or not).
6. Presence of blood in stool.
Physical Exam
Need to determine if child dehydrated and estimate extent of dehydration.
1. Weight is most accurate measure of percent dehydration, but often a recent previous weight not available.
2. Mild dehydration (3-5%) - often has no changes in vitals nor physical exam.
3. Moderate dehydration (6-10%) – increased heart rate, decrease in tears and urine output, slightly prolonged capillary refill, mucous membranes tacky. Child generally irritable, but consolable.
4. Severe dehydration (>10%) – child becoming lethargic with significant decrease in urine output. Skin is cold and clammy, mucous membranes are dry and child producing no tears.
Work-Up
For the majority of patients, there is no need to do a stool culture, UA nor serum electrolytes. If stool is bloody or something suspicious in history, consider sending for bacterial culture. If child severely dehydrated, would send serum electrolytes.
Treatment
1. Oral rehydration is the preferred treatment of fluid and electrolyte losses for children with mild to moderate dehyration.
2. OTC rehydration fluids that most closely resemble the sodium, potassium and osmolality losses from diarrheal stools are Pedialyte and Infalyte.
3. Soft drinks, fruit drinks and sports drinks should be avoided because they lack electrolytes and are hyperosmolar which can induce more diarrhea.
4. If child has diarrhea, but is not clinically dehydrated, they should continue to be fed age appropriate diets and the type of oral fluids they take in is less important.
5. The child who is dehydrated should be rehydrated first and restarted on age appropriate diet as soon as possible.
6. Net balance of nutrients, rather than the number of stools should be the primary concern. Suboptimal absorption of some food is better than no absorption of no food. Focus on complex CHO foods like rice, wheat noodles, potatoes, bread, cereal; also lean meats, veggies, yogurt, bananas. Classic BRAT diet is well tolerated, but low in energy, protein and fat.
7. If child is also vomiting, can often still achieve rehydration orally if give sips or teaspoons of fluid on a frequent (every 15 min.) basis.
8. Encourage continuation of breastfeeding – is the best choice.
9. Most children need no reduction in lactose (unless severe illness) – reduced lactose may mean reduced calorie diet.
10. Many Mexicans use rice-water. Is actually not a bad choice. Rice is well absorbed.
11. As a general rule, pharmacologic agents should not be used to treat acute diarrhea
- Anti-motility agents like Immodium AD and Lomotil contraindicated in young children.
- Pepto-Bismol not recommended, but further studies may demonstrate role.
- Adsorbents (Kaopectate) not recommended because no proven benefit (but probably not harmful).
- Lactobacillus containing compounds have shown some benefit, but inadequate studies.
References:
1. AAP Practice Parameter on the Management of Acute Gastroenteritis in Young Children, Pediatrics, 97: 424-436, 1996.
2. MB Cohen, Non-Antimicrobial Therapy of Diarrheal Disease: Earth, Brine, and Fiber, AAP CME Seminar, March, 2001.
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ACUTE OTITIS MEDIA
Acute otitis media is a very common pediatric disease and approximately 80% of children will have one episode by three years of age. It is defined as rapid onset of signs and symptoms of acute infection within the middle ear. The highest incidence is between 6-18 months of age during the winter season. Acute otitis media is the most common reason for outpatient antimicrobial treatment in the United States.
Risk Factors
1. Attendance at daycare.
2. Altered immune system.
3. Exposure to smoke.
4. First episode before 6 months of age.
5. Family history.
6. Anatomical variations – cleft palate, Down syndrome, craniosynostosis.
7. Not being breastfed – three months needed for any protective effect.
8. Native American or Alaskan Eskimo
9. Early use of antibiotics – increase in AOM in countries where antibiotics readily availale.
10. White/Male.
Pathogenesis
Normally the eustachian tube equalizes pressure between the middle ear and the atmosphere, protects the middle ear from nasopharyngeal secretions and bacteria, and drains secretions from the middle ear into the nasopharynx. If the eustachian tube is obstructed, bacteria may proliferate in the middle ear space. In addition, obstruction may lead to increased negative pressure within the middle ear and “sucking” of pathogens into the middle ear space. Obstruction is often caused by an upper respiratory viral infection which results in congestion or inflammation of the respiratory mucosa. There may also be functional obstruction due to the fact that in infants the eustachian tube is shorter, wider and more horizontal, and the supporting structures are underdeveloped. Finally, there may be extrinsic obstruction due to tumors or enlarged lymphoid tissue.
Microbiology
1. Streptococcus pneumoniae (25-50%, mean 38) – least likely to resolve spontaneously, increasing incidence of antibiotic resistance.
2. Non-typeable Hemophilus influenza (15-50%, mean 27) – up to 55% beta-lactamase producers, associated with conjunctivitis (conjunctivitis-otitis syndrome).
3. Moraxella catarrhalis (2-15%, mean 10) – up to 100% beta-lactamase producers and also associated with conjunctivitis.
4. Group A Streptococcus (2-3%)
5. Viral (<10%) – often associated with bacterial superinfection.
6. Others – Staphylococcus aureus, Mycoplasma, Chlamydia – uncommon.
7. Newborns have increased incidence of gram negative organisms and GBS.
8. If tympanostomy tubes, can develop acute otitis caused by organisms associated with otitis externa (Staph aureus, Staph epidermis, Pseudomonas).
9. Nasopharyngeal cultures are usually not indicated. They are sensitive, but not specific. They are more helpful for monitoring antibiotic susceptibility patterns.
Symptoms
1. Often preceded by URI.
2. Usually sudden onset.
3. Nonspecific signs/symptoms – fever, irritability, anorexia, and vomiting.
4. Specific signs/symptoms – otorrhea, otalgia.
5. Decreased hearing.
Diagnosis
Best done with a pneumatic otoscope. Usually a symptomatic child with a red, bulging, poorly mobile tympanic membrane. Often overdiagnosed due to relying solely on color, past history, parental pressure or rechecking too soon after previous treatment. Tympanometry often useful for confirming the presence of fluid previously identified with pneumatic otoscope. Tympanometry has a better negative predictive value and about 50% of abnormal tympanograms will have normal middle ears. Tympanocentesis was previously performed with a higher frequency. Today typically done only as part of a study or in children with immunodeficiency syndromes or treatment failures in order to identify an organism with sensitivities.
Management
1. Somewhere between 60-80% of cases will resolve spontaneously, but there is no clinical means to distinguish between those that need to be treated with those that don’t. It is generally accepted that antibiotics decrease the length of symptoms in the short-term, but there is no proven decreased incidence of recurrence nor otitis media with effusion in the long-term. Antibiotic treatment is always associated with some harms or side effects.
2. Amoxicillin is still considered the first antibiotic of choice. Need to consider high dose (80-90mg/kg/day) in children with risk factors like daycare attendance or recent antibiotic treatment.
3. If otitis associated with conjunctivitis, need to use a beta-lactamase resistant antibiotic.
4. One dose of IM Ceftriaxone has been shown to be effective, but may need 2-3 doses for resistant Strep pneumo.
5. Second –line therapy includes high dose Augmentin, Omnicef (Cefdinir), Vantin (Cefpodoxime), Cefzil (Cefprozil), or Ceftin (Cefuroxime axetil).
6. Macrolides not the best choice due to Strep pneumo as well as H. flu resistance.
7. Duration of treatment is variable and data not conclusive whether 5 or 7 days as good as 10 days.
8. Ibuprofen and paracetamol have been shown to reduce pain in short-term.
9. If child is not clinically improved within 48-72 hours rechecking child is recommended and changing the antibiotic is an option.
10. Once treated the middle ear effusion usually becomes sterile, but may persist for weeks to months, therefore rechecking has its pluses and minuses.
11. Prophylactic use of antibiotics in children who have had more than 3 infections in 6 months or more than 4 in one year may decrease the frequency of AOM, but inconsistent evidence. Unfortunately, prophylaxis is a major contributor to emergence of antibiotic resistance.
Complications
Serious complications are rare, but include hearing loss, perforation, mastoiditis, intracranial abscess, sinus thrombosis, meningitis and facial nerve paralysis.
References:
1. Dowell SF, Butler JC, Grebink GS, et al. Acute otitis media: management and surveillance in an era of pneumococcal resistance – A report from the Drug Resistant Strep. Pneum Therapeutic Working Group. Ped. Infect. Dis. Journal, 1999; 18:1-9.
2. Feigin, Cherry. Textbook of Pediatric Infectious Diseases, Edition 4, Vol. 1.
3. BMJ Publishing Group, Clinical Evidence Pediatrics, Issue 7, 2002.
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OTITIS MEDIA WITH EFFUSION
Defined as the presence of fluid in the middle ear without signs or symptoms of acute infection. In some instances, aspiration of the fluid may yield the presence of bacteria similar to those found in acute otitis media. Congenital or early-onset hearing loss is an accepted risk factor for delayed or impaired speech and language development. Since otitis media with effusion is often associated with a mild to moderate degree of hearing loss, most physicians have made the assumption that it can interfere with language/speech development. It is currently uncertain and unproved whether changes in hearing due to middle ear fluid has any long-term effect on development.
Risk Factors
1. Day care attendance.
2. High number of siblings.
3. Low socioeconomic group.
4. Frequent URIs.
5. Bottle-feeding.
6. Household smoking.
Physical Findings/Diagnosis
1. Often an incidental finding.
2. May be seen following an acute otitis media episode – may persist for weeks to months, median duration 23 days.
3. May present with decreased hearing, ear discomfort or behavioral changes.
4. A pneumatic otoscope is recommended for assessing the middle ear and the presence of fluid.
5. Exam will show decreased mobility of the TM. Fluid may appear as bubbles, clear, yellow or grayish. TM may appear thickened or opaque.
6. Tympanometry can be helpful in confirming diagnosis (flat or Type B). Has a better negative predictive value (if normal, middle ear normal).
7. Otitis media with effusion often misdiagnosed as acute otitis media.
Treatment
Most people refer to the Clinical Practice Guidelines as outlined by the Agency for Health Care Policy and Research. These guidelines specifically address what to do with children ages 1-3 years. More than half the children will have spontaneous resolution of the otitis media with effusion within 3 months.
1. Antibiotic therapy – Some evidence to show faster resolution of OME with antibiotic use. No significant effect on long term outcomes. Definite adverse effects due to side effects of medication in addition to the ever increasing problem of microbial resistance.
2. Environmental risk factor control counseling.
3. No evidence or inadequate evidence for use of antihistamines, decongestants or steroids.
4. After 3 months of bilateral effusion, hearing test should be performed. If greater than 20 decibel bilateral hearing loss should consider antibiotic treatment or ENT referral for myringotomy tube placement. Should evaluate speech and language development.
5. Placement of myringotomy tubes is recommended after 4-6 months of bilateral effusion with bilateral hearing deficit.
6. Adenoidectomy and tonsillectomy either alone or combined have not been proven effective for the treatment of otitis media with effusion.
7. New long-term study out of Pittsburgh by Paradise et al is evaluating long-term outcomes of children with otitis media with effusion. New evidence may show no long term detrimental effects on development.
References:
1. American Academy of Pediatrics, Practice Guideline – Managing Otitis Media with Effusion in Young Children, Pediatrics, Vol. 94, #5, November 1994.
2. BMJ Publishing Group, Clinical Evidence Pediatrics, Issue 7, 2002.
3. Paradise J, Feldman HM, Campbell TF, et al. Effect on early or delayed insertion of tympanostomy tubes for persistent otitis media on developmental outcomes at the age of three years. N Engl J Med 2001; 344:1179-1187.
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ANEMIA
Need to be aware of normal values for children of different ages in order to correctly diagnose anemia. See chart below extracted from CDC data: (chart unavailable)
Important History
1. Birth History – preterm infants have less stores and higher requirements due to accelerated growth. Normal nadir in full term infants around 3 months of age (RBC lifespan 120 days). Need to find out about any blood loss at birth.
2. Family History
3. Ethnicity/Race –
Mediterranean – thalassemia
Sephardic Jew, Filipinos, Greeks, and Kurds – G6PD
African Americans – Hgb S and C, alpha thalassemia
Asians – alpha thalassemia
4. Diet – all infants should use formula with iron. If breastfed, should supplement after 6 months. Only about 10% of iron in whole milk is available for absorption and it may cause GI bleeding and loss of iron. Also, if drinking lots of whole milk after age 1 yr., unlikely eating other foods rich in iron. Good sources of iron include cereals, greens, meats and beans. Ascorbic acid enhances the absorption of dietary iron.
5. Growth history – chronic disease
6. Bleeding history
7. Pica
8. Medications
Physical Examination
1. Skin – petechiae, purpura, jaundice, hemangiomas
2. Enlarged liver – malignancies, extramedullary hematopoesis, chronic diseases
3. Significant adenopathy – leukemias and lymphomas
4. Heart rate and presence of murmur
5. Extremities – radial anomalies associated with congenital anemias (Fanconi’s)