Acute Otitis Media

Pt with personal and family h/o otitis media presents with acute onset ear pain. Parents report fever, irritability, poor feeding, and pulling/tugging/rubbing of the ear. Attends daycare; parents smoke at home. Bulging, erythematous/cloudy tympanic membrane with air-fluid level on exam.

• Tylenol/Motrin for pain

• Amoxicillin 80 mg/kg/day divided every 12 hours x

  • 10 days in children < 2 y/o

  • 7 days children > 2 y/o

• Refer for tympanostomy tube placement for either of the following:

  • 3 or more episodes in the past 6 months

  • 4 or more episodes in the past year

• Parents advised that

  • 80% of cases resolve within 3 days without antibiotics

  • Antibiotics increase risk of vomiting, diarrhea, rash

Note: No treatment and follow-up in 3 months is recommended for otitis media with effusion

Upper Airway Cough Syndrome (UACS)

A.K.A. Post-Nasal Drip

Pt >6 y/o with atopy presents with cough x4 weeks. Parents report rhinorrhea, nasal stuffiness, sneezing, itching. No wheezing, suspicion of foreign body aspiration. Afebrile with post-nasal drainage and cobblestoning of posterior pharynx on exam.

• Pt > 2 y/o: Start intranasal fluticasone (Veramyst) 27.5 mcg/spray, one spray per nostril daily

• Loratadine

  • Pt 2-6 y/o: Start loratadine 5mg qd

  • Pt > 6 y/o: Start loratadine 10 mg qd

• Parents advised to make f/u appointment if no clinical improvement within 2 months

Notes

• Chronic cough in children defined as > 4 weeks

• UACS is estimated to be the 3rd most common cause of cough in children younger than 6 years

  • Asthma = 36%

  • Protracted bacterial bronchitis = 12%

  • Upper airway cough syndrome = 9%

Protracted Bacterial Bronchitis (PBB)

Pt < 6 y/o with h/o asthma presents with cough x 4 weeks. Parents describe wet/moist, productive nighttime cough that interferes with sleep, SOB, intermittent wheezing. Asthma symptoms well controlled before 4 weeks ago and parents deny exposure to any asthma triggers. Afebrile and well appearing with rattling lung sounds on exam.

• CXR shows bilateral peribronchial accentuation with focal consolidated infiltrates; negative for foreign body aspiration

• Start amoxicillin/clavulanate (Augmentin) x 2 weeks

• Parents advised to schedule appointment if symptoms do not resolve s/p antibiotic course

Notes

• Chronic cough in children defined as >4 weeks

• PBB is estimated to be the 2nd most common cause of cough in children < 6 y/o (asthma = 36%, PBB = 12%, upper airway cough syndrome = 9%)

• CXR showing bilateral peribronchial accentuation with focal infiltrates may indicate PBB or asthma

• If untreated, PBB can result in bronchiectasis

• See Chest 2017; 151:884 and Ann Thorac Med. 2018 Jan-Mar; 13(1): 7–13 for further information

Acute Bronchitis

Pt with no h/o asthma presents with acute onset cough. Symptom onset >10 days ago. No altered mental status, rhinorrhea, coughing paroxysms, post-tussive emesis. Afebrile with HR and RR WNL; no crackles on exam.

• Not currently peak influenza season and presenting with intermediate influenza risk within 36h of symptom onset: Obtain influenza PCR

• Unvaccinated pt with cough lasting >3 weeks and whooping sound s/p cough: Obtain B. pertussis PCR, serology

• Low suspicion for PNA; do not obtain CXR

• Treatment

  • Pt < 6 y/o: Parents cautioned against use of cough/cold preparation

  • Pt > 1 y/o: Parents encouraged to try dark honey

• Adult Treatment

  • Pt encouraged to try dark honey, echinacea, pelargonium

  • Trial of dextromethorphan 20 mg q6 hours

  • Pt wheezing: Administer PRN albuterol inhaler and consider episodic high-dose episodic inhaled corticosteroids

  • Patient advised that symptoms can last up to 3 weeks; f/u encouraged to fill pocket prescription if symptoms do not resolve by this time

Notes

• Etiology

  • 90% of cases are due to viral infection

    • Common cold generally last < 10 days while acute bronchitis can last up to 3 weeks

    • Presence or absence of green sputum cannot be used to differentiate between viral and bacterial illness

  • Do not test for influenza during peak season or outside of flu season due to high pretest probability and low positive predictive value, respectively

  • Pertussis suspected with pt presents with coughing paroxysms, whooping sounds, post-tussive emesis, etc.

• Treatment

  • Dextromethorphan is not effective for cough suppression in children

  • Using the term "chest cold" can reduce use of antibiotics

Bronchiolitis (RSV)

Patient < 2 y/o with h/o eczema and no h/o intubation presents in January with increased respiratory effort. Parents report 3 days of increasing cough and decreased oral intake. Sick contacts include siblings and other children at daycare. Initial SPO2 94%. Low grade fever, tachycardia, rhinorrhea, nasal flaring, dry mucous membranes, grunting, mild retractions, and wheezing/crackles on exam.

• Obtain daily weights to assess hydration status

• Do not obtain virus panel

• CXR shows non-specific peribronchiolar cuffing, hyperinflation, and atelectasis

• Treatment

  • Start supplemental (blow-by) oxygen to maintain SPO2 > 90%

  • Nasal suction bulb PRN; avoid over-suctioning and/or deep suction

  • Respiratory rate > 60 breath/min or unable to maintain sufficient PO intake: Administer fluids via IV and/or nasogastric tube

  • Antipyretics

    • Weight > 2.7 kg (6 lbs): Acetaminophen q6h PRN fever

    • Age > 6 months, weight > 5.4 kg (12 lbs): Ibuprofen q6h PRN fever

• Counseling

  • Parents counseled that symptoms typically peak at 2-3 days and last 7-10 days

  • Parents reassured that it is unlikely a child will be hospitalized during the full illness course

  • Parents educated about the importance of hand washing and avoidance of second hand smoke to reduce risk for future respiratory infection

Notes

• Lower respiratory tract infection most commonly caused by respiratory syncytial virus (RSV)

• Peak season: December through March

• Prophylaxis

  • Palivizumab: RSV monoclonal antibody administered monthly during peak RSV season (maximum 5 doses)

  • Administer to infants

    • Born before 29 WGA

    • Born before 32 WGA with chronic lung disease of prematurity

    • With hemodynamically significant heart disease

• Diagnosis and treatment

  • Respiratory virus panels (PCR) cost between $1,000 and $3,500 and do not change management

  • Routine CXR is not recommended

  • Continuous pulse oximetry is not required

  • Treatment such as albuterol, epinephrine, corticosteroids, and/or antibiotics are ineffective and should be avoided

  • Infants with respiratory rates > 60 breaths/min may demonstrate poor feeding and benefit from NG tube or IV hydration

• Predictors of severity

  • Safe discharge predicted by age > 2 months, no h/o intubation, h/o eczema, initial SPO2 of 94%, and adequate oral intake

  • More concerning s/sx include tachycardia, evidence of dehydration (decreased weight, dry mucous membranes), and increased respiratory effort

Croup (Parainfluenza)

2 y/o pt born at 37 WGA and with no h/o intubation presents with acute onset cough and hoarseness. Parents report 2-3 days of low-grade fever and nasal congestion; symptoms typically worse at night. Parents deny possibility for recent foreign-body aspiration. Low-grade fever, tachypnea, nasal flaring, barking cough, inspiratory stridor, retractions, cyanosis, disorientation on exam. No drooling, wheezing, crackles noted.

• Do not obtain respiratory virus panel at present; may reconsider if pt does not respond to initial treatment

• CXR shows steeple sign

• Treatment

  • Administer single-dose oral dexamethasone 0.6 mg/kg

  • Westley Croup Score 3 or greater: Administer 0.5 mL nebulized racemic epinephrine

  • Administer oxygen to maintain SPO2 >94%

• Monitor for 2 hours; admit to hospital if no improvement after initial treatment

• Parents counseled that symptoms typically peak at 48 hours and resolve after 1 week

Notes

• Pathology: Virally-mediated swelling of larynx, trachea, and bronchi

• Epidemiology

  • Most common between age 6 months and 3 years

  • Croup is responsible for 99% of acute onset stridor cases in children

  • 75% of cases are due to parainfluenza virus

  • Risk factors for severe croup include prematurity, prior intubation, and age < 3 years

• Differential

  • Absence of cough and presence of drooling should raise suspicion for epiglottis

  • Steeple sign is not sensitive or specific for croup

• Nebulized epinephrine reduces length of hospital stay in severe cases

Pertussis (Whooping Cough)

Pt with no h/o DTaP or TDaP vaccination presents with cough and intermittent apneic episodes. Cough started > 2 weeks ago. Current symptoms include coughing paroxysms followed by whooping sound and emesis. Low grade fever on exam.

• Cough duration

  • < 4 weeks: Obtain PCR and culture

  • > 4 weeks: Obtain serology

• CXR shows no foreign body

• Treatment

  • Cough duration < 3 weeks: Start azithromycin (see notes for dosing)

  • Cough duration < 6 weeks and pregnant pt with small infant who works in health care: Start azithromycin (see notes for dosing)

  • Start post-exposure prophylaxis for all close contacts

• Pt and parents advised that pertussis is highly contagious

Notes

• Due to risk of transmission, antibiotics are started within 6 weeks of cough for a pt who is pregnant, anyone working with infants, and healthcare workers

• Close contact prophylaxis

  • Close contact definition: Regular, face-to-face exposure within 3 feet of the symptomatic patient.

  • Threshold for "regular" can change based on the individual’s risk for contracting the illness, e.g. would be lower for immunocompromised individuals.

• Azithromycin dosing

  • Age 1-5 month: 10 mg/kg x 5 days

  • Children 6+ months: 10 mg/kg on day 1 then 5 mg/kg days 2-5

  • Adults: 500 mg on day 1 then 250 mg days 2-5

Functional Abdominal Pain

Pt with h/o physical/sexual abuse presents with acute on chronic abdominal pain. Denies fever, weight loss, vomiting, bloody stools. Reports anxiety, bullying at school. Appropriate progression along growth curve; no fever, CVA tenderness, HSM, abdominal mass, jaundice on exam.

• Consider CBC, CRP, ESR, U/A, beta-hCG, total IgA, anti-tissue transglutaminase IgA, FOBT, and/or fecal ova/parasite testing

• Consider abdominal x-ray to r/o fecal retention

• Treatment

  • Start cognitive behavioral therapy

  • Start lactobacillus, lactol with pH-dependent peppermint oil

  • Child/adolescent > 40 kg: Consider trial of famotidine 20 mg BID

  • Consider trial of cyproheptadine

    • 2-6 y/o: 2 mg q8h

    • 7+ y/o: 4 mg q8h

  • If symptoms do not improve, consider referral to GI

  • Reassurance provided to family

Notes

• Responsible for 90-95% of chronic abdominal pain in children

• No evidence for fiber, amitriptyline, citalopram when treating pain

Abdominal Migraine

7 y/o pt with presents with acute on chronic abdominal pain. Pain can be diffuse or periumbilical with episodes lasting 2 to 72 hours and affecting normal activities. Reports associated unilateral H/A, photophobia, N/V, anorexia that worsen with stress, physical activity. Denies presence of blood in stool. Afebrile with pallor on exam.

• Consider CBC, U/A, beta-hCG, FOBT

• Initial treatment

  • Start Tylenol, ibuprofen for pain

  • Zofran for nausea

• Persistent symptoms

  • Consider propranolol and cyproheptadine for prophylaxis

  • 12+ y/o: Consider sumatriptan for acute pain

• Counseling

  • Parents advised to validate symptoms but avoid reinforcing symptoms with secondary gain, e.g. missing school

  • Family counseled about appropriate sleep habits, hydration

  • Family informed that symptoms generally dissipate in early adolescence

Note: Responsible for 5-15% of chronic abdominal pain in children

Functional Constipation

4 y/o pt with no h/o irritable bowel disease presents with acute on chronic abdominal pain and constipation. Parents report voluntary stool retention, two or fewer BMs per week, hard/painful BMs, stools that obstruct toilet, and at least one episode of stool incontinence per week. Deny bloody stools, delayed meconium passage at birth. Large fecal mass in recutm, normal cremasteric/anal wink/patellar reflexes on exam.

• Consider obtaining TSH, lead level, fecal occult blood testing

• Consider abdominal x-ray

• Treatment

  • Perform fecal disimpaction in office

  • Trial of dietary fiber, fruit juices (e.g. prune, pear)

    • < 4 months: 2 ounces diluted fruit juice

    • > 4 months: 4 ounces diluted fruit juice

  • Polyethylene glycol (Miralax)

    • < 18 months: 1 tsp qd

    • 18 months to 3 years: 2 tsp qd

    • Weight-based: 0.8 g/kg/day in 8 ounces fluid; maximum 34 g qd

  • 2+ y/o: Dulcolax 10 mg qd

  • Glycerin suppository daily

• Counseling

  • Parents counseled about recognizing withholding behavior; regular toileting/incentive systems encouraged

  • Parents counseled to expect prolonged course with frequent relapses

• Consider GI referral for persistent symptoms

Notes

• Most common cause of abdominal pain in children

• Diagnosed using Rome III criteria; vary based on developmental age

• Treatment options for children

  • Osmotic/lubricant laxatives

    • Polyethylene glycol 3350 powder (MiraLax)

    • Lactulose (70 percent solution)

    • Sorbitol (70 percent solution)

    • Magnesium hydroxide (milk of magnesia)

    • Mineral oil

  • Stimulant laxatives

    • Senna

    • Bisacodyl (Ducolax)

    • Glycerin suppositories

  • Stool softener: Docusate

• Enemas do not improve outcomes in children with severe constipation

Hirschsprung Disease

48 hour old infant with h/o trisomy 21, genitourinary anomalies, hearing impairment presents with delayed passage of meconium. Parents report bilious vomiting, decreased appetite. Fever, weight loss, abdominal distention, perforate anus, tight anal sphincter, empty rectum, squirt sign on exam.

• Obtain CBC, CMP

• Consider abdominal x-ray

• Obtain anorectal manometry, rectal suction biopsy

• Consider additional screening for congenital abnormalities of kidney/urinary tract (CAKUT)

• Parents advised that definitive management will include surgery

• Refer to pediatric surgeon

Notes

• Most common cause of lower intestinal obstruction in neonates

• Squirt sign is passage of stool with introduction of finger into rectum

• Suction biopsy show intestinal aganglionosis extending 2-4 cm proximal to internal anal sphincter

Pediatric Infectious Diarrhea

Pt with no h/o inflammatory bowel disease and no recent infections/hospitalizations presents with acute onset diarrhea. Reports fever, N/V, abdominal pain. Recently returned from international vacation; family went swimming and consumed shellfish, raw milk, unpasteurized juice, undercooked meats/fish/eggs, and uncooked produce while abroad. Fever, dry mucous membranes, abdominal pain, joint pain, erythema nodosum on exam.

• Labs

  • Obtain CBC, CMP

  • Obtain U/A to r/o HUS

  • Bloody stools with fever: Evaluate stool culture for Yersinia, Campylobacter, Salmonella enterica, Shigella, STEC

  • Pt > 2 y/o with exposure to abx within previous 12 weeks: Obtain C. difficile PCR

  • Diarrhea lasting > 14 days: Evaluate for parasitic infection

  • Pt with h/o AIDS: Obtain stool cultures for cryptosporidium, Cyclospora, Cystoisospora, microsporidia, Mycobacterium avium complex, and cytomegalovirus

• Treatment

  • Maintain hydration: Recommend electrolyte maintenance solution (see notes for recipe) and/or apple juice mixed half-and-half with water

  • Pt younger than 3 months with recent international travel, fever ≥ 100.4°F, abdominal pain, suspected shigella infection: Start empiric azithromycin 10 mg/kg qd x 3 days (max/adult dose = 500 mg)

• Parents advised that infectious diarrhea is generally self-limited

Notes

• Etiology

  • Report any diarrhea potentially caused by food or water-borne illness to identify possible outbreaks

  • Post-infectious irritable bowel syndrome due to recent infection should be considered and ruled out

• Bloody diarrhea

  • Bloody diarrhea mnemonic: You're Constantly SShitting Erythrocytes (Yersinia, Campylobacter, Salmonella/Shigella, E. coli)

  • STEC: Shiga toxin-producing E. Coli

• Physical Exam

  • Assess patient's volume status on exam to identify possible dehydration, e.g. mucous membranes

  • Extraintestinal and/or post-infectious manifestations may include reactive arthritis, erythema nodosum, or glomerulonephritis

• Treatment

  • Oral rehydration therapy recipe: Mix 6 teaspoons sugar + 1/2 teaspoon salt in 1 liter of water and boil; allow to cool before consumption

  • See JAMA article: Electrolyte maintenance solution vs. dilute apple juice

  • IDSA Criteria for Empiric Antibiotic Therapy

    • Pt < 3 m/o with suspected bacterial etiology

    • Suspected Shigella infection with abdominal pain and documented fever ≥ 100.4°F (38°C)

    • Recent international travel with temperature ≥ 100.4°F (38°C) and/or s/sx sepsis

Inguinal Hernia

1 y/o male pt with h/o intermittent, reducible inguinal mass presents with painful groin mass. Previously, mass increased in size with increased abdominal pressure, e.g. crying. Inguinal mass extending into scrotum on exam.

• Consider ultrasound to verify presence of hernia

• Treatment

  • Reducible inguinal mass; refer to surgery for evaluation

  • Non-reducible, tender groin mass with concern for incarceration; emergent surgical reduction indicated

  • Pt counseled about importance of follow-up with surgery

Notes

• Reducible, non-incarcerated hernias: Non-emergent surgery referral

• Reducible, incarcerated hernias: Repair should occur within 2-5 days

Intussusception

2 y/o pt with h/o Meckel's diverticulum presents with acute onset RLQ tenderness. Pain is colicky and parents report concomitant onset of vomiting, red stools. Palpable abdominal mass, currant-jelly stool in diaper on exam.

• Obtain CBC, CMP

• Ultrasound shows target sign at ileocecal junction

• Perform pneumatic enema

• Parent's advised that intussusception recurs in 10% of cases

Notes

• Most common form of intestinal obstruction between 6 and 36 months of age

• 90% of classes occur at the ileocecal junction

• Pneumatic (air) enema is diagnostic and therapeutic

Ovarian Torsion

Adolescent female with presents with severe, intermittent, unilateral, and non-radiating lower quadrant abdominal pain. Reports N/V. Denies fever, vaginal discharge, dyspareunia, menses complications. Unilateral abdominal pain with palpation, enlarged/tender adnexa on exam.

• Obtain CBC

• Ultrasound shows enlarged adnexa (ovary > 5cm) and decreased flow on doppler

• Consult OBGYN for detorsion surgery

Note: In pediatric patients, torsion can occur in the absence of an ovarian mass

Duchenne Muscular Dystrophy (DMD)

6 y/o M with h/o delayed crawling/walking as compared to siblings presents with fatigue, falls. Pt had difficulty holding his head up as an infant. Parents first became concerned lower extremity muscle weakness when pt was 2-3 y/o. Calf pseudohypertrophy, lower extremity muscle weakness, scoliosis on exam.

• Labs

  • Obtain serum thyroxine, TSH, vitamin D

  • Serum creatinine kinase between 3,000 and 50,000 U/L

  • Obtain genetic analysis to confirm diagnosis

• Treatment

  • Vitamin D < 30 ng/mL; start vitamin D supplementation

  • Start prednisone 0.75 mg/kg/day to slow disease progression, improve outcomes

  • Regular, gentle exercise recommended to prevent disuse atrophy

  • Refer to pediatric neurology, pediatric cardiology

  • Decreased growth velocity: Refer to pediatric endocrinology

• Parents advised that fatal complications are generally due to late pulmonary and cardiac involvement

Notes

• Most common fatal disease affecting children

• Head lag due to neck muscle weakness is a specific, early presentation

• On average, two years elapse between initial parental concern and formal diagnosis

• Rule out hypothyroidism as it can mimic DMD

• If serum CK elevated but less than 3,000 U/L, repeat testing in 2-3 weeks

• Patients are at increased risk of long-bone fracture due to decreased mobility, corticosteroid use

 Scoliosis

USPSTF Screening Recommendation: Grade D

Spondylolysis

Adolescent patient presents with back pain for > 3 weeks. Pain located at the level of L4-L5 and is worse with lumbar spine hyperextension. Patient actively involved in gymnastics, football, soccer, weightlifting, volleyball, dance. Hyperlordosis and limited flexion/extension on exam. Pain reproduced with single-leg hyperextension.

• Obtain lumbar spine x-ray with AP/lateral/bilateral oblique views

  • Evaluate for stress fracture of pars interarticularis

  • Diagnosis uncertain s/p plain film: Consider lumbosacral SPECT scan

• Treatment

  • Recommend relative rest from offending activity, NSAIDs for pain

    • Patient may return to full activity in 6 months

    • Consider referral to physical therapy after ruling out spondylolisthesis (see below)

  • Refer to orthopedics if symptoms persist

Spondylolisthesis

12 y/o F gymnast presents with chronic and paroxysmal lumbar back pain. Chronic pain is a dull ache in the lumbar region. Paroxysmal pain is sharp, worse with extension (e.g. during back handspring), and radiates both laterally and into the buttocks. Paroxysmal pain sometimes accompanied by paresthesias in the back/buttocks and transient lower extremity weakness. Denies fever, chills, night pain, urinary retention, fecal incontinence. Kyphotic posture, hyperlordosis with anterior pelvic tilt, pain with deep L-spine palpation, hamstring/gluteal weakness, and positive Stark (single leg hyperextension) test on exam.

• Imaging

  • Obtain plain anteroposterior (AP) and lateral radiograph of the lumbar spine and evaluate for fracture/vertebral displacement

  • Obtain MRI if plain films do not show pathology and

    • Pain persists after 2-3 weeks rest

    • Patient is an athlete and wishes to return to play

• Imaging reveals spondylothisthesis: Refer to orthopedics for back brace x 6 weeks

Notes

• Pathophysiology:

  • Stress fracture in pars interarticularis (spondylosis) leading to vertebrals displacement (spondylolisthesis)

  • Other sports related injuries may include serving/spiking ball in tennis/volleyball

• Stark test

  • Patient stands on each leg and extends back

  • Considered positive if pain is elicited

• Imaging

  • Consider repeating plain films if both x-ray and MRI are negative but pain persists for > 6 weeks

  • CT is not indicated

Little League Elbow (Medial Epicondyle Apophysitis)

11 y/o M with h/o arm/elbow injury presents with progressive medial elbow pain in while throwing. Patient pitches for multiple teams. Reports decreased pitching velocity, numbness/paresthesia in affected arm. Elbow swelling, decreased ROM of affected elbow, tenderness with palpation of medial elbow/distal arm/forearm on exam.

• X-ray showing medial epicondyle hypertrophy/epiphyseal widening, loose cartilaginous bodies, osteochondral lesions

• Ice, Tylenol, NSAIDs for swelling/pain

• Complete rest from throwing for 4-6 weeks; restart with graduated throwing program.

• May resume competitive throwing at 12 weeks; limit pitches to 200/week and 90/outing

• Loose cartilaginous bodies/avulsion fracture on x-ray and/or failure of symptoms to improve after 12 weeks; refer to orthopedics

Osgood-Schlatter Disease (Tibial Tuberosity Apophysitis)

Adolescent pt with presents with anterior knee pain/swelling. Pt actively involved in soccer, basketball, gymnastics, volleyball. Tenderness/swelling of tibial tubercle on exam.

• Plain x-ray shows fragmentation/irregular ossification at tibial tubercle

• Treatment

  • Recommend rest from painful activities, icing, NSAIDs

  • Perform quadriceps stretching as part of strengthening program

  • May return to full activity in 6-8 weeks

• Pt advised that residual bony deformity may occur

Sever's Disease (Calcaneal Apophysitis)

10 y/o with h/o participation in soccer, basketball, volleyball, track presents with activity-related pain in posterior heel. Parents report pt recently started a growth spurt. Tenderness with medial/lateral compression of posterior calcaneus on exam

• Consider plain x-ray

• Recommend activity modification, icing, gastrocnemius-soleus stretching, NSAIDs, and heel cushions

• May return to pain-free activity in 3-6 weeks

Little League Shoulder

14 y/o M with presents with insidious-onset lateral shoulder pain. Pt plays baseball, tennis, and volleyball. Primarily throws breaking pitches, e.g. sliders, curveballs. Tenderness with palpation of proximal/lateral humerus on exam.

• Bilateral AP shoulder x-ray in internal/external rotation show unilateral widening of the proximal humeral physis

• Tylenol/NSAIDs for pain

• Abstain from throwing/overhead sports for 3 months

• Begin strengthening exercises when comfortable, interval throwing program when pain free

• Parents advised that injury is generally self limited

• Consider adequate rest periods, icing to prevent future episodes

Notes

• Pathophysiology: Overuse injury resulting in epiphysiolysis of the proximal humerus

• See OrthoBullets for more information

Hip Osteonecrosis (Legg-Calve-Perthes)

7 y/o Caucasian M with h/o low birth weight, perinatal HIV infection, sickle cell disease presents with insidious onset hip and knee pain. Parents report progressive, decreased hip ROM and intermittent antalgic gait; no fever. Decreased abduction and internal rotation of hip on exam.

• Radiography showing femoral head lucency and subchondral sclerosis/collapse

• MRI showing osteonecrosis of the femoral head

• Refer to pediatric orthopedics

Notes

• Risk factors

  • Age

    • May occur in patients age 2-12 years

    • Most common in children age 4-8 years

    • Poor prognosis in children older than 6 years

  • Sex: 5 times more common in boys

  • Race: More common in white as compared to black children

• Pathophysiology: Avascular necrosis of the femoral head

• Presentation

  • Pain can be referred to knee

  • Antalgic gait may be intermittent

Slipped Capital Femoral Epiphysis

13 y/o African American male with h/o obesity presents with deep hip pain while weight-bearing. Physical exam reveals antalgic gait with external foot rotation. Pain with log roll and straight leg raise against resistance. Pain with hip internal rotation relieved by external rotation.

• Radiography shows posterior displacement of femur under epiphysis and through the epiphyseal (growth) plate

• Refer to orthopedics

• Patient and parents counseled that risk for avascular necrosis is 30% if not appropriately treated

Notes

• Epidemiology

  • Most common in children ages 11-16 years

  • Risk factors: African American ethnicity, Male sex, obesity, physical activity

• Pathophysiology: Femoral head displaced posteriorly through growth plate

• Presentation

  • Pain generally anterior and within proximal third of thigh

  • Up to 33% of patients present with referred lower thigh or knee pain

Metatarsus Adductus

Newborn M with h/o prematurity presents with bilateral intoeing. Parents report twin sibling diagnosed with metatarsus adductus. Bilateral intoeing with kidney-shaped foot and deviated heel-bisector line on exam; forefoot abducts to neutral when heel placed in neutral position.

• Treatment

  • Parents informed that imaging and treatment are generally not indicated

  • Severe metatarsus adductus in a child who is not walking; refer to pediatric orthopedics for adjustable shoes vs. serial casting x 6-8 weeks

• Parents reassured that 85-90% of cases resolve by 1 year of age

Notes

• More common in males, twins, and premature infants

• Differential diagnosis

  • 2% of cases are associated with developmental dysplasia of the hip

  • In metatarsus varus (rare), the forefoot does not abduct to neutral when heel is in neutral position

• Severity determined by heel bisector line (normal = 2nd toe)

  • Mild = 3rd toe

  • Moderate = between 3rd/4th toes or on 4th toe

  • Severe = between 4th and 5th toes

• Adjustable shoes are effective and less expensive than casting in pre-walking patients with motivated parents

• Surgical correction is contraindicated due to high failure and complication rates

Internal Tibial Torsion

3 y/o pt with h/o frequent falls presents with bilateral intoeing. Forward facing patellae with feet pointing inward on exam.

• No suspicion for rickets, Blount disease, or skeletal dysplasia; do not refer for imaging

• Consider surgery if thigh-foot angle is greater than 15 degrees at age 8 years

• Parents informed that braces and orthotics are ineffective

• Parents reassured that most cases resolve by age 5 years and 90% resolve by age 8 years

Notes

• Most common cause of intoeing overall

• Most common between ages 2-4 years

Femoral Anteversion

5 y/o F with h/o sitting in W position, clumsy gait presents with bilateral intoeing. Parents report family h/o femoral anteversion. Increased internal hip rotation (60 to 90 degrees) with reduced external hip rotation (10 to 15 degrees), inward pointing feet/patellae, bilateral intoeing, and circumduction gait on exam.

• Consider surgery at age 8 years for severe functional or cosmetic abnormality

• Parents informed that radiography in not recommended and that braces/orthotics are ineffective

• Parents reassured that 80% improve/resolve by 10 years of age

Notes

• Most common cause of intoeing in school aged children

• Diagnosed based on increased internal hip rotation and decreased external hip rotation

Fever in Infant 0 to 90 Days

Infant < 29 Days

Pt presents with sudden onset fever > 38.5 C. Parents report cough, increased WOB, diarrhea with blood/mucus in stool. Parents concerned about decreased oral intake, decreased production of wet/dirty diapers. Fever, tachypnea, grunting, nasal flaring, retractions, decreased responsiveness on exam.

• Obtain CBC, BMP, blood culture, U/A with culture

• Obtain CSF cell count/differential, glucose, and protein

• Obtain CSF bacterial culture and enterovirus PCR

• Obtain procalcitonin, CRP for risk stratification

• Additional tests

  • Presenting during influenza season: Obtain influenza PCR

  • Respiratory distress: Obtain CXR

  • Diarrhea: Obtain stool culture

• Treatment

  • Admit to hospital and start empiric coverage with cefotaxime, ampicillin

  • Positive influenza PCR and within 48h of symptom onset; consider oseltamivir 3 mg/kg/dose BID x 5 days vs. supportive care

  • Supportive care

    • Maintain adequate hydration

    • Titrate oxygen to maintain saturations > 92%

Notes

• Empiric antibiotic doses vary depending on the child's age and weight; see the Red Book (AAP) or UpToDate.com for specific dosing.

• Oseltamivir has been studied in children under 1 year, but may not be appropriate for those under one month; consult a pharmacist

Infant 29-60 Days

Pt with h/o prematurity, congenital abnormality presents with sudden onset fever > 38.5 C. Parents report cough, increased WOB, diarrhea with blood/mucus in stool, and treatment with antibiotics during previous 7 days. Tachypnea, grunting, nasal flaring, retractions on exam.

• Obtain CBC, BMP, blood culture, U/A with culture

• Presenting during influenza season: Obtain influenza PCR

• Risk factors for invasive bacterial infection, not currently influenza season, or negative influenza PCR:

  • Obtain CSF cell count and differential, glucose, and protein

  • Obtain CSF bacterial culture and enterovirus PCR

  • Obtain procalcitonin, CRP for risk stratification

• Additional tests

  • Respiratory distress: Obtain CXR

  • Diarrhea: Obtain stool culture

• Treatment

  • Toxic appearing, ANC < 1,000, PNA on CXR, confirmed UTI, and/or CSF pleocytosis: Admit to hospital and start empiric coverage with cefotaxime

  • Non-toxic with reliable caregivers: Administer ceftriaxone 50 mg/kg IM and f/u in 24 hours

  • Concern for Enterococcus and/or Listeria infection: Add ampicillin

  • CSF positive for S. pneumoniae meningitis: Add vancomycin 15 mg/kg

  • Positive influenza PCR and within 48h of symptom onset: Start oseltamivir 3 mg/kg/dose BID x 5 days

  • Supportive care

    • Maintain adequate hydration

    • Titrate oxygen to maintain saturations > 92%

Notes

• Manage according to adjusted chronological age = (chronological age in weeks - [40 - WGA at birth])

• Infections of concern: Respiratory (most common), meningitis (most concerning), UTI

• Factors that increase risk for bacterial infection: H/o prematurity/congenital abnormality, comorbid medical conditions, antibiotic therapy within the previous 7 days

• U/A is indicated if s/sx of pediatric UTI and/or if respiratory complaints are present. UTI is confirmed with U/A showing positive LE, nitrites, or > 5 WBC/HPF.

• Empiric antibiotic doses vary depending on the child's age and weight; see the Red Book (AAP) or UpToDate.com for specific dosing.

• While oseltamivir is recommended within 48h of symptom onset, it may reduce morbidity/mortality in children if started later.

• Children who do not meet hospitalization criteria (see plan), have confirmed influenza without respiratory distress, or who have confirmed UTI may be discharged to home with appropriate therapy and f/u within 24 hours.

Infant 61-90 Days

Pt with h/o prematurity, congenital abnormality presents with sudden onset fever > 38.5 C. Parents report cough, increased WOB, diarrhea with blood/mucus in stool, and treatment with antibiotics during previous 7 days. Tachypnea, grunting, nasal flaring, retractions on exam.

• Labs

  • Obtain CBC, BMP, blood culture, U/A with culture

  • Presenting during influenza season: Obtain influenza PCR

  • Risk factors for invasive bacterial infection, not currently influenza season, or negative influenza PCR:

    • Obtain CSF cell count and differential, glucose, and protein

    • Obtain CSF bacterial culture and enterovirus PCR

    • Obtain procalcitonin, CRP for risk stratification

  • Additional tests

    • Respiratory distress: Obtain CXR

    • Diarrhea: Obtain stool culture

  • Treatment

    • Toxic appearing, ANC < 1,000, PNA on CXR, confirmed UTI, and/or CSF pleocytosis: Admit to hospital and start empiric coverage with cefotaxime

    • Non-toxic with reliable caregivers: Administer ceftriaxone 50 mg/kg IM and f/u in 24 hours

    • Concern for Enterococcus and/or Listeria infection: Add ampicillin

    • CSF positive for S. pneumoniae meningitis: Add vancomycin

    • Positive influenza PCR and within 48h of symptom onset: Start oseltamivir 3 mg/kg/dose BID x 5 days

  • Supportive care

    • Maintain adequate hydration

    • Titrate oxygen to maintain saturations > 92%

Notes

• Manage according to adjusted chronological age = (chronological age in weeks - [40 - WGA at birth])

• Infections of concern: Respiratory (most common), meningitis (most concerning), UTI

• Factors that increase risk for bacterial infection: H/o prematurity/congenital abnormality, comorbid medical conditions, antibiotic therapy within the previous 7 days

• U/A is indicated if s/sx of pediatric UTI and/or if respiratory complaints are present. UTI is confirmed with U/A showing positive LE, nitrites, or > 5 WBC/HPF.

• Empiric antibiotic dosing depends on the child's age and weight: See the Red Book (AAP) or UpToDate.com for specific dosing.

• While oseltamivir is recommended within 48h of symptom onset, it may reduce morbidity/mortality in children if started later.

• Children who do not meet hospitalization criteria (see plan), have confirmed influenza without respiratory distress, or who have confirmed UTI may be discharged to home with appropriate therapy and f/u within 24 hours.

Iron Deficiency Anemia

1 y/o with h/o prematurity, immigration from a developing nation presents for fatigue/irritability. Parents report pt regularly tries to eat dirt/clay; deny recent viral illness, rash, joint pain. Growth delay, glossitis, systolic murmur, skin pallor on exam.

• Labs

  • CBC shows low hemoglobin, low MCV, elevated RDW, and reticulocyte count <2%; MCV/RBC > 13

  • Iron studies show low ferritin, elevated TIBC

  • Lead level WNL

• Start 1 month trial 6 mg/kg iron supplementation to be taken at breakfast; repeat CBC upon completion

• Parents advised to limit cow's milk consumption to < 20 ounces per day and supplement diet with iron-rich foods

Notes

• Etiology

  • Insufficient iron intake is the most common reason for childhood anemia; affects 3-10% of children

  • No recent viral illness/rash/joint pain decreases likelihood of transient anemia due to Parvovirus B19

• Labs

  • Low MCV + elevated RDW indicates iron deficiency

  • Mentzer index = MCV/RBC count; values > 13 indicate greater likelihood of iron deficiency decreased likelihood of Thalassemia

  • Reticulocyte count <2% indicates that the anemia is not due to a destructive process

  • Normal hemoglobin levels are based on age; hemoglobin increase of >1g/dL one month after supplementation confirms diagnosis

• Iron supplementation in exclusively breastfed infant:

  • <37 WGA: Supplement iron (2 mg/kg/day) from 1 to 12 months of age

  • Full term: Iron supplementation starting at 4 months and continuing until child is eating sufficient iron-containing foods

Lead Toxicity

Pt with h/o immigration from developing nation presents with subacute abdominal pain, irritability, lethargy. Parents report milestone regression and are concerned about possibility of ADHD. Pt lives in house built before 1970. HTN on exam.

• CBC shows microcytic anemia; peripheral smear shows basophilic stippling

• Obtain serum ferritin, TIBC to r/o iron deficiency anemia

• Lead level

  • 5-14 mcg/dL: Repeat lead level to confirm result

  • 15-44 mcg/dL: Obtain abdominal x-ray and perform whole bowel irrigation if suspected lead particles present

  • 45-69 mcg/dL: Repeat level within 48 hours and administer DMSA 10 mg/kg/dose TID x 5 days and then BID x 14 days. Provide nutritional supplementation with MVT with iron and 2 8oz glasses milk.

  • 70 mcg/dL or greater: Emergency consultation advised; contact regional poison control center (1-800-222-1222)

• Parents counseled about routes and risks of lead exposure

• Parents advised screen all children living in the household for lead

• Health department notified

Henoch-Schonlein Purpura (IgA Vasculitis)

5 year old presents with acute onset diffuse/colicky abdominal pain, arthralgias/arthritis, purpura. Symptoms preceded by sore throat. Hypertension and palpable, non-blanching purpura primarily located on lower extremities.

• Labs

  • CBC may show thrombocytopenia

  • Obtain initial CMP to evaluate creatinine, serum albumin

  • Evaluate early morning CMP for creatinine > 30 µmol/L

  • Obtain PT/PTT/INR

  • Evaluate urinalysis for proteinuria, hematuria

  • Consider skin biopsy

• Severe abdominal pain: Consider ultrasound to rule out intussusception

• Treatment

  • Continue supportive therapy

  • Arthritic pain: Acetaminophen per pediatric dosing

  • Positive strep test and age > 3 years and GFR > 30: Amoxicillin 50 mg/kg qd x 10 days (maximum daily dose 1,000 mg/day)

  • Renal involvement as evidenced by elevated creatinine, proteinuria, and/or hematuria

    • Prednisone 1 mg/kg/day x 2 weeks followed by 2 week taper

    • HTN: Amlodipine 0.1 mg/kg/day (maximum daily dose 5 mg/day)

    • Consult nephrology

    • Monitor BP, creatinine, and urinalysis monthly for six months

  • Refractory abdominal/arthritic pain and/or scrotal swelling: Consider prednisone (see dosing above)

• Counseling

  • Parents informed that 95% of cases resolve spontaneously within 8 weeks

  • Avoid ibuprofen due to abdominal pain and concern for renal involvement

  • Relapses can occur for up to 10 years following illness

Notes

• Epidemiology

  • Most common systemic vasculitis of childhood

    • Typically occurs between age 3-15 years with peak prevalence at age 4-6 years

    • Only 10% of cases occur in adults

  • Sometimes associated with preceding streptococcal pharyngitis

• Pediatric Rheumatology European Society Criteria

  • Mandatory: Purpura or petechiae with lower limb predominance

  • At least one of the following:

    • Arthritis or arthralgia

    • Acute onset diffuse abdominal pain

    • Renal involvement: Proteinuria or hematuria

    • Histopathology: Leukoclastic vasculitis or proliferative glomerulonephritis with IGA deposits

• Treatment

  • Calcium channel blockers (e.g. amlodipine) are indicated for hypertension associated with renal involvement

  • Corticosteroids

    • Prophylactic treatment does not prevent renal disease (SOR A)

    • Early treatment may reduce joint and abdominal pain